Conditions: Autoantibody Positive Non-diabetic Relatives at Risk for Type 1 Diabetes High Risk Impaired Glucose Tolerance
Keywords: type 1 diabetes pre-diabetic autoantibody positive at risk for type 1 diabetes glucose intolerance relatives of people with type 1 diabetes
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 76
Healthy volunteers: no

Brief summary:
The study will determine whether the anti-CD3 monoclonal antibody, teplizumab, can help to prevent or delay the onset of type 1 diabetes (T1D) in relatives determined to be at very high risk for developing the disease. Teplizumab has been studied in new onset type 1 diabetes for testing of efficacy and safety in previous studies; other studies are currently in progress. The results of previous studies indicate that teplizumab reduces the loss of insulin production during the first year after diagnosis in individuals with type 1 diabetes. The purpose of this study is to determine if teplizumab can interdict the immune process that causes the destruction of insulin secreting beta cells in the pancreas during the "pre-diabetic" state and thereby prevent or delay the onset of type 1 diabetes.

Detailed description:
The study plans to enroll approximately 71 subjects between the ages of 8-45 years, over 2-3 years. The study is projected to last between 4-6 years, depending upon rate of enrollment and number of subjects who develop diabetes.

The main study objective is to determine whether intervention with teplizumab will prevent or delay the development of type 1 diabetes in high risk autoantibody positive non-diabetic relatives of individuals with T1D. Secondary outcomes are to include analyses of C-peptide and other measures from Oral Glucose Tolerance Testing (OGTT), safety, tolerability, and other mechanistic outcomes will be assessed during the study.

Arms:
arm 1: Intravenous infusions of teplizumab given for 14 consecutive days. Each infusion takes about 30 minutes and is followed by a 2 hour observation period. arm 2: Intravenous infusion of placebo (saline) will be given for 14 consecutive days. Infusions will take approximately 30 minutes and will be followed by a two hour observation period.

Interventions: intervention 1: Teplizumab intervention 2: Placebo infusion
Intervention descriptions: intervention 1: intravenous infusions intervention 2: Placebo for Teplizumab

Protocol document:
Prot_000.pdf: 
 TrialNet Protocol: TN10 Anti-CD3 Prevention 
 
      Protocol Version: 25Jun14 
 
 
 
 
 
 
 
ANTI-CD3 MAB (TEPLIZUMAB) FOR PREVENTION OF 
DIABETES IN RELATIVES AT-RISK FOR TYPE 1 
DIABETES MELLITUS  
 
(Protocol TN-10) 
 
VERSION  
 
 June 25, 2014 
 
Implementation Date: July 30, 2014 
 
IND # 102, 629  
 
EudraCT # 2013-002248-98        
 
 
 
Supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 
the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute of 
Child Health and Human Development (NICHD), the National Center for Research 
Resources (NCRR), the Juvenile Diabetes Research Foundation International (JDRF), and 
the American Diabetes Association (ADA). 
 
 
 


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PREFACE 
 
The TrialNet Type 1 Diabetes Protocol TN-10, Anti-CD3 (teplizumab) for Prevention of Diabetes in 
Relatives at risk for Type 1 Diabetes Mellitus (T1DM), describes the background, design, and 
organization of the study.  The protocol will be maintained by the TrialNet Coordinating Center 
(TNCC) over the course of the study through new releases of the entire protocol, or issuance of 
updates either in the form of revisions of complete chapters or pages thereof, or in the form of 
supplemental protocol memoranda. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Abbreviations  
ADA 
American Diabetes Association 
AE 
Adverse event 
ALT 
Alanine aminotransferase 
AST 
Aspartate aminotransferase 
AUC 
Area under the curve 
CBC 
Complete blood count 
CFR 
Code of Federal Regulations 
CMV 
Cytomegalovirus  
CRF 
Case report form 
DCCT 
Diabetes Control and Complications Trial  
DPT-1 
Diabetes Prevention Trial of Type I Diabetes 
DSMB 
Data and Safety Monitoring Board 
EBV 
Epstein-Barr virus 
FDA 
US Food and Drug Administration  
GAD 
Glutamate decarboxylase 
GCP 
Good clinical practice 
HbA1C 
Hemoglobin A1C 
HIV 
Human immunodeficiency virus 
ICH 
International Conference on Harmonisation 
IRB 
Institutional Review Board 
ITN 
Immune Tolerance Network 
NCI-
CTCAE 
National Cancer Institute Common Terminology Criteria for 
Adverse Events 
PE 
Physical exam 
PPD 
Purified protein derivative test 
SAE 
Serious adverse event 
T1DM 
Type 1 diabetes mellitus 
TNCC 
TrialNet Coordinating Center 
 


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TABLE OF CONTENTS 
 
TABLE OF CONTENTS ........................................................................................................................................1 
 
1. 
INTRODUCTION ......................................................................................................................................... 4 
1.1. 
Study Overview ......................................................................................................................... 4 
1.2. 
Statement of Purpose ................................................................................................................. 4 
2. 
BACKGROUND AND SIGNIFICANCE ......................................................................................................5 
2.1. 
Type 1 Diabetes (T1DM) .......................................................................................................... 5 
2.1.1. 
Definition and metabolic characteristics of Type 1 diabetes mellitus ............................... 5 
2.1.2. 
Natural History of Type 1 Diabetes ................................................................................... 5 
2.2. 
Development of Teplizumab ..................................................................................................... 7 
2.3. 
Clinical Studies ......................................................................................................................... 8 
2.3.1. 
Study 1: A Phase I/II Trial ................................................................................................. 8 
2.3.2. 
Study 2: A Phase II Multiple-Dose Trial, NCT00806572 ................................................. 9 
2.3.3. 
ITN 017: A Phase I dosing study ..................................................................................... 10 
2.3.4. 
“ABATE Trial” ITN027 NCT00129259 ......................................................................... 10 
2.3.5. 
“Delay Trial” NCT00378508 ........................................................................................... 10 
2.3.6. 
“Protégé Trial” NCT00385697 ........................................................................................ 10 
2.3.7. 
“Protégé Encore Trial” NCT00385697 ............................................................................ 11 
2.4  
Evaluations of Safety Experience with Teplizumab and the Basis for the Proposed Clinical 
Protocol .......................................................................................................................................... 11 
2.5. 
Use of Teplizumab in Children ............................................................................................... 11 
2.6. 
Additional information ............................................................................................................ 12 
3. 
STUDY DESIGN .........................................................................................................................................13 
3.1. 
Overview ................................................................................................................................. 13 
3.2. 
Objectives ................................................................................................................................ 13 
3.2.1. 
Primary Objective ............................................................................................................ 13 
3.2.2. 
Secondary Objectives....................................................................................................... 13 
3.3. 
Summary of Inclusion/Exclusion Criteria ............................................................................... 13 
3.3.1. 
Inclusion Criteria ............................................................................................................. 13 
3.3.2. 
Exclusion Criteria ............................................................................................................ 15 
3.4. 
Enrollment ............................................................................................................................... 16 
3.5. 
Double-Masking and Description of Treatment Groups ......................................................... 16 
3.6. 
Treatment Assignment ............................................................................................................ 16 
3.6.1. 
Procedures for Unmasking ............................................................................................... 17 
3.7. 
Study Assessments .................................................................................................................. 17 
3.8. 
Quality Assurance ................................................................................................................... 17 
3.9. 
Study Timeline ........................................................................................................................ 17 
3.9.1. 
Study Duration ................................................................................................................. 17 
3.9.2. 
Follow-up Studies ............................................................................................................ 18 
4. 
PATIENT MANAGEMENT ....................................................................................................................... 19 
4.1. 
Screening Visit and Eligibility Assessment ............................................................................ 19 
4.2. 
Anti-CD3 mAb Trial for At-risk Subjects Initial Visit ........................................................... 19 
4.3. 
Randomization and Baseline visits ......................................................................................... 19 
4.4. 
Close Monitoring..................................................................................................................... 19 


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4.5. 
Administration of Teplizumab ................................................................................................ 20 
4.5.1. 
Drug Administration ........................................................................................................ 20 
4.5.2. 
Drug Withholding in an Individual Subject During the 14 Day Treatment Period ......... 21 
4.5.3. 
Further Evaluation after Withholding Infusions .............................................................. 22 
4.6. 
Interruption of Enrollment/Trial Cessation ............................................................................. 22 
4.7. 
Prophylactic Medications ........................................................................................................ 24 
5. 
STUDY VISIT ASSESSMENTS ................................................................................................................ 25 
5.1. 
General Assessments ............................................................................................................... 25 
5.2. 
Laboratory Assessments .......................................................................................................... 25 
5.3. 
Mechanistic Outcome Assessments ........................................................................................ 25 
5.4. 
Metabolic Outcome Assessments............................................................................................ 26 
5.5. 
Laboratory Measures Related to Teplizumab Administration ................................................ 26 
5.6. 
Visit Windows ......................................................................................................................... 26 
6. 
ADVERSE EVENT REPORTING AND SAFETY MONITORING ......................................................... 27 
6.1. 
Adverse Event Definition ........................................................................................................ 27 
6.1.1. 
Adverse Event .................................................................................................................. 27 
6.1.2. 
Serious Adverse Event ..................................................................................................... 27 
6.1.3. 
Unexpected Adverse Event .............................................................................................. 28 
6.1.4. 
Grading Event Severity and Causality ............................................................................. 28 
6.2. 
Adverse Event Reporting and Monitoring .............................................................................. 28 
7. 
PARTICIPANT SAFETY ............................................................................................................................29 
7.1. 
Protecting Against or Minimizing Potential Treatment Risks ................................................ 29 
7.1.1. 
Prohibited Medications .................................................................................................... 29 
7.2. 
Expected Side Effects and Adverse Events ............................................................................. 29 
7.2.1. 
Hematologic ..................................................................................................................... 29 
7.2.2. 
Cytokine Release Syndrome ............................................................................................ 30 
7.2.3. 
Lymphoproliferative Disease ........................................................................................... 30 
7.2.4. 
Anti-idiotype Responses .................................................................................................. 31 
7.2.5. 
Infection ........................................................................................................................... 31 
7.2.6. 
Rash.................................................................................................................................. 31 
7.3 
Pregnancy ................................................................................................................................ 31 
8. 
STATISTICAL CONSIDERATIONS AND ANALYSIS PLAN .............................................................. 33 
8.1 
Primary Outcome .................................................................................................................... 33 
8.2 
Primary Analysis ..................................................................................................................... 33 
8.3 
Secondary Outcomes and Analyses ........................................................................................ 34 
8.4 
Study Power and Sample Size ................................................................................................. 35 
8.5 
Interim Monitoring Plan .......................................................................................................... 36 
8.6. 
Withdrawal Criteria- Individual Subjects ............................................................................... 37 
9. 
ETHICAL CONSIDERATIONS AND COMPLIANCE WITH GOOD CLINICAL PRACTICE ............ 38 
9.1. 
Statement of Compliance ........................................................................................................ 38 
9.2. 
Participating Centers ............................................................................................................... 38 
9.3. 
Informed Consent .................................................................................................................... 39 
9.4. 
Study Subject Confidentiality ................................................................................................. 39 
9.5. 
Risks and Benefits ................................................................................................................... 41 
9.6. 
Ethics ....................................................................................................................................... 41 
10. STUDY ADMINISTRATION .....................................................................................................................42 
10.1. 
Organizational Structure ...................................................................................................... 42 


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10.2. 
Role of Industry ................................................................................................................... 42 
10.3. 
Groups and Committees ...................................................................................................... 42 
10.3.1. 
Anti-CD3 Prevention Study Chair ............................................................................... 42 
10.3.2. 
TrialNet Chairman’s Office and TrialNet Coordinating Center .................................. 42 
10.3.3. 
Clinical Sites ................................................................................................................ 42 
10.3.4. 
Diabetes Adjudication Committee ............................................................................... 43 
10.3.5. 
Clinical Site Monitoring ............................................................................................... 43 
10.4. 
Medical Monitor and Data Safety and Monitoring Board (DSMB) .................................... 43 
10.5. 
Sample and Data Storage ..................................................................................................... 43 
10.6. 
Preservation of the Integrity of the Study ............................................................................ 44 
10.7. 
Participant Reimbursement and Compensation ................................................................... 44 
APPENDIX 1- Natural History to Teplizumab in At-Risk Relatives Study Flow Chart             
(Subjects ≥18yo) .................................................................................................................................... 47  
APPENDIX 2 - Natural History of Teplizumab in At-Risk Relatives Study Flow Chart            
(Subjects <18yo)  ................................................................................................................................... 49 
APPENDIX 3 - Schedule of Assessments……………………………………………………………. 51 
11. REFERENCES .......................................................................................................................................... 53 
 


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1. INTRODUCTION 
1.1. 
Study Overview 
 
Title 
Anti-CD3 mAb (teplizumab) for prevention of diabetes in 
relatives at-risk for Type 1 diabetes mellitus  
IND Sponsor 
MacroGenics, Inc. Under IND  102,629 
Study Supported by 
National Institute of Diabetes, Digestive and Kidney Diseases 
Conducted By  
Type 1 Diabetes Trial Network (TrialNet) 
Protocol Chair 
Dr. Kevan Herold, Yale University 
Accrual Objective 
The study plans to enroll approximately 71 subjects over 6 
years.  The study is projected to last between 6-10 years, 
depending upon rate of enrollment and number of subjects 
who develop diabetes.  
Study Design 
The study is a 2-arm, multicenter, randomized, placebo 
controlled masked clinical trial.  All subjects will receive close 
monitoring for development of T1DM. 
Treatment Description 
Subjects will receive teplizumab + close monitoring for 
development of T1DM or placebo + close monitoring for 
development of T1DM.   
Objective 
To assess the safety, efficacy, and mode of action of 
teplizumab for prevention of T1DM.  
Primary Outcome 
The primary objective is to determine whether intervention 
with teplizumab will prevent or delay the development of 
T1DM in high risk autoantibody positive non-diabetic relatives 
of patients with T1DM.   
Secondary Outcome 
Secondary outcomes are to include analyses of C-peptide 
and other measures from the OGTT; safety and tolerability; 
and mechanistic outcomes. 
Major Inclusion Criteria 
Autoantibody positive relatives of T1DM proband with 
abnormal glucose tolerance. 
Age 1-45 years at the time of enrollment in TN01 and age ≥ 8 
at time of randomization in this trial. 
 
 
1.2. Statement of Purpose 
 
This protocol describes the background, design, and organization of study of the anti-CD3 
monoclonal antibody, teplizumab [hOKT3γ1(Ala-Ala)] for prevention of diabetes in relatives at very 
high risk for T1DM.  The protocol was written by Dr. Kevan Herold, Chair of the TrialNet Anti-CD3 
Protocol Committee, the TrialNet Chairman’s Office at the University of Miami and the Benaroya 
Research Institute, and the TNCC.  Significant changes that occur to this protocol during the course 
of the trial require the formal approval of the TrialNet Steering Committee.  The study protocol, along 
with the required informed consent forms, will be approved by each participating institution’s 
Institutional Review Board (IRB) or Ethics Committee/Research Ethics Board (EC/REB). 


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2. BACKGROUND AND SIGNIFICANCE 
 
2.1. Type 1 Diabetes (T1DM) 
 
2.1.1. Definition and metabolic characteristics of Type 1 diabetes mellitus 
 
Type 1 diabetes mellitus (T1DM) is an immune-mediated disease in which insulin-producing beta 
cells are completely or near completely destroyed, resulting in life-long dependence on exogenous 
insulin.  It is a chronic and potentially disabling disease that represents a major public health and 
clinical concern.  The number of patients being diagnosed with type 1 diabetes is increasing each 
year and is approaching an epidemic level in some countries that track this information (1; 2). 
 
Compared to individuals with the more common form of diabetes, Type 2 diabetes, (where individuals 
retain some endogenous insulin production which is inadequate to maintain normal glucose and lipid 
metabolism), the metabolic impairment in T1DM is much more severe and the loss of insulin 
production more complete. Continuous exogenous insulin therapy is needed to prevent ketoacidosis 
and allow assimilation of food and to maintain life. Most likely as a consequence of the absolute 
deficiency of insulin, glucose counterregulation (i.e. the hormonal response to insulin induced 
hypoglycemia) is impaired, and therefore, hypoglycemia is a frequent complication of the disease. 
The occurrence of hypoglycemia limits the ability to achieve near normal glucose control. The 
Diabetes Control and Complications study (DCCT) showed that the long term complications could be 
reduced with near normal control of glucose levels but at the cost of an increased frequency of severe 
hypoglycemia (3). While there have been significant improvements in insulin delivery systems, such 
as continuous subcutaneous insulin infusions with insulin pumps, normal glucose control, particularly 
in children, is rarely achieved.  Therefore, individuals with Type 1 diabetes remain at risk for 
secondary end-organ complications including visual impairment and blindness, renal failure, vascular 
disease and limb amputation, peripheral neuropathy, stroke, acute risk for severe hypoglycemia, and 
others. Moreover, at the time of diagnosis, many individuals, and children in particular, suffer 
significant morbidity frequently requiring ICU admission.  As described below, virtually all the 
individuals identified for enrollment into this prevention trial will develop diabetes.  Clearly, prevention 
of the onset of the disease itself would represent a significant advancement.   
 
2.1.2. Natural History of Type 1 Diabetes 
 
Much is known about the natural history of the type 1 diabetes disease process (4). Although all 
people are susceptible, relatives of individuals with T1DM are at much greater risk for development of 
the disease.  In the general population, approximately 0.3 % of individuals will develop T1DM. In 
contrast, those with a relative with T1DM have a 5% incidence of disease – a 15 fold increase (5).  
Further risk stratification among family members depends upon genetic, immune and metabolic data 
(6).   
 
Beta cell destruction generally begins in genetically susceptible individuals years before clinical 
onset(7). The autoimmune process that causes beta cell destruction is clinically silent and can only 
be identified by the detection of autoantibodies such as Islet Cell Antibodies (ICA), anti-glutamic acid 
decarboxylase (GAD)65ab, anti-ICA512ab, anti-insulin autoantibodies (mIAA) (5), and the recently 
described antibodies to a zinc transporter (ZnT8) (8). Continued immune mediated beta cell 


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destruction occurs until physiologic insulin demand cannot be met by the remaining beta cells, 
resulting in hyperglycemia and clinical diagnosis of T1DM (9)(10).   
 
Based on data from the Diabetes Prevention Trial, type 1 diabetes (DPT-1), the risk for developing 
diabetes in relatives without the disease can be defined by the presence of autoantibodies and the 
degree of metabolic impairment (11-13).  The DPT-1 study was one of the first large-scale prevention 
trials of T1DM.  The aim of this trial, which tested >100,000 relatives of individuals with T1DM, was to 
study whether either low dose parenteral insulin or oral insulin administration would prevent the 
development of T1DM. The results of the DPT-1 study showed that neither parenteral nor oral insulin 
prevented the development of T1DM, (although a secondary analysis of the data suggested some 
effect of oral insulin in delaying the onset of diabetes in a subgroup of subjects defined by high anti-
insulin antibodies and normal glucose tolerance)(13).  
 
Autoantibody positive subjects enrolled in the DPT-1 study who had impaired or indeterminate 
glucose tolerance (any glucose level after ingestion of oral glucose of > 200 mg/dL and/or a glucose 
level 2 hours after ingestion of oral glucose of 140-200 mg/dL and/or fasting glucose between 110 – 
126 mg/dL during a standard oral glucose tolerance test were at very high risk (78% over 5 years) of 
developing T1DM over a 5 – 6 year follow up.  The risk was particularly high for individuals under the 
age of 18 (Figure 1). 
 
 
 
 
 
 
 
Similar results confirming the very high risk of those with abnormal glucose were found in the ENDIT 
(European Nicotinamide Diabetes Intervention Trial) study in which Nicotinamide failed to prevent the 
onset of diabetes in relatives at risk for the disease (14).  
 
 
Figure 1: Risk of diabetes among individuals recruited for 
the DPT-1 study with abnormal glucose tolerance, stratified 
by age≤ 18 or > 18 yrs. 


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It is important to note that the diagnosis of diabetes is based on a glucose threshold that is associated 
with risk of secondary endorgan complications of the disease rather than the pathologic process that 
leads to hyperglycemia. Detailed analyses of metabolic function in individuals who do and do not 
progress to diabetes in the DPT-1 study have been published (10; 15; 16). These studies have 
identified the progressive loss of stimulated C-peptide responses to a mixed meal over time in high 
risk individuals. The differences between the responses in the prediabetic period and after the 
diagnosis of diabetes are modest but statistically significant. These studies describe a progressive 
predictable loss of beta cell function rather than a precipitous change. In addition, they also suggest 
that once metabolic impairment has occurred, the risk is extremely high. These combined 
immunologic and metabolic studies suggest to us that those individuals differ from those in whom the 
diagnosis of T1DM has been made only in the time of progression. 
 
There have been no therapies tested to date which are aimed only at those at very high risk for 
development of T1DM (~80% as described above). The previous DPT-1 and ENDIT studies enrolled 
subjects with a broad range of risk – the overall 5-year risk in the target population was between 50-
60%. However, in newly diagnosed subjects, there is reason to believe that individuals with more beta 
cell function may show a better response to interventions. Earlier studies with Cyclosporine A 
suggested that response to immune therapies is greatest in those with higher levels of insulin 
secretion at the time of diagnosis of T1DM (17). In a recently published study of another non-FcR 
binding anti-CD3 mAb, Keymeulen et al found that clinical responses to drug were greatest in those in 
the upper half of C-peptide responses at the time of study entry (18). 
 
Therefore, the rationale for this study is that individuals with immunologic markers of T1DM and 
abnormal glucose tolerance are at very high risk for progression to overt disease. They have a 
condition that differs from overt diabetes only in the duration of the autoimmune process that results 
in beta cell destruction. Intervention at the “prediabetic” stage is likely to be more effective than 
intervention in those in whom frank hyperglycemia has developed and beta cell function has 
deteriorated further because insulin production is greater before compared to after the diagnosis. 
 
2.2. 
Development of Teplizumab 
 
The Fc-engineered teplizumab [hOKT3γ1 (Ala-Ala)] was developed as an approach to mitigate the 
adverse effects of OKT®3 resulting from Fc/FcR engagement (19).  OKT®3 produces profound, 
transient T-cell depletion in vivo.  It also activates T cells, is strongly mitogenic, and its use in vivo is 
associated with severe cytokine-release syndrome (incidence >90%).  The cytokine-release 
syndrome induced by OKT®3 is characterized by fever, chills, nausea, vomiting and other symptoms, 
and usually requires corticosteroid therapy to suppress.  OKT®3 also is associated with a small 
incidence of EBV lymphomas (~1%-2%).  T-cell activation is strongly facilitated by the interaction of 
Fc component of OKT®3 with Fc receptors on lymphocytes (Fc/FcR engagement).   
 
Teplizumab is a 150-KD humanized mAb that binds the CD3-e epitope of the T cell receptor (TCR) 
complex with affinity equal to OKT®3, but it differs  from OKT®3 in two properties: 
 
1. The humanization process has resulted in the generation of a mAb that used less than 10% of the 
original murine amino acids in the antibody construction.  The clinical consequence of this 
property is reduced immunogenicity or formation of anti-idiotypic antibodies. 
 
2. Two amino acids have been changed (leucine234 to an alanine and leucine 235 to an alanine) in the 
Fc portion of the immunoglobulin that disrupt Fc receptor and complement component C1q 


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binding.  These two amino acid changes were aimed at eliminating the majority of cytokine-
mediated toxicity observed during infusions of OKT®3.  
 
The modified Fc component of teplizumab minimizes the activating capacity of the antibody 
compared with unmodified murine OKT®3.  Although the primary mechanism of action of the antibody 
involves binding the CD3 antigen target on T cells, subsequent mechanisms involved in the 
therapeutic effects are incompletely understood.  These mechanisms of action appear to involve 
weak agonistic activity on T cells as well as the generation of regulatory cytokines and regulatory T 
cells leading to the development of tolerance (20; 21). 
 
2.3. 
Clinical Studies 
 
As of March 2009, over 500 subjects have been treated with teplizumab including over 450 
individuals with T1DM.  Other subjects who have received teplizumab include subjects undergoing 
renal allograft rejection, individuals receiving islet transplantation, and patients with psoriatic arthritis.  
 
Two clinical trials testing safety and efficacy have been completed using teplizumab in participants 
with recent onset T1DM; Study 1 (a phase I/II trial); Study 2 (protocol ITN007AI [NDB01]), as well as 
one PK/safety study (protocol ITN017AI).  In addition, four clinical studies to preserve beta cell 
function in those with T1DM are underway.  These studies are described below.  Further information 
about these studies and other clinical experience with teplizumab are in the Investigator’s Brochure. 
 
2.3.1. Study 1: A Phase I/II Trial 
Study 1 was a randomized, controlled, phase I/II, three-center trial that enrolled a total of 43 
participants and tested two dosing regimens with hOKT3γ1(Ala-Ala)(23; 30).  The clinical efficacy 
outcome tested was change in C-peptide response to MMTT in treated as compared to control 
groups. 
 
The results of these studies suggest that treatment with the anti-CD3 mAb hOKT3γ1 (Ala-Ala) 
reduces the loss of insulin production over the first year in individuals with T1DM (Table 1)(23; 30). 
 
Table 1.  Changes in C-peptide response to an MMTT among participants in study 1 
 
At 1 year, the mean area under the curve (AUC) of the C-peptide response was 97+9.6% of the 
response at baseline in the drug-treated group (vs. 53+7.6% in the control group, p=0.001).   
 
Follow-up was extended for 2 years after study entry.  There continued to be a significant drug 
treatment effect at 2 years (p=0.002), although the meal stimulated C-peptide responses were falling 
Patient 
Group 
Change at 6 months 
Change at 1 year 
 
No 
change 
 
 
No 
change 
 
Drug treated 9 
6 
6 
7 
8 
6 
Control* 
2 
2 
15 
1 
3 
15 
p<0.01; * Two control participants withdrew from the study.   


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in both the drug treated and control groups.  The differences between the two groups were 44% at 
both year 1 and year 2 (31). 
 
Figure 2.  C-peptide response to an MMTT over 2-year period in study 1.  There was a significant 
effect of drug treatment on the C-peptide responses over the 2 year period (p=0.002).  (The data 
represent mean ± SEM of the study groups.) 
 
In the patients with diabetes, the drug treatment was associated with improvement in the hemoglobin 
A1C (HbA1C) levels (p=0.004) and reduced use of insulin (p=0.001) over the 2-year period. 
 
2.3.2. Study 2: A Phase II Multiple-Dose Trial, NCT00806572 
Protocol ITN007AI [NDB01]) started in June 2002 to assess the ability of the regimen to prolong the 
duration of the clinical response and to increase the number of responders (31). In study 2, the drug 
was to be administered soon after clinical diagnosis and at 6 and 12 months after diagnosis. Between 
June and August 2002, 10 patients were enrolled in study 2 (6 were randomized to the drug treatment 
group and 4 to the control group) and those assigned to the drug treatment group received one 
course of hOKT3γ1 (Ala-Ala) treatment.  Further enrollment and hOKT3γ1 (Ala-Ala) treatments were 
stopped based on adverse event findings.  Further investigation into the potential differences of the 
drug products and their preparations indicated that the absolute amount of drug that was 
administered to the six experimental patients in study 2 was greater than had been used in study 1.
Month
0
6
12
18
24
AUC (pmol/ml/240min)
0
20
40
60
80
100
120
140
160
Drug
Control


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2.3.3. ITN 017: A Phase I dosing study 
Following discontinuation of Protocol ITN007, protocol ITN017 was conducted to determine a safe 
dose to be used for studies of teplizumab in subjects with Type 1 diabetes. Six subjects were enrolled 
in this open label trial. There were no serious adverse events in the first dosing cohort of 4 subjects. 
The study was discontinued when the first subject in the higher dosing cohort developed 
hyperbilirubinemia. The current dosing regimen is based on the findings from ITN017. 
 
2.3.4.  “ABATE Trial” ITN027 NCT00129259  
This Phase II randomized open label study will test whether two courses of treatment (each for 14 
days) within 8 weeks of diagnosis and at 1 year will improve C-peptide responses 2 years after 
diagnosis. There have been 6 serious adverse events in this trial. Three of these were judged to be 
study drug related. Two of the 3 were lymphopenia that was not unexpected, and one was cytokine 
release syndrome. This study showed reduced decline in C-peptide in the drug-treated vs control 
group (p=0.001, manuscript in preparation).  
 
2.3.5.  “Delay Trial” NCT00378508 
This randomized, double blind, placebo controlled trial will test the ability of a single 14 day course of 
treatment with teplizumab to prevent the loss of C-peptide 1 year after study enrollment. The “Delay 
Trial” offers optional retreatment for all subjects who retain detectable levels of insulin production, 1 
year after study entry. The inclusion criteria for the Delay Trial differs from other studies in its 
enrollment of individuals with Type 1 diabetes of duration of 4 – 12 months. There have been two 
serious adverse events in this trial, neither of which was judged to be study drug related. The analysis 
of the primary endpoint (difference in C-peptide responses to a mixed meal test at 12 mos adjusted 
for baseline C-peptide response and duration stratum) showed significantly greater responses in the 
teplizumab treated group (p=0.03, manuscript submitted). However, because of an imbalance in 
HgbA1c levels at baseline, an additional analysis was performed correcting for the baseline HgbA1c 
level, C-peptide AUC, and duration stratum, and difference in the primary endpoint was 17.7% 
(p=0.09). Nonetheless, the drug treated group lost significantly less of the baseline C-peptide AUC 
level (20.6%) compared to placebo treated subjects (37%)(p=0.04) after correction for baseline C-
peptide AUC, baseline HgbA1c, and duration stratum, and a greater proportion of subjects lost 
detectable C-peptide in the placebo group (p=0.02). In a post-hoc analysis subjects with HgbA1c 
levels < 6.5% and younger (< age 15 yrs) subjects showed significant responses to teplizumab after 
correction for duration strata and baseline C-peptide and baseline HgbA1c levels (as a covariate in 
the analysis of age strata).  
 
2.3.6.  “Protégé Trial” NCT00385697 
This is a Phase II/III multicenter study to compare efficacy, safety, and tolerability of 3 dose levels of 
teplizumab relative to placebo, in subjects within 12 weeks of T1DM diagnosis.  Segment 1 was an 
open label study of 30 subjects which has completed enrollment.   
The results from the analysis of the primary endpoint were announced in October 2010 and published 
in 2011. The primary endpoint (a comparison of the proportion of subjects with hemoglobin 
A1C<6.5% who were using < 0.5U/kg/d of exogenous) was not met. However, a posthoc analysis of 
the effects of full dose of drug treatment showed that the C-peptide levels in the teplizumab treatment 
group were significantly greater than in placebo treated control subjects 12 months after enrollment 
(Sherry et al, 2011).  
 
 


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2.3.7. “Protégé Encore Trial” NCT00385697 
This is a Phase II/III multicenter study to compare efficacy, safety, and tolerability of 3 dose levels of 
teplizumab relative to placebo, in subjects within 12 weeks of T1DM diagnosis.  Enrollment into this 
double-masked, placebo controlled, four arm trial was ended in October 2010, prior to completing 
enrollment. A follow up study of subjects is underway. 
 
 
2.4  
Evaluations of Safety Experience with Teplizumab and the Basis for the 
Proposed Clinical Protocol 
 
Safety reviews of the use of teplizumab in patients with type 1 diabetes were carried out in 2004, 
2006, and continue on an ongoing basis by Data Safety and Monitoring Boards. These evaluations 
identified the occurrence of mild cytokine release, during the first 6 days of drug treatment, in about 
10% of subjects.  The 2006 safety  evaluation noted that study drug was discontinued in 6/60 
individuals due to adverse events characterized by laboratory abnormalities of consumptive 
coagulopathy and were thought to be due to the release of cytokines that occurred with the initial 
doses of drug.  Specifically, the signs that identified this complex included any of the following: a) 
fever (of grade 3), b) an increase in the PT and/or PTT and an increase in the level of D-dimers, c) an 
increase in the total bilirubin level, d) hypotension, and e) an increase in liver enzymes.  In each case, 
the abnormal findings began within the first 6 days of drug administration, and frequently with the first 
dose of drug. In all 6 cases, drug administration was stopped prior to administration to a complete 
course of protocol-defined treatment. The laboratory abnormalities were self-limited, did not progress, 
and completely resolved without sequelae. 
 
Based on these analyses, additional laboratory studies to evaluate the presence of cytokine release 
were recommended, and more stringent criteria for withholding drug were developed. With the 
modified criteria, all subjects who discontinued drug administration because of adverse events were 
identified by the second dose of drug. These new evaluations are incorporated into this and other 
ongoing protocols. More information is available in the Investigator’s Brochure. 
 
2.5. 
Use of Teplizumab in Children 
 
The majority of new cases of T1DM occur in children under the age of 18.  Moreover, given that the 
duration of diabetes is a significant risk factor for the development of diabetes complications and the 
clearly recognized difficulty in attaining excellent metabolic control of diabetes during adolescence (3; 
32), it is critical that children are included in studies of the prevention of type 1 diabetes.  The 
experience gained from DPT-1 and other studies demonstrates that children are more likely to have 
risk factors associated with rapid progression of the disease, suggesting a difference in the natural 
history of the disease from that in adults, and again demonstrating the need to include children in 
prevention studies. 
 
600 subjects have participated in clinical trials of teplizumab: 100 in open-label studies (all treated 
with teplizumab) and approximately 500 in randomized, blinded studies (approximately 80% treated 
with teplizumab). See Table 2 shown below which displays enrollment by age group. 
 
 
 


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Table 2:  Age Distribution of Subjects by Study in Previous and Ongoing T1DM Studies (Data 
Available as of July 2009) 
 
 
 
Open-label (Treated with Teplizumab) 
 
 
Blinded 
Open- 
Label & 
Blinded 
Age 
Range 
(years) 
Herold 
Study 
1 
ITN 007 
(NDB01) 
ITN017 
ITN027 
(Abate) 
Protégé 
Segment 1 
Total 
Delay 
Protégé 
Segment 2 
Total 
8-11 
9 
2 
2 
24 
11 
48 
7 
73 
128 
12-17 
8 
1 
4 
23 
16 
52 
9 
189 
250 
>18 
5 
3 
0 
4 
11 
23 
2 
230 
255 
Total 
22 
6 
6 
51 
38 
123 
18 
492 
633 
Notes:  Protégé is Protocol CP-MGA031-01.  The Herold studies are investigator-initiated studies.  For 
further information regarding these studies, please refer to the Investigator’s Brochure  
 
Dr. Herold and colleagues reviewed the adverse event experience of the completed trials and 
concluded that although the number of subjects was small, there was no apparent relationship of age 
to the number or severity of adverse events.   
 
In addition to the possibility of delaying or preventing the onset of T1DM, which is unproven, there are 
other prospects for direct benefit to children by their participation in the study.  These include the 
recognized benefits of being in a clinical study, and of close monitoring for development of diabetes 
which significantly prevents morbidity associated with onset of the disease in the community including 
ICU admissions.  The intervention has the prospect of direct benefit to the individual subject and in 
addition, is likely to yield general knowledge about T1DM which is of importance for the 
understanding and amelioration of T1DM in children. 
 
The study procedures, while greater than minimal risk, offers the possibility of benefit due to the close 
monitoring for all participants, including children.  Assent of children along with consent of the parents 
will be obtained prior to any study procedures.  This research proposal in children is therefore 
consistent with United States Department of Health and Human Services, Protection of Human 
Subjects, 45CFR46.405 (research involving greater than minimal risk but presenting the prospect of 
direct benefit to individual subjects) and with 21CFR50.52 (Clinical investigations involving greater 
than minimal risk but presenting the prospect of direct benefit to individual subjects). 
 
 
2.6. 
Additional information 
 
Please refer to the Teplizumab Investigator’s Brochure for further non-clinical and clinical information 
on the antibody. 


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3. STUDY DESIGN 
 
3.1. 
Overview 
 
This is a multicenter, double masked, randomized, placebo- controlled study to determine whether 
treatment of subjects at high risk for diabetes with teplizumab results in delay or prevention of clinical 
T1DM.  
3.2. 
Objectives 
 
3.2.1. Primary Objective 
 
The primary objective of the study is to determine whether treatment of at-risk subjects with 
teplizumab results in a delay or prevention of T1DM.  
 
3.2.2. Secondary Objectives 
 
• 
to determine whether treatment with teplizumab is superior to placebo with respect to C-
peptide responses to oral glucose, as obtained from timed collections during longitudinal 
tests  
• 
to compare the safety and tolerability of teplizumab to placebo  
• 
to assess the effects of treatment on mechanistic outcomes 
 
3.3. 
Summary of Inclusion/Exclusion Criteria 
 
Participants must meet all entry criteria for the protocol as outlined below. 
 
3.3.1. Inclusion Criteria:  
Study subjects must be or have: 
 
1. Participant in TrialNet Natural History Study (TN01) and thus a relative of a proband** with T1DM. 
2. Between the ages of 1-45 years at the time of enrollment in TN01 and age ≥ 8            
      at time of randomization in this trial 
3. Subject (or parent or legal guardian if the subject is a minor) is willing to provide Informed Consent. 
4. Individuals <18 years of age at time of randomization must have had a TrialNet conducted OGTT 
demonstrating abnormal glucose tolerance* within 7 weeks (52 days) of the baseline visit (visit 0). 
5. Individuals ≥18 years of age at time of randomization must have had two consecutive TrialNet 
conducted OGTT’s demonstrating abnormal glucose tolerance, the most recent of which must have 
been within 7 weeks (52 days) of the baseline visit (visit 0).   
 
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The second occasion must occur within the six months prior to study drug administration, but does 
not need to involve the same two autoantibodies as were found on the first occasion. The 
autoantibodies that are to be confirmed are anti-GAD65, anti-ICA512, anti-insulin (MIAA), ZnT8 
and/or ICA. 
7. Weigh at least 26 kg at randomization.  
8. If participant is female with reproductive potential, she must have a negative pregnancy test on Day 0 
and be willing to avoid pregnancy for at least one year from randomization.   
9. If participant is male, he must be willing to avoid pregnancy in any partners for at least one year from 
randomization. 
10. Willing and medically acceptable to postpone live vaccine immunizations for one year after treatment. 
11. Willing to forego other forms of experimental treatment during the study. 
 
 * a. Fasting plasma glucose ≥ 110mg/dL, and <126mgdL 
  or  
   b. 2 hour plasma glucose ≥140mg/dL, and <200mg/dL 
  or 
  c. 30, 60, or 90 minute value on OGTT ≥200mg/dL  
 
Fasting glucose levels of 110-125 mg/dL qualify subjects as having abnormal glucose tolerance in 
this protocol as it reflects the criteria used for entry into the DPT-1 (33) study and the DPT-1 data was 
used for the calculation of diabetes risk for this trial.  Using data for individuals with Type 2 diabetes, 
the ADA uses a different glucose range to define  impaired fasting glucose(34).  
** A proband is an individual diagnosed with diabetes before age 40 and started on insulin therapy 
within one year of diagnosis, or if subjects with probands considered to have type 1 diabetes by their 
physician who do not meet this definition, the TrialNet Eligibility Committee for the TrialNet Natural 
History/Pathway to Prevention Study (TN01) must have approved enrollment in TN01. 


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3.3.2. Exclusion Criteria: 
 Study subjects cannot be randomized if they have: 
 
1. If ≥18yo: Diabetes, or have a screening OGTT with:  
a. Fasting plasma glucose ≥126 mg/dL, or 
b. 2 hour plasma glucose ≥ 200mg/dL  
2. If <18yo: Diabetes, or have a screening random glucose ≥200mg/dL 
3. Lymphopenia (< 1000 lymphocytes/µL). 
4. Neutropenia (< 1500 PMN/µL ). 
5. Thrombocytopenia (< 150,000 platelets/µL). 
6. Anemia (Hgb < 10 grams/deciliter [g/dL]). 
7. AST or ALT >1.5 x ULN.  
8. Total bilirubin >1.5 x upper limit of normal (ULN) with the exception of subjects with the diagnosis 
of Gilbert’s syndrome who may be eligible provided they have no other causes leading to 
hyperbilirubinemia. 
9. INR > 0.1 above the upper limit of normal at the participating center’s laboratory. 
10. Chronic active infection other than localized skin infections. 
11. A positive PPD test. 
12. Vaccination with a live virus within 8 weeks of randomization 
13. Vaccination with a killed virus within 4 weeks of randomization.  
14. A history of infectious mononucleosis within the 3 months prior to enrollment. 
15. Laboratory or clinical evidence of acute infection with EBV or CMV.  
16. Serological evidence of current or past HIV, Hepatitis B or Hepatitis C infection. 
17. Be currently pregnant or lactating, or anticipate getting pregnant. 
18. Chronic use of steroids or other immunosuppressive agents. 
19. A history of asthma or atopic disease requiring chronic treatment.  
20. Untreated hypothyroidism or active Graves’ disease at randomization. 
21. Current use of non-insulin pharmaceuticals that affect glycemic control. 
22. Prior OKT®3 or other anti-CD3 treatment. 
23. Administration of a monoclonal antibody within the year before randomization.   
24. Participation in any type of therapeutic drug or vaccine clinical trial within the 12 weeks before 
randomization. 
25. Any condition that, in the opinion of the investigator, would interfere with the study conduct or the 
safety of the subject. 
 


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3.4. 
Enrollment 
Potential study subjects will be identified through the ongoing TrialNet Natural History/Pathway to 
Prevention study. In this study, first and second degree relatives of patients with T1DM are screened 
for biochemical autoantibodies and ICA. Those individuals who test positive are then further staged 
with the performance of an OGTT. The results of this OGTT performed in a TrialNet study will be 
used to determine eligibility for this protocol. 
The TrialNet Natural History/Pathway to Prevention study screens participants at over 200 clinical 
sites.  The infusion of teplizumab or placebo will occur at a limited number of designated TrialNet 
infusion sites, whereas the initial screening visit and follow-up testing, as described in the Schedule of 
Assessments, may occur at other (non-infusion)TrialNet sites.  
3.5. 
Double-Masking and Description of Treatment Groups 
 
The intervention will be conducted only amongst those who consent to participate.  Subjects will be 
randomized to receive either teplizumab or placebo.  All subjects will undergo close monitoring for the 
development of diabetes. Subjects and clinical investigators will be masked as to treatment 
assignment.  The intervention protocol will be conducted at approved TrialNet clinical sites with 
appropriate facilities. All blood and serum samples for the primary and secondary outcome 
determinations will be sent to the TrialNet Core Laboratories for analysis. Clinical laboratory studies 
that will be used for determining eligibility for study drug infusion will be performed at the local sites.  
 
Participants will be randomly assigned in a 1:1 ratio (within the two strata defined by age at 
enrollment: <18 and 18 or older) to the following 2 groups: 
 
• 
to receive teplizumab (14 day IV infusion) followed by close monitoring for 
T1DM development 
• 
to receive placebo (14 day IV infusion) followed by close monitoring for T1DM 
development 
 
 
3.6. 
Treatment Assignment 
 
After participants provide informed consent, complete the screening visit(s), and meets all of the 
inclusion criteria and none of the exclusion criteria, participants will be randomized to receive either 
teplizumab or placebo.   
 
Participants will be randomized in equal allocations to each group. The randomization method will be 
stratified by TrialNet study site and whether the participant is less than 18 years of age or 18 years 
and older. This approach ensures that study site will not be a potential confounder. The TNCC will 
generate the randomization numbers and tables. 
 


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3.6.1. Procedures for Unmasking 
 
Emergency unmasking will occur upon notification of the TrialNet Central Pharmacy and TNCC via 
the 24 hour emergency number and approval by TrialNet Chair, NIDDK TrialNet program officer, or 
TrialNet Medical Monitor. Non-emergent unmasking will occur upon notification of the TNCC and 
approval by TrialNet Chair or NIDDK TrialNet program officer. If unmasking is approved, the study 
sponsor and appropriate TrialNet committees (e.g. Safety Monitoring) will be notified of the event as 
soon as reasonably possible; however, they will not be unmasked.  
 
3.7. 
Study Assessments 
 
During the course of the study, participants will frequently undergo assessments of their glucose 
tolerance status, insulin production, immunologic status, and overall health and well-being (see 
Schedule of Assessments).   
 
Samples will be drawn for storage in the National Institute for Diabetes and Digestive and Kidney 
Disease (NIDDK) Repository and at TrialNet Laboratory Sites for future analysis.  
3.8. 
Quality Assurance 
 
During the study, duplicate collections of blood samples for assays will be obtained in a small sample 
of subjects for the purpose of external quality surveillance of the performance of the TrialNet Central 
Laboratories.  
3.9. 
Study Timeline 
 
 
3.9.1. Study Duration 
The study is designed to provide 80% statistical power to detect a 60% risk reduction with a one-
sided test at the 0.025 significance level.  This risk reduction is expected to result in a delay in the 
median time to onset of diabetes of 7.52, 8.93, and 10.6 yrs. for the age cohorts < 18 and ≥18 within 
strata 1, 2, and 3, respectively.  To attain these design parameters will require the observation of 40 
participants that are diagnosed on-study with T1DM.  Consequently, the total sample size and study 
duration can only be approximated.  The study plans to enroll approximately 71 subjects over 
approximately 6 years, and is projected to last between 6 and 10 years.  As the study progresses, 
projections of the study end will be computed and updated based on the rate of enrollment, the 
observed hazard rate and the rate of loss-to-follow-up.   


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3.9.2. Follow-up Studies 
Although subjects who develop diabetes will have reached the study endpoint, these individuals will 
be offered annual follow up for a minimum of two years  Those individuals who have not developed 
diabetes by study end will continued to be followed as part of the TrialNet Natural History/Pathway to 
Prevention study protocol.   
 
Individuals who develop T1DM may be eligible for interventional studies sponsored by TrialNet or 
other organizations under separate INDs. In the event that a subject wishes to participate in another 
investigational study that has, as an exclusion, treatment with experimental or immune modulatory 
drugs, the subject may request and be told of their treatment group assignment for the anti-CD3 
prevention study.  Every attempt will be made to minimize potential bias that this may introduce.  The 
TNCC will make treatment assignment information available to the site investigator of the new study 
after the subject is determined to be willing to participate and not otherwise excluded from the new 
study. Other study group members will not be informed of the treatment assignment information.  
Mitigation of bias issues must be balanced against safety and interests of participants.  
 


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4. PATIENT MANAGEMENT 
 
4.1. 
Screening Visit and Eligibility Assessment 
 
This study will draw participants from the TrialNet Natural History/Pathway to Prevention Study.   
 
The initial testing for autoantibodies, HLA type, and Oral Glucose Tolerance Test (OGTT) will be done 
as part of Natural History/Pathway to Prevention.  Those individuals with two confirmed diabetes-
related autoantibodies and abnormal glucose tolerance on the OGTT, will then be eligible for 
additional tests and possible enrollment into this study. 
 
Appendices 1 and 2 summarize the flow of subjects from the Natural History/Pathway to Prevention 
Study into this study. 
 
4.2. 
Anti-CD3 mAb Trial for At-risk Subjects Initial Visit 
 
Prior to the initial visit, this study will be described to the potential participant.  The 
participant/parent/guardian will be asked to sign an informed consent document describing the 
purpose, risks, and benefits of screening for the trial.  A participant’s signature indicates that he/she 
understands the potential risks and benefits of study participation. Subjects less than age 18, qualify 
for the study with a single OGTT with abnormal glucose tolerance. Those age 18 or older, require two 
consecutive OGTTs with abnormal glucose tolerance. Qualifying OGTTs may occur under the 
auspice of another TrialNet study or as a part of this visit if needed. During these visits, other clinical 
tests will also be performed to determine eligibility.  
 
Any participant either not eligible or not willing to be randomized into this study is eligible for 
continued follow-up as part of the TrialNet Natural History/Pathway to Prevention Study.   
 
4.3. 
Randomization and Baseline Visits 
 
Review will be made to be certain the subject meets study eligibility criteria.  Prior to randomization, 
the intervention and follow-up phases of the study will be described to the participant.  The 
participant/parent/guardian will be asked to sign an informed consent document indicating that he/she 
understands the study as well as the potential risks and benefits of study participation.   
 
Participants will be randomized to either the treatment arm or the control arm.  The randomization 
and the baseline visit must occur within 7 weeks of the qualifying OGTT in order to ensure that 
participants have abnormal glucose tolerance at time of randomization and study drug administration.  
Note, subjects who are febrile at the time of baseline visit, may have the visit postponed up to five 
days outside the 7 week window if needed because of intercurrent illness. At or prior to the baseline 
visit (visit 0), subjects < age 18 will undergo an OGTT. 
 
 
4.4. 
Close Monitoring 
 
During the study period, all participants will receive close monitoring for development of diabetes.  
OGTT tests will be performed at 3 and 6 months and every 6 months thereafter.  In addition, at three 


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month intervals (where there is no OGTT scheduled), a random (non-fasting) glucose level will be 
measured. At each visit and via routine contact in between visits, participants will be asked directed 
questions about the presence or absence of symptoms associated with diabetes such as blurry 
vision, unintended weight loss of more than 3 kg, polyuria, and polydypsia.  If subjects respond 
affirmatively to any of these questions or if any of the post-prandial glucose values are greater than 
200 mg/dL, further evaluation, including fasting glucose or an OGTT, will be performed.  Individuals in 
both of the study arms will have laboratory and mechanistic studies performed as detailed in the 
Schedule of Assessments. 
 
4.5. 
Administration of Teplizumab 
 
4.5.1. Drug Administration 
 
Teplizumab or saline will be administered via IV infusion over 14 days.  The 14 day course must 
commence within 7 weeks of the qualifying OGTT, except in the case of interim illness as noted 
above (Section 4.3).   
 
Subjects will be randomized to 1 of 2 treatment arms and will receive a 14-day course of 
teplizumab and/or placebo. The treatment course will be administered on Study Days 0–13. The 2 
treatment arms are described below. 
 
• 
Arm #1: Subjects will receive a 14-day course of teplizumab consisting of daily IV doses 
of 51 micrograms/meter squared (µg/m2), 103 µg/m2, 207 µg/m2, and 413 µg/m2 on Study 
Days 0–3, respectively, and one dose of 826 µg/m2 on each of Study Days 4–13. The total 
dose for a 14-day course is approximately 9034 µg/m2. For subjects weighing 70 kg and 
having a body surface area (BSA) of 1.92 m2, this dosing schedule delivers ~18 milligrams 
(mg) of teplizumab.  
• 
Arm #2: Subjects will receive a 14-day course of IV placebo only. 
 
The subject’s BSA will be calculated by the pharmacist using the Mosteller formula. The BSA will 
be calculated on Study Day 0, and will be based on the subject’s height and weight on that day. 
This calculation will be used for dosing over the entire 14 days. For dosing purposes the 
participant’s BSA should be rounded up to the nearest tenth place regardless of the number in the 
hundredth position. For example, if the BSA is 1.61, it will be rounded up to 1.7 and if the BSA is 
1.67, it will also be rounded up to 1.7. The dose should be rounded to the nearest whole number.  
For example if the participant’s BSA is 1.722, on Day 0 the participant would receive 92μg. 
 
 
The Mosteller formula 
BSA (m²) = ( [Height(cm) x Weight(kg) ]/ 3600 )½ 
 
 
Teplizumab or saline is administered via an IV infusion over a minimum of 30 minutes in the 
research or hospital setting. This infusion should be given at the same time each day +/- 4 hours. 
Vital signs will be monitored for 2 hours after each infusion. Subjects are permitted to leave the 
research or hospital setting each day upon completion of the 2 hours of post-infusion monitoring if 
they remain within approximately one hour (driving time) of the treatment center.  


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The formulation of teplizumab will consist of: 
• 
10 mM sodium phosphate 
• 
150 mM sodium chloride 
• 
0.05 mg/mL Tween 80 
• 
pH 6.1  
 
Final drug product will be provided at a concentration of 1 mg/mL for a total of 2 mg of recoverable 
drug product per vial. 
 
The vials should be stored upright at 2°–8° C and must not be frozen.  Because there is no 
preservative and drug loss occurs over time, administration of study drug should begin as soon as 
possible and no later than 2 hours after preparation.  The infusion must be complete within 6 hours of 
preparation.  The drug may be prepared into a bag for infusion or into a syringe for delivery by 
infusion pump. Intravenous drug delivery devices, including IV bags and tubing, must be composed of 
PVC.  
 
Laboratory studies that will be obtained prior to each dose are described in the Schedule of 
Assessments. The results of chemistries including liver function tests, WBC, Hgb, Hct, platelets, and 
INRs must be reviewed each day they are drawn prior to commencement of the drug infusion.    
 
4.5.2. Drug Withholding in an Individual Subject During the 14 Day Treatment Period 
Chemistries, liver function studies, CBC and differentials, and INR studies will be evaluated before 
drug is administered on each day that these studies are drawn as described in the attached Schedule 
of Assessments. 
 
The following situations, laboratory abnormalities, or adverse events will lead to withholding of drug 
treatment during the treatment course: (Note: Day 0 is the first day of infusion) 
 
1. Withdrawal of consent 
2. Pregnancy for a female subject 
3. Anaphylaxis requiring hemodynamic support (i.e., epinephrine and/or blood pressure 
medications) or mechanical ventilation. 
4. Hepatic abnormalities*:   
a. Defined as total bilirubin >1.3 mg/dL on Day 1, ≥2.0 mg/dL on other days. 
i. The exception will be for subjects diagnosed prior to randomization with 
Gilbert’s syndrome. These subjects will be monitored with GGT levels. They 
may receive drug if the total bilirubin exceeds these levels provided the GGT is 
≤ 3 times the ULN. Otherwise, drug will be withheld. 
b. AST level >2 times ULN on Day 1.  AST, ALT or LDH ≥3.0 times ULN on other days 
5. Thrombocytopenia*:  Defined as a platelet count < 140,000 on Day 1 and < 100,000 on other 
days.   
6. Neutropenia*:  Defined as <1000 cells/mm3 (grade 3). 
7. Anemia*:  Defined as hemoglobin ≤ 8.5 g/dL or a drop in ≥2g/dL compared with prior to 
infusion to a value < 10.0 g/dL. 
8. Coagulopathy*:  INR > 0.1 above the upper limit of normal at the laboratory.   
9. Fever:  Grade 3 pyrexia on Day 0 or 1. 
10. Other adverse events:  Defined as a grade 3 or higher adverse event, regardless of 
relatedness to study drug, except for: lymphopenia, hypoglycemia, hyperglycemia, 


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fatigue/malaise, insomnia, cheilitis, dry skin, nail changes, hot flushes/flashes, headache, 
myalgia, flu-like symptoms.   
11. Any medically important event such as a concurrent illness, complications or abnormal 
laboratory test result that, in the opinion of the investigator, contraindicates continued dosing 
of study drug. 
A laboratory test result meeting any of the above abnormalities noted by (*) should be confirmed on 
the same day as the initial test. Drug dosing will not occur while awaiting confirmation of the 
laboratory abnormality. If laboratory abnormalities are confirmed, or if any of the other situations listed 
above occur, the drug infusions will be discontinued in that participant and the procedures listed 
below will be followed. The drug infusions may not be resumed.  Depending on the severity of the 
event, further reporting may be required as outlined below. 
If the laboratory test is not confirmed when tested on the same day, drug dosing may be continued at 
the discretion of the site investigator. 
 
The Study Chair, TNCC, and Medical Monitor will be notified within 24 hours of any subject who is 
discontinued from study drug dosing.  Participants who are discontinued from teplizumab dosing will 
continue to receive follow-up care and evaluation as scheduled. 
 
4.5.3. Further Evaluation after Withholding Infusions 
 
The following are minimal assessments to be performed for those participants in whom an infusion is 
withheld (as described above): 
 
1. LIVER TESTS:  Total and direct bilirubin, AST, ALT, alkaline phosphatase the day the adverse 
event occurs and followed with frequent laboratory studies in order to establish the day that the 
event resolves. Additional studies may include an abdominal ultrasound to assess liver status and 
GI consult when necessary.  If GGT, AST or ALT is > 3 x ULN and bilirubin >2 x ULN, evaluation 
should be done to determine if there is a cause other than study drug for these abnormalities 
(e.g., acute viral hepatitis, alcoholic and autoimmune hepatitis, biliary tract disorders, 
cardiovascular causes such as right heart failure or concomitant medications). 
2. HEMATOLOGIC TESTS:  CBC, differential, INR, D-dimer, and fibrinogen the day the adverse event 
occurs. The peripheral blood smear will be studied for evidence of RBC fragmentation.  The CBC 
and differential and INR, will be frequently repeated in order to establish the day that the event 
resolves.   
3. DRUG LEVELS:  Teplizumab levels  
4. ADDITIONAL SAMPLES:  Serum samples for storage and potential future analysis. 
 
4.6. 
Interruption of Enrollment/Trial Cessation 
 
Sections 4.5.2 and 4.5.3 describe monitoring and procedures for withholding drug treatment in 
individual patients.  This section lists clinical and laboratory adverse events that will necessitate 
interruption of enrollment in the trial as a whole.  As part of their ongoing safety review, the DSMB will 
make independent judgments regarding other adverse events requiring trial interruption.   
 
1. Any drug related death* 


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2. Occurrence of anaphylaxis during study treatment in any participant.  Anaphylaxis is 
defined in this protocol as a requirement of hemodynamic support or mechanical 
ventilation.  
3. Stopping of drug infusions for criteria listed in section 4.5.2 in more than 2 of the first 10 
enrolled subjects or in more than 20% of the total number of  teplizumab treated subjects. 
4. Grade 3 cytokine release syndrome (according to CTCAE criteria) at any time in more 
than 2 of the first 10 or more than 20% of the total number of teplizumab treated subjects. 
5. The occurrence of ALT or AST ≥3x ULN and bilirubin >2x ULN at any time in any one 
subject, with the exception of those who have been diagnosed with Gilbert’s syndrome 
prior to randomization and have met the criteria listed in section 4.5.2 for this occurrence.   
6. Grade 3 hypotension at any time in more than 2 of the first 10 or more than 20% of the 
total number of teplizumab treated subjects. 
7. Grade 3 thrombocytopenia at any time in more than 2 of the first 10 or more than 20% of 
the total number of teplizumab treated subjects. 
8. Clinical mononucleosis syndrome which may include: Grade 2 or above fever, pharyngitis, 
lymphoadenopathy, splenomegaly, or rash, with detectable EBV viral load more than one 
week after the last dose of drug in any 3 of the first 10 or more than 25% of the total 
number of teplizumab  treated subjects. 
9. Severe adverse event: defined by CTCAE criteria of grade 3 or greater in any 2 of the first 
3 patients or 3 of the first 7 drug treated patients at any time with the exception of Grade 3  
lymphopenia within the first 30 days of drug treatment . In addition, severe adverse event 
of grade 3 or greater in more than 20% of the total number of teplizumab treated subjects. 
10. Failure of the absolute number of lymphocytes to recover to 80% of the pretreatment level 
2 months after the final dose of drug in 2 of the first 10 or 20% of the total number of 
teplizumab treated subjects. 
 
In the event that these criteria are met, study enrollment will be suspended and the Institutional 
Review Boards/Ethics Committees/Research Ethics Board (IRB/EC/REB), and FDA and other 
applicable regulatory authorities will be notified that enrollment has been interrupted in order to 
perform a safety review of the enrolled subjects. The safety review will include a comprehensive 
evaluation of the safety experience from this trial as well as data from other ongoing studies with 
teplizumab in other disease settings. Before enrollment will resume, a satisfactory report of the safety 
review will be provided to the FDA, other applicable regulatory authorities, Institutional Review 
Boards/Ethics Committees/Research Ethics Boards (IRB/EC/REB), and the DSMB. 
 
*During this trial, any death event will be temporarily considered unexpected and potentially drug-
related until the event is adjudicated by the DSMB. In this event, the trial will be interrupted, including 
dosing of subjects already enrolled and enrollment of new subjects, until the death event is 
adjudicated by the DSMB and deemed “unlikely to be related to study drug.” 


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4.7. 
Prophylactic Medications 
 
Ibuprofen and antihistamine will be administered prophylactically prior to teplizumab/placebo infusion 
on the first 5 days of treatment.  Further dosing of Ibuprofen, antihistamines, and/or acetaminophen 
can be used as needed for fever, malaise, headache, arthralgia, or rash. 
 


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5. STUDY VISIT ASSESSMENTS 
 
The schedule of evaluations and laboratory studies is presented in Appendix 3, Schedule of 
Assessments.  A summary of assessments for the Protocol is given below. 
 
5.1. 
General Assessments 
 
General assessments for this Protocol will include: 
 
• 
Informed consent 
• 
Inclusion/exclusion criteria 
• 
Medical history including lifestyle and participant experience assessment     
• 
Physical examination including height/weight, abdominal circumference 
• 
Concomitant medications 
• 
Adverse events 
 
5.2. 
Laboratory Assessments 
 
The following clinical laboratory assessments will be performed during the study as described in the 
Schedule of Assessments (SOA): 
• 
Chemistry (sodium, potassium, chloride, CO2, glucose, BUN, creatinine) 
• 
Liver function tests (ALT, AST, LDH, alkaline phosphatase, total protein, albumin, total and 
direct bilirubin). Prior to each infusion, GGT will be run locally in subjects with Gilbert’s 
syndrome. 
• 
Hematology (complete blood count with differential and platelets) 
• 
INR 
• 
Purified protein derivative (PPD) test 
• 
Urine pregnancy test 
• 
Antibodies to HIV, hepatitis B (antiHBcAb, HBsAg), hepatitis C (HCV) 
• 
Cytomegalovirus antibodies (CMV IgG and IgM) and viral load  
• 
Epstein-Barr virus antibodies (EBV IgG, IgM and EBNA) and viral load as indicated 
• 
Samples for virology and other immunization titers 
• 
ECG 
 
5.3. 
Mechanistic Outcome Assessments 
 
TrialNet will perform immune and genetic assays to further understand mechanisms that may be 
underlying the type 1 diabetes disease process and response to therapy.  For this purpose, samples 
for PBMC, DNA, RNA, plasma, and serum will be obtained.  HLA testing may be done either under 
the auspices of TrialNet Natural History/Pathway to Prevention or this protocol. 


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5.4. 
Metabolic Outcome Assessments 
Metabolic assessments will consist of: 
 
1. OGTT 
o Primary study outcome - Glucose tolerance status. The diagnostic criteria for diabetes 
from the 2003 Report of the Expert Committee on the diagnosis and classification of 
diabetes will be used (34). This study will be performed every 6 months or more frequently 
if clinically indicated based on a random glucose level of > 200 mg/dL.  
o The C-peptide and insulin data from the OGTT will be used to measure insulin secretion. 
o The insulin, glucose and C-peptide data from the OGTT will be used to measure insulin 
sensitivity. 
 
2. HbA1c   
o Measure of glycemic control. 
 
5.5. 
Laboratory Measures Related to Teplizumab Administration 
 
Laboratory tests to measure drug level and immune response to the drug: 
• 
Trough drug levels of teplizumab will be measured during the last 4 days of mAb 
administration in 12 subjects of each of the age strata: ≥ 16 yrs, 12-15 yrs, and 8-11 yrs. 
• 
Antibodies against teplizumab will be measured at month 3 in 12 subjects from each age 
strata: ≥ 16 yrs, 12-15 yrs, and 8-11 yrs.  
 
5.6. 
Visit Windows 
 
The baseline visit must occur within 7 weeks after  qualifying OGTT (with the exception that 
individuals who are febrile at the time of the scheduled baseline visit, may have up to an additional 5 
days).  Visit 14 must be +/- 2 days.  Visit 15 is to be +/- 4 days.  All other visits described in the 
Schedule of Assessments can be ± 3 weeks. 
 


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6.  ADVERSE EVENT REPORTING AND SAFETY MONITORING 
 
6.1. 
Adverse Event Definition 
 
6.1.1. Adverse Event 
 
In this clinical trial, an adverse event is any occurrence or worsening of an undesirable or unintended 
sign, symptom or disease whether or not associated with the treatment and study procedures.   
 
Throughout the study, the investigator must record all adverse events on source documents.  Events 
not related to diabetes onset, hypoglycemia, or hyperglycemia which are Grade 2 or greater per the 
NCI CTCAE (see Section 6.1.4. Grading Event Severity below) must be reported to TNCC.  The 
investigator should treat participants with adverse events appropriately and observe them at suitable 
intervals until the events resolve or stabilize. 
 
Adverse events may be discovered through: 
• observation of the participant; 
• questioning the participant; 
• unsolicited complaint by the participant 
Questioning of the participant should be conducted in an objective manner. 
6.1.2. Serious Adverse Event 
 
A serious adverse event (SAE) or reaction is defined as “any adverse event occurring at any dose 
that suggests a significant hazard, contraindication, side effect, or precaution.”  This includes but is 
not limited to any of the following events: 
1. Death.  A death that occurs during the study or that comes to the attention of the 
investigator during the protocol-defined follow-up after the completion of therapy must be 
reported whether it is considered to be treatment related or not. 
2. A life-threatening event.  A life-threatening event is any adverse therapy experience that, 
in the view of the investigator, places the participant at immediate risk of death from the 
reaction as it occurred. 
3. Inpatient hospitalization or prolongation of existing hospitalization. 
4. Persistent or significant disability. 
5. An event that required intervention to prevent permanent impairment or damage.  An 
important medical event that may not result in death, be life threatening, or require 
hospitalization may be considered an SAE when, based on appropriate medical 
judgment, it may jeopardize the participant and may require medical or surgical 
intervention to prevent one of the outcomes listed above. 
6. Congenital anomaly or birth defect. 
7. Grade 4 or higher lymphopenia for 7 or more days occurring in the first 30 days after the 
start of the teplizumab/placebo infusion. 
8. Grade 3 or higher lymphopenia occurring anytime later than the first 30 days after the 
start of the teplizumab/placebo infusion. 


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Regardless of the relationship of the adverse event to study drug, the event must be reported as a 
serious adverse event if it meets any of the above definitions. 
 
6.1.3. Unexpected Adverse Event 
 
An adverse event is considered unexpected when the nature (specificity) or severity of the event is 
not consistent with the risks described in the Investigator’s Brochure or the informed consent 
document. 
 
6.1.4. Grading Event Severity and Causality 
 
TrialNet has adopted usage of the National Cancer Institute (NCI) Common Technology Criteria for 
Adverse Events (CTCAE) and/or study-specific criteria for classification to describe the severity of 
adverse events.  Hypoglycemia and hyperglycemia will be reported as adverse events only in the 
case of requiring the assistance of others due to loss of consciousness or DKA. TN Investigators will 
also provide an assessment of relationship of AE to study drug as not, unlikely, possibly, probably, or 
definitely related.  
 
6.2. 
Adverse Event Reporting and Monitoring 
 
Adverse events will be reported to the TrialNet Coordinating Center.  The investigator will grade their 
severity according to common toxicity criteria or study-specific criteria and will make a determination 
of their relation to therapy.  Events will be assessed and reported consistent with the ICH Guideline 
for Good Clinical Practice and per the guidance of the DHHS Office for Human Research Protections 
(OHRP).   
 
The adverse event case report form for the protocol must be completed for all reportable adverse 
events (AE).  For reporting serious adverse events (SAE), the TrialNet MedWatch Form should also 
be completed and faxed to the TNCC within 24 hours of when the site was notified of the event.  This 
will be reviewed by the TrialNet Medical Monitor, the TrialNet Safety Committee, and the DSMB as 
appropriate.  Deaths must be reported immediately.  Event outcome and other follow-up information 
regarding the treatment and resolution of the event will be obtained and reported when available, if 
not known at the time the event is initially reported.  The follow-up information should contain 
sufficient detail to allow for a complete medical assessment of the case and an independent 
determination of possible causality.  
 
Adverse events will be assessed by the TrialNet Medical Monitor.  The DSMB will conduct regular 
safety reviews approximately every three to six months (and otherwise as needed) of adverse events 
by treatment group assignment.  Serious adverse events as well as adverse events leading to study 
discontinuation will be reviewed by the DSMB. All adverse events will also be reported to 
MacroGenics by the TNCC. 
 


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7. PARTICIPANT SAFETY 
 
7.1. 
Protecting Against or Minimizing Potential Treatment Risks 
 
Subjects will not be enrolled who have other active serious medical problems. Frequent monitoring of 
patients with history, physical examination, and laboratory studies will allow for early identification of 
adverse events.  All participants will be required to have adequate hemoglobin to allow safe frequent 
venipuncture.  Every attempt will be made to minimize the number of venipunctures. 
 
All infusions will take place in a facility that has resuscitation capabilities. 
 
Participants will be counseled by study personnel and requested to avoid pregnancy for 1 year 
following drug administration for safety purposes.  This applies to females on study and female sexual 
partners of males. 
 
7.1.1. Prohibited Medications  
 
Participants will be instructed not to use Prednisone, other immunosuppressive agents, or chronic 
inhaled or nasal corticosteroids during this trial in order to reduce infectious risks and to prevent 
possible impact on progression to diabetes.  However, as an intention to treat study, no individual will 
be withdrawn from analysis if this occurs. 
Participants who receive teplizumab/placebo will be instructed not to receive live vaccinations for 1 
year after dosing.  In addition, participants should not receive vaccination with a killed virus vaccine 
less than 4 weeks after treatment with study drug unless approved by the study chair or the study ID 
team. 
 
7.2. 
Expected Side Effects and Adverse Events 
 
A full description of the adverse events experienced by subjects in trials using teplizumab is in the 
Investigator’s Brochure.  The descriptions below highlight the most common drug related events and 
potential adverse events. 
 
7.2.1. Hematologic 
The drug causes a reduction in the number of circulating lymphocytes. Grade 3 or higher 
lymphopenia has been seen during drug administration in 15% of subjects. However, in more than 
85% of individuals, circulating lymphocytes return to ≥80% of baseline values by 2 months after 
initiation of treatment.  A single SAE (i.e., prolonged CD4 cytopenia) has occurred in a subject who 
was given 2 times the proposed dose of drug.  This subject did not develop infections and the CD4 
cytopenia resolved spontaneously after two years.   
Neutropenia, eosinophilia, and thrombocytopenia have also been seen during drug administration. 
Overall these adverse events have occurred in < 5% of subjects but have been up to grade 3 in < 2% 
of individuals. They have resolved spontaneously or with withholding of drug in all cases. This risk will 
be mitigated by having platelet and neutrophil count reviewed before administration of 


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teplizumab/placebo as indicated in the SOE. No specific therapy for the eosinophila is planned. 
Specific treatment stopping rules are described in Section 4.5.2.  
 
Mild anemia has been seen in 21.9% of subjects. This risk will be mitigated by having the hemoglobin 
reviewed before administration of teplizumab/placebo as indicated in the SOA.   
 
7.2.2. Cytokine Release Syndrome 
Cytokine release syndrome (CRS) has been described in 5.7% of drug treated subjects – the 
syndrome was mild or moderate in 5/6 reported subjects. Compared to FcR binding anti-CD3 
antibodies like OKT3, the CRS that has occurred with Teplizumab is reduced in frequency and 
severity. The clinical experience to date suggests that the occurrence of CRS may be seen with the 
initial doses of the drug and is dose related. The single reported case of moderate disseminated 
intravascular coagulation was related to the occurrence of cytokine release syndrome.  In a previous 
phase II trial  (using a drug dose that is 2 times higher than the proposed dose), symptoms of CRS—
including headache, nausea, vomiting, fever, myalgias, arthralgias, and shaking—occurred over the 
first 3 days of drug treatment, but subsequently resolved.   The potential for occurrence of cytokine 
release syndrome has led to the drug withholding rules listed in Section 4.5.2.  
Manifestations of CRS have also included hyperbilirubinemia and increased liver function tests. In the 
PK/safety trial (ITN017AI), a grade 4 direct hyperbilirubinemia, which may have been a manifestation 
of a cytokine release syndrome, was observed.   
Transient increases in the alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) 
up to 5 times normal (grades 1 and 2) levels have been seen in all trials.  These abnormalities have 
been transient.  Grade 1 hypoalbuminemia has been seen in patients receiving the anti-CD3 mAb 
with other immunosuppressive agents for prevention of transplant rejection. 
This risk will be mitigated by having INR and liver function tests, including bilirubin, reviewed before 
administration of teplizumab/placebo as described in the SOE and the specific drug withholding rules 
listed in Section 4.5.2.  
 
7.2.3. Lymphoproliferative Disease 
Although not raised as an issue in the single-dose studies of hOKT3γ1 (Ala-Ala), immunosuppression 
of any sort may predispose participants to additional risks such as infection or lymphoproliferative 
disease.  On a theoretical basis, this risk is minimal since the total duration of immunosuppression is 
short.  Clinical experience in transplant recipients, treated with other biologic agents, suggests that 
the risk of lymphoproliferative disease is highest in participants who develop infections with EBV 
around the time of immunosuppression.  Nonetheless, the lymphoproliferative syndrome associated 
with reactivation of EBV infection that was seen in an islet transplant patient treated with teplizumab 
and other immunosuppressive drugs occurred in a subject who was EBV IgG+ before study entry.  
Therefore, a careful history will be taken regarding development of mononucleosis-like illnesses 
during the period preceding and after study enrollment. Subjects will be screened for CMV viral load.  
Subjects will be screened for EBV infection with serology (VCA IgG, VCA IgM, and EBNA) and EBV 
viral loads as indicated.  The finding of a positive viral load will preclude enrollment for at least 90 
days after the viral load becomes undetectable.  In this situation, the subject will need to repeat 
OGTT assessments to ensure continued eligibility for the trial.  Samples for EBV and CMV viral will 
be obtained after drug treatment as described in the SOE.  These will be routinely measured in 
symptomatic subjects.  This aggressive monitoring scheme will allow us to determine whether 
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7.2.4. Anti-idiotype Responses 
Anti-idiotype antibodies have been detected in up to 50% of patients administered teplizumab.  The 
presence of these antibodies may diminish efficacy of future cycles of study drug and/or lead to 
manifestations of antigen-antibody complexes such as serum-sickness illness or hypersensitivity 
reactions. The titer of these anti-idiotype antibodies has been < 1:1000 and patients with anti-idiotype 
antibodies have been retreated with Teplizumab without adverse effects or detectable changes in the 
efficacy of the drug.  To date, no adverse effects have been reported as a result of these antibodies.   
 
7.2.5. Infection 
As with any therapy that suppresses the immune system, there is a risk of developing infections.  On 
a theoretical basis, this risk is minimal, as the total duration of immunosuppression is short.  Overall, 
in open labeled trials with teplizumab, 49.5% of subjects have experienced infections of any kind. Of 
these, 48.6% were classified as mild or moderate. There have been two cases of TB reported in 
Protégé trial participants in India and Ukraine respectively. However, trial remains blinded so 
relatedness is not known at this time. 
An increase in herpes virus infections has occurred with teplizumab administration. Specifically, up to 
10% of subjects have had a transient increase in EBV viral load, but this was not necessarily 
associated with an increase in mononucleosis like syndrome. There have been case reports of 
herpes zoster in the Protégé study. Some occurred during dosing and others were over 270 days 
after commencing dosing. All subjects recovered and none of the cases were serious.  
 
This risk will be mitigated by having subjects report even mild illness between study visits.  They will 
be specifically asked about infectious adverse events during the study visit, and they will be 
monitored regularly for infections and appropriate anti-infective therapy will be instituted if indicated. 
Consultation with TrialNet infectious disease team will be available. All infectious adverse events will 
be reviewed by the TrialNet ID team, Medical Monitor and DSMB if serious. 
 
7.2.6. Rash 
Rash has been seen in 42-62% of subjects treated with drug.  The rashes that have been observed 
include a macular rash on the face, neck, and trunk, as well as a maculopapular rash on the 
extremities.  The latter rash has occurred on the hands and feet and has resolved spontaneously but 
with peeling of the skin.  Biopsies of the rash performed in two subjects showed histologic findings of 
spongiosis consistent with eczematous dermatitis.  A severe rash occurred in one subject, receiving 
hOKT3γ1(Ala-Ala) for prevention of islet allograft rejection on the 3rd day of drug administration. It 
was classified as severe and the patient was hospitalized.  A biopsy of the rash showed a moderate 
mixed perivascular dermal infiltrate consistent with a drug reaction.  Supportive care was given, the 
drug dosage was reduced, and the rash resolved. 
 
7.3 Pregnancy 
 
Pregnant and lactating women will not be included in the study. Females must have a negative 
pregnancy test prior to enrolling in the study and will be required to use a reliable and effective form 
of birth control during the study. Male participants will also be required to prevent pregnancy in their 
partners.  At every study visit the sexual activity of participants of reproductive age will be re-
assessed.  If a subject who was previously sexually inactive becomes sexually active, s/he will be 
counseled about the need to use a reliable and effective form of birth control.  Female subjects of 


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childbearing potential will also be required to undergo urine pregnancy tests at regular intervals 
including prior to teplizumab/placebo administration. A positive pregnancy test will result in holding of 
scheduled drug infusion. 
 
All pregnancies that are identified during the study must be followed to conclusion and the outcome of 
each must be reported.  The investigator should be informed immediately of any pregnancy whether 
occurring in a female participant or the female partner of a male participant.  The investigator should 
report all pregnancies to TrialNet within the same timeframe (24 hours) as SAEs, using the SAE 
report form.  Monitoring of the participant should continue until the conclusion of the pregnancy, and a 
follow-up SAE report form detailing the outcome of the pregnancy should be submitted to TrialNet. 


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8.    STATISTICAL CONSIDERATIONS AND ANALYSIS PLAN 
 
Analyses of study data will be conducted to address all objectives of the trial and other 
interrelationships among data elements of interest to the investigators and of relevance to the 
objectives of the study.  Analyses by gender and race/ethnicity, as appropriate, are also planned.    
Primary analysis of treatment effect will be conducted under the intention-to-treat principle whereby 
outcome data from all subjects randomized will be included regardless of treatment compliance.  
8.1 
Primary Outcome 
 
The primary outcome is the elapsed time from random treatment assignment to the development of 
diabetes or time of last contact among those randomized.  
Criteria for diabetes onset (T1DM) are, based on glucose testing, or the presence of unequivocal 
hyperglycemia with acute metabolic decompensation (diabetic ketoacidosis).  One of the following 
criteria must be met on two occasions as soon as possible but no less than one day apart for 
diabetes to be defined:  
1. 
Symptoms of diabetes plus casual plasma glucose concentration > 200 mg/dL (11.1 
mmol/l). Casual is defined as any time of day without regard to time since last meal. 
The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight 
loss.  
 
2. 
Fasting plasma glucose ≥ 126 mg/dL (7 mmol/l).  Fasting is defined as no caloric 
intake for at least 8 hours. 
 
3. 
2 hour plasma glucose ≥ 200 mg/dL (11.1 mmol/l). The test should be performed using 
a glucose load containing the equivalent of 1.75g/kg body weight to a maximum of 75 
g anhydrous glucose dissolved in water.  
 
It is preferred that at least one of the two testing occasions involve an OGTT.   
Cases identified will be confirmed as having diabetes if the glucose values to make these 
determinations were obtained in a TrialNet laboratory as part of an OGTT.   Cases diagnosed with 
diabetes by symptoms and casual glucose >200mg/dL or by other criteria than the above will be 
adjudicated by the TrialNet Diabetes Adjudication committee. 
8.2  
Primary Analysis 
 
The study design is a randomized double-blind placebo controlled trial.  The primary objective of the 
TrialNet Anti-CD3 Trial is to assess the effect of teplizumab versus control on the risk of diabetes 
onset in the target population as defined by the eligibility criteria.    
The cumulative incidence of diabetes onset over time since randomization within each treatment 
group will be estimated using the Kaplan-Meier method (proportion surviving diabetes-free as a 
function of time).  The difference between groups in the cumulative incidence functions, and the 


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associated hazard functions, will be tested at the 0.025 level, one-sided, using the Cox Proportional 
Hazards (PH) model, stratified by age and the OGTT status (confirmed abnormal or not) at prior to 
randomization (35, 36).  The estimates of cumulative incidence of diabetes and the test will be 
adjusted for age at enrollment.  The relative risk of diabetes onset between groups will be estimated 
from the PH model.  The critical values will be determined by the group-sequential procedure outlined 
in the section entitled Interim Monitoring Plan below.  
 
8.3  
Secondary Outcomes and Analyses  
 
A variety of secondary analyses are planned, some of which will include the following. 
 
1. 
Subgroup analyses will be conducted comparing the effects of teplizumab versus control on 
the risk of diabetes within subsets of the study cohort. Subgroups of the population will be classified 
by age (stratum) gender, race/ethnicity, specific antibody status at baseline, and presence or absence 
of HLA DQB1*0602. Differences in the treatment effect between subgroups will be tested using a 
covariate by treatment group interaction term in a PH model.  
 
Similar analyses will be conducted using the values of quantitative baseline factors including 
weight, BMI, and the immunologic and metabolic factors described in Section 5 that include the 
autoantibody titers, basal C-peptide, OGTT stimulated C-peptide (peak and AUC mean), and 
measures of insulin resistance modeled from the OGTT. The treatment effect within the quantitative 
levels of each factor will be assessed through a covariate by treatment group interaction in a PH 
model. Such an analysis will also be conducted to assess the effects of age as quantitative covariate.  
 
Additional covariates may be defined during the conduct of the study. The reporting of the 
analyses will distinguish between factors specified prior to primary analysis and those identified post-
hoc during analysis.  
2. 
Longitudinal analyses will assess the effects of teplizumab versus control treatment on 
immunologic and metabolic markers over time up to the onset of diabetes. Differences between 
groups in the mean levels of quantitative factors over time will be assessed using a normal errors 
linear model for repeated measures. Differences between groups in the prevalence of qualitative 
factors over time will be assessed using generalized estimating equations for categorical measures. 
Generalized estimating equations may also be employed for the analysis of quantitative factors when 
the normal errors assumptions are violated (37).   
 
 
Once a subject develops diabetes, the subject will have reached the primary outcome of the 
study. However, the subject may still be followed for assessment of other outcomes that will permit 
continued longitudinal assessment of metabolic and immunologic parameters. This requirement may 
be satisfied through participation in another study in TrialNet. 
 
3.  
The association of demographic, genetic, immunologic, metabolic, and lifestyle factors, among 
others, both at baseline and over time, with the risk of diabetes onset will be assessed in Cox PH 
Models over time. The effects of changes in longitudinal factors on diabetes risk will be assessed 
using time-dependent covariates for these factors. Analyses will be conducted separately within the 
treatment and control groups, and differences between groups in covariate effects (group by 
covariate interactions) will be assessed.   
 


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8.4  
Study Power and Sample Size  
 
Applying the eligibility criteria for this study to the data from the Natural History Study (TN-01), hazard 
and accrual rates were estimated from the TrialNet Natural History/Pathway to Prevention Study 
(PTP; TN-01) for the three eligible strata: 1) ages 8-17 with a confirmed abnormal OGTT, 2) ages 8-
17 with an abnormal OGTT that is not confirmed, (expanded eligibility criteria), and 3) 18 or older with 
a confirmed abnormal OGTT. Assumptions included a constant risk over time and 25% probability of 
agreeing to participate.  For those subjects that never received a confirmatory OGTT in the PTP study 
we presumed they are divided by stratum size between stratum 1 and stratum 2 in the same 
proportions as these groups are in the PTP Study. Likewise, hazard rates for T1DM of these grouped 
strata were determined by weighted average of the hazard rates from the PTP data. That is, for the 8-
17 age groups the 3 strata: a) Abnormal OGTT confirmed: HR=0.1771 and accrual rate: 14.6 (35% by 
size) b) Abnormal but no confirmatory test: HR=0.3370 and accrual rate: 14.1 (33% by size) c) 
Abnormal OGTT followed by normal OGTT: HR=0.1222 and accrual rate: 13.5 (32% by size) were 
weighted to derive the hazard rates for strata 1 and 2. In a similar manner the accrual for 8-17 age 
groups was determined yielding: 22.0 and 20.3 (multiplied by 0.25, probability of agreeing to 
participate) for strata 1 and 2, respectively.  
 
The  estimated hazard rate is 0.231, 0.194 and 0.164 per year for strata 1, 2, and 3, respectively.  
The median time to T1DM onset for the control group based on a constant hazard rate is 3.01, 3.57, 
and 4.23 years for strata 1, 2, and 3, respectively.  The effect size for this trial is a 60% reduction in 
the risk of T1DM (i.e., hazard ratio of experimental to control equals 0.4). This reduction in risk 
translates into a median time to T1DM of 7.52, 8.93, and 10.6 years for the teplizumab group for 
strata 1, 2, and 3, respectively (the increase is 4.51, 5.36, and 6.34 years, respectively).  These 
design characteristics are displayed in the graph below.   
 
On-Study Time (Years)
Proportion T1D-Free
Teplizumab for T1D Prevention Trial
Expected Proportion T1D-Free
Under Alternative Hypothesis
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
1
2
3
4
5
6
7
8
9
10
Placebo
Teplizumab
Age      OGTT                      Stratum
8-17   Confirmed Abnormal       1
8-17   Unconfirmed Abnormal    2 
18+    Confirmed Abnormal        3
4.51  years
6.34  years
 
 
The primary hypothesis test will be the Wald test of the treatment assignment variable when modeling 
the time to T1DM using the Cox model adjusting for baseline age and OGTT status (expanded 
eligibility criteria). To achieve statistical power of 80% for a one-sided Wald test at the 0.025 
significance level and the effect size described above, will require enrollment and follow-up of enough 
participants to observe 40 subjects with T1DM onset (38) (this is the “event” sample size in contrast 
to the study sample size).  This event sample size reflects the combination of the study sample size 


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and the amount of follow-up at which the fixed-sample primary hypothesis test may be conducted.  
Although group sequential testing will be employed, the method of Lan and DeMets maintains the 
power while controlling the type I error used in determining the fixed sample size.   
 
Participants <18yo will undergo an OGTT prior to the first infusion. The results of this study will be 
incorporated into the analysis of the primary outcome variable but will not be used to determine 
eligibility for the study. The study sample size and duration are variable when fixing the “event” 
sample size. In the absence of any safety concerns and evoking any stopping rules, closing accrual 
should not occur until sufficient participants are accrued so that projections (based on the observed 
T1DM rates and the actual accrual pattern) indicate that within a reasonable follow-up period the 
event sample size will be achieved.  The constant hazard rate assumption is retained to compute the 
initial projection.  The projected annual accrual is 5.5, 5.1 and 1.6 for strata 1, 2 and 3, respectively.  
Allowing for a 5% per year drop-out rate and the approximately 3 dozen subjects already enrolled, the 
study will need to accrue a total of 71 subjects in 3 years and follow all those enrolled for another 4 
years beyond the last enrolled subject to achieve a statistical power of 80% (39). 
 
 
 
 
 
Note the accrual period and the study sample size are only projections since the actual accrual rate, 
the control hazard rate and the loss to follow-up rate are estimates from the PTP Study or other 
similar trials.  Furthermore, the over-all hazard rate is sensitive to the age distribution of the enrolled 
study population which is also an approximation. As the study progresses, projections of the study 
duration will be computed based on the observed data (noncomparative treatment analysis) and if in 
conflict, will be brought to the attention of  the DSMB and the TrialNet governing body to determine 
the best course of action. 
 
 
 
 
8.5 
Interim Monitoring Plan 
 
Interim analyses will be conducted when 50% of the expected number of cases of T1DM have been 
observed and will be reviewed by the TrialNet Data and Safety Monitoring Board (DSMB) for 
assessment of effectiveness and safety. The same primary endpoint analysis described above will be 
used to evaluate the evidence of a treatment group effect during interim analyses.  The Wald test 
from the PH model will be transformed to a z-score (with negative values indicating a reduction in risk 
in the teplizumab treated group).  If a group sequential stopping boundary is crossed, the DSMB may 
terminate the trial early.   The Lan and DeMets (40) spending function with an O’Brien-Fleming 
boundary will be used to protect the type I error probability for the primary outcome analyses, and to 
assess the significance of the interim results periodically during the trial.  The spending function (
1
α ) 
that approximates the O’Brien-Fleming boundaries is: 
     
*
/2
1
*
( )
2
2
Z
t
t
α
α


=
−Φ 



 
 


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where *t  is the information fraction (
*
0
1
t
<
≤) and α  is the fixed-sample type I error (i.e., 0.025). 
 
The DSMB will also be informed if there is a serious lack of evidence of a treatment effect (i.e. futility 
analysis). The boundaries are based on the paper by Lachin (41).  The study should be stopped 
based on the futility of rejecting the null hypothesis at the completion of the trial if: 
*
( )
0
HR
Z
t
≥
 when 
*
0.5
 
0.8
t
≤
<
 or if 
*
( )
0.8
HR
Z
t
≥−
 when 
*
0.8
t ≥
.   
 
Using Lachin’s formulas a onetime use of either boundary for the design parameters above 
(
1
1
2.8
Z
Z
α
β
θ
−
−
≡
+
=
) raises the type II error to approximately 0.204 and 0.202, respectively.  For 
larger values of 
*t  the increase to the error probability is even less.  Furthermore, by the laws of 
probability a single use of each rule will increase the type II error no more than the sum of the 
increase (i.e., 0.15+0.004+0.002 = 0.156).   
 
Additional analysis will assess potential adverse outcomes of treatment and will assess the incidence 
of all severe adverse events. 
 
8.6. 
Withdrawal Criteria- Individual Subjects 
 
An intent–to-treat approach will be used. Subjects will not be replaced.  All data acquired prior to 
termination for the reasons outlined below will be included in the primary analysis unless patient 
withdraws consent. Every effort will be made to conduct a final study visit with the participant and 
participants will be followed clinically until, if applicable, all adverse events resolve.  
 
• 
Withdrawal of consent 
• 
Withdrawal by the participant 
• 
Withdrawal by the investigator  
• 
Intercurrent illness or event that precludes further visits to the study site or ability to evaluate 
disease  


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9. ETHICAL CONSIDERATIONS AND COMPLIANCE WITH GOOD CLINICAL PRACTICE 
 
9.1. 
Statement of Compliance 
 
This study will be conducted in compliance with the protocol and consistent with current Good Clinical 
Practices (GCP), adopting the principles of the Declaration of Helsinki, and all applicable regulatory 
requirements (ICH E6, 45CFR46, and FDA 21CFR sections 11, 50, 56, 312). 
 
Prior to study initiation, the protocol and the informed consent documents will be reviewed and 
approved by an appropriate Independent Ethics Committee/Research Ethics Board (IEC/REB) or 
Institutional Review Board (IRB).  Any amendments to the protocol or consent materials must also be 
approved before they are implemented. 
 
9.2. 
Participating Centers 
 
Participating TrialNet clinical sites must have an appropriate assurance, such as a Federal-wide 
Assurance (FWA) or an Unaffiliated Investigators Agreement (UIA), with the Office for Human 
Research Protections (OHRP), since they are actively engaged in research and provide informed 
consent.  The protocol and consent forms will be approved by Institutional Review Boards or Ethics 
Committees/Research Ethics Boards at each of the participating clinical sites.  HIPAA and applicable 
local regulations will be followed by each participating institution in accordance with each institution’s 
requirements.  The participating international sites will obtain approval from their corresponding 
review boards in accordance with their local procedures and institutional requirements. 
 
The investigator is required to keep accurate records to ensure the conduct of the study is fully 
documented.  The investigator is required to ensure that all source documentation is legibly 
completed for every participant entered in the trial. 
 
The investigational sites participating in this study will maintain the highest degree of confidentiality 
permitted for the clinical and research information obtained from participants participating in this 
study.  When a subject participates in this study at more than one TrialNet site, sharing of this 
information is required. Medical and research records will be maintained at each site in the strictest 
confidence.  However, as a part of the quality assurance and legal responsibilities of an investigation, 
the investigational site must permit authorized representatives of the sponsor(s) and regulatory 
agencies to examine (and when required by applicable law, to copy) records for the purposes of 
quality assurance reviews, audits and evaluation of the study safety and progress.  Unless required 
by the laws permitting copying of records, only the coded identity associated with documents or other 
participant data may be copied (obscuring any personally identifying information).  Authorized 
representatives, as noted above, are bound to maintain the strict confidentiality of medical and 
research information that may be linked to identify individuals.  The investigational site will normally 
be notified in advance of auditing visits. 
 
 
 
 
 
 


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9.3. 
Informed Consent 
 
The process of assuring that individuals (and parent/guardian if less than 18 years of age) are making 
an informed decision about participating in this study includes both verbal and written communication.  
Written materials include a Participant Handbook and written consent forms.  There are several 
consent forms for this study.  One is a Screening consent form that describes the procedures, risks, 
and benefits, and eligibility requirements for the study.  The second is the Intervention consent form, 
which describes the procedures, risks, and benefits for the remainder of the study.  A third consent 
form is for use at clinical sites that will be performing the post-treatment visits, but not the treatment 
visits.  The consent forms will be reviewed with participants (and their guardian in the case of 
participants under 18 years of age) and the participant will be given time to review the written consent 
form and ask questions.  An assent form has also been developed for participants less than 18 years 
of age (unless local IRB requirements differ in procedure).  
 
As part of the informed consent process, the participant and/or parent or guardian (if the participant is 
less than 18 years of age) will also be required to complete a short, written Volunteer Understanding 
Quiz that is designed to ensure that the subject understands the study, as well as what is being asked 
of him/her. The participant will be given a copy of their signed consent/assent forms.   
 
The consent process will be conducted by qualified study personnel (the Trial or Study Coordinator 
and/or Investigator or other designee).  All participants (or their legally acceptable representative) 
must read, sign and date a consent form prior to participation in the study, and/or undergoing any 
study-specific procedures. 
 
The informed consent form must be updated or revised whenever there is new, clinically significant  
information applicable to the safety of the participants,  when indicated for a protocol amendment, 
and/or whenever any new information becomes available that may affect a patient’s participation in 
the study.   
 
Subjects will be re-consented if they reach the age of 18 years while enrolled in the study. 
 
9.4. 
Study Subject Confidentiality 
 
Study records with the study subject’s information for internal use at the clinical sites will be secured 
at the study site during the study. Identifying study subject information may be shared between 
TrialNet clinical sites that are involved in study procedures and/or oversight of the participant. At the 
end of the study, all records will continue to be kept in a secure location. There are no plans to 
destroy the records.  
 
Study subject data, which is for reporting purposes, will be stored at The TrialNet Coordinating 
Center. Data sent to the Coordinating Center will identify participants by the unique TrialNet 
Identification Number. The data entry system at the Coordinating Center is a secured, password 
protected computer system.  At the end of the study, all study databases will be archived at the 
Coordinating Center for long-term storage.  De-identified safety data will be shared with MacroGenics 
during the course of the study so the company may meet its regulatory reporting requirements as the 
drug manufacturer and IND sponsor.  Additional de-identified data will be shared with MacroGenics at 
the end of the study. 
 
 


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Stored samples including genetic samples could be utilized to learn more about causes of type 1 
diabetes, its complications (such as eye, nerve, and kidney damage) and other conditions for which 
individuals with diabetes are at increased risk, and how to improve treatment.  The results of these 
future analyses, and any mechanistic studies will not be made known to the participant. 


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9.5. 
Risks and Benefits 
 
The risks of this study are presented in this protocol, the Investigator’s Brochure and informed 
consent form.  There is no guaranteed benefit to subjects for their participation in the study.  This 
study will examine whether intervention with teplizumab will delay or prevent the onset of diabetes, 
but there is no guarantee that this will occur.  However, all subjects will benefit from close monitoring 
for the development of diabetes.  This close monitoring significantly reduces the morbidity typically 
associated with clinical onset of disease. 
 
Special consideration regarding risks and benefits for children is described in section 2.5. 
 
9.6. 
Ethics 
 
The study protocol, along with the required informed consent forms, will be approved by each 
participating institution’s Institutional Review Board (IRB) or Ethics Committee/Research Ethics Board 
(EC/REB) at international sites prior to the initiation of any research procedures (at the site). In 
addition to details described in the sections above (informed consent, confidentiality, and risks and 
benefits) the investigators have reviewed and considered ethical ramifications in the design and 
development of this protocol. The investigators have made every effort to minimize and monitor risks 
and discomforts to participants throughout the course of the study.  


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10.    STUDY ADMINISTRATION 
 
10.1. Organizational Structure 
 
This study is part of Type 1 Diabetes TrialNet, which is funded by the National Institutes of Health. 
Funding will cover the costs of administration and laboratory tests associated with this study during 
the participant’s period of follow-up.  
 
10.2. Role of Industry 
 
The IND holder is MacroGenics, Inc.  MacroGenics will provide teplizumab and placebo for the study 
and financial support for clinical trial monitoring supplemental to standard TrialNet procedures.  Eli 
Lilly and Company holds an exclusive license from MacroGenics to develop and commercialize 
teplizumab. Under TrialNet’s direction, MacroGenics will perform measurements such as PK and anti-
teplizumab antibodies as indicated on coded samples.  Data and data analysis will be conducted by 
TrialNet investigators. 
 
10.3. Groups and Committees 
 
10.3.1. Anti-CD3 Prevention Study Chair 
 
The Study Chair and TrialNet executive committee will receive periodic reports from the TNCC on the 
progress of the study.  These will include accrual rates and baseline demographic characteristics. 
Interim data summaries provided to others (except those that could lead to unmasking of the 
treatment arms) will first be supplied to the Study Chair for review. Criteria and results of ongoing 
monitoring of the TrialNet labs in terms of reproducibility will also be provided on a routine basis and 
reported on during Anti-CD3 Prevention Study Committee meetings, as scheduled. As appropriate, 
abstracts and manuscripts dealing with the progress of the trial shall be directed by the Study 
Committee.  
 
10.3.2. TrialNet Chairman’s Office and TrialNet Coordinating Center 
 
The TrialNet Chairman’s Office and TNCC will work together in providing leadership to the TrialNet 
study group to include protocol and manual preparation, training for clinical sites, development of 
statistical design for each study, and analysis of study results.  The TNCC will also coordinate 
interactions among the participating TrialNet clinical centers, test laboratories including TrialNet core 
laboratories and other subcontract laboratories, NIDDK, and other sponsoring agencies. 
 
10.3.3. Clinical Sites 
 
Each Principal Investigator at the participating TrialNet clinical site will oversee all operations at that 
site.  The clinical sites will forward all laboratory and data collection form information to the TNCC for 
analysis.  Conference calls and site visits, as needed, will facilitate evaluation of the trial 
management.  Certain TrialNet sites will be involved in recruitment and follow up of subjects and 
some sites will also administer study drug.  
 


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10.3.4. Diabetes Adjudication Committee 
 
A TrialNet Diabetes Onset Adjudication Committee will review all relevant information for each subject 
who does not meet the criteria stated in section 8.1 but has been otherwise diagnosed as having 
developed diabetes. The Committee will determine whether the diagnosis of diabetes in each of these  
subjects is sufficiently sound so as to include that subject among the cases who have reached the 
primary outcome in the statistical analysis. The Committee will be masked to treatment assignment 
as it reviews each case masked to treatment assignment. 
 
10.3.5. Clinical Site Monitoring 
 
In order to conduct this study with established research principles, site visits will be conducted during 
the study to evaluate study conduct.  All sites will be monitored by the Coordinating Center and 
appropriate TrialNet committees for patient enrollment, compliance with protocol procedures, 
completeness and accuracy of data entered on the case report forms (CRFs), and the occurrence 
and reporting of adverse events (AEs) and serious adverse events (SAEs).   
 
10.4. Medical Monitor and Data Safety and Monitoring Board (DSMB) 
 
All adverse events will be recorded on the adverse event forms, which will be sent to the local IRBs, 
per their reporting requirements, and to the TNCC according to reporting guidelines.  
 
An independent physician will be designated to serve as the medical monitor for this study who will 
maintain regular contact with the study and the study chair.  (S)he will review all adverse event 
reports, masked to treatment assignment, and will file event reports with regulatory authorities as 
appropriate.   
 
The DSMB will meet approximately every 3 months and as needed to review indicators of safety.  In 
addition, they will meet every 6 months to review the interim effectiveness and potential toxicity of the 
study treatments based on interim analyses of indicators of effectiveness and safety prepared by the 
TNCC separately by treatment group.  The DSMB will independently evaluate whether there are 
grounds to modify or discontinue the study. 
 
 
10.5. Sample and Data Storage 
 
Samples to be stored for research purposes will be located at the NIDDK Repository and at TrialNet 
Sites.  While TrialNet is active, the use of the samples will be restricted to TrialNet researchers unless 
researchers from outside of TrialNet obtain approval from the TrialNet Steering Committee and the 
NIDDK to utilize the samples.  Samples that are obtained for pharmacokinetics and measurement of 
anti-teplizumab antibodies may be made available to MacroGenics for analysis.  All samples will be 
coded with unique study numbers, but TrialNet researchers will be able to identify samples if it is 
necessary to contact participants for reasons of health or for notification to them about future studies. 
Approval from the TrialNet Steering Committee and the NIDDK would be required before such linkage 
could occur.  Researchers from outside of TrialNet will not be permitted to identify samples.  
 
Data collected for this study will be sent to the TNCC.  After the study is completed, the safety study 
data will be sent to MacroGenics by the TNCC to allow integration of all safety data on teplizumab.  


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De-identified data will be stored at the NIDDK Repository, under the supervision of the NIDDK/NIH, 
for use by researchers including those outside of TrialNet. 
 
When TrialNet is completed, samples will continue to be stored at the NIDDK Repository Sites.  Since 
the stored data will be fully de-identified upon the completion of TrialNet, it will no longer be possible 
to identify samples.  Thus, whereas a sample can be destroyed upon a participant’s request during 
the existence of the TrialNet, it can no longer be destroyed once TrialNet is completed.  However, 
there will still be the potential to link data derived from the samples with data that had been derived 
from TrialNet studies.  Once TrialNet is completed, researchers will only obtain access to samples 
through grant proposals approved by the NIDDK.  The NIDDK will convene an external panel of 
experts to review requests for access to samples. 
 
10.6. Preservation of the Integrity of the Study 
 
The scientific integrity of the trial dictates that results be reported on a study-wide basis; thus, an 
individual Center will not report the data collected from its site alone.  All presentations and 
publications using TrialNet trial data must protect the main objectives of the trial.  Data that could be 
perceived as threatening the study outcome will not be presented prior to release of the primary study 
outcomes.  Approval as to the timing of presentations of data and the meetings at which they might 
be presented will be granted by the TrialNet Steering Committee.  Study results should be discussed 
with the news media only upon authorization of the Steering Committee, and never before the results 
are presented.  Any written statements about this study that are shared with national media must be 
approved by TrialNet before release. 
 
10.7. Participant Reimbursement and Compensation 
 
Participants will be compensated for each visit attended in the study. 
 


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APPENDIX 1: Natural History/Pathway to Prevention to Teplizumab in At-Risk 
Relatives Study Flow Chart for Subjects ≥18yo 
Natural 
History 
Screening 
 
   Procedures 
First or second degree relative 
Initial AutoAntibody draw 
 
   Results to move   
   on 
AutoAntibodies (AA) 
At least one autoantibody confirmed positive, or two autoantibodies present 
 
 
 
 
 
 
Natural 
History 
Risk 
Assessment 
 
   Procedures 
Confirmation of autoantibody status, OGTT, HLA  
   Results to move 
onto                        
teplizumab 
AutoAntibodies (AA)1 
At least two confirmed diabetes related autoantibodies confirmed to be present 
on two occasions. Confirmation of 2 positive autoantibodies must occur within 
six months prior to randomization, but the confirmation does not have to involve 
the same 2 autoantibodies. 
OGTT 
Fasting Plasma Glucose  > 110 mg/dL and < 126 mg/dL OR 
     2-hr Plasma Glucose  >140 mg/dL and < 200 mg/dL OR 
30, 60, or 90 minute glucose ≥ 200 mg/dL 
 
 
 
 
 
Teplizumab  
eligibility visit 
 
   Procedures 
Screening consent is signed. OGTT2 (unless abnormal glucose tolerance has 
been previously confirmed from a test in TrialNet within 7 weeks (52 days) of 
randomization), laboratory assessments, PPD, History, PE, Volunteer Quiz, 
Education.  
 
   Results to move   
   on 
OGTT with abnormal glucose tolerance (if applicable) 
Does not meet any exclusion criteria3 
 
 
 
 
Teplizumab 
Baseline 
and 
Randomization 
visit 
 
   Procedures 
Intervention consent signed.  Baseline laboratory assessments, dosing of 
teplizumab/placebo  


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1If autoantibodies are not confirmed positive on the second test a tiebreaker draw will be required. 
2If the OGTT confirms abnormal glucose tolerance, the subject is eligible to proceed with 
randomization.  If the OGTT is consistent with diabetes, the subject is not eligible for enrollment. 
He/She may be eligible for enrollment in the future if subsequent studies do not confirm the diagnosis 
of diabetes and the above entry criteria are met.  If neither abnormal glucose tolerance or diabetes is 
confirmed, the subjects may have repeat studies as outlined above to meet the entry criteria.   
 3If subject not eligible or unwilling to participate in teplizumab in at-risk, subject may be followed in 
TN Natural History/Pathway to Prevention Study. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX 2: Natural History/Pathway to Prevention to Teplizumab in At-Risk 
Relatives Study Flow Chart for Subjects <18yo 
Natural 
History 
Screening 
 
   Procedures 
First or second degree relative 
Initial AutoAntibody draw 
 
   Results to move   
   on 
AutoAntibodies (AA) 
At least one autoantibody confirmed positive, or two autoantibodies present 
 
 
 
 
 
 
Natural 
History 
Risk 
Assessment 
 
   Procedures 
Confirmation of autoantibody status, OGTT, HLA  
   Results to move 
onto                        
teplizumab 
AutoAntibodies (AA)1 
At least two confirmed diabetes related autoantibodies confirmed to be present 
on two occasions. Confirmation of 2 positive autoantibodies must occur within 
six months prior to randomization, but the confirmation does not have to involve 
the same 2 autoantibodies. 
OGTT 
Fasting Plasma Glucose  > 110 mg/dL and < 126 mg/dL OR 
     2-hr Plasma Glucose  >140 mg/dL and < 200 mg/dL OR 
30, 60, or 90 minute glucose ≥ 200 mg/dL 
 
 
 
 
 
Teplizumab  
eligibility visit 
 
   Procedures 
Screening consent is signed. Random Glucose2 or OGTT if not previously 
performed, laboratory assessments, PPD, History, PE, Volunteer Quiz, 
Education.  
 
   Results to move   
   on 
Non-Fasting Random Glucose <200mg/dL, or OGTT with abnormal glucose 
tolerance  
Does not meet any exclusion criteria3 
 
 
 
 
Teplizumab 
Baseline 
and 
Randomization 
visit 
 
   Procedures 
Intervention consent signed.  Baseline laboratory assessments, OGTT, dosing of 
teplizumab/placebo  


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1If autoantibodies are not confirmed positive on the second test a tiebreaker draw will be required. 
2If the Random Glucose is consistent with diabetes, the subject is not eligible for enrollment. He/She 
may be eligible for enrollment in the future if subsequent studies do not confirm the diagnosis of 
diabetes and the above entry criteria are met.  If neither abnormal glucose tolerance or diabetes is 
confirmed, the subjects may have repeat studies as outlined above to meet the entry criteria.   
 3If subject not eligible or unwilling to participate in teplizumab in at-risk, subject may be followed in 
TN Natural History/Pathway to Prevention Study. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX 3 - Schedule of Assessments 
Week of Trial 
  
  
  
  
  
  
  
  
  
  
  
  
  
2 
  
6 
  
  
  
  
  
  
  
  
  
  
  
  
  
Month of Trial 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
3 
6 
1
2 
1
8 
2
4 
3
0 
3
6 
4
2 
4
8 
5
4 
6
0 
6
6 
721
0 
Day of Trial 
-
1 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
1
0 
1
1 
1
2 
1
3 
2
0 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Visit number 
-
1 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
1
0 
1
1 
1
2 
1
3 
1
4 
1
5 
1
6 
1
7 
1
8 
1
9 
2
0 
2
1 
2
2 
2
3 
2
4 
2
5 
2
6 
2
7 
28 
Study drug1 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chemistries 2,3 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
X 
 
X 
 
X 
 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
INR2 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBC with diff2 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
X 
X 
Liver Function2,3 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
X 
 
X 
 
X 
 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
mAb levels4 
 
X 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anti-teplizumab response 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
EBV and CMV viral 
loads5  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
 
 
 
EBV/CMV serology 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
 
 
 
History/Physical exam6 
X 
X 
 
 
 
 
X 
 
 
 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Oral Glucose Tolerance7 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HIV, HepB and C 
serology 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PPD test 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine pregnancy test 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HbA1c 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Mechanistic 
assessments8 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
glycemic status9 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EKG 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
1= Drug dosing: Day 0: 51 mcg/m2, Day 1: 103 mcg/m2, Day 2: 207 ug/m2, Day 3: 413 ug/m2, Days 4 - 13: 826 ug/m2. 
2= These studies must be reviewed prior to drug administration (see protocol re: drug withholding). INR and CBC with diff are done locally at all specified visits.  
3= Liver Function tests (ALT, AST, LDH, alkaline phosphatase, total protein, albumin, total and direct bilirubin) and Chemistries (sodium, potassium, chloride, CO2, glucose, BUN, creatine) are done locally at 
specified visits 0-13. Tests are done centrally at all other specified visits. 
4= These PK samples will be done on the first 12 subjects in each of the age strata: ≥ 16, 12-15, and 8-11. 
5= At Screen, EBV viral load will be measured on all subjects except those VCA IgG+, VCA IgM-, EBNA+ by serology.  After study drug treatment, EBV and CMV viral load samples will be collected from all 
subjects.  Viral loads will be measured in symptomatic subjects. 
6= Directed/limited physical exam for visits at month 3, 6, 18, 30, 42, 54, 66, and then q 6 months. 
7= Screening OGTT only applicable for participants ≥18yo, unless abnormal glucose tolerance has been previously confirmed by a test in TrialNet within 7 weeks (52 days) of randomization. If OGTT consistent 
with DM, repeat within 1 month.  Glucose, insulin, and C-peptide are collected at each OGTT. Participants <18yo will undergo an OGTT at or prior to the baseline visit (visit 0). The results of this study will 
not be used to determine eligibility for the study 
8=Includes samples for RNA, plasma, serum, DNA, measures of B and T cell number and function to understand the effect of therapy on the immune system and infectious disease.  
The schedule for these assessments may vary as appropriate.  At no time will the blood draw volume exceed what is allowable according to the subject’s age and body weight (For  
subjects <18, 5ml/kg per visit, 9.5 mg/kg in an 8 week period.) 
9= Screening random glucose only applicable for participants <18yo not undergoing an OGTT on the same day. All subjects will have interim  contact with study personnel for formal inquiry about adverse 
events, presence or absence of blurred vision, polyuria, polydypsia, unintended weight loss.  In addition, random glucose samples will be obtained at 3 month intervals in which there is no OGTT scheduled.   
Those with symptoms or glucose >200mg/dl will undergo fasting glucose or OGTT evaluation. 
Additional samples will be drawn in the case of drug withholding (see protocol: drug withholding 4.5.2) 


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10= The assessments at month 72 will be repeated every 6 months.  


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11.  
REFERENCES 
 
1. Harris MI, Cowie C, Stern MP, Boyko EJ, Reiber GE, Bennett PH: Diabetes in America, National 
Diabetes Information Clearinghouse 2007 
2. Variation and trends in incidence of childhood diabetes in Europe. EURODIAB ACE Study Group. 
Lancet 355:873-876, 2000 
3. The effect of intensive treatment of diabetes on the development and progression of long-term 
complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial 
Research Group. N Engl J Med 329:977-986, 1993 
4. Atkinson MA: ADA Outstanding Scientific Achievement Lecture 2004. Thirty years of investigating 
the autoimmune basis for type 1 diabetes: why can't we prevent or reverse this disease? Diabetes 
54:1253-1263, 2005 
5. Riley WJ, Maclaren NK, Krischer J, Spillar RP, Silverstein JH, Schatz DA, Schwartz S, Malone J, 
Shah S, Vadheim C, et al.: A prospective study of the development of diabetes in relatives of patients 
with insulin-dependent diabetes. N Engl J Med 323:1167-1172., 1990 
6. Sherr J, Sosenko J, Skyler JS, Herold KC: Prevention of type 1 diabetes: the time has come. Nat 
Clin Pract Endocrinol Metab 4:334-343, 2008 
7. Eisenbarth GS: Type I diabetes mellitus. A chronic autoimmune disease. N Engl J Med 314:1360-
1368, 1986 
8. Wenzlau JM, Juhl K, Yu L, Moua O, Sarkar SA, Gottlieb P, Rewers M, Eisenbarth GS, Jensen J, 
Davidson HW, Hutton JC: The cation efflux transporter ZnT8 (Slc30A8) is a major autoantigen in 
human type 1 diabetes. Proc Natl Acad Sci U S A 104:17040-17045, 2007 
9. Sosenko JM, Palmer JP, Greenbaum CJ, Mahon J, Cowie C, Krischer JP, Chase HP, White NH, 
Buckingham B, Herold KC, Cuthbertson D, Skyler JS: Patterns of metabolic progression to type 1 
diabetes in the Diabetes Prevention Trial-Type 1. Diabetes Care 29:643-649, 2006 
10. Tsai EB, Sherry NA, Palmer JP, Herold KC: The rise and fall of insulin secretion in type 1 
diabetes mellitus. Diabetologia 49:261-270, 2006 
11. Effects of insulin in relatives of patients with type 1 diabetes mellitus. N Engl J Med 346:1685-
1691., 2002 
12. Effect of intensive therapy on residual beta-cell function in patients with type 1 diabetes in the 
diabetes control and complications trial. A randomized, controlled trial. The Diabetes Control and 
Complications Trial Research Group. Ann Intern Med 128:517-523, 1998 
13. Skyler JS, Krischer JP, Wolfsdorf J, Cowie C, Palmer JP, Greenbaum C, Cuthbertson D, Rafkin-
Mervis LE, Chase HP, Leschek E: Effects of oral insulin in relatives of patients with type 1 diabetes: 
The Diabetes Prevention Trial--Type 1. Diabetes Care 28:1068-1076, 2005 
14. Gale EA, Bingley PJ, Emmett CL, Collier T: European Nicotinamide Diabetes Intervention Trial 
(ENDIT): a randomised controlled trial of intervention before the onset of type 1 diabetes. Lancet 
363:925-931, 2004 
15. Sosenko JM, Krischer JP, Palmer JP, Mahon J, Cowie C, Greenbaum CJ, Cuthbertson D, Lachin 
JM, Skyler JS: A Risk Score for Type 1 Diabetes Derived from Autoantibody Positive Participants in 
The Diabetes Prevention Trial- Type 1. Diabetes Care, 2007 
16. Sosenko JM, Palmer JP, Rafkin-Mervis L, Krischer JP, Cuthbertson D, Matheson D, Skyler JS: 
Glucose and C-peptide changes in the perionset period of type 1 diabetes in the Diabetes Prevention 
Trial-Type 1. Diabetes Care 31:2188-2192, 2008 
17. Bougneres PF, Carel JC, Castano L, Boitard C, Gardin JP, Landais P, Hors J, Mihatsch MJ, 
Paillard M, Chaussain JL, et al.: Factors associated with early remission of type I diabetes in children 
treated with cyclosporine. N Engl J Med 318:663-670., 1988 
18. Keymeulen B, Vandemeulebroucke E, Ziegler AG, Mathieu C, Kaufman L, Hale G, Gorus F, 
Goldman M, Walter M, Candon S, Schandene L, Crenier L, De Block C, Seigneurin JM, De Pauw P, 
Pierard D, Weets I, Rebello P, Bird P, Berrie E, Frewin M, Waldmann H, Bach JF, Pipeleers D, 


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Chatenoud L: Insulin needs after CD3-antibody therapy in new-onset type 1 diabetes. N Engl J Med 
352:2598-2608, 2005 
19. Xu D, Alegre ML, Varga SS, Rothermel AL, Collins AM, Pulito VL, Hanna LS, Dolan KP, Parren 
PW, Bluestone JA, Jolliffe LK, Zivin RA: In vitro characterization of five humanized OKT3 effector 
function variant antibodies. Cell Immunol 200:16-26., 2000 
20. Bisikirska B, Colgan J, Luban J, Bluestone JA, Herold KC: TCR stimulation with modified anti-
CD3 mAb expands CD8 T cell population and induces CD8CD25 Tregs. J Clin Invest 115:2904-2913, 
2005 
21. Herold KC, Burton JB, Francois F, Poumian-Ruiz E, Glandt M, Bluestone JA: Activation of human 
T cells by FcR nonbinding anti-CD3 mAb, hOKT3gamma1(Ala-Ala). J Clin Invest 111:409-418, 2003 
22. Mach H, Middaugh CR, Lewis RV: Statistical determination of the average values of the extinction 
coefficients of tryptophan and tyrosine in native proteins. Anal Biochem 200:74-80, 1992 
23. Herold KC, Hagopian W, Auger JA, Poumian-Ruiz E, Taylor L, Donaldson D, Gitelman SE, Harlan 
DM, Xu D, Zivin RA, Bluestone JA: Anti-CD3 monoclonal antibody in new-onset type 1 diabetes 
mellitus. N Engl J Med 346:1692-1698., 2002 
24. Chatenoud L, Primo J, Bach JF: CD3 antibody-induced dominant self tolerance in overtly diabetic 
NOD mice. J Immunol 158:2947-2954., 1997 
25. Chatenoud L, Thervet E, Primo J, Bach JF: Anti-CD3 antibody induces long-term remission of 
overt autoimmunity in nonobese diabetic mice. Proc Natl Acad Sci U S A 91:123-127., 1994 
26. Herold KC, Bluestone JA, Montag AG, Parihar A, Wiegner A, Gress RE, Hirsch R: Prevention of 
autoimmune diabetes with nonactivating anti-CD3 monoclonal antibody. Diabetes 41:385-391., 1992 
27. Fife BT, Guleria I, Gubbels Bupp M, Eagar TN, Tang Q, Bour-Jordan H, Yagita H, Azuma M, 
Sayegh MH, Bluestone JA: Insulin-induced remission in new-onset NOD mice is maintained by the 
PD-1-PD-L1 pathway. J Exp Med 203:2737-2747, 2006 
28. Sherry N, Chen W, Kushner JA, Glandt M, Tang Q, Tsai S, Santamaria P, Bluestone J, Brillantes 
AM, Herold K: Exendin-4 improves reversal of diabetes in NOD mice treated with anti-CD3 mAb by 
enhancing recovery of ? cells. Endocrinology, 2007 
29. Belghith M, Bluestone JA, Barriot S, Megret J, Bach JF, Chatenoud L: TGF-beta-dependent 
mechanisms mediate restoration of self-tolerance induced by antibodies to CD3 in overt autoimmune 
diabetes. Nat Med 9:1202-1208, 2003 
30. Herold KC, Gitelman SE, Masharani U, Hagopian W, Bisikirska B, Donaldson D, Rother K, 
Diamond B, Harlan DM, Bluestone JA: A Single Course of Anti-CD3 Monoclonal Antibody 
hOKT3{gamma}1(Ala-Ala) Results in Improvement in C-Peptide Responses and Clinical Parameters 
for at Least 2 Years after Onset of Type 1 Diabetes. Diabetes 54:1763-1769, 2005 
31. Herold KC, Gitelman S, Greenbaum C, Puck J, Hagopian W, Gottlieb P, Sayre P, Bianchine P, 
Wong E, Seyfert-Margolis V, Bourcier K, Bluestone JA: Treatment of patients with new onset Type 1 
diabetes with a single course of anti-CD3 mAb teplizumab preserves insulin production for up to 5 
years. Clin Immunol, 2009 
32. Tamborlane WV, Beck RW, Bode BW, Buckingham B, Chase HP, Clemons R, Fiallo-Scharer R, 
Fox LA, Gilliam LK, Hirsch IB, Huang ES, Kollman C, Kowalski AJ, Laffel L, Lawrence JM, Lee J, 
Mauras N, O'Grady M, Ruedy KJ, Tansey M, Tsalikian E, Weinzimer S, Wilson DM, Wolpert H, 
Wysocki T, Xing D: Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl 
J Med 359:1464-1476, 2008 
33. Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. 
National Diabetes Data Group. Diabetes 28:1039-1057, 1979 
34. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. 
Diabetes Care 26:3160-3167, 2003 
35. Cox DR: Regression model and Life Tables J R Stat Soc 34B:187-220, 1972 
36. Kalbfleisch JD, Prentice RL: The statistical analysis of failure time data., 1980 
37. Diggle PJ, Heagerty PJ, Liang K-Y, Zeger SL: Analysis of longitudinal data. Oxford, UK, Oxford 
Clarendon Press, 1994 


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38. Schoenfeld D.  Sample-sizes for the Proportional Hazards Regression Model. Biometrics 
1983;39:499-503 1983 
39. Lachin JM, Foulkes MA.  Evaluation of sample size and power for analyses of survival with 
allowance for nonuniform patient entry, losses to follow-up, noncompliance, and stratification. 
Biometrics 1986; 42(3):507-519. 
40. Lan KKG, DeMets DL. Discrete sequential boundaries for clinical trials. Biometrika 1983; 70:659-
663 
41.JM Lachin.  Futility interim monitoring with control of type I and II error probabilities using the 
interim Z-value or confidence limit.  Clinical Trials 2009; 6 (6) 565-573  
 
 

SAP_001.pdf: 
1 
 
Statistical Analysis Plan 
 
 
TRIAL FULL TITLE 
ANTI-CD3 MAB (TEPLIZUMAB) FOR PREVENTION 
OF DIABETES IN RELATIVES AT-RISK FOR TYPE 1 
DIABETES 
MELLITUS (Protocol TN-10)
EUDRACT NUMBER 
Phase 
Phase IIb 
SAP VERSION 
ISRCTN NUMBER 
SAP VERSION DATE 
March 27, 2018 
TRIAL STATISTICIAN 
Brian Bundy 
TRIAL CHIEF 
INVESTIGATOR 
Kevan Herold 
SAP AUTHOR 
Jeffrey Krischer 


2 
 
Table of Contents 
 
1. 
Abbreviations and Definitions ........................................................................................................................3 
2. 
Introduction ........................................................................................................................................................3 
Preface ................................................................................................................................................................ 3 
Purpose of the analyses .......................................................................................................................................3 
Primary Outcome ............................................................................................................................................... 3 
3. 
Primary Analysis ...............................................................................................................................................4 
4. 
Secondary Outcomes and Analyses ............................................................................................................4 
5. 
Study Power and Sample Size ......................................................................................................................6 
6. 
Interim Monitoring Plan ............................................................................................................................... 8 
7. 
General Considerations .............................................................................................................................. 9 
Timing of Analyses .................................................................................................................................................9 
Analysis Populations ..............................................................................................................................................9 
The Intention to Treat Population (ITT) ................................................................................................. 9 
Full Analysis Population ..................................................................................................................................9 
Per Protocol Population .............................................................................................................................. 9 
Safety Population ......................................................................................................................................... 9 
Adjustment of Confidence Intervals and p-values .................................................................................. 9 
Missing Data ............................................................................................................................ 10  
8. 
Safety Analyses .......................................................................................................................................... 10 
Adverse Events .................................................................................................................................................... 10 
Deaths, Serious Adverse Events and other Significant Adverse Events ................................................ 10 
9. 
Reporting Conventions ................................................................................................................................. 10 
10. 
Per Protocol Analysis ................................................................................................................................ 11 
11. 
Technical Details ........................................................................................................................................ 11 
References ............................................................................................................................................................. 12 


3 
 
1. 
Abbreviations and Definitions 
 
 
AE 
Adverse Event 
ADA 
American Diabetes Association 
AUC 
Area Under the Curve 
BMI 
Body Mass Index 
DSMB 
Data Safety Monitoring Committee 
ITT 
Intent to Treat 
OGTT 
Oral Glucose Tolerance Test 
PH 
Proportional hazards 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
T1DM 
Type 1 Diabetes Mellitus 
 
 
 
2. 
Introduction 
 
Preface 
 
The rationale for this study is that individuals with immunologic markers of T1DM and abnormal 
glucose tolerance are at very high risk for progression to overt disease. They have a condition 
that differs from overt diabetes only in the duration of the autoimmune process that results in 
beta cell destruction. It is hypothesized that intervention at the “prediabetic” stage is likely to be 
more effective than intervention in those in whom frank hyperglycemia has developed and beta 
cell function has deteriorated further because insulin production is greater before compared to 
after the diagnosis. 
 
Purpose of the analyses 
 
Analyses of study data will be conducted to address all objectives and other interrelationships 
among elements of study data of interest to the investigators and of relevance to the objectives 
of the study. Analyses by sex, age, and race/ethnicity are also planned. 
All primary analyses will be conducted under the intention-to-treat principle whereby all outcome 
data in all randomized subjects will be included, regardless of treatment compliance. 
 
Primary Outcome 
 
The primary outcome is the elapsed time from random treatment assignment to the development 
of diabetes or time of last contact in the Intention to Treat Population  
 
Criteria for diabetes onset are, as defined by the American Diabetes Association (ADA), based 
on glucose testing, or the presence of unequivocal hyperglycemia with acute metabolic 
decompensation (diabetic ketoacidosis)(1,2). For criteria based on glucose testing, one of the 
following criteria must be met on two occasions as soon as possible but no less than one day 
apart for diabetes to be defined: 
 
1. 
Symptoms of diabetes plus casual plasma glucose concentration > 200 mg/dL 


4 
 
(11.1 mmol/l). Casual is defined as any time of day without regard to time since 
last meal. The classic symptoms of diabetes include polyuria, polydipsia, and 
unexplained weight loss. 
 
2. 
Fasting plasma glucose ≥ 126 mg/dL (7 mmol/l). Fasting is defined as no caloric 
intake for at least 8 hours. 
 
3. 
2 hour plasma glucose ≥ 200 mg/dL (11.1 mmol/l) on an Oral Glucose Tolerance 
Test (OGTT). The test should be performed using a glucose load containing the 
equivalent of 1.75g/kg body weight to a maximum of 75 g anhydrous glucose 
dissolved in water. 
 
 
3. 
Primary Analysis 
 
The study design is a randomized double-blind placebo controlled trial. The primary objective 
of the TrialNet Anti-CD3 Trial is to assess the effect of teplizumab versus control on the risk of 
diabetes onset in the intention-to-treat population. 
 
The cumulative incidence of diabetes onset over time since randomization within each treatment 
group will be estimated using the Kaplan-Meier method (proportion surviving diabetes-free as a 
function of time). The difference between groups in the cumulative incidence curves, and the 
associated hazard functions, will be tested at the 0.025 level, one-sided, using the Cox 
Proportional Hazards (PH) model with discrete time intervals at the 6 month OGTT intervals (3,4). 
The hazard ratio of diabetes onset between treatment arms will be estimated from the PH model. 
The critical values will be determined by the group-sequential procedure outlined in the section 
entitled Interim Monitoring Plan below. The primary test of treatment effect will be adjusted for the 
design strata and any covariates identified using the procedure outlined below. 
 
Using a step-up procedure additional covariates will be tested and included in the model only if 
they improve the log-likelihood at 0.10 level (2-sided). This will be accomplished with the treatment 
assignment variable included but the inclusion/exclusion of the candidate covariates will be 
completely independent of the treatment variable’s impact on the model.  The candidate covariates 
to be tested for inclusion are: sex, BMI, HbA1c, HLA (DR3/4 vs. others), baseline C-peptide 
(fasting, peak, AUC), baseline OGTT glucose (fasting, 2-hour, AUC), autoantibody presence 
(mIAA, GADA, IA2A, ZnT8) at study entry. The Wald test associated with treatment variable in the 
full, adjusted model will be used for the test of treatment effect described in the previous 
paragraph. Thus, the adjustment of the significance level, as with multiple testing, is unnecessary. 
 
 
4. 
Secondary Outcomes and Analyses 
 
The original design of this study anticipated a two-year enrollment period and follow-up of 3 years 
after the last subject was enrolled for a total of 5 years. To deal with the potential loss of drug effect, 
the treatment arms will be compared at 5 years, as if the study did follow the original plan (i.e., had 
the study progressed according to the original plan with the minimum accrual, 50% of the subjects 
would have been followed for 4 years and 50% for 5 years. For purposes of this secondary outcome, 
study subjects will be censored at 5 years following their randomization date). This will be the 
principal pre-specified secondary objective All other planned secondary objective will be considered 
exploratory. 
 


5 
 
 
Exploratory, pre-specified secondary analyses are identified below. 
 
1. For those quantitative baseline factors (including weight, BMI, and the immunologic and 
metabolic factors, including the autoantibody titers, basal C-peptide, OGTT stimulated C-
peptide (peak and AUC mean), and measures of insulin secretion and insulin resistance 
modeled from the OGTT) entered into the model used in the primary analysis, an attempt 
will be made to distinguish levels or intervals that correspond to different diabetes risk. 
The treatment effect within the quantitative levels of each factor will then be assessed 
through a covariate by treatment group interaction in a PH model. Such an analysis will 
also be conducted to assess the effects of age as quantitative covariate as described 
above. 
 
2. Additional exploratory subgroup analyses will be conducted comparing the effects of 
teplizumab versus control on the risk of diabetes within subsets of the study cohort. Pre-
specified subgroups of the enrolled population will be classified by age (8-17 and 18-45) 
sex, race/ethnicity, autoantibody type and titer at baseline, OGTT in the diabetic range at 
baseline (yes/no), and HLA risk categories, including the presence or absence of HLA 
DQB1*0602 and other factors deemed important (such as site and temporal effects) 
Differences in the treatment effect between subgroups will be tested using a covariate by 
treatment group interaction term in a PH model (3) and significance levels reported 
regardless of whether they achieve nominal significance due to the lack of statistical power.  
 
3. Although there is limited power, the diabetes-free proportion at 1,2 and 3 years after 
randomization will be calculated and compared using the Kaplan-Meier estimates of the 
proportions and the Greenwood estimates of the variance. 
 
4. Longitudinal analyses will assess the effects of teplizumab versus control treatment on 
immunologic and metabolic markers over time up to the onset of diabetes. Differences 
between groups in the mean levels of quantitative factors over time will be assessed using 
a normal errors linear model for repeated measures. Differences between groups in the 
prevalence of qualitative factors over time will be assessed using generalized estimating 
equations for categorical measures. Generalized estimating equations may also be 
employed for the analysis of quantitative factors when the normal errors assumptions are 
violated (5). 
 
5. Once a subject develops diabetes, the subject will have reached the primary outcome of 
the study. However, the subject may still be followed for assessment of other outcomes 
that will permit continued longitudinal assessment of metabolic and immunologic 
parameters. This requirement may be satisfied through participation in another study in 
TrialNet. 
 
6. The association of demographic, genetic, immunologic, metabolic, and lifestyle factors, 
among others, both at baseline and over time, with the risk of diabetes onset will be 
assessed in Cox PH Models over time. The effects of changes in longitudinal factors on 
diabetes risk will be assessed using time-dependent covariates for these factors. Analyses 
will be conducted separately within the treatment and control groups, and differences 
between groups in covariate effects (group by covariate interactions) will be assessed.  
Assumptions regarding a constant hazard rate will be tested to examine differential efficacy 
over time. 
 


6 
 
7. Evidence that the HR is not constant over the period of follow up will be assessed and 
the risk of diabetes will be assessed in a PH model.  The primary test for treatment effect 
is based on the Cox model, which assumes a proportional hazards between treatment 
groups. If there is a true treatment effect but it is not proportional over the follow-up period 
the test will have substantially less statistical power than stated in the statistical section 
of the protocol. Therefore, to establish a reasonable guide to pursue the possibility of a 
non-proportional treatment effect we will use the guideline requiring a significance level 
of 0.10 or less of the Wald test from the standard Cox model.  Due to the modest size of 
this trial, nominal level for significance when testing for violations in proportional hazards 
will not be specified. Rather, graphical diagnostics using Schoenfeld residuals will be 
employed to explore evidence for a monotonically decreasing effect of treatment over the 
follow-up p e r io d .  Also, plotting the Kaplan-Meier time-to-T1D rates by treatment group 
on the log-log scale will be used to quantify any diminishing effect of treatment (equal 
distance separation of curves indicates proportional hazard).  We will characterize any 
such decreasing effect of treatment by model parameterization with monotonically 
deceasing benefit over the follow-up time.  Initially, a treatment interaction with log-
transformed time-on-study will be fit to the data and the log likelihood improvement in the 
fit noted. Other time transforms will be explored only to characterize mathematically the 
rate of the diminishing effect. Of particular interest will be characterizing the point in follow-
up where the hazard ratio is 1. Any variations in proportional hazards other than a 
monotonically decreasing effect will not be of interest because of the possibility that it is 
simply random error. 
 
5. 
Study Power and Sample Size 
 
Applying the eligibility criteria for this study to the data from the Natural History Study (TN-01), 
hazard and accrual rates were estimated from the TrialNet Natural History/Pathway to Prevention 
Study (PTP; TN-01) for the three eligible strata: 1) ages 8-17 with a confirmed abnormal OGTT, 
2) ages 8-17 with an abnormal OGTT that is not confirmed, (expanded eligibility criteria), and 3) 
18 or older with a confirmed abnormal OGTT. Assumptions included a constant risk over time and 
25% probability of agreeing to participate. For those subjects that never received a confirmatory 
OGTT in the PTP study we presumed they are divided by stratum size between stratum 1 and 
stratum 2 in the same proportions as these groups are in the PTP Study. Likewise, hazard rates 
for T1DM of these grouped strata were determined by weighted average of the hazard rates from 
the PTP data. That is, for the 8-17 age groups the 3 strata: a) Abnormal OGTT confirmed: 
HR=0.1771 and accrual rate: 14.6 (35% by size) b) Abnormal but no confirmatory test: HR=0.3370 
and accrual rate: 14.1 (33% by size) c) Abnormal OGTT followed by normal OGTT: HR=0.1222 
and accrual rate: 13.5 (32% by size) were weighted to derive the hazard rates for strata 1 and 2. 
In a similar manner the accrual for 8-17 age groups was determined yielding: 22.0 and 20.3 
(multiplied by 0.25, probability of agreeing to participate) for strata 1 and 2, respectively. 
 
The estimated hazard rate is 0.231, 0.194 and 0.164 per year for strata 1, 2, and 3, respectively. 
The median time to T1DM onset for the control group based on a constant hazard rate is 3.01, 
3.57, and 4.23 years for strata 1, 2, and 3, respectively. The effect size for this trial is a 60% 
reduction in the risk of T1DM (i.e., hazard ratio of experimental to control equals 0.4). This 
reduction in risk translates into a median time to T1DM of 7.52, 8.93, and 10.6 years for the 
teplizumab group for strata 1, 2, and 3, respectively (the increase is 4.51, 5.36, and 6.34 years, 
respectively).  These design characteristics are displayed in the graph below. 


7
 
Teplizumab for T1D Prevention Trial 
Expected Proportion T1D-Free 
Under Alternative Hypothesis 
 
 
 
 
 
4.51  years  
 
6.34  years 
 
 
Placebo 
Teplizumab 
 
Age 
OGTT 
Stratum 
8-17   Confirmed Abnormal  
1 
8-17   Unconfirmed Abnormal    2 
18+    Confirmed Abnormal 
3 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
On-Study Time (Years) 
 
The primary hypothesis test will be the Wald test of the treatment assignment variable when 
modeling the time to T1DM using the Cox model adjusting for baseline age and OGTT status 
(expanded eligibility criteria). To achieve statistical power of 80% for a one-sided Wald test at the 
0.025 significance level and the effect size described above, will require enrollment and follow-up 
of enough participants to observe 40 subjects with T1DM onset (38) (this is the “event” sample 
size in contrast to the study sample size). This event sample size reflects the combination of the 
study sample size and the amount of follow-up at which the fixed-sample primary hypothesis test 
may be conducted. Although group sequential testing will be employed, the method of Lan and 
DeMets maintains the power while controlling the type I error used in determining the fixed sample 
size. 
 
Participants <18yo will undergo an OGTT prior to the first infusion. The results of this OGTT will 
be incorporated into the analysis of the primary outcome variable but will not be used to determine 
eligibility for the study. The study sample size and duration are variable when fixing the “event” 
sample size. In the absence of any safety concerns and evoking any stopping rules, closing 
accrual should not occur until sufficient participants are accrued so that projections (based on 
the observed T1DM rates and the actual accrual pattern) indicate that within a reasonable follow-
up period the event sample size will be achieved. The constant hazard rate assumption is 
retained to compute the initial projection.  The projected annual accrual is 5.5, 5.1 and 1.6 for 
strata 1, 2 and 3, respectively.  Allowing for a 5% per year drop-out rate and the approximately 3 
dozen subjects already enrolled, the study will need to accrue a total of 71 subjects in 3 years 
and follow all those enrolled for another 4 years beyond the last enrolled subject to achieve a 
statistical power of 80% (39). 
 
Note the accrual period and the study sample size are only projections since the actual accrual 
rate, the control hazard rate and the loss to follow-up rate are estimates from the PTP Study or 
other similar trials.  Furthermore, the over-all hazard rate is sensitive to the age distribution of the 
enrolled study population, which is also an approximation. As the study progresses, projections 
of the study duration will be computed based on the observed data (noncomparative treatment 
analysis) and if in conflict, will be brought to the attention of  the DSMB and the TrialNet governing 
body to determine the best course of action. 
P ro p o r t io n  T 1 D - F re e 
0      0 . 1   0 . 2   0 . 3   0 . 4   0 . 5   0 . 6   0 . 7   0 . 8   0 . 9     1 


8 
 
6. 
Interim Monitoring Plan 
 
Interim analyses will be conducted periodically during the study and will be reviewed by the 
TrialNet Data and Safety Monitoring Board (DSMB) for assessment of effectiveness and safety; 
the TrialNet DSMB meets at least every six months to review study progress and safety. An 
independent medical monitor will closely monitor the events in the trial as described in section 
10.4. If a group sequential stopping boundary is crossed, the DSMB may terminate enrollment 
into the trial early.  The Lan-DeMets (7) spending function with an O’Brien-Fleming boundary will 
be used to protect the type I error probability for the primary outcome analyses, and to assess 
the significance of the interim results periodically during the trial.  The spending function that 
approximates the O’Brien-Fleming boundaries is: 
 
 
 
 
where t* 
0.025). 
is the information fraction ( 0 t* 1) and is the fixed-sample type I error (i.e., 
 
 
The DSMB will also be informed if there is a serious lack of evidence of a treatment effect (i.e. 
futility analysis). The boundaries are based on the paper by Lachin (41). The study should be 
stopped based on the futility of rejecting the null hypothesis at the completion of the trial if: 
ZHR (t*) 0 when 0.5 t*  0.8 or if ZHR (t* ) 0.8 when t*  0.8 . 
 
 
 
Using Lachin’s formulas a onetime use of either boundary for the design parameters above ( 
Z1Z12.8 ) raises the type II error to approximately 0.204 and 0.202, respectively. For 
larger values of t*
 the increase to the error probability is even less.  Furthermore, by the laws of 


9 
 
probability a single use of each rule will increase the type II error no more than the sum of the 
increase (i.e., 0.15+0.004+0.002 = 0.156). 
 
 
Additional analysis will assess potential adverse outcomes of treatment and will assess the 
incidence of all severe adverse events. 
 
7. General Considerations 
 
 
1. Analysis Populations 
 
The Intention to Treat Population (ITT) 
The intention to treat population comprises all randomized (as planned) subjects. 
 
Full Analysis Population 
The Full Analysis Set (FAS) will comprise all subjects who received any study drug and who 
participated in at least one post-baseline assessment. These will be analyzed as randomized. 
FAS will be the primary efficacy population. So, FAS is a subset of ITT. 
 
Per Protocol Population 
The Per Protocol Set (PPS) will comprise all subjects who did not substantially deviate from 
the protocol as to be determined on a per-subject basis before data base lock and unblinding.  
 
Safety Population 
All subjects who received any study treatment (including control) but excluding subjects who 
drop out prior to receiving any treatment. 
 
During accrual, 2 subjects enrolled on the >= 18 year of age stratum did not have a second OGTT 
prior to randomization to confirm abnormal glucose tolerance.  Eligibility is technically unknown 
without the results of the missing test. Given that the these subjects had an OGTT on study 
indicated abnormal glucose tolerance, not necessarily consecutive, we considered these 
conditions sufficient to retain these subjects for analysis. 
 
2. Timing of Analyses 
 
The final analysis will come after sufficient numbers of events (40 or more) have been reported 
in the FAS population to achieve the planned 80% statistical power for the primary analysis. 
 
3. Adjustment of Confidence Intervals and p-values 
 
There was 1 interim analysis conducted when 18 subjects were diagnosed with T1D. We applied 
the Lan-DeMets decision rule as outlined in the protocol and spent type I error of p = 0.00083, 
one-sided. Therefore, the final analysis should be conducted at 0.0242 level (to preserve type I 
error).  Given this almost negligible difference from 0.025, all p-values will be reported as if a 
fixed-sample size test was conducted and only noting the adjusted critical value p-value in the 
results section if the primary hypothesis test falls within the narrow range (i.e., 0.0242 – 0.025). 
 
 


10 
 
4. Missing Data 
 
In general, missing values will be assumed to be missing completely at random (MCAR) unless 
empirical evidence to the contrary can be established internal to the study.  The methodology 
employed in analyzing time-to-T1D utilizes whatever follow-up has been recorded for each subject 
(i.e., maximum utilization of follow-up time).  Presuming no evidence against MCAR, and the 
modest size of the trial, no methods will be employed to impute additional follow-up of subjects 
that drop out (i.e., lost to follow-up).  All secondary endpoints will use the complete-case analysis 
approach which limits the analytical cohort to those subjects that have the secondary endpoint of 
interest measured and recorded.  In modeling to adjust for risk factors associated with the 
endpoint (i.e. covariates), missing values will be assigned the mean from the known covariate 
cohort.  This simple rule will be employed only if the percent missing is less than 10% for the 
analytical cohort.  If the missing is 10% to 20% a separate indicator for missing will be included in 
the modeling.  If the missing in exceeds 20% the covariate will be removed from consideration. 
 
8. Safety Analyses 
 
Safety will be evaluated with summary of adverse events for the safety population. The 
following parameters will be assessed during the study: 
 
Adverse Events 
The summary statistics will be produced in accordance with Section 8. 
Treatment emergent adverse events (AEs) are those events that occur after the baseline 
assessment. Only Grade 2 or greater adverse events were reported in this study. The incidence 
of the following AEs will be reported: 
 
A tabular summary of AE will present: Number of subjects with any AE; Number of SAEs with 
outcome death; Number subjects with SAE; Number subjects with AEs leading to discontinuation 
of study drug, even if by protocol; Number of subjects with AEs leading to 
discontinuation of study; Total number of AEs; Total number of SAEs [TABLE]. 
 
The Adverse Events summary tables will include number of adverse events, the number of 
subjects in each treatment group in whom the event occurred, and the incidence of occurrence 
and should be grouped by system organ class, preferred terms and/or other interested variables 
(e.g., relatedness, intensity and seriousness). [TABLE] 
 
When calculating the incidence of adverse events, or any sub-classification thereof by treatment, 
time period, severity, etc., each subject will only be counted once and any repetitions of adverse 
events will be ignored; the denominator will be the total population size. 
Deaths, Serious Adverse Events and other Significant Adverse Events 
 
All formal testing of adverse effects will be based on the subject as the experimental unit. Thus 
for comparing incidence of AE within system organ by treatment group, a one-sided Fisher’s exact 
test will be conducted at 0.05 level (higher incidence in experimentally treated group is the 
alternative hypothesis). Also, highest AE grade will be determined for each subject and 
compared by treatment group using a 2 sample Wilcoxon test (one-sided at 0.05).  No correction 
for multiple testing will be employed in order that the statistical power is maintained. 
 
 
 
 


11 
 
9. Reporting Conventions 
 
P-values ≥0.01 will be reported to 2 decimal places; p-values less than 0.01 and >0.001 will be 
reported to 3 decimal places; p-values less than 0.001 will be reported as “<0.001”. The mean, 
standard deviation, and any other statistics other than quantiles, will be reported to one decimal 
place greater than the original data. Quantiles, such as median, or minimum and maximum will 
use the same number of decimal places as the original data. Estimated parameters, not on the 
same scale as raw observations (e.g. regression coefficients) will be reported to 3 significant 
figures. 
 
10. Per Protocol Analysis 
 
Quantifying the evidence of any dose response relationship is part of a complete analysis of any 
well run and completed clinical trial. This is especially true when the trial’s primary outcome is 
negative to explore whether there is evidence that deviations from the treatment protocol may 
have played a role in the negative outcome. Given this we plan to assess the treatment hazard 
ratio by the degree of compliance to the protocol scheduled dose in a quantitative manner. 
 
Using the Cox model we will assess the evidence for an effect of treatment compliance  including 
the entire cohort. The number of infusions of treatment and/or the treatment dose will be 
introduced into the model to determine its effect on risk.  If there is evidence that it is predictive 
(<=0.05, one-sided) then a treatment-infusions of therapy, or dose, interaction term will be 
introduced to see if there is a different compliance gradient between the two treatment groups. 
The procedure for including covariates, such as age, will follow the set up procedure as described 
above under Primary and Secondary analyses. 
 
 
 
11. Technical Details 
 
The analysis will be performed in R, S-Plus or SAS. 
The distributional assumptions as well as other assumptions underpinning the planned analyses 
will be checked. Final decisions regarding analysis methods and choice of explanatory variables 
will be taken then. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


12 
 
 
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