Conditions: Keratoconjunctivitis, Atopic Keratoconjunctivitis, Vernal Conjunctivitis, Allergic
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 12
Healthy volunteers: no

Brief summary:
Topical rVA576 for treatment of atopic keratoconjunctivitis (AKC), vernal keratoconjunctivitis (VKC),and severe allergic conjunctivitis (seasonal (SAC) or perennial (PAC)): a randomised placebo-controlled double masked parallel trial (TRACKER)

Detailed description:
Recombinant rVA576 is a small protein (16.7kDa) which has two independent actions. It inhibits the activation and cleavage of complement C5 and it binds and inactivates leukotriene B4 (LTB4). It acts on the complement system by preventing the cleavage of C5 by C5 convertase into C5a and C5b and so is effective in inhibiting terminal complement activity irrespective of the activating pathway.

Atopic keratoconjunctivitis (AKC) is a type of allergic conjunctivitis which involves mast cell activation due to the predominance of inflammatory mediators such as eosinophils and Th2-generated cytokines (Mishra et al. 2011).

Recombinant rVA576 eye drops solution is the investigational medicinal product. It is intended for ophthalmic use by topical administration to the eye.

Recombinant rVA576 is a compact small protein molecule with a lipocalin-like structure consisting of alpha helices and a beta barrel. There is a surface-active site which binds to the complement C5 molecule with a high affinity (KD 1.85 x 10-8 M) and an internalised active site which binds the small eicosinoid molecule leukotriene B4 (Hepburn et al. 2007).

Arms:
arm 1: Part 1: The first 3 patients selected for the study will be treated with the active drug in an open-label manner at intervals of 1 week and will have weekly clinic visits until Day 14, after which the visit will be every two weeks. When the first 3 patients have completed two weeks of treatment and the safety and tolerability data has been reviewed by the PI and an independent clinician, provided the data is favourable the randomisation process will begin (Part 2). The first 3 patients will continue treatment for a total of 8 weeks and will be assessed throughout the trial by the Principal Investigator according to the Schedule of Events arm 2: Part 2: Sixteen patients will be randomised 1:1. between active and placebo and patients allocated to either group will receive the appropriate product throughout the trial. arm 3: Part 2: Sixteen patients will be randomised 1:1. between active and placebo and patients allocated to either group will receive the appropriate product throughout the trial.

Interventions: intervention 1: rVA576 intervention 2: Placebo intervention 3: rVA576
Intervention descriptions: intervention 1: Part 1: The first 3 patients selected for the study will be treated with the active drug in open-label. intervention 2: Part 2: Sixteen patients will be randomised 1:1. between active and placebo and patients allocated to either group will receive the appropriate product throughout the trial. intervention 3: Part 2: Sixteen patients will be randomised 1:1. between active and placebo and patients allocated to either group will receive the appropriate product throughout the trial.

Protocol document:
Prot_000.pdf: 
 
CONFIDENTIAL 
Page 1 of 81 
 
Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
 
 
 
 
 
 
 
 
 
 
Topical rVA576 for treatment of atopic keratoconjunctivitis: a randomised 
placebo controlled double masked parallel trial (TRACKER) 
 
 
 
 
 
PROTOCOL NUMBER:  
AK701 
 
DATE:  
 
 
10 February 2020 
 
VERSION NUMBER: 
8.0 
 
Previous: 
DATE:  
 
 
27 November  2019 
 
VERSION NUMBER: 
7.1 
 
 
SPONSOR:   
 
Akari Therapeutics Plc 
 
EudraCT 
 
 
2017-002835-40 
NCT number  
 
NCT04037891 
 
 
This protocol, which is the property of Akari Therapeutics Plc, is provided subject to the 
recipient’s agreement to maintain it in confidence, and is intended solely for the guidance of 
this clinical investigation. This protocol may only be disclosed to those associated with the 
clinical investigation who have a need to know and who have agreed in advance to maintain it 
in confidence. It may not be disclosed to any third party or used other than for its intended 
purpose unless approved in advance and in writing by Akari Therapeutics Plc. 
 
 


 
CONFIDENTIAL 
Page 2 of 81 
 
Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
 
 
 
SPONSOR ADDRESS: 
75 Wimpole Street  
London W1G 9RT, UK 
 
AUTHORISED SIGNATORY:  
Dr Wynne H Weston-Davies MB FRCS 
75-76 Wimpole Street  
London W1G 9RT, UK 
 
 
SPONSOR’S MEDICAL EXPERT: 
Dr Wynne H Weston-Davies MB FRCS 
 
Telephone: +44 (0)20 8004 0268 
 
 
Mobile: +44(0)7801 281283 
 
 
  
 
 
 
 
 
 
Complement activity (CH50, drug levels, anti-drug antibodies): 
 
CH50 
The Doctors Laboratory 
The Halo Building 
1 Mabledon Place 
London, W1CH 9AX 
UK 
Unbound rVA576 and Anti-Drug antibody 
SYNLAB pharma institute AG 
Sternenfeldstrasse 14 
4127 Birsfelden, 
Switzerland 
 
 


 
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Page 3 of 81 
 
Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
TABLE OF CONTENTS 
TABLE OF CONTENTS .....................................................................................................3 
LIST OF ABBREVIATIONS ..............................................................................................6 
PROTOCOL SIGNATURE PAGE .....................................................................................8 
1 
PROTOCOL SYNOPSIS ..............................................................................................9 
2 
INTRODUCTION .......................................................................................................40 
2.1 
Overview of the Disease, treatment options and unmet need .......................40 
2.2 
rVA576 .........................................................................................................40 
3 
PRIOR EXPERIENCE WITH THE INVESTIGATIONAL PRODUCT ...................41 
3.1 
Investigational Product .................................................................................41 
3.2 
Summary of Nonclinical and Clinical Studies Relevant to the Clinical 
Trial ..............................................................................................................41 
3.2.1 
Non-clinical experience: ...................................................................42 
3.2.2 
Clinical experience ...........................................................................43 
3.3 
Summary of Known and Potential Risks and Benefits to Human Subjects .46 
3.4 
Description of/and Justification for the Route of Administration, Dosage 
Regimen and Treatment Period(s) ................................................................52 
3.4.1 
Post corneal graft in mice (personal communication) ......................53 
3.4.2 
Effect of topical rVA576 on Experimental Immune Conjunctivitis 
(EIC) .................................................................................................53 
4 
TRIAL POPULATION ...............................................................................................55 
4.1 
Inclusion Criteria ..........................................................................................55 
4.2 
Exclusion Criteria .........................................................................................55 
4.3 
Concomitant Therapy ...................................................................................56 
4.3.1 
Prohibited Medications .....................................................................56 
4.3.2 
Neisseria immunisation and antibiotic prophylaxis ..........................56 
4.4 
Contraception ................................................................................................57 
4.4.1 
Exposure of Partners During the Study ............................................57 
4.4.2 
Sperm Donation ................................................................................58 
4.4.3 
Egg Donation ....................................................................................58 
4.4.4 
Breast Feeding ..................................................................................58 
5 
TRIAL OBJECTIVES AND ENDPOINTS ................................................................58 
5.1 
Trial objectives .............................................................................................58 
5.2 
Endpoints ......................................................................................................58 
5.2.1 
Primary endpoint ...............................................................................58 
5.2.2 
Secondary endpoint ...........................................................................58 
5.2.3 
Exploratory endpoints .......................................................................59 
6 
TRIAL DESIGN AND PROCEDURES .....................................................................59 
6.1 
Trial Design ..................................................................................................59 
6.2 
Duration of trial ............................................................................................59 
6.3 
Dosing Scheme .............................................................................................61 


 
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10 February 2020 
6.4 
Method of Assigning Subjects to Treatments and Blinding (Part 2) ............61 
6.4.1 
Emergency Unmasking for Safety Reasons ......................................62 
6.5 
Compliance ...................................................................................................62 
6.6 
Missed Doses ................................................................................................62 
6.7 
Trial Procedures ............................................................................................62 
6.8 
Rescue Therapy ............................................................................................64 
6.9 
Safety and Efficacy Assessments .................................................................64 
6.9.1 
Clinical scoring .................................................................................65 
6.9.2 
Patient diary card ..............................................................................66 
6.10 
Laboratory Tests ...........................................................................................67 
6.11 
Medical Photography ....................................................................................67 
7 
REASON FOR WITHDRAWAL / EARLY DISCONTINUATION .........................67 
7.1 
Termination or Suspension of the Study ......................................................67 
7.2 
Withdrawal Criteria ......................................................................................68 
8 
SAFETY REPORTING ..............................................................................................68 
8.1 
Definitions ....................................................................................................68 
8.1.1 
Adverse Event ...................................................................................68 
8.1.2 
Adverse Drug Reaction (ADR) .........................................................69 
8.1.3 
Unexpected Adverse Reaction ..........................................................69 
8.1.4 
Serious Adverse Event or Serious Adverse Reaction .......................69 
8.1.5 
Suspected Unexpected Serious Adverse Reaction (SUSAR) ...........69 
8.2 
Procedures for Recording of Safety Events ..................................................69 
8.2.1 
General ..............................................................................................69 
8.2.2 
Pre-existing Conditions .....................................................................71 
8.2.3 
Overdose ...........................................................................................71 
8.2.4 
Pregnancy ..........................................................................................71 
8.2.5 
Reporting of Adverse Events ............................................................71 
8.3 
Reporting Procedures for Serious Adverse Events .......................................71 
8.4 
Expedited Safety Reporting ..........................................................................72 
8.5 
Development Safety Update Reports ...........................................................72 
9 
ACCOUNTABILITY PROCEDURES .......................................................................72 
10 COMPLIANCE ...........................................................................................................72 
11 STATISTICS ...............................................................................................................73 
11.1 
Statistical Methods .......................................................................................73 
11.2 
Primary Analysis ..........................................................................................73 
11.3 
Secondary Analyses ......................................................................................73 
11.4 
Number of Subjects ......................................................................................74 
11.5 
Significance Level ........................................................................................74 
11.6 
Missing, Unused or Spurious Data ...............................................................74 
11.7 
Deviations from the Statistical Plan .............................................................74 
11.8 
Subjects to be Included in the Analysis ........................................................75 
12 DIRECT ACCESS TO SOURCE DOCUMENTS .....................................................75 
13 QUALITY CONTROL AND QUALITY ASSURANCE ..........................................75 


 
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Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
14 ETHICAL CONSIDERATIONS ................................................................................75 
15 DATA HANDLING, RECORD KEEPING AND SAMPLE COLLECTION ...........75 
16 FINANCING AND INSURANCE .............................................................................76 
17 PUBLICATION POLICY ...........................................................................................76 
17.1 
Scoring of Clinical Signs and Symptoms – AKC and VKC ........................77 
17.2 
Scoring of Clinical Signs and Symptoms -  Severe Allergic Conjunctivitis 
- SAC or PAC ...............................................................................................78 
17.3 
Schedule of Events and Blood Draws ..........................................................79 
18 REFERENCES ............................................................................................................80 
 
LIST OF TABLES 
 
Table 1 
Summary of Treatment-Emergent Adverse Events (TEAEs) from AK577 ... 47 
Table 2 
Summary of Adverse Events Observed in AK578 ......................................... 49 
Table 3 
Summary of Treatment Related Adverse Events from AK579 (COBALT) ... 50 
Table 4 
Treatment Related Adverse Events for AK581 .............................................. 51 
Table 5 
Eye comfort scoring ........................................................................................ 66 
Table 6 
Laboratory Tests ............................................................................................. 67 
 
LIST OF FIGURES 
 
Figure 1 
AK577 Mean (+/-SD) CH50-Time Plot ......................................................... 44 
Figure 2 
Lactate dehydrogenase (LDH) level and complement activity (CH50 U 
Eq/mL) during treatment with rVA576 for AK578 ........................................ 45 
Figure 3 
Corneal graft survival in mice ......................................................................... 53 
Figure 4 
Effect of rVA576 on Experimental Immune Conjunctivitis ........................... 54 
Figure 5 
Effect of rVA576 on Experimental Immune Conjunctivitis at Day 12 (second 
experiment) ..................................................................................................... 54 
Figure 6 
Trial Design..................................................................................................... 60 
 
 


 
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Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
LIST OF ABBREVIATIONS 
 
Abbreviation Definition/Term 
AD 
Atopic Dermatitis 
ADA 
Anti-drug Antibody 
ADR 
Adverse Drug Reaction 
AE 
Adverse Event 
AKC 
Atopic keratoconjunctivitis 
ANOVA 
Analysis of Variance 
ARDS 
Adult Respiratory Distress Syndrome 
BP 
Blood Pressure 
BUT 
Break Up Time 
CIP 
Conjunctival Impression Cytology 
CRF 
Case Report Form 
CRO 
Contract Research Organisation 
CSLM 
Confocal Scanning Laser Microscopy 
CK 
Creatinine Kinase 
CT 
Computerised Tomography 
DLT 
Dose Limiting Toxicity 
EC 
Ethics Committee 
ECG 
Electrocardiogram 
ED 
Effective Dose 
EIC 
Experimental Immune Conjunctivitis 
EMA 
European Medicines Agency 
ELISA 
Enzyme-Linked Immunosorbent Assay 
ETDRS 
Early Treatment Diabetic Retinopathy Study 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HED 
Human Equivalent Dose 
HRP 
Horseradish Peroxidase 
ICH 
International Committee on Harmonisation 
IRB 
Institutional Review Board (or equivalent, e.g. Ethics Committee) 
IMP 
Investigational Medicinal Product 
ITT 
Intention to Treat 
i.v. 
Intravenous 
KS 
Keratoconjunctivitis sicca 
LLOQ 
Lower Limit of Quantification 
LPS 
Lipopolysaccharide  
MAC 
Membrane Attack Complex 
MAD 
Multiple Ascending Dose 
MedDRA 
Medical Dictionary of Regulatory Activities 


 
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Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
Abbreviation Definition/Term 
MHRA 
Medicines and Healthcare Regulatory Agency 
MTD 
Maximum Tolerated Dose 
MMP 
Mucous membrane pemphigoid 
MMP-9 
Matrix metalloprotease 9 
MW 
Molecular Weight 
NOAEL 
No Observable Adverse Event Level 
OD 
Oculus Dexter (Right Eye) 
OmCI 
Ornithodoros moubata Complement Inhibitor 
OS 
Oculus Sinister (Left Eye) 
OVA 
Ovalbumin  
PAC 
Perennial allergic conjunctivitis 
PAD 
Pharmacologically Active Dose 
PBS 
Phosphate Buffered Saline 
PI 
Principal Investigator 
PNH 
Paroxysmal Nocturnal Haemoglobinuria 
POM 
Prescription Only Medicine 
PP 
Per Protocol 
p.r.n 
pro re nata (as necessary) 
QA 
Quality Assurance 
QC 
Quality Control 
SAC 
Seasonal allergic conjunctivitis 
SAD 
Single Ascending Dose 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SJS 
Stevens Johnson Syndrome 
SS 
Sjögren’s Syndrome 
s.c. 
Subcutaneous 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TBUT 
Tear film break up time 
TCA 
Terminal Complement Activity 
TEAE 
Treatment Emergent Adverse Events  
TMF 
Trial Master File 
ULN 
Upper Limit of Normal 
VKC 
Vernal keratoconjunctivitis 


 
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Page 8 of 81 
 
Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
PROTOCOL SIGNATURE PAGE  
 
 
 
 
Protocol Title: 
 
Topical rVA576 for treatment of atopic keratoconjunctivitis: a 
randomised placebo controlled double masked parallel trial 
(TRACKER) 
 
AK701 
 
Authorized Sponsor Representative Signature: 
 
Signature: 
 
 
 
Date: 
 
 
Dr Wynne H Weston-Davies MB FRCS 
Akari Therapeutics Plc, 
75 Wimpole Street 
London 
W1G 9RT 
UK 
 
Principal Investigators Signatures:  
I agree with the content of this protocol and the confidential nature of the documentation 
made as part of this study. I also acknowledge that the Sponsor of the study has the right to 
discontinue the study at any time. I have read the protocol and understand it and will work 
according to it as well as per the principles of Good Clinical Practice, applicable laws and 
regulations and the Declaration of Helsinki. 
 
Signature: 
 
 
 
Date: 
 
 
 
 


 
CONFIDENTIAL 
Page 9 of 81 
 
Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
1 
PROTOCOL SYNOPSIS 
 
Protocol Title: 
 
Topical rVA576 for treatment of atopic keratoconjunctivitis: a 
randomised placebo controlled double masked parallel trial 
(TRACKER) 
Protocol Number: AK701 
Sponsor: 
 
Akari Therapeutics Plc 
75 Wimpole Street 
London W1G 9RT 
UK 
Investigational 
Product(s): 
rVA576 (2.5 mg/mL) eye drops solution or placebo. For Ophthalmic 
use. 
Phase of 
Development: 
I/II 
Indication: 
Moderate to severe atopic keratoconjunctivitis (AKC), vernal 
keratoconjunctivitis (VKC),and severe allergic conjunctivitis 
(seasonal (SAC) or perennial (PAC)) 
 
 
Study Center(s): 
 
Sites in United Kingdom and Spain 
Objectives: 
 
Primary Objectives: Safety and tolerability of topical rVA576 for 
AKC, VKC and severe allergic conjunctivitis (SAC or PAC) 
 
Secondary Objective:  
Efficacy of topical rVA576 for the treatment of patients with AKC, 
VKC, and severe allergic conjunctivitis (SAC or PAC) 
Study Design: 
Randomised, double masked, placebo controlled parallel group 
comparison with open label sentinel group. 
  
Part 1: The first 3 patients selected for the study will be treated with 
active drug in open-label manner at intervals of 1 week and will have 
weekly clinic visits until Day 14, after which the visit will be every 
two weeks. When the first 3 patients have completed two weeks of 
treatment and the safety and tolerability data has been reviewed by 
the PI and an independent clinician, provided the data is favourable 
the randomisation process will begin (Part 2). The first 3 patients will 
continue treatment for a total of 8 weeks and will be assessed 
through-out the trial by the Principal Investigator according to the 
Schedule of Events 
 
Part 2: Sixteen patients will be randomised 1:1. between active and 
placebo and patients allocated to either group will receive the 
appropriate product throughout the trial. 
 
All randomised patients will be seen and assessed at bi-weekly 
intervals until the end of the study by a masked observer who will not 
know to which product, active or placebo the patients have been 
randomised. Unmasking for individual patients may be ordered by: 


 
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Page 10 of 81 
 
Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
 
1. The PI 
2. Any medically qualified person having temporary or long-
term clinical responsibility for the well-being of the patient 
 
At the conclusion of the trial all patients will, if they wish, be 
informed as to the nature of the treatment they received. 
Planned Number 
of Subjects: 
up to 19  
Subject 
Population: 
Patients with moderate to severe AKC, VKC, or  severe allergic 
conjunctivitis(seasonal (SAC) or perennial (PAC)) 
Criteria for 
Inclusion and 
Exclusion: 
Inclusion Criteria: 
1. Aged 18 and above 
2. Diagnosis of moderate to severe AKC, VKC, or severe 
allergic conjunctivitis (seasonal or perennial). Defined as: 
• AKC, VKC  - a composite symptom/sign score from 
one eye of ≥ 18 out of 33 (see Clinical Scoring Section 
17.1) 
• Severe allergic conjunctivitis (SAC or PAC) -  a 
composite symptom/sign score from one eye of ≥ 15 
out of 27 (see Clinical Scoring Section 17.1) 
3. Will have had received some topical therapy during the last 
3 months without improvement but will not currently be 
receiving systemic immunotherapy. Topical therapy may be 
topical 
calcineurin 
inhibitors, 
antihistamines 
or 
corticosteroids alone or in combination. Lubricants or 
artificial tears will not a count as topical therapy for these 
purposes. 
4. Will have had at least 7 days without topical ocular 
corticosteroids prior to entry 
5. Willing to give informed consent  
6. Willing to use highly effective contraceptive precautions for 
the duration of the study and for 90 days after the last dose of 
IMP 
7. Willing to avoid prohibited medications for duration of study 
(see list of prohibited medications) 


 
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Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
 
Exclusion Criteria: 
1. Eye surface disease other than AKC, VKC or severe allergic 
conjunctivitis (SAC or PAC) 
2. Contact lens use during the study 
3. Complete or partial tarsorrhaphy. If such a procedure 
becomes necessary during the course of the trial patients may 
remain in the trial providing that at least 50% of the eye 
surface remains visible to slit lamp examination 
4. Ankyloblepharon of any degree at entry to the trial 
5. Known or suspected ocular malignancy 
6. Active ocular infection at entry to the trial. Patients with eye 
surface bacterial, viral, fungal or protozoal infection may 
enter the trial after elimination of the infection as confirmed 
by eye swabs 
7. Known or suspected uveitis 
8. Participation in any other clinical trial within 1 month of 
enrolment 
9. Use of any of the following prohibited medications: 
• Eculizumab 
• Any other investigational complement inhibitor 
whether systemic or topical (e.g. RA101495) 
• Montelukast 
• Zafirlukast 
• Pranlukast  
• Zileuton  
• Hypericum perforatum (St John’s wort) 
10. Corneal perforation 
11. Uncontrolled glaucoma (increase in dose of glaucoma 
medication or surgical intervention for glaucoma within 3 
months prior to entry) 
12. Pregnancy (females) 
13. Breast feeding (females) 
14. Known allergy to ticks or severe reaction to arthropod venom 
(e.g. bee or wasp venom) 
15. Use of topical ocular steroids within 7 days of the Screening 
visit 
16. Failure to satisfy the PI of suitability to participate for any 
other reason 


 
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Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
Treatment 
Regimen: 
 
Part 1: Sterile eye drops 0.25% w/v (2.5 mg/mL), solution in 6mL 
glass vials containing 1mL solution. Eye dropper pipettes will also 
be supplied.  
 
Part 2: Sterile rVA576 0.25% w/v (2.5 mg/mL) or placebo solution 
in 6 mL glass vials containing 1 mL. Eye dropper pipettes will also 
be supplied.  
 
The product should be administered as one drop to each eye every 
12 hours (i.e. twice daily) for a total of 56 Days.  
 
Background therapy:  
Patients should continue on whatever topical therapy they are on at 
the time of screening (ciclosporin or antihistamines) but this should 
remain stable during the trial. Lubricants and artificial tears may be 
used ad libitum but should not be administered for 15 minutes before 
or after the trial medication. In the event of worsening of signs or 
symptoms that, in the clinician’s opinion is so severe as to necessitate 
a change of medication, ciclosporin and/or antihistamines may be 
introduced or increased in dose/frequency and this will be considered 
as a treatment failure for purposes of efficacy analysis. Topical 
corticosteroids may be added following introduction or increase in 
ciclosporin/antihistamine therapy if considered necessary.  
 
Should not be on topical ocular steroids at start of the trial but may 
be used as rescue therapy during the trial if necessary (see above) 
Duration of 
Treatment: 
56 Days each for active and placebo dosing plus 7 (±2) days between 
screening and entry and 28 (±2) days between final trial visit and 
follow up visit. Total trial duration 6-12 months. 
Endpoints: 
 
Primary Endpoint:  
Incidence of ocular treatment emergent adverse events during the 
treatment period (adverse events which have occurred during the 
56 days following randomisation (Part 2 of the study only) will be 
considered in the analysis of the primary safety outcome). 
Secondary Endpoints will include: 
 
• Post-instillation comfort, as graded on patient diary cards at 
the following intervals Days 1-14, Day 15-28, Day 29-42 and 
Day 43-56 
• Visual acuity by Early Treatment Diabetic Retinopathy Study 
(ETDRS) charts comparison from Day 1 to Day 56 
• Change from Day 1 in composite clinical scores at Day 14, 
28, 42 and 56 
• Number and percentage of patients with MMP-9 positive 
levels at Days 1, 28 and 56 
• Change from Day 1 in Tear film break up time (TBUT) at 
Day 14, 28, 42 and 56 
 


 
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Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
Statistical 
Methods: 
The two parts of the study will be reported separately. Data from 
patients included in Part 1 will only be listed, while the following text 
applies for data from patients included in Part 2: 
 
Safety analyses will be performed using the Safety Analysis Set, and 
efficacy analyses will be performed using the Full Analysis Set. 
 
Ocular adverse events which have occurred during the treatment 
period will be considered in the analysis of the primary safety 
outcome. The difference between the two treatments in the 
proportion of patients experiencing any ocular treatment-emergent 
AEs will be reported with its associated 95% confidence interval. 
 
 


 
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Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
SUBSTANTIAL AMENDMENT 1 
 
Summary of Changes and Justification – Version 2.0 – Version 3.0 
 
Change 1: Title 
Previous text:  
Topical rVA576 for treatment of atopic keratoconjunctivitis: a randomised placebo single 
masked parallel trial (TRACKER) 
 
Current text:  
Topical rVA576 for treatment of atopic keratoconjunctivitis: a randomised placebo controlled 
double masked parallel trial (TRACKER) 
Justification: The design of the study has been changed to improve the scientific validity 
of the study and to protect the trial integrity by complete blinding.  
 
Change 2: Synopsis: study design 
 
Previous text: 
Randomised, single masked, placebo controlled parallel group comparison with open label 
sentinel group. 
  
Part 1: … When the first 3 patients have completed two weeks of treatment and the safety and 
tolerability data has been reviewed by the PI and Medical director, provided the data is 
favourable the randomisation process will begin (Part 2).  
 
Part 2: Sixteen patients will be randomised 1:1. Active and placebo drug product will be 
labelled X and Y, or vice versa, in a randomised fashion and patients allocated to either group 
will receive the appropriate product throughout the trial. 
 
All randomised patients will be seen and assessed at bi weekly intervals until the end of the 
study by a masked observer who will not know to which group, X or Y, the patients have been 
randomised. Even if the masked observer becomes aware of the group assignment they will 
continue to be masked. Unmasking of the nature of X and Y will not take place until after 
database lock. The PI will be aware of which patients have been allocated to X or Y but will 
remain unaware of the treatment being received unless the trial or patient is to be unmasked for 
safety reasons. Unmasking may be ordered by: 
 
1. The PI 
2. Any medically qualified person having temporary or long-term clinical responsibility for 
the well-being of the patient 
 
Should unmasking take place during the trial, although the PI will become aware of the nature 
of X and Y, the masked observer and the trial patients will, to the greatest extent possible, 
remain unaware of the identities of X and Y in order to maintain the integrity of the trial. 
 
Current text: 
Randomised, single double masked, placebo controlled parallel group comparison with open 
label sentinel group. 


 
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Protocol AK701 - version 8.0  
© Akari Therapeutics Plc 
10 February 2020 
 Part 1: When the first 3 patients have completed two weeks of treatment and the safety and 
tolerability data has been reviewed by the PI and Medical director an independent clinician, 
provided the data is favourable the randomisation process will begin (Part 2).  
Part 2: Sixteen patients will be randomised 1:1 Active and placebo drug product will be 
labelled X and Y, or vice versa, in a randomised fashion between active and placebo and 
patients allocated to either group will receive the appropriate product throughout the trial. 
All randomised patients will be seen and assessed at bi-weekly intervals until the end of the 
study by a masked observer who will not know to which group X or Y product, active or 
placebo the patients have been randomised. Even if the masked observer becomes aware of the 
group assignment they will continue to be masked. Unmasking of the nature of X and Y will 
not take place until after database lock. The PI will be aware of which patients have been 
allocated to X or Y but will remain unaware of the treatment being received unless the trial or 
patient is to be unmasked for safety reasons. Unmasking for individual patients may be 
ordered by: 
 
1. The PI 
2. Any medically qualified person having temporary or long-term clinical responsibility for 
the well-being of the patient 
 
Should unmasking take place during the trial, although the PI will become aware of the nature 
of X and Y, the masked observer and the trial patients will, to the greatest extent possible, 
remain unaware of the identities of X and Y in order to maintain the integrity of the trial. 
 
Justification: 
The design of the study has been changed to improve the scientific validity of the study 
and to protect the trial integrity by complete blinding.  
 
 
Change 3 Section 4.4 Contraception 
Previous text:  
Patients who are or become sexually active during the course of the study must use, with their 
partner, two approved methods of highly effective contraception from the time of signing the 
Informed Consent Form (ICF) until 90 days after the last dose of rVA576.  
Two or more of the following methods are acceptable and must include at least one barrier 
method: 
• … 
• Barrier methods must be used in conjunction with another method. 
 
Alternatively, true abstinence is acceptable when consistent with the patient’s preferred and 
usual lifestyle. If a patient is usually not sexually active but becomes active during the course 
of the study, they and their partner should use two of the contraceptive methods listed above. 
Any female patient who becomes pregnant during the course of the trial will be withdrawn 
from the trial unless she consents to a termination of the pregnancy. 
Current Text: 
All trial participants (male and female) of childbearing potential must use, with their 
partner, a combination of two an approved methods of highly effective contraception with at 


 
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least one barrier method of contraception from the time of signing the Informed Consent 
Form (ICF) until 90 days after the last dose of rVA576.  
The following methods of highly effective contraception are acceptable and must be 
combined with at least one of the barrier method of contraception 
• … 
• Barrier methods must be used in conjunction with a another method highly effective 
method of contraception listed above 
 
Alternatively, true abstinence is acceptable when consistent with the patient’s preferred and 
usual lifestyle. If a patient is usually not sexually active but becomes active during the course 
of the study, they and their partner should use two of the contraceptive methods listed above. 
Any female patient who becomes pregnant during the course of the trial will be withdrawn 
from the trial unless she consents to a termination of the pregnancy. 
 
Justification: To address the MHRA concerns on contraceptive measurements. 
 
Change 4 section 4.4.1 Exposure of Partners During the Study 
Previous text: 
There is a risk of drug exposure through ejaculate (which also applies to vasectomised males) 
which might be harmful to the sexual partners, including pregnant partners of male patients. 
Barrier contraception should be used throughout the study and for 90 days after the last day of 
IMP administration. 
 
New text: 
There is a risk of drug exposure through ejaculate (which also applies to vasectomised males) 
which might be harmful to the sexual partners, including pregnant partners of male patients. 
Barrier contraception A combination of an approved method of highly effective 
contraception with at least one barrier method of contraception should be used throughout 
the study and for 90 days after the last day of IMP administration. 
Justification: To address the MHRA concerns on contraceptive measurements. 
 
Change 5 section 6.1 Trial Design 
Previous text: 
Part 1: …When the third of the first 3 patients has completed their first 2 weeks treatment, the 
PI will review the safety, tolerability and ease of application for each patient before deciding 
to proceed to the randomised, single-masked comparative phase of the study (Part 2).  
Part 2: A randomised, single-masked, placebo-controlled trial of topical rVA576 or placebo 
eye drops in moderate to severe AKC. The part 2 trial population will comprise 16 patients 
who meet the inclusion and exclusion criteria (Section 4.1 and Section 4.2). In this part, the 
fully masked sub-investigator will see all patients to assess safety and conduct the clinical 
examinations used for the composite clinical scores.  
Current text: 
Part 1: When the third of the first 3 patients has completed their first 2 weeks treatment, the 
PI will review the safety, tolerability and ease of application for each patient before deciding 
to proceed to the randomised,  single double masked comparative phase of the study (Part 2).  


 
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Part 2: A randomised, single double-masked, placebo controlled trial of topical rVA576 or 
placebo eye drops in moderate to severe AKC. The part 2 trial population will comprise 16 
patients who meet all the inclusion and none of the exclusion criteria (Section 4.1 and Section 
4.2). In this part, the fully masked sub-investigator will see all patients to assess safety and 
conduct the clinical examinations used for the composite clinical scores.  
Justification: 
The design of the study has been changed to improve the scientific validity of the study 
and to protect the trial integrity by complete blinding.  
 
 
Change 6- Figure 6  
Previous text: single masked 
Current text: double masked 
Justification: 
The design of the study has been changed to improve the scientific validity of the study 
and to protect the trial integrity by complete blinding.  
 
Change 7-Section 6.3 Dosing Scheme 
Previous text: 
The patients will be randomised to receive either rVA576 active or placebo in single masked 
fashion. 
 
Current text: 
The patients will be randomised to receive either rVA576 active or placebo in single double 
masked fashion. 
 
Justification: 
The design of the study has been changed to improve the scientific validity of the study 
and to protect the trial integrity by complete blinding.  
 
Change 8 section 7.4: Method of Assigning Subjects to Treatments and Masking 
Previous text: 
After the initial 3 open label patients (Part 1), subsequent patients entering this clinical trial 
will be randomised in permuted blocks to either treatment X or Y (i.e. in each block of patients 
the actual order of X or Y will vary randomly). 
This master data set will be output from the system to generate an unmasked treatment 
sequence. The unmasked treatment sequence will be further manipulated to remove any 
unmasking information, thus creating a masked treatment allocation list which will be provided 
to the dispensing pharmacist. 
At the Screening visit, the investigator, or other site personnel under the direction of the 
investigator, should access the eCRF to register the subject, obtain the subject identification 
number. Upon confirmation of a subject’s eligibility at the randomisation visit, the investigator, 
or designee, will contact the Pharmacist to register the subject as randomized and obtain the 
assigned medication letter to be dispensed to this subject. This information will be recorded in 
the patient notes and transcribed eCRF.  
An X/Y randomisation where X is active and Y placebo (or vice versa) will be used in this 
study. It is accepted that this is less rigorous than a patient by patient randomisation and that 
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an individual patient but that is acceptable to the Sponsor given that there is no absolute 
requirement for the study to be either comparative or masked. X/Y randomisation allows an 
early indication of a separation, either of safety or efficacy, between the two groups whilst the 
trial is still in progress even though the actual nature of X and Y is still masked. 
 
Current text: 
After the initial 3 open label patients (Part 1), subsequent patients entering this clinical trial 
will be randomised in permuted blocks to either treatment X or Y (i.e. in each block of patients 
the actual order of X or Y will vary randomly) in a 1:1 fashion. 
This master data set will be output from the system to generate an unmasked treatment 
sequence. The unmasked treatment sequence will be further manipulated to remove any 
unmasking information, thus creating a masked treatment allocation list which will be provided 
to the dispensing pharmacist. 
At the Screening visit, the investigator, or other site personnel under the direction of the 
investigator, should access the eCRF to register the subject, obtain the subject identification 
number. Upon confirmation of a subject’s eligibility at the randomisation visit, the investigator, 
or designee, will contact the Pharmacist to register the subject as randomized and obtain the 
assigned medication letter next sequence number to be dispensed to this subject. This 
information will be recorded in the patient notes and transcribed eCRF.  
An X/Y randomisation where X is active and Y placebo (or vice versa) will be used in this 
study. It is accepted that this is less rigorous than a patient by patient randomisation and that 
there is a risk of the study becoming unmasked if, for instance, the mask has to be broken for 
an individual patient but that is acceptable to the Sponsor given that there is no absolute 
requirement for the study to be either comparative or masked. X/Y randomisation allows an 
early indication of a separation, either of safety or efficacy, between the two groups whilst the 
trial is still in progress even though the actual nature of X and Y is still masked. 
Justification: 
The design of the study has been changed to improve the scientific validity of the study 
and to protect the trial integrity by complete blinding.  
 
Change 9 Section 6.4.1 Emergency Unmasking for Safety Reasons 
Current text: 
In the unlikely event of an emergency where, in the opinion of the investigator, discontinuation 
of study treatment for an individual patient is not sufficient and the study treatment must be 
unmasked in order to evaluate further course of action, the investigator should contact the 
sponsor or designee’s Medical Monitor in the first instance to discuss the unmasking and to 
confirm that unmasking of the subject is necessary and directly impacts the subject’s immediate 
medical management.  
The investigator will consult the randomisation codes held by the CRO, the trial pharmacist, 
the Sponsor or his own copy, supplied in a sealed envelope and decide what, if any, further 
action to take. Since this will mean that he will be unmasked as to the nature of X and Y, the 
study as a whole will be unmasked as far as he is concerned but, to the greatest extent possible, 
other study personnel (e.g. the clinical examiner and study nurses) should remain masked,  
The information must not be included in the subject’s source files, until the conclusion of the 
study, to ensure the treatment assignment will remain blinded to the CRO monitor and other 
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Once the study treatment has been unmasked, the subject will complete the Early Termination 
visit and then discontinue study treatment. The subject will also be seen for post-treatment 
follow-up. 
 
Proposed text: 
In the unlikely event of an emergency where, in the opinion of the investigator, discontinuation 
of study treatment for an individual patient is not sufficient and the study treatment must be 
unmasked in order to evaluate further course of action, the investigator should contact the 
sponsor or designee’s Medical Monitor in the first instance to discuss the unmasking and to 
confirm that unmasking of the subject is necessary and directly impacts the subject’s immediate 
medical management. will have direct access to the randomisation codes for unmasking. 
The investigator will consult his own copy of the randomisation codes held by the CRO, the 
trial pharmacist, the Sponsor or his own copy, supplied in a sealed envelopes individually 
numbered for each patient and decide what, if any, further action to take. Since this will mean 
that he will be unmasked as to the nature of X and Y, the study as a whole will be unmasked 
as far as he is concerned but, to the greatest extent possible, other study personnel (e.g. the 
clinical examiner and study nurses) should remain masked,  
The information must not be included in the subject’s source files, until the conclusion of the 
study, to ensure the treatment assignment will remain blinded to the CRO monitor and other 
study personnel not involved with the subject’s immediate care.  
 
Change 10 section 6.7 Trial Procedures 
Previous text: 
Screening Period:  
Part 2- Randomisation: Upon confirmation of a subject’s eligibility at the randomisation visit, 
the investigator, or designee, will contact the Pharmacist to register the subject as randomised 
and obtain the assigned medication letter to be dispensed to this subject. 
Dosing Period: 
Part 2: The remaining 16 patients will be randomised 1:1. Active and placebo drug product 
will be labelled X and Y, or vice versa, in randomised fashion and patients allocated to either 
group will receive the appropriate medication throughout the trial. 
All randomised patients will be seen and assessed at Day 14 and thereafter at 2 weekly intervals 
by a masked observer who will not know to which group, X or Y, the patients have been 
randomised and, in any case, will be unaware of the identity of X or Y.  
 
Current text: 
Screening Period:  
Part 2- Randomisation: Upon confirmation of a subject’s eligibility at the Randomisation 
visit, the investigator, or designee, will contact the Pharmacist to register the subject as 
randomized and obtain the assigned medication letter to be dispensed to this subject number.  
Dosing Period: 
Part 2: The remaining 16 patients will be randomised 1:1 Active and placebo drug product will 
be labelled X and Y, or vice versa, in randomised fashion and patients allocated to either group 
will receive the appropriate medication throughout the trial. to active or placebo and will 


 
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receive the appropriate medication throughout the trial identified by their randomisation 
number. 
All randomised patients will be seen and assessed at Day 14 and thereafter at 2 weekly intervals 
by a masked observer. who will not know to which group, X or Y, the patients have been 
randomised and, in any case, will be unaware of the identity of X or Y.  
Justification: 
The design of the study has been changed to improve the scientific validity of the study 
and to protect the trial integrity by complete blinding.  
 
Change 11 Section 7.2 Withdrawal Criteria 
Previous text: 
All withdrawals must be documented in the eCRF. A patient may be withdrawn in any of the 
following circumstances: 
• Pregnancy unless the patient wishes to consent to a termination. 
 
Current Text: 
All withdrawals must be documented in the eCRF. A patient may be withdrawn in any of the 
following circumstances: 
• Pregnancy unless the patient wishes to consent to a termination. 
 
Justification: To address the MHRA concerns on pregnancy termination. 
 
Change 12 section 8.2.4 Pregnancy 
Previous text: 
…  If at least one of the above-mentioned examinations is positive, administration of the IMP 
must be stopped, and the patient must be immediately withdrawn from the study unless the 
patient consents to a termination in which case treatment would continue. 
 
Current text: 
If at least one of the above-mentioned examinations is positive, administration of the IMP must 
be stopped, and the patient must be immediately withdrawn from the study unless the patient 
consents to a termination in which case treatment would continue. 
Justification: To address the MHRA concerns on pregnancy termination. 
 
Change 13 Section 8.2.5 Reporting of Adverse Events 
Previous text: 
Transfusions of PRBC do not need to be reported as an AE. In the same way, the overnight 
stay for a transfusion of PRBC does not need to be reported as an SAE. 
On the other hand, progression of the underlying disease (at Investigator’s discretion) or 
potential complications have to be reported as adverse events. 
 
 


 
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New text: 
All adverse events, whether in the opinion of the investigator, drug-related or not will be 
reported in the CRF. 
Transfusions of PRBC do not need to be reported as an AE. In the same way, the overnight 
stay for a transfusion of PRBC does not need to be reported as an SAE. 
On the other hand, progression of the underlying disease (at Investigator’s discretion) or 
potential complications have to be reported as adverse events. 
Justification: This was an error in the protocol and it is now been confirmed that all 
adverse events will be reported. 
 
SUBSTANTIAL AMENDMENT 2 
 
Change 1: Protocol Signature Page 
 
Previous text: Mr Sajjad Ahmad, Moorfields Eye Hospital, London, EC1V 2PD 
 
Current text: Mr Sajjad Ahmad, Moorfields Eye Hospital, London, EC1V 2PD 
 
 
Justification: Sponsor is looking into opening one additional site in the UK 
 
 
Change 2: Synopsis 
 
Previous text: 
 
PI(s): 
Mr Sajjad Ahmad 
Study Center(s): 
 
Moorfields Eye Hospital 
London EC1V 2PD 
UK 
  
Current text: 
 
PI(s): 
Mr Sajjad Ahmad 
Study Center(s): 
 
Moorfields Eye Hospital  
London EC1V 2PD 
UK  
Sites in the United Kingdom 
  
Justification: Sponsor is looking into opening one additional site in the UK 
 
 
 
 
 
 
Previous text: 


 
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Duration of 
Treatment: 
56 Days each for active and placebo dosing plus 3 (±2) days between 
screening and entry and 28 (±2) days between final trial visit and 
follow up visit. Total trial duration 6-12 months. 
 
Current text: 
 
Duration of 
Treatment: 
56 Days each for active and placebo dosing plus 3 7 (±2) days 
between screening and entry and 28 (±2) days between final trial visit 
and follow up visit. Total trial duration 6-12 months. 
 
 
Justification: The screening window has been widened to allow additional time for results 
and arrival of medication at site. 
 
 
Change 3: Synopsis. Endpoints: Primary Endpoint and section 5.2.2 
 
• Previous text:  
• Post-instillation comfort, as graded on patient diary cards at Days 14, 28, 42 and 56 
• Improvement from Day 1 in composite clinical scores at Day 14, 28, 42 and 56 
• Number and percentage of patients with MMP-9 positive levels at Days 1, 14, 28, 42 
and 56 
• Comparison of the Conjunctival impression cytology results in each treatment group 
from Day 1 to Day 56 [NB these investigations will be done for qualitative research 
information only and will not form part of the statistical analysis since it is unlikely that 
the reporting will be completed for some months after study datalock] 
 
 
Current Text: 
• Post-instillation comfort, as graded on patient diary cards at the following intervals 
Days 1-14, Day 15-28, Day 29-42 and Day 43-56 
• Improvement Change from Day 1 in composite clinical scores at Day 14, 28, 42 and 
56 
• Number and percentage of patients with MMP-9 positive levels at Days 1, 14, 28, 42 
and 56 
• Comparison of the Conjunctival impression cytology results in each treatment group 
from Day 1 to Day 56 [NB these investigations will be done for qualitative research 
information only and will not form part of the statistical analysis since it is unlikely that 
the reporting will be completed for some months after study datalock] 
 
Justification: The language in the endpoints has been adapted: 
• Post instillation comfort will be reviewed by the investigator at the time the patient 
attends the clinical visit, but the  investigator will look at the comfort over the total 
time since the last visit (intervals) rather than a single timepoint as it was 
previously suggested in the protocol. 
• Improvement amended to change: as the sponsor cannot assume there will be an 
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• The number of MMP-9 has been reduced. This is a test which gives a binary result 
so after reviewing it has been decided that only 3 timepoints are needed. 
• Deleted conjunctival impression cytology endpoint as this is an exploratory 
endpoint and it was inadvertently repeated under secondary endpoints.  
 
Change 4: Section 4.3 Concomitant Therapy  
 
Previous text:  
All patients in the study must be receiving maximum topical ciclosporin (Ikervis). This should 
be administered as late as possible before retiring for the night. 
All patients will be receiving a topical antihistamine (olopatadine hydrochloride) once daily. 
This should be administered in the morning at least 15 minutes before the morning dose of 
rVA576. 
 
 
Current text:  
All patients in the study must be receiving maximum topical ciclosporin (Ikervis). This could 
be up to four times a day at investigator’s discretion. The last dose of ciclosporin  should 
be administered as late as possible before retiring for the night. 
All patients will be receiving a topical antihistamine (olopatadine hydrochloride) once twice 
daily. This should be administered in the morning at least 15 minutes before or after the 
morning dose of rVA576. 
 
Justification:  
The frequency of antihistamine has been corrected as olopatadine  is taken twice daily by 
all patients. 
 
Ciclosporin is indicated for the treatment of severe keratitis in patients with dry eye 
disease and the recommended dose is 1 drop of 0.1% to each eye once daily. It has become 
known that ophthalmologists in tertiary referral centres such as Moorfields Eye Hospital 
often increase the frequency of topical Ciclosporin to twice, three or four times a day 
before considering a switch to systemic immunosuppression. Therefore a proportion of 
patients attending outpatients clinics may be on increased frequency Ciclosporin dosing 
and the Sponsor would like to be able to include these patients in the study. However, no 
change in frequency of Ciclosporin dosing will be made once a patient has been selected 
for the study. 
 
 
Change 5: 6.3 Dosing Scheme 
 
Previous text: 
• Ciclosporin: IKERVIS eye drops 1 mg/ml emulsion one drop to the affected eye(s) at 
bedtime;  
• Topical antihistamine (olopatanol 0.2%, one drop to the affected eye(s) once daily) 
 
Patients will be instructed to use the antihistamine drop (olopatadine 0.2 %) as soon as possible 
after waking. They will be instructed to instill the first doses of the test eye drops 1 hour later 
 
Current text: 


 
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Ciclosporin: IKERVIS eye drops 1 mg/ml emulsion one drop to the affected eye(s) up to 
four times a day; 
• Topical antihistamine (olopatadine 0.2% 1 mg/mL, one drop to the affected eye(s) once 
twice a day) 
 
Patients will be instructed to use the antihistamine drop (olopatadine 1 mg/mL) as prescribed 
by the investigator. They will be instructed to instill the first doses of the test eye drops 1 hour 
later 
 
Justification:  
Ciclosporin is indicated for the treatment of severe keratitis in patients with dry eye 
disease and the recommended dose is 1 drop of 0.1% to each eye once daily. It has become 
known that ophthalmologists in tertiary referral centres such as Moorfields Eye Hospital 
often increase the frequency of topical Ciclosporin to twice, three or four times a day 
before considering a switch to systemic immunosuppression. Therefore a proportion of 
patients attending outpatients clinics may be on increased frequency Ciclosporin dosing 
and the Sponsor would like to be able to include these patients in the study. However, no 
change in frequency of Ciclosporin dosing will be made once a patient has been selected 
for the study. 
 
The frequency of antihistamine has been corrected as this is taken twice daily by all 
patients. The concentration of olopatadine has been corrected to reflect the fact that it is 
a 1mg/mL solution 
 
 
Change 6: section 6.4: Method of Assigning Subjects to Treatments and Masking 
 
Previous text: Upon confirmation of a subject’s eligibility at the Randomisation visit, the 
investigator, or designee, will contact the Pharmacist to register the subject as randomised and 
obtain the next sequence number to be dispensed to this subject. 
 
Current text: Upon confirmation of a subject’s eligibility at the Randomisation visit, the 
investigator, or designee, will contact the Pharmacist CRO, Tailored Clinical Research 
Solution (TCRS), to register the subject as randomised and obtain the next sequence number 
to be dispensed to this subject. 
 
Justification: Due to the possibility of a further site being added to the trial then it was 
decided that the randomisation could no longer be the responsibility of the Pharmacist 
and has been transferred to the CRO in charge of the study.  Since the randomisation is 
blinded then this will not mean that the CRO risks being unblinded. 
 
 
Change 7: section 6.7 Trial Procedures 
 
Previous text: 
 
The following investigations and diagnostic procedures will be carried out in this order at clinic 
visits in accordance with the Schedule of Events (i.e. not all evaluations will be carried out at 
every visit).  


 
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• Medical History, general and indication specific 
• Visual acuity by ETDRS 
• Clinical examination, gross and slit lamp with clinical scoring 
• Tear film break up time (TBUT) 
• Conjunctival impression cytology (CIP) 
• MMP-9 estimation using the Inflammadry® device 
• rVA576 blood levels 
• Systemic complement activity by serum CH50 ELISA activity. 
• Anti-drug antibodies (ADA) 
• Pregnancy Test 
• Adverse Events 
• Post instillation comfort as graded on patient diary cards (five-point grading from 
0 (perfectly comfortable) to 4 (Severe, intolerable itching or burning). For full description 
see Section 17.1. 
 
Current text: 
 
The following investigations and diagnostic procedures will be carried out in this order at clinic 
visits in accordance with the Schedule of Events (i.e. not all evaluations will be carried out at 
every visit).  
 
By the Investigator 
• Medical History, general and indication specific 
• Adverse Events 
• Post instillation comfort as graded on patient diary cards (five-point grading from 
0 (perfectly comfortable) to 4 (Severe, intolerable itching or burning). For full description 
see Section 17.1. 
• Clinical examination, gross and slit lamp with clinical scoring 
• MMP-9 estimation using the Inflammadry® device 
• Conjunctival impression cytology (CIP) 
• Tear film break up time (TBUT) 
 
By the nurse or other qualified person (these may be done on any order and either before or 
after the Investigator's examination) 
• rVA576 blood levels 
• Visual acuity by ETDRS 
• Systemic complement activity by serum CH50 ELISA activity. 
• Anti-drug antibodies (ADA) 
• Pregnancy Test 
 
Justification: This has been amended to provide clarity and further information on who 
will be doing which test. 
 
Previous text: 
 
Screening Period:  


 
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Patients may enter the trial within 3 days (±2 days) of screening providing that there has been 
no change in the inclusion/exclusion criteria. 
 
 
Current text: 
 
Screening Period:  
Patients may enter the trial within 3 7 days (±2 days) of screening providing that there has been 
no change in the inclusion/exclusion criteria. 
 
Justification: The screening window has been increased to allow additional time for 
results and arrival of medication at site. 
 
 
Previous text: 
 
Screening Period:  
Part 2- Randomisation: Upon confirmation of a subject’s eligibility at the Randomisation 
visit, the investigator, or designee, will contact the Pharmacist to register the subject as 
randomised and obtain the assigned medication number. This information will be recorded in 
the patient notes and transcribed eCRF. 
 
Current text: 
 
Screening Period:  
Part 2- Randomisation: Upon confirmation of a subject’s eligibility at the Randomisation 
visit, the investigator, or designee, will contact the Pharmacist CRO, TCRS, to register the 
subject as randomised and obtain the assigned medication number. This information will be 
recorded in the patient notes and transcribed eCRF. 
Justification:  
Due to the possibility of a further site being added to the trial then it was decided that the 
randomisation could no longer be the responsibility of the Pharmacist and has been 
transferred to the CRO in charge of the study.  Since the randomisation is blinded then 
this will not mean that the CRO risks being unblinded. 
 
 
Change 8: Sections 6.9 Safety and Efficacy Assessment 
Previous text: 
Conjunctival impression cytology will be done on both eyes at the start of the trial (Day 1) and 
at the conclusion of the trial (Day 56) for all patients. Analyses of the films will be done at 
Moorfields Hospital using an immunofluorescent technique (qualitative results only) and/or by 
flow cytometry (quantitative and qualitative results). These results will not be included in the 
primary statistical analysis and will be done for research information only as the reporting may 
not be available until some weeks after conclusion of the trial and database lock. 


 
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Current Text: 
Conjunctival impression cytology will be done on both eyes at the start of the trial (Day 1) and 
at the conclusion of the trial (Day 56) for all patients. Analyses of the films will be done at 
Moorfields Hospital using an immunofluorescent technique (qualitative results only) and/or by 
flow cytometry (quantitative and qualitative results). These results will not be included in the 
primary statistical analysis and will be done for research information only as the reporting may 
not be available until some weeks after conclusion of the trial and database lock. 
Justifications: This was an error as conjunctival impression cytology is an exploratory 
endpoint and should not be listed under this section. 
 
Change 9: Section 6.9.2 Patient Diary Card 
Previous text: 
All patients will be issued with a diary card and will be asked to score the least comfortable 
eye on a scale of 0 to 4 as shown in Table 5 below. A note will be made on the card as to which 
eye is being scored. If both eyes feel the same, the right eye will be scored. 
 
Current Text: 
All patients will be issued with a diary card and will be asked to score comfort the least 
comfortable eye on a scale of 0 to 4 as shown in Table 5 below.  The patient may make 
further comments (e.g. a difference in comfort between the two eyes) in the diary card. A 
note will be made on the card as to which eye is being scored. If both eyes feel the same, the 
right eye will be scored. 
Justification: This was an error in the protocol and it is now in line with the patient diary 
card instructions. 
 
Change 10: section 6.11 Medical Photography 
 
Previous text: none 
 
Current text: 
For better assessment of the eye, medical photography may be performed at investigator's 
discretion and photographs of both eyes may be obtained during the evaluation of the composite 
score and related ocular adverse events. During the consent obtained at screening the patients 
will be allowed to opt out of the medical photography. Declining consent for medical 
photography will not impact patient's participation in the study. Patient's confidentiality will 
be protected during medical photography of the eye. 
 
Justification: This was added to the protocol as Principal Investigator confirmed it is 
standard practice for documenting disease progression or improvement.   
 
 
Change 11: Section 11.1 Statistical Methods 
 


 
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Previous text: 
The Baseline value will be defined as the last non-missing measurement collected or derived 
prior to the Day 1 dose. 
 
New text: 
The baseline value will be defined as the pre-dose value on Day 1, if that is missing, it will be 
defined from the most recent value available. 
 
Justification: This sentence was amended for a more accurate definition of the baseline 
value 
 
AMENDMENT 3 
 
Summary of changes from Version 4.0 to Version 5.0 
 
Change 1 Exclusion Criteria # 11 
 
Previous Text: Glaucoma 
 
Current Text: Uncontrolled glaucoma (increase in dose of glaucoma medication or surgical 
intervention for glaucoma within 3 months prior to entry) 
 
Justification: A high proportion of AKC patients also have glaucoma. The investigators 
and the sponsor consider that this should not be a reason to exclude a patient from 
participating in this study providing that the condition has been stable or improving 
during the 3 months prior to entry as evidenced by there having been no increase in the 
dose of glaucoma medication or a surgical intervention for glaucoma within that period. 
 
 
Change 2: Synopsis Treatment Regime 
 
Previous Text: Should not be on topical steroids at start of the trial but may be used as rescue 
therapy during the trial if necessary. 
 
Current Text: Should not be on topical ocular steroids at start of the trial but may be used as 
rescue therapy during the trial if necessary. 
 
Justification: To add clarification that only topical ocular steroids are not allowed. 
Patient may continue to use topical steroids other than in the eye (eg steroid cream or 
ointment for atopic dermatitis). 
 
 
 
Change 3 section 6.3: Dosing Scheme 
 
Previous Text: Patients should not have used topical steroids for 1 month prior to entry to the 
trial but, at the discretion of the investigator, may receive them as rescue medication during the 
trial. 
 


 
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Current Text: Patients should not have used topical ocular steroids for 2 weeks prior to entry 
to the trial but, at the discretion of the investigator, may receive them as rescue medication 
during the trial. 
 
Justification: To add clarification that only topical ocular steroids are not allowed. 
Patient may continue to use topical steroids other than in the eye (eg steroid cream or 
ointment for atopic dermatitis). 
Wash out period for topical ocular steroids has been reduced. Topical ocular steroids 
have a short half life i.e. 2.8 hours for lotprednol etabonate (Comstock & DeCory 2012). 
Therefore, 2 weeks is deemed sufficient time.  
 
 
Change 4 Section 6.3: dosing Scheme 
 
Previous Text: All patients entering the trial will have been on maximal topical therapy for at 
least three months before entry on the study and will continue on this therapy (background 
therapy) for the duration of the study.  
Current Text: All patients entering the trial will have been on maximal topical therapy 
(meaning the maximal labelled dose or frequency of dosing) for at least three months before 
entry on the study and will continue on this therapy (background therapy) for the duration of 
the study.  
 
Justification: to add clarity on what it is considered maximal topical therapy.  
 
Change 5 section 6.8 Rescue Therapy 
 
Previous Text: Topical steroids will be considered Rescue Therapy.  
 
Current Text: Topical ocular steroids will be considered Rescue Therapy.  
 
Justification: To add clarification that only topical ocular steroids are not allowed. 
Patient may continue to use topical steroids other than in the eye (eg steroid cream or 
ointment for atopic dermatitis). 
 
AMENDMENT 4 
Justification:  The three patients in Part 1 who were treated open label and non-
comparative have now been treated. The third patient reached the end of week 2 but then 
withdrew consent for reasons not medication-related but had reached the point in the 
study at which the safety assessment was scheduled. This assessment has taken place and 
clearance for the study to proceed to Part 2, the randomised, double-masked, placebo-
controlled part, has been given. 
The three patients treated found the drops generally comfortable and well-tolerated, 
although full analysis of the patient diary cards after each instillation has not yet been 
undertaken. There were no serious or severe treatment emergent adverse events. A mean 
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baseline was seen in the two patients who completed the study and the patient who 
withdrew at 14 days had a 12% improvement from baseline. 
 
During Part 1 recruitment was considerably slower than anticipated at all three study 
sites. More than 100 patients were pre-screened but only 3 entered the study. Whilst there 
were a variety of reasons for this, including patients finding the weekly visits at the 
beginning of Part 1 too frequent and co-morbidities such as uncontrolled glaucoma, a 
substantial number of patients who were willing to enter the trial failed to meet the 
threshold score of 22 out of a possible total of 33 in the composite sign/symptom score.  
 
Summary of changes from Version 5.0 to Version 6.0 
 
 
Change 1 Inclusion Criterion # 2 
 
Previous text: Diagnosis of moderate to severe AKC with a composite symptom/sign score 
from one eye of ≥ 22 out of 33  
 
Current text: Diagnosis of moderate to severe AKC, VKC or PKC with a composite 
symptom/sign score from one eye of ≥ 18 out of 33 
 
Justification: The entry threshold of 22 in this study was arbitrary and was intended to 
include patients on the moderate – severe end of the spectrum of severity although there 
seems to be no agreed definition of what values constitute the boundaries between mild, 
moderate and severe using this scale. 
 
It is considered that, if the threshold entry score was lowered from 22 to 18, a significant 
extra number of potential patients would be eligible to join the trial and that all patients 
so recruited would still be considered to fall into the moderate to severe category of AKC. 
It is also considered that this change would have no implications as far as safety is 
concerned. 
 
VKC and PKC are pathophysiologically almost identical conditions to AKC and it is 
considered that the effect of rVA576 on these conditions will be similar to those seen in 
AKC. This change is being made to broaden the patient base and increase the rate of 
recruitment. 
 
Change 2 Exclusion Criterion #1 updated 
 
Previous text: Eye surface disease other than AKC 
 
Current text: Eye surface disease other than AKC, VKC or PKC 
 
Justification: As above for Change 2. 
 
 
Change 3 New Exclusion Criterion #15 added 
 
Previous text: N/A  
 


 
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Current text: Use of topical ocular steroids within 14 days of Screening visit 
 
Justification: It was considered that, although the text “Patients should not have used 
topical ocular steroids for 2  weeks prior to entry to the trial” appears in the body text, 
additional wording should be included in the eligibility criteria to ensure this is 
highlighted at the time of screening. 
 
Change 4 Section 4.3 Concomitant Medications 
 
Previous text: The evening dose of rVA576 should be administered at a minimum 30 minutes 
before ciclosporin. 
 
Current text: The evening dose of rVA576 should be administered at a minimum 15 minutes 
before ciclosporin. 
 
Justification – To make this easier for the patient to remember.  
 
Change 5 Section 6.3 Dosing Scheme 
Previous text: Patients should not have used topical ocular steroids for 2 weeks prior to entry 
to the trial 
 
Current text: Patients should not have used topical ocular steroids for 14 days prior to entry to 
the trial 
 
Justification: To clarify the exact timescale 
 
Change 6 Section 6.7 Trial Procedures 
Previous text: Patients may enter the trial within 7 days (±2 days) of screening providing that 
there has been no change in the inclusion/exclusion criteria. 
 
Current text:  Patients may enter the trial within 7 days (±2 days) of screening providing that 
there has been no change in the inclusion/exclusion criteria. It must be noted when organizing 
the first dosing visit that the IMP will take 4 days from the Randomisation to be sent to 
site and to be ready for dispensing. 
 
Justification – it was considered pertinent to remind the sites at this juncture that, 
although theoretically screening may not take 7 days, there is a time constraint placed 
upon them by the delivery and processing of the IMP 
 
Change 7 Section 6.5 
 
In addition, daily automated text messages reminders may be sent to the patient or the clinic 
staff may call the patient to ensure adherence to taking the study drug at the same time each 
day. 
 
Example text as follows (subject to slight changes): “A gentle reminder - please administer 
your medicine this morning/evening and record the time in the Patient Dosing Diary.  
 
Justification – Text message is no longer being offered to the patient 


 
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Change 8 Section 6.7 Trial Procedures 
 
Previous text: Conjunctival impression cytology (CIP)  
 
Current text: Conjunctival impression cytology (CIP) (Optional) 
 
Justification- Making this consistent with the protocol 
Change 9 Section 17.2 Schedule of Events and Blood Draws: 
 
Previous text: Serum pregnancy test will be performed at screening, Day 56. 
 
Current text: Urine pregnancy test to be performed at Screening, Day 1, Day 28, Day 56, Day 
84 and Unscheduled visit 
 
Justification: Serum pregnancy test will not be necessary, as urine pregnancy is sensitive 
enough to justify patient withdrawal from the study  
 
Change 10 Section 6.4  
Previous text: At the Screening visit, the investigator, or other site personnel under the direction 
of the investigator, should access the eCRF to register the subject, obtain the subject 
identification number. Upon confirmation of a subject’s eligibility at the Randomisation visit, 
the investigator, or designee, will contact the CRO, Tailored Clinical Research Solution 
(TCRS), to register the subject as randomised and obtain the next sequence number to be 
dispensed to this subject. This information will be recorded in the patient notes and transcribed 
eCRF. 
 
Current text: Upon confirmation of a subject’s eligibility at the Screening visit, the 
investigator, or other site personnel under the direction of the investigator, should access the 
eCRF to register the subject and obtain the Subject Identification number. In addition, the 
investigator, or designee, will contact the CRO, Tailored Clinical Research Solution (TCRS), 
to register the subject as randomised.  Sharp Clinical will provide the Randomisation ID to 
TCRS. TCRS will forward this information to sites for recording in the patient notes and 
transcribed eCRF.  
 
Justification- Updated process of randomisation 
 
Change 11 Schedule of Events and Blood Draws Table 17.2 
Administration of Drug added to Day 1,7,14,21,28,42 and 56. 
 
Justification: This had been omitted from previous versions. It was felt that, in order to 
clarify that sites must leave 4 days between Screening and first dose, in order to allow 
time for the IMP to be delivered and prepared, this was more easily clarified if IMP 
administration was overtly listed in this table. 
 
Change 12 Section 4.1 – Inclusion Criteria  
 
Previous Text: Willing to use adequate contraceptive precautions for the duration of the study 
and for 90 days. 


 
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Current Text: Willing to use highly effective contraceptive precautions for the duration of the 
study and for 90 days after the last dose of IMP. 
 
Justification: This make it more clear to the patient that they should use highly effective 
contraceptive precaution and not just adequate contraception for the duration of the 
study. Furthermore, the want to clear state that it is 90 days after the last dose and not 90 
days after the study.  
 
AMENDMENT 5 
 
Change 1 – Removal of PKC and addition of severe allergic conjunctivitis (seasonal (SAC) 
or perennial (PAC)) patients 
 
Section 1 - Indication: 
• Previous Text: Moderate to severe atopic keratoconjunctivitis (AKC), vernal 
keratoconjunctivitis (VKC) and perennial keratoconjunctivitis (PKC) 
 
• Current Text: Moderate to severe atopic keratoconjunctivitis (AKC), vernal 
keratoconjunctivitis (VKC), and perennial keratoconjunctivitis (PKC) and severe 
allergic conjunctivitis (seasonal (SAC) or perennial (PAC)) 
 
Section 1 – Primary Objectives: 
• Previous Text: Safety and tolerability of topical rVA576 for AKC, VKC and PKC 
 
• Current Text: Safety and tolerability of topical rVA576 for AKC, VKC and PKC and 
severe allergic conjunctivitis (SAC or PAC) 
 
Section 1 – Secondary Objectives: 
• Previous Text: Efficacy of topical rVA576 for the treatment of patients with AKC, 
VKC and PKC 
 
• Current Text: Efficacy of topical rVA576 for the treatment of patients with AKC, VKC 
and PKC and severe allergic conjunctivitis (SAC or PAC) 
 
Section 1 – Subject Population: 
• Previous Text: Patients with moderate to severe AKC, VKC or PKC 
 
• Current Text: Patients with moderate to severe AKC, VKC, or  PKC severe allergic 
conjunctivitis (seasonal (SAC) or perennial (PAC)) 
 
Section 1 and Section 4.1 – Inclusion Criteria: 
• Previous Text: Diagnosis of moderate to severe AKC, VKC or PKC with a composite 
symptom/sign score from one eye of ≥ 18 out of 33 (see Clinical Scoring Section 
17.1) 
 
• Current Text: Diagnosis of moderate to severe AKC, VKC or severe allergic 
conjunctivitis (seasonal or perennial). Defined as: 


 
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• AKC, VKC or PKC with - a composite symptom/sign score from one eye 
of ≥ 18 out of 33 (see Clinical Scoring 17.1) 
• Severe allergic conjunctivitis -  a composite symptom/sign score from 
one eye of ≥ 15 out of 27 (see Clinical Scoring Section 17.1) 
•  
Section 1 and Section 4.2 – Exclusion Criteria: 
• Previous Text: Eye surface disease other than AKC, VKC or PKC 
 
• Current Text: Eye surface disease other than AKC, VKC or  PKC severe allergic 
conjunctivitis (SAC or PAC) 
 
 
Justification: The term PKC replaced with seasonal allergic conjunctivitis (SAC) and 
perennial allergic conjunctivitis (PAC). As with AKC, these are  severe allergic eye 
diseases unresponsive to topical therapy. 
 
Justification for adding severe allergic conjunctivitis. 
Severe allergic conjunctivitis (SAC) has a similar aetiology to AKC and VKC, the 
principal differences being that patients may not necessarily have other forms of atopy 
such as asthma or eczema as manifested in AKC and that, by definition, the cornea is not 
affected as it is in the keratoconjucitivitides. However, SAC may progress to AKC in time 
and so it is important that adequate treatment be started before there is significant 
corneal damage. It is therefore proposed that SAC is added to the list of indications for 
this study. Since SAC patients do not have corneal involvement it is proposed that a 
modified form of the composite symptom and sign scoring system is used. This will utilise 
four symptoms and five signs scored from 0 to 3. In order to enter the study patients will 
have to score 15 out of a possible 27 instead of 18 out of a possible 33 as for AKC, VKC 
and PKC patients.  
 
 
Change 2 – Scoring system added for patients with severe allergic conjunctivitis (SAC 
or PAC) 
 
Section 1 and Section 4.1 – Inclusion Criteria: 
• Previous Text: Diagnosis of moderate to severe AKC, VKC or PKC with a composite 
symptom/sign score from one eye of ≥ 18 out of 33 (see Clinical Scoring Section 
17.1) 
 
• Current Text: Diagnosis of moderate to severe AKC, VKC or severe allergic 
conjunctivitis (seasonal or perennial). Defined as: 
• AKC, VKC or PKC with - a composite symptom/sign score from one eye 
of ≥ 18 out of 33 (see Clinical Scoring 17.1) 
• Severe allergic conjunctivitis -  a composite symptom/sign score from 
one eye of ≥ 15 out of 27 (see Clinical Scoring Section 17.1) 
 
Section 6.9.1 Clinical Scoring: 
• Previous Text: A composite score of 5 symptoms and 6 signs will be used 
 


 
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• Current Text: A composite score of 5 symptoms and 6 signs will be used for AKC 
and VKC patients, and a composite score of 4 symptoms and 5 signs will be used  
for patients with severe allergic conjunctivitis - SAC or PAC 
 
Section 6.9.1 ClinicalClincial Scoring: 
• Previous Text: The maximum possible score for symptoms and signs combined is 33. 
To qualify for entry to the trial patients must score a minimum of 18 at the Screening 
visit. 
 
• Current Text: The maximum possible score for symptoms and signs combined is 33 
(AKC/VKC) or 27 (severe allergic conjunctivitis) . To qualify for entry to the trial 
patients must score: 
 
AKC or VKC - a minimum of 18 at the Screening visit. ........... 
……….. 
Severe allergic conjunctivitis - SAC or PAC - a minimum of 15 at the Screening 
visit. 
The following symptoms will be scored: 
1. Itching 
2. Tearing 
3. Discomfort (burning, stinging or foreign body sensation) 
4. Photophobia 
 
The following signs will be scored: 
1. Upper tarsal conjunctival hyperaemia  
2. Upper bulbar conjunctival hyperaemia  
3. Chemosis  
4. Upper tarsal conjunctival papillae  
5. Blepharitis 
 
Section 17.2: 
• Previous Text: N/A 
 
• Current Text: New table inserted for scoring Severe Allergic Conjunctivitis - SAC or 
PAC 
 
Justification: Scoring modified in line with the inclusion of patients with seasonal allergic 
conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC) 
 
Change 3 
 
Section 1: 
Previous Text: Sites in United Kingdom 
 
Current Text: Sites in United Kingdom and Spain 
 
Justification: Trial sites to be opened in Spain to increase recruitment 


 
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Change 4 
Section 1 and Section 4.1 – Inclusion Criteria: 
Previous Text: Will have had maximal topical therapy for at least 3 months without 
improvement but will not currently be receiving systemic immunotherapy. 
 
Current Text: Will have had received maximal some topical therapy for at least during the 
last 3 months without improvement but will not currently be receiving systemic 
immunotherapy. Topical therapy may be topical cyclosporin, antihistamines or 
corticosteroids alone or in combination. Lubricants or artificial tears will not a count as 
topical therapy for these purposes. 
 
Justification for dropping the medication entry requirements 
Since initiating this study it has been found that there is a wide variation in medications 
that patients with moderate to severe AKC take. In large part this is because of reluctance 
by patients to use ciclosporin eye drops even when they have been prescribed by their 
ophthalmologist as a necessary part of their treatment. These drops are well known to 
cause stinging and burning in some patients and for that reason they often will not use 
them at all or use them intermittently or with poor compliance. Similarly some patients 
are reluctant to use antihistamine drops, mainly for perceived lack of efficacy. The 
previous requirement that patients entering this trial should be on maximal doses of 
ciclosporin for at least three months prior to entry has proved to be a major barrier to 
entry. 
After discussion with the investigators it has been decided that the strict entry 
requirements regarding prior medication at entry be dropped and that patients should 
be allowed to enter whatever topical medication they are taking at that point with the 
proviso that they should not be taking topical corticosteroids for at least 7 days prior to 
entry in order to avoid a steroid withdrawal rebound. Patients may continue to take their 
background medication during the trial if they wish. Any changes will be recorded. 
 
 
 
Change 5 
 
Section 1 and Section 4.2 – Exclusion Criteria: 
• 
Previous Text: Topical ocular corticosteroid use in the 14 days prior to entry 
 
• Current Text: Topical ocular corticosteroid use in the 147 days prior to entry 
 
 
Justification: See change 4  
 
Change 6 
Section 1 and Section 4.1 – Inclusion Criteria: 
Previous Text: History of atopy other than ocular (dermatitis, asthma, hay fever) 
 
Current Text: History of atopy other than ocular (dermatitis, asthma, hay fever) 
 
Justification: updated in line with inclusion of patients with seasonal allergic 
conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC) 


 
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Change 7 
Section 1 and Section 6.3 – Dosing Scheme: 
Previous Text: Background therapy:  
o Topical ciclosporin  
o Topical lubricant 
o Topical antihistamine 
 
Current Text: Background therapy:  
o Topical ciclosporin  
o Topical lubricant 
o Topical antihistamine 
Patients should continue on whatever topical therapy they are on at the time of screening 
(ciclosporin or antihistamines) but this should remain stable during the trial. Lubricants 
and artificial tears may be used ad libitum but should not be administered for 15 minutes 
before or after the trial medication. In the event of worsening of signs or symptoms that, 
in the clinician’s opinion is so severe as to necessitate a change of medication, ciclosporin 
and/or antihistamines may be introduced or increased in dose/frequency and this will be 
considered as a treatment failure for purposes of efficacy analysis. Topical corticosteroids 
may be added following introduction or increase in ciclosporin/antihistamine therapy if 
considered necessary. 
 
Justification: See change 4 
 
Change 8 
Section 6.8 – Rescue therapy: 
Previous Text: Topical ocular steroids will be considered Rescue Therapy.  
 
After entry into the trial, subjects will be recommended to not receive Rescue Therapy from 
the first dose of rVA576 as far as possible unless assessed by PI as needed. 
 
Current Text: Topical ocular steroids will be considered Rescue Therapy.  
In the event of worsening of signs or symptoms that, in the clinician’s opinion is so severe 
as to necessitate a change of medication, ciclosporin and/or antihistamines may be 
introduced or increased in dose/frequency and this will be considered as a treatment 
failure for purposes of efficacy analysis.  
 
The introduction or increase in dose/frequency of ciclosporin or antihistamines will be 
considered as Rescue Therapy. 
 
After entry into the trial, subjects will be recommended to not receive Rescue Therapy from 
the first dose of rVA576 as far as possible unless assessed by PI as needed. 
 
Justification: Updated to align with the changes in the background therapy. 
 
AMENDMENT 6 (NON-SUBSTANTIAL) 
 
Change 1 
Section 4.3 Concomitant Therapy 
 


 
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Previous Text: All patients in the study must be receiving maximum topical ciclosporin 
(Ikervis).   This could be up to four times a day at investigators discretion. The last dose of 
ciclosporin should be administered as late as possible before retiring for the night. The evening 
dose of rVA576 should be administered at a minimum 15 minutes before ciclosporin. 
All patients will be receiving a topical antihistamine (olopatadine hydrochloride) twice daily. 
This should be administered at least 15 minutes before or after the dose of rVA576. 
Current Text: These two paragraphs have been removed. 
Justification: These paragraphs should have been removed in protocol v7 to align with 
the changes in the background therapy  
 
 
AMENDMENT 7 
 
Change 1 
Protocol synopsis and Section 4.1 - Inclusion criterion 3: 
• Previous Text: Topical therapy may be topical cyclosporin, antihistamines or 
corticosteroids alone or in combination 
 
• Current Text: Topical therapy may be topical cyclosporin calcineurin inhibitors, 
antihistamines or corticosteroids alone or in combination 
 
Justification: In the UK almost all patients using topical ocular calcineurin inhibitors are 
prescribed ciclosporin A emulsion. This trial has now been expanded to include clinical 
sites in Spain where it is more usual to use topical tacrolimus. To accommodate this the 
permitted medications have been changed to allow any topical calcineurin inhibitor. 
 
Change 2 
Section 3.4.2 and 4.0: 
Removal of the terms: ‘steroid-resistant' and ‘resistant to topical corticosteroid treatment’. 
 
Justification: The intention of this trial is to treat patients with established, moderate to 
severe allergic conjunctivitis such as atopic keratoconjunctivitis (AKC). Most patients 
newly presenting with such conditions are normally treated initially with topical 
antihistamines. If these fail to control the condition the usual next step is to add 
intermittent topical corticosteroids of ascending potency before adding topical 
calcineurin inhibitors. Since initiating this trial, it has become apparent that not all 
patients are treated with topical corticosteroids before progressing to topical calcineurin 
inhibitors and so the term ‘steroid-resistant’ may not be appropriate in all cases. The 
composite clinical sign and symptom score used to assess the suitability of patients for 
entry to the trial ensures that only patients falling into the moderate to severe categories 
will in fact be deemed suitable and so the term ‘steroid-resistant’ is not a necessary or 
appropriate descriptor and will be removed. 
 
Change 3 
Section 4.3: 


 
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• Previous Text: All patients may use an eye lubricant pro re nata (p.r.n.). This should 
not be given within 15 minutes before or after rVA576. The exact choice of lubricant 
is left to the patient but should be one of the following: 
• Current Text: All patients may use an eye lubricant pro re nata (p.r.n.). This should not 
be given within 15 minutes before or after rVA576. The exact choice of lubricant is left 
to the patient but should be one of the following the following are recommended: 
Justification: In general ophthalmologists recommend the use of preservative-free 
lubricants as preservatives, particularly benzalkonium chloride, are known to be 
associated with eye irritation in some patients. For that reason, when the trial opened at 
Moorfields Eye Hospital in London, the hospital pharmacy list of non-preserved 
lubricants was included as permitted medications. Since then it has been found that some 
patients have their own preferred lubricants, some of which contain preservatives. It has 
therefore been decided to allow patients to use whatever lubricant or artificial tear they 
are most comfortable with. 
 
Change 4 
New wording: Interim analyses may also be conducted. Details of any analyses will be outlined 
in the SAP. 
Justification: When originally planned it was intended that the total duration of the trial 
would be less than 6 months. However, because the selection criteria were set to include 
patients on the moderate to severe end of the severity spectrum who had already been 
shown to be resistant to maximum topical therapy, recruitment has proved to be much 
slower than anticipated. As the trial has now exceeded its planned duration by more than 
a year and recruitment of the randomised part has now reached 50% of the planned 
population, it is now felt that an interim futility analysis is justified to see whether 
continuing the trial would be futile or would provide further useful information 
 
 
 


 
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2 
INTRODUCTION 
2.1 Overview of the Disease, treatment options and unmet need  
Atopic keratoconjunctivitis (AKC) is a type of allergic conjunctivitis which involves mast cell 
activation due to the predominance of inflammatory mediators such as eosinophils and Th2-
generated cytokines (Mishra et al. 2011). Treatment is initially with topical lubricants, 
antihistamines, immunomodulators (e.g. ciclosporin A) and intermittent steroids but systemic 
immunotherapy may become necessary in patients unresponsive to topical therapy. This 
usually affects 10 - 15% of the population with 5 – 10% of patients who experience severe 
AKC progressing to complete vision loss. AKC represents a severe chronic allergy primarily 
in adult population. AKC sufferers usually exhibit symptoms such as itching, burning, tearing, 
erythematosus and swollen eye lids. The disease may lead to corneal scarring and may also 
lead to vascularisation of the corneal Both eyes are usually affected equally. There is substantial 
unmet need for topical agents that will prevent the progression of corneal involvement and the 
requirement for systemic immunomodulators (La Rosa et al. 2013). 
Evidence for LTB4 being an important inflammatory mediator in AKC itself is limited and 
circumstantial. This is almost certainly because it has not hitherto been a subject of study in 
this condition since no negative evidence exists. However, there is more evidence for the role 
of LTB4 in other closely related eye surface inflammatory diseases including vernal 
keratoconjunctivitis (VKC), Sjögren’s syndrome (SS), mucous membrane pemphigus and 
contact lens-related dry eye. These conditions are histopathologically similar to AKC and the 
evidence consists mainly of a number of studies demonstrating high tear fluid levels of LTB4 
in these conditions. There have been a few attempts to intervene therapeutically by this route 
using cysteinyl leukotriene receptor antagonists and a meta-analysis of the literature showed 
that these agents were significantly more effective than placebo although less effective than 
oral antihistamines (Gane & Buckley 2013). There is less direct evidence for the role of 
complement activation in eye surface inflammation although complement is known to be an 
important driver of other forms of eye inflammation such as uveitis (Zhang et al. 2017).  
2.2 rVA576 
Recombinant rVA576 is a small protein (16.7kDa) which has two independent actions. It 
inhibits the activation and cleavage of complement C5 and it binds and inactivates leukotriene 
B4 (LTB4). It is a recombinant version of a near identical native protein isolated from the saliva 
of the Ornithodoros moubata tick where its function is to counteract host immune responses 
aimed at preventing successful blood feeding by the parasite (Hepburn et al. 2007). 
It acts on the complement system by preventing the cleavage of C5 by C5 convertase into C5a 
and C5b and so is effective in inhibiting terminal complement activity irrespective of the 
activating pathway. rVA576 is currently in clinical development for the treatment of 
complement mediated diseases including paroxysmal nocturnal haemoglobinuria (PNH) and 
atypical haemolytic uraemic syndrome (aHUS). In these conditions, it is administered by 
subcutaneous injection and has its effect through total blockade of the terminal complement 
system and prevention of the formation of the membrane attack complex (MAC). In these 
conditions the contribution, if any, of LTB4 inhibition is unclear and it is thought that 
complement plays the major role. 
LTB4 is a potent pro-inflammatory mediator which has powerful leukocyte attractant 
properties. It is released predominantly from epithelial cells including bronchoalveolar, 
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in circulation and it is believed to achieve its effect mainly through local release and the 
establishment of concentration gradients. In that respect, topical administration of rVA576, 
where possible, seems to offer advantages including sparing the infection protective effects of 
the systemic complement system.  
3 
PRIOR EXPERIENCE WITH THE INVESTIGATIONAL PRODUCT 
3.1 Investigational Product 
Recombinant rVA576 0.25% w/v (2.5 mg/mL) eye drops solution is the investigational 
medicinal product. It is intended for ophthalmic use by topical administration to the eye. 
Recombinant rVA576 is a compact small protein molecule with a lipocalin-like structure 
consisting of alpha helices and a beta barrel. There is a surface-active site which binds to the 
complement C5 molecule with a high affinity (KD 1.85 x 10-8 M) and an internalised active site 
which binds the small eicosinoid molecule leukotriene B4 (Hepburn et al. 2007).  
The molecular mass of rVA576 as predicted by molecular modelling and confirmed by mass 
spectrometry is 16.7855 kDa. The amino acid sequence of rVA576 showing disulphide bridges 
is shown below: 
 
The investigational medicinal product (IMP) solution is a sterile aqueous solution in phosphate 
buffered saline (PBS) where the Osmolarity and pH correspond to that of the ocular mucosa. 
The IMP for this clinical trial will be presented as single-use 6 mL glass vials each containing 
a nominal 1 mL of rVA576 solution at 0.25% w/v (2.5 mg/mL). Administration will be by 
single-use ocular pipettes.  
The IMP can be stored frozen at -20oC and will have an initial shelf-life of 12 months which 
may be extended as further stability data becomes available and once defrosted can be stored 
refrigerated at 2 – 8oC for 7 days. 
The placebo is an identical formulation to the active drug product without rVA576. The placebo 
solution will be provided as a nominal 1 mL eye drops in 6mL glass vials, and should be stored 
frozen at -20 oC with an initial shelf-life of 12 months and then refrigerated at 2-8 oC and stored 
for a total of up to 7 days at this temperature. 
3.2 Summary of Nonclinical and Clinical Studies Relevant to the Clinical Trial 
Recombinant rVA576 is a small protein (MW 16.8kDa) which is derived from a native protein 
discovered in the saliva of the Ornithodoros moubata tick (Nunn et al. 2005). Its function in 
tick saliva is to assist the parasite in feeding by suppressing the host immune reactions that 
would otherwise alert the host to the presence of the parasite which could then be removed by 
scratching or grooming. It has been known for some time that all species of ticks, which can 
feed undisturbed on their hosts including rodents, cattle, dogs and man, for periods of 14 days 
or more, secrete an array of immunomodulatory peptides and proteins in their saliva in order 


 
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to take control of their hosts’ local and systemic immune and inflammatory responses 
(Francischetti et al. 2009).  
The complement system is an important part of the innate immune system in many animal 
species including all mammals. There are three known pathways in the cascade: the classical, 
the alternative and the lectin but all converge on a final common pathway. At this point 
complement C5, a product of the classical pathway is acted upon by the enzyme C5 convertase, 
a product of the alternative pathway, to form C5a and a cluster of proteins (C5b, C6, C7, C8, 
and C9) which are collectively known as the membrane attack complex (MAC). It is known 
that many human autoimmune diseases are associated with inappropriate reactions to products 
of the final common pathway of the complement system. In particular myasthenia gravis, in 
which individuals form antibodies to their own acetyl choline receptors (approximately 70% 
of all myasthenia gravis (MG) patients) is associated with either inappropriate reaction to or 
over-production of MAC proteins (Lang & Vincent 2009).  
Recombinant rVA576 binds to the C5 molecule, preventing C5 convertase from activating and 
cleaving C5 to form C5a and the MAC. It appears to do this by interfering with a productive 
interaction between C5 and the C5 convertases, as rVA576 does not directly block the 
convertase cleavage site on C5 (Jore et al. 2016). The binding of rVA576 to C5 is high affinity 
(KD 1.0 x 10-9 M) and the rate of dissociation between C5 and rVA576 is very low, but the 
interaction is not irreversible (Roversi et al. 2013). High resolution X-ray crystallography has 
resolved the precise details of the binding interaction between rVA576 and C5 (Jore et al. 
2016). 
Inhibition of the C5 complement system is a therapeutic target in a wide range of autoimmune 
and inflammatory diseases including rheumatoid arthritis, Crohn’s disease, hypersensitivity 
pneumonitis, ischaemia reperfusion injury, sepsis, myasthenia gravis, paroxysmal nocturnal 
haemoglobinuria (PNH) and age related macular degeneration (Agostini et al. 2004, de Vries 
et al. 2003, Godau et al. 2004, Mollnes & Kirschfink 2006, Nozaki et al. 2006, Sarma et al. 
2006, Tuzun et al. 2008, Ward et al. 2003). 
Independently from complement inhibition, the rVA576 molecule also binds leukotriene B4 
(LTB4) at a separate, internalised binding site. This is a high-affinity binding site that 
outcompetes the natural receptors, BLT1 and BLT2 and results in an effectively irreversibly 
bound complex (Kuhn et al. 2016). It is thought that natural selection over many millions of 
years has paired these two activities in a single molecule because of synergies between the 
complement, eicosanoid and thrombotic pathways which have only recently become 
recognised but are still not completely elucidated (Hill et al. 2013). 
3.2.1 Non-clinical experience:  
In mechanistic pharmacology studies rVA576 has been administered to a number of species of 
laboratory animals including rats, mice, non-human primates, pigs and rabbits. Routes of 
administration have included intravenous, intraperitoneal, subcutaneous, inhaled and topical 
ocular. It has been effective in blocking the terminal complement pathway in all species tested 
to date and, in so doing, alleviating the effects of experimentally induced conditions including 
asthma, sepsis, adult respiratory distress syndrome (ARDS), myasthenia gravis, experimental 
autoimmune neuritis (EAN), bullous pemphigoid and myocardial infarction. For full details of 
these studies refer to the Investigators Brochure (IB). 
In toxicology studies rVA576 has been administered to rats, mice and non-human primates by 
the intravenous and subcutaneous routes and to rabbits by the topical ocular route. In these 
studies, which have included doses of up to 70 times the highest human equivalent dose (HED) 


 
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by the intravenous route, there have been no deaths attributable to the drug and minimal drug-
related adverse events. For full details of these studies refer to the IB. 
In the 3 day irritation study the average irritation index for the low dose was 0.75, for high dose 
it was 0.5 and for placebo (PBS vehicle) it was 0.33. All of these values are rated as no irritation. 
The conclusion was that rVA576 is non-irritable after repeated administration in the 
concentrations 1.25 and 5 mg/mL into the rabbits’ conjunctival sac used under the conditions 
of the study. A 56 Day ocular tolerance study with ocular irritation test was carried out in white 
New Zealand rabbits using rVA576 1.25 and 5 mg/mL or placebo (PBS) administered twice a 
day. The study showed only slight conjunctival redness in some animals from the active group.  
3.2.2 Clinical experience 
Experience gained with eculizumab (Soliris®) in the treatment of PNH and aHUS in several 
thousand patients for up to 13 years suggests that long term C5 inhibition is generally safe apart 
from the increased tendency to N. meningitidis infection which results from total blockade of 
the terminal complement system. The calculated minimum dose of rVA576 in humans required 
to achieve complete complement blockade is 0.57mg/kg (40mg for a 70kg individual). In this 
trial, the maximum delivered dose is 0.2mg (40µL per eye x 0.25%), which is two hundredth 
of the dose required to achieve total complement blockade. In the unlikely event that the entire 
topical dose will be systemically absorbed it is considered that it would have no impact on the 
complement blockade and therefore patients participating in this trial will not be required to 
take prophylactic measures against Neisseria meningitides such as vaccination and treatment 
with antibiotics. 
To date (May 2018) rVA576 has been administered to approx. 42 subjects, 32 healthy 
volunteers and 11 patients. In these patients, rVA576 has generally been found to be well 
tolerated. 
Phase Ia Trial VA576 
A single ascending dose (SAD) Phase Ia (VA576) clinical trial of rVA576, administered by 
s.c. injection, was performed to validate this route of administration and to establish the dose 
needed to completely inhibit C5 activation in the vascular compartment. The starting dose was 
one eighth of the dose found to induce total C5 blockade in rodent and non-human primate 
(NHP) PK studies. The dose was doubled in each of the succeeding 3 cohorts of 6 subjects, 
until in Cohort 4 the target dose expected to fully inhibit complement (0.57mg/kg) was reached. 
This s.c. dose of rVA576 was found to produce complete terminal complement blockade, as 
determined by Classical haemolytic 50% lysis Units Equivalent/ml (CH50 U Eq/ml) assay in 
all four subjects. 
In this study, there were no serious adverse event (SAEs) or dose related adverse events (AE) 
and the drug was well tolerated. 
AK577 
A Phase Ib dose range finding study (AK577) was conducted in which 4 cohorts of healthy 
volunteer subjects were studied. All subjects received ascending doses of 4 x 30 mg doses 
12 hourly (or the placebo equivalent), before going on to receive maintenance doses at 1 of 3 
dose levels for a further 5-days, or in the case of Cohort 4 for a further 19 days. 
There were 6 subjects in each of Cohort 1 (30mg once a day maintenance dose), Cohort 2 
(22.5 mg once a day maintenance dose) and Cohort 3 (15 mg once a day maintenance dose) 


 
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with 4 active subjects receiving rVA576 and 2 subjects receiving placebo in each cohort. 
Cohorts 1, 2 and 3 subjects were followed during a 2-day recovery period from Day 7 to 9. 
Cohort 4 (comprising 4 active subjects only) received ascending doses like Cohorts 1, 2 and 3 
and a maintenance dose of 22.5 mg once a day for 19 days. Cohort 4 subjects were followed 
during a 7-day recovery period from Day 21 to 28.  
As shown in Figure 1, the ascending dose rapidly reduced Terminal Complement Activity 
(TCA) below the lower limit of quantification (LLOQ) for the Enzyme-Linked Immunosorbent 
Assay (ELISA) CH50 assay and TCA was essentially completely inhibited at maintenance 
doses of 30mg once daily for 5 days and 22.5 once daily for both 5 and 19 days. 
One subject stopped treatment in Cohort 1. The subject, who had received 3 doses of rVA576 
and 4 doses of ciprofloxacin, experienced significantly raised creatinine kinase (CK) and serum 
myoglobin level on Day 2. The Investigator considered that this AE was reported as 
rhabdomyolysis. The Investigator considered it to be related to the administration of 
ciprofloxacin, as it is a known, but rare side effect of the drug.  
Figure 1 
AK577 Mean (+/-SD) CH50-Time Plot 
 
 
In general, all adverse events were mild to moderate in intensity and all resolved. For further 
details, please refer to the IB. 
In trial AK578, a single PNH eculizumab resistant patient has received daily doses of rVA576 
since the 8 February 2016 under protocol AK578. The patient is a 30-year-old male with PNH, 
(granulocyte clone size: 90%) and severe haemolysis (LDH 3 to 17 x upper limit of normal 
prior to treatment with rVA576), transient renal failure, extreme fatigue, symptoms of muscle 
dystonia and no history of thrombosis. He remained severely haemolytic during 6 months of 
eculizumab treatment despite adequate drug levels and no human anti-drug antibodies. Other 
causes of haemolysis were excluded. This patient was also shown to have a p.Arg885Ser 
polymorphism in C5 which rendered him non-responsive to eculizumab therapy. 
Recombinant rVA576 was initially administered by s.c. injection at an ablating dose of 
0.57 mg/kg on day 1, followed by a maintenance dose of 0.14 mg/kg per day thereafter. 
Peripheral blood samples were drawn for PK/PD. Since this was the first occasion that rVA576 


 
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had been administered to a PNH patient, it was important to tailor the dose for best therapeutic 
effect. The protocol therefore allowed doubling of the dose and/or shortening of the dose 
interval on the basis of clinical symptoms and CH50 levels to achieve adequate and sustained 
complement inhibition. 
There was a good initial response to the ablating dose of 0.57mg/kg rVA576, with CH50 levels 
decreasing from baseline 96 U Eq/mL to < 8 U Eq/mL the limit of quantification in the CH50 
ELISA. Clinical symptoms and laboratory markers of haemolysis improved during the first 
few days dosing at 0.14mg/kg every 24 hours. However as shown in Figure 2, 6 days into the 
treatment, pre-dose CH50 had increased to 20.9 U Eq/ml and the patient experienced 
haemolysis-associated symptoms with dark urine and no further decrease of his LDH. The 
same occurred after doubling of the dose to 0.29 mg/kg once per day so the dose and dose 
interval were changed to 0.14mg/kg administered every 12 hours. This resulted in stable 
complement inhibition with CH50 levels < 8 U Eq/mL (the limit of quantification) and no 
breakthrough symptoms. The LDH rapidly decreased to around 500 IU/L and thereafter to 
approximately 1.5xULN - indicated by the horizontal broken green line at 273 LDH IU/mL.  
There have been 7 SAEs to date (May 2018), but no treatment related SAEs and the most 
commonly reported AEs have been mild injection site reactions. No patient has had to have a 
dose adjustment or discontinued the trial due to drug related AEs. 
Figure 2 
Lactate dehydrogenase (LDH) level and complement activity (CH50 U 
Eq/mL) during treatment with rVA576 for AK578 
 
 
AK579 (COBALT), a 90 day, open label Phase II trial of rVA576 in complement-inhibitor 
naïve patients with PNH finished in December 2017 although a full dataset analysis has not yet 
been completed. Eight patients entered the trial, one of whom was withdrawn after 43 days for 
a suspected co-morbidity unrelated to the study drug. Preliminary results indicated that a daily 
dose of 45 mg given either singly or in two divided doses was sufficient to fully inhibit terminal 


 
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complement activity and control disease signs and symptoms. This dose was arrived at 
following an initial exploratory dosing regimen in which escalation to 30mg once daily or 
22.5 mg 12 hourly was found to be less effective in reducing and maintaining terminal 
complement activity. The 45 mg daily dose has been selected for all future clinical trials 
requiring systemic complement inhibition. All 7 patients who completed the trial remain in the 
long-term extension study AK581 (CONSERVE) at the current date (21 June 2018). 
The most common Treatment Emerging Adverse Events (TEAE) during COBALT was 
injection site reactions which accounted for the majority of the adverse events, all of which 
were all mild to moderate in intensity and declined towards the end of the 90-day trial. These 
reactions were in line with those expected with any drug delivered by the s.c. route. Anti-drug 
antibody studies have indicated that all patients treated for longer than 21 days develop low 
titre antibodies but that these are non-neutralising and begin to decline in magnitude from about 
Day 60 onwards. 
3.3 Summary of Known and Potential Risks and Benefits to Human Subjects 
The clinical implications of complement C5 blockade can be deduced from a combination of 
genetic and epidemiological studies, animal studies, clinical experience and experience with 
eculizumab. Complement C5 deficiency in humans is a rare, familial condition, caused by a 
variety of genetic defects, including mutations in the C5 exons. Those affected have a 
predisposition to gram negative infections, particularly meningococcal meningitis 
(Densen 1989), herpetic infections and seborrheic dermatitis (Bartholomew & Shanahan 
1990). 
In the SAD trial (VA576) the drug was well tolerated, there were no serious or severe adverse 
reactions and only mild injection site reactions. A total of three adverse reactions were reported 
in two of 16 subjects who received the active drug and in one of eight subjects who received 
placebo. There was no dose relationship, three of the four AEs occurring at the lowest dose and 
one in the third of four ascending doses. The AEs were mild and self-limiting and consisted of 
light headedness (1), symptoms of a cold (1), pain in the arm related to the injection site (1) 
and intolerance to bright light (1). 
In the multi-dose Phase Ib study (AK577) there was a subject in Cohort 1 who received three 
doses of rVA576 and 4 doses of ciprofloxacin and experienced significantly raised CK and 
serum myoglobin level on Day 2. The subject was clinically stable and troponin was negative. 
The Principal Investigator (PI) decided to stop rVA576 and ciprofloxacin and withdraw the 
subject. The subject did not experience any symptoms relating to the raised CK and myoglobin 
levels. The CK level dropped significantly by Day 6 and had returned to normal by Day 28. 
The Investigator considered that this AE was related to the administration of ciprofloxacin as 
it is a known but rare side effect of the drug. He did not consider that it was related to rVA576. 
(Table 1) shows the treatment-emergent AEs observed in study AK577. In general, all AEs 
were mild to moderate in intensity and all resolved. As described above, there was one patient 
who withdrew from treatment. 


 
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Table 1 
Summary of Treatment-Emergent Adverse Events (TEAEs) from AK577 
System Organ Class 
Preferred Term 
Doses 
Placebo 
N= 6 
N (%) 
rVA576  
30 mg od 5d 
N = 4 
N (%) 
rVA576  
22.5 mg od 5d 
N = 4 
N (%) 
rVA576 
15 mg od 5d 
N = 4 
N (%) 
rVA576 22.5 mg 
od 19d 
N = 4 
N (%) 
Total rVA576 
N = 16 
N (%) 
Number 
of 
subjects 
with AEs 
 
1 (16.7) 
2 (50.0) 
1 (25.0) 
1 (25.0) 
3 (75) 
7 (43.8) 
General disorders and 
administration site 
conditions 
Total number of 
subjects 
1 (16.7) 
0 
1 (25.0) 
1 (25.0) 
2 (50.0) 
4 (25) 
Injection site pain 
1 (16.7) 
0 
0 
1 (25.0) 
2 (50.0) 
3 (18.8) 
Injection site reaction 
0 
0 
0 
0 
2 (50.0) 
1(6.3) 
Influenza like illness 
0 
0 
1 (25.0) 
0 
0 
1 (6.3) 
Injection site bruising 
0 
0 
0 
0 
1 (25.0) 
1 (6.3) 
Injection site erythema 
0 
0 
0 
0 
1 (25.0) 
1 (6.3) 
Injection site swelling 
0 
0 
0 
0 
1 (25.0) 
1 (6.3) 
Musculoskeletal and 
connective tissue 
disorders 
Total number of 
subjects 
1 (16.7) 
1 (25.0) 
1 (25.0) 
1 (25.0) 
0 
3 (18.8) 
Back pain 
0 
0 
0 
1 (25.0) 
0 
1 (6.3) 
Musculoskeletal pain 
1 (16.7) 
0 
0 
0 
0 
0 
Pain in extremity  
0 
0 
1 (25.0) 
0 
0 
1 (6.3) 
Rhabdomyolysis 
0 
1 (25.0) 
0 
0 
0 
1 (6.3) 


 
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System Organ Class 
Preferred Term 
Doses 
Placebo 
N= 6 
N (%) 
rVA576  
30 mg od 5d 
N = 4 
N (%) 
rVA576  
22.5 mg od 5d 
N = 4 
N (%) 
rVA576 
15 mg od 5d 
N = 4 
N (%) 
rVA576 22.5 mg 
od 19d 
N = 4 
N (%) 
Total rVA576 
N = 16 
N (%) 
Nervous system 
disorders 
Total number of patients 
0 
1 (25.0) 
1 (25.0) 
0 
1 (25.0) 
3 (18.8) 
Headache 
0 
1 (25.0) 
1 (25.0) 
0 
1 (25.0) 
3 (18.8) 
Presyncope 
0 
0 
1 (25.0) 
0 
0 
1 (6.3) 
Eye Disorders 
Total number of 
subjects 
0 
2 (50.0) 
0 
0 
0 
2 (12.5) 
Lacrimation increased 
0 
1 (25.0) 
0 
0 
0 
1 (6.3) 
Photophobia 
0 
1 (25.0) 
0 
0 
0 
1 (6.3) 
Respiratory, thoracic 
and mediastinal 
disorders 
Total number of 
subjects 
0 
1 (25.0) 
0 
0 
0 
1 (6.3) 
Cough 
0 
1 (25.0) 
0 
0 
0 
1 (6.3) 
Rhinorrhoea 
0 
1 (25.0) 
0 
0 
0 
1 (6.3) 
Injury, poisoning, and 
procedural 
complications 
Total number of 
subjects 
0 
0 
0 
0 
1 (25.0) 
1 (6.3) 
Contusion 
0 
0 
0 
0 
1 (25.0) 
1 (6.3) 
Skin and s.c. tissue 
disorders 
Total number of 
subjects 
0 
0 
1 (25.0) 
0 
0 
1 (6.3) 
Rash pruritic 
0 
0 
1 (25.0) 
0 
0 
1 (6.3) 


 
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There has been a single patient enrolled in the PNH eculizumab resistant protocol (AK578) to 
date and one SAE was reported during the first week of treatment. This 30-year-old male 
patient experienced a PNH-related complaint (fatigue, dark urine) on Day 6 of daily 
maintenance dosing. He was admitted into the hospital for additional laboratory examinations 
and discharged on Day 7 and fully recovered. The Investigator considered that this SAE was 
unrelated to rVA576, but the dose was increased and haemolysis was brought under control. 
This patient also reported 28 AEs during the 22-month study period (Table 2). All AEs were 
mild or moderate, resolved spontaneously and no treatments were given.  
Table 2 
Summary of Adverse Events Observed in AK578 
System Organ Class 
Preferred Term 
Related 
Possibly Related 
No of subjects with AEs 
Total number of AEs 
31 
9 (29%) 
22 (71%) 
General disorders and 
administration site 
reactions 
Total no of AE’s 
9 
7 
Injection site reaction 
8 
0 
Pain injection site 
1 
0 
Flu-like symptoms 
0 
4 
Malaise 
0 
2 
Fatigue 
0 
1 
Nervous system 
disorders 
Total no of AE’s 
0 
7 
Headache 
0 
6 
Insomnia 
0 
1 
Respiratory and 
thoracic and 
mediastinal disorders 
Total no of AE’s 
0 
4 
Cough 
0 
1 
Dyspnoea 
0 
1 
Sore throat 
0 
2 
Gastrointestinal 
disorders 
Total no of AE’s 
0 
2 
Abdominal pain 
0 
1 
Nausea 
0 
1 
Skin and s.c. tissue 
disorders 
Total no. of AE’s 
0 
1 
Rash 
0 
1 
Vascular disorders 
Total no of AE’s 
0 
1 
Cold fingers and toes 
0 
1 
 


 
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In the AK579 study, seven out of the eight patients who participated in the study experienced 
TEAEs. The most common TEAE was injection site reactions which accounted for the majority 
of the adverse events, which were all mild to moderate in intensity and declined towards the 
end of the 90-day trial. These reactions were to be expected with a s.c. formulation. It should 
be noted that the clinical trial is on-going and so the adverse events are not yet finalized and 
may change once the data is fully cleaned and verified. 
Table 3 
Summary of Treatment Related Adverse Events from AK579 (COBALT) 
System Organ Class 
No. of 
Patients 
Related 
Possibly Related 
TOTAL 
N (%) 
Grade 
1 
Grade 
2 
Total 
Grade 
1 
Grade 
2 
Total 
Treatment Related Adverse 
events  
6 (68.5) 
42 
1 
43 
72 
8 
80 
123 
General disorders and 
administration site 
conditions 
6 (68.5) 
41 
1 
42 
63 
4 
67 
109 
Injection site erythema 
5 (62.5) 
29 
0 
29 
11 
1 
12 
41 
Injection site pruritus 
4 (50.0) 
5 
0 
5 
6 
3 
9 
14 
Injection site bruising 
3 (37.5) 
5 
1 
6 
1 
0 
1 
7 
Injection site pain 
3 (37.5) 
0 
0 
0 
24 
0 
24 
24 
Injection site swelling 
2 (25.0) 
1 
0 
1 
11 
0 
11 
12 
Injection site discharge 
1 (12.5) 
0 
0 
0 
8 
0 
8 
8 
Injection site hypersensitivity 
1 (12.5) 
0 
0 
0 
1 
0 
1 
1 
Injection site induration 
1 (12.5) 
0 
0 
0 
1 
0 
1 
1 
Injection site haematoma 
1 (12.5) 
1 
0 
1 
0 
0 
0 
1 
Gastrointestinal Disorders 
2 (25.0) 
1 
0 
1 
2 
0 
2 
3 
Abdominal discomfort 
1 (12.5) 
1 
0 
1 
0 
0 
0 
1 
Diarrhoea 
1 (12.5) 
0 
0 
0 
1 
0 
1 
1 
Paraesthesia oral 
1 (12.5) 
0 
0 
0 
1 
0 
1 
1 
Investigations 
1 (12.5) 
0 
0 
0 
2 
0 
2 
2 
Neutrophil count decreased 
1 (12.5) 
0 
0 
0 
1 
0 
1 
1 
White blood cell count 
decreased 
1 (12.5) 
0 
0 
0 
1* 
0 
1 
1 
Metabolism and nutrition 
disorders 
1 (12.5) 
0 
0 
0 
4 
0 
4 
4 
Hypophosphataemia 
1 (12.5) 
0 
0 
0 
2 
0 
2 
2 
Hypoproteinaemia 
1 (12.5) 
0 
0 
0 
2 
0 
2 
2 
Musculoskeletal and 
connective tissue disorders 
1 (12.5) 
0 
0 
0 
0 
1 
1 
1 
Osteoarthritis 
1 (12.5) 
0 
0 
0 
0 
1* 
1 
1 
Nervous System disorders 
1 (12.5) 
0 
0 
0 
1 
0 
1 
1 
Headache 
1 (12.5) 
0 
0 
0 
1 
0 
1 
1 
Skin and s.c. tissue disorders 
1 (12.5) 
0 
0 
0 
0 
3 
3 
3 
Pruritus 
1 (12.5) 
0 
0 
0 
0 
1 
1 
1 
Rash 
1 (12.5) 
0 
0 
0 
0 
2 
2 
2 
* AEs on-going, not resolved and not recovered 
 
 
In AK579 there have been four SAEs to date, none of which were treatment related. These 
SAEs have occurred in two patients. In one patient (826-001-102), there was a staphylococci 


 
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infection which was considered grade 3 and was determined to be a staphylococcus epidermidis 
infection, which resolved with concomitant medication (conmeds). One patient (826-102-001) 
has experienced angina pectoris (grade 3), dyspnoea (grade 2) and lethargy (grade 2). The 
angina pectoris resolved, dyspnoea was resolving and lethargy was on-going at the time of this 
report. None of the patients needed to have their treatment disrupted or changed. 
In the long-term safety study (AK581), only 2 patients have experienced treatment-related 
adverse events to date. As seen in AK579, these are mostly injection site reactions and they 
have all resolved. 
Table 4 
Treatment Related Adverse Events for AK581 
System Organ 
Class 
No. of  
Patients 
Related 
 
Possibly Related 
TOTAL 
N (%) 
Grade 
1 
Grade 
2 
Total 
Grade 
1 
Grade 
2 
Grade 
3 
Total 
All Related TEAEs 
3/7 
4 
0 
4 
0 
4 
1 
5 
9 
General disorders 
and 
administration site 
conditions 
2 
4 
0 
4 
0 
0 
0 
0 
4 
Injection site 
pruritus 
1 
1 
0 
1 
0 
0 
0 
0 
1 
Injection site pain 
1 
2 
0 
2 
0 
0 
0 
0 
2 
Injection site 
swelling 
1 
1 
0 
1 
0 
0 
0 
0 
1 
Gastrointestinal 
Disorders 
1 
0 
2 
2 
0 
0 
0 
0 
2 
Nausea 
1 
0 
1 
1 
0 
0 
0 
0 
1 
Vomiting 
1 
0 
1 
1 
0 
0 
0 
0 
1 
Abdominal pain 
1 
0 
0 
0 
0 
1 
0 
1 
1 
Investigations 
1 
0 
0 
0 
0 
1 
1 
2 
2 
Neutrophil count 
decreased 
1 
0 
0 
0 
0 
0 
1 
1 
1 
White blood cell 
count decreased 
1 
0 
0 
0 
0 
1 
0 
1 
1 
This data is preliminary and not source verified. 
 
Overall, the adverse event profile shows few adverse events other than injection site reactions, 
which are to be expected with daily s.c. injections. There has been one SAE which was the 
worsening of paroxysmal nocturnal haemoglobinuria which was classed as Grade 3 and was 
not related to rVA576. 
Going forward, Akari proposes not to report injection site reactions which are classified as 
Grade 1, but only injection site reactions which are grade 2 or above will be reported. All other 
adverse events, regardless of grade, will be reported. 
rVA576 is a xenologous protein with the recombinant protein originally derived from a cDNA 
encoding a tick salivary protein. Like other biological drugs (including antibodies), there is a 
possibility that chronic use of rVA576 may be associated with the formation of ADAs which 
could neutralise the effect of the drug or cause untoward adverse reactions. Approximately 
70% of both mice and NHPs receiving daily doses of rVA576 for 28 days develop detectable 
ADA. The antibodies were of low titre and did not neutralise the complement inhibitory activity 
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dosed with rVA576 for 21 days and in none of the subjects dosed with rV576 for 7 days. The 
antibodies were of low titre and did not neutralise the complement inhibitory activity of 
rVA576. All patients (n = 8), except one in AK579, have developed detectable ADA. 
Dependent on the subject, antibodies were first detectable between Day 14 to Day 90. Again, 
the antibodies were of low titre and do not neutralise the complement inhibitory activity of 
rVA576 (the first five of eight subjects in AK579 have been tested to date). The Dutch 
eculizumab resistant PNH patient who has been receiving rVA576 for more than 21 months 
first had detectable ADA at Day 16, which peaked at Day 60 and declined thereafter. The 
appearance of ADA does not appear to be associated with an increase in the rate or severity of 
injection site reactions. Our experience with rVA576 to date appears similar to patient 
experience with other parasite derived therapeutic molecules, such as the leech-derived 
anticoagulant lepirudin (Greinacher & Warkentin 2008), where the majority of patients develop 
detectable ADA which have no effect on the inhibitory function of the protein.  
The potential of rVA576 to induce phototoxicity is at present unknown. For this reason, patients 
taking rVA576 should be advised to avoid excessive exposure to sunlight or UV light (e.g. 
sunbeds) for the duration of the study and up to 7 days after last dose.  
3.4 Description of/and Justification for the Route of Administration, Dosage 
Regimen and Treatment Period(s) 
The justification for using rVA576 in the treatment of AKC is that it is a disease of the eye 
surface in which the first line of current treatment is with topical agents. It is only after the 
failure of such agents that treatment moves on to systemic corticosteroids, antihistamines and 
immunosuppressants, all of which carry a greater risk of systemic side effects. Recombinant 
rVA576 has been demonstrated to be bioavailable by the topical ocular route in two preclinical 
models, Post Corneal Graft and Experimental Immune Conjunctivitis. It has been shown to be 
well tolerated and non-irritant in rabbit eyes over 56 days and, in view of the association 
between complement and LTB4 in eye surface inflammation other than AKC it was considered 
to be justified to trial it by this route in this condition. 
The 0.25% (2.5 mg/mL) has been selected for this trial. In the 12-day preclinical experimental 
immune conjunctivitis (EIC) trial, this dose and 0.5% were equally effective and both were 
significantly superior to 0.125% and 0.0625%. The lowest of the two most effective doses was 
therefore selected. 
AK701, whilst not a first in man study, is a first study by this route. Additionally, in this early 
development study, the patients (or their carers) will be using screw top vials and separate 
pipettes with rubber bulb dispensers with which patients may not be familiar with. For these 
reasons, the principal investigator (PI) wishes to treat the first three patients in an open-label, 
non-comparative manner, starting one week apart (Part 1) in order to gain reassurance that 
subsequent patients will be capable of dosing using these devices.  
The first dose to these three patients will be given in the clinic observed by the PI. Given the 
current systemic clinical experience with rVA576 and the favourable ocular irritation and 
tolerance results, no particular safety issues are anticipated in this or other parts of the study. 
Although information on patient device handling could also be obtained using placebo product, 
there would be no justification for keeping patients on placebo in open-label fashion for 8 
weeks and therefore it is proposed that they will all receive active drug which will provide 
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3.4.1 Post corneal graft in mice (personal communication) 
This study, conducted by Professor John Forrester in Aberdeen, was designed to examine the 
effect of rVA576 on mismatched corneal grafts in mice. Recombinant rVA576 was 
administered as topical ocular drops (0.2%) and systemically (0.6mg/kg) by intravenous 
injection to BALB/c mice who had received cross-strain mismatched corneal grafts for 14 days 
once daily after graft. Time to graft rejection was assessed using a Kaplan Meier survival 
design. The results, shown in Figure 3 below, indicated that rVA576 had a trend towards 
reducing the rate of graft rejection when used topically but this did not quite reach statistical 
significance. When used systemically it had no effect. 
Figure 3 
Corneal graft survival in mice 
 
 
3.4.2 Effect of topical rVA576 on Experimental Immune Conjunctivitis (EIC) 
An initial non-GLP study was conducted by Dr Virginia Calder at the Institute of 
Ophthalmology, London using the method of Adahome (Ahadome et al. 2016) C57 BL6 mice 
were sensitized to OVA for 14 days by systemic injection with adjuvant and then eyes were 
challenged daily with topical OVA. The resulting eye surface inflammation was treated from 
Day 3 onwards with rVA576 at one of four concentrations (0.0625%, 0.125%, 0.25% and 
0.5%) or with EV131, a histamine binding protein, or a combination of rVA576 and EV131. 
No effect was seen from Day 3 to Day 5 but on Day 6 (the final day before the experiment was 
terminated) a significant fall in inflammation as assessed clinically by a masked observer was 
seen in mice treated with the three lowest concentrations of rVA576. This correlated with the 
subsequent eye histology (see Figure 4 below). Flow cytometry confirmed a significant 
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Figure 4 
Effect of rVA576 on Experimental Immune Conjunctivitis 
 
 
Following the study summarised above, a further non-GLP was undertaken by Dr Calder at the 
Institute of Opthalmology (Personal Communication) in order to confirm the previous results, 
to determine if the anti-inflammatory effect persisted for longer than 4 days, to further explore 
the optimum dose and to compare the anti-inflammatory effect to ciclosporin A, corticosteroid 
(dexamethasone) and the combination of both.  
The second EIC study confirmed the earlier result, showed that the duration of effect lasted 
until at least Day 12 of treatment (the end of the study) and showed that 0.5% and 0.25% were 
equally effective and superior to the lower concentrations (Calder V. Personal 
Communication). For that reason 0.25% has been selected as the concentration for the clinical 
study. The study also showed that topical rVA576 at 0.25% and 0.5% was as effective as topical 
ciclosporin A alone or in combination with dexamethasone and at Day 12, but not at other time 
points, was superior to dexamethasone alone (Figure 5). 
Figure 5 
Effect of rVA576 on Experimental Immune Conjunctivitis at Day 12 
(second experiment) 
 
 


 
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Taken overall, these results suggested that rVA576 has an anti-inflammatory effect on the eye 
either when injected or used topically.  
Current rabbit eye toxicology supports a study of up to 56 days (see Section 3.2.1). The 
proposed study will last 56 days (8 weeks) per patient since it is considered that in moderate to 
severe, AKC a study of this length will have the best chance of demonstrating clinical effect. 
4 
TRIAL POPULATION 
The study population will be up to 19 patients above the age of 18 with moderate to severe 
AKC, VKC or severe allergic conjunctivitis (SAC or PAC). Patients may be male or female. 
4.1 Inclusion Criteria 
1. Aged 18 and above 
2. Diagnosis of moderate to severe AKC,VKC or severe allergic conjunctivitis (seasonal or 
perennial). Defined as: 
• AKC, VKC - a composite symptom/sign score from one eye of ≥ 18 out of 
33 (see Clinical Scoring 17.1) 
• Severe allergic conjunctivitis -  a composite symptom/sign score from one 
eye of ≥ 15 out of 27 (see Clinical Scoring Section 17.1) 
3. Will have had received some topical therapy during the last 3 months without improvement 
but will not currently be receiving systemic immunotherapy. Topical therapy may be 
topical calcineurin inhibitors, antihistamines or corticosteroids alone or in combination. 
Lubricants or artificial tears will not a count as topical therapy for these purposes. 
4. Will have had at least 7 days without topical ocular corticosteroids prior to entry 
5. Willing to give informed consent  
6. Willing to use highly effective contraceptive precautions for the duration of the study and 
for 90 days after the last dose of IMP. 
7. Willing to avoid prohibited medications for duration of study (see list of prohibited 
medications) 
 
4.2 Exclusion Criteria 
1. Eye surface disease other than AKC, VKC or  severe allergic conjunctivitis (SAC or PAC) 
2. Contact lens use during the study 
3. Complete or partial tarsorrhaphy. If such a procedure becomes necessary during the course 
of the trial patients may remain in the trial providing that at least 50% of the eye surface 
remains visible to slit lamp examination 
4. Ankyloblepharon of any degree at entry to the trial 
5. Known or suspected ocular malignancy 
6. Active ocular infection at entry to the trial. Patients with eye surface bacterial, viral, fungal 
or protozoal infection may enter the trial after elimination of the infection as confirmed by 
eye swabs 
7. Known or suspected uveitis 
8. Participation in any other clinical trial within 1 month of enrolment 
9. Use of any of the following prohibited medications: 
– Eculizumab 
– Any other investigational complement inhibitor whether systemic or topical (e.g. 
RA101495) 
– Montelukast 
– Zafirlukast 
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– Zileuton  
– Hypericum perforatum (St John’s wort) 
10. Corneal perforation 
11. Uncontrolled glaucoma (increase in dose of glaucoma medication or surgical intervention 
for glaucoma within 3 months prior to entry) 
12. Pregnancy (females) 
13. Breast feeding (females) 
14. Known allergy to ticks or severe reaction to arthropod venom (e.g. bee or wasp venom) 
15. Use of topical optical steroids within 7 days of the Screening Visit 
16. Failure to satisfy the PI of suitability to participate for any other reason 
 
4.3 Concomitant Therapy 
At screening, the PI will ask the patient about any current ongoing medications. During the 
course of the study, patients should be reminded to record any concomitant medications in their 
patient diaries and the PI should discuss medications at each visit. All concomitant medications, 
including herbal and vitamin supplements, must be recorded into the electronic case report 
form (eCRF). 
All patients may use an eye lubricant pro re nata (p.r.n.). This should not be given within 15 
minutes before or after rVA576. The exact choice of lubricant is left to the patient but the 
following are recommended: 
Unpreserved carmellose 1% (e.g. Cellusan) 
Unpreserved sodium hyaluronate ~0.1% (e.g. Hylo-Tear) 
Unpreserved sodium hyaluronate ~0.2% (e.g. Hylo-Forte) 
 
 
4.3.1 Prohibited Medications 
Use of systemic immunosuppressives, antihistamines or corticosteroids during the trial is 
forbidden. Other drugs acting directly on the complement or eicosanoid systems either topically 
or systemically including; 
• Eculizumab 
• Any other investigational complement inhibitor whether systemic or topical (e.g. 
RA101495) 
• Montelukast 
• Zafirlukast 
• Pranlukast  
• Zileuton  
• Hypericum perforatum (St John’s wort) 
 
4.3.2 Neisseria immunisation and antibiotic prophylaxis 
Neisseria meningitidis immunisation and antibiotic prophylaxis are not considered necessary 
for patients participating in this trial because the maximum dose of rVA576 that patients would 
be exposed, to even if the total dose from both eyes was to be systemically absorbed, would be 
0.1mg. The dose needed to completely ablate the terminal complement system in a 70kg adult 
is approximately 40mg and it is considered that 0.1mg would have no inhibitory effect on 
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4.4 Contraception 
There are no specific, identified risks to mother or foetus from rVA576 therapy. A segment 1 
reproductive toxicology study has been undertaken in mice (YUU0001) to assess the effects of 
0, 0.5, 5 and 10 mg/kg/day rVA576 on the fertility and early embryonic development of the 
mouse when administered for at least 14 days before and during pairing, and then to Day 6 of 
gestation in females and until the day before necropsy for males. The study reported no deaths 
or clinical signs considered to be associated with the doses of rVA576 test; the causes of death 
for 1 male and 1 female found dead during the study were considered to be unrelated to test 
item administration. There was no effect of rVA576 on body weight, food intake, mating 
activity, fertility and mating, pregnancy or uterine implantation. There were no findings at 
necropsy considered to be related to rVA576 and group mean ovary and testes weights for 
animals given the test item were similar to Controls. Segment 2 and 3 reproductive toxicology 
studies will be undertaken prior to seeking market approval. Until the reproductive toxicology 
studies are completed, patients being treated with rVA576 should be advised to use the 
following precautions against sexual exposure and pregnancy. 
All trial participants (male and female) of childbearing potential must use, with their partner, a 
combination of an approved method of highly effective contraception with at least one barrier 
method of contraception from the time of signing the Informed Consent Form (ICF) until 90 
days after the last dose of rVA576. Women of child bearing potential are considered those 
women who have menarche and until becoming post-menopausal unless permanently 
sterilised. Permanent sterilisation methods include hysterectomy, bilateral salpingectomy, and 
bilateral oophorectomy. A postmenopausal state is defined as no menses for 12 months without 
an alternative cause. 
The following methods of highly effective contraception are acceptable and must be combined 
with at least one of the barrier method of contraception: 
• Surgical sterilisation (i.e. bilateral tubal removal, bilateral ovary removal, hysterectomy for 
female partners; vasectomy for males) 
• Placement of an intrauterine device or intrauterine system 
• Hormonal contraception associated with the inhibition of ovulation (implantable, patch, 
oral) 
 
• Barrier methods: 
o For male patients, this must be a condom; for female patients, either their 
partner’s use of a condom or the patient’s use of an occlusive cap [diaphragm 
or cervical/vault caps] with spermicidal foam/gel/film/cream/suppository 
o Barrier methods must be used in conjunction with a highly effective method of 
contraception listed above 
 
Alternatively, true abstinence is acceptable when consistent with the patient’s preferred and 
usual lifestyle. Any female patient who becomes pregnant during the course of the trial will be 
withdrawn from the trial. 
Male patients who have been sterilised are required to use one barrier method of contraception 
(condom). 
4.4.1 Exposure of Partners During the Study 
There is a risk of drug exposure through ejaculate (which also applies to vasectomised males) 
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combination of an approved method of highly effective contraception with at least one barrier 
method of contraception should be used throughout the study and for 90 days after the last day 
of IMP administration. 
4.4.2 Sperm Donation 
Male patients should not donate sperm for the duration of the study and for at least 90 days 
after the last day of IMP administration. 
4.4.3 Egg Donation 
Female patients should not donate eggs for the duration of the study and for at least 90 days 
after the last dose of IMP administration. 
4.4.4 Breast Feeding 
Female patients should not breast feed infants for the duration of the study and for at least 
90 days after the last day of IMP administration. 
5 
TRIAL OBJECTIVES AND ENDPOINTS 
5.1 Trial objectives 
Part 1: An additional objective for the first 3 patients is to allow the P.I. to assess the patients’ 
ability to use the eye dropper and vials correctly 
Part 1 and Part 2: The primary trial objective is to demonstrate the safety and tolerability of 
rVA576 when given by topical ocular administration to patients with AKC, VKC, and severe 
allergic conjunctivitis (SAC or PAC).  
The secondary objective is to demonstrate efficacy in this patient population in Part 2 of the 
study. 
To assess whether rVA576 0.25% eye drops, solution is effective in mitigating the signs and 
symptoms of AKC, VKC, and severe allergic conjunctivitis (SAC or PAC) and whether they 
have any effect on surrogate markers of inflammation.  
Efficacy will be defined as a difference in the mean composite clinical score between active 
and placebo treated patients in part 2 of the study. Clinical assessments and safety assessments 
in the randomised part of the study will be performed by a masked reviewer 
5.2 Endpoints 
5.2.1 Primary endpoint 
• Incidence of ocular treatment emergent adverse events during the treatment period (adverse 
events which have occurred during the 56 days following randomisation (Part 2 of the study 
only) will be considered in the analysis of the primary safety outcome). 
 
5.2.2 Secondary endpoint 
• Post-instillation comfort, as graded on patient diary cards at the following intervals Days 
1-14, Day 15-28, Day 29-42 and Day 43-56 
• Visual acuity by Early Treatment Diabetic Retinopathy Study (ETDRS) charts comparison 
from Day 1 to Day 56 
• Change from Day 1 in composite clinical scores at Day 14, 28, 42 and 56 
• Number and percentage of patients with MMP-9 positive levels at Days 1, 28, and 56 
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5.2.3 Exploratory endpoints 
• Systemic absorption by blood sampling 
• If enough tear fluid can be collected analysis of complement C3, C5 and LTB4 will be 
performed 
• A comparison of the number of patients requiring rescue therapy at any stage of the trial 
and the number on such therapy at the end of the trial 
• Comparison of the Conjunctival impression cytology results in each treatment group from 
Day 1 to Day 56 using flow cytometry analysis [NB Because these may not be reported for 
some time after completion of the trial and database lock, they will not form part of the 
statistical analysis and will be used for research information only] 
 
6 
TRIAL DESIGN AND PROCEDURES 
6.1 Trial Design 
The trial will comprise 2 parts: 
Part 1: The first 3 patients selected for the study will be treated with active drug in open-label 
manner. They will have weekly clinic visits for up the first 2 weeks and thereafter biweekly 
visits. When the third of the first 3 patients has completed their first 2 weeks treatment, the PI 
will review the safety, tolerability and ease of application for each patient before deciding to 
proceed to the randomised,  double masked comparative phase of the study (Part 2). The 
3 patients will continue on the study and complete the 8 weeks trial as open label patients.  
Part 2: A randomised, double-masked, placebo controlled trial of topical rVA576 or placebo 
eye drops in moderate to severe AKC, VKC and severe allergic conjunctivitis (SAC or PAC). 
The part 2 trial population will comprise 16 patients who meet all the inclusion and none of the 
exclusion criteria (Section 4.1 and Section 4.2).  
6.2 Duration of trial 
The estimated duration of the study for an individual patient is approximately 13 weeks. The 
duration from the First Patient Screened to Last Patient Last Visit (LPLV) will be 
approximately 7-8 months. 
At the end of the 56 Days the subjects will return to their usual standard of care therapy, as this 
is the first clinical trial of rVA576 in patients with AKC, VKC and severe allergic conjunctivitis 
(SAC or PAC) and the long-term efficacy and safety is not yet established. 
 


 
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Figure 6 
Trial Design 
 
 


 
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6.3 Dosing Scheme 
Part 1: The product will be supplied as a sterile 0.25% solution in 6 mL glass vials containing 
1 mL of rVA576 solution. Single use eye dropper pipettes will also be supplied. The vials are 
for single use (one drop to each eye) and must be retained and returned to the site at each clinic 
visit. 
Part 2: The product will be supplied as a sterile 0.25% solution in 6 mL glass vials containing 
1 mL of solution of either rVA576 or placebo. Eye dropper pipettes will also be supplied. The 
vials are for single use (one drop to each eye) and must be retained and returned to the site at 
each clinical visit. 
The patients will be randomised to receive either rVA576 active or placebo in double masked 
fashion. The product should be administered as one drop to each eye every 12 hours (i.e. twice 
daily) for a total of 56 days.  
The product should be stored frozen in the site Pharmacy until the first 7 days’ supply is to be 
given to the patient and then every 7 days thereafter. The product once unfrozen should be kept 
at 2 -8 °C for a maximum of 7 days. 
All patients entering the trial will have been on maximal topical therapy (meaning the maximal 
labelled dose or frequency of dosing) for at least three months before entry on the study and 
will continue on this therapy (background therapy) for the duration of the study.  
Background therapy: 
Patients should continue on whatever topical therapy they are on at the time of screening  but 
this should remain stable during the trial. Lubricants and artificial tears may be used ad libitum 
but should not be administered for 15 minutes before or after the trial medication. In the event 
of worsening of signs or symptoms that, in the clinician’s opinion is so severe as to necessitate 
a change of medication, ciclosporin and/or antihistamines may be introduced or increased in 
dose/frequency and this will be considered as a treatment failure for purposes of efficacy 
analysis. Topical corticosteroids may be added following introduction or increase in 
ciclosporin/antihistamine therapy if considered necessary.  
 
See Concomitant Medications for further details of choice of eye lubricants. 
Patients should not have used topical ocular steroids for 7 days prior to entry to the trial but, at 
the discretion of the investigator, may receive them as rescue medication during the trial. A 
comparison of the number of patients requiring rescue therapy at any stage of the trial and the 
number on such therapy at the end of the trial will be an additional exploratory endpoint. 
Use of systemic immunosuppressives, antihistamines or corticosteroids during the trial is 
forbidden. Patients who, in the opinion of the investigator, require such treatment will be 
withdrawn from the trial. If the reason for giving such treatment is related to their primary 
pathology (AKC, VKC, or severe allergic conjunctivitis (SAC or PAC)) they will be regarded 
as treatment failures. 
6.4 Method of Assigning Subjects to Treatments and Blinding (Part 2) 
After the initial 3 open label patients (Part 1), subsequent patients entering this clinical trial 
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The randomisation will be generated using the ‘Prisym Medica Clintrial’ software package. 
The required number of records, along with treatment allocation codes, treatment descriptions 
and required randomisation block size will be entered into the system according to the study 
requirements. One master set of codes will be generated within the Prisym system to facilitate 
printing of labels.  
Upon confirmation of a subject’s eligibility at  the Screening visit, the investigator, or other 
site personnel under the direction of the investigator, should access the eCRF to register the 
subject and obtain the Subject Identification number. In addition, the investigator, or designee, 
will contact the CRO, Tailored Clinical Research Solution (TCRS), to register the subject as 
randomised.  TCRS will forward the Randomisation ID to sites for recording in the patient 
notes and transcribed eCRF.  
6.4.1 Emergency Unmasking for Safety Reasons  
In the unlikely event of an emergency where, in the opinion of the investigator, discontinuation 
of study treatment for an individual patient is not sufficient and the study treatment must be 
unmasked in order to evaluate further course of action, the investigator will have direct access 
to the randomisation codes for unmasking.  
The investigator will consult his own copy of the randomisation codes supplied in a sealed 
envelopes individually numbered for each patient and decide what, if any, further action to 
take.  
Once the study treatment has been unmasked, the subject will complete the Early Termination 
visit and then discontinue study treatment. The subject will also be seen for post-treatment 
follow-up. 
6.5 Compliance 
As a measure of compliance, all empty rVA576 vials will be returned by the patient to the site 
and Patient Dosing Diaries will be reviewed by research staff at each study visit.  
 
6.6 Missed Doses 
If a patient misses a dose, it may be taken later unless it is within 3 hours of the next scheduled 
dose, in which case it should not be taken and the patient should resume normal dosing at the 
time of the scheduled dose. Precautions about not using other eye drops within 15 minutes 
before or after the rVA576 dose should continue to be observed. 
6.7 Trial Procedures  
The total number of clinic visits including screening and follow-up will be a minimum of 7 
with additional visits at the discretion of the PI. 
The following investigations and diagnostic procedures will be carried out at clinic visits in 
accordance with the Schedule of Events (i.e. not all evaluations will be carried out at every 
visit).  
By the Investigator 
• Medical History, general and indication specific 
• Adverse Events 
• Post instillation comfort as graded on patient diary cards (five-point grading from 
0 (perfectly comfortable) to 4 (Severe, intolerable itching or burning). For full description 
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• Clinical examination, gross and slit lamp with clinical scoring. For full description see 
Section 17.1 (AKC and VKC) and 17.2 (severe allergic conjunctivitis - SAC or 
PAC).MMP-9 estimation using the Inflammadry® device 
• Conjunctival impression cytology (CIP) (Optional) 
• Tear film break up time (TBUT) 
 
By the nurse or other qualified person (these may be done on any order and either before or 
after the Investigator's examination) 
• rVA576 blood levels 
• Visual acuity by ETDRS 
• Systemic complement activity by serum CH50 ELISA activity. 
• Anti-drug antibodies (ADA) 
• Pregnancy Test (Urine) 
 
Screening Period:  
Potential trial patients will visit the clinic for an initial visit at which time their suitability for 
the trial will be assessed by the Principal Investigator (PI) and the purpose, nature and possible 
benefits and risks will be explained. Patients will be given a detailed patient information leaflet 
and will be given sufficient time to consider their participation before entering the trial.  
Patients may enter the trial within 7 days (±2 days) of screening providing that there has been 
no change in the inclusion/exclusion criteria. It must be noted when organizing the first dosing 
visit that the IMP will take 4 days from the Randomisation to be sent to site and to be ready for 
dispensing. 
Part 1- open label: The first 3 patients selected for the study will be treated with active drug 
in open-label manner at weekly intervals. The first dose to these three patients will be given in 
the clinic observed by the PI.  
Part 2- Randomisation: Upon confirmation of a subject’s eligibility at the Randomisation 
visit, the investigator, or designee, will contact the CRO, TCRS, to register the subject as 
randomised and obtain the assigned medication number. This information will be recorded in 
the patient notes and transcribed eCRF. 
Dosing Period: 
Patients or their carers will collect clinical trial supplies from the clinical trial site at each clinic 
visit. Between visits new supplies will be delivered from the Pharmacy to the patient’s home 
by a courier service arranged by the Sponsor at a pre-arranged time and date. 
Part 1: Patients will be seen by the PI on Day 7 and thereafter every 14 days (±2 days) during 
the trial or more frequently if necessary. The trial dosing period will terminate after 56 days’ 
treatment at which time patients will return to the clinic for a final assessment.  
Part 2: The remaining 16 patients will be randomised 1:1 to active or placebo and will receive 
the appropriate medication throughout the trial identified by their Randomisation number.  
All randomised patients will be seen and assessed at Day 14 and thereafter at 2 weekly intervals 
by a masked observer.  
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Patients or their carers will be taught how to administer the eye drops. They will also be taught 
how to store the drug during the trial.  
Patients (or their carers) will remove one vial from the refrigerator 10 minutes before 
administration to allow the vial to warm to room temperature. One drop will be administered 
topically to each eye using the same vial and same pipette for both eyes.  
The drops will be administered twice a day, as near to 12 hours apart as possible (e.g. 8am and 
8pm). Vials will be used only once for administration to both eyes. Used vials will be returned 
to the trial pharmacy at each clinic visit for compliance checking. A daily diary card will be 
kept in which administration will be recorded together with a record of comfort and any adverse 
events. 
Patients and their carers will be provided with clear written and illustrated instructions detailing 
the correct procedure for transporting, storing and administering the IMP. 
An attempt will be made to collect tear fluid from patients in the trial using either glass capillary 
tubes or micropipettes according to the method of Sack et al (Sack et al. 1992). However, this 
may be difficult or impossible in the clinical trial setting as the induction of reflex tearing would 
obviate the results of the investigation by dilution of the mediators. If sufficient fluid is 
collected from individual patients (> 10µL) it will be analysed for complement products and/or 
LTB4. If insufficient is collected from individual patients any fluid collected may be pooled 
and analyses done on the total aliquot. 
Follow up: 
Patient will return again 28 days ±7 days for a follow-up visit. 
6.8 Rescue Therapy 
Topical ocular steroids will be considered Rescue Therapy.  
In the event of worsening of signs or symptoms that, in the clinician’s opinion is so severe as 
to necessitate a change of medication, ciclosporin and/or antihistamines may be introduced or 
increased in dose/frequency and this will be considered as a treatment failure for purposes of 
efficacy analysis.  
The introduction or increase in dose/frequency of ciclosporin or antihistamines will be 
considered as Rescue Therapy. 
After entry into the trial, subjects will be recommended to not receive Rescue Therapy from 
the first dose of rVA576 as far as possible unless assessed by PI as needed. 
6.9 Safety and Efficacy Assessments 
Safety will be assessed by the Investigator from history and clinical examination. Adverse 
events (AE) will be recorded in the CRFs and in part 2 of the study, a comparison will be made 
between the number, type and severity of AEs between the treatment groups. 
Comfort will be assessed on the basis of the patient diary cards. A comparison of the total 
comfort scores between the randomised treatment groups in part 2 of the study, will be made 
at the conclusion of the trial. For each treatment group a total comfort score of < 10 will be 
deemed to be comfortable/acceptable, 10 - 19 will be moderately uncomfortable, 20 - 29 will 
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Composite eye sign and symptom scoring will be carried out by the investigator/blind 
assessor (depending on the part of the study) at each scheduled clinic visit. Symptoms will be 
scored by the patient in response to specific questioning by the investigator/blind assessor. 
Signs will be scored by the investigator/blind assessor as a result of the clinical examination. 
At each visit the patient will be asked which eye feels to be the worst affected at the time of 
the visit and that eye will be used for the examination. If both eyes seem to the patient to be 
equally affected the right eye will always be used. The worst affected eye may change from 
visit to visit. 
For each sign/symptom a numerical score 0 – 3 will be awarded (see table in Section 17.1 
(AKC and VKC) and 17.2 (severe allergic conjunctivitis - SAC or PAC). These scores will be 
summed at the conclusion of the examination and this will be known as the composite score. 
The minimum possible composite score is 0, the maximum 33 (AKC and VKC) or 27 (severe 
allergic conjunctivitis (SAC or PAC)). All statistical comparisons, in part 2 of the study, will 
be done on the basis of the composite score for each patient/visit. 
MMP-9 detection using the Inflammadry® device. This device will give a binary 
(positive/negative) result which will be recorded in the CRFs at each time point and a 
comparison of the numbers of positives in each randomised treatment group will be made. 
Tear film break up time (TBUT). Tear breakup time (TBUT) is a clinical test used to assess 
for evaporative dry eye disease. To measure TBUT, fluorescein is instilled into the patient’s 
tear film and the patient is asked not to blink while the tear film is observed under a broad beam 
of cobalt blue illumination. The TBUT is recorded as the number of seconds that elapse 
between the last blink and the appearance of the first dry spot in the tear film. A TBUT under 
10 seconds is considered abnormal. 
This test will be performed in one eye only at the time points specified in the Schedule of 
Events. 
6.9.1 Clinical scoring 
Clinical scoring will be according to the method described by Akpek (Akpek et al. 2004). This 
will be carried out at each clinic visit by the PI or his designated sub-investigator(s). A 
composite score of 5 symptoms and 6 signs will be used for AKC and VKC patients, and a 
composite score of 4 symptoms and 5 signs will be used  for patients with severe allergic 
conjunctivitis - SAC or PAC. One eye only should be scored which will be the eye judged as 
worst affected at each visit by the patient. In the event that the patient judges both eyes to be 
equally affected the right eye will be assessed. Scoring will be on a scale of 0 to 3 where 0 is 
unaffected, 1 is mildly affected, 2 is moderately affected and 3 is severely affected (see Section 
17.1 and 17.2 for full details). The maximum possible score for symptoms and signs combined 
is 33 (AKC/VKC) or 27 (severe allergic conjunctivitis) . To qualify for entry to the trial patients 
must score: 
AKC or VKC - a minimum of 18 at the Screening visit. 
The following symptoms will be scored: 
1. Itching 
2. Tearing 
3. Discomfort (burning, stinging or foreign body sensation) 
4. Discharge 
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The following signs will be scored: 
1. Bulbar conjunctival hyperaemia 
2. Tarsal conjunctival papillary hypertrophy 
3. Punctate keratitis 
4. Neovascularisation of cornea 
5. Cicatrising conjunctivitis 
6. Blepharitis 
 
Severe allergic conjunctivitis - SAC or PAC - a minimum of 15 at the Screening visit. 
The following symptoms will be scored: 
1. Itching 
2. Tearing 
3. Discomfort (burning, stinging or foreign body sensation) 
4. Photophobia 
 
The following signs will be scored: 
1. Upper tarsal conjunctival hyperaemia  
2. Upper bulbar conjunctival hyperaemia  
3. Chemosis  
4. Upper tarsal conjunctival papillae  
5. Blepharitis 
 
6.9.2 Patient diary card 
All patients will be issued with a diary card and will be asked to score comfort on a scale of 0 
to 4 as shown in Table 5 below. The patient may make further comments (e.g. a difference 
in comfort between the two eyes) in the diary card.  
Table 5 
Eye comfort scoring 
Score 
Description 
0 
Perfectly comfortable 
1 
Slight discomfort. Aware of some burning, itching or stinging for up to half a minute 
after using the eye drop, solution but the discomfort improves without treatment. 
2 
Moderate discomfort. Burning, itching or stinging lasts for half a minute or longer but 
improves without treatment. 
3 
Severe discomfort. Burning, itching or stinging last for at least half a minute and requires 
washing the eyes to relieve it. 
4 
Unbearable burning itching or stinging. So severe that you cannot continue treatment. 
 
Scoring will be carried out at 0.5, 1, 2, 3 and 5 minutes after instillation of the drops and, in 
addition, patients will be asked to insert a brief description (up to 5 words) of how the eyes feel 
at the 3-minute time point. A list of suggested descriptor words will be provided but patients 
will be free to use any terminology they wish. Suggested descriptors are: 
• Normal, cool, comfortable, smooth, fresh 
• Uncomfortable, gritty, dry, sticky 
• Burning, itchy, stinging, painful 
 
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Diary cards will be checked by the trial nurse or the PI/blind assessor at each visit to ensure 
that they are being filled in correctly and regularly. 
6.10 Laboratory Tests  
The following laboratory tests will need to be conducted at the applicable visits, per Schedule 
of Events. The assessments will be conducted at the central laboratory, as indicated in the 
following table:  
Table 6 
Laboratory Tests 
Central Lab 
 
PK (Unbound rVA576) 
Anti-Drug Antibody (ADA) 
PD (CH50) 
The analyses will be performed in masked fashion as far as the Central; Lab is concerned and unmasking will not be performed 
until the conclusion of the trial. 
 
6.11 Medical Photography 
For better assessment of the eye, medical photography may be performed at investigator's 
judgement and photographs of both eyes may be obtained during the evaluation of the 
composite score and related ocular adverse events. During the consent obtained at screening 
the patients will be allowed to opt out of the medical photography. Declining consent for 
medical photography will not impact patient's participation in the study. Patient's 
confidentiality will be protected during medical photography of the eye. 
 
7 
REASON FOR WITHDRAWAL / EARLY DISCONTINUATION 
7.1 Termination or Suspension of the Study 
The Sponsor may prematurely terminate or suspend the study at any time for the following 
reasons: 
• Safety concerns e.g. due to occurrence of many serious ADRs 
• Achieving the purpose of the study is considered impossible e.g. due to inadequate 
recruitment of patients 
 
The Sponsor may prematurely terminate or suspend the study as well at a particular medical 
institution at any time during the course of the study, if major violations/deviations of the 
protocol or other procedures have not been improved or International Committee on 
Harmonisation (ICH) GCP has not been followed. 
If the study is prematurely terminated or suspended, the Sponsor should promptly inform the 
Investigators. The Investigator or designee should promptly inform the participating patients 
and change the study medication to other appropriate therapy(ies). All supplies must be 
returned.  
The Investigator may prematurely terminate or suspend the study at their medical institution 
with the agreement of the Sponsor. This may be done at any time during the study if they 
consider that ensuring patient safety during the study is difficult due to safety concerns (e.g., 
occurrence of many SAEs). 
The party which terminates the study will provide a written statement as to the reason for the 
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The Sponsor (or CRO) will notify Regulatory Authorities, as appropriate of premature 
terminations or other suspensions. The Investigator or their designee should promptly inform 
the corresponding Ethics Committee (EC).  
7.2 Withdrawal Criteria 
In accordance with applicable regulations, a patient has the right to withdraw from the study at 
any time and for any reason without prejudice to their future medical care by the physician or 
at the Institution. Should a patient withdraw from the study, the patient will not undergo any 
further study-specific procedures or receive any treatment mandated by the protocol. 
If a patient fails to attend scheduled trial assessments, the Investigator must determine the 
reasons and the circumstances as completely and accurately as possible. 
In the event of the premature withdrawal of a patient from the trial, the end of trial visit should 
be carried out as completely as possible. Minimally, a safety assessment should be performed.  
In the case of withdrawal due to the occurrence of unacceptable toxicity, the patient will be 
requested to remain under the supervision of the Investigator until the toxicity has resolved or 
is no longer considered to be clinically significant by the Investigator. 
If an AE classified as severe results in patient withdrawal from the study, the patient will be 
followed until the AE (or SAE) resolves or stabilises, and any interventions required to resolve 
or stabilise the event will be recorded in the eCRF. 
All withdrawals must be documented in the eCRF. A patient may be withdrawn in any of the 
following circumstances: 
• Withdrawal of consent (mandatory withdrawal) 
• Intake of non-permitted concomitant medications (may be discussed with the Sponsor and 
dependent on the nature of the medication) 
• Patient is non-compliant with more than three consecutive missed doses and two missed 
clinic visits, in the opinion of the Investigator (discretionary withdrawal) 
• If discontinuation is considered necessary by the Investigator and/or Sponsor (mandatory 
withdrawal) 
• Request of Regulatory Agency (mandatory withdrawal) 
• Patient develops an illness that would compromise his participation in the study (may be 
discussed with sponsor) 
• Pregnancy 
 
8 
SAFETY REPORTING 
8.1 Definitions 
8.1.1 Adverse Event 
Any untoward medical occurrence in a patient or clinical trial patient administered a medicinal 
product and which does not necessarily have a causal relationship with this treatment. 
An AE can therefore be any unfavourable and unintended sign (including an abnormal 
laboratory finding), symptom or disease temporally associated with the use of the study 
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8.1.2 Adverse Drug Reaction (ADR) 
All untoward and unintended responses to an investigational medicinal product related to any 
dose administered. All cases judged by either the reporting medically qualified professional or 
the Sponsor as having a reasonable suspected causal relationship to the study medication 
qualify as ADRs.  
8.1.3 Unexpected Adverse Reaction 
An adverse reaction, the nature or severity of which is not consistent with the applicable 
product information (e.g. IB for an unauthorized investigational medicinal product or summary 
of product characteristics for an authorized product). 
8.1.4 Serious Adverse Event or Serious Adverse Reaction 
Any untoward medical occurrence or effect at any dose that:  
• Results in death, 
• Is life-threatening,  
• Requires inpatient hospitalization or prolongation of existing hospitalization, 
• Results in persistent or significant disability/incapacity, or 
• Is a congenital abnormality / birth defect. 
 
NOTE: Other events that may not result in death, are not life threatening, or do not require 
hospitalization, may be considered a serious adverse event when, based upon appropriate 
medical judgment, the event may jeopardize the patient and may require medical or surgical 
intervention to prevent one of the outcomes listed above. Examples of such events include, but 
are not limited to, severe early onset reaction such as anaphylaxis, vasovagal episodes, 
episodes of hypotonia, hyporeactivity or hyperventilation, or convulsions. 
All SAEs will be reported to the Sponsor (or designee) within 24 hours of notice of occurrence. 
The Sponsor (or their designee) will be responsible for reporting the AE to the appropriate 
regulatory authorities and the ECs within the legally specified period. It is important to 
distinguish between SAEs and severe AEs. Severity is a measure of intensity whereas 
seriousness is defined by the criteria above. An AE of severe intensity need not necessarily be 
considered serious. For example, a migraine headache that incapacitates a patient for many 
hours may be considered a severe AE, whereas a stroke that results in a limited degree of 
disability may be considered mild, but should be reported as an SAE. 
8.1.5 Suspected Unexpected Serious Adverse Reaction (SUSAR) 
A serious adverse reaction, the nature or severity of which is not consistent with the applicable 
product information (e.g. IB for an unapproved investigational product or Summary of Product 
Characteristics for an approved product). 
Treatment Emergent Adverse Events (TEAEs) 
Treatment emergent adverse events (TEAEs) are undesirable events not present prior to 
medical treatment, or an already present event that worsens either in intensity or frequency 
following the treatment. 
8.2 Procedures for Recording of Safety Events 
8.2.1 General 
All adverse events occurring during the Study (from the time point of signing of the ICF until 
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investigator or reported by the patient, whether or not attributed to the IMP, shall be recorded 
in patient`s medical records and on the eCRF.  
The following information shall be recorded:  
• Description 
• Date of onset and end date 
• Severity 
• Assessment of relatedness to the IMP 
• Seriousness 
• Measures taken for management of the AE 
• Outcome of the event 
 
Follow-up information should be provided as necessary.  
AEs considered as being related to the IMP as judged by a medically qualified Investigator, or 
the Sponsor, must be followed until their resolution or when patient`s status is considered as 
stable. All related AEs that result in a patient’s withdrawal from the Study or are present at the 
end of the Study, should be re-evaluated and if needed followed until a satisfactory resolution 
occurs. 
It will be left to the investigator’s clinical judgment whether or not an AE is of sufficient 
severity to require termination of IMP administration. A patient may also voluntarily withdraw 
from IMP administration due to AEs perceived as intolerable. If either of these occurs, the 
patient will be given appropriate care under medical supervision until symptoms cease or the 
condition becomes stable. 
The severity of reported events shall be assessed on the following scale:  
• 1 = mild 
• 2 = moderate 
• 3 = severe  
 
The causal relationship of AEs to the IMP must be assessed by the investigator, or by a 
medically qualified designee, in accordance with the following criteria: 
TERM 
DEFINITION 
Unrelated 
Clinical event with an incompatible time relationship to administration of the 
investigational medical product (IMP), and that could be explained by underlying disease 
or other drugs or chemicals or is incontrovertibly not related to the IMP 
Possibly related 
Clinical event with a reasonable time relationship to IMP administration, and that is 
unlikely to be attributed to concurrent disease or other drugs or chemicals 
Related 
Clinical event with plausible time relationship to IMP administration and that cannot be 
explained by concurrent disease or other drugs or chemicals 
 
The degree of certainty with which an AE is attributed to IMP administration (or alternative 
causes, e.g. natural history of the underlying disease, concomitant therapy, etc.) will be 
determined by how well the experience can be understood in terms of one or more of the 
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• Known pharmacology of the IMP 
• Reactions of a similar nature have been previously observed with the IMP or this class of 
drug 
• A temporal relationship to IMP administration, terminating with IMP withdrawal or 
recurring on re challenge 
• Alternative cause 
At the last scheduled visit, the investigator shall instruct each patient to report any subsequent 
event(s) that the patient, or her personal physician, believes might reasonably be related to 
participation in this Study. The investigator should notify the Sponsor (or designee) of any 
death or SAE occurring at any time after a patient has discontinued or terminated study 
participation that may reasonably be related to this Study.  
8.2.2 Pre-existing Conditions 
For purposes of this Study a pre-existing condition means a diagnosed, clinically significant 
finding, symptom or laboratory abnormality present at screening. Subsequently, during the 
course of the Study it shall be recorded as an AE/SAE if the frequency, intensity, or the 
character of the condition worsens during the study period.  
8.2.3 Overdose 
The total amount of rVA576 in single drops is so small that overdosage by this route is 
considered to be impossible (1 drop of rVA576 0.25% solution contains 0.15 mg, one three 
hundredth of the standard systemic therapeutic dose) even if totally systemically absorbed. 
Since there are no known adverse events associated with systemic overdosage the risk of ocular 
overdosage, whether accidental or intentional, is therefore considered to be negligible). 
8.2.4 Pregnancy 
Recombinant rVA576 is contraindicated during pregnancy. If pregnancy is suspected, a blood 
sample for serum HCG examination must be sent to the sub-contracted laboratory within 
48 hours. As during the first pregnancy weeks the test may be negative it may be confirmed by 
an ultrasound examination. If at least one of the above-mentioned examinations is positive, 
administration of the IMP must be stopped and the patient must be immediately withdrawn 
from the study. All pregnancies (even if suspected) must be reported on the appropriate eCRF 
page (Pregnancy form) within 24 hours from the moment when the investigator became aware 
of the pregnancy (or suspected pregnancy). In any case each pregnancy must be followed till 
its termination (either by birth of a child or abortion) and the eCRF Pregnancy form has to be 
updated.  
8.2.5 Reporting of Adverse Events 
All adverse events, whether in the opinion of the investigator, drug-related or not will be 
reported in the CRF. 
8.3 Reporting Procedures for Serious Adverse Events  
Any SAE occurring during the Study has to be managed by established SoC to protect life and 
health of participating patients. If such treatment represents a significant deviation from the 
protocol, the investigator shall immediately notify the study monitor and/or the Sponsor to 
determine whether the patient should be dropped from the Study, or not. 
All SAEs, irrespective of their causality, must be notified to the Pharmacovigilance provider 
(PVP) of the Sponsor, within 24 hours of investigator’s knowledge of the event. Reporting 
shall be done on the corresponding SAE form, provided to each centre during the initiation 
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Fax: +420 227 204 958 
E-mail: safety@akaritx.com 
The provided information shall contain as much detail regarding the event as available. 
Investigators shall not wait to receive additional information to fully document the event, 
before notifying the SAE to Akari Therapeutics Plc. The SAE reporting form should detail all 
relevant aspects of the AEs listed in Section 8.2. Where applicable, information from relevant 
hospital records or autopsy reports should be obtained and provided to Akari Therapeutics Plc. 
8.4 Expedited Safety Reporting  
Any SAE, which is unexpected and at least possibly related to the IMP, requiring expedited 
reporting to the respective regulatory authority, EudraVigilance and ECs / Institutional Review 
Boards (IRBs) of the sites participating in this Study is patient to following timelines:  
• 7 calendar days for SUSARs involving death and life-threatening events, 
• 15 calendar days for SUSARs involving hospitalization or prolongation of hospitalization 
or persistent or significant disability/incapacity or congenital anomaly/birth defect or any 
other significant clinical/laboratory event of major concern in the opinion of the 
Investigator. 
 
Day zero (clock start) for expedited reporting purposes is the date of initial information or of 
the relevant follow-up information received in any form (in writing or verbal) by any personnel 
of Sponsor or contracted parties including the CRO and the Pharmacovigilance Provider (PVP). 
All SUSARs will be reported to the respective competent authorities, ECs (IRBs) and 
Investigators within specified timelines in accordance with corresponding national legislation. 
8.5 Development Safety Update Reports 
Development Safety Update Reports will be prepared by Akari Therapeutics Plc on an annual 
basis and distributed to all competent authorities and to relevant ECs in accordance with the 
corresponding national regulations. 
9 
ACCOUNTABILITY PROCEDURES 
The PI and the hospital pharmacist are responsible for study medication accountability, 
reconciliation, and record maintenance. Drug accountability records will be maintained during 
the study, including the amount of study medication received from the Sponsor, the amount 
distributed to each patient, and the amount of unused drug returned to the Sponsor or destroyed 
at Sponsor’s request. In addition, in the event of necessary disposal of opened but wasted 
medication, the disposal should be documented appropriately (i.e. witnessed) in accordance 
with applicable local regulations, and “Good Clinical Practice” (GCP) procedures. 
10 COMPLIANCE 
Patients will fill in diary cards recording each dose and the time and date that it was 
administered. In addition, all used vials should be retained in the container provided and 
returned to the trial pharmacy at each clinic visit. The trial pharmacist will keep records of the 
number of vials returned for each patient and a full reconciliation will be carried out at the 
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11 STATISTICS 
11.1 Statistical Methods 
A Statistical Analysis Plan (SAP) will be prepared and finalised prior to unmasking of the study 
for the analysis. The SAP will provide full details of the analyses, data displays, algorithms to 
be used for data derivations and handling of missing data. SAS® statistical software version 9.3 
or above will be used for analysing the data (SAS Institute, Inc., Cary, North Carolina). 
Continuous variables will be summarized using the number of patients, number of missing 
values, mean, median, standard deviation, standard error, minimum, and maximum. 
Categorical variables will be summarized using number of patients, number of missing values, 
frequency counts, and percentages. Unless otherwise specified, missing data will not be 
included in the denominator for percentage calculation. Change from baseline may be 
substituted with percentage change from baseline or ratio to baseline if the distribution of an 
individual parameter suggests this. 
The baseline value will be defined as the pre-dose value on Day 1, if that is missing, it will be 
defined from the most recent value available. 
The two parts of the study will be reported separately. Data from patients included in Part 1 
will only be listed, while the following sections apply for data from patients included in Part 2. 
11.2 Primary Analysis 
Ocular adverse events which have occurred during the 56 days of treatment following 
randomisation will be considered in the analysis of the primary safety outcome. The difference 
between the two treatments in the proportion of patients experiencing any ocular treatment 
emergent AEs as coded under MedDRA System Organ class: Eye disorders will be reported 
with its associated 95% Confidence interval. 
A treatment-emergent adverse event (TEAE) will defined as an adverse event that started, or 
increased in severity, after the first dose of study medication was taken. The incidence of 
TEAEs will be summarized by System Organ Class, Higher Level Term and Preferred Term. 
Additional summaries will be produced, such as summary of serious TEAEs, summary of 
TEAEs by intensity/severity, or by relationship to study drug. 
11.3 Secondary Analyses 
• Post-instillation comfort, as graded on patient diary cards, will be summarised by treatment 
group at Days 14, 28, 42 and 56. The weekly comfort scores will be compared between 
treatment groups.  
• The observed values and change from Baseline in composite clinical scores, in individual 
symptom and in sign scores, at Days 14, 28, 42 and 56 will be summarised and plotted by 
treatment group. The change from Baseline in composite clinical scores will be analysed 
with a Mixed-effects Model for Repeated Measures. The model will include baseline 
composite clinical score as a covariate, treatment group, visit and patient group (AKC/VKC 
or SAC/PAC) as fixed factors and the treatment arm by visit interaction.  The Least Square 
means over time with associated 95% confidence intervals will be plotted, as well as 
adjusted LS mean difference to placebo and 95% confidence interval. 
• The number and proportion of patients with MMP-9 positive levels at Days 14, 28, 42 and 
56 will be summarised, and compared between treatment groups. 
• The observed values and change from Baseline in Tear film break up time at Days 14, 28, 
42 and 56 will be summarised and compared between treatment groups.  
 


 
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Additional analyses will be defined in the SAP. Other endpoints, such as visual acuity, 
Conjunctival impression cytology results, use of rescue therapy and PK will be analyzed as 
indicated above depending on whether their outcome measure is a continuous or categorical 
variable. 
Listings will also be used to display data at the individual patient’s level. 
Interim analyses may also be conducted. Details of any analyses will be outlined in the SAP. 
11.4 Number of Subjects 
Up to 19 patients (3 in part 1 of the study and up to 16 in part 2), to include active and placebo 
treated, will be enrolled under this protocol. The sample size for this study was determined 
based on practical, and not statistical, considerations.  
11.5 Significance Level 
The primary objective of the study is to assess the safety and tolerability of topical rVA576 for 
AKC, VKC and severe allergic conjunctivitis (SAC or PAC) and the study is not powered for 
the primary analysis.  
For the secondary efficacy analyses, a nominal level of 5% will be considered significant, and 
no multiplicity adjustment will be introduced. Some significant findings are expected to occur 
by chance so undue consideration will not be given to any particular significant difference. 
Interpretation of the results will be based on patterns of differences and in conjunction with the 
results of the primary analyses. 
11.6 Missing, Unused or Spurious Data 
Missing data that cannot be retrieved from source records or other repositories will be recorded 
as such in the CRFs and will not be entered into the statistical analysis. Spurious data will be 
examined by the Sponsor’s monitor, medical or statistical advisors and a decision made as to 
how it should be handled. If there is an obvious transcription or data entry error such as a 
misplaced decimal point in a biochemical parameter this will be discussed with the CRO or the 
laboratory and, if all parties agree, it will be corrected and endorsed by both the PI and the 
Sponsor prior to database lock.  
No imputations will be made for missing demographic characteristics or disease characteristics. 
However, rules for handling of outcomes missing data or incomplete dates will be described 
fully in the SAP. The treatment of outliers will be addressed in the SAP. If applicable, full and 
modified data sets will be included in the SAP with a complete explanation of data handling 
and analysis methods to ensure completeness. 
Unused data (e.g. superfluous blood pressure recordings or haematological results in addition 
to those required by the protocol will remain part of the source documentation and only be 
incorporated into the trial documents and analysis if there is reason for them to be (e.g. an 
unexpected fall in blood pressure that might constitute an AE). 
11.7 Deviations from the Statistical Plan 
It is not envisaged that there should be any deviations from the statistical plan since this is 
primarily a safety study. Any unexpected deviations (e.g. a requirement for a trend analysis not 
foreseen in planning the trial) will be discussed with the PI and the statistical advisor and the 
rationale for such an analysis will be included in the trial report. 


 
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11.8 Subjects to be Included in the Analysis 
Three populations will be considered in the analysis of Part 2 of the study:  
1. Full Analysis Set: This population will be defined as all subjects randomized to treatment 
who received at least one dose of investigational product. This will be the primary 
population for assessing efficacy. Subjects will be classified by the study medication they 
were randomised to.  
2. Safety Analysis Set: This population will be defined as all subjects randomized to treatment 
who received at least one dose of investigational product. Randomized subjects will only 
be excluded if there is clear evidence of failure to take investigational product. This will be 
the primary population for assessing safety. Subjects will be classified by the actual study 
medication they receive.  
3. Pharmacokinetic Analysis Set: This population will be defined as all subjects who take at 
least one dose of rVA576 and have at least one PK sample taken and analysed. This will 
be the primary population for assessing PK.  
12 DIRECT ACCESS TO SOURCE DOCUMENTS 
The CRO, hospitals and PIs carrying out this study will allow the Sponsor direct access to all 
source documents and will permit trial-related auditing of clinical, pharmacy and laboratory 
facilities.  
13 QUALITY CONTROL AND QUALITY ASSURANCE 
Hospitals/departments taking part in the trial are responsible for maintaining their own SOPs 
and QA/QC procedures. The Sponsor will also maintain its SOPs, QA and QC procedures and 
will, at its discretion, carry out a full or partial audit of the trial site facilities and SOPs. The 
Sponsor will be responsible for monitoring the trial and carrying out full or representative 
source data verification. 
14 ETHICAL CONSIDERATIONS 
The application will be reviewed and approved by appropriate Ethics Committees prior to the 
trial commencing. All ethical aspects of the study will be in accordance with ICH Good Clinical 
Practice (GCP) guidelines and the requirements of the Declaration of Helsinki. 
15 DATA HANDLING, RECORD KEEPING AND SAMPLE COLLECTION 
The CRO and hospitals will supply and complete the source documentation and all related 
documentation (e.g. ECG traces, laboratory data) and at the conclusion of the trial will transfer 
these to the CRO who will be responsible for data entry and analysis. The original 
documentation will be returned to the hospitals for archiving (at least 20 years after completing 
of the trial) and the Sponsor will also keep duplicates for the same purpose.  
Biological samples may only be stored indefinitely for the purpose of additional research 
related to this protocol if the patient has given informed consent for additional scientific 
research (directly related to this protocol). If no informed consent was obtained, samples must 
be destroyed after the patient has completed all protocol treatment and procedures. 
Storage of biological samples on site is subject to the site’s guidelines. When samples are 
shipped to another facility (e.g. a central laboratory), they should be stripped from any 
identifying information and labeled with a code (trial name, patient study number, date and 
time of collection).  


 
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Protocol AK701 - version 8.0 
© Akari Therapeutics Plc 
10 February 2020 
16 FINANCING AND INSURANCE 
The Sponsor will have a commercial contract in place with the hospital and the PI and the 
hospitals/universities who will be responsible for any payments to subjects and for payment of 
travel and other expenses. 
The Sponsor has a clinical trials insurance policy in place, underwritten by AON Limited. A 
copy of the policy/certificate of insurance will be supplied separately. 
17 PUBLICATION POLICY 
The trial will be registered with EUDRACT or the U.S. National Institutes of Health 
ClinicalTrials.gov website and the results will be posted when available.  
The PI of the clinical units has independent rights of publication but will agree to discuss any 
intended publications or presentations with the Sponsor and to allow the Sponsor reasonable 
time to make comments, file or add to patent applications or request changes to the manuscript.  
 


 
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Page 77 of 81 
 
Protocol AK701 - version 8.0 
© Akari Therapeutics Plc 
10 February 2020 
17.1 Scoring of Clinical Signs and Symptoms – AKC and VKC 
 
SYMPTOM 
0 
1 
2 
3 
Itch 
No desire to rub or scratch the eye 
Occasional desire to rub or scratch the 
eye 
Frequent need to rub or scratch the 
eye 
Constant need to rub or scratch the 
eye 
Tearing 
Normal tear production 
Positive sensation of fullness of the 
conjunctival sac without tears spilling 
over the lid margin 
Intermittent, infrequent spilling of 
tears over the lid margin 
Constant, or nearly constant, spilling of 
tears over the lid margins 
Discomfort (including burning, 
stinging, and foreign body sensations) 
Absent 
Mild 
Moderate 
Severe 
Discharge 
No abnormal discharge 
Small amount of mucoid discharge 
noted in the lower cul-de-sac 
Moderate amount of mucoid 
discharge noted in the lower cul-de-
sac and in the marginal tear strip; 
presence of crust upon awakening 
Eyelids tightly matted together upon 
awakening, requiring warm soaks to 
pry lids apart; warm soaks necessary 
to clean eyelids during the day 
Photophobia 
No difficulty experienced 
Mild difficulty with light causing 
squinting 
Moderate difficulty, necessitating dark 
glasses 
Extreme photophobia, causing the 
patient to stay indoors; cannot stand 
natural light even with dark glasses 
SIGN 
0 
1 
2 
3 
Bulbar conjunctival hyperaemia 
Absent 
Mild 
Moderate 
Severe 
Tarsal conjunctival papillary 
hypertrophy 
No evidence of papillary formation 
Mild papillary hyperaemia 
Moderate papillary hypertrophy with 
oedema of the palpebral conjunctiva 
and hazy view of the deep tarsal 
vessels 
Severe papillary hypertrophy 
obscuring the visualization of the deep 
tarsal vessels 
Punctate keratitis (superficial epithelial 
keratitis and punctate staining of the 
cornea with fluorescein) 
No evidence of punctate keratitis 
One quadrant of punctate keratitis 
Two quadrants of punctate keratitis 
Three or more quadrants of punctate 
keratitis 
Neovascularization of cornea (new 
vessel formation, crossing the limbus 
onto the clear cornea by 2 mm) 
 
No evidence of new vessel Formation 
Presence of neovascularization in 1 
quadrant of cornea  
Presence of neovascularization in 2 
quadrants of cornea 
Presence of neovascularization in 3 
quadrants of cornea 
SIGN 
0 
1 
2 
3 
Cicatrizing conjunctivitis (superficial 
scarring of the conjunctiva) 
No evidence of cicatrisation 
 
Presence of subepithelial fibrosis 
Presence of fornix foreshortening  
Symblepharon formation 
Blepharitis (hyperaemia and oedema 
of eyelid skin with meibomian gland 
dysfunction) 
No evidence of blepharitis 
Presence of mild redness and oedema 
of the eyelid with meibomian gland 
dysfunction 
Moderate inflammation with 
hyperaemia, scales, and scurf of eyelid 
skin and toothpaste phenomenon 
Severe inflammation, with cracks in 
the eyelid skin, loss of eyelashes, and 
lid oedema 


 
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Page 78 of 81 
 
Protocol AK701 - version 8.0 
© Akari Therapeutics Plc 
10 February 2020 
17.2 Scoring of Clinical Signs and Symptoms -  Severe Allergic Conjunctivitis - SAC or PAC 
 
SYMPTOM 
0 
1 
2 
3 
Itch 
No desire to rub or scratch the eye 
Occasional desire to rub or scratch the 
eye 
Frequent need to rub or scratch the 
eye 
Constant need to rub or scratch the 
eye 
Tearing 
Normal tear production 
Positive sensation of fullness of the 
conjunctival sac without tears spilling 
over the lid margin 
Intermittent, infrequent spilling of 
tears over the lid margin 
Constant, or nearly constant, spilling of 
tears over the lid margins 
Discomfort (including burning, 
stinging, and foreign body sensations) 
Absent 
Mild 
Moderate 
Severe 
Photophobia 
No difficulty experienced 
Mild difficulty with light causing 
squinting 
Moderate difficulty, necessitating dark 
glasses 
Extreme photophobia, causing the 
patient to stay indoors; cannot stand 
natural light even with dark glasses 
SIGN 
0 
1 
2 
3 
Upper tarsal conjunctival hyperaemia 
Absent 
Mild 
Moderate 
Severe 
Upper bulbar conjunctival hyperaemia 
Absent 
Mild 
Moderate 
Severe 
Chemosis 
Absent 
Mild 
Moderate 
Severe 
Upper tarsal conjunctival papillae  
Absent. Normal smooth conjunctival 
surface 
Roughness to appearance of upper 
tarsal conjunctiva but no papillae 
≥1mm 
Roughness of upper tarsal conjunctiva 
and some scattered papillae ≥1mm 
Cobblestone appearance of upper 
tarsal papillae 
Blepharitis (hyperaemia and oedema 
of eyelid skin with meibomian gland 
dysfunction) 
No evidence of blepharitis 
Presence of mild redness and oedema 
of the eyelid with meibomian gland 
dysfunction 
Moderate inflammation with 
hyperaemia, scales, and scurf of eyelid 
skin and toothpaste phenomenon 
Severe inflammation, with cracks in 
the eyelid skin, loss of eyelashes, and 
lid oedema 
 


 
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Page 79 of 81 
 
Protocol AK701 - version 8.0 
© Akari Therapeutics Plc 
10 February 2020 
17.3 Schedule of Events and Blood Draws  
 
 
 
Screening 
Day 1 
Day 7 
(±2 Days) 
Day 14 
(±2 Days) 
Day 28 
(±2 Days) 
Day 42 
(±2 Days) 
Day 56 
(±2 days) 
Day 84 
(±7 days) 
Unscheduled 
Day -7 – Day 1 
Baseline 
Pre-dose 
Patients 1 – 3 only 
 
 
 
End of dosing 
Follow-up Visit 
 
Eligibility, ICF & Medical 
History & Demographics 
x 
 
 
 
 
 
 
 
 
Visual acuity by ETDRS 
x 
x 
x 
x 
x 
x 
x 
x 
x 
CH50  
 
x 
 
 
 
 
x 
 
 
rVA576 Drug Level (PK)5 
 
x5 
 
x5 
 
 
x5 
 
 
Drug Administration6 
 
x 
x 
x 
x 
x 
x 
 
 
Antibodies (ADA) 
 
x 
 
x 
 
 
x 
 
 
Drug Accountability 
 
 
x 
x 
x 
x 
x 
 
x 
Pregnancy test (urine) 
x 
x 
 
 
x 
 
x 
x 
x 
AEs & Concomitant  
Medications 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Eye Swab 
x 
 
 
 
 
 
 
 
 
Clinical Scoring1 
x2 
x 
x 
x 
x 
x 
x 
x 
x 
Conjunctival Impression 
Cytology (Optional) 
 
x 
 
 
 
 
x 
 
 
MMP-9 Estimation using an 
Inflammadry® Device3 
 
x 
 
 
x 
 
x 
 
 
Tear film break up time 
 
x 
x 
x 
x 
x 
x 
x 
x 
Patient Diary Cards4 
 
 
x 
x 
x 
x 
x 
 
x 
1. 
The score is a composite of five symptoms and six signs (AKC/VKC) or four symptoms and five signs (severe allergic conjunctivitis), each graded 0 – 3 (0 = absent and 3 = most severe). The eye regarded by 
the patient as being most severely affected will be assessed. In the event the patient regards both eyes as being equally affected, the right eye will be assessed. 
2. 
A total score of ≥18 out of a possible 33 (AKC/VKC), or ≥15 out of a possible 27 (severe allergic conjunctivitis), is required at the Baseline (Day1) visit for trial inclusion. 
3. 
This test will be performed at every scheduled visit, with one assay performed per eye. 
4. 
The Diary Cards will record the time of every IMP administration, suspected adverse events, comfort and ease of IMP administration. The Diaries will be reviewed by the Investigator at each visit. 
5. 
PK samples should be taken pre- and 1 hour post-dose 
6. 
It should be noted that 4 days should be allowed between Randomisation and first dose  for delivery and preparation of the IMP


 
CONFIDENTIAL 
Page 80 of 81 
 
Protocol AK701 - version 8.0 
© Akari Therapeutics Plc 
10 February 2020 
18 REFERENCES 
[Ahadome et al. 2016] Ahadome SD, Abraham DJ, Rayapureddi S, Saw VP, Saban DR, Calder 
VL, Normal JT, Ponticos M, Daniels JT, Dart JK. Aldehyde dehydrogenase inhibition 
blocks mucosal fibrosis in human and mouse ocular scarring. J Cl Insight 2016; 1(12): 
1-17. 
[Agostini et al. 2004] Agostini CL, Facco TM, Semenzato G. New aspects of hypersensitivity 
pneumonitis. Curr Opin Pulm Med, 2004; 10: 378-82. 
[Akpek et al. 2004] Akpek EK, Dart JK, Watson S, Christen W, Dursun D, Yoo S, O’Brien 
TP, Schein OD, Gottsch JD. A randomized trial of topical cyclosporin 0.05% in topical 
steroid-resistant atopic keratoconjunctivitis, Ophthalmology, 2004; 111: 476-82. 
[Bartholomew & Shanahan 1990] Bartholomew WR, Shanahan TC. Complement components 
and receptors: deficiencies and disease associations, Immunol Ser, 1990; 52: 33-51. 
[Comstock &. DeCory 2012] Timothy L. Comstock and Heleen H. DeCory. Advances in 
Corticosteroid Therapy for Ocular Inflammation: Loteprednol Etabonate. International 
Journal of Inflammation, 2012; Article ID 789623, 4. 
 
[Densen 1989] Densen, P. Interaction of complement with Neisseria meningitidis and Neisseria 
gonorrhoeae. Clinical microbiology reviews 1989; 2 Suppl: S11-17. 
 
[de Vries et al. 2003] de Vries B, Kohl J, Leclercq WK, Wolfs TG, van Bijnen AA, Heeringa 
P, Buurman WA. Complement factor C5a mediates renal ischemia-reperfusion injury 
independent from neutrophils, J Immunol; 2003 170: 3883-9. 
[Francischetti et al. 2009] Francischetti IM, Sa-Nunes A, Mans BJ, Santos IM, Ribeiro JM. 
The role of saliva in tick feeding, Front Biosci (Landmark Ed), 2009; 14: 2051-88. 
[Gane & Buckley 2013] Gane J, Buckley R. Leukotriene receptor antagonists in allergic eye 
disease: a systematic review and meta-analysis. J Allergy Clin Immunol Pract. 2013 
1(1):65-74. 
[Godau et al. 2004] Godau J, Heller T, Hawlisch H, Trappe M, Howells E, Best J, Zwirner J, 
Verbeek JS, Hogarth PM, Gerard C, Van Rooijen N, Klos A, Gessner JE, Kohl J. C5a 
initiates the inflammatory cascade in immune complex peritonitis, J Immunol, 2004 
173: 3437-45. 
[Greinacher & Warkentin 2008] Greinacher A, Warkentin TE. The direct thrombin inhibitor 
hirudin. Thromb Haemost 2008) 99: 819-829. 
[Hepburn et al. 2007] Hepburn NJ, Williams AS, Nunn MA, Chamberlain-Banoub JC, Hamer 
J, Morgan BP, Harris CL. In vivo characterization and therapeutic efficacy of a C5-
specific inhibitor from the soft tick Ornithodoros moubata J Biol Chem, 2007; 282: 
8292-9. 
[Hill et al. 2013] Hill A, Kelly RJ, Hillmen P. Thrombosis in paroxysmal nocturnal 
hemoglobinuria, Blood, 2013; 121: 4985-96. 
[Jore et al. 2016] Jore MM, Johnson S, Sheppard D, Barber NM, Li Yi, Nunn MA, Elmund H, 
Lea SM. Structural basis for therapeutic inhibition of complement C5. Nat Struct Mol 
Biol 2016; 23(5): 378-386. 


 
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Protocol AK701 - version 8.0 
© Akari Therapeutics Plc 
10 February 2020 
[Kuhn et al. 2016] Kuhn N, Schmidt CQ, Schlapschy M, Skerra A. PASylated Coversin, a C5-
Specific Complement Inhibitor with Extended Pharmacokinetics, Shows Enhanced 
Anti-Hemolytic Activity in Vitro, Bioconjug Chem, 2016; 27: 2359-71. 
[La Rosa et al. 2013] La Rosa M, Lionetti E, Reibaldi M, Russo A, Longo A, Leonardi S, 
Tomarchia S, Aritabile T, Reibaldi A. Allergic conjunctivtis: a comprehensive review 
of literature. Italian J of Peds 2013; 39. 
[Lang & Vincent 2009] Lang B, Vincent A. Autoimmune disorders of the neuromuscular 
junction, Curr Opin Pharmacol, 2009; 9: 336-40. 
[Mishra et al. 2011] Mishra GP, Tamboli V, Jwala J, Mitra AK. Recent Patents Emerging 
Therapeutics in the Treatment of Allergic Conjunctivitis. Recent Pat Inflamm Allergy 
Drug Disco 2011; 5(1): 26-36. 
[Mollnes & Kirschfink 2006] Mollnes TE, Kirschfink M. Strategies of therapeutic complement 
inhibition Mol Immunol, 2006; 43: 107-21. 
[Nozaki et al. 2006] Nozaki M, Raisler BJ, Sakurai E, Sarma JV, Barnum SR, Lambris JD, 
Chen Y, Zhang K, Ambati BK, Baffi JZ, Ambati J. Drusen complement components 
C3a and C5a promote choroidal neovascularization, Proc Natl Acad Sci U S A, 2006; 
103: 2328-33. 
[Nunn et al. 2005] Nunn MA, Sharma A, Paesen GC, Adamson S, Lissina O, Willis AC, Nuttall 
PA. Complement inhibitor of C5 activation from the soft tick Ornithodoros moubata, J 
Immunol, 2005; 174: 2084-91. 
[Roversi et al. 2013] Roversi P, Ryffel B, Togbe D, Maillet I, Teixeira M, Ahmat N, Paesen 
GC, Lissina O, Boland W, Ploss K, Caesar JJE, Leonhartsberger S, Lea SM, Nunn MA. 
Bifunctional lipocalin ameliorates murine immune complex-induced acute lung injury. 
J. Biol Chem. 2013; 288: 18798-18802. 
[Sack et al. 1992] Sack RA, Tan KO, Tan A. Diurnal tear cycle: evidence for a nocturnal 
inflammatory constitutive tear fluid. Investigative Ophthalmology and Visual Science 
1992; 33(3): 626-640. 
[Sarma et al. 2006] Sarma VJ, Huber-Lang M, Ward PA. Complement in lung disease, 
Autoimmunity, 2006; 39: 387-94. 
[Tuzun et al. 2008] Tuzun E, Li J, Saini SS, Yang H, Christadoss P. 2008. Targeting classical 
complement pathway to treat complement mediated autoimmune diseases, Adv Exp 
Med Biol, 2008; 632: 265-72. 
[Ward et al. 2003] Ward PA, Riedemann NC, Guo RF, Huber-Lang M, Sarma JV, Zetoune FS. 
Anti-complement strategies in experimental sepsis, Scand J Infect Dis, 2003; 35: 601-
3. 
[Zhang et al. 2017] Zhang L, Bell BA, Li Y, Caspi RR, Lin F. Complement Component C4 
Regulates the Development of Experimental Autoimmune Uveitis through a T Cell-
Intrinsic Mechanism. Front Immunol. 2017 Sep 11;8:1116. 

SAP_001.pdf: 
Syne qua non study no: TNS18002 
 
Akari Therapeutics Plc study no: AK701 
 
Date: 12JUL2021 
Page 1 of 19 
Version: Final 4.0 
ST/form/010/11 
 
 
 
 
 
 
 
 Topical rVA576 for TReatment of AtopiC KERatoconjunctivitis: a 
Randomised Placebo Controlled Double Masked Parallel Trial 
(TRACKER) 
 
 
 Akari Therapeutics Plc Study No: AK701 
Syne qua non Ltd Study No:  TNS18002 
 
 
Statistical Analysis Plan  
 
 
Version: Final 4.0 
Date: 12 July 2021 
 
 
 
Author 
 
 
For Akari Therapeutics Plc 
If signing manually, please include:  Signature + Date + Full Name + Position 
 
 
 


Syne qua non study no: TNS18002 
 
Akari Therapeutics Plc study no: AK701 
 
Date: 12JUL2021 
Page 2 of 19 
Version: Final 4.0 
ST/form/010/11 
 
Contents 
 
1 
Introduction ..................................................................................................................................... 5 
2 
Study Objectives and Design .......................................................................................................... 5 
2.1 
Study Objectives ......................................................................................................................... 5 
2.2 
Study Endpoints .......................................................................................................................... 5 
2.3 
Study Design ............................................................................................................................... 6 
2.4 
Visit Structure .............................................................................................................................. 6 
3 
Sample Size .................................................................................................................................... 6 
4 
Randomisation ................................................................................................................................ 6 
5 
Interim analysis & reporting of Part 1 .............................................................................................. 7 
6 
Analysis Plan ................................................................................................................................... 7 
6.1 
General ....................................................................................................................................... 7 
6.2 
General Derivations .................................................................................................................... 7 
6.3 
Analysis Sets .............................................................................................................................. 8 
6.4 
Data presentations ...................................................................................................................... 8 
6.5 
Disposition of patients ................................................................................................................. 9 
6.6 
Protocol Deviations ..................................................................................................................... 9 
6.7 
Background and Demographic Characteristics .......................................................................... 9 
6.7.1 
Demography ............................................................................................................................ 9 
6.7.2 
Medical History ...................................................................................................................... 10 
6.7.3 
Ophthalmic History ................................................................................................................ 10 
6.8 
Background Therapy and Concomitant Medications ................................................................ 10 
6.9 
Administration of Study treatment and Exposure ..................................................................... 10 
6.9.1 
Compliance ............................................................................................................................ 10 
6.9.2 
Exposure ................................................................................................................................ 11 
6.10 
Efficacy Evaluation ................................................................................................................... 11 
6.10.1 
Primary Endpoint ................................................................................................................... 11 
6.10.2 
Secondary Endpoints ............................................................................................................. 11 
6.10.3 
Exploratory Endpoints ............................................................................................................ 15 
6.10.4 
Additional Summaries ............................................................................................................ 16 
6.11 
Pharmacokinetics ..................................................................................................................... 16 
6.12 
Pharmacodynamics .................................................................................................................. 16 
6.13 
Anti-drug Antibodies ................................................................................................................. 17 
6.14 
Safety Evaluation ...................................................................................................................... 17 
6.14.1 
Adverse Events ...................................................................................................................... 17 
6.15 
Pregnancy Test ......................................................................................................................... 19 
6.16 
Eye Swab .................................................................................................................................. 19 
6.17 
Changes from the Protocol Planned Analysis .......................................................................... 19 
7 
References .................................................................................................................................... 19 
 
 


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Modification History 
 
Version Change History 
Reason 
Date 
1.0 
First Version 
N/A 
27 FEB 2020 
2.0 
1. Clarification of outputs to 
be produced for Part 1 
 
2. Update to baseline 
definition to account for 
non-compliance of 
treatment schedule 
 
3. Update to derivation of 
post-inhillation comfort 
scores to account for 
missing data and 
clarification of average 
score derivation 
 
Updates made 
following review of dry 
run outputs. 
15 JUN 2021 
3.0 
1. Update to medication 
presentation to remove 
separate background 
medication summaries and 
listings. 
2. Update to the definitions of 
compliance calculations 
 
Updates made 
following review of data 
cleaning. 
22 JUN 2021 
4.0 
1. Summaries of efficacy 
endpoints by indication 
group added. 
Further updates made 
following review of dry 
run output and clinical 
consideration. 
 
DDMMMYY
YY 
 
 
 


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LIST OF ABBREVIATIONS 
 
AE 
Adverse Event 
AIC 
Akaike Information Criterion 
AKC  
Atopic Keratoconjunctivitis  
ATS 
All Treated Set 
CRF 
Case Report Form 
ETDRS  
Early Treatment Diabetic Retinopathy Study  
FAS 
Full Analysis Set 
LLOQ 
Lower Limit of Quantification 
LS 
Least Squares 
LTB4 
Leukotriene B4 
MedDRA 
Medical Dictionary for Regulatory Activities 
MMP-9  
Matrix Metalloprotease 9  
PAC 
Perennial Allergic Conjunctivitis 
PI 
Principal Investigator 
PK 
Pharmacokinetic 
PT 
Preferred Term 
RAN 
All Randomised Patients 
SAC 
Seasonal Allergic Conjunctivitis 
SAF 
Safety Analysis Set 
SAP 
Statistical Analysis Plan 
SD 
Standard Deviation 
SOC 
System Organ Class 
TEAE 
Treatment Emergent Adverse Event 
TBUT 
Tear Film Break Up Time 
VKC 
Vernal Keratoconjunctivitis 
WHO Drug World Health Organization Drug Dictionary 
 
 


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1 INTRODUCTION 
This document details the statistical analysis of the data that will be performed for the 
Akari Therapeutics Plc study: Topical rVA576 for TReatment of Atopic 
KERatoconjunctivitis: a randomised placebo controlled double masked parallel trial 
(TRACKER).  
The proposed analysis is based on the contents of Version 8.0 of the protocol (dated 
10th February 2020). In the event of future amendments to the protocol, this statistical 
analysis plan (SAP) may be modified to account for changes relevant to the statistical 
analysis.  
The table, listing and figure shells are supplied in a separate document. 
Comparison of the conjunctival impression cytology results will be done for qualitative 
research information and will not form part of this statistical analysis plan. 
2 STUDY OBJECTIVES AND DESIGN 
2.1 Study Objectives 
The primary objective of Part 1 and Part 2 of the study is to demonstrate the safety 
and tolerability of rVA576 (nomacopan) when given by topical ocular administration to 
patients with atopic keratoconjunctivitis (AKC), vernal keratoconjunctivitis (VKC) and 
severe allergic conjunctivitis (seasonal allergic conjunctivitis (SAC) or perennial 
allergic conjunctivitis (PAC)). 
An additional objective for the first 3 patients (Part 1) is to allow the Principal 
Investigator (PI) and independent clinician to assess the patients’ ability to use the eye 
dropper and vials correctly. 
The secondary objective of Part 2 of the study is to demonstrate efficacy in this patient 
population, specifically to assess whether nomacopan 0.25% eye drops solution is 
effective in mitigating the signs and symptoms of AKC, VKC, and severe allergic 
conjunctivitis (SAC or PAC) and whether they have any effect on markers of 
inflammation. 
2.2 Study Endpoints 
The primary endpoint of the study is: 
• Incidence of ocular treatment emergent adverse events during the treatment 
period. The adverse events (AEs) which have occurred during the 56 days 
following randomisation (Part 2 of the study only) will be considered in the 
analysis of the primary safety outcome.  
The secondary endpoints are: 
• Post-instillation comfort, as graded on patient diary cards at the following 
intervals: Days 1 to 14, 15 to 28, 29 to 42 and 43 to 56  
• Visual acuity by Early Treatment Diabetic Retinopathy Study (ETDRS) charts 
comparison from Day 1 to Day 56  
• Change from Day 1 in composite clinical scores (including Symptom and Sign 
subcomponents) at Day 14, 28, 42 and 56  


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• Number and percentage of patients with Matrix metalloprotease 9 (MMP-9) < 
40 ng/mL and ≥ 40 ng/mL assessed using Inflamma Dry (Quidel) device at Days 
1, 28 and 56  
• Change from Day 1 in Tear film break up time (TBUT) at Day 14, 28, 42 and 56  
The exploratory endpoints are: 
• Systemic absorption by blood sampling 
• If enough tear fluid can be collected analysis of complement C3, C5 and 
leukotriene B4 (LTB4) will be performed  
• A comparison of the number of patients requiring rescue therapy at any stage 
of the trial and the number on such therapy at the end of the trial  
2.3 Study Design 
This will be a multi-centre study in two parts.  The target patient population comprises 
male and female patients above the age of 18 with moderate to severe AKC, VKC and 
severe allergic conjunctivitis (SAC or PAC). 
Part 1: The first 3 patients selected for the study will be treated with active drug in an 
open-label manner. They will have weekly clinic visits for the first 2 weeks and 
thereafter biweekly visits. When the third of the first 3 patients has completed their first 
2 weeks treatment, the PI and independent clinician will review the safety, tolerability 
and ease of application for each patient before deciding to proceed to the randomised, 
double-masked comparative phase of the study (Part 2).  The 3 patients will continue 
on the study and complete the 8 weeks trial as open label patients.  
Part 2: A randomised, double-masked, placebo controlled, parallel group trial of topical 
rVA576 or placebo eye drops in moderate to severe AKC, VKC and severe allergic 
conjunctivitis (SAC or PAC). The Part 2 trial population will comprise 16 patients who 
meet the inclusion and exclusion criteria (Section 4.1 and 4.2 of protocol). Patients will 
have a screening visit and 4 visits occurring every 2 weeks over 8 weeks. 
2.4 Visit Structure 
The visit structure and scheduled assessments are detailed in protocol section 6.7 
(visit structure) and protocol section 17.2 (schedule of events and blood draws). 
3 SAMPLE SIZE 
Up to 19 patients, 3 active in Part 1 of the study and up to 16 randomised to active or 
placebo in Part 2, will be enrolled under this protocol. The sample size for this study 
was determined based on practical, and not statistical, considerations. 
4 RANDOMISATION 
Patients will only be randomised in Part 2 of the study.  They will be randomised in a 
1:1 fashion.  There will be no stratification. 


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5 INTERIM ANALYSIS & REPORTING OF PART 1 
No interim analysis is planned.   
 
The decision to proceed to Part 2 will be determined through PI and an independent 
clinician review of the data for the first three patients up until the time that the third 
patient has completed the second week of the study.  Medical History, Adverse Event, 
Concomitant Medication and Compliance data will be reviewed via the clinical 
database.  A trend analysis will be carried out for the adverse events.  No statistical 
outputs will be produced at this time, but the patients from Part 1 will be included in 
the same patient listings as for Part 2 as a separate group.  Should the study be 
discontinued after Part 1, the listings described in the sections below will be produced 
for Part 1 only.  The summary tables and figures described in the following sections 
relate to Part 2 only unless otherwise stated. 
6 ANALYSIS PLAN 
6.1 General 
Summary statistics for continuous variables will consist of number of non-missing 
observations (n), mean, standard deviation (SD), minimum, 25th percentile, median, 
75th percentile and maximum, unless specified otherwise.  The precision of these 
variables is defined in the table, figure and listing shells document. 
For categorical variables the number and percentage of patients in each category will 
be presented, based on the number of non-missing observations apart from 
disposition of patients, protocol deviations, background and demographic 
characteristics, prior and concomitant medications/procedures and adverse events 
where the percentage will be based on the number of patients in the analysis set. 
Any statistical tests will be performed using a two-tailed 5% overall significance level, 
unless otherwise stated.  The null hypothesis at all times will be that the treatments 
are equivalent.  All comparisons between the treatments will be reported with 95% 
confidence intervals for the difference. 
6.2 General Derivations 
This section provides details of general derivations. Detailed descriptions of specific 
parameter derivations are provided later in the SAP. 
 
• Definition of baseline 
The Baseline value will be defined as the pre-dose value on Day 1, if that is missing 
or the first administration is not on Day 1, it will be defined from the most recent value 
available and recorded prior to the first administration of study treatment.  
• Incomplete dates 
For calculation purposes, incomplete dates will be completed using worst case, the 
most conservative value possible. For example, if the start date has a missing day 
value, the first day of the month will be imputed for study day computations. If day is 


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missing for an end date, the last day of the month will be imputed. Similar logic will be 
assumed for missing month and year components. 
 
• Methods for handling withdrawals and missing data 
There will be no imputation of missing data. Screening data will be used if baseline is 
missing. 
Statistical testing and graphical presentations will not be carried out for any given 
score or measurement if there are less than 5 results, for either the placebo or active 
group, for that score or measurement at any single time point. 
6.3 Analysis Sets 
The Enrolled Set includes all patients who passed screening irrespective of whether 
they received the study treatment. 
The All Treated Set (ATS) includes all patients who have received study treatment.  
The Pharmacokinetic Analysis Set (PK Analysis Set) includes all patients who take 
at least one dose of nomacopan and have at least one PK sample taken and analysed. 
This will be the primary population for assessing PK.  
The Safety Analysis Set (SAF) includes all patients who received at least one dose 
of investigational product. This will be the primary population for assessing safety. 
Patients will be classified by the actual study medication they receive.  
The following analysis sets apply to subjects in Part 2 of the study only: 
• The All Randomised Patients Set (RAN) consists of all patients who were 
randomised, irrespective of the treatment they received, if any.  If this analysis 
set coincides with the full analysis set, it will be omitted from the tables and 
listings. 
• The Full Analysis Set (FAS) includes all patients randomised to treatment who 
received at least one dose of investigational product. This will be the primary 
population for assessing efficacy. Patients will be classified by the study 
medication they were randomised to.  
The definitions for all analysis sets are sufficient to determine the patients included 
within these analysis sets and so do not require listing and agreeing prior to database 
lock. Actual study medication will be determined from the Study Drug Dispensing and 
Return Case Report Form (CRF) page. 
6.4 Data presentations 
The data will be summarised in tabular form by treatment group apart from disposition 
of patients, protocol deviations and background and demographic data which will be 
summarised by treatment group and overall patients. 
The following treatment labels will be used “nomacopan 0.25% eye drops”, “Placebo” 
and “Overall” (where applicable). For disposition of patients, “All patients” will be 
presented combining Part 1 and Part 2. 


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Only scheduled post-baseline visual acuity, clinical scoring, TBUT and categorical 
MMP-9 estimation will be tabulated, post-baseline repeat/unscheduled assessments 
will be disregarded, although they will be listed. 
Analysis sets and study completion/withdrawal will be summarised using the enrolled 
set. Background and demographic characteristics will be summarised using the FAS. 
The efficacy endpoints will be summarised using the FAS. Prior/concomitant 
medications, administration of study treatment and exposure and safety will be 
summarised using the SAF. Pharmacokinetics will be based on the PK Analysis Set. 
Eligibility listings will be based on the screened set and sorted by patient number.  
Analysis set listings will be based on the enrolled set, PK will be based on the PK 
Analysis Set, safety listings and all other listings will be based on the ATS set. 
Listings will be sorted by treatment group, patient number and date/time of 
assessment.  Treatment groups will be presented in the following order: “Part 1, 
Treatment: nomacopan 0.25% eye drops”, “Part 2, Treatment:  nomacopan 0.25% eye 
drops”, “Part 2, Treatment: Placebo”. 
Graphical presentations of the data will also be provided where appropriate. 
6.5 Disposition of patients 
For Part 1 and Part 2, the number and percentage of all patients enrolled, included in 
the RAN, FAS, SAF, PK Analysis Set, who completed the study and prematurely 
discontinued the study, who completed study treatment and prematurely discontinued 
study treatment and study duration, will be summarised. 
The number and percentage of patients will be summarised by their reasons for 
withdrawal from the study and study treatment. 
Study duration will be derived as the number of days between date of starting drug 
administration and the date of study completion or the date of early study withdrawal. 
The date of starting drug administration will be determined from the Comfort Diary 
Card CRF page. 
Eligibility for each of the analysis sets along with reasons for exclusion will be listed. 
Study completion/withdrawal data will be listed. 
6.6 Protocol Deviations 
Details of all protocol deviations (date, deviation category, specific details and 
classification of major or minor) and patient eligibility will be listed. 
6.7 Background and Demographic Characteristics 
6.7.1 Demography 
Demographic characteristics (age, sex, ethnic origin and race) collected at Screening 
will be summarised along with indication (AKC, VKC, SAC, PAC), patient group 
(AKC/VKC and SAC/PAC) and country/site. 
Age is calculated in years from the date of informed consent. 
All patient demographic data including informed consent will be listed. 


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6.7.2 Medical History 
Medical history events will be coded using the latest Medical Dictionary for Regulatory 
Activities (MedDRA) dictionary version.  The version used will be indicated in the data 
summaries and listings.  The number and percentage of patients will be presented for 
ongoing conditions and previous conditions separately by system organ class (SOC), 
and preferred term (PT), where SOC and PT will be presented in decreasing frequency 
of the total number of patients with medical history events. All events will be listed. 
6.7.3 Ophthalmic History 
The number and percentage of patients with any significant ophthalmic history will be 
presented for ongoing and previous conditions separately and also by condition, where 
conditions will be presented in the order: Cataract, Pseudophakia, Glaucoma, 
Glaucoma surgery, Eye lid surgery, Other surgery on the eyes, Other.  All events will 
be listed. 
6.8 Background Therapy and Concomitant Medications 
Medications will be coded using the latest World Health Organization Drug dictionary 
(WHO Drug) version.  The version used will be indicated in the data summaries and 
listings. 
Prior medications are defined as those that started and ended prior to the first 
administration of study treatment. Medications that are ongoing at the first 
administration of study treatment or started after time of first administration will be 
deemed to be concomitant medications. If medication dates are incomplete and it is 
not clear whether the medication was concomitant, it will be assumed to be 
concomitant. 
For Part 1 and Part 2, the number and percentage of patients taking concomitant 
medications will be summarised by medication class and standardised medication 
name, where medication class and standardised medication name will be presented 
in decreasing frequency of the total number of patients with medications. The number 
of patients receiving rescue therapy will be presented similarly (see section 6.10.3.3). 
In summary tables, patients taking multiple medications in the same medication class 
or having the same standardised medication recorded multiple times in the study will 
be counted only once for that specific background therapy type, medication class and 
standardised medication name.  
Background therapy and medication data will be listed together, where concomitant 
medications and background therapy as identified via the eCRF will be flagged.  
Background therapy diary card data will be listed. 
6.9 Administration of Study treatment and Exposure 
6.9.1 Compliance 
For Part 1 and Part 2, the number of vials dispensed, the number of used vials 
returned, the number of vials expected to have been used and compliance for each 
patient will be summarised by treatment group. 
• number of vials expected to have been used = 2 x (number of days that a 
subject administered eye drops dependent on date of first and last dose) 


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where number of days that a subject administered eye drops dependent on 
date of first and last dose is derived from the Study Drug Dispensing and Return 
CRF page data as “date of final study drug return – date of first study drug 
dispensing”. If a patient does not return their final dispensed study drug vials 
then the date of study competition/withdrawal will be used instead of date of 
return. 
• compliance (vial return) = 100 x (total number of used vials returned / total 
number of vials expected to have been used) 
• compliance (exposure) = 100 x (total number of doses administered / (total 
number of vials expected to have been used* 2) 
The multiplication from 2 is required as each vial holds a dose per eye and the 
number of doses is counted per eye treated. 
6.9.2 Exposure 
For Part 1 and Part 2, the number of doses of study treatment administered (total 
number of occasions that a time of study drug was recorded) and the number of days 
of exposure to the study treatment ([last date of dosing - first day of dosing] + 1) will 
be summarised. These data will be obtained from the comfort diary card data. 
All study drug dispensing and return data will be listed. The number of vials expected 
to have been used for each period will be presented. This will be calculated as 2 x 
(number of days that a subject administered eye drops dependent on date of first and 
last dose within each period) 
where number of days that a subject administered eye drops dependent on date 
of first and last dose within each period is derived from the Study Drug 
Dispensing and Return CRF page data as “date of last study drug return for the 
period – date of first study drug dispensing for the period”. 
6.10 Efficacy Evaluation 
6.10.1 Primary Endpoint 
The primary endpoint is a safety outcome and is described under section 6.14.1.1. 
6.10.2 Secondary Endpoints 
6.10.2.1 
Post-instillation comfort 
Post-instillation comfort scores will only be available for the least comfortable eye.   
The eye that the scoring was recorded on will not be captured on the eCRF. 
A score of 0 to 4 will be recorded at 0.5 min, 1 min, 2 min, 3 min and 5 min each 
morning and evening on diary card. 
The total score over two-week periods for days 1 to 14, 15 to 28, 29 to 42 and 43 to 
56 will be calculated for each patient by summing the scores from the five timepoints 
taken each morning and evening over the 14 days, therefore the total score will have 
a possible range of 0 to 560. If there are 20 or more missing data points during the 
period, then the total score will not be calculated and set to missing. 
For derived non-missing scores, an average score for the period will also be calculated 
as follows: 


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𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠=
𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠
𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑜𝑜𝑜𝑜 𝑛𝑛𝑛𝑛𝑛𝑛−𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑 
The average score at each two week-period will be classified as follows: an average 
total comfort score of < 10 will be deemed to be comfortable/acceptable, 10 – 19 will 
be moderately uncomfortable, 20 – 29 will be very uncomfortable and ≥ 30 will be 
severely/unacceptably uncomfortable.  
The number and percentage of missing data over the two-week period will be 
calculated, where 140 data points would expected to be recorded over 14 day period.  
Should the five scores not be available at any morning or evening timepoint there will 
be no imputation, and the total score and classification will be derived for the two-week 
period for that patient regardless of missing data.  
6.10.2.1.1 
Descriptive Summaries 
Descriptive statistics for the total comfort score and the 14 day average comfort score 
will be presented along with the number and percentage of patients at each comfort 
classification will be presented for each treatment group for Days 1 to 14, Days 15 to 
28, Days 29 to 42 and Days 43 to 56 for the recorded eye.  The percentage will be out 
of the number of patients at each timepoint who had some data and therefore the total 
score could be calculated. 
The percentage of missing data points will be summarised for each treatment group 
for Days 1 to 14, Days 15 to 28, Days 29 to 42 and Days 43 to 56. 
6.10.2.1.2 
Analysis 
The classification of the average daily post-instillation comfort score will be analysed 
using an ordinal logistic regression model. The model will include treatment and visit 
as fixed effects and a treatment-by-visit interaction. 
The following variance/covariance matrix structures for the repeated visits by a patient 
will be assessed: Compound symmetry, 1st order autoregressive, Toeplitz and 
unstructured. The variance/covariance matrix structure that results in the smallest 
Akaike information criterion (AIC), indicating the best model fit will be selected. 
Assumptions about the proportionality of odds will also be assessed by appropriate 
methods such as by fitting fixed and random effects at each partition and testing the 
equality of the effects at different partitions. Should assumptions not hold, then the 
treatment odds ratios for the individual cumulative levels of the variable will be 
presented. 
The adjusted least squares (LS) estimate for the treatment odds ratio 
(nomacopan:Placebo) along with corresponding 95% CI will be presented for each 
treatment period.  
A null hypothesis of no change in classification of total post-instillation comfort score 
at Days 43 to 56 between treatment groups (nomacopan/Placebo) will be assessed 
and a p-value will also be reported. 
The extent of missing data will be taken into consideration when analysing the total 
score data. Should it be felt appropriate, alternative analysis may be carried out and/or 


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sensitivity analyses using imputation methods such as last observation carried forward 
will also be considered. 
6.10.2.1.3 
Listing 
All post-instillation comfort diary card data will be listed. 
6.10.2.2 
Visual acuity by Early Treatment Diabetic Retinopathy Study 
(ETDRS) charts 
6.10.2.2.1 
Descriptive Summaries 
Descriptive statistics for observed and change from baseline (Day 1) number of 
ETDRS letters will be presented for each treatment group at each visit for right eye, 
left eye and the score from worse of the two eyes at the visit.  The worst eye is 
determined from the eye assessed on the clinical scoring CRF page at the same visit. 
The number and percentage of patients whose assessed eye differed from the 
previous assessment will be presented. 
6.10.2.2.2 
Analysis 
Change from baseline (Day 1) for the ETDRS on the worst eye at Day 14, Day 28, 
Day 42 and Day 56 will be analysed using a mixed-effect model for repeated 
measures.  The model will include baseline ETDRS as a covariate, treatment group 
and visit as fixed factors and the treatment-by-visit interaction. 
The variance/covariance matrix structure that results in best model fit will be selected 
using the process described in section 6.10.2.1.2. 
Assumptions of normality will be assessed visually using diagnostic plots.  Should 
assumptions of normality not hold, transformations such as percentage change and 
ratio to baseline will be considered.  If there remains uncertainty regarding the 
assumptions, a non-parametric analysis may be considered as an alternative. 
The LS means and 95% confidence interval will be presented for each visit and 
treatment.  The adjusted LS mean difference (nomacopan - placebo) and 95% 
confidence interval will be presented for each visit. 
A null hypothesis of no change in ETDRS at Day 56 between treatment groups 
(nomacopan - placebo) will be assessed and a p-value will also be reported. 
6.10.2.2.3 
Listing 
All visual acuity data will be listed, including the worst eye assessment. 
6.10.2.3 
Clinical scores 
Clinical scores will only be available for the eye judged as worst affected at each visit 
by the patient. In the event that the patient judges both eyes to be equally affected the 
right eye will be assessed.  The eye that the scoring was recorded on will be captured 
on the eCRF and presented in the listing. 
The clinical score is calculated from the Symptom and Sign sub-components. 
For AKC and VKC the Symptom sub-component consists of 5 items and the Sign sub-
component consists of 6 items with each item being given a score between 0 and 3.  


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The Total and Symptom and Sign sub-components are calculated as the sum of all 
items, Symptom items and Sign items respectively giving a possible range of 0 to 33 
on the Total score, 0 to 15 on the Symptom score, and 0 to 18 on the Sign score.  
For SAC and PAC the Symptom sub-component consists of 4 items and the Sign sub-
component consists of 5 items with each item being given a score between 0 and 3.  
The Total and Symptom and Sign sub-components are calculated as the sum of all 
items, Symptom items and Sign items respectively giving a possible range of 0 to 27 
on the Total score, 0 to 12 on the Symptom score, and 0 to 15 on the Sign score.  The 
sign sub-component items are different for SAC and PAC to AKC/VKC. 
For all indications, should an item be missing there will be no imputation and the score 
will be missing for that timepoint.  
6.10.2.3.1 
Descriptive Summaries 
Descriptive statistics for the observed and change from baseline (Day 1) clinical scores 
for the total clinical score, the overall symptom and sign subcomponent scores and 
each item score will be presented for each treatment group at each visit for the 
recorded eye. 
6.10.2.3.2 
Analysis 
Change from baseline (Day 1) for the total score at Day 14, Day 28, Day 42 and Day 
56 will be analysed using a mixed-effect model for repeated measures.  The model 
will include baseline total clinical score as a covariate, treatment group, visit and 
patient group (AKC/VKC or SAC/PAC) as fixed factors and the treatment arm by visit 
interaction. 
The variance/covariance matrix structure that results in best model fit will be selected 
using the process described in section 6.10.2.1.2. 
Assumptions of normality will be assessed visually using diagnostic plots.  Should 
assumptions of normality not hold, transformations such as percentage change and 
ratio to baseline will be considered.  If there remains uncertainty regarding the 
assumptions an alternative analysis, for example non-parametric analysis, may be 
considered. 
The LS means and 95% confidence interval will be presented for each visit and 
treatment.  The adjusted LS mean difference (nomacopan - placebo) and 95% 
confidence interval will be presented for each visit. 
A null hypothesis of no change in clinical score at Day 56 between treatment groups 
(nomacopan - placebo) will be assessed and a p-value will also be reported based on 
the relevant mixed-effect model. 
Where there is sufficient data (see section 6.2) the item scores will be analysed using 
the same method as for the total score.  
Where there is a sufficient number of patients receiving rescue therapy, additional 
analysis (as described above) may be conducted using the same methods as the 
recorded clinical scores by imputing the worst-case score for all post-rescue therapy 
visits. 


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6.10.2.3.3 
Listing 
All clinical score data will be listed. 
6.10.2.4 
MMP-9 positive levels 
The number and percentage of patients with MMP-9 negative (< 40ng/mL) and positive 
(> 40ng/mL) assessed using the Inflamma Dry device will be presented for each 
treatment group at each visit for right and left eyes. 
All MMP-9 data will be listed. 
6.10.2.5 
Tear film break up time 
Tear film break up time (TBUT) will only be available for one eye.  The eye that the 
test was carried out on will be captured on the eCRF and will be presented in the 
listing. 
6.10.2.5.1 
Descriptive Summaries 
Descriptive statistics for observed and change from baseline (Day 1) TBUT will be 
presented for each treatment group at each visit for the recorded eye. 
6.10.2.5.2 
Analysis 
Change from baseline (Day 1) for TBUT (in seconds) at Day 14, Day 28, Day 42 and 
Day 56 will be analysed using a mixed-effect model for repeated measures for the 
recorded eye.  The model will include baseline TBUT as a covariate, treatment group 
and visit as fixed factors and the treatment-by-visit interaction. 
The variance/covariance matrix structure that results in best model fit will be selected 
using the process described in section 6.10.2.1.2. 
Assumptions of normality will be assessed visually using diagnostic plots.  Should 
assumptions of normality not hold, transformations such as percentage change and 
ratio to baseline will be considered.  If there remains uncertainty regarding the 
assumptions a non-parametric analysis may be considered as an alternative. 
The LS means and 95% confidence interval will be presented for each visit and 
treatment.  The adjusted LS mean difference (nomacopan - placebo) and 95% 
confidence interval will be presented for each visit. 
A null hypothesis of no change in TBUT at Day 56 between treatment groups 
(nomacopan - placebo) will be assessed and a p-value will also be reported. 
6.10.2.5.3 
Listing 
All TBUT data will be listed. 
6.10.3 Exploratory Endpoints 
6.10.3.1 
Systemic absorption of nomacopan by blood sampling 
Covered under section 6.11. 
6.10.3.2 
Tear fluid analysis of complement C3, C5 and LTB4 
If sufficient data, tear fluid data will be listed. 


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6.10.3.3 
Rescue therapy 
The number and percentage of patients that received a rescue medication (as 
indicated on the Concomitant Medications CRF page) at any stage of the trial (during 
Day 1 to Day 56 (last dose) and during Day 56 to Day 84 (follow-up visit) to be 
presented separately) and the number and percentage of patients that were receiving 
a rescue medication at the end of the trial (indicated as ongoing on the CRF) will be 
presented in a summary table by treatment group. 
The number and percentage of patients that received a rescue medication will be 
presented for each treatment group for Days 1 to 14, Days 15 to 28, Days 29 to 42 
and Days 43 to 56 to compliment the intervals for the efficacy analysis. The percentage 
will be out of the number of patients at each timepoint who had data for comfort scores 
to be calculated. 
A patient is considered to have taken rescue medication during an interval where the 
start date (Day 1 or later) occurs during that interval, or if they continue to receive 
rescue medication that started in a previous interval. 
6.10.4 Additional Summaries 
Key efficacy endpoints for patients in the FAS in Part 1 and Part 2 will be listed by 
individual patient alongside a summary (Mean (SD)) by treatment group and by 
indication group (Part 2 only: AKC/VKC and SAC/PAC) at each timepoint. Details of 
endpoints to be presented are as follows: 
• Comfort score: 
o Total and average daily score will be presented for each treatment 
period. 
• Visual Acuity: 
o Number of ETDRS letters will be presented for right eye, left eye and 
the score from worse of the two eyes for each visit.   
• Clinical scores: 
o The total clinical score, the overall symptom and sign subcomponent 
scores will be presented for each visit. 
• Tear film break up time: 
o TBUT in seconds will be presented at each visit. 
6.11 Pharmacokinetics 
Serum concentrations of nomacopan will be listed and summarised over time. If < 50% 
of patients have data which are greater than LLOQ then table outputs with summary 
statistics will not be produced.  Should the summary statistics be produced values 
below the lower limit of quantification (LLOQ) will be set to 0.5 × LLOQ for calculation 
of summary serum concentration statistics.  
6.12 Pharmacodynamics 
Serum terminal complement activity measured by CH50 U Eq/ml and change from 
baseline will be summarised by treatment group for each visit. 


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Summary statistics will include observed values, change from baseline and the ratio 
to baseline (% activity). Ratio will be calculated as: 
 
𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅 𝑡𝑡𝑡𝑡 𝑏𝑏𝑏𝑏𝑏𝑏𝑏𝑏𝑏𝑏𝑏𝑏𝑏𝑏𝑏𝑏= 𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂 𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣
𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵 𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣∗100 
Given the very small amount of nomacopan being administered topically, the 
expectation is that active and placebo patients in Part 2 will have equivalent CH50 
values and a comparison between the groups will be tabulated. 
All pharmacodynamic data will be listed. 
6.13 Anti-drug Antibodies 
. All anti-drug antibody data will be listed. 
6.14 Safety Evaluation 
6.14.1 Adverse Events 
AEs will be coded using the latest MedDRA dictionary version.  The version used will 
be indicated in the data summaries and listings. 
Ocular AEs will be identified using SOC “Eye disorders”. 
A treatment-emergent adverse event (TEAE) is defined as an AE that started on or 
after the start of the administration of study treatment. If AE dates are incomplete and 
it is not clear whether the AE was treatment-emergent, it will be assumed to be 
treatment-emergent.  When the AE occurs on the same day as start of administration 
of study treatment a separate file will be transferred from data management to indicate 
whether they are treatment emergent or not (see Data Management Plan section 6).  
If it is not confirmed via Data Management, the start date will be imputed as the date 
of the first dose of study drug. AEs will be considered treatment-emergent if all or part 
of the date of onset of the AE is missing and it cannot be determined if the AE meets 
the definition for treatment-emergent. 
Any AE commencing after the last administration of study treatment (Day 56) plus 30 
days will not be considered treatment emergent. 
A treatment-related TEAE is defined as a TEAE that is possibly related or related to 
the study treatment. If the TEAE has a missing relationship it is assumed to be related 
to the study treatment for analysis purposes. 
6.14.1.1 
Primary Endpoint 
The number and percentage of patients who experienced ocular TEAEs will be 
presented for each treatment group. Treatment groups will be presented in the 
following order: “Part 1, Treatment: nomacopan 0.25% eye drops”, “Part 2, Treatment:  
nomacopan 0.25% eye drops”, “Part 2, Treatment: Placebo”.  
The difference in the percentage of patients (nomacopan -placebo) and exact 95% 
confidence interval for the difference, using Chan and Zhang method (1999), will be 
presented for those in part 2 of the study (nomacopan-placebo) and for those in both 
parts of the study combined (nomacopan-placebo). 


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6.14.1.2 
Other Summary Tables 
A summary table will present the following for Part 1 and Part 2,:  
• TEAEs (events and patients).  
• Serious TEAEs (events and patients).  
• Serious study treatment related TEAEs (events and patients). 
• TEAEs by severity (mild/moderate/severe) (events and patients). 
• TEAEs by relationship to study treatment and the pooled study treatment 
related category (events and patients). 
• TEAEs leading to discontinuation of study treatment (patients only). 
• Study treatment related TEAEs leading to discontinuation of study treatment 
(patients only). 
• TEAEs leading to death (patients only). 
In the above summaries, if a patient experienced more than one TEAE, the patient will 
be counted once using the most related event for the “by relationship to study 
treatment” and “related to study treatment” summaries and at the worst severity for the 
“by severity” summary. 
The following tables will be presented: 
• TEAEs by system Organ Class (SOC) and Preferred Term (PT). 
• TEAEs by PT. 
• TEAEs by SOC, PT and severity 
• TEAEs by SOC, PT and relationship to study treatment and the pooled related 
categories (related). 
For all of the above, SOC and PT will be presented in decreasing frequency of the 
total number of patients with TEAEs. 
Further details of the above four tables are given below: 
1. If a patient experienced more than one TEAE, the patient will be counted once 
for each SOC and once for each PT. 
2. If a patient experienced more than one TEAE, the patient will be counted once 
for each PT. 
3. If a patient experienced more than one TEAE, the patient will be counted once 
for each SOC and once for each PT at the worst severity. 
4. If a patient experienced more than one TEAE, the patient will be counted once 
for each SOC and once for each PT using the most related event. 
AE data will be listed in full and this will also include a treatment emergent flag, 
cessation of event relative to first dosing of study treatment and duration of AE. The 
listing will be reported by events during “Days 1-56”  (treatment period) and “Days 57-
84” (follow-up period). 
This listing will be repeated presenting only serious TEAEs. 


Syne qua non study no: TNS18002 
 
Akari Therapeutics Plc study no: AK701 
 
Date: 12JUL2021 
Page 19 of 19 
Version: Final 4.0 
ST/form/010/11 
 
6.15 Pregnancy Test 
All pregnancy test details will be listed. 
6.16 Eye Swab 
All eye swab data will be listed. 
6.17 Changes from the Protocol Planned Analysis 
• Section 11.1 of the protocol states that the baseline value will be defined as the 
pre-dose value on Day 1, if that is missing, it will be defined from the most 
recent value available. This has been updated to take account of any patients 
who do not take their first dose on Day 1. 
• Section 11.3 of the protocol states that the weekly comfort scores for post-
instillation comfort, as graded on patient diary cards will be compared.  To be 
in-line with the secondary endpoint, the scores over the two-weekly period will 
be compared. 
• Section 11.8 of the protocol states that the Safety Analysis Set will include only 
randomized subjects from Part 2 of the study. To be in line with ICH E9 
guidelines section 6.3 we will include all treated subjects regardless of the part 
of the study they are enrolled into. 
7 REFERENCES 
Chan ISF, Zhang Z. Test-based exact confidence intervals for the difference of two 
binomial proportions. Biometrics. 1999;55:1202–1209