Conditions: Healthy
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 70
Healthy volunteers: yes

Brief summary:
The main objectives of this trial are to investigate safety and tolerability of BI 474121 in healthy male and female young and elderly subjects following oral administration of multiple rising doses per day over 14 days.

Detailed description:

Arms:
arm 1: Young participants administered 1 tablet of 2.5 milligrams (mg) BI 474121 orally once daily over a treatment period of 14 days.

On Day -1, 1, and 14, 75 micrograms (μg) of midazolam for injection used as oral solution were administered orally once daily. arm 2: Young participants administered 2 tablets of 2.5 mg BI 474121 orally once daily (daily dose: 5 mg) with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h) over a treatment period of 14 days. arm 3: Young participants administered 1 tablet of 10 milligrams (mg) BI 474121 orally once daily with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h) over a treatment period of 14 days.

On Day -1, 1, and 14, 75 micrograms (μg) of midazolam for injection used as oral solution were administered orally once daily with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h). arm 4: Young participants administered 2 tablets of 10 milligrams (mg) BI 474121 orally once daily (daily dose: 20 mg) with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h) over a treatment period of 14 days.

On Day -1, 1, and 14, 75 micrograms (μg) of midazolam for injection used as oral solution were administered orally once daily with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h). arm 5: Young participants administered 3 tablets of 10 milligrams (mg) BI 474121 orally once daily (daily dose: 30 mg) with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h) over a treatment period of 14 days.

On Day -1, 1, and 14, 75 micrograms (μg) of midazolam for injection used as oral solution were administered orally once daily with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h). arm 6: Young participants administered matching placebo to part A once daily with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h) over a treatment period of 14 days.

On Day -1, 1, and 14, 75 micrograms (μg) of midazolam for injection used as oral solution were administered orally once daily with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h) for placebo participants matched to 2.5mg BI, 10mg BI, 20mg BI, and 30mg BI groups. arm 7: Elderly participants administered matching placebo to part B once daily with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h) over a treatment period of 14 days arm 8: Elderly participants administered 2 tablets of 2.5 mg BI 474121 orally once daily (daily dose: 5 mg) with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h) over a treatment period of 14 days. arm 9: Elderly participants administered 1 tablet of 10 milligrams (mg) BI 474121 orally once daily with 240 milliliter (mL) of water after an overnight fast of at least 10 hours (h) over a treatment period of 14 days.

Interventions: intervention 1: BI 474121 intervention 2: Midazolam intervention 3: Placebo
Intervention descriptions: intervention 1: BI474121 intervention 2: Midazolam intervention 3: Placebo

Protocol document:
Prot_000.pdf: 
001-MCS-40-106-RD-11 (6.0) / Saved on: 13 Jun 2018
Clinical Trial Protocol
TITLE PAGE
Document Number:
c31468495-04
EudraCT No.
2020-001003-17 
BI Trial No.
1411-0002
BI Investigational
Medicinal Product
BI 474121
Title
Safety, tolerability and pharmacokinetics of multiple rising oral 
doses of BI 474121 in young and elderly healthy male and female 
subjects (double-blind, randomised, placebo-controlled, parallel 
group design) and evaluation of midazolam interaction in young 
healthy male and female subjects (nested, open, fixed-sequence, 
intra-individual comparison)
Lay Title
A study in healthy men and women who are either between 
18 - 45 years or between 65 - 80 years to test how different doses 
of BI 474121 are tolerated
Clinical Phase
I
Clinical Trial Leader
Phone: 
Fax:
Principal 
Investigator
Phone: 
Fax: 
Status
Final Protocol (Revised Protocol (based on global amendment 3))
Version and Date
Version: 4.0
Date: 13 July 2021
Page 1 of 115
Proprietary confidential information
© 2021 Boehringer Ingelheim International GmbH or one or more of its affiliated companies. All rights reserved.
This document may not - in full or in part - be passed on, reproduced, published or otherwise used without prior written permission


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CLINICAL TRIAL PROTOCOL SYNOPSIS
Company name
Boehringer Ingelheim
Protocol date
26 June 2020
Revision date
13 July 2021
BI trial number
1411-0002
Title of trial
Safety, tolerability and pharmacokinetics of multiple rising oral doses of BI 474121 
in young and elderly healthy male and female subjects (double-blind, randomised, 
placebo-controlled, parallel group design) and evaluation of midazolam interaction 
in young healthy male and female subjects (nested, open, fixed-sequence, intra-
individual comparison)
Principal Investigator
Trial site
Clinical phase
I
Trial rationale
Safety, tolerability and pharmacokinetics of BI 474121 will be assessed in young 
healthy male and female (Part A) and elderly healthy male and female subjects 
(Part B) using single and multiple rising oral doses in order to provide the basis 
for a potential ongoing clinical development of BI 474121 for the treatment of 
cognitive impairment in patients with Alzheimer’s Disease and schizophrenia.
Furthermore the effect of BI 474121 on the pharmacokinetics of midazolam given 
as oral microdose in dose groups 2.5 mg, 10 mg, 20 mg and 30 mg will be assessed 
in young healthy male subjects.
Trial objectives
To investigate safety, tolerability and pharmacokinetics following multiple rising 
oral doses of BI 474121 and to investigate the effect of BI 474121 on the 
pharmacokinetics of midazolam given as oral microdose.
Trial endpoints
Primary endpoint to assess safety and tolerability of BI 474121 is the percentage 
of subjects with drug-related adverse events (AEs)
Further criteria: AEs including clinically relevant findings from the physical 
examination, safety laboratory tests, 12-lead electrocardiogram (ECG), vital signs 
(blood pressure [BP], pulse rate [PR]), orthostatic testing, and Columbia Suicidality 
Severity Scale (C-SSRS)
Secondary endpoints:
After first dose: AUC0-24, Cmax of BI 474121
After last dose: AUCτ,ss, Cmax,ss of BI 474121
After single doses: AUC0-tz and Cmax of Midazolam (DG 2.5 mg, 10 mg, 20 mg and 
30 mg)


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Trial design
Double-blind, randomised within dose groups, placebo-controlled, parallel-group 
design and nested, open, fixed-sequence, intra-individual comparison.
Number of subjects 
total entered
70*
each treatment
Part A 50* 10 per dose group (8 on BI 474121 and 2 on placebo)**
Part B 20* 10 per dose group (8 on BI 474121 and 2 on placebo)**
* Based on experience gained during the trial conduct (e.g. preliminary PK data), 
intermediate doses (e.g. 7.5 mg, 15 mg) may be tested provided the planned and approved 
highest dose will not be exceeded. The addition of further dose groups exceeding the already 
tested dose levels for the evaluation of safety findings will be subject to a substantial CTP 
amendment requiring approval. Thus, the actual number of subjects participating in the study
may exceed 70, but is not to exceed 90 subjects entered.
** Part A (young healthy male and female subjects) will be conducted in 5 dose groups;
Part B (elderly healthy male and female subjects) will be conducted in 2 dose groups after 
respective dose level of Part A has been completed and was shown to be safe and well-
tolerated. In each dose group of the elderlies at least 3 subjects will be aged 75 to 80.
Diagnosis
Not applicable
Main criteria
for inclusion
Healthy male/female subjects, age of 18 to 45 years (inclusive), body mass index 
(BMI) of 18.5 to 29.9 kg/m2 (inclusive)
Elderly healthy male/female volunteers, age 65 and 80 years, BMI range: ≥18.5 
and 29.9 kg/m2
Test product (1):
BI 474121 as 2.5 mg and 10 mg uncoated tablet
dose
Part A: 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg
Part B: 5 mg, 10 mg
mode of admin.
Oral with 240 mL of water after an overnight fast of at least 10 h
Comparator product to
test product (1):
Placebo matching to 2.5 mg and 10 mg uncoated tablets
dose
Not applicable
mode of admin.
Oral with 240 mL of water after an overnight fast of at least 10 h
Test product (2):
Midazolam for injection used as oral solution
dose
75 μg q.d.
mode of admin.
Oral with 240 mL of water after an overnight fast
Duration of treatment
BI 474121 or placebo over 14 days with once daily multiple doses
Midazolam: Day -1, Day 1, and Day 14 (1 single dose, each)


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Statistical methods
Descriptive statistics will be calculated for all endpoints.
 
 
Midazolam: (DG 2.5 mg, 10 mg, 20 mg and 30 mg in Part A)
Relative bioavailability will be estimated by the ratios of the geometric means 
(test/reference) for the AUC0-tz and Cmax of Midazolam. Additionally, their two-
sided 90% CIs will be provided.


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FLOW CHART
Visit
Day
Planned time (relative to 
first drug administration) 
[h:min]
Approximate clock time 
of actual day [h:min]
Event and comment
Safety laboratory14
PK blood 8, 10, 13, 19
PK urine 10, 11
Orthostatic testing 15
C-SSRS
12-lead ECG
Vital signs (BP, PR)
Questioning for AEs and 
concomitant therapy 6
1
-21 to -3
Screening (SCR)1
A16
x
x
x
x18
2
-3 to -1
-72:00
08:00
Ambulatory visit
B7,16
x
x18
x
-117
-25:30
06:30
Admission to trial site and 
allocation to treatment2: 
BI 474121 or placebo only 
in Part A (2.5 mg,10 mg, 
20 mg, 30 mg) 
administration
x5
x2,13,19
x
x2
x2
x2,18
x
-24:00
08:00
Midazolam only in Part A 
(2.5 mg,10 mg, 20 mg, 
30 mg) administration
-23:45
08:15
x13,19
-23:30
08:30
x13,19
-23:00
09:00
x13,19
-22:30
09:30
x13,19
-22:00
10:00
240 mL fluid intake
x13,19
-21:00
11:00
x13,19
-20:00
12:00
240 mL fluid intake, 
thereafter lunch3
x13,19
-18:00
14:00
x13,19
-16:00
16:00
Snack (voluntary)3
x13,19
-14:00
18:00
Dinner3
x13,19
-12:00
20:00
x13,19
117
-1:00
07:00
Admission to trial site and 
allocation to treatment2: 
BI 474121 or placebo for 
subjects without midazolam 
profiling 
x5
x13,19
x
x12
x18
X
0:00
08:00
First drug administration & 
Midazolam only in Part A 
(2.5 mg,10 mg, 20 mg, 
30 mg) 
▲
│
│
│
0:15
08:15
x13
│
0:30
08:30
x13
│
X
1:00
09:00
x13
│
1:30
09:30
x13
│
2:00
10:00
240 mL fluid intake
x8,13
│
X
3:00
11:00
x13
│
4:00
12:00
240 mL fluid intake, 
thereafter lunch3
x13
┼
│
6:00
14:00
x13
│
8:00
16:00
Snack (voluntary)3
x13
┼
X
10:00
18:00
Dinner3
x13
│
12:00
20:00
x13
┼
2
23:45
07:45
x13
│
x
x9
x18
X
24:00
08:00
Drug administration
▼


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Visit
Day
Planned time (relative to 
first drug administration) 
[h:min]
Approximate clock time 
of actual day [h:min]
Event and comment
Safety laboratory14
PK blood 8, 10, 13, 19
PK urine 10, 11
Orthostatic testing 15
C-SSRS
12-lead ECG
Vital signs (BP, PR)
Questioning for AEs and 
concomitant therapy 6
2
3
47:45
07:45
C
x
x18
X
48:00
08:00
Drug administration
4
72:00
08:00
Drug administration
x18
5
95:45
07:45
C
x
x
x9
x18
X
96:00
08:00
Drug administration
6
120:00
08:00
Drug administration
x18
X
7
143:45
07:45
x18
X
144:00
08:00
Drug administration
8
167:45
07:45
C
x
x
x9
x18
X
168:00
08:00
Drug administration
170:00
10:00
x
x
9
192:00
08:00
Drug administration
x18
X
10
216:00
08:00
Drug administration
x18
X
11
239:45
07:45
C
x
x
x9
x18
X
240:00
08:00
Drug administration
242:00
10:00
x
x
12
264:00
08:00
Drug administration
x18
13
287:45
07:45
x
x9
x18
X
288:00
08:00
Drug administration
14
311:45
07:45
C
x8,13,19
x
x9
x18
X
312:00
08:00
Last BI 474121 or placebo 
administration & Midazolam
only in Part A 
(2.5 mg,10 mg, 20 mg, 
30 mg)
▲
│
│
│
│
312:15
08:15
x8,13,19
│
312:30
08:30
x8,13,19
│
313:00
09:00
x8,13,19
│
x
x9
x
313:30
09:30
x8,13,19
│
314:00
10:00
240 mL fluid intake 
x8,13,19
│
x
x9
x
X
315:00
11:00
x8,13,19
│
316:00
12:00
240 mL fluid intake, 
thereafter lunch3
x8,13,19
┼
│
x9
x
X
318:00
14:00
x8,13,19
│
x
320:00
16:00
Snack (voluntary)3
x8,13,19
┼
x9
x
X
322:00
18:00
Dinner3
x8,13,19
│
324:00
20:00
x8,13,19
┼
x
x9
x
X
15
336:00
08:00
Breakfast
x8,13,19
▼
x
x9
x18
X
348:00
20:00
x8
16
360:00
08:00
Breakfast, confirmation of 
fitness, discharge from trial 
site
C
x8
x
x9
x18
X
17
384:00
08:00
Ambulatory visit
x8
x18
X
18
408:00
08:00
Ambulatory visit
x8
x18
X
3
21 to 23
End of trial (EoT) 
examination4
D
x
x18
X


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1.
Subject must be informed and written informed consent obtained prior to starting any screening procedures. Screening 
procedures include physical examination, orthostatic testing, check of vital signs including body temperature, ECG, 
safety laboratory (including drug screening and pregnancy test in women with childbearing potential), C-SSRS, 
demographics (including determination of body height and weight, smoking status and alcohol history), relevant 
medical history, concomitant therapy and review of inclusion/exclusion criteria. In the elderly subjects (DG 5 and 6) a 
dementia screening test (Mini-Mental State Examination, MMSE) will be conducted.
2.
The time is approximate; the procedures are to be performed and completed within the 2 h prior to drug administration. 
Allocation to treatment may be performed at any time following enrolment but must be completed prior to (first) drug 
administration.
3.
If several actions are indicated at the same time, the intake of meals will be the last action.
4.
At the end of trial visit the EoTrial examination includes physical examination, body weight, vital signs including
assessment of body temperature, ECG, safety laboratory, recording of AEs, and concomitant therapies. In the elderly 
subjects (DG 5 and 6) a dementia screening test (Mini-Mental State Examination, MMSE) will be conducted.
5.
Additional urine drug screening and alcohol breath test as well as a pregnancy test in women with childbearing potential 
will be done at this time.
6.
AEs and concomitant therapies will be recorded throughout the trial, but will be specifically asked for at the times
indicated in the Flow Chart above.
7.
Safety laboratory to be taken and to be medically evaluated within 3 days prior to first administration of study drug; this 
safety laboratory assessment can be omitted if the screening examination is performed on Days -5,-4,-3.
8.
At this time, an additional blood sample for metabolite identification will be taken for the 10 mg and 30 mg dose group 
(refer to Section 5.3.2.2).
9.
The ECG recording has to be performed in triplicate at this time.
10. Sampling times and periods may be adapted based on information obtained during the trial (e.g., due to preliminary PK 
data) including addition of samples and visits as long as the total blood volume removed does not exceed 500 mL per 
subject.
11. A blank urine sample (x) is to be obtained prior to administration of trial medication. Other urine samples are to be 
collected over the stated post-dose intervals (◄––│––│––►) 0-4, 4-8, 8-12, and 12-24 h.
12. On Day 1(prior to drug administration) 3 triplicate ECGs are recorded within approximately one hour. The recordings 
should be separated by at least 15 minutes. 
13. Collection of PK tubes for assessment of midazolam only in Part A (2.5 mg, 10 mg, 20 mg and 30 mg) on Day -1, on 
Day 1 / 2 and Day 14 / 15 in addition to PK tubes for the assessment of BI 474121.
14. Letters A, B, C and D describe different sets of safety laboratory examinations (see Table 5.2.4: 1).
15. Includes 1st measurement in supine position (~X+5 min), 2nd measurement immediately after standing up (~X+6min), 
3rd measurement after 3 min in a standing position (~X+9 min)
16. PCR test for SARS-COV-2 will be performed during screening and within four days prior to admission to trial site on 
day -3.
17. For convenience subjects maybe admitted to trial site on the day prior to first dosing day. 
18. Vital signs include additional assessment of body temperature.
 


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TABLE OF CONTENTS
TITLE PAGE ......................................................................................................1
CLINICAL TRIAL PROTOCOL SYNOPSIS ................................................2
FLOW CHART...................................................................................................5
TABLE OF CONTENTS ...................................................................................8
ABBREVIATIONS.......................................................................................... 13
1.
INTRODUCTION.................................................................................... 16
1.1
MEDICAL BACKGROUND............................................................................16
1.2
DRUG PROFILE...............................................................................................16
1.2.1.8
Drug product ............................................................................27
1.2.2
Midazolam .............................................................................................27
1.3
RATIONALE FOR PERFORMING THE TRIAL........................................28
1.3.1
Study population...................................................................................28
1.3.3
Maximum dose ......................................................................................29
1.4
BENEFIT - RISK ASSESSMENT ...................................................................31
1.4.1
Expected benefit for the target population.........................................31
1.4.2
Procedure-related risks ........................................................................32
1.4.3
Drug-related risks and safety measures..............................................32
1.4.3.1
BI 474121.................................................................................32
1.4.3.2
Midazolam ...............................................................................33
1.4.3.3
Safety measures .......................................................................33
2.
TRIAL OBJECTIVES AND ENDPOINTS........................................... 36
2.1
MAIN OBJECTIVES, PRIMARY AND SECONDARY ENDPOINTS ......36
2.1.1
Main objectives......................................................................................36
2.1.2
Primary endpoint..................................................................................36
2.1.3
Secondary endpoints.............................................................................36


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2.2.2.1
Safety and tolerability..............................................................37
3.
DESCRIPTION OF DESIGN AND TRIAL POPULATION.............. 40
3.1
OVERALL TRIAL DESIGN AND PLAN ......................................................40
3.2
DISCUSSION OF TRIAL DESIGN, INCLUDING THE CHOICE OF 
CONTROL GROUP..........................................................................................42
3.3
SELECTION OF TRIAL POPULATION ......................................................43
3.3.1
Main diagnosis for trial entry..............................................................43
3.3.2
Inclusion criteria...................................................................................43
3.3.3
Exclusion criteria ..................................................................................44
3.3.4
Withdrawal of subjects from treatment or assessments ...................46
3.3.4.1
Discontinuation of trial treatment ............................................46
3.3.4.2
Withdrawal of consent to trial participation ............................47
3.3.4.3
Discontinuation of the trial by the sponsor..............................47
3.3.5
Replacement of subjects .......................................................................48
4.
TREATMENTS........................................................................................ 49
4.1
INVESTIGATIONAL TREATMENTS ..........................................................49
4.1.1
Identity of the Investigational Medicinal Products ...........................49
4.1.2
Selection of doses in the trial................................................................50
4.1.3
Method of assigning subjects to treatment groups ............................50
4.1.4
Drug assignment and administration of doses for each subject .......51
4.1.5
Blinding and procedures for unblinding ............................................52
4.1.5.1
Blinding ...................................................................................52
4.1.5.2
Unblinding and breaking the code...........................................53
4.1.6
Packaging, labelling, and re-supply ....................................................53
4.1.7
Storage conditions.................................................................................53
4.1.8
Drug accountability ..............................................................................54
4.2
OTHER TREATMENTS, EMERGENCY PROCEDURES, 
RESTRICTIONS ...............................................................................................54
4.2.1
Other treatments and emergency procedures....................................54
4.2.2
Restrictions............................................................................................55
4.2.2.1
Restrictions regarding concomitant treatment .........................55
4.2.2.2
Restrictions on diet and life style.............................................55
4.3
TREATMENT COMPLIANCE.......................................................................56
5.
ASSESSMENT ......................................................................................... 57
5.1
ASSESSMENT OF EFFICACY.......................................................................57
5.2
ASSESSMENT OF SAFETY............................................................................57
5.2.1
Physical examination ............................................................................57
5.2.2
Vital signs...............................................................................................57


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5.2.3
Orthostatic tests ....................................................................................57
5.2.4
Safety laboratory parameters..............................................................58
5.2.5
Electrocardiogram................................................................................60
5.2.5.1
12-lead resting ECG.................................................................60
5.2.6
Suicidality assessment...........................................................................63
5.2.7
Mini-Mental State Examination (MMSE)..........................................63
5.2.8
Assessment of adverse events...............................................................63
5.2.8.1
Definitions of adverse events...................................................63
5.2.8.1.1 Adverse event ............................................................63
5.2.8.1.2 Serious adverse event ................................................63
5.2.8.1.3 AEs considered ‘Always Serious’.............................64
5.2.8.1.4 Adverse events of special interest .............................64
5.2.8.1.5 Intensity (severity) of AEs.........................................65
5.2.8.1.6 Causal relationship of AEs ........................................65
5.2.8.1.7 Suicidal risk assessed by the C-SSRS .......................66
5.2.8.2
Adverse event collection and reporting ...................................67
5.2.8.2.1 AE collection.............................................................67
5.2.8.2.2 AE reporting to the sponsor and timelines ................68
5.2.8.2.3 Information required..................................................68
5.2.8.2.4 Pregnancy ..................................................................68
5.3
DRUG CONCENTRATION MEASUREMENTS AND 
PHARMACOKINETICS..................................................................................68
5.3.1
Assessment of pharmacokinetics .........................................................68
5.3.2
Methods of sample collection...............................................................69
5.3.2.1
Blood sampling for pharmacokinetic analysis.........................69
5.3.2.2
Blood sampling for metabolism analysis.................................70
5.3.2.3
Urine sampling for pharmacokinetic analysis..........................70
 
5.4
ASSESSMENT OF BIOMARKERS................................................................72
5.5
BIOBANKING ...................................................................................................73
5.6
OTHER ASSESSMENTS .................................................................................73
5.7
APPROPRIATENESS OF MEASUREMENTS.............................................74


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6.
INVESTIGATIONAL PLAN.................................................................. 75
6.1
VISIT SCHEDULE............................................................................................75
6.2
DETAILS OF TRIAL PROCEDURES AT SELECTED VISITS ................75
6.2.1
Screening period....................................................................................75
6.2.2
Treatment period ..................................................................................75
6.2.3
Follow-up period and trial completion ...............................................76
7.
STATISTICAL METHODS AND DETERMINATION OF
SAMPLE SIZE......................................................................................... 77
7.1
STATISTICAL DESIGN – MODEL ...............................................................77
7.2
NULL AND ALTERNATIVE HYPOTHESES ..............................................77
7.3
PLANNED ANALYSES....................................................................................77
7.3.1
Primary endpoint analyses...................................................................78
7.3.2
Secondary endpoint analyses ...............................................................78
7.3.4
Safety analyses.......................................................................................81
7.4
INTERIM ANALYSES .....................................................................................82
7.5
HANDLING OF MISSING DATA ..................................................................83
7.5.1
Safety......................................................................................................83
7.5.2
Pharmacokinetics..................................................................................83
7.6
RANDOMISATION ..........................................................................................83
7.7
DETERMINATION OF SAMPLE SIZE ........................................................83
8.
INFORMED CONSENT, TRIAL RECORDS, DATA 
PROTECTION, PUBLICATION POLICY, AND 
ADMINISTRATIVE STRUCTURE...................................................... 84
8.1
TRIAL APPROVAL, SUBJECT INFORMATION, INFORMED 
CONSENT ..........................................................................................................84
8.2
DATA QUALITY ASSURANCE .....................................................................85
8.3
RECORDS..........................................................................................................85
8.3.1
Source documents .................................................................................85
8.3.2
Direct access to source data and documents.......................................86
8.3.3
Storage period of records.....................................................................86
8.4
EXPEDITED REPORTING OF ADVERSE EVENTS .................................86
8.5
STATEMENT OF CONFIDENTIALITY AND SUBJECT PRIVACY.......87
8.5.1
Collection, storage and future use of biological samples and 
corresponding data ...............................................................................87
8.6
TRIAL MILESTONES .....................................................................................87
8.7
ADMINISTRATIVE STRUCTURE OF THE TRIAL ..................................88
9.
REFERENCES......................................................................................... 90


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9.1
PUBLISHED REFERENCES...........................................................................90
9.2
UNPUBLISHED REFERENCES.....................................................................91
10. APPENDICES .......................................................................................... 93
10.1
COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)...............93
10.1.1 Columbia-Suicide Severity Rating Scale (C-SSRS) 
Baseline/Screening ................................................................................93
10.1.2 Columbia-Suicide Severity Rating Scale (C-SSRS) Since Last 
Visit.........................................................................................................96
10.2
DILUTION INSTRUCTIONS FOR MIDAZOLAM (ONLY IN PART A 
IN DG 2.5 MG, 10 MG, 20 MG AND 30 MG).................................................99
10.2.1 Required equipment and dosing aids – overview...............................99
10.2.2 Dilution procedure................................................................................99
10.2.3 In-use stability.....................................................................................100
10.2.4 Mode of application ............................................................................100
10.3
SARS-COV-2 RELATED MEASURES ........................................................101
10.4
DEMENTIA SCREENING TEST (MINI-MENTAL STATE 
EXAMINATION, MMSE)..............................................................................104
11. DESCRIPTION OF GLOBAL AMENDMENT(S)............................ 107
11.1
GLOBAL AMENDMENT 1 ...........................................................................107
11.2
GLOBAL AMENDMENT 2 ...........................................................................110
11.3
GLOBAL AMENDMENT 3 ...........................................................................115


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ABBREVIATIONS
AD
Alzheimer’s disease
AE
Adverse event
AESI
Adverse events of special interest
ANOVA
Analysis of variance
 
AUC0-24
Area under the concentration-time curve of the analyte in plasma over the 
time interval from 0 to 24
AUC0-tz
Area under the concentration-time curve of the analyte in plasma over the 
time interval from 0 to the last quantifiable data point
 
BA
Bioavailability
BI
Boehringer Ingelheim
BMI
Body mass index (weight divided by height squared)
BP
Blood pressure
CA
Competent authority
cAMP
Cyclic adenosine monophosphate
CDISC
Clinical Data Interchange Standards Consortium 
cGMP
Cyclic guanosine monophosphate
CI
Confidence interval
CIAS
Cognitive impairment associated with schizophrenia
 
 
 
 
Cmax
Maximum measured concentration of the analyte in plasma
CNS
Central nervous system
CRF
Case Report Form, paper or electronic (sometimes referred to as ‘eCRF’)
CSF
Cerebrospinal fluid
C-SSRS
Columbia Suicidality Severity Rating Scale
CTM
Clinical Trial Manager
CTP
Clinical trial protocol


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CTR
Clinical trial report
DILI
Drug induced liver injury
ECG
Electrocardiogram
eCRF
Electronic case report form
eDC
Electronic data capture 
EDTA
Ethylenediaminetetraacetic acid
EoTrial/EoT
End of trial
EudraCT
European Clinical Trials Database
F
Absolute bioavailability factor
 
FIH
First in Human
GCP
Good Clinical Practice
gCV
Geometric coefficient of variation
gMean
Geometric mean
HR
Heart rate
IB
Investigator’s brochure
IEC
Independent Ethics Committee
IPD
Important Protocol Deviation
IRB
Institutional Review Board
ISF
Investigator site file
LC-MS/MS
Liquid chromatography with tandem mass spectrometry
LTP
Long term potentiation
MDA
Methylenedioxyamphetamine
MDMA
Methylenedioxymethamphetamine
MedDRA
Medical Dictionary for Regulatory Activities
MMSE
Mini-Mental State Examination
NMDAR
N-methyl-D-aspartate receptor
NOAEL
No observed adverse effect level
PCR
Polymerase chain reaction
PDE2
PhosphoDiEsterase 2
PE
Polyethylene
PfOS
Powder for reconstitution of an oral solution
PK
Pharmacokinetic(s)


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PKS
Pharmacokinetic set
PP
Polypropylene
PR
Pulse rate
QoL
Quality of life
QT
Time between start of the Q-wave and the end of the T-wave in an 
electrocardiogram
QTc
QT interval corrected for heart rate using the method of Fridericia (QTcF) 
or Bazett (QTcB)
R
Reference treatment
RAAS
Renin-angiotensin-aldosterone system
REP
Residual effect period
RR
Respiratory rate
SAE
Serious adverse event
SCR
Screening
SOP
Standard operating procedure
SRD
Single-rising dose
ss
(at) steady state
T
Test product or treatment
 
TMF
Trial master file
TS
Treated set
TSAP
Trial statistical analysis plan
tz
Time of last measurable concentration of the analyte in plasma
ULN
Upper limit of normal
 
 
extravascular administration
XTC
Ecstasy


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1.
INTRODUCTION
 
1.1
MEDICAL BACKGROUND
AD and schizophrenia are chronic, severe, and disabling brain disorders affecting both men 
and women. Available symptomatic treatments for AD consist of acetylcholinesterase 
inhibitors (AChEIs) and memantine which, however, are widely acknowledged as having 
very limited efficacy. More effective symptomatic treatment remains a major unmet medical 
need. Existing treatment options for schizophrenia (i.e., first- and second-generation 
antipsychotics) are primarily efficacious in treating positive symptoms, but have limited 
efficacy for treating the cognitive and negative symptoms of the disorder. No pharmacologic 
therapies have been approved for the symptomatic treatment of the cognitive impairment seen 
in patients with schizophrenia.
Schizophrenia and AD are characterized by abnormalities in glutamatergic pathways related 
 
 
 
 
 
 
 
 
 
 
 
 
 
1.2
DRUG PROFILE
 
 


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1.2.1.8
Drug product
Please refer to Section 4.1. For a more detailed description of the BI 474121 profile, please 
refer to the current IB [c26859058].
1.2.2
Midazolam
Midazolam is a sensitive substrate of CYP3A4, used both in vitro and in vivo as a probe drug 
for CYP3A4 drug interactions. Absorption is rapid, with maximum concentrations reached 
around 15 to 30 min. Clearance is also rapid, with an elimination half-life of 1.5 to 2.5 h. The 
PK of midazolam has been found to be dose proportional over a range of at least 0.001 µg to 


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3 mg [R17-3022]. For further information, refer to the summary of product characteristics 
[R20-1842].
 
 
 
 
 
 
 
 
 
 
 
1.3
RATIONALE FOR PERFORMING THE TRIAL
This is the second trial with BI 474121 and the first with multiple dose administration. The 
objective of this trial is to investigate the safety, tolerability, pharmacokinetics and 
pharmacodynamics of BI 474121 in young and elderly healthy male and female subjects. 
 
. This trial will also provide in the selected population of  young and elderly 
healthy male and female subjects pharmacokinetic information at steady state exposure.
Based on in vitro screening data, it cannot be excluded that BI 474121 might be an
 
 
 
The safety- and PK data obtained in this study will contribute to define appropriate doses for
further clinical studies with BI 474121.
1.3.1
Study population
Regarding the pursued indications we consider it very important to early include in clinical 
studies all age groups for which they will have significant utility.  The early evaluation of 
demographic factors such as age and gender will help to optimize planning and conduct of
later studies in patients. For this reason the study is planned to include young and elderly 
healthy male and female subjects.


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1.3.3
Maximum dose
The maximum dose of this trial is 30 mg QD over 2 weeks (see Section 1.2.1.6), and this 
dose will not be exceeded in this trial. Furthermore dose escalation will be guided by 
preliminary PK analysis (see Sections 1.4.3.3 and 7.4).


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1.4
BENEFIT - RISK ASSESSMENT
1.4.1
Expected benefit for the target population
Participation in this clinical trial is without any (therapeutic) benefit for healthy subjects. 
Their participation, however, is of major importance for the development of BI 474121 as 
treatment for CIAS as well as for symptomatic treatment of mild to moderate AD.
Subjects are exposed to risks of study procedures and risks related to the exposure to the trial 
medication.
It is broad understanding that aging has a significant effect on the responses to 
pharmacological interventions.
 
 
 
 
 
 
 
Elderlies are the target population for the intended indication of cognitive deficits in 
Alzheimer disease. Due to the short duration of this Phase I study a therapeutic benefit for a 
participating elderly subject is not expected. The subject, however, may benefit in the future
from an innovative treatment option if successfully developed.


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1.4.2
Procedure-related risks
The use of an indwelling venous catheter or venepuncture for e.g. blood sampling may result 
in mild bruising, syncope, and, in rare cases, in transient inflammation of the wall of the vein, 
or nerve injury, potentially resulting in paraesthesia, reduced sensibility, and/or pain for an 
indefinite period.
The total volume of blood withdrawn per subject during the entire study will not exceed the 
volume of a normal blood donation (500 mL). No health-related risk to healthy subjects is 
expected from withdrawal of this volume of blood.
1.4.3
Drug-related risks and safety measures
1.4.3.1
BI 474121
Factors of risk may derive from particular knowledge or the lack thereof, regarding (1) the 
mode of action, (2) the nature of the target, (3) the relevance of animal models, (4) findings in 
non-clinical safety studies and (5) initial clinical experience with BI 474121.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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1.4.3.2
Midazolam
Midazolam is a short-acting benzodiazepine central nervous system (CNS) depressant and 
frequently used for preoperative sedation, anxiolysis and amnesia. There is a long-lasting 
safety experience with midazolam at doses of 1mg and beyond. The administered oral 
microdose of 75 µg of midazolam is far below the dose range used in the clinical setting. 
Based on numerous published studies [R17-3022, R17-3023], treatment risks with a
microdose of midazolam (i.e. 1/100 of a pharmacologically active dose) are considered
unlikely. For further information, refer to the summary of product characteristics [R20-1842].
1.4.3.3
Safety measures
The following safety measures will be applied in order to minimize the risk for healthy 
volunteers:

Careful dose selection, no dose will be included which has not been previously studied in 
the FIH study.

The dose escalation factor is limited to 2.

For safety reasons, each dose group of 10 subjects (8 on active drug, 2 on placebo) will be 
divided into 2 cohorts of 5 subjects each (4 on active drug, 1 on placebo). Both cohorts 
will be dosed in a randomized fashion and each drug administration will be separated by 
at least 10 min. In the dose groups of the elderly subjects only subjects aged 65-74 will be 
assigned to the first cohort.

For each dose group, the 2 cohorts will be separated by at least 70 h (between treatment 
of the first subject of each cohort) to account for any intolerability resulting from 3 
repeated doses of BI 474121. A continuous safety evaluation, including results of safety 


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laboratories, ECG readings, recordings of vital signs and adverse events will be 
performed before the individual subject and the subsequent cohort is dosed.

Interim measurements of BI 474121 plasma concentrations will be performed. 
 
 
 
 
 
 
 

Repeated standard safety laboratory measurements will be performed before and during 
the treatment period (refer to Flow Chart and Section 5.2.4). This will also include serum 
markers to support the detection of skeletal muscle injury.

Repeated triplet 12-lead ECGs are scheduled throughout the study from Day 1 to Day 16.

Orthostatic testing will be performed prior to and following study drug administration at 
the time points indicated in the Flow Chart to assess hemodynamic effects of BI 474121.

Prior to each dose escalation, a documented safety review will be performed by the 
Principal Investigator (or an authorized deputy) and the Clinical Trial Leader (or an 
authorized deputy). For details, refer to Section 3.1.

Subjects will be hospitalized from Day-1 to Day 16 and will be discharged only after a 
formal assessment and confirmation of fitness by an investigator or qualified designee. 
Throughout the study, subjects will be under close medical observation and thoroughly 
monitored for both, expected and unexpected adverse events.
In summary, BI 474121 has the potential to become an oral treatment for patients with AD 
and CIAS, indications with a large medical need.
Based upon preclinical and first clinical data for BI 474121 as well as the implemented safety 
measures described above, healthy subjects will not be exposed to undue risks in relation to 
the important information expected from this trial as a basis for further clinical development 
of this compound.
Healthy volunteers are not expected to have any direct benefit from participation in this 
clinical trial with BI 474121. Considering the medical need for an effective treatment in 
patients with AD and CIAS, the sponsor considers that the benefit outweighs the potential 
risks and justifies exposure of healthy young and elderly human volunteers.
It should be stressed that the B/R assessment for elderly subjects as opposed to younger ones
is considered comparable. Healthy elderly subjects would per protocol not have relevant 
comorbid medical conditions or concomitant medications that would represent a significant 
increased risk compared to younger subjects. Furthermore, as this is an early Phase I study, 
the protocol already includes measures to minimize any potential risks that are identified with 
respect to the MoA.


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Healthy elderly volunteers are at increased risk for severe COVID-19 infection [c32354239]. 
The risk to these subjects is considered increased based on the need for the study participant 
to leave his/her home, and potentially be exposed to people infected with SARS-CoV-2 
during transportation to and from the study site, and interactions with people at the facility 
where the study site is located. This risk may not be necessarily higher than that associated 
with leaving home for any other reasons (i.e. unrelated to study participation). Appropriate 
risk minimization measures should be taken in accordance with the public health precautions 
implemented in the country where the study will be conducted (e.g. minimizing time at the 
clinic, replacement of physical visits with remote visits, minimizing the use of public 
transportation to the site etc.). It is noted that this risk is not exclusive of BI 474121 clinical 
trials, but rather relevant for any clinical trial requiring in-person visits.


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2.
TRIAL OBJECTIVES AND ENDPOINTS
2.1
MAIN OBJECTIVES, PRIMARY AND SECONDARY ENDPOINTS
2.1.1
Main objectives
The main objectives of this trial are to investigate safety and tolerability of BI 474121 in
healthy male and female young and elderly subjects following oral administration of multiple 
rising doses per day over 14 days.
Secondary objectives are the exploration of pharmacokinetics (PK) of BI 474121 after single 
and multiple oral dosing.
In addition, the effect of BI 474121 on the pharmacokinetics of midazolam, given as an oral
microdose, will be explored in dose groups 2.5 mg, 10 mg, 20 mg and 30 mg of Part A.
2.1.2
Primary endpoint
The primary endpoint for assessment of safety and tolerability of BI 474121 is the percentage 
of subjects with drug-related adverse events.
2.1.3
Secondary endpoints
The following pharmacokinetic parameters will be determined if feasible:
BI 474121
After the first dose:

AUC0-24 (area under the concentration-time curve of the analyte in plasma 
from 0 to 24h)

Cmax (maximum measured concentration of the analyte in plasma)
After the last dose:

AUCτ,ss (area under the concentration-time curve of the analyte in plasma at steady 
state over a uniform dosing interval τ)

Cmax,ss (maximum measured concentration of the analyte in plasma at steady state over 
a uniform dosing interval τ)
Midazolam
After each of the three doses:

AUC0-tz (area under the concentration-time curve of the analyte in plasma over the
time interval from 0 to the last quantifiable data point)

Cmax


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2.2.2.1
Safety and tolerability
Safety and tolerability of BI 474121 will be assessed based on:

AEs (including clinically relevant findings from the physical examination)

Safety laboratory tests

12-lead ECG

Vital signs (blood pressure, pulse rate, orthostatic testing)

C-SSRS questionnaire

MMSE (only for Part B)


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3.
DESCRIPTION OF DESIGN AND TRIAL POPULATION
3.1
OVERALL TRIAL DESIGN AND PLAN
Overall, 60 subjects are planned to participate in this Phase I trial.
The multiple-rising dose (MRD) trial is designed as double-blind, randomised, and placebo-
controlled within parallel dose groups. The MRD part consists of a 2 week treatment period 
from Day 1 to Day 14 and discharge from the study site on Day 16. In addition, the study will 
evaluate the effect of BI 474121 on the pharmacokinetic profile of midazolam in selected 
dose groups of the young population (DG 1 (2.5 mg), 3 (10 mg), 4 (20 mg) and 7 (30 mg), 
Table 3.1: 1). A schematics of study procedures is provided in Figure 3.1: 1 below.
Figure 3.1: 1
Example of overall design
It is planned to include 50 young and 20 elderly healthy male and female subjects. Study 
duration for an individual subject will comprise about 6 to 7 weeks. The young subjects will 
be assigned to 4 and the elderly subjects to 2 sequential dose groups consisting of 10 subjects 
per group (see Table 3.1: 1). The dose groups with the elderly subjects will be included after 
the corresponding dose level in the young group was shown to be safe and well tolerated. The 
investigator (after consultation with the sponsor) is allowed to alter the scheduled dose 
groups (e.g., add low and/or intermediate dose groups) based on experience gained during the 
study (for instance, based on preliminary PK data), provided the planned and approved 
highest dose is not exceeded. Thus, the actual number of subjects entered may be more than 
70, but is not to exceed 90. Such changes may be implemented via non-substantial CTP 


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amendments. However, changes due to safety findings will be only implemented via 
substantial amendment.
Within each dose group, 8 subjects will receive BI 474121 and 2 will receive placebo. Only 
one dose level is tested within one dose group. For safety reasons, the dose groups will 
consist of two cohorts of 5 subjects each with 4 subjects on active treatment and 1 subject on 
placebo. For each dose group, the 2 cohorts will be separated by at least 70 h (between 
treatment of the first subject of each cohort). For the evaluation of the effect of BI 474121 on 
the PK of midazolam, participating subjects will receive a midazolam microdose on Day -1 
without treatment of BI 474121, and concomitantly to BI 474121 on Day 1 and Day 14 of the 
MRD part. In DG 5 and 6, assigned to the elderly subjects, at least 3 subjects of each dose 
group should be aged 75 to 80. The first cohort of each elderly dose group (DG 5 and 6) will 
only include subjects aged 65 to 74. Subjects aged 75 to 80 will be assigned to the second 
cohort of the respective dose group.
The dose groups are outlined in Table 3.1: 1 below.
Table 3.1: 1
Dose groups
Young
Elderlies
Dose Group
1
2
3
4
7
5
6
Daily dose (mg)
2.5
5
10
20
30
5
10
Number of subjects
10
10
10
10
10
10
10
Subjects receiving placebo
2
2
2
2
2
2
2
Subjects receiving BI 474121
8
8
8
8
8
8
8
The groups will be dosed consecutively in ascending order, and a time interval of at least 
7 days will be maintained between the last drug administration to subjects in the previous 
dose group and the first drug administration to subjects in the next higher dose group.
The decision to treat the next dose group will be based upon safety, tolerability and 
pharmacokinetic data of all the preceding dose groups.
The next dose group will only be treated if, in the opinion of the investigator, no safety 
concerns have arisen in the preceding dose groups (i.e. no dose-limiting events occurred), and 
if none of the pre-specified trial-specific stopping criteria have been met (refer to Section 
3.3.4.3).
A documented safety review must take place prior to each dose escalation. Furthermore, an 
unscheduled safety review meeting can be requested anytime by the Principal Investigator (or 
an authorised deputy) or the sponsor of the study (for instance, due to the occurrence of any 
unforeseen adverse events).
Although no formal Safety Review meeting will take place within a given dose group, safety 
will be continuously monitored during this trial, and an individual will only be dosed in the 
absence of any safety concern (i.e. no dose-limiting events occurred) and if none of the pre-
specified trial-specific stopping criteria have been met (refer to Section 3.3.4.3).


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At minimum, data from at least 6 subjects on active drug need to be available for escalation 
to the next higher dose. For the minimum dataset with regards to preliminary PK data, see 
Section 7.4. The minimum data set for review consists of the following:

AEs in the current and preceding dose groups up to at least 48 h after final dosing of 
the current dose group, including clinically relevant findings from ancillary safety 
testing listed below (Note: AEs may be ongoing at the time of Safety Reviews and 
AE information may be subject to change prior to Database Lock)

Results from 12-lead ECG in the current and preceding dose groups up to at least 48 h 
after final dosing of the current dose group

Vital signs (incl. orthostatic testing) in the current and preceding dose groups up to at 
least 48 h after final dosing of the current dose group

Clinical laboratory tests in the current and preceding dose groups up to at least 48 h 
after final dosing of the current dose group

Preliminary PK data for the selected time as per Section 7.4

Check of criteria for stopping subject treatment as per Section 3.3.4.1
The decision to escalate the dose will be made jointly by the Principal Investigator (or an 
authorised deputy) and the Clinical Trial Leader (or an authorised deputy) after in-depth 
analysis of all available safety data, especially SAEs (if occurred), AEs, and out-of-range 
laboratory results (if considered clinically significant). In addition and depending on the 
results and findings, suitable experts from the sponsor or external institutions may be 
consulted on an as needed basis. In these cases, expert recommendations will be documented 
in the minutes of the Safety Review and considered for the decision making. Dose escalation 
will only be permitted if no safety concerns exist neither in the opinion of the Principal 
Investigator (or an authorised deputy) nor the Clinical Trial Leader (or an authorised deputy).
Safety Reviews can be conducted face-to-face or by video/telephone conference. The Clinical 
Trial Leader is responsible for the organisation and minutes of the reviews. Minutes will be 
signed off by the Principal Investigator (or an authorised deputy) and Clinical Trial Leader 
(or an authorised deputy), and will be filed in the ISF and TMF.
An overview of all relevant trial activities is provided in the Flow Chart. For visit schedules 
and details of trial procedures at selected visits, refer to Sections 6.1 and 6.2, respectively.
3.2
DISCUSSION OF TRIAL DESIGN, INCLUDING THE CHOICE OF 
CONTROL GROUP
For multiple-rising dose trials, the sequential rising dose design described in Section 3.1 is 
viewed favourably under the provision not to expose the subjects involved to undue risks.
Double -blind conditions regarding the subject’s treatment (active or placebo) are maintained 
within each dose group. However, subjects and investigators will be aware of the dose of 
drug administered. The disadvantage of the trial design is a possible observer bias with regard 
to the dose-dependent effects; in addition, the sequential dosing of groups could potentially 
result in time-related effects. However, as such effects are expected to be small relative to the 


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differences between the doses in the broad range investigated, unbiased comparisons between 
treatments can still be expected.
It is standard in single or multiple rising dose trials involving healthy volunteers to include a 
placebo group to control for safety, tolerability, and pharmacodynamic effects of the trial 
medication. Each dose group consists of 10 subjects, with 8 on active treatment, and 2 on 
placebo. For data analysis purposes, the placebo control group will include all subjects of all 
dose groups treated with placebo. Eight subjects per active treatment group are generally
considered to be sufficient for the exploratory evaluation of pharmacokinetics.
The evaluation of a potential CYP3A4 interaction with BI 474121 using a microdose of
midazolam is considered to be acceptable. A microdose of midazolam is not expected to have
any pharmacological effects. Therefore, subjects are not exposed to undue risks. Also, the
evaluation of the investigational drug should not be influenced. This assessment will allow
for better judgement regarding acceptable co-medications in a Proof of Clinical Concept
study and later in the phase 3 development.
3.3
SELECTION OF TRIAL POPULATION
It is planned that 70 healthy male and female subjects (at least 3 subjects per dose group of 
each sex) will enter the study. The actual number of subjects entered may exceed the total of 
70 if additional intermediate doses are tested (see Section 3.1). Subjects will be recruited 
from the volunteers' pool of the trial site.
No data on reproductive toxicology are available at this time. Therefore women with 
childbearing potential who are enrolled in this clinical trial must use a highly effective 
method of birth control throughout the trial and follow-up period.
A log of all subjects enrolled into the trial (i.e. who have signed informed consent) will be 
maintained in the ISF irrespective of whether they have been treated with investigational drug 
or not.
3.3.1
Main diagnosis for trial entry 
The study will be performed in healthy subjects.
3.3.2
Inclusion criteria
Subjects will only be included in the trial if they meet the following criteria:
1.
Healthy male or female subjects according to the assessment of the investigator, as based 
on a complete medical history including a physical examination, vital signs (BP, PR), 
12-lead ECG, and clinical laboratory tests
2.
Age of 18 to 45 years (inclusive) for young or 
65 to 80 years (inclusive) for elderly healthy volunteers
3.
BMI of 18.5 to 29.9 kg/m2 (inclusive)
4.
Signed and dated written informed consent prior to admission to the study, in accordance 
with GCP and local legislation


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3.3.3
Exclusion criteria
Subjects will not be allowed to participate, if any of the following general criteria apply:
1.
Any finding in the medical examination (including BP, PR or ECG) deviating from 
normal and assessed as clinically relevant by the investigator
2.
Repeated measurement of systolic blood pressure outside the range of 100 to 140 mm
Hg, diastolic blood pressure outside the range of 50 to 90 mmHg, or pulse rate outside 
the range of 50 to 90 bpm
3.
Any laboratory value outside the reference range that the investigator considers to be of 
clinical relevance
4.
Any evidence of a concomitant disease assessed as clinically relevant by the 
investigator
5.
Gastrointestinal, hepatic, renal, respiratory, cardiovascular, metabolic, immunological
or hormonal disorders
6.
Cholecystectomy or other surgery of the gastrointestinal tract that could interfere with 
the pharmacokinetics of the trial medication (except appendectomy or simple hernia 
repair)
7.
Diseases of the central nervous system (including but not limited to any kind of seizures 
or stroke), and other relevant neurological or psychiatric disorders
8.
History of relevant orthostatic hypotension, fainting spells, or blackouts
9.
Chronic or relevant acute infections
10.
History of relevant allergy or hypersensitivity (including allergy to the trial medication
or its excipients)
11.
Use of drugs within 30 days of planned administration of trial medication that might 
reasonably influence the results of the trial (including drugs that cause QT/QTc interval
prolongation)
12.
Intake of an investigational drug in another clinical trial within 60 days of planned  
administration of investigational drug in the current trial, or concurrent participation in 
another clinical trial in which investigational drug is administered
13.
Smoker (more than 10 cigarettes or 3 cigars or 3 pipes per day)
14.
Inability to refrain from smoking on specified trial days
15.
Alcohol abuse (consumption of more than 12 g per day for females and 24 g per day for
males)
16.
Drug abuse or positive drug screening
17.
Blood donation of more than 100 mL within 30 days of planned administration of trial 
medication or intended blood donation during the trial
18.
Intention to perform excessive physical activities within one week prior to the 
administration of trial medication or during the trial
19.
Inability to comply with the dietary regimen of the trial site
20.
A marked baseline prolongation of QT/QTc interval (such as QTc intervals that are 
repeatedly greater than 450 ms in males or repeatedly greater than 470 ms in females)
or any other relevant ECG finding at screening


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21.
A history of additional risk factors for Torsade de Pointes (such as heart failure, 
hypokalemia, or family history of Long QT Syndrome)
22.
Subject is assessed as unsuitable for inclusion by the investigator, for instance, because 
the subject is not considered able to understand and comply with study requirements, or 
has a condition that would not allow safe participation in the study
23.
Male subjects with WOCBP partner or female subjects of childbearing potential who 
are unwilling to use a highly effective method of birth control from time point of 
administration of trial medication until 30 days thereafter. Highly effective methods of 
birth control are:
-
Subject is sexually abstinent (true abstinence, in line with the preferred and usual 
lifestyle of the subject)
-
Male subject is vasectomised (vasectomy at least 1 year prior to enrolment and the 
subject has received medical assessment of the surgical success ), plus condom in 
male subject
-
Use of intrauterine device (IUD) or intrauterine hormone-releasing system (IUS) by 
females
-
Use of progestogen-only hormonal contraception by females that inhibits ovulation 
(only injectables or implants), plus condom in male subject
-
Use of combined (estrogen and progestogen containing) hormonal contraception by 
females that prevents ovulation (oral, intravaginal or transdermal), plus condom in 
male subject
-
Female partner is surgically sterilised (including hysterectomy)
-
Female partner is postmenopausal, defined as no menses for 1 year without an 
alternative medical cause (in questionable cases a blood sample with FSH above 
40 U/L and estradiol below 30 ng/L is confirmatory)
- Sperm donation is not allowed from the time point of drug administration until 
30 days thereafter
24.
Orthostatic hypotension during orthostatic testing at Day -3 to -1, that the investigator 
considers to be of clinical relevance
In addition, the following SARS-CoV-2-specific exclusion criteria apply:
25.
A positive PCR test for SARS-CoV-2 and clinical symptoms suggestive for this disease 
at screening or on Day -3
Female subjects will not be allowed to participate, if any of the following apply:
26.
Positive pregnancy test
27.
Lactation
For study restrictions, refer to Section 4.2.2.


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3.3.4
Withdrawal of subjects from treatment or assessments
Subjects may discontinue trial treatment or withdraw consent to trial participation as a whole 
(‘withdrawal of consent’) with very different implications; please see Sections 3.3.4.1 and 
3.3.4.2 below.
If a subject is removed from or withdraws from the trial prior to the first administration of 
trial medication, the data of this subject will not be entered in the case report form (CRF) and 
will not be reported in the clinical trial report (CTR). If a subject is removed from or 
withdraws from the trial after the first administration of trial medication, this will be 
documented and the reason for discontinuation must be recorded in the CRF; in addition, the 
data will be included in the CRF and will be reported in the CTR.
At the time of discontinuation, a complete end of trial examination will be performed, if 
possible, and the information will be recorded in the CRF. If the discontinuation occurs 
before the end of the REP (see Section 1.2.1.7), the discontinued subject should if possible be 
questioned for AEs and concomitant therapies at or after the end of the REP in order to 
ensure collection of AEs and concomitant therapies throughout the REP, if not contrary to 
any consent withdrawal of the subject.
Since the risks of drug exposure of a (pregnant) female partner of a male study participant via 
the seminal fluid are yet unknown, adequate contraception as outlined in Section 3.3.2 is a 
prerequisite for participation in the study.
If it is known that a subject becomes pregnant during the trial, administration of the trial 
medication is to be stopped immediately, and the subject is to be removed from the trial. The 
subject is to be followed until she has given birth or until the end of the pregnancy. The 
subject’s data are to be collected until the end of the trial (last visit of last subject) and 
reported in the CTR. For reporting of pregnancy and associated events, refer to 
Section 5.2.8.2.4.
3.3.4.1
Discontinuation of trial treatment
An individual subject will discontinue trial treatment if:
1.
The subject wants to discontinue trial treatment, without the need to justify the decision
2.
The subject has repeatedly shown to be non-compliant with important trial procedures 
and, in the opinion of both, the investigator and sponsor representative, is not willing or 
able to adhere to the trial requirements in the future 
3.
The subject needs to take concomitant medication that interferes with the 
investigational medicinal product or other trial treatment
4.
The subject can no longer receive trial treatment for medical reasons (such as 
pregnancy, surgery, adverse events [AEs], or diseases)
5.
An AE or clinically significant laboratory change or abnormality occurs that the 
investigator assesses as warranting discontinuation of treatment. This may include cases 
of sustained symptomatic hypotension (BP <90/50 mmHg) or hypertension (BP 
>180/100 mmHg), clinically relevant changes in ECG requiring intervention, or 
unexplained hepatic enzyme elevations at any time during the trial


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6.
The subject has an elevation of AST and/or ALT ≥3-fold ULN and an elevation of total 
bilirubin ≥2-fold ULN (measured in the same blood sample) and/or needs to be 
followed up according to the DILI checklist provided in the ISF
7.
The subject has a serious adverse reaction or a severe non-serious adverse reaction.
In addition to these criteria, the investigator may discontinue subjects at any time based on 
his or her clinical judgment.
Even if the trial treatment is discontinued, the subject remains in the trial and, given his/her 
agreement, will undergo the procedures for early treatment discontinuation and follow up as 
outlined in the Flow Chart and Section 6.2.3.
3.3.4.2
Withdrawal of consent to trial participation
Subjects may withdraw their consent to trial participation at any time without the need to 
justify the decision. If a subject wants to withdraw consent, the investigator should be 
involved in the discussion with the subject and explain the difference between trial treatment 
discontinuation and withdrawal of consent to trial participation, as well as explain the options 
for continued follow up after trial treatment discontinuation, please see Section 3.3.4.1 above.
3.3.4.3
Discontinuation of the trial by the sponsor
Boehringer Ingelheim reserves the right to discontinue the trial at any time for any of the 
following reasons (#2, #5, #6 and #7 mandatory discontinuation criteria):
1.
Failure to meet expected enrolment goals overall or at a particular trial site.
2.
New toxicological findings, serious adverse events, or any safety information
invalidating the earlier positive benefit-risk assessment. Violation of GCP, or the CTP, 
or the contract with BI impairing the appropriate conduct of the trial.
3.
The sponsor decides to discontinue the further development of the investigational 
product.
4.
Dose escalation will be stopped if at least 2 subjects on active treatment at one dose 
level have relevant individual QT prolongations, i.e. a QTc increase of greater than 
60 ms from baseline and/or an absolute QT or QTc greater than 500 ms, as confirmed 
by a repeat ECG recording.
5.
 
 
6.
Dose escalation will be terminated if more than 50% of the subjects at one dose level 
show drug-related and clinically relevant adverse events of moderate or severe 
intensity, or if at least one drug-related serious adverse event is reported.
7.
Occurrence of severe non-serious adverse events considered as drug-related by the 
investigator in 2 subjects of the same dose group (8 subjects), or occurrence of at least 
one drug-related serious adverse event. Moreover, dose escalation will be terminated if 


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more than 3 of the actively dosed subjects at one dose level show drug-related and 
clinically relevant adverse events of at least moderate intensity.
The investigator / trial site will be reimbursed for reasonable expenses incurred in case of 
trial termination (except if item 3 applies).
3.3.5
Replacement of subjects
If some subjects do not complete the trial, the Clinical Trial Leader together with the Trial 
Pharmacokineticist and the Trial Statistician are to decide, if and how many subjects will be 
replaced. However, in case more than 4 subjects on  active treatment discontinue the trial 
because of events related to safety and tolerability, replacement of subjects will require a 
substantial amendment. Replacement of subjects should always be done in mutual agreement 
with the principal investigator. A replacement subject will be assigned a unique trial subject 
number, and will be assigned to the same treatment as the subject he or she replaces.


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4.
TREATMENTS
4.1
INVESTIGATIONAL TREATMENTS
The investigational product BI 474121 and matching placebo has been manufactured by 
BI Pharma GmbH & Co. KG.
Midazolam has been manufactured by
and has a market
authorisation.
4.1.1
Identity of the Investigational Medicinal Products
The characteristics of the test products are given below:
BI 474121 2.5 mg tablet
Substance:
BI 474121
Pharmaceutical formulation: Uncoated tablet
Source:
BI Pharma GmbH & Co. KG, Germany
Unit strength:
2.5 mg
Posology:
1-0-0 for 2.5 mg DG and 2-0-0 for 5 mg DG
Route of administration:
oral
Duration of use:
14 days with q.d. multiple dosing
BI 474121 10 mg tablet
Substance:
BI 474121
Pharmaceutical formulation: Uncoated tablet
Source:
BI Pharma GmbH & Co. KG, Germany
Unit strength:
10 mg
Posology:
1-0-0 for 10 mg DG, 2-0-0 for 20 mg DG, 3-0-0 for 30 mg DG
Route of administration:
oral
Duration of use:
14 days with q.d. multiple dosing
The characteristics of the reference product (placebo) are given below:
Tablet formulation
Substance:
Matching placebo in size and weight to 2.5 and 10 mg tablet
Pharmaceutical formulation: Uncoated tablet
Source:
BI Pharma GmbH & Co. KG, Germany
Unit strength:
--
Posology:
Matching to the test product (1-0-0)
Route of administration:
oral


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Duration of use:
14 days with q.d. multiple dosing
Midazolam-Microdosing: (only for Part A in 2.5 mg, 10 mg, 20 mg and 30 mg DG)
Substance:
Midazolam (Midazolam-ratiopharm®)
Pharmaceutical formulation: Solution for injection
Source:
Unit strength:
5 mg/ 5 mL diluted to 50 μg/mL•1.5 mL (75 μg)
Posology:
q.d.
Route of administration:
oral
4.1.2
Selection of doses in the trial
The doses selected for this trial cover the estimated therapeutic range and include a safety 
margin (see Section 1.2).
4.1.3
Method of assigning subjects to treatment groups
Prior to the screening visit, subjects will be contacted in writing and informed about the 
planned visit dates. The subjects willing to participate will be recruited to dose groups 
(2°cohorts per dose group) according to their temporal availability. As soon as enough 
subjects are allocated to 1 of the 14 dose cohorts, the following subjects will be allocated to 
one of the other dose cohorts. Eight (10) of the 14 dose cohorts only consist of young 
subjects, while the remaining 4 of the 14 dose cohorts only contain elderly subjects. 
Allocation of subjects to dose cohorts is not influenced by trial personnel, but only by the 
subjects’ temporal availability. Because the study includes healthy subjects from a 
homogenous population, relevant imbalances between the dose groups are not expected.
Subjects will be assigned to treatments (active treatment or placebo) prior to the first 
administration of trial medication. For this purpose, the randomisation list will be provided to 
the trial site in advance. Numbers of the randomization lists will be allocated to subjects by 
the method ‘first come - first served’ at the time of registration. Subjects are then assigned to 
treatment according to the randomisation list. Once a subject number has been assigned, it 
cannot be reassigned to any other subject.
For the purpose of replacing subjects in the MRD part, the respective randomisation list will 
be provided to the unblinded pharmacist of the trial site in advance. Since spare medication 
will be available as bulk supply, in case of replacement the unblinded pharmacist needs to 
select the appropriate treatment (active treatment or placebo) for the replacing subject.
The randomisation procedure is described in Section 7.6.
Midazolam (only for Part A in 2.5 mg, 10 mg, 20 mg and 30 mg DG)
The dose of midazolam used for the DDI evaluation was chosen to be 75 μg which is within
the definition of a microdose, i.e. a 1/100th of the therapeutic dose (in case of midazolam
7.5°mg) or 100 μg whichever is smaller. Since midazolam PK is dose proportional ranging


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from the microdose to the therapeutic dose, the microdose should still be able to accurately
predict CYP3A4 DDI liability, while remaining below a pharmacologically active
concentration.
A solution for injection was chosen for administration as an oral solution, as a solution for
injection is meant to be diluted and, thus, there is data available regarding the stability and
compatibility of a diluted solution. Furthermore, the solution for injection contains
midazolam in isotonic saline solution, while the oral solution has added excipients, making it
less than ideal for such a dilution. Finally, the IV solution has been successfully diluted and
administered orally as a microdose in previous clinical studies without any reports of AEs
[R17-3022, R17-3023].
4.1.4
Drug assignment and administration of doses for each subject
The treatments to be evaluated are outlined in Table 4.1.4: 1 below. The number of units for 
placebo corresponds to the number of units of the corresponding dose level.
Table 4.1.4: 1
BI 474121 and placebo treatments, oral administration
Dose
group
Substance
Pharmaceutical 
form
Unit strength
Number of units 
per administration
Total daily
dose
1
BI 474121
Tablet
2.5 mg
1 tablet for 14 days
2.5 mg
2
BI 474121
Tablet
2.5 mg
2 tablets for 14 days
5 mg
3
BI 474121
Tablet
10 mg
1 tablet for 14 days
10 mg
4
BI 474121
Tablet
10 mg
2 tablets for 14 days
20 mg
5
BI 474121
Tablet
2.5 mg
2 tablets for 14 days
5 mg
6
BI 474121
Tablet
10 mg
1 tablet for 14 days
10 mg
7
BI 474121
Tablet
10 mg
3 tablets for 14 days
30 mg
1-7
Placebo*
Tablet
--
identical to active treatment
--
* Subjects receiving placebo are equally distributed across dose groups
Table 4.1.4: 2
Midazolam, oral administration (only for Part A in 2.5 mg, 10 mg, 
20 mg and 30 mg DG)
Dose
group
Substance
Pharmaceutical 
form
Unit strength
Number of units 
per administration
Total daily 
dose
1, 3, 4
and 7
Midazolam
Solution for
injection
5mg/5ml
1 (Day -1), 1 (Day 1) and 1(Day 
14)
75 μg
(oral)
The oral solutions for dosing midazolam will be prepared according to the instruction given
in Appendix 10.2 by pharmacists or qualified pharmacy staff members or qualified medical
study personnel at the trial site under the responsibility of the investigator.


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The trial medication will be administered to the subjects, while in a standing position, as an 
oral dose together with about 240 mL of water under supervision of the investigating
physician or an authorised designee. The so-called four-eye principle (two-person rule)
should be applied for administration of trial medication and – if applicable – its preparation
(e.g. reconstitution), if correct dosage cannot be ensured otherwise. To ensure a dosing
interval of 24 h, the administration of trial medication should take place at the same time
every day.
Administration of trial medication will be performed after subjects have fasted overnight; 
fasting is to start no later than 10 h before the scheduled dosing. The investigator (or 
authorised designee) will administer the trial medication as an oral dose together with about 
240 mL of water to subjects who are in a standing position. To ensure a dosing interval of 
24 h, the administration of trial medication should take place at the same time every day.
For drug administration, the so-called four-eye principle (two-person rule) should be applied. 
For this, an authorised employee of the trial site should witness the administration of trial 
medication, and – if applicable – its preparation (e.g. reconstitution), if correct dosage cannot 
be ensured otherwise.
Subjects will be kept under close medical surveillance during hospitalisation up to Day 16.
During the first 2 h after drug administration, subjects are not allowed to lie down (i.e. no 
declination of the upper body of more than 45 degrees from upright posture except for 
medical examination) or to sleep.
4.1.5
Blinding and procedures for unblinding
4.1.5.1
Blinding
The trial is designed double-blind with regard to subjects and investigators (as well as the 
research staff at the trial site) in order to eliminate observer or performance bias. This means 
avoiding systematic differences in assessments regarding the subject’s treatment (active drug 
or placebo). According to the rising dose design, the current dose level will be known to 
subjects and investigators.
At the trial site, access to the randomisation schedule is restricted to unblinded pharmacists 
and pharmacy staff members. Access to the codes, which is mandatory in case of subject 
replacement, will be controlled and documented by a signed confidentiality statement, which 
will be stored in the TMF. Persons directly involved in the clinical conduct of the trial will 
not have access to the treatment allocation prior to database lock.
Regarding the sponsor, the database of this trial will be handled open-label, meaning that the 
trial functions of the sponsor are unblinded (including Clinical Trial Leader, data manager, 
statistician, bioanalyst, pharmacokineticist, pharmacometrician, drug metabolism scientist as 
well as dedicated CRO personnel). The objective of the trial is not expected to be affected.
The trial site will only be unblinded after locking of the database.
In addition, the trial bioanalyst/ TCPK/ TCPKa will request the randomisation codes prior to 
official unblinding to perform the interim/ preliminary PK analysis. He or she will confirm in 
writing that the codes will be treated confidentially.
Midazolam (only for Part A in 2.5 mg, 10 mg, 20 mg and 30 mg DG)


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This segment of the trial will be handled in an open fashion throughout (that is, during the
conduct, including data cleaning and preparation of the analysis). This is considered
acceptable because the potential for bias seems to be low and does not outweigh practical
considerations.
Within the ECG laboratory, the staff involved with interval measurements and assessments 
will be blinded with respect to the treatment within each dose level and also with regard to 
the recording data and time as well as time points of the ECGs. The interval measurements 
for a given subject will be performed in a random and blinded sequence by a single 
technician. No more than two different blinded readers will evaluate the ECGs of the study.
4.1.5.2
Unblinding and breaking the code
The investigator or designee will be supplied with a set of sealed envelopes containing the 
medication codes for each subject according to the randomisation scheme. The envelopes will 
be kept unopened at the trial site until the end of data collection. An envelope may only be 
opened in emergency situations when the identity of the trial drug must be known to the 
investigator in order to provide appropriate medical treatment or otherwise assure safety of 
trial participants. If the envelope for a subject is opened, the sponsor must be informed 
immediately. The reason for breaking the code must be documented on the envelope and/or 
appropriate CRF page along with the date and the initials of the person who broke the code.
Midazolam (only for Part A in 2.5 mg, 10 mg, 20 mg and 30 mg DG)
As this part of the trial will be conducted in an open fashion, the treatment information will
be known. Therefore, no emergency envelopes will be provided.
4.1.6
Packaging, labelling, and re-supply
BI 474121 will be provided by BI. They will be packaged and labelled in accordance with 
local law and the principles of Good Manufacturing Practice.
For details of packing and the description of the label, refer to the ISF.
The telephone number of the sponsor and the name, address and telephone number of the trial 
site are provided in the subject information form. The EudraCT number is indicated on the 
title page of this protocol as well as on the subject information and informed consent forms. 
Examples of the labels will be available in the ISF.
Re-supply is only planned for DG 7 (30 mg).
Midazolam
Midazolam for injection used as oral solution will be obtained by the clinical trial site from a 
public pharmacy. The drug will be dispensed out of the original, unmodified packages.
4.1.7
Storage conditions
Drug supplies will be kept in their original packaging and in a secure limited access storage 
area in accordance with the recommended (labelled) storage conditions. If necessary, a 
temperature log must be maintained to make certain that the drug supplies are stored at the 


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correct temperature. If the storage conditions are found to be outside the specified range, the 
local clinical monitor (as provided in the list of contacts) is to be contacted immediately.
4.1.8
Drug accountability
The investigator or designee will receive the investigational drugs from the sponsor when the 
following requirements are fulfilled:

Approval of the clinical trial protocol by the IRB / ethics committee

Availability of a signed and dated clinical trial contract between the sponsor and the 
investigational site

Approval/notification of the regulatory authority,  e.g. competent authority

Availability of the curriculum vitae of the Principal Investigator

Availability of a signed and dated clinical trial protocol
Only authorised personnel documented in the form 'Trial Staff List' may dispense medication 
to trial subjects. The trial medication must be administered in the manner specified in the 
CTP.
The investigator or designee must maintain records of the product’s delivery to the trial site, 
the inventory at the site, the use by each subject, and the disposal of unused products. These 
records will include dates, quantities, batch / serial numbers, expiry ('use-by') dates, and the 
unique code numbers assigned to the investigational medicinal product and trial subjects.
The investigator or designee will maintain records that document adequately that the subjects 
were provided the doses specified by the CTP and reconcile all investigational medicinal 
products received from the sponsor. At the time of disposal of remaining trial medication, the 
investigator or designee must verify no remaining supplies are in the investigator’s 
possession.
All unused trial medication will be disposed of locally by the trial site upon written 
authorisation of the trial clinical monitor. Receipt, usage, and disposal of trial medication 
must be documented on the appropriate forms. Account must be given for any discrepancies.
4.2
OTHER TREATMENTS, EMERGENCY PROCEDURES, 
RESTRICTIONS
4.2.1
Other treatments and emergency procedures
There are no special emergency procedures to be followed. No additional treatment is 
planned. However, if adverse events require treatment, the investigator can authorise 
symptomatic therapy. In those cases, subjects will be treated as necessary and, if required, 
kept under supervision at the trial site or transferred to a hospital until all results of medical 
evaluations are acceptable.


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Midazolam only for Part A in 2.5 mg, 10 mg, 20 mg and 30 mg DG
Midazolam will be administered (only for Part A in 2.5 mg, 10 mg, 20 mg and 30 mg DG) as 
a 75 μg dose on Days -1, 1, and 14 to assess the potential influence of BI 474121on CYP3A4 
modulation. For dilution and administration instructions, refer to Appendix 10.2.
4.2.2
Restrictions
4.2.2.1
Restrictions regarding concomitant treatment
In principle, no concomitant therapy is allowed. All concomitant or rescue therapies will be 
recorded (including time of intake on study days) on the appropriate pages of the CRF.
Known inhibitors/inducers of CYP3A should be avoided during the entire study. However, in 
case of adverse events in need of treatment, the investigator can authorise symptomatic 
therapy.
4.2.2.2
Restrictions on diet and life style
While admitted to the trial site, the subjects will be instructed not to consume any foods or 
drinks other than those provided by the staff. Standardised meals will be served at the times
indicated in the Flow Chart. No food is allowed for at least 4 h after drug intake on Days -1, 
1 and 14. On the remaining days (Days 2 to 13), food is not allowed for at least 2 h after drug 
intake.
From 1 h before drug intake until lunch, fluid intake is restricted to the water administered 
with the drug, and an additional 240 mL of water served on Day 1 and 14 at 2 h and 4 h post-
dose (mandatory for all subjects).
During the days of urine collection, total fluid intake should be at least 1.5 litres and should 
not exceed 3.5 litres.
Alcoholic beverages, grapefruits, Seville oranges (sour or bitter oranges) and their juices, and 
dietary supplements and products containing St. John's wort (Hypericum perforatum) are not 
permitted from 7 days before the first administration of trial medication until after the last PK 
sample of each study period is collected.
Methylxanthine-containing drinks or foods (such as coffee, tea, cola, energy drinks, or 
chocolate) are not allowed starting 10 h before first trial drug administration until last PK 
sampling of the trial.
Smoking is not allowed during in-house confinement while admitted to the trial site.
Poppy-seed containing products should not be consumed starting 4 days before first trial drug 
administration until last PK sampling of the trial.
Excessive physical activity (such as competitive sport) should be avoided from 7 days before 
the first administration of trial medication until the end of trial examination.
Female subjects of child-bearing potential are requested to maintain adequate contraception 
throughout the course of the trial (see Section 3.3.2 for the definition of adequate measures).


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4.3
TREATMENT COMPLIANCE
Compliance will be assured by administration of all trial medication in the study centre under 
supervision of the investigating physician or a designee. The measured plasma concentrations 
of trial medication will provide additional confirmation of compliance.
Subjects who are non-compliant (for instance, who do not appear for scheduled visits or 
violate trial restrictions) may be removed from the trial and the CRF will be completed 
accordingly (for further procedures, please see Section 3.3.4.1).


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5.
ASSESSMENT
5.1
ASSESSMENT OF EFFICACY
Not applicable. No efficacy endpoints will be evaluated in this trial.
5.2
ASSESSMENT OF SAFETY
5.2.1
Physical examination
At screening, the medical examination will include demographics, height and body weight, 
smoking and alcohol history (results not mandatory to be entered into CRF or to be reported),
relevant medical history and concomitant therapy, review of inclusion and exclusion criteria, 
review of vital signs (BP, PR),assessment of body temperature, 12-lead ECG, laboratory 
tests, and a physical examination. At the end of trial examination, it will include review of 
vital signs, assessment of body temperature, 12-lead ECG, laboratory tests, and a physical 
examination including determination of weight.
5.2.2
Vital signs
Systolic and diastolic blood pressures (BP) as well as pulse rate (PR) or heart rate (heart rate 
is considered to be equal to pulse rate) will be measured by a blood pressure monitor 
(Dinamap,
) at the times indicated in the 
Flow Chart, after subjects have rested for at least 5 min in a supine position. All recordings 
should be made using the same type of blood pressure recording instrument on the same arm, 
if possible.
5.2.3
Orthostatic tests
At the time points indicated in the Flow Chart orthostatic tests will be performed. Subjects 
should have spent at least 5 min in the supine position before blood pressure and pulse rate 
will be measured the first time. Further 2 measurements will be performed immediately after 
standing up and after 3 min in a standing position. All recordings shall be made using the 
same type of blood pressure recording instrument described in 5.2.2 on the same arm if 
possible.
The term “Orthostatic dysregulation” will be used to describe adverse events that occur 
during orthostatic testing. Typical symptoms of orthostatic dysregulation are dizziness, 
diaphoresis, tachycardia (PR >100 bpm) or even fainting (which is reflected in the 
assessment of AE intensity).
At the time points given in the Flow Chart the following sequence of measurements should 
be adhered: 12 lead-ECG and vital signs will be done before blood sampling. Orthostatic 
testing will be done after blood sampling. While standing up the subject will be accompanied 
by medical staff.


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5.2.4
Safety laboratory parameters
For the assessment of laboratory parameters, blood and urine samples will be collected by the 
trial site at the times indicated in the Flow Chart after the subjects have fasted for at least 
10 h. For retests, at the discretion of the investigator or designee, overnight fasting is not 
required. The parameters that will be determined are listed in Tables 5.2.4: 1 and 5.2.4: 2. 
Reference ranges will be provided in the ISF, Section 10.
Manual differential white blood cell count or urine sediment examinations will only be 
performed if there is an abnormality in the automatic blood cell count or in the urinalysis, 
respectively.
Table 5.2.4: 1
Routine laboratory tests
Functional lab 
group
BI test name [comment/abbreviation]
A
B
C
D
Haematology
Haematocrit
Haemoglobin
Red Blood Cell Count/Erythrocytes 
Reticulocytes, absol.
White Blood Cells/Leucocytes 
Platelet Count/Thrombocytes (quant)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Automatic WBC 
differential, relative
Neutrophils/Leukocytes; Eosinophils/Leukocytes; Basophils/ 
Leukocytes; Monocytes/Leukocytes; 
Lymphocytes/Leukocytes 
X
X
X
X
Automatic WBC 
differential, 
absolute
Neutrophils, absol.; Eosinophils, absol.; Basophils, absol. ; 
Monocytes, absol.; Lymphocytes, absol.
X
X
X
X
Manual differential 
WBC (if automatic
differential WBC is 
abnormal and 
clinically relevant 
in the opinion of
the investigator)
Neut. Poly (segs); Neut. Poly (segs), absol.; Neutrophils 
Bands;  Neutrophils Bands, absol.; Eosinophils/Leukocytes; 
Eosinophils, absol.; Basophils/ Leukocytes; Basophils, absol.; 
Monocytes/ Leukocytes; Monocytes, absol.; 
Lymphocytes/Leukocytes; Lymphocytes, absol.
Coagulation
Activated Partial Thromboplastin Time 
Prothrombin time – INR (International Normalization Ratio)
Fibrinogen
X
X
X
X
X
--
X
X
--
X
X
X
Enzymes
AST [Aspartate transaminase] /GOT, SGOT 
ALT [Alanine transaminase] /GPT, SGPT
Alkaline Phosphatase
Gamma-Glutamyl Transferase 
Glutamate Dehydrogenase (GLDH)
Creatine Kinase [CK]
Creatine Kinase Isoenzyme MB [only if CK is elevated]
Myoglobin
Lactic Dehydrogenase
Lipase
X
X
X
X
X
X
X
X
X
X
X
X
--
--
X
X
X
X
X
--
X
X
X
X
X
X
X
X
X
--
X
X
X
X
X
X
X
X
X
X
A: parameters to be determined at Visit 1 (screening examination) 
B: parameters to be determined at Visit 2 on Days -3, -2 or -1 (laboratory assessment can be omitted if 
screening examination is performed on Days -5, -4, -3; for time points refer to Flow Chart)
C: parameters to be determined during Visit 2 on Days 3, 5, 8, 11, 14, 16 (for time points refer to Flow Chart)
D: parameters to be determined at Visit 3 (end of trial examination)


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Table 5.2.4: 1
Routine laboratory tests (cont.)
Functional lab group
BI test name [comment/abbreviation]
A
B
C
D
Hormones
Thyroid Stimulating Hormone 
X
--
--
--
Substrates
Glucose (Plasma)
Creatinine 
Bilirubin, Total 
Bilirubin, Direct
Protein, Total
Albumin
C-Reactive Protein (Quant)  
Uric Acid 
Cholesterol, total 
Triglyceride
X
X
X
X
X
X
X
X
X
X
--
X
X
X
--
--
X
--
--
--
X
X
X
X
X
--
X
--
--
--
X
X
X
X
X
X
X
X
--
--
Electrolytes
Sodium
Potassium
Chloride
Calcium
X
X
X
X
X
X
--
X
X
X
X
X
X
X
X
X
Urinalysis (Stix)
Urine Nitrite (qual)
Urine Protein (qual)
Urine Glucose (qual)
Urine Ketone (qual)
Urobilinogen (qual)
Urine Bilirubin (qual)
Urine Haemoglobin (qual)
Urine WBC/Leucocytes (qual)
Urine pH
X
X
X
X
X
X
X
X
X
--
--
--
--
--
--
--
--
--
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Urine sediment
(microscopic 
examination if 
erythrocytes, 
leukocytes nitrite or 
protein are abnormal 
in urine)
Only positive findings will be reported (for instance, the 
presence of sediment bacteria, casts in sediment, squamous 
epithelial cells, erythrocytes, leukocytes)
A: parameters to be determined at Visit 1 (screening examination) 
B: parameters to be determined at Visit 2 on Days -3, -2 or -1 (laboratory assessment can be omitted if 
screening examination is performed on Days -5, -4, -3; for time points refer to Flow Chart)
C: parameters to be determined during Visit 2 on Days 3, 5, 8, 11, 14, 16 (for time points refer to Flow Chart)
D: parameters to be determined at Visit 3 (end of trial examination)
The tests listed in Table 5.2.4: 2 are exclusionary laboratory tests that may be repeated as 
required. The results will not be entered in the CRF/database and will not be reported in the 
CTR. Except for pregnancy tests and drug screening, it is planned to perform these tests at 
screening only. Pregnancy testing in women will be performed at screening, prior to start of
treatment, and as part of the end of trial examination. Drug screening will be performed at 
screening and prior to start of treatment period.
SARS-COV-2 specific test will be conducted at screening and on day -3, for details refer to 
Appendix 10.3.


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Table 5.2.4: 2
Exclusionary laboratory tests
Functional lab group
Test name 
Drug screening (urine)
Amphetamine/MDA
Barbiturates
Benzodiazepine
Cannabis
Cocaine 
Methadone
Methamphetamines/MDMA/XTC
Opiates 
Phencyclidine
Tricyclic antidepressants
Infectious serology (blood)
Hepatitis B surface antigen (qualitative)
Hepatitis B core antibody (qualitative)
Hepatitis C antibodies (qualitative)
HIV-1 and HIV-2 antibody (qualitative)
Pregnancy test (urine)
Beta human chorionic gonadotropin (beta-HCG)
To encourage compliance with alcoholic restrictions, a breath alcohol test (e.g. Alcotest®
 will be performed at screening, prior to start of 
treatment and may be repeated at any time during the study at the discretion of an investigator 
or designee. The results will not be included in the CTR.
The laboratory tests listed in Tables 5.2.4: 1 and 5.2.4: 2 will be performed at
. Laboratory data will 
be transmitted electronically from the laboratory to the trial site.
The pregnancy test will be conducted as indicated in the Flow Chart using a marketed test 
kit,eg. from 
 hcg urine.
Drug screening.will be performed using Multidrogen Pipettiertest 
 
or comparable test systems.
Drug screening and pregnancy testing will be analysed at the trial site.
5.2.5
Electrocardiogram
5.2.5.1
12-lead resting ECG
Recording
Twelve-lead resting ECGs (I, II, III, aVR, aVL, aVF, V1 - V6) will be recorded using a 
computerised electrocardiograph (CardioSoft EKG System
) at the time points given in the Flow Chart. Electrode placement will be performed 
according to the method of Wilson, Goldberger and Einthoven modified by Mason and Likar 
(hips and shoulders instead of ankles and wrists). Precise electrode placement will be marked 
with an indelible mark on the skin to allow reproducible placement throughout the study.
To achieve a stable heart rate at rest and to assure high quality recordings, the site personnel 
will be instructed to assure a relaxed and quiet environment, so that all subjects are at 
complete rest.


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All ECGs will be recorded for a 10 sec duration after subjects have rested for at least 5 min in 
a supine position. ECG recording will always precede all other study procedures scheduled 
for the same time (except for blood drawing from an intravenous cannula that is already in 
place) to avoid compromising ECG quality.
ECGs will be recorded as single ECGs or as triplicate ECGs (i.e. three single ECGs recorded 
within 180 sec) as indicated in the Flow Chart.
ECGs may be repeated for quality reasons for instance due to alternating current artefacts, 
muscle movements, or electrode dislocation. For repetition within triplicate ECGs the time 
window of 180 sec applies as well. The repeat ECGs are assigned to the respective scheduled 
time point.
Additional (unscheduled) ECGs may be recorded for safety reasons. These ECGs are 
assigned to the prior scheduled time point in the sponsor’s database.
Storing
All ECGs will be stored electronically on the Muse Cardiology Information System (
.
Data transfer
For time points specified in the Flow Chart, ECGs will be transferred electronically to the 
for evaluation and/or storage except for 
ECG from screening and EoTrial which will not be transferred.
In case of repeat ECGs due to quality reasons, only the repeated ECG recordings will be 
transferred to the central ECG lab, whereas the initially recorded ECGs will be discarded. 
Unscheduled ECGs (for safety reasons) will be transferred to the central ECG lab but will not 
be included into the statistical analysis of interval lengths.
Data transfer from the central ECG lab to the sponsor is described in the ECG data transfer 
agreement (see TMF).
Evaluation
a) Central ECG lab
Central ECG lab evaluation will be performed post-study for the first of three 
replicate ECGs per time point as indicated in the Flow Chart. For baseline, where 
3 triplicate ECGs are recorded, only the first ECG of each triplicate (i.e. 3 single 
ECGs) will be evaluated.
This will include the determination of cardiac QRS-axis as assessed by the ECG 
machine’s algorithm as well as the intervals RR, PR, QRS and QT measured semi-
automatically.
Heart rate (HR) and the QT interval corrected for HR (QTc e.g. QTcF and QTcB) will 
be determined by the sponsor (see TSAP for details).
All semi-automatic interval measurements in one subject will be performed on the 
same lead. The intervals will be measured from four cardiac cycles (beats) in lead II. 
If lead II shows a flat T wave or is not measurable for any reason, lead V5 will be 


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used, or if that lead is not measurable, then lead I will be used. The lead actually used 
will be reported in the CTR.
For automatic interval measurements no lead will be provided. After quality control, 
the fiducial point markings will be reviewed by the cardiologist assigned to the study.
Morphological analyses of the ECGs will be performed by a board-certified 
cardiologist or equivalent who is to evaluate only the first of three replicate 12-lead 
ECGs recorded per time point as indicated in the Flow Chart.
The ECG interpretation will include an overall assessment (normal, abnormal 
clinically relevant, abnormal clinically not relevant, not evaluable) and findings with 
respect to e.g. rhythm, conduction, presence of myocardial infarction, ST-segment, 
T-wave, and presence of U-wave. Basis of the terminology used for the evaluation is 
the CDISC EG standard findings list as specified in the data transmission agreement.
For blinding arrangements see Section 4.1.5. No more than two blinded readers will 
evaluate all ECGs of the study. ECGs from a particular subject should be evaluated by 
a single reader.
For quality assurance and control of measurements, all ECGs of a subject will be 
subsequently reviewed by the ECG technician supervisor or his/ her designee to 
assess the overall variance of the measured intervals and, to detect accidental 
switching of leads and/ or false subject assignments of the ECGs. After quality 
control, the fiducial point markings will be reviewed by the cardiologist assigned to 
the study.
Evaluation of ECGs will comply with the ICH E14 guidance document and 
supplements [R07-4722, R16-0366] as well as the FDA requirements for annotated 
digital ECGs [R09-4830].
b) Trial site
All local ECGs will be evaluated by the investigator or a designee.
For the inclusion or exclusion (see Section 3.3) of a subject and for the assessment of 
cardiac safety during the study, the QT and QTcB values generated by the 
computerised ECG system or their manual corrections by the investigators will be 
used. In doubtful cases, ECGs may be sent upfront (i.e. prior to the regular data 
transfer) for cardiologic assessment by the central lab. In this case, these centrally 
measured results would overrule any other results obtained.
Abnormal findings, irrespective of whether they originate from central or local evaluation, 
will be reported as AEs (during the trial) or baseline conditions (at screening) if judged 
clinically relevant by the investigator.
Any ECG abnormalities will be monitored carefully and, if necessary, the subject will be 
removed from the trial and will receive the appropriate medical treatment.


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5.2.6
Suicidality assessment
Based on the FDA guidance on prospective assessment of suicidality [R12-4395] suicidal 
ideation and behaviour should be assessed as part of the evaluation of any drug being 
developed for a psychiatric condition. This recommendation also refers to clinical trials in 
healthy volunteers with multiple dose administration of the IMP.
Further, with multiple doses of BI 474121, suicidal thoughts and behavior will also be 
assessed by C-SSRS [R08-1147]. For details see Section 5.2.8.1.7. The original Columbia 
Suicidal Severity Rating scale is shown in Appendix 10.1.
C-SSRS will be performed at the times indicated in the Flow Chart.
5.2.7
Mini-Mental State Examination (MMSE)
The cognitive state will be explored only in elderlies at screening and EOT using a highly 
standardized test tool (MMSE [R96-2656]).
5.2.8
Assessment of adverse events
5.2.8.1
Definitions of adverse events
5.2.8.1.1
Adverse event
An adverse event (AE) is defined as any untoward medical occurrence in a patient or clinical 
investigation subject administered a medicinal product and which does not necessarily have 
to 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 a medicinal 
product, whether or not considered related to the medicinal product.
The following should also be recorded as an AE in the CRF and BI SAE form (if applicable):

Worsening of the underlying disease or of other pre-existing conditions

Changes in vital signs, ECG, physical examination, and laboratory test results, if they 
are judged clinically relevant by the investigator
If such abnormalities already pre-exist prior to trial inclusion, they will be considered as 
baseline conditions and should be collected in the eCRF only.
5.2.8.1.2
Serious adverse event
A serious adverse event (SAE) is defined as any AE which fulfils at least one of the 
following criteria:
Results in death 
Is life-threatening, which refers to an event in which the patient was at risk of death at 
the time of the event; it does not refer to an event that hypothetically might have 
caused death if more severe, 


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Requires inpatient hospitalisation  
Requires prolongation of existing hospitalisation
Results in persistent or significant disability or incapacity 
Is a congenital anomaly/birth defect 
Is deemed serious for any other reason if it is an important medical event when based 
upon appropriate medical judgment which may jeopardise the patient and may 
require medical or surgical intervention to prevent one of the other outcomes listed in 
the above definitions. Examples of such events are intensive treatment in an 
emergency room or at home for allergic bronchospasm, blood dyscrasias or 
convulsions that do not result in hospitalisation or development of dependency or 
abuse
5.2.8.1.3
AEs considered ‘Always Serious’
Cancers of new histology and exacerbations of existing cancer must be classified as a serious 
event regardless of the time since discontinuation of the trial medication and must be reported 
as described in 5.2.8.2, subsections ‘AE Collection’ and ‘AE reporting to sponsor and 
timelines’.
In accordance with the EU Medicines Agency initiative on Important Medical Events, 
Boehringer Ingelheim has set up a list of further AEs, which, by their nature, can always be 
considered to be ‘serious’ even though they may not have met the criteria of an SAE as 
defined above.
The latest list of ‘Always Serious AEs’ can be found in the eDC system, an electronic data 
capture system which allows the entry of trial data at the trial site. These events should 
always be reported as SAEs as described above.
5.2.8.1.4
Adverse events of special interest
The term adverse events of special interest (AESI) relates to any specific AE that has been 
identified at the project level as being of particular concern for prospective safety monitoring 
and safety assessment within this trial, e.g. the potential for AEs based on knowledge from
other compounds in the same class. AESIs need to be reported to the sponsor’s 
Pharmacovigilance Department within the same timeframe that applies to SAEs, please 
see Section 5.2.8.2.2.
The following are considered as AESIs:

Hepatic injury
A hepatic injury is defined by the following alterations of hepatic laboratory 
parameters: 
o
An elevation of AST (aspartate transaminase) and/or ALT (alanine 
transaminase) ≥3-fold ULN combined with an elevation of total bilirubin 
≥2-fold ULN measured in the same blood sample, or
o
Aminotransferase (ALT, and/or AST) elevations ≥10 fold ULN


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These lab findings constitute a hepatic injury alert and the subjects showing these lab 
abnormalities need to be followed up according to the ‘DILI checklist’ provided in the 
eDC system. In case of clinical symptoms of hepatic injury (icterus, unexplained 
encephalopathy, unexplained coagulopathy, right upper quadrant abdominal pain, 
etc.) without lab results (ALT, AST, total bilirubin) available, the Investigator should 
make sure that these parameters are analysed, if necessary in an unscheduled blood 
test. Should the results meet the criteria of hepatic injury alert, the procedures
described in the DILI checklist should be followed.
5.2.8.1.5
Intensity (severity) of AEs
The intensity (severity) of the AE should be judged based on the following:
Mild:
Awareness of sign(s) or symptom(s) that is/are easily tolerated
Moderate:
Sufficient discomfort to cause interference with usual activity
Severe:
Incapacitating or causing inability to work or to perform usual activities
5.2.8.1.6
Causal relationship of AEs
Medical judgment should be used to determine the relationship, considering all relevant 
factors, including pattern of reaction, temporal relationship, de-challenge or re-challenge, 
confounding factors such as concomitant medication, concomitant diseases and relevant 
history.
Arguments that may suggest that there is a reasonable possibility of a causal relationship 
could be:

The event is consistent with the known pharmacology of the drug 

The event is known to be caused by or attributed to the drug class

A plausible time to onset of the event relative to the time of drug exposure

Evidence that the event is reproducible when the drug is re-introduced

No medically sound alternative aetiologies that could explain the event (e.g. pre-
existing or concomitant diseases, or co-medications)

The event is typically drug-related and infrequent in the general population not 
exposed to drugs (e.g. Stevens-Johnson syndrome)

An indication of dose-response (i.e. greater effect size if the dose is increased, smaller 
effect size if dose is reduced)
Arguments that may suggest that there is no reasonable possibility of a causal relationship 
could be:

No plausible time to onset of the event relative to the time of drug exposure is evident 
(e.g. pre-treatment cases, diagnosis of cancer or chronic disease within days / weeks 
of drug administration; an allergic reaction weeks after discontinuation of the drug 
concerned)

Continuation of the event despite the withdrawal of the medication, taking into 
account the pharmacological properties of the compound (e.g. after 5 half-lives). Of 


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note, this criterion may not be applicable to events whose time course is prolonged 
despite removing the original trigger

Additional arguments amongst those stated before, like alternative explanation (e.g. 
situations where other drugs or underlying diseases appear to provide a more likely 
explanation for the observed event than the drug concerned)

Disappearance of the event even though the trial drug treatment continues or remains 
unchanged
5.2.8.1.7
Suicidal risk assessed by the C-SSRS
At the time points, specified in the Flow Chart, potential suicidality or suicidal ideations will 
be assessed using the ‘Columbia-Suicide Severity Rating Scale (C-SSRS).
The C-SSRS is a semi-structured, investigator-rated interview, developed by clinical experts 
in cooperation with the FDA, assessing both suicidal behavior and suicidal ideation. It does 
not give a global score, but provides some categorical and some severity information 
specifically for behavior and ideation.
The C-SSRS interview may be administered by any type of physician, psychologist, clinical 
social worker, mental health counselor, nurse, or coordinator with C-SSRS training. It has a 
typical duration of five minutes, and causes only a low burden on subjects. At a minimum, 
the interview consists of 2 screening questions related to suicidal ideation and 4 related to 
suicidal behavior, and may be expanded to up to 17 items in case of positive responses. Free 
text entries are allowed for; the investigator has to directly evaluate the scale and write a 
report.
The C-SSRS has been widely used in large multinational clinical trials. The C-SSRS will be 
administered at the screening visit (using the ‘screening/baseline’ version) with the aim to 
exclude subjects with active moderate or severe symptomatology within a specified time 
prior to the screening or baseline visit. The life time history of suicidal ideation and behavior 
will also be recorded.
After the baseline visit the assessment ‘since last visit’ will be performed at each clinic or 
phone visit (‘since last visit’ version). The investigator is to review positive and negative 
reports for plausibility and clinical relevance. Doubtful reports may be repeated or reports 
may be validated by a consulting psychiatrist. If there is a confirmed positive report of 
suicidal behavior or suicidal ideation type 4 or 5 after start of trial, the investigator is to 
immediately interview the subject during the clinic visit, and/or is to consult a psychiatrist. If 
the positive report is confirmed, appropriate actions for the subject’s safety have to be 
initiated.
All C-SSRS reports of suicidal ideation type 4 or 5 and all reports of suicidal behaviour must 
be reported as separate SAEs by the investigator. For ‘Self-injurious behaviour, no suicidal 
intent’ (Type 11) standard AE / SAE reporting rules are to be applied.
For each negative report (suicidal ideation type 1, 2 or 3) after start of the trial, the 
investigator is to decide based on clinical judgment whether it represents an adverse event 
(AE) as defined in the protocol, and if it is considered an AE then it must be reported 
accordingly.


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5.2.8.2
Adverse event collection and reporting
5.2.8.2.1
AE collection
Upon enrolment into a trial, the subject’s baseline condition is assessed (for instance, by 
documentation of medical history/concomitant diagnoses), and relevant changes from 
baseline are noted subsequently.
Subjects will be required to report spontaneously any AEs as well as the time of onset, end
time, and intensity of these events. In addition, each subject will be regularly assessed by the 
medical staff throughout the clinical trial and whenever the investigator deems necessary. As 
a minimum, subjects will be questioned for AEs (and concomitant therapies) at the time 
points indicated in the Flow Chart. Assessment will be made using non-specific questions 
such as ‘How do you feel?’. Specific questions will be asked wherever necessary in order to 
more precisely describe an AE.
A carefully written record of all AEs shall be kept by the investigator in charge of the trial. 
Records of AEs shall include data on the time of onset, end time, intensity of the event, and 
any treatment or action required for the event and its outcome.
The following must be collected and documented on the appropriate CRF(s) by the 
investigator:

From signing the informed consent onwards until an individual subject’s end of trial: 
o
All AEs (serious and non-serious) and all AESIs 
o
The only exception to this rule are AEs (serious and non-serious) and AESIs in 
Phase I trials in healthy volunteers, when subjects discontinue from the trial 
due to screening failures prior to administration of any trial medication. In 
these cases, the subjects’ data must be collected at trial site but will not be 
entered in the CRF or trial database and will not be reported in the CTR.

After the individual subject’s end of trial:
o
The investigator does not need to actively monitor the subject for new AEs 
but should only report any occurrence of cancer, SAEs and AESIs of 
which the investigator may become aware of by any means of 
communication, e.g. phone call. Those AEs should be reported on the BI 
SAE form (see section 5.2.8.2.2), but not on the CRF.


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5.2.8.2.2
AE reporting to the sponsor and timelines
The Investigator must report SAEs, AESIs, and non-serious AEs which are relevant for the 
reported SAE or AESI, on the BI SAE form via fax immediately (within 24 hours) to the 
sponsor’s unique entry point (country specific contact details will be provided in the ISF). 
The same timeline applies if follow-up information becomes available. In specific occasions 
the Investigator could inform the sponsor upfront via telephone. This does not replace the 
requirement to complete and fax the BI SAE form.
With receipt of any further information to these events, a follow-up SAE form has to be 
provided. For follow-up information, the same rules and timeline apply as for initial 
information.
5.2.8.2.3
Information required
All (S)AEs, including those persisting after the individual subject’s end of trial, must be 
followed up until they have resolved, have been assessed as ‘chronic’ or ‘stable’, or no 
further information can be obtained.
5.2.8.2.4
Pregnancy
In rare cases, pregnancy might occur in a clinical trial. Once a subject has been enrolled in 
the clinical trial and has taken trial medication, the investigator must report any drug 
exposure during pregnancy in a trial participant immediately (within 24 hours) by means of 
Part A of the Pregnancy Monitoring Form to the sponsor’s unique entry point.
The outcome of the pregnancy associated with the drug exposure during pregnancy must be 
followed up and reported to the sponsor’s unique entry point on the Pregnancy Monitoring 
Form for Clinical Trials (Part B).
The ISF will contain the Pregnancy Monitoring Form for Clinical Trials (Part A and Part B) 
as well as non-trial specific information and consent for the pregnant partner.
As pregnancy itself is not to be reported as an AE, in the absence of an accompanying SAE 
and/or AESI, only the Pregnancy Monitoring Form for Clinical Trials and not the SAE form 
is to be completed. If there is an SAE and/or AESI associated with the pregnancy, an SAE 
form must be completed in addition.
5.3
DRUG CONCENTRATION MEASUREMENTS AND 
PHARMACOKINETICS
5.3.1
Assessment of pharmacokinetics
Date and clock times of drug administration and pharmacokinetic sampling will be recorded
in the CRFs.
The actual sampling times will be used for determination of pharmacokinetic parameters.
PK sampling times and periods may be adapted during the trial based on information 
obtained during trial conduct (e.g. as a result of preliminary PK data), including addition of 


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samples and visits, as long as the total blood volume taken per subject does not exceed 
500 mL. Such changes would be implemented via non-substantial CTP Amendments.
5.3.2
Methods of sample collection
5.3.2.1
Blood sampling for pharmacokinetic analysis
BI 474121
For quantification of BI 474121 concentrations in plasma, approx. 2.7 mL of blood will be 
drawn from an antecubital or forearm vein into an K2-EDTA (potassium ethylenediamine-
tetraacetic acid)-anticoagulant blood drawing tube at the times indicated in the Flow Chart. 
Blood will be withdrawn either by means of an indwelling venous catheter or by 
venepuncture with a metal needle.
The EDTA-anticoagulated blood samples will be centrifuged for approximately 10 min at 
approximately 2000 x g to 4000 x g and at 4 to 8 °C. Two plasma aliquots will be obtained 
and stored in polypropylene tubes. The first aliquot should contain at least 0.5 mL of plasma. 
The process from blood collection until transfer of plasma aliquots into the freezer should be 
completed in less than 90 min, with interim storage of blood samples and aliquots on ice. The 
time each aliquot was placed in the freezer will be documented. Until transfer on dry ice to 
the analytical laboratory, the aliquots will be stored upright at approximately  20°C or below 
at the trial site. The second aliquot will be transferred to the analytical laboratory after the 
bioanalyst has acknowledged safe arrival of the first aliquot. At the analytical laboratory, the 
plasma samples will be stored at approximately -20°C or below until analysis.
At a minimum, the sample tube labels should list BI trial number, subject number, visit, and 
planned sampling time. Further information such as matrix and analyte may also be provided.
Plasma samples will be transferred to
After completion of the trial, the plasma samples may be used for further methodological 
investigations (e.g., for stability testing or assessment of metabolites). However, only data 
related to the analyte and/or its metabolite(s) including anti-drug antibodies (if applicable) 
will be generated by these additional investigations. The study samples will be discarded after 
completion of the additional investigations, but not later than 5 years after the CTR is 
archived.
Midazolam (only Part A 2.5 mg, 10 mg, 20 mg and 30 mg)
For quantification of midazolam plasma concentrations, 4 mL of blood will be taken from an
antecubital or forearm vein into a K3-EDTA-anticoagulant blood drawing tube at the times
indicated in the Flow Chart. Blood will be withdrawn by means of either an indwelling
venous catheter or by venipuncture with a metal needle.
The EDTA-anticoagulated blood samples will be centrifuged for about 10 min at about
2000 g to 4000 g and at 4 to 8 °C. Two plasma aliquots will be obtained and stored in
polypropylene tubes. The first aliquot should contain at least 1.0 mL plasma the second


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aliquot should contain the remaining plasma. The process from blood collection until transfer
of plasma aliquots into the freezer should be completed within 120 min. For each aliquot the 
time when the sample was placed in the freezer will be documented. Until transfer on dry ice 
to the analytical laboratory, the aliquots will be stored upright at about -20°C or below at the 
trial site. The second aliquot will be transferred to the analytical laboratory after the 
bioanalyst has acknowledged safe arrival of the first aliquot. At the analytical laboratory, 
plasma samples will be stored at about -20°C or below until analysis.
At a minimum, sample tube labels should list the following information: BI trial number,
subject number, visit, and planned sampling time. Further information, such as matrix and
analyte, may also be provided.
Plasma samples will be transferred to
5.3.2.2
Blood sampling for metabolism analysis
Additional K2-EDTA plasma samples for the identification of drug metabolites will be 
investigated in the 10 mg and 30 mg dose groups. Based on the knowledge gained during the 
trial conduct, e.g. from preliminary PK results, the dose group may be modified to a different 
one. The change will be implemented via a non-substantial CTP amendment.
The blood samples will be drawn at the same time points as PK samples on Day 1 to 18 (see 
Flow Chart). At each of these times, 2.7 mL blood will be needed for metabolite analysis. 
The blood samples will be processed in the same way as the PK samples (see Section 
5.3.2.1). However, the plasma obtained (approximately 1 mL) will be transferred into a single 
polypropylene tube. Samples will be stored at approximately -20°C or below until transfer to 
the metabolism laboratory.
At a minimum, the sample tube labels should list BI trial number, subject number, visit, 
planned sampling time and ‘MetID’.
Plasma samples dedicated to metabolism investigation are transferred to:
Only data related to the parent compound and its metabolites will be acquired. Evaluation of 
drug metabolism will be reported separately and will not be included in the CTR. The study 
samples will be discarded after completion of the experiments but not later than 5 years after 
the CTR has been archived.
5.3.2.3
Urine sampling for pharmacokinetic analysis
A blank urine sample will be collected before administration of trial medication (within 2 h 
before drug dosing) and two 0.5 mL aliquots will be retained to check for analytical 
interference by concomitant or rescue medication.


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All urine voided during the sampling intervals indicated in the Flow Chart will be collected in 
2 L polyethylene (PE) containers and stored at about 2 - 8°C. Subjects are told to empty their 
bladders at the end of each sampling interval. In order to facilitate urine sampling, subjects 
will be advised to drink at least 100 mL water before the end of each urine sampling interval.
The urine weight/volume for each collection interval will be documented (however, no 
correction for the specific gravity of urine is done; i.e., 1 L is defined to be equal to 1 kg). 
Urine containers will be stored at about 2°to 8°C between sampling times. Two 0.5 mL 
aliquots will be stored in polypropylene (PP) tubes for bioanalytical measurements. If more 
than one collection container is used in an interval, the contents of all containers are to be 
mixed before aliquots are prepared. Mixing should be done by transferring the entire content 
of all collection containers into a single polyethylene) (PE)/PP or glass container, and stirring 
the mixed fractions for about 1 min (manually or using a stir bar or other stirring device made 
of PE, PP, Teflon, or glass).
At a minimum, the sample tube labels should list BI trial number, subject number, visit, and 
planned collection time. Further information, such as matrix and analyte may also be 
provided.
Until transfer on dry ice to the analytical laboratory, the urine samples will be stored at 
approximately -20°C or below at the trial site. The second aliquot will be transferred after the 
bioanalyst has acknowledged safe arrival of the first aliquot. At the analytical laboratory, the 
urine samples will be stored at approximately -20°C or below until analysis.
Urine samples will be transferred to
After completion of the trial, the urine samples may be used for further methodological 
investigations (e.g., for stability testing or assessment of metabolites). However, only data 
related to the analyte and/or its metabolite(s) will be generated by these additional 
investigations. The study samples will be discarded after completion of the additional 
investigations but not later than 5 years after the CTR has been archived.
 
 
 
 
 
 
 
 
 
 


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5.5
BIOBANKING
Not applicable.
5.6
OTHER ASSESSMENTS
No other assessments are planned for this trial.


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5.7
APPROPRIATENESS OF MEASUREMENTS
All measurements performed during this trial are standard measurements and will be 
performed in order to monitor subjects’ safety and to determine pharmacokinetic and 
pharmacodynamic parameters in an appropriate way. The scheduled measurements will allow 
monitoring of changes in vital signs, standard laboratory values, and ECG parameters that 
might occur as a result of administration of trial medication. The safety assessments are 
standard, are accepted for evaluation of safety and tolerability of an orally administered drug, 
and are widely used in clinical trials. The pharmacokinetic parameters and measurements 
outlined in Section 5.3. are generally used assessments of drug exposure.


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6.
INVESTIGATIONAL PLAN
6.1
VISIT SCHEDULE
Exact times of measurements outside the permitted time windows will be documented. The 
acceptable time windows for screening and the end of trial examination are provided in the 
Flow Chart.
Study measurements and assessments scheduled to occur ‘before’ trial medication 
administration on Day -1, Day 1 and Day 14 are to be performed and completed within a 
2 h-period prior to the trial drug administration (including blank values for PK and 
Biomarker).
For the first 4h after trial drug administration, the acceptable deviation from the scheduled 
time will be ±10 min for vital signs and ECG and ±30 min for laboratory tests. Thereafter, the 
acceptable deviation will be ±30 min. 
The tolerance for drug administration will be ±1 min on Day 14. On all other treatment days 
it will be ±15 min.
If several activities are scheduled at the same time point in the Flow Chart, ECG should be 
the first and meal the last activity. Furthermore, if several measurements including 
venepuncture are scheduled for the same time, venepuncture should be the last of the 
measurements due to its inconvenience to the subject and possible influence on physiological 
parameters.
For planned individual plasma concentration sampling times and urine collection intervals,
refer to the Flow Chart. While these nominal times should be adhered to as closely as 
possible, the actual sampling times will be recorded and used for the determination of 
pharmacokinetic parameters.
If a subject misses an appointment, it will be rescheduled if possible. The relevance of 
measurements outside the permitted time windows will be assessed no later than at the Report 
Planning Meeting.
6.2
DETAILS OF TRIAL PROCEDURES AT SELECTED VISITS
6.2.1
Screening period
After having been informed about the trial, all subjects will provide written informed consent 
in accordance with GCP and local legislation prior to enrolment in the study. For information 
regarding laboratory tests (including drug and virus screening), ECG, C-SSRS, MMSE (only 
Part B), vital signs including assessment of body temperature, orthostatic testing and physical 
examination, refer to Sections 5.2.1 to 5.2.5.
For details on SARS-CoV-2 specific measures, refer to Appendix 10.3.
6.2.2
Treatment period
Each subject will receive a single dose of BI 474121 or placebo from Day 1 to Day 14.


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A single midazolam microdose will be administered on Day -1, Day 1 and on Day 14 (in 
Part A DG of 2.5 mg, 10 mg, 20 and 30 mg).
Trial medication will be taken orally by each subject under direct supervision of the 
investigator or
designee. Details on treatments and procedures of administration are 
described in Section 4.1.4.
Study participants will be admitted to the trial site in the morning of Day -1or Day 1 and will 
stay hospitalised up to Day 16. The subjects will be discharged on Day 16 after formal 
assessment and confirmation of their fitness by the investigator or 
 designee. On other 
study days, the study will be performed in an ambulatory fashion.
For details on time points and procedures for collection of plasma and urine samples for PK 
analysis, refer to Flow Chart and Section 5.3.2.
The safety measurements performed during the treatment period are specified in Section 5.3
of this protocol and in the Flow Chart. For details on times of all other trial procedures, refer 
to the Flow Chart. AEs and concomitant therapy will be assessed continuously from 
screening until the end of trial examination.
6.2.3
Follow-up period and trial completion
For AE assessment, laboratory tests, recording of ECG and vital signs, including body 
temperature, MMSE (only Part B) and physical examination during the follow-up period, 
see Sections 5.2.1 to 5.2.5.
Subjects who discontinue treatment before the end of the planned treatment period should 
undergo the EoTrial Visit.
All abnormal values (including laboratory parameters) that are assessed as clinically relevant 
by the investigator will be monitored using the appropriate tests until a return to a medically 
acceptable level is achieved. (S)AEs persisting after a subject’s EoTrial Visit must be 
followed until they have resolved, have been sufficiently characterised, or no further 
information can be obtained.


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7.
STATISTICAL METHODS AND DETERMINATION OF
SAMPLE SIZE
7.1
STATISTICAL DESIGN – MODEL
The main objectives of this trial will be assessed by calculating descriptive statistics for 
safety as well as for PK 
parameters, which will be compared between the dose
groups. Descriptive statistics will be calculated separately for young and elderlies.
 
Relative bioavailability will be estimated for dose groups 
1, 3, 4 and 7 of young only for midazolam. 
 
.
7.2
NULL AND ALTERNATIVE HYPOTHESES
It is not planned to test any statistical hypotheses in this study.
Any confidence intervals computed are to be interpreted in the perspective of the exploratory 
character of the study; i.e., confidence intervals are considered as interval estimates for 
effects.
7.3
PLANNED ANALYSES
Analysis sets
Statistical analyses will be based on the following analysis sets:

Treated set (TS): The treated set includes all subjects who were randomized and 
treated with at least one dose of study drug. The treatment assignment will be 
determined based on the first treatment the subjects received. The treated set will be 
used for safety analyses.
Pharmacokinetic parameter analysis set (PKS): This set includes all subjects in the 
treated set (TS) who provide at least one PK endpoint that was not excluded due to a 
protocol violation relevant to the evaluation of PK or due to PK non-evaluability (as 
specified in the following subsection ‘Pharmacokinetics’). Thus, a subject will be 
included in the PKS, even if he/she contributes only one PK parameter value for one 
period to the statistical assessment. Descriptive and model based analyses of PK 
parameters will be based on the PKS.
Details will be given in the TSAP.
Adherence to the protocol will be assessed by the trial team. Important protocol deviation  
(iPD) categories will be specified in the Integrated Quality and Risk Management Plan, iPDs
will be identified no later than in the Report Planning Meeting, and the iPD categories will be 
updated as needed.


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Pharmacokinetics
The pharmacokinetic parameters listed in Section 2.1 and Section 2.2.2.2 for drug 
BI 474121 and midazolam will be calculated according to BI standards.
Plasma and urine concentration data and parameters of a subject will be included in the 
statistical pharmacokinetic (PK) analyses if they are not flagged for exclusion due to a 
protocol violation relevant to the evaluation of PK (to be decided no later than in the Report
Planning Meeting) or due to PK non-evaluability (as revealed during data analysis, based on 
the criteria specified below). Exclusion of a subject’s data will be documented in the CTR.
Relevant protocol deviations may be

Incorrect trial medication taken, i.e. the subject received at least one dose of trial 
medication the subject was not assigned to

Incorrect dose of trial medication taken

Use of restricted medications
Plasma and urine concentrations and/or parameters of a subject will be considered as non-
evaluable, if for example

The subject experienced emesis that occurred at or before two times median tmax of 
the respective treatment (Median tmax is to be determined excluding the subjects 
experiencing emesis),

Missing samples/concentration data at important phases of PK disposition curve.
Plasma/urine concentration data and parameters of a subject which is flagged for exclusion 
will be reported with its individual values but will not be included in the statistical analyses.
Only concentration values within the validated concentration range and actual sampling times 
will be used for the calculation of pharmacokinetic parameters. Concentrations used in the 
pharmacokinetic calculations will be in the same format as in the bioanalytical report (that is 
to the same number of decimal places provided in the bioanalytical report).
7.3.1
Primary endpoint analyses
The primary endpoint as specified in Section 2.1.2 will be derived according to BI standards.
The analysis will be based on the treated set (TS) and will be descriptive in nature.
7.3.2
Secondary endpoint analyses
Primary analyses
The secondary endpoints (refer to Section 2.1.3) will be analysed descriptively. Analyses will 
be performed for the parent drug and will be based on the PKS.


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Midazolam: 
Relative bioavailability will be estimated for dose groups 1, 3, 4 and 7 of young only for 
AUC0-tz and Cmax of midazolam. These endpoints will be compared separately between the 
last dose of midazolam and the first dose of midazolam and between the second dose of 
midazolam and the first dose of midazolam (test/reference). The statistical analysis will be 
performed separately for each dose group and separately for the group of subjects receiving 
placebo. Analyses will be conducted for the placebo group to better account for variability in 
plasma concentrations seen between midazolam treatment periods. The statistical model used 
for the analysis of the secondary endpoints will be an ANOVA model on the logarithmic 
scale. This model will include effects accounting for the following sources of variation: 
‘subjects’, and ‘time point’. The effect ‘subjects’ will be considered as random, whereas the 
other effects will be considered as fixed. The model is described by the following equation:
!"# = μ + " + $# + eij , where
!"#
logarithm of the endpoint for subject j (j=1, 2,…, 8) at time point i: Day -1 
(first dose of midazolam, i=1), Day 1 (second dose of midazolam) or at Day 14 
(last dose of midazolam, i=2) respectively,
μ
the overall mean,
"
the effect associated with time point i (Day -1 i=1 , Day 1 or Day 14, i=2),
$#
(random) effect of subject j, j=1, 2, ..., 8, and
eij
random error associated with subject j at time i (assumed to be independent


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and identically normally distributed).
The effect of BI 474121 on midazolam will be estimated by the difference in the expected 
means log(test)-log(reference) (with the second and the last doses of midazolam respectively 
as the test and the first dose of midazolam as the reference) estimated by the difference in the 
corresponding adjusted means (Least Squares Means) for Cmax and AUC0-tz. Additionally, 
their two-sided 90% confidence intervals (CIs) will be calculated based on the residual error 
from ANOVA. These quantities will then be back transformed to the original scale to provide 
the point estimate and 90% CIs for each secondary endpoint. This method corresponds to the 
two one-sided t-tests procedure, each at the 5% significance level. Since the main focus is on 
estimation and not testing, an acceptance range is not specified.


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7.3.4
Safety analyses
Safety will be assessed as defined by the endpoints listed in Section 2.1.2 and 2.2.2 based on 
the treated set (TS). Safety analyses will be descriptive in nature and will be based on BI 
standards.
For all analyses the treatment actually administered (= treatment at onset) to the subject will 
be used (any deviations from the randomised treatment will be discussed in the minutes of the 
Report Planning Meeting).
Treatments will be compared in a descriptive way. The placebo group in the safety evaluation 
will consist of all subjects treated with placebo, regardless of the dose group in which they 
were treated. The test treatment groups will be compared to the placebo group in a descriptive 
way. Tabulations of frequencies/proportions will be used for the evaluation of categorical 
(qualitative) data, and tabulations of descriptive statistics will be used to analyse continuous 
(quantitative) data.
Measurements (such as ECGs, vital signs, or laboratory parameters) or AEs will be assigned 
to treatments (see Section 4.1) based on the actual treatment at the planned time of the 
measurement or on the recorded time of AE onset (concept of treatment-emergent AEs).
Therefore, measurements planned or AEs recorded prior to first intake of trial medication will 
be assigned to the screening period, those between the first trial medication intake and end of 
REP (see Section 1.2.1.7) will be assigned to the treatment period. Events occurring after the 
REP but prior to trial termination date will be assigned to ’follow-up’. These assignments 
including the corresponding time intervals will be defined in detail in the TSAP. Note that 
AEs occurring after the last per protocol contact but entered before database lock will be 
reported to Pharmacovigilance only and will not be captured in the trial database.
Additionally, further treatment intervals (called analysing treatments) may be defined in the 
TSAP in order to provide summary statistics for other than above periods, such as combined 
treatments, on-treatment totals, or periods without treatment effects (such as screening and 
post-study intervals).
Adverse events will be coded using the Medical Dictionary for Regulatory Activities 
(MedDRA). Frequency, severity, and causal relationship of AEs will be tabulated by 


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treatment, system organ class and preferred term. SAEs, AESIs (see Section 5.2.8.1) and 
other significant AEs (according to ICH E3) will be listed separately. 
Previous and concomitant therapies will be presented per treatment group without 
consideration of time intervals and treatment periods.
Laboratory data will be compared to their reference ranges. Values outside the reference 
range as well as possibly clinically significant values will be highlighted in the listings. 
Additionally, differences from baseline will be evaluated.
Vital signs or other safety-relevant data will be assessed with regard to possible on-treatment 
changes from baseline. 
The ECG variables QT, HR, QTcF, QTcB, PR, QRS, and RR obtained from the centralised 
evaluation of 12-lead ECG recordings will be the basis for the derivation of quantitative and 
categorical ECG endpoints. These endpoints and their analyses will be described in the 
TSAP.
 
7.4
INTERIM ANALYSES
No interim analysis is planned. However, a preliminary analysis of PK parameters (Cmax,ss
and AUCτ,ss of BI 474121), provided as individual values and geometric means of the dose 
groups will be performed. This analysis will be performed for dose group 1 before 
proceeding to dose group 2, for dose group 2 before proceeding to dose group 3 and 5, for 
dose group 3 before proceeding to dose group 4 and 6 and for dose group 4 before proceeding 
to dose group 7. Data from a portion of the subjects of the dose groups will be sufficient as 
long as the data from at least 4 subjects on active treatment were available. Explorative 
analysis will be conducted for all dose groups (i.e. also in DG 6 and DG 7).
In contrast to the final PK calculations, the preliminary analysis will be based on planned 
sampling times rather than on actual times, regardless of whether actual times were within the 
time windows. Therefore, minor deviations may occur between preliminary and final results. 
The preliminary analysis will provide individual and mean concentration/effect-time profiles 
and summary statistics of individual values without subject identification information. The 
preliminary results will be distributed to the investigator and the trial team.
Depending on the results of available preliminary PK analyses and the tolerability and safety 
of the compound, changes to the dosing schedule (e.g., additional intermediate doses) and 
additional PK preliminary analysis may be performed, if requested by the Trial Clinical 
Monitor, the investigator, or Trial Clinical Pharmacokineticist. Preliminary PK results will 
not be reported in the CTR.
No inferential statistical interim analysis is planned. However, after completion of each dose 
group the investigator (or his or her deputy) is allowed to postpone further dose progression 
until a preliminary analysis of the data has been performed.


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7.5
HANDLING OF MISSING DATA
7.5.1
Safety
It is not planned to impute missing values for safety parameters.
7.5.2
Pharmacokinetics
Handling of missing PK data will be performed according to BI standards.
PK parameters that cannot be reasonably calculated based on the available drug 
concentration-time data will not be imputed.
7.6
RANDOMISATION
Subjects will be randomised within each dose group in a 4:1 ratio (test treatment to placebo).
In Part B for the first cohort of each elderly dose group (DG 5 and 6) only subjects aged 65 to 
74 will be randomized. For the second cohort of elderlies, first 3 subjects aged 75 to 80 will 
be randomized and subsequently the cohort will be completed with subjects aged either 65 to 
74 or subjects aged 75 to 80.
The sponsor will arrange for the randomisation as well as packaging and labelling of trial 
medication. The randomisation list will be generated using a validated system that uses a 
pseudo-random number generator and a supplied seed number so that the resulting allocation 
is both reproducible and non-predictable.
The randomisation list will contain additional blocks to allow for subject replacement (refer 
to Section 3.3.5).
7.7
DETERMINATION OF SAMPLE SIZE
It is planned to include a total of 70 subjects in this trial. The planned sample size is not based 
on a power calculation. The size of 10 subjects per dose group (8 on active treatment, and 2 
on placebo) is commonly used in multiple-rising dose studies of the present type and is in 
general considered as sufficient for the exploratory evaluation of multiple dose safety and 
pharmacokinetics.
Additional subjects may be entered to allow testing of additional doses on the basis of 
experience gained during the trial conduct (e.g. preliminary PK data), provided the planned 
and approved highest dose will not be exceeded. Thus, the actual number of subjects entered 
may exceed 70, but will not exceed 90 subjects entered.


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8.
INFORMED CONSENT, TRIAL RECORDS, DATA 
PROTECTION, PUBLICATION POLICY, AND 
ADMINISTRATIVE STRUCTURE
For details on SARS-CoV-2 specific measures, refer to Appendix 10.3.
The trial will be carried out in compliance with the protocol, the ethical principles laid down 
in the Declaration of Helsinki, in accordance with the ICH Harmonized Guideline for Good 
Clinical Practice (GCP), relevant BI Standard Operating Procedures (SOPs), the EU 
regulation 536/2014 and other relevant regulations. Investigators and site staff must adhere to 
these principles.
Standard medical care (prophylactic, diagnostic, and therapeutic procedures) remains the 
responsibility of the subject’s treating physician.
The investigator will inform the sponsor immediately of any urgent safety measures taken to 
protect the trial subjects against any immediate hazard, as well as of any serious breaches of 
the protocol or of ICH GCP.
The Boehringer Ingelheim transparency and publication policy can be found on the following 
web page: trials.boehringer-ingelheim.com [R20-2551]. The rights of the investigator and of 
the sponsor with regard to publication of the results of this trial are described in the 
investigator contract. As a general rule, no trial results should be published prior to archiving 
of the CTR.
The terms and conditions of the insurance coverage are made available to the investigator and 
the  subjects, and are stored in the ISF.
8.1
TRIAL APPROVAL, SUBJECT INFORMATION, INFORMED CONSENT
This trial will be initiated only after all required legal documentation has been reviewed and 
approved by the responsible Institutional Review Board (IRB) / Independent Ethics 
Committee (IEC) and competent authority (CA) according to national and international 
regulations. The same applies for the implementation of changes introduced by amendments.
Prior to a subject’s participation in the trial, written informed consent must be obtained from
each subject (or the subject’s legally accepted representative) according to ICH-GCP and to 
the regulatory and legal requirements of the participating country. Each signature must be 
personally dated by each signatory and the informed consent and any additional subject-
information form retained by the investigator as part of the trial records. A signed copy of the 
informed consent and any additional subject information must be given to each subject or the 
subject’s legally accepted representative.
The subject must be given sufficient time to consider participation in the trial. The 
investigator or delegate obtains written consent of the subject’s own free will with the 
informed consent form after confirming that the subject understands the contents. The
investigator or
 delegate must sign (or place a seal on) and date the informed consent form. 
If a trial collaborator has given a supplementary explanation, the trial collaborator also signs 
(or places a seal on) and dates the informed consent.


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Re-consenting may become necessary when new relevant information becomes available and 
should be conducted according to the sponsor’s instructions.
The consent and re-consenting process should be properly documented in the source 
documentation.
8.2
DATA QUALITY ASSURANCE
A risk-based approach is used for trial quality management. It is initiated by the assessment 
of critical data and processes for trial subject protection and reliability of the results as well as 
identification and assessment of associated risks. An Integrated Quality and Risk 
Management Plan documents the rationale and strategies for risk management during trial 
conduct including monitoring approaches, vendor management and other processes focusing 
on areas of greatest risk. 
Continuous risk review and assessment may lead to adjustments in trial conduct, trial design 
or monitoring approaches. 
A quality assurance audit/inspection of this trial may be conducted by the sponsor, sponsor’s 
designees, or by IRB / IEC or by regulatory authorities. The quality assurance auditor will 
have access to all medical records, the investigator’s trial-related files and correspondence, 
and the informed consent documentation of this clinical trial.
8.3
RECORDS
CRFs for individual subjects will be provided by the sponsor. See Section 4.1.5.2 for rules 
about emergency code breaks. For drug accountability, refer to Section 4.1.8.
8.3.1
Source documents
In accordance with regulatory requirements, the investigator should prepare and maintain 
adequate and accurate source documents and trial records for each trial subject that include 
all observations and other data pertinent to the investigation. Source data as well as reported 
data should follow the ‘ALCOA principles’ and be attributable, legible, contemporaneous, 
original, and accurate. Changes to the data should be traceable (audit trail).
Data reported on the CRF must be consistent with the source data or the discrepancies must 
be explained.
Before providing any copy of subjects’ source documents to the sponsor, the investigator 
must ensure that all subject identifiers (e.g., subject’s name, initials, address, phone number,
and social security number) have properly been removed or redacted to ensure subject
confidentiality.
If the subject is not compliant with the protocol, any corrective action (e.g. re-training) must 
be documented in the subject file.
For the CRF, data must be derived from source documents, for example:

Subject identification: sex, year of birth (in accordance with local laws and 
regulations)


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
Subject participation in the trial (substance, trial number, subject number, date subject 
was informed)

Dates of subject’s visits, including dispensing of trial medication

Medical history (including trial indication and concomitant diseases, if applicable)

Medication history

AEs and outcome events (onset date [mandatory], and end date [if available])

SAEs (onset date [mandatory], and end date [if available])

Concomitant therapy (start date, changes)

Originals or copies of laboratory results and other imaging or testing results, with 
proper documented medical evaluation (in validated electronic format, if available)

ECG results (original or copies of printouts)

Completion of subject’s participation in the trial (end date; in case of premature 
discontinuation, document the reason for it, if known)

Prior to allocation of a subject to a treatment into a clinical trial, there must be 
documented evidence in the source data (e.g. medical records) that the trial participant 
meets all inclusion criteria and does not meet any exclusion criteria. The absence of 
records (either medical records, verbal documented feedback of the subject or testing 
conducted specific for a protocol) to support inclusion/exclusion criteria does not 
make the subject eligible for the clinical trial.
8.3.2
Direct access to source data and documents
The investigator /institution will allow site trial-related monitoring, audits, IRB / IEC review 
and regulatory inspections. Direct access must be provided to the CRF and all source 
documents/data, including progress notes, copies of laboratory and medical test results, which 
must be available at all times for review by the Clinical Research Associate, auditor and 
regulatory inspector (e.g. FDA). They may review all CRFs and informed consents. The 
accuracy of the data will be verified by direct comparison with the source documents 
described in Section 8.3.1. The sponsor will also monitor compliance with the protocol and 
GCP.
8.3.3
Storage period of records
Trial site:
The trial site(s) must retain the source and essential documents (including ISF) according to
contract or the local requirements valid at the time of the end of the trial (whatever is longer).
Sponsor:
The sponsor must retain the essential documents according to the sponsor’s SOPs.
8.4
EXPEDITED REPORTING OF ADVERSE EVENTS
BI is responsible to fulfil their legal and regulatory reporting obligation in accordance with 
regulatory requirements.


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8.5
STATEMENT OF CONFIDENTIALITY AND SUBJECT PRIVACY
Individual subject data obtained as a result of this trial is considered confidential and 
disclosure to third parties is prohibited with the exceptions noted in Section 8.7.
Data protection and data security measures are implemented for the collection, storage and 
processing of patient data in accordance with the principles 6 and 12 of the WHO GCP 
handbook.
Personalised treatment data may be given to the subject’s personal physician or to other 
appropriate medical personnel responsible for the subject’s welfare. Data generated at the site 
as a result of the trial need to be available for inspection on request by the participating 
physicians, the sponsor’s representatives, by the IRB / IEC and the regulatory authorities.
8.5.1
Collection, storage and future use of biological samples and corresponding 
data
Measures are in place to comply with the applicable rules for the collection, biobanking and 
future use of biological samples and clinical data, in particular

Sample and data usage has to be in accordance with the separate biobanking informed 
consent

The BI-internal facilities storing biological samples from clinical trial participants as 
well as the external banking facility are qualified for the storage of biological samples 
collected in clinical trials

An appropriate sample and data management system, incl. audit trail for clinical data 
and samples to identify and destroy such samples according to ICF is in place

A fit for the purpose documentation (biomarker proposal, analysis plan and report) 
ensures compliant usage

A fit for purpose approach will be used for assay/equipment validation depending on 
the intended use of the biomarker data

Samples and/or data may be transferred to third parties and other countries as 
specified in the biobanking ICF
8.6
TRIAL MILESTONES
The start of the trial is defined as the date when the first subject in the whole trial signs 
informed consent.
The end of the trial is defined as the ‘date of the last visit of the last subject in whole trial’.
Early termination of the trial is defined as the premature termination of the trial for any 
reason before the end of the trial as specified in this protocol.
Temporary halt of the trial is defined as any unplanned interruption of the trial by the 
sponsor with the intention to resume it.
Suspension of the trial is defined as an interruption of the trial based on a Health Authority 
request.


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The EC/competent authority in each participating EU member state will be notified about the 
trial milestones according to the laws of each member state.
A final report of the clinical trial data will be written only after all subjects have completed 
the trial in all countries (EU or non-EU), so that all data can be incorporated and considered
in the report.
The sponsor will submit to the EU database a summary of the final trial results within one 
year from the end of a clinical trial as a whole, regardless of the country of the last patient 
(EU or non-EU).
8.7
ADMINISTRATIVE STRUCTURE OF THE TRIAL
The trial is sponsored by Boehringer Ingelheim (BI).
The trial will be conducted at 
 under the supervision of the Principal Investigator. Relevant documentation on the
participating (Principal) Investigators (e.g. their curricula vitae) will be filed in the ISF.
BI has appointed a Trial Clinical Monitor, responsible for coordinating all required trial 
activities, in order to

Manage the trial in accordance with applicable regulations and internal SOPs

Direct the clinical trial team in the preparation, conduct, and reporting of the trial

Ensure appropriate training and information of clinical trial managers (CTM), Clinical 
Research Associates, and investigators of participating trial sites
The trial medication will be provided by the
(BI 474121 and matching placebo) or will be obtained by the 
clinical trial site from public pharmacy (midazolam).
Safety laboratory tests will be performed by the local laboratory of the trial site
Analyses of BI474121 concentrations in plasma and urine will be performed at 
The analyses midazolam concentrations in plasma (DGs 1, 3, 4 and 7) will be performed at 
tic analysis of CPI and CPIII will be performed at
 
The metabolic identification will be performed at 
 
The digitally recorded 12-lead ECGs will be sent to a specialised contract research 
organisation 
 for evaluation.


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On-site monitoring will be performed by BI or a contract research organisation appointed by 
BI.
Data management and statistical evaluation will be done by BI or a contract research
organisation appointed by BI, according to BI SOPs.
Tasks and functions assigned in order to organise, manage, and evaluate the trial are defined 
according to BI SOPs. A list of responsible persons and relevant local information can be 
found in the ISF.


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9.
REFERENCES 
9.1
PUBLISHED REFERENCES
R07-4722
Guidance for industry: E14 clinical evaluation of QT/QTc interval 
prolongation and proarrhythmic potential for non-antiarrhythmic drugs.
Rockville: U.S. Department of Health and Human Services, Food and Drug 
Administration, Center for Drug Evaluation and Research (CDER), Center 
for Biologics Evaluation and Research (CBER) (2005).
R08-1147
Posner K. State of the science: measurement of suicidal adverse events and the 
Columbia Suicide Severity Rating Scale. 47th NCDEU Ann Mtg, Boca Raton, 
11-14 Jun 2007. 2007:15.
R09-4830
Brown BD, Badilini F. HL7 aECG implementation guide (March 21, 2005).
R10-5092
Cooke SF, Bliss TVP. Plasticity in the human central nervous system. Brain
129, 1659 - 1673 (2006).
R10-5102
Reymann KG, Frey JU. The late maintenance of hippocampal LTP:
requirements, phases, 'synaptic tagging', 'late-associativity' and
implications. Neuropharmacology 52, 24 - 40 (2007).
R12-4395
Guidance for industry: suicidal ideation and behavior: prospective 
assessment of occurrence in clinical trials (draft guidance, August 2012). 
http://www.fda.gov/downloads/Drugs/GuidanceRegulatoryInformation/Gui
dances/UCM22 5130.pdf (access date: 5 October 2012); 2012.
R13-4518
Hu NW, Ondrejcak T, Rowan MJ. Glutamate receptors in preclinical
research on Alzheimer's disease: update on recent advances. Pharmacol
Biochem Behav 100, 855 - 862 (2012).
R13-4521
Lin CH, Lane HY, Tsai GE. Glutamate signaling in the pathophysiology
and therapy of schizophrenia. Pharmacol Biochem Behav 100, 665 – 677
(2012).
R16-0366
E14 Implementation Working Group
ICH E14 guideline: the clinical evaluation of QT/QTc interval prolongation 
and proarrhythmic potential for non-antiarrhythmic drugs: questions & 
answers (R3) (current version dated 10 December 2015).
http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/E
fficacy/E1 4/E14_Q_As_R3__Step4.pdf (access date: 29 January 2016) ; 
Geneva: International Council for Harmonisation of Technical 
Requirements for Pharmaceuticals for Human Use (2015).
R17-3022
Halama B, Hohmann N, Burhenne J, Weiss J, Mikus G, Haefeli WE, et al. 
A nanogram dose of the CYP3A probe substrate midazolam to evaluate 
drug interactions. Clin Pharmacol Ther 2013;93(6):564-571.
R17-3023
Hohmann N, Kocheise F, Carls A, Burhenne J, Haefeli WE, Mikus G. 
Midazolam microdose to determine systemic and pre-systemic metabolic 
CYP3A activity in humans. Br J Clin Pharmacol 2014;79(2):278-285.


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R18-1409
Gomez L, Breitenbucher JG. PDE2 inhibition: potential for the treatment of
cognitive disorders. Bioorg Med Chem Lett. 2013. 23: 6522–6527.
R20-1842
Midazolam-ratiopharm 2 mg/ ml Injektionsloesung, Midazolam-ratiopharm
5 mg/5 ml Injektionsloesung, Midazolam-ratiopharm 15 mg/3 ml
Injektionsloesung (ratiopharm), verschreibungspflichtig 
(Fachinformation, Stand der Information: August 2018).
R20-2551
Policy on transparency and publication of clinical study data: registration of 
clinical studies, disclosure of results in publications and results databases 
and access to study data and documents. http://trials.boehringer-
ingelheim.com/content/dam/internet/opu/clinicaltrial/com_EN/documents/P
olicy2.pdf; Boehringer Ingelheim; 2014.
R96-2656
Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical 
method for grading the cognitive state of patients for the clinician. J 
Psychiatr Res 1975;12(3):189-198.
9.2
UNPUBLISHED REFERENCES
c26859058
 Investigator's Brochure BI 474121 Alzheimer's
Disease and Schizophrenia. Current version.
c32354239
Benefit-Risk Assessment in context of COVID-19 pandemic 
for patients participating in clinical trials investigating BI 474121. 
20 May 2020.
c33667635
Safety data listings, 8-05-output-snapanalv1-safety-2020-09-18. BI 474121. 
1411-0001. 18 September 2020.
c33854260
ECG data listings, 2020-09-16-ecg-reports-dg-1-7-lst. BI 474121. 
1411-0001. 16 September 2020.
c35964176
Safety data listings, 8-05-output-sanalv1-safety-2021-05-31. BI 474121. 
1411-0002. 31 May 2021.
c36095753
ECG data listings, 2021-06-15-ecg-reports-dg-1-6-lst. BI 474121.
1411-0002. 15 June 2021.
n00265648
 18B128. BI 474121: 4-week
oral (gavage) toxicity study in rats.
n00268539
 Prediction of
BI 474121 Pharmacokinetics and Therapeutic Dose in Human. 
02 August 2019.
n00269861
 In vitro inhibition of human, rat and monkey
recombinant phosphodiesterase (PDE) 2A and human recombinant PDE1a,
1b and 1c by BI 474121. 05 June 2019.


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n00271367
 GM20LK. BI 474121. Toxicity Study by Oral Gavage
Administration to Cynomolgus Monkeys for 4 Weeks Followed by a 
4 Week Recovery Period.
n00281202
BI 474121: 13 Week Oral (Gavage) Administration Toxicity 
Study in the Monkey Followed by a 4 Week Recovery Period. 8419673. 
20 April 2021.


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10.
APPENDICES
10.1
COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)
10.1.1
Columbia-Suicide Severity Rating Scale (C-SSRS) Baseline/Screening


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10.1.2
Columbia-Suicide Severity Rating Scale (C-SSRS) Since Last Visit


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10.2
DILUTION INSTRUCTIONS FOR MIDAZOLAM (ONLY IN PART A IN 
DG 2.5 MG, 10 MG, 20 MG AND 30 MG)
10.2.1
Required equipment and dosing aids – overview
Dosing and diluting syringes:
1.
2-part disposable
NORM-JECT® Syringes 3 mL
2.
2-part disposable
 NORM-JECT® Syringes 24 mL
3. Needle tip
Only CE certified syringes WITHOUT rubber stoppers are to be used!
10.2.2
Dilution procedure
Solution for use with up to 13 subjects
Step 1: Open the commercial isotonic saline solution (0.9% NaCl).
Step 2: Attach a needle tip to the 3 mL syringe and withdraw a bit more than 1 mL of the 
midazolam solution [concentration: 1 mg/mL] from the originator ampoule using a 
3 mL syringe.


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Step 3: Remove any air bubbles in syringe (turn upside down and gently push out air by 
depressing the plunger); ensure that exactly 1 mL midazolam solution remains in the 
3 ml syringe.
Step 4: Remove and dispose of needle tip; transfer the full 1 mL of midazolam solution into 
an appropriate glass container (with cap) by completely depressing the plunger on 
the 3 mL syringe.
Step 5: Attach a needle tip to the 24 mL syringe and withdraw a bit more than 19 mL isotonic 
saline solution into the 24 mL syringe; remove air bubbles (see Step 3) and ensure 
exactly 19 mL isotonic saline solution remains in the 24 ml syringe.
Step 6: Remove and dispose of needle tip; transfer the full 19 mL of isotonic saline solution 
into the same glass container with the midazolam solution by completely depressing 
the plunger on the 24 mL syringe.
Step 7: Following addition of the midazolam and saline solutions into the glass container, 
ensure the glass container is closed using the corresponding cap. The content of the 
glass container should be mixed thoroughly by swirling gently for approximately 
1 min.
Step 8: Extract a little more than 1.5 mL of the dilution solution using a new 3 ml syringe; 
remove bubbles (see Step 3) and ensure that exactly 1.5 mL of the diluted midazolam 
solution (final concentration: 50 µg/mL) remains in the 3 mL syringe; the solution is 
now ready for oral administration. 
The final midazolam microdose Oral Solution concentration is 50 µg/mL, for administration 
of 1.5 mL (75 µg), which can be administered per os directly from the syringe.
10.2.3
In-use stability
The chemical in-use stability of the dilution solution is 24 h after its preparation, incl. storage 
at room temperature (15-25°C) in
2-part disposable
 NORM-JECT®
syringes until administration.
10.2.4
Mode of application
Microdoses of Midazolam will be administered orally as specified in the Clinical Trial 
Protocol (refer to Flow Chart for dosing schedule). 1.5 ml of diluted midazolam solution 
(concentration 50 µg/mL) will be administered from a syringe, as described above.
Please note that it is the responsibility of the TCL to assure that appropriate supplies are used 
for administration of a dose and dosing is limited to the allowed dosing range for a specific 
dose formulation as stated in this Dilution Instruction.


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10.3
SARS-COV-2 RELATED MEASURES
Introduction
Due to the SARS-CoV-2 pandemic outbreak early 2020 additional measures were 
implemented to protect study participants and personal involved in clinical trials. This 
document summarizes these measures.
Screening
The following measures will be performed:
(1)
Study participants will be informed about, and asked to agree to SARS-CoV-2 specific 
requirements with their diagnostic, therapeutic, and legal implications
(2)
A PCR for SARS-CoV-2, as offered by the trial site, will be performed at screening and 
prior to first dosing between Day -4 and Day -1
(3)
Evaluation of subjects before admission to the unit:
Temperature assessment
Questionnaire and medical assessment
SARS-CoV-2 virus test (mandatory)
Trial Conduct
Site-specific Measures
The following site specific measures will be adhered to during the conduct of the trial:
(1)
Requirement that everyone (staff/ subjects/ visitors) wear masks
(2)
Daily evaluation for unit staff (at beginning of shift):
Temperature assessment
Self-assessment and disclosure of any symptoms
(3)
Ongoing evaluation of subjects during their stay in the unit
(4)
Separation of subject in the unit:
Maximum 2-4 subjects per room depending on room size
Until further note: visitors for subjects are not allowed
(5)
Mandatory: SARS-CoV-2 test in case of suspicion of infection
(6)
Protocol in event of SARS-CoV-2 confirmation (including isolation, sponsor/ authority 
notification, contact tracing, quarantined transport home, drop-out/ replacement)
(7)
Additional measures such as use of telemedicine, remote monitoring (potentially), 
replacement of central labs with local labs in discussion with sponsor
(8)
General measures in place include: entry checks for monitors, CRO visitors; 
minimization of Face-to-Face meetings; hygiene and social distancing measures


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Documentation of Adverse Events
SARS-CoV-2 related adverse events will be documented as follows:
(1)
Continue regular AE and SAE documentation, there is no change in the requirements of 
what to document and how.
(2)
Continue also with expedited reporting of SAEs and AESI to PV in addition to 
documentation on the eCRF. The ways of transmitting the information stays as given on 
the contact sheet.
(3)
If a patient experiences a SARS-CoV-2 Virus infection, this will be entered as (S)AE 
(even if the subject did not experience symptoms).
(4)
AE Start Date: The day when the subject experienced SARS-CoV-2 symptoms or the 
day of the positive test should be entered as AE start date, whichever occurred first.
(5)
AE End Date: The date of the last available negative test should be entered as AE end 
date. If the negative test date is not available, the date by when the subject has been 
received notice to be virus free should be used.
For any AE related to SARS-CoV-2, please note that our standard processes should be 
followed, meaning:
(1)
If a SARS-CoV-2 virus Infection is associated with clinical symptoms (AE´s):
Report as a non-serious AE, if the serious criteria are not met
Report as a SAE, if serious criteria are met – e.g., hospitalization, serious for medical 
reasons, or AE term describing the clinical symptoms is on the “always serious 
list”
The mere fact that someone is infected with the SARS-CoV-2 should not lead to a 
judgement of seriousness
Thus, no adaptation to standard procedures, CTPs or CRFs is required
(2)
If a SARS-CoV-2 virus or any other infection is not associated with clinical symptoms, 
meaning there is just a positive SARS-CoV-2 test:
The recommendation would be to consistently capture as a (non-serious) AE, as a 
positive Corona test means a patient has an infection
This also would not require any adaptation to standard processes, CTP or CRF
Here are some examples from other events to illustrate the standard process:
(1)
Event of Pneumonia
Pneumonia is not on the always serious list, from that perspective it is not serious AE
However, if the patient is hospitalized with acute hypoxaemic respiratory failure due 
to SARS-CoV-2virus, then it certainly qualifies for a serious AE
(2)
Event of Viral Infection


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Viral infection treated as an out-patient or day-care is an AE (irrespective of SARS-
CoV-2 positive, negative or unknown)
Viral infection treated with hospitalization is a SAE (irrespective of SARS-CoV-2
positive, negative or unknown)


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10.4
DEMENTIA SCREENING TEST (MINI-MENTAL STATE 
EXAMINATION, MMSE)


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11.
DESCRIPTION OF GLOBAL AMENDMENT(S)
11.1
GLOBAL AMENDMENT 1 
Date of amendment
13 August 2020
EudraCT number
EU number
2020-001003-17
BI Trial number
1411-0002
BI Investigational Medicinal 
Product(s)
BI 474121
Title of protocol
Safety, tolerability and pharmacokinetics of multiple 
rising oral doses of BI 474121 in young and elderly 
healthy male and female subjects (double-blind, 
randomised, placebo-controlled, parallel group 
design) and evaluation of midazolam interaction in 
young healthy male and female subjects (nested, 
open, fixed-sequence, intra-individual comparison)
To be implemented only after approval of the IRB / IEC / Competent 
Authorities
To be implemented immediately in order to eliminate hazard – IRB / IEC / 
Competent Authority to be notified of change with request for approval
Can be implemented without IRB / IEC / Competent Authority approval as 
changes involve logistical or administrative aspects only
Section to be changed
- Clinical trial protocol synopsis, Flow Chart
- 1.4
Benefit - risk assessment
- 3.1
Overall trial design and plan
- 3.3.3 
Exclusion criteria
- 3.3.4.3
Discontinuation of the trial by the
sponsor
- 4.1.4
Drug assignment and administration 
of doses for each subject
- 5.
Assessment
-
- 7.6
Randomisation
- 8
Informed consent, trial records, data 
protection, publication policy, and 
administrative structure
- 9.
References
- 10.
Appendices


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Description of change
Changes were required throughout various sections
of the protocol, and will be described only once 
instead of specifying the same change for each 
section.
- Clinical trial protocol synopsis, Flow Chart
In the dose group of elderly subjects the 
inclusion of at least 3 subjects aged 75 – 80 has 
been added.
At screening and EOT a Mini-Mental State 
Examination (MMSE) test to exclude relevant 
cognitive deficits has been added. 
In the flow chart correction of inconsistencies.
- Benefit - risk assessment
A discussion about the specific B/R in elderlies 
has been added.
The first cohort of each elderly dose group (DG 
5 and 6) will only include subjects aged 65 to 
74. 
- Overall trial design and plan
A schematic diagram of study procedures and 
the study duration of 6 to 7 weeks for an 
individual subject has been added.
- Exclusion criteria
Contraceptive measures (established medical 
success after vasectomy) has been added.
- Discontinuation of the trial by the sponsor
Safety information reverses a positive B/R 
assessment mandatory criterion for trial 
termination
- Assessment
Inclusion of MMSE test.
 
 
- Informed consent, trial records, data 
protection, publication policy, and 
administrative structure
A printed version of the Transparency and 
publication policy  as shared on the BI website 
has been added in the reference section. 
The EoT definition was changed to one 
applicable criterion (date of last subject/last 
visit).
- References
References have been added.
- Appendices


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A copy of the dementia screening test (MMSE) 
has been added (section 10.4).
Rationale for change
Changes are based on feedback of regulatory bodies. 
In context with this amendment minor
inconsistencies were corrected.


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11.2
GLOBAL AMENDMENT 2
Date of amendment
16 June 2021
EudraCT number
EU number
2020-001003-17
BI Trial number
1411-0002
BI Investigational Medicinal 
Product(s)
BI 474121
Title of protocol
Safety, tolerability and pharmacokinetics of multiple 
rising oral doses of BI 474121 in young and elderly 
healthy male and female subjects (double-blind, 
randomised, placebo-controlled, parallel group 
design) and evaluation of midazolam interaction in 
young healthy male and female subjects (nested, 
open, fixed-sequence, intra-individual comparison)
To be implemented only after approval of the IRB / IEC / Competent 
Authorities
To be implemented immediately in order to eliminate hazard – IRB / IEC / 
Competent Authority to be notified of change with request for approval
Can be implemented without IRB / IEC / Competent Authority approval as 
changes involve logistical or administrative aspects only
Section to be changed
Changes were applied to the following sections:
Clinical trial protocol synopsis and Flow Chart
Abbreviations
1.2.1.3
Repeat dose toxicity study
1.2.1.4
Non-clinical pharmacokinetics
1.2.1.6
Clinical experience in humans
1.2.3
Drug interactions
1.3
Rationale for performing the trial
1.3.4
Maximum exposure
1.3.5
Escalation scheme
1.4.3.1
Drug related risks and safety measures
1.4.3.3
Safety measures
2.1.1
Main objectives
3.1
Overall design and plan
3.3
Selection of trial population
3.3.3
Exclusion criteria


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4.1.1
Identity of the Investigational Medicinal 
Products
4.1.3
Method of assigning subjects to 
treatment groups
4.1.4
Drug assignment and administration of 
doses for each subject
4.1.5.1
Blinding
4.1.5.2
Unblinding
4.1.6
Packaging, labelling, and re-supply
4.2.1
Other treatments and emergency 
procedures
5.2.4
Table 5.2.4: 1 routine laboratory tests
5.2.8
Adverse Events of special interest
5.3.2.1
Blood sampling for pharmacokinetic 
analysis
5.3.2
Methods of sample collection
6.2.1
Screening period
6.2.2
Treatment period
6.2.3
Follow up period
7.1
Statistical design model
7.3
Planned analyses
7.4
Interim analyses
7.5.2
Pharmacokinetics
7.7
Determination of sample size
8.7
Administrative structure of the trial
9.2
Unpublished references
10.2
Dilution instructions for midazolam


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Description of change
Changes were required throughout various sections
of the protocol, and will be described only once 
instead of specifying the same change for each 
section. The following changes have been applied to 
below listed sections:
-
Added additional dose group of 30 mg (DG 7)
- Clinical trial protocol synopsis and Flow 
chart
- 1.3
Rationale for performing the trial
- 1.3.4
Maximum exposure
- 1.3.5
Escalation scheme
- 1.4.3.3 Safety measures
- 2.1.1
Main objectives
- 3.1
Overall design and plan
- 4.1.1
Identity of the Investigational 
Medicinal Products
- 4.1.3
Method of assigning subjects to 
treatment groups
- 4.1.4
Drug assignment and administration 
of doses for each subject
- 4.1.5.1 Blinding
- 4.1.5.2 Unblinding
- 4.1.6
Packaging, labelling, and re-supply
- 4.2.1
Other treatments and emergency 
procedures
- 5.3.2.1 Blood sampling for pharmacokinetic 
analysis
- 6.2.2
Treatment period
- 7.1
Statistical design model
- 7.4
Interim analyses
- 8.7
Administrative structure of the trial
- 10.2
Dilution instructions for midazolam
-
Adapted number of cohorts with regard to 
additional dose group
- 4.1.3
Method of assigning subjects to 
treatment groups
-
Adapted planned number of subjects with regard 
to additional dose group of 30 mg
- 3.1
Overall design and plan
- 3.3
Selection of trial population
- 7.7
Determination of sample size
-
 
 


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-
Added section 1.2.3    Drug-Drug-Interactions
-
Added section 1.2.1.3 13-week toxicity study
-
 
-
-
Added body temperature and/or MMSE for 
consistency with Flow Chart in sections:
-
- 6.2.1
Screening period
- 6.2.3
Follow up period
-
Updated interim results of completed 1411-0001 
SRD part in sections: 
- 1.2.1.6 Clinical experience in humans
- 1.4.3.1 Drug related risks and safety 
measures
-
Added interim results of 1411-0002 trial DG 1-6 
to section:
- 1.2.1.6 Clinical experience in humans
 
 
 
-
Removed reference to SOP 001-MCS-36-472
due to SOP retirement
- 7.3
Planned analyses
- 7.5.2
Pharmacokinetics
- 9.2
Unpublished references
-
Minor corrections: 
- Corrected abbreviation C-SSRS from 
Columbia Suicidality Severity Scale to 
Columbia Suicidality Severity Rating Scale 
in Abbreviations
- Corrected planned timepoint for relative 
timepoint -1:00 on Day1 from 7:30 to 7:00 in 
Flow Chart
- Completed missing part of sentence 
'described in the DILI checklist should be 
followed.' as per standard template text in 
section 5.2.8.1.4 Adverse Events of special 
interest
- Corrected Urinalysis Stix parameter Urine 
RBC/Erythrocytes to Urine Haemoglobin in 
section 5.2.4 Table 5.2.4: 1 Routine 


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laboratory tests
- Corrected IB reference document number 
from c26859057 to c26859058 throughout 
the entire document
Rationale for change
Changes severe to implement additional dose group 
DG 7 including all procedures and required CTP 
adaptations as applicable for this dose group. In 
addition, minor inconsistencies were corrected in 
context with this amendment.


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11.3
GLOBAL AMENDMENT 3
Date of amendment
13 July 2021
EudraCT number
EU number
2020-001003-17
BI Trial number
1411-0002
BI Investigational Medicinal 
Product(s)
BI 474121
Title of protocol
Safety, tolerability and pharmacokinetics of multiple 
rising oral doses of BI 474121 in young and elderly 
healthy male and female subjects (double-blind, 
randomised, placebo-controlled, parallel group 
design) and evaluation of midazolam interaction in 
young healthy male and female subjects (nested, 
open, fixed-sequence, intra-individual comparison)
To be implemented only after approval of the IRB / IEC / Competent 
Authorities
To be implemented immediately in order to eliminate hazard – IRB / IEC / 
Competent Authority to be notified of change with request for approval
Can be implemented without IRB / IEC / Competent Authority approval as 
changes involve logistical or administrative aspects only
Section to be changed
Table 1.2.1.6: 5, page 27, row: 2.5 mg, last two lines:
value for RA_Cmax and RA_AUC
Section 3.1, page 41: reference to stopping criteria
Description of change
Table 1.2.1.6: 5 removal of formatting error. Text 
format was changed from white to automatic to make 
text legible
Section 3.1: both references to section 3.3.4.2 were 
changed to section 3.3.4.3
Rationale for change
correction of minor typos and format error


 
 
 
 
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Title: 
 
 
 
 
                                                                                                                   
 
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c31468495
4.0
clinical-trial-protocol-version-04
Safety, tolerability and pharmacokinetics of multiple rising oral doses of BI 474121
in young and elderly healthy  male and female subjects (double-blind, randomised,
placebo-controlled, parallel group design) and evaluation of midazolam interaction in
young healthy male and female subjects (nested, open, fixed-sequence,
intra-individual comparison)
Author-Clinical Trial Leader
14 Jul 2021 08:27 CEST
Verification-Paper Signature
Completion
14 Jul 2021 09:21 CEST
Approval-Team Member Medicine
14 Jul 2021 10:04 CEST
Author-Trial Statistician
14 Jul 2021 17:08 CEST


Boehringer Ingelheim 
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Document Number: 
 Technical Version Number:
 
 
 
(Continued) Signatures (obtained electronically) 
 
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c31468495
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SAP_001.pdf: 
TITLE PAGE
TRIAL STATISTICAL ANALYSIS PLAN
c35155956-01
BI Trial No.:
1411-0002
Title:
Safety, tolerability and pharmacokinetics of multiple rising oral 
doses of BI 474121 in young and elderly healthy male and female 
subjects (double-blind, randomised, placebo-controlled, parallel 
group design) and evaluation of midazolam interaction in young 
healthy male and female subjects (nested, open, fixed-sequence, 
intra-individual comparison)
(including Protocol Amendment No.1-3 [c31468495-04]).
Investigational
Product:
BI 474121
Responsible trial 
statistician:
Phone:
Fax:
Date of statistical 
analysis plan:
03 NOVEMBER 2021 SIGNED 
Version:
1
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1.
TABLE OF CONTENTS
TITLE PAGE............................................................................................................................1
1.
TABLE OF CONTENTS......................................................................................2
LIST OF TABLES ...................................................................................................................4
2.
LIST OF ABBREVIATIONS...............................................................................5
3.
INTRODUCTION.................................................................................................7
4.
CHANGES IN THE PLANNED ANALYSIS OF THE STUDY ......................8
5.
ENDPOINTS..........................................................................................................9
5.1
PRIMARY ENDPOINT........................................................................................9
5.2
SECONDARY ENDPOINTS ...............................................................................9
5.2.1
Key secondary endpoint........................................................................................9
5.2.2
Secondary endpoints .............................................................................................9
6.
GENERAL ANALYSIS DEFINITIONS...........................................................13
6.1
TREATMENTS...................................................................................................13
6.2
IMPORTANT PROTOCOL DEVIATIONS....................................................16
6.3
SUBJECT SETS ANALYSED ...........................................................................16
6.5
POOLING OF CENTRES..................................................................................18
6.6
HANDLING OF MISSING DATA AND OUTLIERS ....................................18
6.7
BASELINE, TIME WINDOWS AND CALCULATED VISITS....................19
7.
PLANNED ANALYSIS ......................................................................................21
7.1
DEMOGRAPHIC AND OTHER BASELINE CHARACTERISTICS .........22
7.2
CONCOMITANT DISEASES AND MEDICATION......................................23
7.3
TREATMENT COMPLIANCE ........................................................................23
7.4
PRIMARY ENDPOINT......................................................................................23
7.4.1
Primary analysis of the primary endpoint........................................................23
7.5
SECONDARY ENDPOINTS .............................................................................24
7.5.1
Key secondary endpoint......................................................................................24
7.5.2
Secondary endpoints ...........................................................................................24
7.7
EXTENT OF EXPOSURE .................................................................................28
7.8
SAFETY ANALYSIS..........................................................................................28
7.8.1
Adverse Events ....................................................................................................28
7.8.2
Laboratory data...................................................................................................30
7.8.3
Vital signs.............................................................................................................30
7.8.4
ECG ......................................................................................................................30
7.8.5
Others ...................................................................................................................33
8.
TIMEPOINT OF RELEASE OF TREATMENT INFORMATION .............34
9. 
REFERENCES ....................................................................................................35


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11.
HISTORY TABLE..............................................................................................42


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LIST OF TABLES
Table 6.1: 1
Treatments and labels used in the analysis.......................................................13
Table 6.3: 1
Subject sets analysed ........................................................................................18
Table 6.7: 1
Time schedule of 12-lead ECG recordings.......................................................19
Table 11: 1
History table .....................................................................................................42


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2.
LIST OF ABBREVIATIONS
See Medicine Glossary:
http://glossary
Term
Definition / description
ALT
Alanine Aminotransferase
ANOVA
Analysis of Variance
AST
Aspartate Aminotransferase
AUC0-24
Area under the concentration-time curve of the analyte in plasma from 0 to 
24h
 
AUC0-tz
Area under the concentration-time curve of the analyte in plasma over the time 
interval from 0 to the last quantifiable data point
AUCτ,ss
Area under the concentration-time curve of the analyte in plasma at steady 
state over a uniform dosing interval τ
BMI
Body mass index
CARE
Clinical Analysis and Reporting Environment
CI
Confidence Interval
Cmax
Maximum measured concentration of the analyte in plasma
Cmax,ss
Maximum measured concentration of the analyte in plasma at steady state over 
a uniform dosing interval τ
CV
Arithmetic Coefficient of Variation
DBLM
Database Lock Meeting
DILI
Drug induced liver injury
ECGPCS
ECG Pharmacokinetic Concentration Set
gCV
Geometric Coefficient of Variation
gMean
Geometric Mean
LLT
Lower Level Term
Max
Maximum


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Term
Definition / description
MedDRA
Medical Dictionary For Regulatory Activities
Min
Minimum
N
Number non-missing observations
P10
10th percentile
P90
90th percentile
PKS
PK parameter analysis set
PO
Per oral
PT
Preferred Term
Q1
1st quartile
Q3
3rd quartile
QD
Quaque die, once daily
R
Reference
RAGe
Report Appendix Generator system
REP
Residual Effect Period
SD
Standard Deviation
SOC
System Organ Class
 
T
Test
TS
Treated Set
TSAP
Trial Statistical Analysis Plan
ULN
Upper Limit of Normal
WHO-DD
World Health Organization Drug Dictionary


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3.
INTRODUCTION
As per ICH E9 (1) the purpose of this document is to provide a more technical and detailed 
elaboration of the principal features of the analysis described in the protocol, and to include 
detailed procedures for executing the statistical analysis of the primary and secondary 
variables and other data.
This Trial statistical analysis plan (TSAP) assumes familiarity with the Clinical Trial Protocol 
(CTP), including Protocol Amendments. In particular, the TSAP is based on the planned 
analysis specification as written in CTP Section 7 “Statistical Methods and Determination of 
Sample Size”. Therefore, TSAP readers may consult the CTP for more background 
information on the study, e.g., on study objectives, study design and population, treatments, 
definition of measurements and variables, planning of sample size, randomisation.
Study data (including data entered in the RAVE EDC system and external data provided by 
suppliers) will be stored in a Clinical Data Repository (CDR).
Pharmacokinetic (PK) parameters 
I will be calculated using 
Phoenix WinNonlinTM software (version 6.3 or higher,
The statistical analyses will be performed within the validated working environment CARE, 
including SASTM (current Version 9.4, by
, and a number 
of SASTM-based tools (e.g., macros for the analyses of AE data or laboratory data; Report 
Appendix Generator system (RAGe) for compilation/formatting of the CTR appendices).


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4.
CHANGES IN THE PLANNED ANALYSIS OF THE STUDY
All analyses as planned in the CTP will be performed and are described in more detail in this
TSAP. The following changes compared to the protocol will be made:
In CTP section 7.3 the following was defined: Important protocol deviation (iPD) categories 
will be specified in the Integrated Quality and Risk Management Plan, iPDs will be identified 
no later than in the Report Planning Meeting, and the iPD categories will be updated as 
needed. Due to SOP changes, the iPD categories are no longer available in IQRM plan but 
included in an Excel spreadsheet (3). The iPD categories originally defined in IQRM plan 
were transferred to the iPD specification file. Minor changes regarding the iPD categories 
were performed only. 
 
 
 
 
 


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5.
ENDPOINTS
5.1
PRIMARY ENDPOINT
Section 2.1.2 of the CTP: 
The primary endpoint for assessment of safety and tolerability of BI 474121 is the percentage 
of subjects with drug-related adverse events.
5.2
SECONDARY ENDPOINTS
5.2.1
Key secondary endpoint
This section is not applicable, as no key secondary endpoints have been defined in the CTP.
5.2.2
Secondary endpoints
Section 2.1.3 of the CTP: 
The following pharmacokinetic parameters will be determined if feasible:
BI 474121
After the first dose:

AUC0-24 (area under the concentration-time curve of the analyte in plasma 
from 0 to 24h)

Cmax (maximum measured concentration of the analyte in plasma)
After the last dose:

AUCτ,ss (area under the concentration-time curve of the analyte in plasma at steady 
state over a uniform dosing interval τ)

Cmax,ss (maximum measured concentration of the analyte in plasma at steady state over 
a uniform dosing interval τ)
Midazolam
After each of the three doses:

AUC0-tz (area under the concentration-time curve of the analyte in plasma over the 
time interval from 0 to the last quantifiable data point)

Cmax


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6.
GENERAL ANALYSIS DEFINITIONS
6.1
TREATMENTS
For basic study information on investigational products, assignment of treatment, please see 
CTP, Sections 3 and 4.
The multiple-rising dose (MRD) trial is designed as double-blind, randomised, and placebo-
controlled within parallel dose groups.
It is planned to include 50 young healthy male and female subjects (part A) and 20 elderly 
healthy male and female subjects (part B). The young subjects will be assigned to 5 and the 
elderly subjects to 2 sequential dose groups consisting of 10 subjects per group (8 subjects 
will receive BI 474121 and 2 will receive placebo).
For details see Table 6.1:1 below.
Table 6.1: 1
Treatments and labels used in the analysis
Treatment
Label in dataset
Short label
P*/**
Placebo
Placebo - A
Placebo - B
Q*
Placebo tablet+Midazolam,solution, 75ug,po,qd
Placebo - A
A
BI 474121, tablet, 2.5 mg, po, qd + Midazolam, 
diluted to 50ug/mL solution, 1.5mL(75ug), po, qd
BI 2.5mg - A
B**
BI 474121, tablet, 2*2.5 mg, po, qd
BI 5mg - A
BI 5mg - B
C
BI 474121, tablet, 10 mg, po, qd + Midazolam, diluted 
to 50ug/mL solution, 1.5mL(75ug), po, qd
BI 10mg - A
D
BI 474121, tablet, 2*10 mg, po, qd + Midazolam, 
diluted to 50ug/mL solution, 1.5mL(75ug), po, qd
BI 20mg - A
I
BI 474121, tablet, 3*10 mg, po, qd + Midazolam, 
diluted to 50ug/mL solution, 1.5mL(75ug), po, qd
BI 30mg - A
H
BI 474121, tablet, 10 mg, po, qd
BI 10mg - B
*:
Each placebo group in the safety evaluation will consist of all placebo treated subjects, regardless of the dose group in 
which they were treated. 
**: 
Young and elderly subjects are randomized to this dose group. For analysis the dose group will be separated into a 
group including young subjects (part A) and a group including elderly subjects (part B)


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Section 1.2.1.7 of CTP:
The Residual Effect Period (REP) of BI 474121, when measurable drug levels and/or 
pharmacodynamic effects are still likely to be present, is not known for this first human 
multiple dose trial. Conservatively, a minimum observation period of at least 5-fold estimated 
t1/2 has been selected, and thus a REP of 7 days is assumed, i.e. the individual subject’s end of 
trial is on Day 21 to Day 23 following dosing with the investigational drug at the earliest.
The following study phases will be defined for the analysis of adverse events (AEs):

Screening (ranging from 0:00 h on day of informed consent until first administration 
of study medication (BI/Placebo/Midazolam))

Mida (Treatments Q, A, C, D, I only (Part A): Midazolam treatment ranging from the 
first time of administration of midazolam until the time of first administration of 
BI/Placebo treatment)

On treatment (BI/Placebo treatment ranging from the first time of administration of 
BI or Placebo until 168 hours (7 days) after the last time of administration of 
BI/Placebo administration

Follow-up (F/U) (ranging from 168 hours (7 days) after last administration of BI or 
Placebo until 0:00 h on day after trial termination date)
Section 7.3.4 of the CTP: Note that AEs occurring after the last per protocol contact but 
entered before database lock will be reported to Pharmacovigilance only and will not be 
captured in the trial database.


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Displays of AEs will be stratified by dose group as specified in Table 6.1:1. The following 
AE displays will be provided in the report:
Section 15.3 of the CTR displays:
In these displays, the on treatment phase (and Midazolam phase, if applicable) will be 
analysed (labelled with the name of the study treatment (short label)). Screening and Follow 
up phases will not be included in this analysis.
The following totals will be provided in addition:

a total over all BI treated on treatment phases (“BI Total”) 

a total over all on treatment phases included in this analysis (“Total”)
In Appendix 16.1.13.1.8 (for ClinicalTrials.gov and EudraCT only) of the CTR the on 
treatment phase (and Midazolam phase, if applicable) will be analysed (labelled with the 
name of the study treatment (short label)). Screening and Follow up phases will not be 
included in this analysis.
The following totals will be provided in addition:

a total over all Placebo treated on treatment phases in part A (“Placebo – A”)

a total over all BI treated on treatment phases in part A (“BI Total – A”)

a total over all on treatment phases in part A included in this analysis (“Total – A”)

a total over all Placebo treated on treatment phases in part B (“Placebo – B”)

a total over all BI treated on treatment phases in part B (“BI Total – B”)

a total over all on treatment phases in part B included in this analysis (“Total – B”)

a total over all Placebo treated on treatment phases (“Placebo Total”)

a total over all BI treated on treatment phases (“BI Total”)

a total over all on treatment phases included in this analysis (“Total”)
In Section 15.4 and Appendix 16.2 (Listings) of the CTR displays, screening and follow-up 
periods will be included and no totals will be provided.
For detailed information on the handling of the treatments refer to Technical TSAP ADS 
(analysis data set) plan and Analysis Data Reviewers guide. 


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6.2
IMPORTANT PROTOCOL DEVIATIONS
Data discrepancies and deviations from the CTP will be identified for all treated subjects. 
Consistency check listings (for identification of deviations of time windows) and a list of 
protocol deviations (e.g. deviations in drug administration, in blood sampling times, etc.) will 
be provided to be discussed at the Report Planning Meeting (RPM). At this meeting, all 
manual deviations identified at the sites by the CRAs and deviations too complex to program 
will be reviewed by the trial team to decide which are considered important. For definition of 
important protocol deviations (iPD), and for the process of identification of these, refer to the 
Boehringer Ingelheim (BI) SOP "Identify and Manage Important Protocol Deviations (iPD)" 
(2).
Categories which are considered to be iPDs in this trial were defined in the integrated quality 
and risk management plan (IQRMP) prior to trial initiation. The iPD list was transferred into 
the iPD specification file (due to changes in the SOP) (3). Within this transfer some minor 
adaptations were done to comply with new naming conventions and categorisations. IPDs will
be identified no later than in the Report Planning Meeting and the iPD categories in the iPD 
specification file will be updated as needed. If any iPDs are identified, they are to be 
summarised into categories and will be captured in the RPM/DBLM minutes (the decision 
log) and in the iPD specification file. The decision on exclusion of subjects from analysis sets 
will be made after discussion of exceptional cases and implications for analyses.
The iPD specification file (e.g. the DV domain specifications) will be stored within the TMF 
in EDMS.
The iPDs will be summarised and listed.
6.3
SUBJECT SETS ANALYSED
Section 7.3 of the CTP:

Treated set (TS): The treated set includes all subjects who were randomized and 
treated with at least one dose of study drug (BI 474121, Placebo, Midazolam). The 
treatment assignment will be determined based on the first treatment the subjects 
received. The treated set will be used for safety analyses, 
 
Pharmacokinetic parameter analysis set (PKS): This set includes all subjects in the 
treated set (TS) who provide at least one PK endpoint that was not excluded due to a 
protocol violation relevant to the evaluation of PK or due to PK non-evaluability (as 
specified in the following subsection ‘Pharmacokinetics’). Thus, a subject will be 
included in the PKS, even if he/she contributes only one PK parameter value for one 
period to the statistical assessment. Descriptive and model based analyses of PK 
parameters will be based on the PKS.
All ECG analyses are performed on the TS,
 


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
 
 
 
 
 
 
 
 
 
Plasma and urine concentration data and parameters of a subject will be included in the 
statistical pharmacokinetic (PK) analyses if they are not flagged for exclusion due to a 
protocol violation relevant to the evaluation of PK (to be decided no later than in the Report 
Planning Meeting) or due to PK non-evaluability (as revealed during data analysis, based on 
the criteria specified below). Exclusion of a subject’s data will be documented in the CTR.
Relevant protocol deviations may be

Incorrect trial medication taken, i.e. the subject received at least one dose of trial 
medication the subject was not assigned to

Incorrect dose of trial medication taken

Use of restricted medications
Plasma and urine concentrations and/or parameters of a subject will be considered as non-
evaluable, if for example

The subject experienced emesis that occurred at or before two times median tmax of the 
respective treatment (Median tmax is to be determined excluding the subjects 
experiencing emesis),

Missing samples/concentration data at important phases of PK disposition curve.
Plasma/urine concentration data and parameters of a subject which is flagged for exclusion 
will be reported with its individual values but will not be included in the statistical analyses.
Only concentration values within the validated concentration range and actual sampling 
times will be used for the calculation of pharmacokinetic parameters. Concentrations used in 
the pharmacokinetic calculations will be in the same format as in the bioanalytical report
(that is to the same number of decimal places provided in the bioanalytical report).


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Table 6.3: 1
Subject sets analysed
Subject set
Class of endpoint
Treated set
PKS
ECGPCS
Primary endpoint and further safety 
assessments (incl. ECG)
X
Analyses of PK endpoints 
X
Demographic/baseline parameters
X
Important protocol deviations
X
Disposition
X
Exposure
X
6.5
POOLING OF CENTRES
This section is not applicable, because the study was performed in only one centre.
6.6
HANDLING OF MISSING DATA AND OUTLIERS
Handling of missing data and outliers will be performed as described in the CTP, Section 7.5.
 
 
The only exceptions where imputation might be necessary for safety evaluation are AE dates. 
Missing or incomplete AE dates are imputed according to BI standards (see BI-KMED-BDS-
HTG-0035) (4).
Missing data and outliers of PK data are handled according to BI standards (see BI-KMED-
TMCP-MAN-0012 (5) and BI-KMED-TMCP-MAN-0014 (6).
If single cardiac cycles of an ECG (out of the generally four) are missing, the arithmetic mean 
for this single ECG will be computed with the reduced (1, 2 or 3) number of cardiac cycles.


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If replicate ECG recordings are missing, the arithmetic means per time point will be computed 
with the reduced number (1 or 2) of recordings.
For the classification of the on-treatment QTc/QT intervals into ‘no new onset’ / ‘new onset’ 
categories, the handling of missing value is described in Appendix Section 10.1.3.
 
 
 
6.7
BASELINE, TIME WINDOWS AND CALCULATED VISITS
The baseline value is defined as the last measurement before first administration of BI 474121
or Placebo, which is planned as visit 2, day 1, ptm -1:00h or day -1, ptm -25:30h for the 
analysis of orthostatic testing.
Adherence to time windows will be checked via the consistency check listings at the RPM.
Unscheduled measurements of laboratory data, orthostatic testing and vital signs data will be 
assumed to be repeat measurements of the most recent scheduled measurement (e.g. for 
follow-up or confirmation of a particular value). Therefore, unscheduled measurements will 
be assigned to the planned time point of the previous scheduled measurement. 
There will be a centralised evaluation of the 12-lead ECG recordings at the time points and 
for the ECG recordings specified in Table 6.7: 1 below:
Table 6.7: 1
Time schedule of 12-lead ECG recordings
Visit
Day
Planned time [hh:mm]
(relative to drug 
administration)
Study phase
Central evaluation
1
-21 to -3
Screening
NA
2
-1
-25:30
NA
(part A only)
1
-1:00
Baseline
first ECG of each of the 
3 triplicates at baseline
-0:45
-0:30
2
23:45
On-treatment
first single ECG of the 
triplicate
5
95:45
8
167:45
11
239:45


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Table 6.7: 1
Time schedule of 12-lead ECG recordings - continued
Visit
Day
Planned time [hh:mm]
(relative to drug 
administration)
Study phase
Central evaluation
2
13
287:45
On-treatment
first single ECG of the 
triplicate
14
311:45
313:00
314:00
316:00
320:00
324:00
15
336:00
16
360:00
3
21 to 23
End-of-trial 
examination
NA
At Screening and End-of-trial examination ECG recordings are performed as single ECGs and 
will not be transferred to central ECG lab. Three triplicate ECGs will be recorded as the 
baseline before the first drug administration, but only the first ECG of each of the 3 baseline 
triplicates will be transferred to the database. At all other time points, 1 triplicate ECG will be 
recorded, but only the first single ECG of the triplicate will be transferred to the database. The 
baseline value of an ECG variable is defined as the mean of all transferred ECG variable 
values prior to drug administration.
 
 
 
 
 
 
 
 
 
 
 


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7.
PLANNED ANALYSIS
Results are shown separately for part A and part B (except some outputs in Appendix 
16.1.13.1).
Safety analysis (refer to Section 7.8) will be performed by
and 
will be presented in Sections 15.1 to 15.4 of the CTR and in Appendix 16.2 and 16.1.13.1.
Statistical model-based analysis of PK endpoints will be performed by
and will be presented in Section 15.5 of the CTR and in Appendix 16.1.13.3.
Descriptive data analysis of PK endpoints and concentrations will be performed by the 
 at 
 and will be 
presented in Section 15.6 of the CTR and in Appendix 16.1.13.5.
 
 
The format of the listings and tables will follow the BI standards (see BI-KMED-BDS-HTG-
0045 (7)) with the exception of those generated for PK-calculations following BI standards 
for PK/PD analysis (8).
The individual values of all subjects will be listed, sorted by dose group/placebo, subject 
number and visit. 
The listings will be included in Appendix 16.2 of the CTR.
For end-of-text tables, the set of summary statistics for non-PK
parameters is: 
N 
number non-missing observations 
Mean
arithmetic mean
SD
standard deviation 
Min
minimum 
Median
median 
Max
maximum
For analyte concentrations and PK
parameters, the following descriptive statistics will 
additionally be calculated:
Nobs 
number of observations
CV 
arithmetic coefficient of variation
gMean
geometric mean
gCV
geometric coefficient of variation
P10 
10th percentile
Q1 
1st quartile
Q3 
3rd quartile
P90 
90th percentile


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The data format for descriptive statistics of concentrations will be identical to the data format 
of the respective concentrations. The descriptive statistics of PK 
 parameters will be 
calculated using the individual values with the number of decimal places as provided by the 
evaluation program. Then the individual values as well as the descriptive statistics will be 
reported with three significant digits in the CTR.
Tabulations of frequencies for categorical data will include all possible categories available in 
CRF and will display the number of observations in a category, as well as the percentage (%). 
Percentages will be rounded to one decimal place and will be based on all subjects in the 
respective subject set whether they have non-missing values or not. The category 'missing' 
will be displayed only if there are actually missing values.
Exclusion of PK 
 parameters
The ADS “ADPP” (PK parameters) 
 
contains column variables APEXC and APEXCO indicating inclusion/exclusion 
(APEXC) of a PK 
 parameter and an analysis flag comment (APEXCO). All analyses 
based on the PKS will include parameters if they are not flagged for exclusion, that is APEXC
is equal to “Included”.
Exclusion of PK 
 concentrations
The ADS “ADPC” (PK concentrations per time-point or per time-interval)
 contains column variables 
ACEXC and ACEXCO indicating inclusion/exclusion (ACEXC) of a concentration and an 
analysis flag comment (ACEXCO). Exclusion of a concentration depends on the analysis flag 
comment ACEXCO. For example, if ACEXCO is set to ‘ALL CALC’, the value will be 
excluded for all types of analyses based on concentrations. If ACEXCO is set to ‘DESC 
STATS’ the value will be excluded from descriptive evaluations per planned time point/time 
interval. If ACEXCO contains the addition ‘TIME VIOLATION’ or ‘TIME DEVIATION’ 
the value can be used for further analyses based on actual times. If ACEXCO is set to ‘HALF 
LIFE’, the value will be excluded from half-life calculation (and, as a consequence, any 
calculation that relies on λz) only; the value is included for all other analyses.
Further details are given in BI-KMED-TMCP-MAN-0014 “Noncompartmental 
Pharmacokinetic / Pharmacodynamic Analyses of Clinical Studies” (6) and BI-KMED-
TMCP-MAN-0010: “Description of Analytical Transfer Files and PK/PD Data Files” (9).
7.1
DEMOGRAPHIC AND OTHER BASELINE CHARACTERISTICS
Only descriptive statistics are planned for this section of the report, based on the TS.
The data will be summarised by treatment group and in total.


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7.2
CONCOMITANT DISEASES AND MEDICATION
Frequency tables are planned for this section of the report, based on the TS.
Concomitant diseases will usually be coded using the latest version of the coding system of 
the Medical Dictionary for Drug Regulatory Activities (MedDRA). Medications will usually 
be coded using the latest version of the World Health Organization Drug Dictionary (WHO-
DD). The coding version number will be specified during RPM. The coding version number 
will be displayed as a footnote in the respective output.
The diagnoses and medications will be listed. Subjects without any concomitant diagnoses or 
concomitant therapies should be marked with a “No” in the respective column.
The relevance of the concomitant therapies to the evaluation of PK will be decided no later 
than at the RPM/DBLM.
7.3
TREATMENT COMPLIANCE
Section 4.3 of the CTP: Compliance will be assured by administration of all trial medication 
in the study centre under supervision of the investigating physician or a designee. The 
measured plasma concentrations of trial medication will provide additional confirmation of 
compliance.
It is not intended to list the compliance separately. Any deviations from complete intake will 
be addressed in the RPM/DBLM (cf. TSAP Section 6.2) and described in the CTR.
7.4
PRIMARY ENDPOINT
7.4.1
Primary analysis of the primary endpoint
Please refer to Section 7.8.1 for the description of the analysis of the primary endpoint.


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7.5
SECONDARY ENDPOINTS
7.5.1
Key secondary endpoint
This section is not applicable as no key secondary endpoints have been specified in the 
protocol.
7.5.2
Secondary endpoints
Section 7.3.2 of the CTP: The secondary endpoints (refer to Section 5.2.2) will be analysed 
descriptively. Analyses will be performed for the parent drug and will be based on the PKS. 
 
 
 

 
 
 
 
 
 
 
Midazolam: 
Relative bioavailability will be estimated for dose groups A, C, D and I of young only for 
AUC0-tz and Cmax of midazolam. These endpoints will be compared separately between the last 
dose of midazolam and the first dose of midazolam and between the second dose of 
midazolam and the first dose of midazolam (test/reference). The statistical analysis will be 
performed separately for each dose group and separately for the group of subjects receiving 
placebo. Analyses will be conducted for the placebo group to better account for variability in 
plasma concentrations seen between midazolam treatment periods. The statistical model used 


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for the analysis of the secondary endpoints will be an ANOVA model on the logarithmic scale. 
This model will include effects accounting for the following sources of variation: ‘subjects’, 
and ‘time point’. The effect ‘subjects’ will be considered as random, whereas the other effects 
will be considered as fixed. The model is described by the following equation:
 ! =  +  + "! + #$ , where
 !
logarithm of the endpoint for subject j (j=1, 2,…, 8) at time point i: Day -1 
(first dose of midazolam, i=1), Day 1 (second dose of midazolam) or at Day 14 
(last dose of midazolam, i=2) respectively,

the overall mean,
 
the effect associated with time point i (Day -1 i=1 , Day 1 or Day 14, i=2),
"!
(random) effect of subject j, j=1, 2, ..., 8, and
#$
random error associated with subject j at time i (assumed to be independent
and identically normally distributed).
The effect of BI 474121 on midazolam will be estimated by the difference in the expected 
means log(test)-log(reference) (with the second and the last doses of midazolam respectively 
as the test and the first dose of midazolam as the reference) estimated by the difference in the 
corresponding adjusted means (Least Squares Means) for Cmax and AUC0-tz. Additionally, 
their two-sided 90% confidence intervals (CIs) will be calculated based on the residual error 
from ANOVA. These quantities will then be back transformed to the original scale to provide 
the point estimate and 90% CIs for each secondary endpoint. This method corresponds to the 
two one-sided t-tests procedure, each at the 5% significance level. Since the main focus is on 
estimation and not testing, an acceptance range is not specified.
The implementation for this analysis will be accomplished by using the CSD macros based on 
PKS. The following SAS code can be used:
PROC MIXED DATA=indata; 
CLASS subject timepoint; 
MODEL logpk = timepoint / DDFM=KR; 
RANDOM subject; 
LSMEANS timepoint / PDIFF CL ALPHA=0.1; 
ESTIMATE 'T-R' timepoint-1 1; 
RUN;  
(to be analysed separately with T=endpoint after second dose of Midazolam and 
T=endpoint after last dose of Midazolam, R is the endpoint after first dose of 
Midazolam in both analyses)
 
 
 
 


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7.7
EXTENT OF EXPOSURE
Descriptive statistics are planned for this section of the report based on the TS. The date and 
time of each drug administration will be listed for each subject.
7.8
SAFETY ANALYSIS
All safety analyses will be performed on the TS except the 
 
If not stated otherwise, the safety results will be sorted by treatment group.
The safety data for treated subjects who failed to complete the study (dropouts or 
withdrawals) will be reported as far as their data are available. All withdrawals will be 
documented and the reason for withdrawal recorded.
7.8.1
Adverse Events
AEs will usually be coded with the most recent version of MedDRA. The version to be used 
will be specified in RPM.
The analyses of AEs will be descriptive in nature and will be based on BI standards as
presented in “Analysis and Presentation of Adverse Event Data from Clinical Trials – Display 
Template” [BI-KMED-BDS-HTG-0041] (10) and [BI-KMED-BDS-HTG-0066] (11). All 
analyses of AEs will be based on the number of subjects with AEs and NOT on the number of 
AEs.


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The analysis of AEs will be based on the concept of treatment emergent AEs. That means that 
all AEs will be assigned to ‘screening’, ‘Mida’ (part A only), ‘on-treatment’ or ‘follow-up’ 
phases as defined in Section 6.1.
According to ICH E3 (12), in addition to Deaths and serious adverse events, ‘other 
significant’ AEs need to be listed in the clinical trial report. These will be any non-serious 
adverse event that led to an action taken with study drug (e.g. discontinuation or dose reduced 
or interrupted). An overall summary of adverse events will be presented. 
The frequency of subjects with AEs will be summarised by treatment, primary system organ
class (SOC) and preferred term (PT). Separate tables will be provided for subjects with
serious AEs, for subjects with drug-related AEs, for subjects with drug-related serious adverse 
events and for subjects with AESIs. In addition, the frequency of subjects with AEs will be 
summarised by treatment, worst intensity, primary system organ class (SOC) and preferred 
term (PT).
The SOCs and PTs will be sorted by frequency (within SOC). The MedDRA version number
(most recent version) will be displayed as a footnote in the respective output.
According to the clinical study protocol, adverse events of special interest (AESI) will be
analysed:
Section 5.2.8.1.4 of the CTP: The following are considered as AESIs:

Hepatic injury
A hepatic injury is defined by the following alterations of hepatic laboratory 
parameters: 
o
An elevation of AST (aspartate transaminase) and/or ALT (alanine 
transaminase) ≥3-fold ULN combined with an elevation of total bilirubin 
≥2-fold ULN measured in the same blood sample, or
o
Aminotransferase (ALT, and/or AST) elevations ≥10 fold ULN
In addition, frequencies of subjects with non-serious AEs that had an incidence of > 5% for at 
least one treatment will be summarised by treatment, primary SOC and PT.
For disclosure of adverse events on EudraCT, additional information not included in a 
standard AE analysis will be performed. The following three entries will be created:

Adverse Events per arm for disclosure on EudraCT

Non-serious Adverse Events for disclosure on EudraCT

Serious Adverse Events for disclosure on EudraCT


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7.8.2
Laboratory data
The analyses of laboratory data will be descriptive in nature and will be based on BI standards 
[BI-KMED-BDS-HTG-0042] (13). 
Laboratory data will be analysed qualitatively via comparison of laboratory data to their 
reference ranges. Values outside the reference range as well as values defined as possibly 
clinically significant will be flagged in the data listings.
Clinically relevant findings in laboratory data will be reported as baseline conditions (at 
screening) or as AEs (during the trial) if judged clinically relevant by the investigator, and 
will be analysed as such.
It is the investigator's responsibility to decide whether a lab value is clinically significantly 
abnormal or not (at the RPM at the latest). 
Descriptive statistics of laboratory data including change from baseline will be calculated by 
planned time point based on the worst value of the subject at that planned time point (or 
assigned to that planned time point).
7.8.3
Vital signs
For vital signs (blood pressure and pulse rate), descriptive statistics including change from 
baseline will be calculated by dose group and by planned time point based on the last value of 
the subject at that planned time point (or assigned to that planned time point). In the listing the 
difference from baseline will also be displayed.
Descriptive statistics over time will also be provided for the orthostatic test results to enable 
checking of orthostatic hypotension occurrence. Subjects should have spent at least 5 min in 
the supine position before blood pressure and pulse rate will be measured the first time. 
Further 2 measurements will be performed immediately after standing up and after 3 min in a 
standing position. An orthostatic hypotension is defined as a decline in systolic blood pressure 
of ≥ 20 mmHg or a decline in diastolic blood pressure of ≥ 10 mmHg within the first three 
minutes after standing up. 
Clinically relevant findings in vital signs will be reported as AEs.
Body temperature will be listed only.
7.8.4
ECG
Continuous safety ECG monitoring (by investigator)
Clinically relevant abnormal findings will be reported as adverse events.
No separate listing or analysis of continuous ECG monitoring will be prepared.


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12-lead ECG
Abnormal findings will be reported as baseline conditions (at screening) or as AEs (during the 
trial) if judged clinically relevant by the investigator. 
All evaluations of ECG data will be based on the TS, 
 
Listing of individual data
For all quantitative endpoints, listings of individual data will be shown in Appendix 16.2. For 
QTcB and RR, only listings will be provided. Occurrences of notable findings will be flagged.
Comments regarding the ECGs will be listed.
Categorical endpoints
For the categorical endpoints, frequency tables will be provided.
Categorical endpoints will also include morphological findings that might be attributable to
treatment. In particular, new onsets of findings not present at baseline will be explored. A
morphological finding observed on treatment that was not reported at baseline will be
categorized as a ‘new onset’ of this finding.
For all subjects with any notable finding in ECG intervals, a separate listing will be created as 
end-of-text display (based on the same display template as in Appendix 16.2), and the 
corresponding time profiles will be shown.
Quantitative endpoints
Descriptive statistics (N, mean, SD, min, median, max) will be provided for the absolute 
values and changes from baseline over time of QTcF, HR, QT, PR and QRS. The time 
profiles of mean and SD for the changes from baseline on treatment will be displayed 
graphically by treatment.
 
 
 
 
 
 
 
 


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Appropriateness of heart rate correction methods of QT interval
To evaluate the appropriateness of the heart rate correction methods, the slope of the 
relationship of QTcF interval versus RR interval will be estimated separately for off-drug 
values and active treatment, by applying the random coefficient model described in Section 
10.1.2 using the QTcF and RR variable values per time point. A scatterplot of QTcF vs RR
including the overall regression lines will be included in the Statistical Appendix of the CTR
(separately for part A and part B).
In addition, the model will be applied to the pairs of log-transformed uncorrected QT and log-
transformed RR, in order to obtain the population slope.


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7.8.5
Others
Physical examination
Physical examination findings, including visual inspection of the skin of palms and soles and 
oral cavity will be reported as relevant medical history/baseline condition (i.e., a condition 
already existent before intake of study drug) or as AE and will be summarised as such. 
No separate listing or analysis of physical examination findings will be prepared.
Suicidality assessment - Columbia Suicidal Severity Rating scale (C-SSRS)
The C-SSRS will be done at screening, visit 2 ptm -25:30 (day -1) (part A only) and visit 2 
ptm 360:00 (day 16). The results will be listed only.
Mini-Mental State Examination (MMSE) – part B only
The MMSE will be done at screening and end of trial examination in elderly subjects. The 
data is not transferred into the database, so no separate listing will be prepared.


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8.
TIMEPOINT OF RELEASE OF TREATMENT 
INFORMATION
The treatment information was released to unblind the trial database per dose group after the 
last patient has completed their End-of-Study/Follow-up visit and the randomization was 
complete for the respective dose group as defined in the “Data Ready to be Unblinded and/or 
Final Trial Closure Notification” (RUN) form.


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9.
REFERENCES
1.
CPMP/ICH/363/96: "Statistical Principles for Clinical Trials", ICH Guideline Topic E9, 
Note For Guidance on Statistical Principles for Clinical Trials, current version.
2.
001-MCS-40-413: "Identify and Manage Important Protocol Deviations (iPD) ", current 
version, IDEA for CON.
3.
BI-KMED-BDS-TMP-0059: “iPD specification document (sdtm-dv-domain-
specification)”, template, current version, KMED.
4.
BI-KMED-BDS-HTG-0035: “Handling of Missing and Incomplete AE Dates”, current 
version; KMED.
5.
BI-KMED-TMCP-MAN-0012: “Standards and processes for analyses performed within 
Clinical Pharmacokinetics/Pharmacodynamics”, current version; KMED.
6.
BI-KMED-TMCP-MAN-0014: “Noncompartmental Pharmacokinetic / Pharmacodynamic 
Analyses of Clinical Studies”, current version; KMED.
7.
BI-KMED-BDS-HTG-0045: “Standards for Reporting of Clinical Trials and Project 
Summaries”, current version; KMED.
8.
BI-KMED-TMCP-OTH-0003: “Graphs and Tables for Clinical Pharmacokinetics and 
Pharmacodynamic Noncompartmental Analyses”, current version, KMED.
9.
BI-KMED-TMCP-MAN-0010: “Description of Analytical Transfer Files and PK/PD Data 
Files”, current version; KMED.
10. BI-KMED-BDS-HTG-0041: “Analysis and Presentation of Adverse Event Data from 
Clinical Trials – Display Template”, current version; KMED.
11. BI-KMED-BDS-HTG-0066: “Analysis and Presentation of AE data from clinical trials”, 
current version, KMED.
12. CPMP/ICH/137/95: “Structure and Content of Clinical Study Reports”, ICH Guideline 
Topic E3; Note For Guidance on Structure and Content of Clinical Study Reports, current 
version.
13. BI-KMED-BDS-HTG-0042: “Handling, Display and Analysis of Laboratory Data”, 
current version; KMED.
14. R18-0143: Garnett C, Bonate PL, Dang Q, Ferber G, Huang D, Liu J, et al; Scientific 
white paper on concentration-QTc modeling. J Pharmacokin Pharmacodyn (2017).


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11.
HISTORY TABLE
Table 11: 1
History table
Version
Date
(DD-MMM-YY)
Author
Sections 
changed
Brief description of change
1 
03-NOV-21
None
This is the final TSAP