A Randomized, Double Blind, Placebo-Controlled Trial of Pioglitazone in Combination with Riluzole in Amyotrophic Lateral Sclerosis

Background Pioglitazone, an oral anti-diabetic that stimulates the PPAR-gamma transcription factor, increased survival of mice with amyotrophic lateral sclerosis (ALS). Methods/Principal Findings We performed a phase II, double blind, multicentre, placebo controlled trial of pioglitazone in ALS patients under riluzole. 219 patients were randomly assigned to receive 45 mg/day of pioglitazone or placebo (one: one allocation ratio). The primary endpoint was survival. Secondary endpoints included incidence of non-invasive ventilation and tracheotomy, and slopes of ALS-FRS, slow vital capacity, and quality of life as assessed using EUROQoL EQ-5D. The study was conducted under a two-stage group sequential test, allowing to stop for futility or superiority after interim analysis. Shortly after interim analysis, 30 patients under pioglitazone and 24 patients under placebo had died. The trial was stopped for futility; the hazard ratio for primary endpoint was 1.21 (95% CI: 0.71–2.07, p = 0.48). Secondary endpoints were not modified by pioglitazone treatment. Pioglitazone was well tolerated. Conclusion/Significance Pioglitazone has no beneficial effects on the survival of ALS patients as add-on therapy to riluzole. Trial Registration Clinicaltrials.gov NCT00690118.


Name and description of the investigational product
Pioglitazone treatment improves insulin sensitivity by a novel mode of action, the activation of PPARγreceptors, in animal models of type 2 diabetes with insulin resistance. The improved insulin sensitivity results in a lowering of glucose and insulin concentrations in non-insulinopenic diabetic animals, but does not affect on those levels in normal animals. Therefore, this compound does not have a potential for hypoglycaemia and can avoid the adverse consequences of long-term hyperinsulinaemia.
Pioglitazone has been shown to lower hyperglycaemia, triglycerides and non-esterified fatty acids (NEFA) and increases insulin sensitivity in animal models of type 2 diabetes mellitus but affects neither normoglycaemia in normal rats and dogs nor hyperglycaemia in insulin-deficient rats treated by streptozocin.
The potential for pioglitazone to elicit unwanted pharmacological effects on the central nervous, cardiovascular, autonomic, renal and digestive systems has been investigated in detail and there is a satisfactory margin of safety with respect to clinically attainable plasma concentrations of pioglitazone.
The maximum dose of pioglitazone administered in clinical trials is 60 mg od, which was well tolerated.
There was no evidence of a reduction in blood glucose in healthy volunteers but significant reductions in blood glucose were observed throughout the clinical studies conducted in patients with type 2 diabetes.
Following oral administration, pioglitazone is rapidly absorbed and peak concentrations of unchanged pioglitazone are usually achieved 2 hours after administration. Proportional increases of the plasma concentration were observed for doses from 2 mg -60 mg. Steady state is achieved after 4-7 days of dosing. Repeated dosing does not result in accumulation of the compound or metabolites. Absorption is not influenced by food intake. Absolute bioavailability is greater than 80 %.

Findings from non-clinical and clinical studies relevant to the trial
The primary pathological feature of ALS is the loss of motor neurons 1 , which is accompanied by a robust glial response including activation of microglia and astrocytes as well as the expression of COX-2 and iNOS in the spinal cord [2][3][4][5] . Both pathologies, motor neuron loss and neuroinflammation can be found in transgenic mice over-expressing mutant variants of the human gene encoding for copper/zinc superoxide dismutase (SOD1), which have been linked to inherited ALS [6][7][8][9] .
The massive appearance of activated microglia and astrocytes already at an early, pre-symptomatic stage of disease in SOD1 transgenic mice suggests that inflammation may contribute to motor neuron degeneration and suppression of the inflammatory component could be neuroprotective. PPARγ activation in microglia and macrophages results in inhibition of pro-inflammatory gene expression  [10][11][12] . It has been demonstrated that PPARγ agonists reduce amyloid beta peptide and cytokine mediated neuroinflammation and neurotoxicity in vitro 13,14 and in vivo 15 .
Originally developed as oral antidiabetics, agonists of PPARγ have been found to exert potent antiinflammatory effects in several models of neuroinflammation 10,16 . Importantly, pioglitazone-mediated reduction of inflammation was neuroprotective in the SOD1-G93A transgenic mouse model of ALS as reported independently by two groups 17,18 . Within the thiazolidinedione class of PPARγ agonists, pioglitazone is the only substance, which penetrates the blood brain barrier to a significant extent 19 and has therefore been chosen for these animal experiments. The results strongly suggest that pioglitazonemediated suppression of inflammation may offer a new therapeutic avenue in ALS treatment, as supported by findings in animal models of multiple sclerosis [20][21][22] , Parkinson's disease 23 , stroke 24 , and Alzheimer's disease 25,26 .

Known and potential risks and benefits, if any, to human subjects
The clinical trial programme showed that pioglitazone is well tolerated. With pioglitazone treatment, oedema can occur but is not usually a cause of withdrawal. Weight may increase during treatment, most likely as a result of increases in subcutaneous fat. Despite weight gain the effects of pioglitazone to improve glycaemic control and lipid profile were maintained. There was no evidence of any toxic effect of pioglitazone on the liver. Increases in CPK and LDH can occur transiently during treatment with pioglitazone but are not of clinical significance.
Pioglitazone has been prescribed to over 3.5 million patients worldwide with over 2 million patient years of usage. The majority of use has been in USA. In Europe, it is estimated that more than 200,000 patients have been prescribed the drug on the market.
Liver toxicity similar in severity and outcome to that reported from the market with troglitazone has not been reported with pioglitazone. In some cases of hepatic reactions, including hepatitis, a role for pioglitazone in their aetiology cannot be ruled out but their nature and incidence is similar to those also reported with other oral hypoglycaemic agents including the sulphonylureas and metformin.
Cases of congestive heart failure (CHF) have been reported in temporal association with pioglitazone use. However, since the background rate of this condition is so high in type 2 diabetes (2-3 cases per 100 per year as reported in the literature), it is not possible to ascribe a clear role for pioglitazone in the development of CHF.
Post-marketing surveillance has thus far not detected any life-threatening suspected ADRs with clear causal relationship to pioglitazone not seen in the clinical trials and has therefore confirmed the ADR profile of pioglitazone reported from clinical trials.
Pioglitazone is contraindicated in patients with: • Known hypersensitivity to pioglitazone or to any of the excipients of the tablet

Description of and justification for the route of administration, dosage, dosage regimen, and treatment period(s)
The route of administration (oral) is supported by established clinical experience with pioglitazone.
Dosage is built on the comparison of effects and pharmacokinetics in men and mice. The dosage regimen is based on the experience with the use of pioglitazone as an antidiabetic. Therefore, in a limited degree we can extrapolate the data from diabetes treatment to ALS.

STUDY PURPOSE, TRIAL OBJECTIVES AND ENDPOINTS
As the efficacy of riluzole to prolong survival in ALS is limited, there is an urgent need to identify other compounds and to evaluate their potential in clinical studies. The pharmacological profile of pioglitazone suggests that this compound may be effective in slowing down the neurodegenerative process observed in ALS and it is therefore important to study this drug in ALS patients. As a significant percentage of patients with ALS will receive riluzole, the study population will consist of patients stabilised on standard riluzole therapy at time of inclusion. After completing this study, patients may have the option to participate in another planned, longer, safety study with pioglitazone.
This study will evaluate the efficacy, safety and tolerability of pioglitazone (45 mg/day) versus placebo in patients with ALS receiving standard, approved therapy (riluzole, 50 mg bid). Mortality defined exclusively as death represents the primary endpoint. Secondary efficacy endpoints will include incidence of tracheotomy or non-invasive ventilation (NIV), ALS Functional Rating Scale (ALSFRS-R; the revised version including the respiratory parameters) and measurement of quality of life using the Euroqol EQ-5D. Assessment of clinical tolerability and safety will be performed by comparison of findings on physical examination, adverse events incidence, and clinical laboratory values across treatment groups.

Trial population
The population consists of 220 enrolled ALS patients as defined by the El Escorial criteria, and modified by the Airlie House criteria (http://www.wfnals.org).

Trial admission
A patient will only be enrolled in the study after obtaining his or her written consent to participation. The investigator must first provide a complete explanation of the study (benefits, risks, rights and obligations) and check that the patient satisfies all the inclusion criteria and none of the exclusion criteria.

Selection criteria
The following inclusion and exclusion criteria are believed to represent the ALS population; in particular they have been thoroughly discussed by European experts (including the coordinating investigator) in a conference held in the European Neuromuscular Center (ENMC) Naarden, Holland in October 2003.
They were used in a similar way in the previous large European ALS trials (Exonhit, Ono, Novartis); the coordinating investigator was involved in the protocol development of each of these trials.

Inclusion criteria
To be considered eligible to participate in this trial a patient must meet the inclusion criteria listed below.
• Possible, probable (clinically or laboratory) or definite ALS according to the revised version of the El Escorial World Federation of Neurology criteria • Disease duration more than 6 months and less than 3 years (inclusive). Disease onset defined as date of first muscle weakness, excluding fasciculation and cramps • Best-sitting SVC between 50 % and 95 % of predicted normal • Continuously treated with 100 mg riluzole daily, for at least 3 months • Capable of thoroughly understanding all information given and giving full informed consent according to GCP • Women of childbearing age must be non-lactating and surgically sterile or using a highly effective method of birth control and have a negative pregnancy test. Acceptable methods of birth control with a low failure rate i.e. less than 1% per year) when used consistently and correct are such as implants, injectables, combined oral contraceptives, hormonal intrauterine devices (IUDs), or double-barrier methods (condom or diaphragm with spermicidal agent or IUD), sexual abstinence or vasectomised partner.
• Onset of progressive weakness within 36 months prior to study Written informed consent must be obtained from all patients prior to any study-related procedure.

Exclusion criteria
In addition, to be eligible for entry into the trial, a patient may not meet the exclusion criteria listed below.
• Previous participation in another clinical study within the preceding 12 weeks • Tracheotomy or assisted ventilation of any type during the preceding three months • Heart failure or heart failure in the patients history (NYHA I to IV) • History of macular oedema • Treatment with thiazolidinediones within 3 months prior to screening • Known or suspected history of alcohol and/or drug abuse • Treatment with gemfibrozil within 3 months prior to screening

Protocol violations
Except in the case of a medical emergency, no protocol violation is authorised outside amendments made by the sponsor and validated by an IEC/IRB. Protocol violations may affect the conduct of the study from legal and ethical points of view and also influence the statistical analysis and pertinence of the study. If a medical emergency or event occurs in a patient leading to a protocol violation this will GERP ALS Study only be allowed for this patient. The investigator must contact the sponsor to see if the patient may continue the study. Any protocol violation must be reported on the case report form.

Design overview
This is a prospective, multicentre, randomized, stratified, parallel-group, double-blind trial comparing placebo with 45 mg pioglitazone as add-on therapy to 100 mg riluzole in amyotrophic lateral sclerosis (ALS) in 220 enrolled patients. For entry, the El Escorial Criteria for the diagnosis of ALS will be used (http://www.wfnals.org). The patients have to be stable on riluzole at least three months prior to randomization. The trial requires an initial screening visit (V0), one baseline visit (V1), 4 subsequent control visits (V2 -V5), and a final visit (V6). The duration of study participation for patients completing the study is 18 months.
After patients are screened for inclusion and exclusion criteria, they are randomly assigned to treatment with either placebo or 45 mg pioglitazone according to their stratum (see section 6.10.1). The dosage will be increased step wise: 15 mg once daily will be applied during the first two weeks, 30 mg once daily during week 3 and 4 and 45 mg once daily from week 5 on up to the end of the study. The study drug will be tablets of 15/30/45 mg base or matching placebo. The drug will be administered orally. In patients with gastrostomy, tablets will be crushed and administered via the feeding tube.

Trial procedures
On enrolment in the trial, a patient will undergo a physical examination and a detailed medical history will be obtained.

Efficacy Variables
Efficacy variables will be determined at the study site by using standard methods.
• Survival / Date of death requiring a death certificate  Any deviation of laboratory parameters from normal ranges will be documented and followed up as appropriate. Clinically significant deviations observed in the screening visit and during the study will be documented in the Case Report Form.

Adverse Events
Adverse events observed by the investigators or reported by the patients will be documented as described in chapter 7.

Demographic Data
• Date of Birth

Medical History
Clinically significant conditions that stopped within the last 5 years and concomitant diseases will be documented. In addition, following items have to be addressed specifically: • Smoking habits within the last 12 months • Alcohol consumption

Physical Examination
• Height • Weight • Radial pulse (with the patient in sitting position for at least 5 minutes) • Blood pressure (according to Riva Rocci using calibrated sphygmomanometers, the patient has to be in a sitting position for at least 5 minutes, blood pressure will be measured twice within 5 minutes, the mean of both measurements will be calculated) •

Trial visits schedule
For the planned trial visits schedule the inclusion date is considered to be the reference date. The dates of the following visits specified in the protocol are calculated in relation to the date of this visit.
If the time of a visit is modified in relation to the visits schedule, the times of the following visits will always be determined with respect to the inclusion visit. The time window for each planned visit will be GERP ALS Study In the case of premature interruption of the study treatment, a complete examination identical to visit V6 should be carried out. Premature study discontinuation must be noted as such on the case report form.
Patients prematurely leaving the study must not rejoin the trial.
Additionally a study physician will contact the patient by telephone 1, 3, 9, and 15 months after study enrolment.
An overview including the time schedule for all visits is given in table 5.2.

Screening Visit (V0)
A signed "Informed Consent" will be obtained from each patient prior to initiating any trial procedure.
Presence of ALS diagnostic criteria will be documented as well as site of onset and ALS status at entry according to El Escorial criteria, and modified by the Airlie House criteria (http://www.wfnals.org ).
Venous blood will be taken for the determination of blood cell count, creatinine, CK, ASAT, ALAT, fasting blood glucose, and HCG or urine pregnancy test (only in women with child bearing potential).
The patients´ eligibility will be determined in accordance with the inclusion/exclusion criteria. A detailed medical history will be taken, and concomitant medication will be recorded. A physical examination, including body weight, height, blood pressure, and radial pulse will be performed. Additionally lung function will be assessed by measuring the patient's vital capacity.

Visit 1 -Baseline visit (V1)
Patients eligible for study participation will enter the study site within 4 weeks after the screening visit and will be randomised to one of the treatment arms.
Blood samples for the determination of blood cell count, creatinine, CK, ASAT, ALAT, fasting blood glucose, and pioglitazone baseline level will be obtained. A physical examination, ALS FRS-R, and EuroQol EQ-5D will be performed. The patient will receive study medication according to the randomization list and a study participant card (see appendix IX).
Any changes in the concomitant medication and adverse events before and during visit 1 will be documented.

Visit 2 -Control for ASAT and ALAT at the patient's general practitioner (V2)
Visit 2 will be performed one month after V1.
The patient's general practitioner will collect blood from the patient to determine creatinine, CK, ASAT, ALAT, and fasting blood glucose. Values will be transmitted to the local study site by fax.  Visit 3,4, and 5 will be performed 2, 6, and 12 months after visit 1 respectively.
Venous blood samples will be taken for the determination of blood cell count, creatinine, CK, ASAT, ALAT, fasting blood glucose, and pioglitazone level. A physical examination, ALS FRS-R, and EuroQol EQ-5D will be performed. Drug accountability will be performed and the patient will be supplied with new study medication. Any changes in the concomitant medication and adverse events will be documented.

Visit 6 -Final Visit (V6)
Visit V6 will be performed 18 months after visit V1. Any adverse events and changes in concomitant medication will be documented.
Blood samples will be taken for the determination of blood cell count, creatinine, CK, ASAT, ALAT, fasting blood glucose, and pioglitazone level. Patients will undergo a physical examination and ALS FRS-R and EuroQol EQ-5D will be performed. The patient will return the study medication of V5 and drug accountability will be performed.

Telephone contacts (T1 -T4)
At months 1, 3, 9, 15, or if a visit has been missed, the patient or its relative will be contacted by telephone to assess the following items: • ALSFRS-R

• Weight
• Adverse events • Changes in concomitant therapies • Compliance to study drug regimen

Unscheduled visits
Unscheduled visits may be carried out at any time during the study in the case of a medical emergency, when a patient would like to report a medical problem or when the investigator considers this necessary for the patient's well being. These unscheduled visits must be recorded on the case report form. In no case must they lead to a modification in the study visits schedule stipulated by the protocol.

Visits following premature discontinuation of study treatment
If a patient discontinues participation in the study for whatever reason, every effort has to be undertaken to perform an early termination visit. In this case, the same investigations have to be performed as in visit V6.

Sequence and duration of trial periods
The duration of treatment will be 18 months resulting in a duration of the trial of about 24 months; 1 month will be reserved for screening, three for recruitment, 18 months for the treatment period, and two for an observational follow-up period after the interventional period. Then the functional and survival data will be analysed.

GERP ALS Study
Protocol

Treatment packaging
Haupt Pharma, Brackenheim/Germany will supply the study drugs. The study drugs will be packed in accordance with AMG. All drug supplies must be stored in accordance with the manufacturer's instructions and must be stored separately from normal clinic (study centre) stocks. The investigator shall be responsible for assuring that the study medication is stored in a dry location and not above 25 C, protected from exposure to any environmental changes and is locked, so that only the investigator and specifically designated other persons can have access.

Treatment labelling
According to article 5 of the German GCP-V the labelling of investigational drugs contains at minimum the following information

Storage of drug supplies
The study drug will be directly sent to the study site. The investigator will confirm receipt of the first and all subsequent batches of study drugs in writing to Haupt Pharma Brackenheim GmbH. All drug supplies must be stored in accordance with the manufacturer's instructions, and separately from normal clinic (study centre) stocks. At the study site, the investigator is responsible for assuring that the study medication is stored properly, protected from exposure to any environmental changes and is locked, so that only the investigator and specifically designated other persons can have access.

GERP ALS Study
Protocol

Treatment assignment
The investigator must only give the study treatments to the patients included in the trial according to the procedures stipulated by the protocol. It is strictly prohibited to use these treatments for any other reason than that described in the protocol. The medication will be given to the patient directly by the investigator. If the patient misses a visit, the medication can be given to a relative or can be sent.

Overdose
There is no specific advice in case of an overdose. General measures should be taken.

Compliance
The investigator will select patients who have the ability to understand and comply with instructions for trial participation. Non-compliant participants will be dropped from further participation in the trial.
Compliance of the patient will be judged by the investigator. Additionally, the study drugs will be dispensed exclusively by the investigator or a designate. All unused study medication will be returned to the investigator. Drug accountability including tablet counts will be performed by the investigator.
Patients will be asked to return their unused study medication including the empty blisters and boxes at each visit. To assess compliance, the remaining tablets will be counted out of the patient's presence. At visit V1, V3, V4, V5, and V6 pioglitazone levels will be measured in the serum of each patient to control compliance. Patients, who have taken more than 120% or less than 80 % of the medication during the treatment period, may continue the trial but will not be included in the per protocol analysis.

Concomitant treatment
Patients will be allowed to continue to use any concomitant medications that they require except medication indexed in the exclusion criteria (as per Summary of product characteristics). If medically acceptable all concomitant medications should be kept constant during the investigation. If a change of concomitant medication is necessary, the investigator has to be informed.
Change of concomitant medication will be documented in the case report form.

Randomisation
At the screening visit (V0), each patient will receive the next consecutive screening number from a block of screening numbers according to their stratum (bulbar onset vs. spinal onset). Patients will be assigned to the bulbar or spinal stratum according to the location of the earliest experienced ALS symptom (defined by the first muscle weakness, or in the case of bulbar onset, by the presence of dysarthria and/or dysphagia). In the case of a patient with simultaneous onset of spinal and bulbar symptoms, onset will be defined as bulbar. Cervical and respiratory onsets are stratified to the spinalonset stratum. This stratum assignment must be consistent with the diagnosis and clinical assessment (i.e., maximum score on bulbar scale and low score on manual muscle testing would contradict the assignment to bulbar stratum).
At the randomization visit (V1), each patient eligible for study participation will receive the next consecutive randomisation/patient number according to his stratum from a block of randomisation numbers per site. The randomisation list will be generated by Haupt Pharma Brackenheim, Germany, using a validated system, which involves a pseudo-random number generator to ensure that the resulting treatment sequence will be both reproducible and non-predictable. Study medication will be packed and blinded by Haupt Pharma Brackenheim, Germany, according to the randomisation list.
Each patient medication box will be sent together with the sealed unblinding codes to the sites. The

GERP ALS Study
Protocol investigator at the site takes care that each patient will be provided with the study medication box of the correct randomisation number.

Blinding
Blinding of investigator and patient is achieved by providing pioglitazone and matching placebo tablets.
The randomisation list is kept confidential by Haupt Pharma Brackenheim, Germany, and is only accessible to authorised personnel until the code is broken. At the end of the trial, any emergency opening of the envelopes will be controlled after collecting the explanations for unblinding and checking the unused treatment units. The code will be broken only at the end of the study after freezing the statistics database (by checking the data, recording any protocol violations etc.) allowing the collected data to be analysed.

Emergency procedure for unblinding
Each study site will receive sealed unblinding envelopes for emergency cases. Haupt Pharma Brackenheim will send the envelopes to the sites together with the matching medication.
In case of an emergency situation the investigator has the right to open the unblinding envelope, but every effort should be taken to avoid unblinding of patients except the information will be needed for the emergency treatment. Opened envelopes have to be signed, dated and the reason for unblinding has to be documented. The envelope has then to be filed in the patient file and the sponsor or the responsible monitor has to be informed. Unblinded patients have to be withdrawn from the study.
Additionally the sponsors' safety contact will receive a full set of sealed unblinding envelopes for emergency cases. As well every effort should be taken to avoid unblinding of patients except the information will be needed for the emergency treatment. Opened envelopes have to be signed, dated and the reason for unblinding has to be documented.
No other reason than an emergency may justify unblinding. After unblinding the investigator must note the date, time and reason on the case report form. The investigator must also immediately inform the trial monitor of the breaking of the blind.

Drug accountability
The investigator must keep a precise record of the dispatch and dispensing of trial medication in a drug accountability record. At all times during the study it must be possible to control that the date of dispensing and the quantity of trial medication given to each subject has been noted.
The investigator must not destroy any label or any box of medication even if only partly used. At the end of the study the investigator must group together all the boxes of used or unused treatments for recovery by the study monitor.

GERP ALS Study
Protocol This definition also applies to events occurring in any comparative group (active treatment or placebo) or during the placebo-treatment phase or during periods when the patient is not receiving any study medication.
Note: the term study treatment refers to all the drugs studied including the reference drugs and any other treatment stipulated in the protocol.

Serious adverse event (SAE)
A serious adverse event is any untoward medical occurrence that at any dose: • Results in death, • is life-threatening, • requires in-patient hospitalisation or prolongation of existing hospitalisation, • results in persistent or significant disability/incapacity, • is a congenital anomaly, birth defect, or The following points should be taken into account when evaluating the seriousness of an adverse event: • The life-threatening criterion indicates that there was an immediate risk of death at the time of its occurrence. This does not mean that if the adverse event had occurred in a more severe form it would have lead to death.
The following are not considered to be serious adverse events: • An event causing a brief visit to a hospital consultation, an open-door or day hospital, • outpatient treatment in the emergency department although the reason for which this treatment was instituted may be serious, or • admission to hospital (more than one night in a hospital bed) including surgical operations planned before or during the study if the condition was present before the study and provided that it does not worsen during the study.
The following are considered to be serious adverse events even if they do not comply with the definition: • Adverse events caused by misuse or overdose, • Any pregnancy discovered during the study.
Note: a state of pregnancy is an exclusion criterion. Hence contraceptive measures are necessary in women with childbearing potential throughout the study. However if pregnancy is discovered during the study the trial treatment must immediately be discontinued and the pregnancy followed to term.
N.B. a non-serious adverse event designates any other event not corresponding to the above-defined criteria.

Non Serious Adverse Events
Non serious adverse events mean adverse event, which are not categorised as serious adverse event.

Severity (Intensity) and outcome
The severity of an adverse event represents the intensity of the event as reported by the patient or assessed by the investigator. It does not reflect the clinical seriousness of the event (for example severe nausea, minor stroke). The intensity is evaluated independently from the relation to the study treatment.
• Mild: the adverse event is transient and easily tolerated by the patient.
• Moderate: the adverse event causes the patient discomfort and interference with the patient's usual activities.

Monitoring and recording of adverse events
At each visit after V0 the investigator must question the patient about the occurrence of any adverse event and note any abnormal laboratory findings. A neutral question such as "since the last visit have you felt any untoward or unusual symptoms other than those related to your illness?" elicits any adverse events experienced by the patient.
Whatever the relation to the study treatment is, any adverse event such as those described in section 7.1 spontaneously reported by the patient or observed by the investigator must be reported on the appropriate page of the case report form. For each adverse event, the following information should be documented: • Description of the event (diagnosis and symptoms in verbatim terms) • Outcome

• Seriousness
• Duration (start date and stop date) • Severity (mild, moderate or severe); see section 7.1.4 • Frequency (permanent, intermittend) • Causal relationship with the study treatment according to the scale shown in section 7.3 • Corrective actions including measures taken for the study treatment The study number, patient number and investigator's signature must also be noted.
Any clinically significant event including any abnormal laboratory result or vital sign must be followed-up until it has completely disappeared or the investigator has assessed its sequelae, even after the end of the study.

GERP ALS Study
Protocol A period of 14 days for follow up of AEs after the patient has routinely or prematurely terminated the study seems sufficient.

Evaluation criteria
The relation between the adverse event and the study medications must be evaluated according to the data collected. Causality assessment will be made by the investigator for both non serious and serious AEs using the 4-category system defined below.

(1) DEFINITE
An adverse event that follows a reasonable temporal sequence from the administration of the drug (including the course after the withdrawal of the drug) and that satisfies any of the following: • Reappearance of similar reaction upon re-administration (re-challenge) • Positive results in drug sensitivity tests (skin test…) • Toxic levels of the drug revealed by measurement of drug concentrations in blood or other body fluids.

(2) PROBABLE
An adverse event that follows a reasonable temporal sequence from the administration of the drug (including the course after the withdrawal of the drug) and for which factors other than the drug, such as underlying diseases, complications, concomitant drugs and concurrent treatments can reasonably be excluded.

(3) POSSIBLE
An adverse event, that follows a reasonable temporal sequence from the administration of the drug (including the course after the withdrawal of the drug) and for which possible involvement of the drug can be argued (*), although factors other than the drug, such as underlying diseases, complications, concomitant drugs and concurrent treatments may also be responsible.
(*) For example, there have been similar reports in the past including reports on its analogues or the occurrence of the event could be predicted from the pharmacological actions / chemical structure of the drug.

(4) UNLIKELY / NOT RELATED
An adverse event that does not follow a reasonable temporal sequence from the administration of the drug or that can be reasonably explained by other factors such as underlying disease, complications, concomitant drugs and concurrent treatments.
Note: if any essential information for the evaluation including temporal sequence of the adverse event from the administration of the drug (including the course after withdrawal of the drug), underlying diseases, complications, concomitant drugs and concurrent treatments is not available, the case can be cited as "lack of data" at the initial report. However, the adverse event shall be categorised into any of (1)-(4) as soon as possible.

Points to consider
The following points must also be taken into account during causality assessment of adverse events: • Timing of the event between administration of the drug and the onset of the adverse event • Drug levels and evidence, if any, of overdose • A known or expected response pattern to the suspect drug. This included: Previous experience with the drug and whether the adverse event is known to have occurred with the drug Physiological effect of the drug Is the adverse event known as an adverse event related to other drugs, which belongs to the same or to similar class?
Can the event be explained by the pharmacological action or with regard to the findings in animal?
Has the patient a specific genetic predisposition (e.g. slow acetylizer)? •

Reporting responsibility
After signature of the consent form, any serious adverse event occurring, while the patient is in the study or during the 2 weeks after the end of the study, must be reported by the investigator.

1-SERIOUS ADVERSE EVENT INITIAL REPORT
As soon as the investigator has been informed about a serious adverse event, he or she should fill in as precisely as possible the serious adverse event report form and assess the responsibility of the study treatment.
The investigator must fax the form within one working day of knowledge of the event to the Safety Contact. This form and the fax machine receipt must be kept in the case report form.
If the event is unexpected and fatal/life-threatening and is considered by the investigator related to the study treatment, the Safety Contact should be informed immediately by phone. If necessary, the other investigators participating in the trial will be informed about the occurrence of such a serious adverse event.
The investigator will report any serious adverse event to the sponsor of the study (safety contact): Prof Both the investigator and the sponsors safety contact will adhere to the GCP-requirements ( § § 12, 13) on documentation and notification.
Suspected unexpected serious adverse reactions (SUSARs) have to be reported to the responsible Ethics Committee at the University of Ulm by the sponsors' safety contact within the defined notification periods according to GCP-V §13 Abs. 2 and 3.
In addition, the sponsors' safety contact will inform the Competent Authorities within the defined notification periods. The other investigators participating in the trial will be informed about the occurrence of such a SUSAR.
In this trial on the fatal disease ALS, the mortality is the efficacy endpoint and the integrity of the trial may be compromised when the blind is systematically broken for reporting of mortality related SUSARs.
Therefore each mortality case will be treated as disease-related and will not be subject to systematic unblinding and expedited reporting. The reporting of these events will be completed within one month after last patient's last visit. The independent Data Safety and Monitoring Board (DSMB) will review the safety data every three month in the ongoing trial with recommendation to the sponsor whether to continue, modify or terminate the trial. All cases of SUSARS that are not efficacy endpoints will be reported as usual.

2-SERIOUS ADVERSE EVENT FOLLOW-UP REPORT
If new information becomes available after transmission of the initial report, a follow-up report should be completed by using the same form. Follow-up information shall be handled in the same way as the initial information (i.e. within one working day of knowledge). A copy of any hospital reports and results of any lab tests must also be attached.

Responsible Nominated Safety Contact
The fax and telephone numbers of the Responsible Nominated Safety Contact are given in the list provided in the present protocol. Additionally the independent Data Monitoring and Safety Committee (DMSC) will have to be informed if an SAE occurs.

Unblinding of treatment / Emergency identification
In the case of a medical emergency requiring identification of the treatment taken by the patient, the code may be unblinded. For more information see section 6.10.3 "emergency unblinding procedure".

Premature discontinuation / Patient replacement
Each patient can at any time withdraw from the study without personal disadvantages and without stating reasons.
Whenever possible, all patients prematurely discontinuing study medication will continue to be followed and complete all scheduled evaluations for the duration of the study. The reason(s) for premature cessation of a patient's participation during the trial, other than death, should be specified on the case report form. Whenever possible the evaluations scheduled for the end of the treatment period should be performed.
Study treatment may be stopped prematurely if any of the following events occur, according to the judgement of the investigator: • Significant intolerance of the study medication, or significant clinical or laboratory findings, e.g.
increase in ASAT or ALAT >2.5 upper limit of normal

Study Termination
Certain circumstances may lead to early termination of an entire study, in particular for ethical or safety reasons such as: • The high frequency and/or unexpected severity of adverse events, • Unsatisfactory recruitment of patients in as far as their quantity or quality is concerned or recurrent incomplete/inappropriate collection of data.
The study may be also stopped prematurely if the interim analysis shows pronounced superiority of the intervention group compared to the placebo group (s. section 8.2.5). The decision to prematurely terminate the study will be taken by the sponsor and the investigator.

Sample size and power considerations
In four previous ALS trials in which the principal investigator was involved, the rate of loss to follow up was less than 1 % (Exonhit/Pentoxifyllin, ONO2506, 5000 mg Vitamin E trial, TCH346-Novartis-Trial).
We expect to repeat this low rate, since ALS is a life threatening disease and the centres involved are experienced in the clinical care for the patients.
The study will be conducted using a two-stage group sequential test design within the ∆-class of critical values according to Wang and Tsiatis. 27 The planned information rates are 0.5 and 1. These information rates fix the weights for combining the p-values using the weighted inverse normal method. 28 The critical values of the group sequential test design were calculated for the standardised (cumulative) test statistic Thus, considering a drop-out rate of 10%, it is planned to enrol a total of 220 patients.

Statistical methods
A Statistical Analysis Plan describing all details of the analyses to be performed will be prepared by the study statistician and approved by the sponsor prior to the start of statistical analysis. The recommendations of the ICH E9 Note for Guidance on Statistical Principles for Clinical Trials (CPMP/ICH/363/96, 1998) will be taken into account.
The primary endpoint will be subjected to a confirmatory analysis. All secondary and safety parameters will be evaluated and reported descriptively.
All individual data as well as results of statistical analyses -whether explicitly discussed in the following sections or not -will be presented in individual subject data listings and statistical summary tables.
Continuous variables will be summarised using the following standard descriptive summary statistics: number of observations, arithmetic mean, standard deviation, minimum, lower quartile, median, upper quartile, maximum. In addition, geometric mean and coefficient of variation derived from log-normally distributed data will be calculated for serum concentrations. Categorical data will be described using absolute and relative frequencies.
A more detailed elaboration of the principal statistical features stated in this protocol will be provided in the statistical analysis plan, which will be finalized prior to unblinding of the database. The statistical analysis plan will take into account any amendment to the study protocol.

Populations
The following data sets will be analysed: • Full-analysis set: All randomised patients who received at least one dose of study medication will be included in the all patients treated set.

GERP ALS Study
Protocol • Per-protocol analysis set: The per protocol analysis set will consist of all patients in the full analysis set without any major protocol violations. Patients with major protocol violations will be excluded from the per-protocol analysis. The classification of major and minor protocol deviations and the resulting definition of analysis sets will be performed prior to the final analysis and will be approved by the sponsor.
All analyses with respect to safety and tolerance will be performed for the full-analysis set. All efficacy analyses will be conducted for the full-analysis set and for the per-protocol analysis set. The primary data set for the efficacy analysis will be the full-analysis set.
A more detailed description of the criteria used for data sort out will be included in the statistical analysis plan before start of the evaluations prior to unblinding the treatment allocation.

Background and demographic characteristics
Assessments made at the screening (V0) and randomization visit V1 will be summarised by treatment group and overall. These assessments will include demographic characteristics and other relevant parameters (such as medical history and physical examination). By-treatment summaries will serve to identify any imbalances between the treatment groups before start of active treatment.
Previous / concurrent diseases will be coded and presented according to the MedDRA terminology.
Summary tables will be provided for the the full-analysis set and for the per-protocol analysis set by means of descriptive statistics and frequency tables where appropriate.

Study medication
Compliance with respect to study medication will be computed based on the available data of the number of dispensed and returned study medication and the number of days the patient should have taken medication (dispensing intervals).

Concomitant therapy
Concomitant medications will be tabulated by generic drug name and Anatomical Therapeutic Chemical (ATC) code for each treatment group.

Efficacy evaluation
The primary objective of the study is to demonstrate the superiority of the test treatment compared to the standard treatment in terms of survival.
The study will be conducted according to a two-stage group sequential test design with possible sample size adaptation after the planned interim analysis. The overall type-I-error rate is set at α = 0.025 (onesided).
The following null hypothesis H 0 will be tested against the alternative hypothesis H A (α = 0.025, one- where λ2 / λ1 is the hazard ratio, λ1 denotes the hazard in the standard group and λ2 in the test group.
The hazard ratio is assumed to be constant across time.
The null hypothesis will be tested using the log-rank test.
The first interim analysis will be conducted after observation of a total of 31 deaths. The null hypothesis will be rejected at the first interim analysis if the calculated test statistic exceeds the critical value 2.797.
In this case, the study may be stopped. If the null hypothesis will not be rejected, the study may be continued until the pre-specified number of 61 deaths (accumulated number of deaths) or a recalculated number of deaths based on the effect size estimation of the first interim analysis were observed.
Data from all subjects will be considered when calculating the second stage log-rank test statistic. At the final (second) analysis, the null hypothesis will be rejected if the calculated inverse normal test statistic exceeds the critical value 1.977.
This procedure preserves the overall (experiment-wise) type I error rate of α = 0.025 in a strong sense.
For estimating the treatment effect, the hazard ratio and the corresponding two-sided 95% repeated confidence interval will be provided.
All other group comparisons are hypothesis generating in nature, i.e., p-values resulting from these statistical tests will be interpreted in the exploratory sense.

Safety evaluation
The full-analysis set will be used to address issues of safety. Adverse events data will be processed in the statistical analysis after coding according to the MedDRA dictionary.
Adverse events (AEs) will be classified as pre-treatment AEs or treatment-emergent AEs. Analyses will be performed for these classes. Pre-treatment AEs are defined to be AEs, which obviously occurred prior to the first administration of study medication. Treatment-emergent AEs are defined to be AEs, which occurred at or after the first administration of study medication. In case of doubt regarding the timing of AE onset the worst-case scenario will be applied, i.e. the AE will be considered as treatmentemergent.
AEs will be analysed regarding their seriousness, severity, outcome and causality assessment. SAEs will be analysed regarding their severity, outcome and causality assessment. Furthermore, all AEs with possible, probable or definite causal relationship to study medication (causality assessment) will be summarised as 'drug-related' AEs. They will be analysed regarding severity and outcome. All analyses will report frequency counts of subjects by MedDRA SOC and preferred term. Furthermore, treatmentemergent AEs will be presented by preferred term and sorted by frequency.
Listings by subject will be provided for SAEs and for AEs.

GERP ALS Study
Protocol

Interim analysis
The study will be conducted according to a two-stage group sequential test design with possible sample size adaptation after the interim analysis. The interim analysis is planned after observation of 31 deaths (expected observation time of 11.1 months). No per-protocol analysis will be performed for the interim evaluation of efficacy and safety.
At the planned interim analysis, the random code of the subjects to be included in the interim analysis will be unblinded by a member of the DMSC. Before unblinding a Statistical Analysis Plan will be prepared for the interim analysis by the unblinded statistician and agreed on between the sponsor and the unblinded statistician. The unblinded statistician will electronically match the random code with the study data and will send confidentially the results and a brief statistical report summarising the results of the interim analysis to the DMSC.

Subgroup Analyses
Subgroup analyses will be performed for the bulbar and spinal stratum.

Multicentre Data
Exploration of possible heterogeneity of treatment effects across centres will be performed in a descriptive manner if appropriate, e.g. by graphical display of the results of the individual centres.
To assess the homogeneity of treatment differences across centres for the primary efficacy variable, treatment-by-centre interaction will be evaluated.

Data handling and record keeping
The investigator must maintain all study records, patient files and other source data for the maximum period of time permitted by the hospital or institution. The data from the individual centre will be transferred to the coordinating centre. They will be monitored at the site and with the help of source documents.
Data processing will be conducted on the basis of the Data Management Plan approved by the sponsor prior to any data management activity. The data cleaning process will be performed according to the Data Validation Plan. The database will be designed by acromion GmbH using the acromion DMS based on Sybase.
Data will be entered into the database using the technique of independent double data entry with a third person-compare where two people enter the same data independently and a third person resolves any discrepancies. Changes made to the data will be documented in an audit trail.

GERP ALS Study
Protocol Page 42 of 94 The following international dictionaries will be used for medical coding in their current installed version at the beginning of coding activities, ensuring that there is only one version used during the study: • Diseases: Medical Dictionary for Regulatory Activities (MedDRA) • Adverse events: Medical Dictionary for Regulatory Activities (MedDRA) • Drugs: WHO-DRL dictionary The statistical analysis will be performed using the software package SAS version 9.1 (SAS Institute Inc., Cary, NC 27513, USA).
All available data will be included in the analyses and will be summarized as far as possible. Unless otherwise specified there will be no substitution of missing data, i.e. missing data will not be replaced, missing data will be handled as 'missing' in the statistical evaluation.
In the case of a premature termination, the last available observation will be used for analysis (LOCF approach), if applicable and considered reasonable. Missing baseline data will not be replaced. A more detailed description of the handling of missing data will be provided in the statistical analysis plan after review of the data for the interim and the final analysis.

ETHICAL ASPECTS
This protocol is in accordance with the principles laid down by the 18 th World Medical Assembly (Helsinki, 1964) and its amendments laid down by World Medical Assemblies. This protocol is also in accordance with laws and regulations of the country in which the trial is performed, as well as any applicable guidelines. It is the responsibility of the investigator to obtain informed consent in compliance from each patient prior to entering the trial or, where relevant, prior to evaluating the patient's suitability for the study.

Independent Ethics Committee Approval
Before implementing this study, the protocol, the proposed informed consent form and other information to subjects, must be reviewed by a properly constituted Independent Ethics Committee / Institutional Review Board (IEC/IRB). A signed and dated statement that the protocol and informed consent have been approved by the IEC/IRB must be given to the sponsor before study initiation. The name and occupation of the chairman and the members of the IEC/IRB must be supplied to the sponsor.

Informed Consent
The investigator must ensure that before enrolment in the study, all eligible patients are given detailed information both orally and in writing, about the following points in particular: • Aims, duration and methods of the study Informed consent must be given by a standard written declaration drafted in simple non-technical language. The patient must read and examine the contents of this form before signing and dating it and he or she must be given a signed copy. No patient may be enrolled in a study before giving his or her informed consent.
The investigator may withdraw the trial drug at any time if he considers that this is in the patient's interest. The patient also has the right to withdraw his or her consent at any time (for the procedure to be followed in the case of premature discontinuation, see section 7.6 "Premature discontinuation").
The investigator must accept to inform all the patients included in the study about any new information on the trial drug discovered during the study in accordance with the recommendations of the sponsor and the IEC/IRB.

Data confidentiality
All the data collected will be processed in a manner guaranteeing the strictest confidentiality. Patients will be informed that the data collected during the study will be archived and processed in accordance with local individual data protection law.
Patients will also be informed that clinical research monitors appointed by the sponsor, Health Authority Inspectors and IEC/IRB members may only obtain access to the source clinical data to check the data in the case report form. This point must be explicitly stated on the consent form.
The investigator must hold an updated list of all patients selected/enrolled in the study by noting the patient's initials in the same way as in the case report form together with the treatment and randomisation number where applicable.

Insurance
A specific insurance was contracted to cover the civil liability of the investigators and sponsors working in therapeutic biomedical research.

ADMINISTRATIVE PROCEDURES
By signing the study protocol, the investigator accepts to comply with the following points:

Regulatory aspects
The study will be conducted in compliance with the current provisions of the German Drug Law and GCP Regulation (GCP-V), the respective decrees and the European Clinical Trial Directive. Regulatory reporting requirements will be agreed on by the parties in the investigator contract.

GERP ALS Study
Protocol

Quality Assurance
The sponsor has to implement Quality Control and Quality Assurance systems to ensure that the study will be conducted according to Good Clinical Practices.

Monitoring
Organization and monitoring of the study will be performed by acromion GmbH, Frechen, Germany, under the responsibility of the study sponsor. The study sites have to be monitored regularly. A monitoring guideline will be established by acromion before the initiation visit. The monitoring visits will take place in regular intervals to ensure that the study will be conducted in compliance with the GCP guidelines.
The study monitor is responsible for setting up the study and follow-up (visits, telephone calls, letters, and fax).
The study monitor will visit study centres in order to check that the case report forms are filled in without omission. The monitor will also control the progress of patient inclusion and make sure that the study treatments are stored, dispensed and accounted for according to the specifications given. The investigator must be available to help the clinical monitor during visits.
The monitor is responsible for reviewing it and clarifying and resolving any data queries during his/her next visit on site. The completed and corrected case report forms for completed visits will be collected by the monitor. A copy of the case report form must be kept by the investigator, who will ensure that it is kept safely with the other study documents such as the protocol, investigator's brochure and any protocol amendments.
Any suspicion of fraud has to be documented and the monitor has to inform the coordinating investigator and / or the sponsor. An audit of the centre will be performed as soon as possible to support or invalidate the suspicion. Based on the audit findings, the coordinating investigator will take appropriate measures.

Data Monitoring and Safety Committee (DMSC)
An independent Data Monitoring and Safety Committee (DMSC) consisting of clinical and statistical experts will be established by the sponsor to review the interim efficacy and safety results. The DMSC meets regularly at three months intervals and if necessary. The DMSC will have access to unblinded data. Based on the results of the interim analysis the DMSC will give written recommendations to the sponsor to continue, to modify, to put on hold or to stop the trial.
The DMSC will act according to its own SOP and will prepare written minutes of its meetings. In order not to disseminate unblinded data and to ensure that all staff involved in the conduct of the study remains blind to the results of the interim analysis, only the members of the DMSC and the unblinded statistician will have access to these data.

GERP ALS Study
Protocol The investigator must allow access to the important documents in the medical file to confirm their consistency with the case report form entries. No information on patient identity is allowed in these documents. The following must be checked: existence of informed consent, adherence to in-/exclusion criteria, tabulation of adverse events and completion of the primary safety and efficacy variables. Other checks that the data given in the case report forms complies with the source document will be carried out in accordance with the study specific monitoring plan.

Data recording
All data reported in the case report forms must be clearly noted with a black ballpoint pen so that carbon copies or photocopies are legible. Corrections must be made by crossing out the incorrect term with a single horizontal line so that it remains legible with the correct term next to it. This correct term must be dated and accompanied by the investigator's initials. The use of correction fluid is prohibited All the information stipulated in the protocol must be provided and any omission must be explained.

Retention of documents
The investigator must draft and keep complete and precise documents on the study in compliance with the German Drug Law and Good Clinical Practices. The study documents comprise the following: • Case report forms

Auditing procedures
Rules of Good Clinical Practice have to be considered in their totality and national or foreign inspectors will be allowed access to original documents including patient files at all times during and after the end of the study. The investigator will accept these requirements by participating in the trial. If patient files are stored on a computer system, the investigator has to ensure that the data will be saved and printed on signed and dated paper. The project leader, clinical research assistants, quality assurance personnel, or health authorities (CA, ICC/IRB) have the right of access to the source documents and the right to check that Good Clinical Practices are respected throughout the study conduct. Health authorities may also request the right to carry out an inspection during the study or after it has ended.

Confidentiality of data
The investigator must ensure to keep the entire study information and documents strictly confidential and to demand the same discretion from the complete study team.
Patient data noted in the case report forms during the study must be kept pseudonymously, i.e. the patient will only be identifiable by random/patient number, and date of birth. If it becomes necessary under exceptional circumstances for administrative or safety reasons to disclose the patient's identity, this information must also be kept strictly confidential.

GERP ALS Study
Protocol

Protocol amendments
It is specified that the appendices attached to this protocol and referred to in the main text of this protocol, form an integral part of the protocol. No changes or amendments to this protocol may be made by the Investigator or the Steering Committee after the protocol has been agreed to and signed by both parties unless such change(s) or amendment(s) have been fully discussed and agreed upon by the Investigator and the SC. Any change agreed upon will be recorded in writing; the written amendment will be appended to this protocol. Approval/advice of amendments by the Ethics Committees is required prior to their implementation, unless there are overriding safety reasons. Prior to initiating the changes, protocol amendments must be submitted to competent authority (BfArM), where applicable, except under emergency conditions.
A copy of the written approvals will be given to the investigators.
Amendments involving only administrative items will be sent to the IEC/IRB and the competent authority for information only.

Clinical trial report and publication
The results of the study will be reported in a Clinical Study Report generated by the coordinating investigator according to Good Clinical Practices and ICH recommendations.
The Steering committee will be responsible for timely publication of the results. It is the goal of the coordinating centre to make sure that either positive or negative results will be distributed internationally. The results of the trial, may they be negative or positive will be presented on internationally meetings; a paper is to be published on the international level. The funding agencies will be informed in the study report.

Designated Study Sites and Recruitment Plan
The following centres agreed to participate in the trial and to recruit 10 to 50 patients. All sites have been selected for their successful recruitment of patients in ALS studies in the past ten years.

FURTHER DETAILS OF THE SAE(S) AND COMMENTS:
Include details of signs/symptoms, tests and investigations, treatment given and event progression. Send additional documentation if available e.g. lab reports, post mortem etc.
HISTORY RELEVANT TO THE SAE: medical, social, family and drug history etc.

TIMING OF THE SAE: (When did the SAE occur?)
Before treatment with study medication During treatment During follow-up (after stopping study medication)  Medical progress is based on research which ultimately must rest in part on experimentation involving human subjects. 5. In medical research on human subjects, considerations related to the well-being of the human subject should take precedence over the interests of science and society. 6. The primary purpose of medical research involving human subjects is to improve prophylactic, diagnostic and therapeutic procedures and the understanding of the aetiology and pathogenesis of disease. Even the best proven prophylactic, diagnostic, and therapeutic methods must continuously be challenged through research for their effectiveness, efficiency, accessibility and quality. 7. In current medical practice and in medical research, most prophylactic, diagnostic and therapeutic procedures involve risks and burdens. 8. Medical research is subject to ethical standards that promote respect for all human beings and protect their health and rights. Some research populations are vulnerable and need special protection. The particular needs of the economically and medically disadvantaged must be recognized. Special attention is also required for those who cannot give or refuse consent for themselves, for those who may be subject to giving consent under duress, for those who will not benefit personally from the research and for those for whom the research is combined with care. 9. Research Investigators should be aware of the ethical, legal and regulatory requirements for research on human subjects in their own countries as well as applicable international requirements. No national ethical, legal or regulatory requirement should be allowed to reduce or eliminate any of the protections for human subjects set forth in this Declaration.  10. It is the duty of the physician in medical research to protect the life, health, privacy, and dignity of the human subject. 11. Medical research involving human subjects must conform to generally accepted scientific principles, be based on a thorough knowledge of the scientific literature, other relevant sources of information, and on adequate laboratory and, where appropriate, animal experimentation. 12. Appropriate caution must be exercised in the conduct of research which may affect the environment, and the welfare of animals used for research must be respected. 13. The design and performance of each experimental procedure involving human subjects should be clearly formulated in an experimental protocol. This protocol should be submitted for consideration, comment, guidance, and where appropriate, approval to a specially appointed ethical review committee, which must be independent of the investigator, the sponsor or any other kind of undue influence. This independent committee should be in conformity with the laws and regulations of the country in which the research experiment is performed. The committee has the right to monitor ongoing trials. The researcher has the obligation to provide monitoring information to the committee, especially any serious adverse events. The researcher should also submit to the committee, for review, information regarding funding, sponsors, institutional affiliations, other potential conflicts of interest and incentives for subjects. 14. The research protocol should always contain a statement of the ethical considerations involved and should indicate that there is compliance with the principles enunciated in this Declaration. 15. Medical research involving human subjects should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person. The responsibility for the human subject must always rest with a medically qualified person and never rest on the subject of the research, even though the subject has given consent. 16 21. The right of research subjects to safeguard their integrity must always be respected. Every precaution should be taken to respect the privacy of the subject, the confidentiality of the patient's information and to minimize the impact of the study on the subject's physical and mental integrity and on the personality of the subject. 22. In any research on human beings, each potential subject must be adequately informed of the aims, methods, sources of funding, any possible conflicts of interest, institutional affiliations of the researcher, the anticipated benefits and potential risks of the study and the discomfort it may entail. The subject should be informed of the right to abstain from participation in the study or to withdraw consent to participate at any time without reprisal. After ensuring that the subject has understood the information, the physician should then obtain the subject's freely-given informed consent, preferably in writing. If the consent cannot be obtained in writing, the non-written consent must be formally documented and witnessed. 23. When obtaining informed consent for the research project the physician should be particularly cautious if the subject is in a dependent relationship with the physician or may consent under duress. In that case the informed consent should be obtained by a well-informed physician who is not engaged in the investigation and who is completely independent of this relationship. 24. For a research subject who is legally incompetent, physically or mentally incapable of giving consent or is a legally incompetent minor, the investigator must obtain informed consent from the legally authorized representative in accordance with applicable law. These groups should not be included in research unless the research is necessary to promote the health of the population represented and this research cannot instead be performed on legally competent persons. 25. When a subject deemed legally incompetent, such as a minor child, is able to give assent to decisions about participation in research, the investigator must obtain that assent in addition to the consent of the legally authorized representative. 26. Research on individuals from whom it is not possible to obtain consent, including proxy or advance consent, should be done only if the physical/mental condition that prevents obtaining informed consent is a necessary characteristic of the research population. The specific reasons for involving research subjects with a condition that renders them unable to give informed consent should be stated in the experimental protocol for consideration and approval of the review committee. The protocol should state that consent to remain in the research should be obtained as soon as possible from the individual or a legally authorized surrogate.

C. ADDITIONAL PRINCIPLES FOR MEDICAL RESEARCH COMBINED
WITH MEDICAL CARE 28. The physician may combine medical research with medical care, only to the extent that the research is justified by its potential prophylactic, diagnostic or therapeutic value. When medical research is combined with medical care, additional standards apply to protect the patients who are research subject. 29. The benefits, risks, burdens and effectiveness of a new method should be tested against those of the best current prophylactic, diagnostic, and therapeutic methods. This does not exclude the use of placebo, or no treatment, in studies where no proven prophylactic, diagnostic or therapeutic method exists. (See footnote*) 30. At the conclusion of the study, every patient entered into the study should be assured of access to the best proven prophylactic, diagnostic and therapeutic methods identified by the study. 31. The physician should fully inform the patient which aspects of the care are related to the research. The refusal of a patient to participate in a study must never interfere with the patient-physician relationship. 32. In the treatment of a patient, where proven prophylactic, diagnostic and therapeutic methods do not exist or have been ineffective, the physician, with informed consent from the patient, must be free to use unproven or new prophylactic, diagnostic and therapeutic measures, if in the physician's judgement it offers hope of saving life, reestablishing health or alleviating suffering. Where possible, these measures should be made the object of research, designed to evaluate their safety and efficacy. In all cases, new information should be recorded and, where appropriate, published. The other relevant guidelines of this Declaration should be followed.

*FOOTNOTE: Note of Clarification on Paragraph 29 of the WMA Declaration of Helsinki
The WMA hereby reaffirms its position that extreme care must be taken in making use of a placebocontrolled trial and that in general this methodology should only be used in the absence of existing proven therapy. However, a placebo-controlled trial may be ethically acceptable, even if proven therapy is available, under the following circumstances: -Where for compelling and scientifically sound methodological reasons its use is necessary to determine the efficacy or safety of a prophylactic, diagnostic or therapeutic method; or -Where a prophylactic, diagnostic or therapeutic method is being investigated for a minor condition and the patients who receive placebo will not be subject to any additional risk of serious or irreversible harm. All other provisions of the Declaration of Helsinki must be adhered to, especially the need for appropriate ethical and scientific review. § 40 Allgemeine Voraussetzungen der klinischen Prüfung (1)  (1) Auf eine klinische Prüfung bei einer volljährigen Person, die an einer Krankheit leidet, zu deren Behandlung das zu prüfende Arzneimittel angewendet werden soll, findet § 40 Abs. 1 bis 3 mit folgender Maßgabe Anwendung: 1. Die Anwendung des zu prüfenden Arzneimittels muss nach den Erkenntnissen der medizinischen Wissenschaft angezeigt sein, um das Leben dieser Person zu retten, ihre Gesundheit wiederherzustellen oder ihr Leiden zu erleichtern, oder 2. sie muss für die Gruppe der Patienten, die an der gleichen Krankheit leiden wie diese Person, mit einem direkten Nutzen verbunden sein. Kann die Einwilligung wegen einer Notfallsituation nicht eingeholt werden, so darf eine Behandlung, die ohne Aufschub erforderlich ist, um das Leben der betroffenen Person zu retten, ihre Gesundheit wiederherzustellen oder ihr Leiden zu erleichtern, umgehend erfolgen. Die Einwilligung zur weiteren Teilnahme ist einzuholen, sobald dies möglich und zumutbar ist.