| E.1 Medical condition or disease under investigation |
| E.1.1 | Medical condition(s) being investigated |
| Spinal Muscular Atrophy (SMA) |
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| E.1.1.1 | Medical condition in easily understood language |
| SMA is a genetic disorder that affects the control of muscle movement. It is caused by a loss of motor neurons, in the spinal cord and the part of the brain that is connected to the spinal cord |
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| E.1.1.2 | Therapeutic area | Diseases [C] - Nervous System Diseases [C10] |
| MedDRA Classification |
| E.1.2 Medical condition or disease under investigation |
| E.1.2 | Version | 20.1 |
| E.1.2 | Level | PT |
| E.1.2 | Classification code | 10041582 |
| E.1.2 | Term | Spinal muscular atrophy |
| E.1.2 | System Organ Class | 10010331 - Congenital, familial and genetic disorders |
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| E.1.2 Medical condition or disease under investigation |
| E.1.2 | Version | 20.0 |
| E.1.2 | Level | LLT |
| E.1.2 | Classification code | 10079419 |
| E.1.2 | Term | Spinal muscular atrophy pre-symptomatic |
| E.1.2 | System Organ Class | 10010331 - Congenital, familial and genetic disorders |
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| E.1.3 | Condition being studied is a rare disease | Yes |
| E.2 Objective of the trial |
| E.2.1 | Main objective of the trial |
| •To evaluate the efficacy of risdiplam in patients with two copies of the survival motor neuron (SMN)2 gene (excluding the known SMN2 gene modifier mutation c.859G> C) and baseline compound muscle action potential (CMAP) amplitude ≥ 1.5 mV, as determined by the proportion of patients who are sitting without support after 12 months of treatment |
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| E.2.2 | Secondary objectives of the trial |
•To evaluate the efficacy of risdiplam on the development of clinically manifested SMA
•To evaluate the efficacy of risdiplam on survival and permanent ventilation
•To evaluate the efficacy of risdiplam on achievement of motor milestones
•To evaluate the efficacy of risdiplam on motor function
•To evaluate the efficacy of risdiplam on growth measures
•To evaluate the efficacy of risdiplam on nutritional status of the patients
•To evaluate the efficacy of risdiplam on the degree of innervation upon treatment with risdiplam
•To evaluate the pharmacodynamic effects of risdiplam
•To evaluate the safety of risdiplam
•To characterize the pharmacokinetics profile of risdiplam
•To identify biomarkers that are predictive of response to risdiplam
•To evaluate parent (or caregiver)-rated health status and health-related quality of life
|
|
| E.2.3 | Trial contains a sub-study | No |
| E.3 | Principal inclusion criteria |
- Males and females aged from birth (1 day) to 6 weeks (42 days) of age at the time of first dose (Day 1); a minimum age of 7 days at first dose is required for the first infant to be enrolled
- Gestational age of 37-42 weeks for singleton births; gestational age of 34-42 weeks for twins
- Body weight >= 3rd percentile for age, using appropriate country-specific guidelines
- Genetic diagnosis of 5q-autosomal recessive SMA, including confirmation of homozygous deletion or compound heterozygosity predictive of loss of function of the SMN1 gene
- Absence of clinical signs or symptoms at screening (Day -42 to Day -2) or at baseline (Day -1) that are, in the opinion of the investigator, strongly suggestive of SMA
- Receiving adequate nutrition and hydration at the time of screening, in the opinion of the investigator
- Adequately recovered from any acute illness at baseline and considered well enough to participate in the study, in the opinion of the investigator
- Able and expected to be able to safely travel to the study site for the entire duration of the study and in accordance to the frequency of required study visits, in the opinion of the investigator
- Able to complete all study procedures, measurements, and visits, and the parent (or caregiver), in the opinion of the investigator, has adequately supportive psychosocial circumstances
- Parent (or caregiver) is willing to consider nasogastric, naso-jejunal, or gastrostomy tube placement during the study to maintain safe hydration, nutrition, and treatment delivery, if recommended by the investigator
- Parent (or caregiver) is willing to consider the use of non-invasive ventilation during the study, if recommended by the investigator
|
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| E.4 | Principal exclusion criteria |
- Concomitant or previous participation in any investigational drug or device study at any time
- Concomitant or previous administration of an SMN2-targeting antisense oligonucleotide, SMN2-splicing modifier, or gene therapy either in a clinical study or as part of medical care
- Presence of significant concurrent syndromes or diseases
- In the opinion of the investigator, inadequate venous or capillary blood access for the study procedures
- Requiring invasive ventilation, tracheostomy or awake non-invasive ventilation
- Awake hypoxemia (SaO2 < 95%) with or without ventilator support
- Multiple or fixed contractures and/or hip subluxation or dislocation at birth
- Systolic blood pressure or diastolic blood pressure or heart rate considered to be clinically significant by the investigator
- Presence of clinically relevant ECG abnormalities before study drug administration; corrected QT interval using Bazett’s method > 460 ms; personal or family history (first degree relatives) of congenital long QT syndrome indicating a safety risk for patients as determined by the investigator. First-degree atrioventricular block or isolated right bundle branch block are allowed
- The infant (and the mother, if breastfeeding the infant) taking any inhibitor of CYP3A4 taken within 2 weeks, any inducer of CYP3A4 taken within 4 weeks, any OCT 2 and MATE substrates within 2 weeks and known FMO1 or FMO3 inhibitors or substrates
- Clinically significant abnormalities in laboratory test results
- Ascertained or presumptive hypersensitivity to risdiplam or to the constituents of its formulation
- Treatment with oral salbutamol or another beta-2 adrenergic agonist taken orally for SMA is not allowed. Use of inhaled beta-2 adrenergic agonists is allowed
- Infants exposed to drugs with known retinal toxicity given to mothers during pregnancy (and lactation) should not be enrolled. Anticipated need for drugs known to cause retinal toxicity during the study.
- Diagnosis of ophthalmic diseases
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|
| E.5 End points |
| E.5.1 | Primary end point(s) |
| 1.The proportion of infants with two copies of the survival motor neuron (SMN) 2 gene (excluding the known SMN2 gene modifier mutation c.859G> C) and baseline compound muscle action potential (CMAP) amplitude >=1.5 mV who are sitting without support. Sitting is defined as “sits without support for 5 seconds” as assessed in Item 22 of the Bayley Scales of Infant and Toddler Development®, Third Edition [BSID-III] Gross Motor Scale. |
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| E.5.1.1 | Timepoint(s) of evaluation of this end point |
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| E.5.2 | Secondary end point(s) |
1.Proportion of infants developing clinically manifested SMA at month 12 and 24 of treatment
2.Time to death or permanent ventilation
3.Proportion of infants who are alive without permanent ventilation at Month 12 and 24 of treatment
4.Proportion of patients alive (at Month 12 and Month 24 of treatment)
5.Proportion of infants who achieve the attainment level of the motor milestones as assessed in the Hammersmith Infant Neurological Examination-2 (head control, sitting, voluntary grasp, ability to kick, rolling, crawling, standing, and walking) at Month 12 and 24 of treatment
6.Proportion of infants with two copies of the SMN2 gene sitting without support at Month 12 of treatment (as assessed in Item 22 of BSID-III Gross Motor Scale) for 5 seconds (independent of the CMAP value at baseline)
7.Proportion of infants sitting without support at Month 24 of treatment (as assessed in Item 22 of the BSID-III Gross Motor Scale) for 5 seconds
8. Proportion of patients with two copies of the SMN2 gene sitting without support (at Month 12 of treatment [as assessed in Item 22 of BSID III Gross Motor Scale]) for 5 seconds (independent of the CMAP value at baseline)
9.Proportion of infants sitting without support at Month 12 of treatment (as assessed in Item 26 of the BSID-III Gross Motor Scale) for 30 seconds
10.Proportion of infants sitting without support at Month 24 of treatment (as assessed in Item 26 of the BSID-III Gross Motor Scale) for 30 seconds
11.Proportion of infants standing at Month 24 of treatment (defined as “Stands Alone” for at least 3 seconds as assessed in Item 40 and 42 of the BSID-III Gross Motor Scale)
12.Proportion of infants walking at Month 24 of treatment (defined as “Walks Alone” takes at least 3 steps as assessed in Item 42 of the BSID-III Gross Motor Scale)
13.Change from baseline score in the Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP INTEND) motor function scale at Month 12 of treatment
14.Proportion of infants who achieve a score of 40 and 50 or higher in the CHOP INTEND motor function scale at Month 12 and 24 of treatment
15.Proportion of infants who achieve a score of 60 or higher in the CHOP INTEND motor function scale at Month 12 of treatment
16.Proportion of patients who meet CHOP INTEND stopping criteria at any point up to Month 24 of treatment
17.Change from baseline (Month 24) in the Hammersmith Functional Motor Scale Expanded (HFMSE) (at Month 60 of treatment).
18.Number and proportion of infants within 3rd percentile of normal range for weight-for-age, length/height-for-age, and weight-for-length/height, (from enrollment) at Month 12, 24, 36, 48, and 60 of treatment
19.Number and proportion of patients within 3rd percentile of normal range for head circumference for age at Month 12 and 24 of treatment
20.Change from baseline percentiles for weight-for-age, length/height-for-age, and weight-for-length/height at Months 12, 24, 36, 48 and 60 of treatment
21.Change from baseline percentiles for head circumference for age at Month 12 and Month 24 of treatment
22.Change from baseline in chest circumference at Month 12 and 24 of treatment
23.Ratio between chest and head circumferences at Month 12 and 24 of treatment
24.Proportion of infants with the ability to swallow at Month 12, 24, 36, 48 and 60 of treatment
25.Proportion of infants with the ability to feed orally at Month 12, 24, 36, 48 and 60 of treatment
26.Change from baseline in CMAP amplitude at Month 12 and 24 of treatment
27.SMN mRNA and SMN protein levels in blood
28.Incidence and severity of adverse events with severity determined according to the National Cancer Institute Common Terminology Criteria for Adverse Events, Version 5 (NCI CTCAE) v5
29.Incidence and severity of serious adverse events
30.Incidence of treatment discontinuation due to adverse events
31.Incidence of abnormal laboratory, ECG values and vital signs abnormalities
32.Incidence of clinically significant findings on ophthalmological examination
33.Plasma concentration of risdiplam and its metabolites
34.Area under curve of risdiplam
35.Concentration at the end of a dosing interval to assess steady-state
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| E.5.2.1 | Timepoint(s) of evaluation of this end point |
1. Up to Month 12 and 24
2. Up to 7 years
3-5. At Month 12 and 24
6. At Month 12
7. At Month 24
8-9. At Month 12
10-12. At Month 24
13. Baseline (Day -1) to Month 12
14. At Month 12 and 24
15. At Month 12
16. Up to Month 24
17. Month 24 to 60
18. At Month 12, 24, 36, 48, and 60
19. At Month 12 and 24
20. Baseline to Month 12, 24, 36, 48 and 60 of treatment
21-22. Baseline to Month 12 and 24
23. At Month 12 and 24
24-25. Baseline to Month 12, 24, 36, 48 and 60 of treatment
26. Baseline to Month 12 and 24
27. Day 1, 56, 196, 364, 728 and at Study Completion/Early Withdrawal
28-35. Up to 7 years
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| E.6 and E.7 Scope of the trial |
| E.6 | Scope of the trial |
| E.6.1 | Diagnosis | No |
| E.6.2 | Prophylaxis | No |
| E.6.3 | Therapy | No |
| E.6.4 | Safety | Yes |
| E.6.5 | Efficacy | Yes |
| E.6.6 | Pharmacokinetic | Yes |
| E.6.7 | Pharmacodynamic | Yes |
| E.6.8 | Bioequivalence | No |
| E.6.9 | Dose response | No |
| E.6.10 | Pharmacogenetic | No |
| E.6.11 | Pharmacogenomic | No |
| E.6.12 | Pharmacoeconomic | No |
| E.6.13 | Others | No |
| E.7 | Trial type and phase |
| E.7.1 | Human pharmacology (Phase I) | No |
| E.7.1.1 | First administration to humans | No |
| E.7.1.2 | Bioequivalence study | No |
| E.7.1.3 | Other | No |
| E.7.1.3.1 | Other trial type description | |
| E.7.2 | Therapeutic exploratory (Phase II) | Yes |
| E.7.3 | Therapeutic confirmatory (Phase III) | No |
| E.7.4 | Therapeutic use (Phase IV) | No |
| E.8 Design of the trial |
| E.8.1 | Controlled | No |
| E.8.1.1 | Randomised | No |
| E.8.1.2 | Open | Yes |
| E.8.1.3 | Single blind | No |
| E.8.1.4 | Double blind | No |
| E.8.1.5 | Parallel group | No |
| E.8.1.6 | Cross over | No |
| E.8.1.7 | Other | No |
| E.8.2 | Comparator of controlled trial |
| E.8.2.1 | Other medicinal product(s) | No |
| E.8.2.2 | Placebo | No |
| E.8.2.3 | Other | No |
| E.8.2.4 | Number of treatment arms in the trial | 1 |
| E.8.3 |
The trial involves single site in the Member State concerned
| No |
| E.8.4 | The trial involves multiple sites in the Member State concerned | Yes |
| E.8.5 | The trial involves multiple Member States | Yes |
| E.8.5.1 | Number of sites anticipated in the EEA | 4 |
| E.8.6 Trial involving sites outside the EEA |
| E.8.6.1 | Trial being conducted both within and outside the EEA | Yes |
| E.8.6.2 | Trial being conducted completely outside of the EEA | No |
| E.8.6.3 | If E.8.6.1 or E.8.6.2 are Yes, specify the regions in which trial sites are planned |
| Australia |
| Brazil |
| China |
| Russian Federation |
| Saudi Arabia |
| United States |
| Belgium |
| Italy |
| Poland |
|
| E.8.7 | Trial has a data monitoring committee | Yes |
| E.8.8 |
Definition of the end of the trial and justification where it is not the last
visit of the last subject undergoing the trial
|
The end of this study is defined as the date when the last patient, last visit occurs.
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| E.8.9 Initial estimate of the duration of the trial |
| E.8.9.1 | In the Member State concerned years | |
| E.8.9.1 | In the Member State concerned months | |
| E.8.9.1 | In the Member State concerned days | |
| E.8.9.2 | In all countries concerned by the trial years | 6 |
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