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2014N191472_07 CONFIDENTIALThe GlaxoSmithKline group of companies TR4117387

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TITLE PAGE

Division: Worldwide DevelopmentInformation Type: Protocol Amendment

Title: A sponsor un-blinded, placebo-controlled study to evaluate the safety, tolerability, pharmacokinetics, and pharmacodynamics of single and repeat, ascending doses of GSK2798745 in healthy subjects and stable heart failure patients

Compound Number: GSK2798745

Development Phase: II

Effective Date: 06-NOV-2015

Protocol Amendment Number: 07

Author (s):

Copyright 2015 the GlaxoSmithKline group of companies. All rights reserved. Unauthorised copying or use of this information is prohibited.

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Revision Chronology

GlaxoSmithKline Document Number

Date Version

2014N191472_00 2014-FEB-05 Original

2014N191472_01 2014-MAR-24 Amendment No. 1

Amendment No. 1: This amendment incorporates the changes requested during MHRA review, and corrects minor discrepancies that were in the original protocol.

2014N191472_02 2014-AUG-12 Amendment No. 2

Amendment No. 2: This amendment incorporates the addition of new assessments for Cohort 3 and 4 and corrects minor discrepancies in the protocol amendment 01.

2014N191472_03 2014-AUG-29 Amendment No. 3

Amendment No. 3: This amendment incorporates the addition of a new exploratory endpoint and assessment for Cohort 3 and corrects minor discrepancies that were in the protocol.

2014N191472_04 2014-DEC-02 Amendment No. 4

Amendment No. 4: This amendment incorporates changes to the dose rationale, the addition of new exploratory endpoints, changes to Cohort 3 and additional assessments for Cohort 4.

2014N191472_05 2015-JUN-26 Amendment No. 5

Amendment No. 5: This amendment allows for the change to a multi-centre study, changes to the eligibility criteria, and changes to the design of Cohort 4.

2014N191472_06 2015-SEP-29 Amendment No. 06

Amendment No. 6: This amendment incorporates the addition of a new Cohort (Cohort 5).

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GlaxoSmithKline Document Number

Date Version

2014N191472_07 2015-NOV-06 Amendment No. 07

Amendment No. 7: This amendment revised the QTc eligibility and withdrawal criteria for Cohorts 4 and 5.

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2014N191472_07 CONFIDENTIALTR4117387

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SPONSOR/MEDICAL MONITOR INFORMATION PAGE

Medical Monitor and Sponsor Contact Information:

Role Name Day Time Phone Number

After-hours Phone/Cell/Pager Number

Fax Number

GSK Address

Primary Medical Monitor

MD

GlaxoSmithKline709 Swedeland Road, King of Prussia, PA 19406 USA

Secondary Medical Monitor

MD


Tertiary Medical Monitor

MD


Sponsor Legal Registered Address:

GlaxoSmithKline Research & Development Limited980 Great West RoadBrentfordMiddlesex, TW8 9GSUK

In some countries, the clinical trial sponsor may be the local GlaxoSmithKline Affiliate Company (or designee). If applicable, the details of the alternative Sponsor and contact person in the territory will be provided to the relevant regulatory authority as part of the clinical trial application.

Regulatory Agency Identifying Number(s): 2013-004547-23

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INVESTIGATOR PROTOCOL AGREEMENT PAGE

For protocol TR4117387I confirm agreement to conduct the study in compliance with the protocol, as amended by this protocol amendment.

I acknowledge that I am responsible for overall study conduct. I agree to personally conduct or supervise the described study.

I agree to ensure that all associates, colleagues and employees assisting in the conduct of the study are informed about their obligations. Mechanisms are in place to ensure that site staff receives the appropriate information throughout the study.

Investigator Name:

Investigator Address:

Investigator Phone Number:

Investigator Signature Date

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TABLE OF CONTENTS

PAGE

LIST OF ABBREVIATIONS...........................................................................................11

1. INTRODUCTION....................................................................................................141.1. Study Rationale ..........................................................................................141.2. Brief Background ........................................................................................15

1.2.1. GSK2798745 ...............................................................................16

2. OBJECTIVES AND ENDPOINTS...........................................................................18

3. STUDY DESIGN ....................................................................................................193.1. Study Schematic.........................................................................................193.2. Study Design Detail ....................................................................................20

3.2.1. Healthy Subjects Single Dose (Cohorts 1 and 2) .........................203.2.1.1. Single Dose Escalation - Cohort 1 ..............................213.2.1.2. Relative Bioavailability and Food Effect -

Cohort 2 .....................................................................223.2.2. Healthy Subjects Repeat Dose - Cohort 3....................................23

3.2.2.1. Dose Considerations - Cohort 3..................................233.2.3. Heart Failure Patients Single and Repeat Dose - Cohort 4 ..........243.2.4. Heart Failure Patients – Cohort 5.................................................27

3.3. Drug Formulation ........................................................................................283.4. Dose Rationale ...........................................................................................28

3.4.1. Pharmacokinetic Predictions for GSK2798745 ............................283.4.2. No Observed Adverse Effect Level (NOAEL) Dose......................29

3.4.2.1. Rat 4-Week Toxicity Study .........................................293.4.2.2. Dog 4-Week Toxicity Study ........................................293.4.2.3. Dog 3-Month Toxicity Study........................................30

3.4.2.3.1. Findings..................................................303.4.2.3.2. Risk Assessment ....................................30

3.4.3. TRPV4 Channel Inhibition............................................................313.4.4. Maximum Starting Dose Using NOAEL........................................323.4.5. Safety Cover Based on Predicted Exposure and NOAEL

from the Pre-Clinical Species.......................................................323.4.5.1. Doses based on clinical data from Cohorts 1-3

in FTIH study..............................................................343.4.6. Dosing and Randomization..........................................................35

3.5. Risk Management.......................................................................................36

4. STUDY POPULATION ...........................................................................................404.1. Number of Subjects ....................................................................................404.2. Eligibility Criteria .........................................................................................41

4.2.1. Inclusion Criteria for Healthy Subjects Cohorts (1-3)....................414.2.2. Inclusion Criteria for Subjects with Heart Failure (Cohort 4) .........424.2.3. Inclusion Criteria for Subjects with Heart Failure (Cohort 5) .........434.2.4. Exclusion Criteria That Apply to All Subjects (Healthy

Subjects and HF Patients in Cohorts 1-4) ....................................44

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4.2.5. Exclusion Criteria for Subjects with Heart Failure (Cohort 4) .................................................................................................45

4.2.6. Exclusion Criteria for Subjects with Heart Failure (Cohort 5) .................................................................................................45

4.3. Lifestyle and/or Dietary Restrictions............................................................464.3.1. Contraception Requirements .......................................................46

4.3.1.1. Male Subjects.............................................................464.3.2. Meals and Dietary Restrictions ....................................................474.3.3. Caffeine, Alcohol..........................................................................484.3.4. Activity .........................................................................................48

4.4. Screen and Baseline Failures .....................................................................484.5. Withdrawal Criteria and Procedures............................................................484.6. Subject Completion.....................................................................................49

5. STUDY TREATMENT ............................................................................................505.1. Investigational Product and Other Study Treatment

Dosage/Administration................................................................................505.2. Treatment Assignment................................................................................515.3. Planned Dose Adjustments and Stopping Criteria.......................................51

5.3.1. Liver Chemistry Stopping Criteria ................................................515.3.2. QTc Withdrawal Criteria...............................................................51

5.3.2.1. Healthy Subjects (Cohorts 1 thru 3)............................515.3.2.2. Heart Failure Patients (Cohorts 4 and 5) ....................52

5.3.3. Other Dose Adjustment/Stopping Safety Criteria .........................535.3.3.1. Troponin Stopping Criteria..........................................535.3.3.2. Asymptomatic Subject ................................................535.3.3.3. Symptomatic Subject..................................................535.3.3.4. Stopping Criteria Related to Digoxin...........................535.3.3.5. Stopping Criteria Related to CrCl and MRI

Scanning ....................................................................545.4. Blinding.......................................................................................................545.5. Packaging and Labelling.............................................................................545.6. Preparation/Handling/Storage/Accountability ..............................................545.7. Assessment of Compliance ........................................................................555.8. Treatment of Study Treatment Overdose....................................................555.9. Treatment after the End of the Study ..........................................................555.10. Concomitant Medications and Non-Drug Therapies....................................56

5.10.1. Permitted Medications for Healthy Subjects.................................565.10.2. Permitted Medications for Heart Failure Patients .........................565.10.3. Prohibited Medications and Non-Drug Therapies for

Healthy Subjects..........................................................................565.10.4. Prohibited Medications and Non-Drug Therapies for Heart

Failure Subjects ...........................................................................56

6. STUDY ASSESSMENTS AND PROCEDURES .....................................................596.1. Time and Events Table ...............................................................................606.2. Demographic/Medical History Assessments ...............................................706.3. Safety .........................................................................................................70

6.3.1. Physical Examinations .................................................................706.3.2. Vital Signs and Other Measures ..................................................716.3.3. Electrocardiogram (ECG).............................................................716.3.4. Telemetry Monitoring ...................................................................71

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6.3.5. Holter Monitoring .........................................................................726.3.6. Audiometry ..................................................................................726.3.7. Remote Monitoring ......................................................................726.3.8. SensiVest ....................................................................................726.3.9. Clinical Laboratory Assessments .................................................726.3.10. Safety Laboratory Samples..........................................................74

6.3.10.1. Sample Collection ......................................................746.3.11. Blood Sample Collection for Troponin..........................................746.3.12. Blood Sample Collection for Digoxin ............................................746.3.13. Suicidality (C-SSRS) and Possible Suicidality Related

Adverse Event(s) .........................................................................746.4. Pharmacokinetics .......................................................................................75

6.4.1. Blood Sample Collection for Pharmacokinetics............................756.4.2. Urine Sample Collection ..............................................................766.4.3. Sample Analysis ..........................................................................76

6.5. Pharmacodynamic Profile ...........................................................................766.6. Transcriptomic and Metabolomic Profiles....................................................776.7. Biomarkers .................................................................................................77

6.7.1. Blood Sample Collection for Biomarkers......................................776.8. Efficacy.......................................................................................................78

6.8.1. Exercise Tolerance for Cohort 3 and Cohort 4 .............................786.8.2. DLco and DLno............................................................................786.8.3. Magnetic Resonance Imaging (Cohort 4).....................................79

6.8.3.1. Subject Scanning Procedures ....................................796.8.3.2. Phantom Scanning .....................................................796.8.3.3. Data Transfer .............................................................806.8.3.4. DCE-MRI Data Analysis .............................................80

6.8.4. Oral Glucose Tolerance Test (OGTT) ..........................................806.8.5. Dyspnoea Scale Scoring..............................................................80

6.9. Pharmacogenetics ......................................................................................80

7. ADVERSE EVENTS, SERIOUS ADVERSE EVENTS, PREGNANCY AND MEDICAL DEVICE INCIDENTS.............................................................................817.1. Adverse Events (AE) and Serious Adverse Events (SAEs).........................81

7.1.1. Time Period for Collecting AE and SAE Information ....................817.1.2. Method of Detecting AEs and SAEs.............................................817.1.3. Definition of Adverse Events........................................................827.1.4. Definition of Serious Adverse Events ...........................................837.1.5. Cardiovascular Events .................................................................847.1.6. Death Events ...............................................................................847.1.7. Prompt Reporting of SAEs to GSK...............................................847.1.8. Regulatory Reporting Requirements for SAEs .............................85

7.2. Pregnancy ..................................................................................................857.2.1. Time Period for Collecting Pregnancy Information .......................857.2.2. Action to be taken if pregnancy occurs in a female partner

of a male study subject ................................................................85

8. DATA MANAGEMENT ...........................................................................................86

9. DATA ANALYSIS AND STATISTICAL CONSIDERATIONS...................................869.1. Hypotheses and Treatment Comparisons...................................................869.2. Sample Size Considerations.......................................................................86

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9.2.1. Cohorts 1-2 (Healthy Subjects Single Dose) ................................869.2.2. Cohort 3 (Healthy Subjects Repeat Dose) ...................................879.2.3. Cohort 4 (Heart Failure Patients Single and Repeat Dose) ..........879.2.4. Cohort 5 (Heart Failure Patients Repeat Dose)............................879.2.5. Interstitial volume (ve) ..................................................................879.2.6. Sample Size Re-estimation..........................................................87

9.3. Data Analysis Considerations .....................................................................879.3.1. Interim Analysis ...........................................................................879.3.2. Final Analyses .............................................................................88

9.3.2.1. Safety Analyses..........................................................889.3.2.2. Pharmacokinetic Analyses..........................................889.3.2.3. Pharmacodynamic Analyses ......................................89

9.3.2.3.1. Cohort 4 and Cohort 5 ............................89

10. STUDY GOVERNANCE CONSIDERATIONS........................................................8910.1. Posting of Information on Publicly Available Clinical Trial Registers............8910.2. Regulatory and Ethical Considerations, Including the Informed

Consent Process ........................................................................................8910.2.1. Urgent Safety Measures ..............................................................90

10.3. Quality Control (Study Monitoring) ..............................................................9010.4. Quality Assurance.......................................................................................9110.5. Study and Site Closure ...............................................................................9110.6. Records Retention ......................................................................................9110.7. Provision of Study Results to Investigators, Posting of Information

on Publically Available Clinical Trials Registers and Publication .................92

11. REFERENCES.......................................................................................................93

12. APPENDICES ........................................................................................................9712.1. Appendix 1: Liver Safety Process ...............................................................9712.2. Appendix 2: Pharmacogenetic Research ..................................................10012.3. Appendix 3: Procedures for Detection, Evaluation, Follow-Up and

Reporting of Adverse Events Recording of AEs and SAEs .......................10512.4. Appendix 4: Treatment Sequences for Cohort 1 .......................................10812.5. Appendix 5 Treatment Regimens..............................................................10912.6. Appendix 6: Dose Rationale Background..................................................11012.7. Appendix 7 Example Copy Suicidality Scale .............................................11212.8. Appendix 8: Protocol Amendment Changes..............................................140

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LIST OF ABBREVIATIONS

3D SPGR 3D Spoiled Gradient EchoAE Adverse EventADME Absorption, Distribution, Metobolism, EliminationALT Alanine transaminaseANP Atrial natriuretic peptideAPI Active pharmaceutical ingredientAST Aspartate aminotransferaseAUC Area under the curveBE BioequivalenceBMI Body mass indexBNP Brain natriuretic peptideC-CASA Columbia Classification Algorithm for Suicide AssessmentCHF Chronic heart failureCI Confidence intervalsCl Low clearanceCmax Maximum concentrationCMT2C Charcot-Marie-Tooth disease Type 2C CNS Central nervous systemCO Carbon monoxideCO2 Carbon dioxideCPK Creatine phosphokinaseCRF Case report formC-SSRS Columbia Suicide Severity Rating ScalecTn Troponin

Cv Coefficient of VarianceCV Cardiovacsular

CYPDCE

Cytochrome P450 enzymeDynamic Contrast Enhanced

DLco Diffusing capacity of the lung for carbon monoxideDLno Diffusing capacity of the lung for nitric oxideDMPK Drug Metabolism and PharmacokineticsDNA Deoxyribonucleic acidECG ElectrocardiogrameCRF Electronic case report formEEG Electroencephalography

Emax Nonlinear model frequently used in dose–response analysesEMEA European Medicines AgencyFDA Food and Drug AdministrationFSH Follicle stimulating hormoneFTIH First time in humanGCPGd

Good Clinical PracticeGadolinium

GFR Glomerular filtration rateGI Gastrointestinal

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GLP Good laboratory practiceGP General practitioner

GSK GlaxoSmithKlineHBsAg Hepatitis B surface antigenHED Human equivalent doseHEK Human embryonic kidney cellsHF Heart failureHIV Human immunodeficiency virusIB Investigator’s BrochureIDSL Integrated Data Standards LibraryIEC Institutional ethics committeeIgM ImmunoglobulinIRB Institutional review boardIUD Intrauterine deviceIUS Intrauterine systemKgKtrans

KilogramExchange rate

LDH Lactate dehydrogenaseLFT Liver function testsLSLV Last subject’s last visitMedDRA Medical Dictionary for Regulatory Activitiesmg MilligramMI Myocardial infarctionmLMRI

MilliliterMagnetic Resonance Imaging

MRSD Maximum recommended starting doseMSDSNaNaCl

Material Safety Data SheetSodiumSodium chloride

nM NanomolarNO Nitrogen oxideNOAELNSF/NFD

No observed adverse event level Nephrogenic Systemic Fibrosis/Nephrogenic Fibrosing Dermopathy

NYHA New York Heart AssociationOGTT Oral glucose tolerance testPAPACS

Pulmonary arteryPicture Archiving and Communication System

PD PharmacodynamicPGx PharmacogeneticPK PharmacokineticsPSRAE Possibly suicidality-related adverse eventPVP Pulmonary venous pressureQOL Quality of LifeRAPReDS

Reporting and analysis planRemote dielectric sensing

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RERRIS

Respiratory exchange ratioRadiology Information System

RNA Ribonucleic acidSPM Study procedures manualT ½TETR

Half lifeEcho Time Repetition Time

TRPV4 Transient receptor potential vanilloid 4Ug MicrogramsULN Upper limit of normalVCO2 Volume of carbon dioxideVdVe

Volume of distributionInterstitial volume

VE VentilationVO2

VpWBC

Volume of oxygenPlasma VolumeWhite Blood Cells

Trademark Information

Trademarks of the GlaxoSmithKline group of companies

Trademarks not owned by the GlaxoSmithKline group of companies

NONE WinNonlin

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1. INTRODUCTION

This study is the First Time in Human Study (FTIH) for GSK2798745 and will evaluate the safety, tolerability, and pharmacokinetics (PK) of single and repeat oral doses of GSK2798745 administered to healthy subjects (Cohorts 1 through 3) and subjects with stable heart failure (Cohorts 4 and 5). In addition, this study will interrogate evidence for a functional effect of transient receptor potential vanilloid 4 (TRPV4) channel blockade on exercise tolerance, lung gas permeability parameters, pulmonary oedema, and vascular permeability in patients with stable heart failure.

1.1. Study Rationale

TPRV4 is an ion channel expressed in the pulmonary vasculature distributed through the alveolar septum. Multiple lines of evidence from animal models have identified an important role for TRPV4 in mediating the development of cardiogenic pulmonary edema. Using a TRPV4 blocker prior to or after the induction of high pulmonary venous pressure in preclinical models leads to amelioration of the anticipated increase in lung edema, accompanied by an improvement in PO2 [Thorneloe, 2012].

Based on the role of TRPV4 in the mediation of fluid associated with cardiogenic pulmonary edema, it is postulated that inhibition of this channel may provide therapeutic benefits in patients presenting with pulmonary edema. Such an apparent improvement in the alveolar septal barrier, leading to a reduction in extravascular lung fluid, may lead to better symptom relief, allowing these patients to increase their exercise tolerance, to reduce orthopnoea and paroxysmal nocturnal dyspnoea, and/or to have less frequent need for hospitalization or acute care. These symptoms and their complications are all thought to be related to high pulmonary venous pressure resulting from left ventricular dysfunction. The extravasation of fluid into pulmonary tissue can lead to enhanced lung stiffness, abnormal gas exchange, and ultimately a sense of dyspnoea.

During exercise, normal physiology would predict a steady flow of fluid into the pulmonary interstitial space, followed by lymphatic drainage. This will likely be amplified when the pulmonary artery (PA) venous pressures begin to increase during a bout of exercise. We hypothesize that this fluid cycle will be disrupted during the administration of the TPV4 blocker, possibly leading to benefits on exercise tolerance and dyspnoea in patients with HF. However, since the physiological consequences of this drug mechanism have not been previously evaluated in humans, we have chosen to initiate the exercise effort in healthy subjects prior to advancing to HF patients.

Prior to this study, GSK2798745 has never been administered to humans. Accordingly, the first phase of this study will address the safety, tolerability, and the pharmacokinetics (PK) of GSK2798745 in healthy adult subjects with single and repeat administration. In addition, the relative bioavailability of GSK2798745 administered via capsule as compared to liquid formulation and effect of food on systemic exposure of GSK2798745 will be evaluated through different cohorts as outlined in Table 1 and study schematics in Section 3. Exercise tolerability will be evaluated in the healthy subjects in the repeat dose cohort (Cohort 3) to further establish safety during exercise as explained above.

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Further, given the potential interstitial fluid excess and thus compromise in gas exchange in healthy subjects during exercise, there may be a beneficial effect.

This study will then progress into patients with stable heart failure. Stable heart failure is defined as patients with an established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) class II or III. This definition includes the maintenance of stable heart failure therapy for 1 month and lack of heart failure hospitalization for at least 3 months. In this cohort we will evaluate the effects of GSK2798745 primarily on safety, including clinical assessments and exercise tolerance. However, despite the small numbers, an exploratory assessment of effect will be performed, which will include assessment of respiratory rates, exercise capacity, alveolar:vascular gas transfer, pulmonary oedema, and vascular permeability. These assessments will test directly or indirectly for the potential reduction in lung interstitial fluid with GSK2798745 and the functional benefit in the setting of exercise.

Dynamic contrast enhanced (DCE) MRI is an established technique for assessing changes in vascular permeability and interstitial water volume. DCE-MRI measures the exchange of an extracellular MRI contrast agent as it travels between the intravascular space and the interstitial space. Pharmacokinetic modeling of DCE-MRI enables quantification of the plasma volume (vp), interstitial volume (ve), and exchange rate (ktrans), a parameter strongly dependent on vascular permeability. DCE-MRI is frequently used within oncology studies (O’Connor, 2007), and is used increasingly in other indications such as renal disease (Buckley, 2006) and rheumatoid arthritis (Hodgson, 2007). DCE-MRI has been used to detect alterations in vascular permeability and interstitial water volume in the lungs of smokers relative to healthy controls (Naish, 2008). An exploratory study (201137) in both healthy volunteers and patients with heart failure has been undertaken to develop DCE-MRI to detect increased interstitial lung fluid via measurement of ve or altered vascular permeability via measurement of ktrans. Preliminary analysis of this study suggests that DCE-MRI may be a useful modality to characterize vascular permeability and interstitial water volume in patients with heart failure.

1.2. Brief Background

Heart failure (HF) is a common clinical syndrome of reduced cardiac function, dyspnea, peripheral edema, impaired exercise capacity, along with frequent hospitalization and early mortality. Pulmonary edema resulting from high pulmonary venous pressure (PVP) is a major cause of morbidity, with clear associated mortality in HF patients. In cardiogenic pulmonary edema, increased PVP causes fluid extravasation from the vascular to the pulmonary interstitial and alveolar spaces. Reduced exercise tolerance, orthopnoea and paroxysmal nocturnal dyspnoea are all thought to be associated symptoms related to interference with gas exchange or upregulation of baroreceptors activating a centrally mediated response related to the sense of air hunger [Redfield, 2003].

Treatment strategies for acute HF-induced pulmonary edema include intravenous diuretics and nitroglycerine, whereas treatment of chronic heart failure involves hemodynamic optimization with beta-adrenergic blockers, angiotensin converting

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enzyme inhibitors or angiotensin receptor antagonists, and aldosterone antagonists, along with the use of diuretics to reduce intravascular volume. These current therapeutic options for the treatment of pulmonary edema are often suboptimal, in part because adequate diuretic therapy has been associated with hypokalemia, hyponatremia, hypotension, and/or deteriorating renal function. Further, exercise-induced increased PVP can mediate the induction of pulmonary interstitial edema even in euvolemic states due to chronic, but poorly characterized, alterations in vascular:alveolar membrane properties. Indeed, the development of novel therapies targeting pulmonary edema has been limited by a lack of knowledge of the underlying mechanisms contributing to edema formation. Treatment is limited, and many patients are refractory to current therapies. This is a substantial clinical problem, creating a need for a novel therapeutic intervention such as TRPV4 blockers.

Pulmonary endothelial cells form a critical part of the alveolar septal barrier, limit extravasation of edema fluid, and express TRPV4, a Ca2+-permeating ion channel [Tiruppathi, 2006]. TRPV4 channels are expressed at the pulmonary alveolar septal barrier, limiting the movement of intravascular fluid into the interstitial and alveolar air spaces [Thorneloe, 2012]. TRPV4 is activated in response to increased PVP causing endothelial cell contraction and detachment. This reduces the integrity of the alveolar barrier and enhances permeability, resulting in pulmonary edema and impairment of gas exchange. Preclinical in vitro and in vivo pharmacology studies with selective TRPV4 blockers and genetic knock-out studies support this proposed mechanism of action. Specifically, TRPV4 blockade inhibits detachment of endothelial cells, reduces PVP-dependent lung permeability, and prevents and resolves pulmonary oedema in preclinical HF models [Thorneloe, 2012]. Furthermore, TRPV4 is expressed in the endothelium of small pulmonary vessels in human lungs and appears to be increased in individuals with congestive HF [Thorneloe, 2012].

To examine the therapeutic potential of this mechanism, GlaxoSmithKline (GSK) developed a TRPV4 channel blocker, GSK2798745. GSK2798745 is a selective, orally-active TRPV4 channel blocker demonstrating in vivo efficacy, by inhibiting the formation of pulmonary oedema induced by a TRPV4 activator as well as by elevated PVP following experimental myocardial infarction (MI) in rats.

1.2.1. GSK2798745

GSK2798745 is a potent and selective human TRPV4 channel blocker, with an IC50 = 2.0nM (nanomolar), assessed by measuring Ca2+ influx induced by the TRPV4 agonist GSK634775 (also numbered SB-436488) in HEK cells transduced with recombinant human TRPV4 channels. In addition, GSK2798745 inhibits hypotonicity-evoked human TRPV4 Ca2+ influx in transduced BHK cells with an IC50 of 1.7nM. GSK2798745 displays a similar potency at rat, mouse, dog and monkey TRPV4. GSK2798745 demonstrates no agonist activity (EC50 > 25uM) against human TRPV4. Administration of GSK2798745 in vivo inhibited the increase in lung wet weight (edema) and decrease in mean arterial pressure induced by a TRPV4 agonist in urethane anesthetized rats.

For detailed information please refer to the Investigator’s Brochure for GSK2798745 [GlaxoSmithKline Document Number 2013N162862_02].

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To date, GSK2798745 has been administered to healthy volunteers as single doses of 0.25, 1.0, 5.0 and 12.5 mg. In Cohort 1, 8 subjects were to receive 3 single doses of GSK2798745 and one dose of placebo (fasted). One subject was withdrawn from the second treatment period prior to dose administration due to vasovagal syncope after intravenous cannulation; therefore, only 7 subjects participated in the second period. A replacement subject was enrolled for subsequent treatment periods. Preliminary review of the blinded data including adverse events, electrocardiographic parameters, telemetry, vital sign measures, clinical laboratory parameters, pulse oximetry, and Holter recordings as well as weight and appetite assessments indicates that there were no clinically significant safety concerns.

In Cohort 2, 12 subjects were to receive 3 single doses of GSK2798745 5mg. However, one subject withdrew for personal reasons after completing the first treatment period. This subject was not replaced and therefore, 11 subjects completed the remaining treatment periods. No clinically significant safety concerns were noted.

In Cohort 3, 8 subjects were to receive repeat doses of GSK2798745 5mg once daily or placebo (6:2 ratio) for 14 days. Four subjects completed 14-days of dosing; however, the second group of 4 subjects only completed 8 days of dosing before the study was placed on temporary halt due to the receipt of new information from the 3-month dog toxicity study. Preliminary review of the blinded data including adverse events, electrocardiographic parameters, telemetry, vital sign measures, clinical laboratory parameters, pulse oximetry, and audiometry as well as weight and appetite assessments indicates that there were no clinically significant safety concerns with repeat administration of GSK2798745.

A preliminary review of the healthy volunteer QT data from Cohorts 1-3 was performed, after exposure to single doses of 0.1mg, 1mg, 5mg, and 12.5mg, and repeat dose exposure of 5mg daily. Categorical analysis demonstrated that no subjects experienced an increase in QTc from baseline of 30-60ms, or >60ms, and no subjects had a QTc value of 480-500ms, or >500ms while on therapy. Exposure response analysis demonstrated no evidence of a relationship between concentration of GSK2798745 and QTc prolongation.

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2. OBJECTIVES AND ENDPOINTS

Objectives Endpoints

Primary

To assess the safety and tolerability of single and repeat oral doses of GSK2798745 in both healthy subjects and stable HF patients

Clinical monitoring of vital signs, Electrocardiograms (ECGs), telemetry monitoring, laboratory safety data [including liver function tests (LFTs)], as well as reporting of adverse events (AEs)

Secondary

To determine the PK profile of single and repeat doses of GSK2798745 in both healthy subjects and stable heart failure patients

To determine the systemic PK profile of single dose of GSK2798745 administration in healthy adult subjects in fed and fasted states

To determine the relative bioavailability of GSK2798745 between liquid and capsule formulations

Plasma concentration and PK parameters derived after single and repeat doses of GSK2798745

Plasma concentration and PK parameters derived after single doses of GSK2798745 in fed and fasted states

Plasma concentration and PK parameters derived after single doses of GSK2798745 following liquid or capsule formulations

Exploratory

Characterize the effects of repeat administration of GSK2798745 on exercise capacity in healthy subjects and subjects with HF

Characterize the effects of repeat administration of GSK2798745 on DLco and DLno in healthy subjects and stable heart failure patients

Characterize the effect of repeat administration of GSK2798745 on DCE-MRI measures of pulmonary oedema and vascular permeability (Cohort 4 only)

Examine plasma volume and MRI physical properties influenced by the tissue microenvironment relaxation rate, and proton density in heart failure patients before and after repeat administration of GSK2798745

Differences in peak VO2, VE/VCO2 slope, RER, exercise time, and VO2 and time at ventilator threshold

Percent change in DLco and DLno

Difference in the interstitial volume (ve) and exchange rate (ktrans) before and after repeat dosing

Plasma volume (vp), T1 relaxation rate, and tissue density (determined from normalized proton density) measured using DCE-MRI

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Objectives Endpoints(Cohort 4 only)

Determine the effect of repeat administration of GSK2798745 on the plasma concentrations of NT-pro BNP in heart failure patients (Cohort 4 only)

Difference in plasma concentration of NT-pro BNP before and after repeat dosing

3. STUDY DESIGN

3.1. Study Schematic

The overall study design is represented in Figure 1, and additional details are summarized in Table 1.

Figure 1 GSK2798745 First Time in Human Study Schematic

The order of conduct of Cohorts 2 and 3 may be changed or the two cohorts may be conducted in parallel. Cohorts 4 and 5 may overlap.

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Table 1 Study Design

Cohort(Planned number)

Phase Assessments Dose or Dose Range1

Healthy subjects single doseCohort 1(n=8)

Single dose escalation (liquid formulation2)

Safety , tolerability and PK 0.25mg-12.5mg

Cohort 2(n=12)

Single dose (liquid2 and capsule formulation)with and without food

Relative bioavailability and effects of food on PK

5mg

Healthy subjects repeat dose3,4

Cohort 3(n=8[3:1 ratio] / dose group)

Repeat dose escalation liquid formulation or capsule5 for 14 days

Safety, tolerability, PK, exploratory tests for feasibility: exercise parameters, lung permeability (DLco and DLno)

5mg

Heart failure patients single dose followed by repeat dose 4,6

Cohort 4 (n=up to 24)(1:1 ratio)

Single dose (at least the first 6 subjects), Repeat dosecapsule for 7 days

Safety, tolerability PK, exploratory tests for feasibility: exercise parameters, lung permeability (DLco and DLno), DCE-MRI, NT-proBNP

2.4mg (initial)

Heart failure patients repeat dose6 Cohort 5(n=8 [3:1 ratio])

Repeat dose (capsule) for 7 days

Safety, pharmacokinetics and lung permeability (DLco and DLno)

2.4mg

1. Doses may change based on safety and exposure data. These doses are for estimation purposes only. 2. Doses greater than or equal to 0.5 mg will be given as a suspension and below 0.5mg will be given as a solution.3. Exposure will not exceed the daily AUC of 1.01hr*ug/mL or Cmax of 0.09ug/mL in any individual in Cohorts 1-3

Any new dose investigated in Cohort 3 will be selected so as to not intentionally exceed the daily AUC of 0.448 µg*h/mL or Cmax of 0.049 µg/mL in any individual.

4. There may be an additional dose added to either Cohort 1, 3, or 4.5. The formulation used will depend on the results of the relative bioavailability being tested in Cohort 2. If Cohort 3

or 4 is conducted concurrently or prior to Cohort 2, the liquid formulation utilized in Cohort 1 will be administered.6. Exposure will not intentionally exceed a daily AUC of 0.448 µg*h/mL or Cmax of 0.049 µg/mL in any individual

participating in Cohorts 4 or 5

3.2. Study Design Detail

3.2.1. Healthy Subjects Single Dose (Cohorts 1 and 2)

The single dose escalating cohort of GSK2798745 (Cohort 1) will be sponsor un-blinded, randomized, and placebo-controlled. The relative bioavailability and food effect cohort will be an open label, fixed schedule, single dose evaluation. Details for study duration are in Table 2 below. For treatment details please refer to the Time and Events table (Section 6.1).

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Figure 2 Study Design for Healthy Subjects Single Dose (Cohorts 1 and 2)

Table 2 Healthy Subjects Single Dose Study Duration

Screening All screening assessments to be completed within 35 days prior to the first dose.

Treatment Period For Cohorts 1 and 2, each subject will take part in up to four study periods

During each study period subjects will be in-house from Day -1 until the post-dose assessments have been completed in each period (48 or 72 hrs post dose depending on the half-life)

Washout Period ≥7 days for an individual subject

Follow-up 7-14 days after last study drug administration

If warranted, additional follow-up visits may be scheduled

Total Duration Cohort 1 (screening within 35 days + 4 treatment periods with washout + follow up of 7-14 days) = approximately 17 weeks

Cohort 2 (screening within 35 days + 3 treatment periods withwashout) + follow up of 7-14 days) = approximately 11 weeks

3.2.1.1. Single Dose Escalation - Cohort 1

In Cohort 1, a sufficient number of subjects will be enrolled such that 8 evaluable subjects will be randomized to 1 of 4 placebo-controlled dose sequences with 2 subjects in each sequence and each subject having four dose periods (3 active dose + 1 placebo dose). In each Treatment Period, subjects will be fasting from midnight to four hours post-dose (Day 1).

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Sentinel dosing: For each dose escalation level, only 2 subjects will be dosed on Day 1, separated by at least 1 hour; one subject will receive drug and one subject will receive placebo. If there are no safety or tolerability concerns, the rest of the cohort will be dosed at least 24 hours after the first dose was given at appropriate intervals.

The objective of Cohort 1 is to achieve an escalation from a low starting dose to a maximum, safe and well-tolerated dose. For each planned single dose, the daily exposure in any individual (24hr) will not intentionally exceed a Cmax of 0.09ug/mL or an AUC of 1.01hr*ug/mL (hereafter referred to as Cmax and/ or AUC) (see Section 3.4).

If any individual is projected to exceed the limiting Cmax and/or AUC in the next Treatment Period during the dose escalation step, that individual may be administered the same current dose or a lower dose in next dosing period. The other subjects not projected to exceed the stopping criteria will be escalated to the next dose accordingly. Dose escalation will be stopped if either criterion for exposure (Cmax and/or AUC0-24) is met.

Progression from one dose in a given group to the next higher dose (or lower dose if needed) in the following period within Cohort 1 will be based on acceptable safety, tolerability and systemic exposure data as reviewed during a dose escalation meeting. The reviewed datasets will at a minimum consist of the listings of any adverse events, liver function test results, flagged vital signs, and flagged findings during continuous cardiac monitoring (telemetry), ECG, laboratory findings and PK results derived from 24-hour plasma profiles.

Progression to the next higher dose level will be stopped if 1 or more subjects experience a serious adverse event considered as having a reasonable probability of being related to drug. Additionally, progression to the next higher dose level will be stopped if 2 or more subjects experience a severe or significant non-serious adverse event considered as having a reasonable probability of being related to drug.

The decision to proceed to the next dose level of GSK2798745 will be made by the Study Team including the Medical Monitor and the Investigator based on safety, tolerability and PK data obtained in at least 4 active subjects at the prior dose level. The maximum dose in this cohort will be selected to minimise the risk of exceeding the pre-defined limits for Cmax and AUC.

3.2.1.2. Relative Bioavailability and Food Effect - Cohort 2

In Cohort 2, a sufficient number of subjects will be enrolled such that 12 evaluablehealthy subjects are included in this cohort. Each subject in Cohort 2 will take part in three single-dose treatment periods in a fixed sequence. All subjects will receive GSK2798745 in this study period. Placebo will not be administered. No sentinel dosing of subjects will be required for this study period. The dose to be administered will be based on safety and exposure data from Cohort 1.

Period 1- Reference Dose: Subjects will receive a liquid dose (suspension or solution). Subjects will be fasting from midnight to four hours post-dose.

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Period 2- Relative Bioavailability: Subjects will receive a capsule formulation (filled in by the pharmacy) in order to assess the relative bioavailability of the capsule formulation as compared to the liquid formulation. The subjects will be fasting from midnight to four hours post-dose.

Period 3- Food Effect: Subjects will receive GSK2798745 following a standard high fat/high calorie meal. The formulation is planned to be the capsule unless the liquid formulation is selected based on available data.

Study procedures and assessments are otherwise planned to be the same as for the dose escalation treatment arms. The timing and number of planned study assessments may be altered during the course of the study based on emerging data from dose escalation study periods.

3.2.2. Healthy Subjects Repeat Dose - Cohort 3

This cohort is constructed as a sponsor un-blinded, randomized, placebo-controlled, 14-day repeat-dose evaluation of GSK2798745. It is planned that up to two doses may be studied based on the safety, tolerability and the systemic exposure data obtained from the single dose studies. A sufficient number of subjects will be enrolled such that up to 16 subjects in a ratio of 6:2 (treatment: placebo) may be evaluated in each planned cohort. However, only 4 subjects completing 14 days of dosing will be deemed sufficient to move into either the next cohort of 8 healthy volunteers or directly into heart failure patients (Cohort 4) without any further testing in healthy volunteers. The effect of TRPV4 channel inhibition on exercise performance will be evaluated. Glucose tolerance will also be evaluated by an oral glucose tolerance test (OGTT). In a TRPV4 knock-out preclinical model, body weight was reduced in the setting of improved glucose handling [Ye, 2012]. These measurements may represent tools to estimate target engagement in these early studies.

3.2.2.1. Dose Considerations - Cohort 3

The maximum daily dose in this repeat dosing arm was originally selected as to not intentionally exceed a daily exposure of AUC of 1.01μg*hr/mL or a Cmax of 0.09μg/mL in any individual. Based on the newly available data from the dog toxicity study, any further dose administration will not intentionally exceed a daily exposure of AUC of 0.448 1μg*hr/mL or a Cmax of 0.049 μg/mL in any individual. See Section 3.4 for dose rationale.

Food intake timing will be determined based on data from Cohorts 1 and 2 (if Cohort 2 is conducted before Cohort 3).

Doses will be administered on Days 1 through14. Based on data from Cohort 1, the second dose in the repeat-dose period may be skipped to estimate the time invariance in PK. It is currently planned to dose once daily, however based on emergent data [e.g., half-life (T1/2)] from the initial study cohorts, dosing may be altered to twice daily. If needed, refer to the study procedures manual (SPM) for a twice-daily dosing time and event table and dose schedule. Subjects may be fasted from midnight to 4 hours after

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dosing on Day 1 and Day 14 that entail serial PK sampling. Meal timings on other days will be based on previous cohort data.

Figure 3 Study Design for Cohort 3: Repeat Dose Administration in Healthy Subjects

Table 3 Healthy Subjects Repeat Dose Study Duration (Cohort 3)


Treatment Period Each subject will take part in only one treatment period andwill be dosed for 14 days.

During the study period, subjects will be in-house from Day -1 until all post-dose assessments have been completed in each period (48 or 72 hrs post dose depending on the half life).

Subjects will have exploratory measurements on Day -1 and between Days 12- 14. The measurements will include exercise testing, OGTT and lung permeability assay (DLco

and DLno); see Section 6.1 for PD assessments.Follow-up 7-14 days after last study drug administration. If warranted,

additional follow-up visits may be scheduled.Total Duration Screening within 45 days + treatment (17 days) + follow up of 7-

14 days = approximately 10 weeks

Two doses of GSK2798745 may be evaluated. A review meeting will be conducted following the first dose level to determine the dose in any proposed second group of subjects. Progression to a higher dose level will not occur if 1 or more subjects experience a serious adverse event considered as having a reasonable probability of being related to drug. Additionally, progression to a higher dose level will not occur if 2 or more subjects experience a severe or significant non-serious adverse event considered as having a reasonable probability of being related to drug. Alternately, a lower dose may be studied if additional information may be gained.

3.2.3. Heart Failure Patients Single and Repeat Dose - Cohort 4

Cohort 4 will be a sponsor un-blinded, randomized, placebo-controlled study in patients with heart failure including a single dose and a subsequent 7-day repeat dose evaluation of GSK2798745. If the first 6 HF subjects tolerate the single dose safely, the single dose portion of Cohort 4 may be discontinued for the remaining HF subjects enrolled into this cohort. The decision to remove the single dose period from Cohort 4 for the remaining

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subjects enrolled will be made by the Study Team including the Medical Monitor and the Investigator based on safety and tolerability once 6 patients with HF have completed both the single and repeat dose sessions. This cohort will enroll patients with mild to moderate dyspnea on exertion (i.e., NYHA Class II or III), thereby including those likely to have some excess fluid in their lungs. The dose will be based on the safety, tolerability and PK data obtained from the single-dose and repeat-dose healthy subject cohorts. A sufficient number of patients will be enrolled such that 18 subjects and possibly 24 subjects are planned be randomized to treatment or placebo at a ratio of 1:1. The main focus of this cohort is the evaluation of safety, pharmacokinetics and tolerability, including safety biochemical testing and assessment of physical examination throughout the 7 days and follow-up.

In addition, we will evaluate the potential pharmacodynamic effect of GSK2798745 in patients with heart failure. Respiratory rates will be quantified over time. Orthopnea will be assessed at the beginning and end of the study. Maximal exercise capacity will be assessed using a standardized bicycle protocol (see Section 6.8.1), prior to repeat-dose administration and during the latter part of the 7 days of treatment. Degree of ventilation (VE) can be compared to the ambient level of CO2, a ratio, which is notably high in HF patients, and possibly reduced with the test agent. This will be supplemented by measures of gas transfer (carbon monoxide and nitric oxide; DLco and DLno) before and immediately after exercise both at baseline and after reaching steady state with GSK2798745. The profound elevation in pulmonary venous pressures during exercise (often observed in HF patients) will likely exacerbate the movement of fluid into the lung tissue, and thereby decrease alveolar:vascular membrane gas transfer. We hypothesize a TRPV4 blocker will limit this exercise-induced change. DCE MRI measures of pulmonary edema (ve) and vascular permeability (ktrans) will also be assessed at baseline and after reaching steady state with GSK2798745.

Dose considerations: The maximum daily dose in the repeat dosing period will not intentionally exceed a daily exposure of AUC of 0.448 μg*hr/mL or a Cmax of 0.049 μg/mL in any individual. Based on data from the previous cohorts, the dose will be 2.4mg in the first group utilizing the capsule formulation administered with or without food. (See Section 3.4.5 for dose rationale). Based on the emerging PK data from these HF patients, the dose level may be modified, if necessary, as long as the exposure does not intentionally exceed a daily exposure of AUC of 0.448 μg*hr/mL or a Cmax of 0.049 μg/mL in any individual.

Further, two dose levels of GSK2798745 may be evaluated in Cohort 4, and additional patients may be recruited for a second separate dose group (up to a maximum of 14-day repeat dose administration). A review meeting will be conducted following the completion of the first group (dosed with a 2.4mg dose) in the event additional information may be gained in investigating a lower dose in a second separate group of subjects.

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Figure 4 Study Design for Cohort 4: Single and Repeat Dose Administration in Patients with HF

Table 4 Study Duration Heart Failure Patients (Cohort 4)

Screening All screening assessments will be completed within 35 days prior to first dose of study medication.

Treatment Period

For single dose (at least the first 6 subjects) followed by repeat dose

Single dose period: subjects (at least the first 6 subjects) will be in-house from Day -1 until all post-dose assessments have been completed (72 hrs post dose).

Subjects will return to the unit after a washout period ≥7 to 21 days for the 7-day repeat dose period.

Repeat dose period: subjects will be in-house from Day -1 until all post-dose assessments have been completed on Day 8.

Each subject will be administered GSK2798745 or placebo (based on randomization) for 7 days.

Subjects will have exploratory measurements on Day -1 and between Days 5 through 7. The measurements will include exercise testing and lung permeability assay (DLco; DLno), (see Section 6.1 for PD assessments), DCE-MRI and NT-proBNP levels will also be measured throughout the period.

Follow-up 7-14 days after last study drug administration.

If warranted, additional follow-up visits may be scheduled.Total Duration Subjects participating in SD and RD: Screening within 35 days +

single dose period + washout + 7-day repeat dose treatment period + follow up (7-14 days after last dose of study medication) = approximately 10 weeks Subjects participating in RD only: Screening within 35 days + 7-day repeat dose treatment period + follow up (7-14 days after last dose of study medication) = approximately 8 weeks

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3.2.4. Heart Failure Patients – Cohort 5

Cohort 5 will be a sponsor un-blinded, randomized, placebo-controlled, 7-day repeat dose evaluation of GSK2798745 in patients with heart failure. To gain additional information on the profile of GSK2798745, this cohort will evaluate safety, pharmacokinetics, and lung permeability (DLco and DLno) in a broader, more general population of patients with heart failure, NYHA Class II or III. Exclusions specifically included in Cohort 4 relevant for MRI scanning have been removed for Cohort 5. A sufficient number of patients will be enrolled such that up to 8 subjects complete the cohort with a treatment to placebo randomization ratio of 3 to 1.

Prior to the initiation of Cohort 5, all available safety data from Cohort 4 will be reviewed by the sponsor. As Cohort 4 will continue to recruit subjects with heart failure into the single dose and repeat dose regimens as outlined in Section 3.2.3, the review of accrued safety data will permit Cohort 5 to avoid the single dose, and immediately initiate the cohort only employing a repeat dose regimen. The repeat dose periods ofCohorts 4 and 5 will constitute our primary evaluation of safety for this early phase study.

Subjects with heart failure participating in Cohort 5 will be required to stay inhouse for the first 4 days of the period. Fitted with a remote monitoring device (which provides 24 hour continuous remote monitoring of ECG, HR, RR and activity level – see Section 6.3.7), they will return to their homes where they will receive visits from registered nurses the mornings of Days 5 and 6 to administer study medication, assess vital signs and dyspnea, collect blood samples for pharmacokinetic analysis, and obtain information on any adverse events.

Dose considerations: The maximum daily dose in the repeat dosing period will not intentionally exceed a daily exposure of AUC of 0.448 μg*hr/mL or a Cmax of 0.049 μg/mL in any individual. Based on data from the previous cohorts, the dose will be 2.4mg utilizing the capsule formulation administered with or without food. (See Section 3.4.5 for dose rationale).

Figure 5 Study Design for Cohort 5

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Table 5 Study Duration for Cohort 5

Screening All screening assessments are to be completed within 35 days prior to the first dose.

Treatment Period Each subject will be administered GSK2798745 or placebo (based on randomization) for 7 days.

Subjects will have safety assessments and other measurements, including DLco and DLno, and PK during the study period.

Subjects will remain in house from Day -1 until Day 4. Day 5, 6, and 8 visits will be in home visits only. For the Day 7 Visit, subjects will return to the clinic.


If warranted, additional follow-up visits may be scheduled.Total Duration Screening within 35 days + 7-day repeat dose study period +

follow up (7-14 days after last dose of study medication) = approximately 8 weeks

3.3. Drug Formulation

All doses in Cohort 1 will be administered either as a suspension or a solution depending on the dose. Cohort 2 will also employ the capsule formulation (filled in by the pharmacy) in order to assess the relative bioavailability of the capsule formulation as compared to the liquid formulation. Cohorts 3 and 4 will employ one of the formulations used in Cohorts 1 or 2. The relative exposure data from Cohort 2 will determine the formulation for subsequent cohorts. In the event that Cohort 3 is conducted concurrently with Cohort 2, the liquid formulation will be administered in the repeat-dose Cohort 3. Based on all the data available from the previous cohorts in this study, Cohorts 4 and 5 will employ capsule formulation.

Please refer to Appendix 5 for more details.

3.4. Dose Rationale

3.4.1. Pharmacokinetic Predictions for GSK2798745

Initial human exposure predictions for GSK2798745 were based on the exposure data collected from preclinical studies in rat and dog. Allometric scaling with and without corrections for factors such as protein binding and maximum life span potential differences between species was employed for these predictions [Davies, 1993; Iwatsubo, 1997, Obach, 1997; Lave, 1999]. After applying these various scaling methods, the range of predicted clearance, volume of distribution and half-life are summarized in Table 6.

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Table 6 Predicted Human Parameters

Clearance [Cl] (ml/min/kg)

Volume of Distribution [Vd]

(L/kg)

Drug Half-life [T1/2] (H)

Bioavailability [F] (%)

0.88 – 1.07 0.87 – 2.30 9 – 30 80 – 100

3.4.2. No Observed Adverse Effect Level (NOAEL) Dose

Four-week (rats and dogs) and 3-month (dog) toxicology studies were conducted to assess the toxicity of GSK2798745.

3.4.2.1. Rat 4-Week Toxicity Study

The dose levels in the oral rat 4-week toxicity study were 0 (vehicle), 10, 60 and 300mg/kg/day. There were various toxicological findings at different doses that are summarized in Table 12. Based on the adverse toxicological findings at the 300mg/kg/day and 60mg/kg/day dose groups in the 4-week study and effects observed at 30mg/kg/day in the 7-day study, the 10mg/kg dose was selected as the NOAEL dose level. The mean AUC and Cmax from the 60mg/kg/day dose group were previously used to estimate the safety margins with respect to the rat species and are listed in Table 8.

3.4.2.2. Dog 4-Week Toxicity Study

The dose levels studied in the oral dog 4-week toxicity study were 0 (vehicle), 3, 10 and 30mg/kg/day. There were various toxicological findings at different doses that are summarized in Table 12. Based on the adverse toxicological findings at the 30mg/kg/day dose group, the 10mg/kg/day dose was selected as the NOAEL dose level. Given that the arterial and cardiac findings at 30mg/kg/day cannot be easily monitored in clinical studies and the mechanism by which they occur is not understood, a 50X exposure margin below the NOAEL dose of 10mg/kg/day was considered the maximum exposure to be achieved in humans in this study, consistent with regulatory guidelines [ICH, 2009]. The Day 1 mean exposures in dogs at 10mg/kg/day were used as this provided the most conservative approach. The mean AUC was 50.4hr*µg/mL and Cmax was 4.51µg/mL at this dose. Applying the 50-fold safety margin, an AUC of 1.01µg*hr/mL and Cmax of 0.09µg*hr/mL were used to estimate the safety margins with respect to the dog species. These safety margins are listed in Table 8.

As the dog exposure levels provide a more conservative stopping limit as compared to theexposure in the rat, the tentative doses for this FTIH will be selected to not knowingly exceed a daily AUC of 1.01µg*hr/mL and/or a Cmax of 0.09µg/mL in any individual in any cohort. This information and exposure limits were utilized in Cohorts 1 through 3 to establish appropriate doses for administration to healthy volunteers. Subsequently, new information has been obtained from the 3-month dog toxicity study and the NOAEL reassessed as 3 mg/kg/day (see below).

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3.4.2.3. Dog 3-Month Toxicity Study

3.4.2.3.1. Findings

GSK2798745 was given, by oral gavage, to male and female dogs (4/sex/group), at doses of 1, 3 or 10 mg/kg/day for 3 months. A control group received the vehicle alone. The peer-reviewed microscopic pathology data identified vascular toxicity in 2 dogs given 10 mg/kg/day. Specifically, arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation, was observed in the epididymides (bilateral) in a male and in the urinary bladder of a female. Neither dog presented with clinical abnormalities, and each survived the scheduled duration of the study. No evidence of vascular toxicity was observed in other tissues of these dogs, and no vascular lesions were seen in any tissues of dogs given 1 or 3 mg/kg/day. Such vascular lesions are not considered new findings with GSK2798745 since lesions like these were seen previously in the 1-month dog study at 30 mg/kg/day. However, the lesions are now being observed at a lower dose. In dogs given 10 mg/kg/day, mean AUC and Cmax (gender-averaged, Day 1) was 48.8 µg.h/mL and 4.09 µg/mL, respectively. In dogs given 3 mg/kg/day (the no-effect dose for vascular toxicity in this study and hence the new NOAEL), mean AUC and Cmax (gender-averaged, Day 1) was 13.5 µg.h/mL and 1.46 µg/mL, respectively.

3.4.2.3.2. Risk Assessment

The original clinical exposure cap was based on one-fiftieth of exposure at the NOAEL of 10 mg/kg/day identified in the 1-month dog study. A clinical exposure cap based on one-fiftieth of exposure at the 3 mg/kg/day dog NOAEL would translate to AUC 0.269 µg.h/mL and Cmax 0.029 µg/mL.

GSK has critically reviewed the vascular findings from the 1-month and the 3-month dog studies. GSK believes it is unlikely that the lesions are attributable to some effect of TRPV4 channel blockage in the dog. Estimates based on the plasma concentration of GSK2798745 that cause full channel blockade in rats (TRPV4-induced lung edema model; refer to the GSK2798745 Investigator’s Brochure), corrected for cross-species differences in in vitro potency and plasma protein binding between rat and dog, suggest that full inhibition of the TRPV4 channel is achieved in the dog at plasma concentrations less than one-hundredth of Cmax at the 3 mg/kg/day NOAEL. Although TRPV4 channel blockade can affect vascular function, we are not aware of any evidence that would link to a potential detrimental vascular effect. Further, the lesions appear to resemble those caused by vasodilators (discussed below). In that context, however, we have no data to suggest that TRPV4 channel blockade results in systemic vasodilation or hypotension in healthy animals. Rather, this notion is paradoxical in that TRPV4 channel activationconsistently results in profound endothelium-dependent vasodilation and hypotension (Willette, 2007; Mendoza, 2010).

Some further aspects of the vascular lesions seen in these dogs that are considered noteworthy:

Dose-response: Based on the pooled data from the month 1- and 3-month studies, the incidence of dogs with vascular lesions shows a dose response with 10 mg/kg/day at the

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low end (2/6 at 30 mg/kg/day [33%]; 2/14 at 10 mg/kg/day [14%]; 0/14 at 3 mg/kg/day (0%]). Although the incidence increased with dose, the lesions were similar in severity and not associated with resultant organ damage at either dose.

Similarity to lesions caused by vasodilators: The character of the lesions, particularly the focal necrosis of arterioles, resembles that of lesions described in animals given high doses of vasodilating agents of various classes (Louden, 2001). In dogs, such lesions are situated more typically in the heart, but can occur randomly at multiple other sites (Louden, 2001), including the urinary bladder (the site of the lesion in one of the dogs given of GSK2798745 10 mg/kg/day) as reported with endothelin receptor antagonists (Jones, 2003) and with an adenosine agonist (Metz,1991). These lesions associated with vasodilators have been regarded as a species-sensitive response in the dog that may not be of predictive value in humans at therapeutic doses (Tesfamariam, 2007).

In considering the points above, GSK proposes a lower clinical exposure cap based on exposure at one-thirtieth of the 3 mg/kg/day dog NOAEL, which translates to an AUC of 0.448 µg.h/mL and a Cmax of 0.049 µg/mL. This also represents approximately one-hundredth and one-eightieth of mean AUC and Cmax, respectively, at 10 mg/kg/day (the low end of the dose response for vascular lesions). While recognizing the serious nature and non-monitorability of this non-clinical hazard, these are still substantial safety margins.

3.4.3. TRPV4 Channel Inhibition

The clinical dose of GSK2798745 was targeted to achieve greater than 80% inhibition of TRPV4 channel over a major fraction of the dosing interval. It assumes that such a high level of TRPV4 channel inhibition will be sufficient to elicit the anticipated physiologic activity of GSK2798745. Based on the new NOAEL level, the targeted exposure should achieve sufficiently high TRPV4 channel inhibition to evaluate the activity of GSK2798745.

A rat study was conducted assessing the ability of different doses of GSK2798745 infusion to reduce the increased lung-to-bodyweight ratio induced by the TRPV4 agonist GSK1016790. The IC50 of GSK2798745 based on this study was 3.3ng/mL. Correcting this IC50 for differences in potency and protein binding between species results in an estimated human IC50 of 2.1-3.2ng/mL. Simulations were performed with different doses/exposures of single doses of GSK2798745 to estimate the time above which at least 80% TRPV4 channel blockade was maintained using an Emax model, IC50 of 2.1-3.2ng/mL and the predicted human PK parameters listed in Table 7. The average inhibition over a 24-hour period was also estimated from these simulations. Results of these simulations are also listed in Table 7. Based on these simulations, the starting dose of 0.25mg is the minimal dose to provide measurable serum concentrations. The estimated TRPV4 channel blockade at this dose of 0.25mg is approximately 25-45%. The maximum targeted exposure (at a dose of 4.0mg) in the FTIH study will provide approximately 90% inhibition over a 24-hour period.

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Table 7 Predicted Time Above 80% TRPV4 Channel Inhibition at Different Doses and Assuming Different Half-life values in Humans

Dose (mg) Predicted AUC(mg*hr/L)

Time above 80% TRPV4 inhibition (post first dose)

Average TRPV4 % inhibition over 24hrs (post first dose)

9hrs Half life 30hrs Half life 9hrs Half life 30hrs Half life0.25 0.04 - 0.07 0 0 35-45 27-360.5 0.09-0.14 0 0 51-60 42-521.5 0.27-0.41 8-14 0-3.5 74-81 68-763.0 0.53-0.81 18-24 15-24 84-89 81-864.0 0.71-1.11 21-24 24 88-91 85-89

3.4.4. Maximum Starting Dose Using NOAEL

The United States Food and Drug Administration (FDA) guidance on estimating the maximum recommended starting dose (MRSD) that may be considered as a safe starting dose in initial clinical trials discusses an approach to calculate a human equivalent dose (HED), based on the no observed adverse event level (NOAEL) dose in the most sensitive or most relevant pre-clinical species [ICH, 2009]. This method, referred to but not explicitly defined by the European Medicines Agency (EMEA), utilizes scaling factors based on differences in body surface area between species to arrive at a MRSD in humans. Based on the toxicology findings in the oral 4-week toxicity studies, the 10mg/kg/day and 60mg/kg/day doses were defined as the NOAEL doses for the dog and the rat species, respectively. The HED calculated by NOAEL approach for dog and the rat species estimated for a 70kg volunteer is 378mg and 672mg, respectively. The dog species provides a conservative (lower) starting dose as compared to the rat dose. An additional safety factor of 50X was applied to the HED based on dog species and the adverse findings of vascular and cardiac lesions in the dog species. Based on the FDA guidance, the MRSD in the FTIH study is calculated to be 7.56mg. However, the starting dose in this FTIH study is 0.250mg and is more than 30-fold lower than the MRSD as per the FDA guidelines.

In summary, the starting dose for GSK2798745 was decided by taking into consideration doses estimated by various approaches discussed above. A low dose of 0.25mg will be used as the starting dose. A 0.25mg dose is at least 30 times lower than the MRSD estimated using NOAEL data. This starting dose is also predicted to have sufficient safety cover based on expected exposures at 0.25mg as shown in Table 8. The exposure from the starting dose is estimated to provide approximately 25-45% TRPV4 channel blockade.

3.4.5. Safety Cover Based on Predicted Exposure and NOAEL from the Pre-Clinical Species

The exposures at doses planned for the current study were estimated using the predicted PK parameters in humans as listed in Table 6. An absolute bioavailability of 80 – 100% was assumed for exposure calculations, thus employing a conservative approach and providing greater safety cover.

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The planned starting dose for the single dose cohort is 0.25mg. As GSK2798745 systemic exposure data become available from lower dose levels, predicted exposures at higher dose levels will be revised and dose escalations will occur with appropriate consideration.

The planned dosing schedule may be adjusted downward to allow for administration of lower doses if dose-limiting toxicities become evident or to obtain additional safety, tolerability or pharmacokinetic information.

If exposures are less than predicted, doses higher than the currently planned 4mg may be used. However, in any case, the daily exposure will not intentionally exceed Cmax of 0.09µg/mL and/or AUC of 1.01g*hr/mL in any individual (Cohorts 1 through 3). If another group of subjects is initiated in Cohort 3, the exposure will not intentionally exceed a daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL in any individual.

The repeat dose cohorts will be a separate cohort of subjects following completion of Cohort 1. The dose(s) selected for repeat dosing will be based on safety and PK data from Cohort 1.

Table 8 represents the initially planned dose range and predicted exposures for clinical evaluation of single doses of GSK2798745 (Cohorts 1 and 2).

Table 8 Predicted Exposure with Safety Cover over the Proposed SD Dose Range

Dose (mg) Human Predicted

Cmax (µg/mL)

Cmax Safety Cover with regard to the stopping limit

of 0.09ug/mL**

Human Predicted AUC (µg*hr/mL)

AUC Safety Cover with regard to the stopping limit of 1.01hr*ug/mL**

Rat# Dog* Rat# Dog*

0.25 0.001-0.004 3301-10481 23-74 0.044-0.068 1843-2801 15-23

0.50 0.002-0.008 1650-5240 12-37 0.089-0.135 921-1401 8-11

0.75 0.004-0.012 1100-3494 8-25 0.133-0.203 614-934 5-8

1.50 0.007-0.023 550-1747 4-12 0.267-0.405 307-467 3-4

2.50 0.012-0.039 330-1048 2-7 0.444-0.676 184-280 2-2

3.50 0.017-0.054 236-749 2-5 0.622-0.946 132-200 1-2

4.0 0.019-0.062 206-655 2-5 0.711-1.081 115-175 1-1

**The stopping AUC and Cmax provide 50X cover from the NOAEL dose (10mg/kg/day) exposure in the 4-week dog study* Exposure values from day 1 of the dog study used given the toxicological findings# Exposure values from day 28 of the rat study used given the toxicological findings. Note: these values were determined based on exposure determined in the 60mg/kg/day group. The range of exposures at doses planned for the current study was estimated using the predicted PK parameters in human as listed in Table 7.

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3.4.5.1. Doses based on clinical data from Cohorts 1-3 in FTIH study

Doses from 0.25 to 12.5 mg were administered in the single ascending dose Cohort 1 of the FTIH study in healthy volunteers. Based on the exposure data from these doses, the 5 mg dose was evaluated to characterize the effect of capsule formulation and food on GSK2798745 exposure in Cohort 2 in healthy volunteers. A 5 mg once daily repeat dose was also evaluated in 8 healthy volunteers (6 active + 2 placebo) in Cohort 3. Of the 6 subjects who received GSK2798745, 3 completed 2 weeks of dosing while the remaining 3 completed 8 days of dosing. No SAEs were observed in any of the subjects dosed with GSK2798745.

All the available data was used to develop a preliminary population PK model and simulate exposures for the heart failure subjects in Cohort 4. The tentative doses and predicted exposures at these doses are listed in Table 9. This was primarily done to explore tentative doses for the Cohort 4 subjects to limit exposure to a lower threshold based on the new preclinical data obtained from the 3-month dog safety study. The new lower threshold of daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL provides a 30X cover from the revised no-effect dose level of 3mg/kg/day exposures observed in the 3-month dog safety study.

Table 9 Predicted Exposures and Safety Margin for the Repeat-Dose Administration in Subjects with Heart Failure (Cohort 4)

Dose (mg)

AUC (ug*hr/mL)Median (90%

prediction Interval)

Safety Margin from AUC of 0.448 ug*hr/mL

Median (90% Prediction Interval)

Cmax (ug/mL)Median (90%


Safety Margin from Cmax of 0.049 ug/mL

Median (90% prediction Interval)

3.0 0.17 (0.09 – 0.29) 79X (46X – 149X) 0.018 (0.011 – 0.028) 81 (52 – 133)

3.5 0.20 (0.11 – 0.35) 67X (38X – 122X) 0.021 (0.013 – 0.033) 70 (44 – 113)

4.25 0.24 (0.13 – 0.42) 56X (32X – 103X) 0.026 (0.015 – 0.041) 56 (36 – 98)

4.5 0.25 (0.14 – 0.44) 54X (31X – 96X) 0.027 (0.016 – 0.043) 54 (34 – 92)

Simulations were also performed to predict the probability that 1 or more subjects in thiscohort of subjects (9 active + 9 placebo) achieve exposures greater than a daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL. The results from these simulations are listed in Table 10. Based on these analyses, a 3 mg dose can be recommended for Cohort 4. The population parameter estimates for the PK model used for simulations are listed in Appendix 6.

Table 10 Predicted Exposure and Probability of Exceeding Threshold AUC and Cmax (Cohort 4)

Dose (mg)





% Probability that ≥ 1 out of 9 subjects exceed threshold

AUC (0.448 ug*hr/mL)

% Probability that ≥ 1 out of 9 subjects exceed threshold

Cmax (0.049 ug*hr/mL)

3.0 0.17 (0.09 – 0.29) 0.018 (0.011 – 0.028) 4.3 2.03.5 0.20 (0.11 – 0.35) 0.021 (0.013 – 0.033) 14.3 6.3

4.25 0.24 (0.13 – 0.42) 0.026 (0.015 – 0.041) 39.0 25.74.5 0.25 (0.14 – 0.44) 0.027 (0.016 – 0.043) 45.0 37.0

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The simulations were based on assumption that GSK2798745 will be administered as a suspension formulation in fasted state, similar to Cohort 1. However, preliminary analyses of the data from Cohort 2 indicated small increases in the systemic exposure of GSK2798745 when the drug was administered in the capsule formulation and with food (high fat meal). These preliminary results are listed in Table 11. Consequently, a 2.4 mg dose in capsule formulation (without any meal restrictions) is recommended for the subjects in Cohorts 4 and 5. A 25% increase in exposure of 2.4 mg (when administered in capsule and without meal restrictions) would result in exposures comparable to 3 mg dose (when administered as suspension and fasted state) and within the stopping criteria of daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL. Additionally, if needed, the dose may be adjusted based on emerging PK and safety data. Any dose selected will not intentionally exceed daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL.

Table 11 Impact of Capsule and Meal on Systemic Exposure of GSK2798745 (preliminary results)

Comparison AUC Ratio (90%CI) Cmax Ratio (90%CI)

Capsule Fasted Vs Suspension Fasted 1.12 (1.00 – 1.25) 1.05 (0.9 – 1.23)

Capsule Fed Vs Capsule Fasted 1.14 (1.02 – 1.28) 1.09 (0.93 – 1.28)Capsule Fed Vs Suspension Fasted 1.28 (1.15 – 1.46) 1.14 (0.98 – 1.33)

To summarize, based on the revised NOAEL established in the 3-month dog toxicity study and a 30-fold safety margin, the planned dose for single and repeat administration of GSK2798745 in Cohorts 4 and 5 will be 2.4mg once daily administered in a capsule without any meal restrictions. The daily exposure will not intentionally exceed a Cmax of 0.049µg/mL and/or an AUC of 0.448g*hr/mL in any individual.

3.4.6. Dosing and Randomization

In Cohort 1, 8 subjects receiving single doses will be randomized to one of the following four sequences with each subject having four dose periods and two subjects in each sequence: PBCD, APCD, ABP D and ABCP, where placebo (P) and ABCD are active doses of GSK2798745.

In Cohort 2, all 12 subjects will assigned to one fixed sequence with each subject having three dose periods: GHI, where G is liquid formulation without food and H is capsule without food and I is capsule with food.

In Cohort 3, up to 8 subjects will be randomized to treatment at a treatment:placebo ratio of 3:1. An additional dose group of another 8 subjects may be randomized at the same ratio.

In Cohort 4, 18 subjects will be randomized to treatment at a treatment:placebo ratio of 1:1. If required, an additional number of subjects (up to 24 total) will be randomized in Cohort 4. An additional separate dose group of approximately 18 to 24 subjects may be randomized to GSK2798745 or placebo to gain additional safety, tolerability, pharmacokinetic and pharmacodynamic information, if needed.

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In Cohort 5, 8 subjects will be randomized to treatment at a treatment:placebo ratio of 3:1.

Detailed randomization tables and doses can be found in Appendix 4 and Appendix 5.

3.5. Risk Management

A summary of potential risk factors and the strategy to mitigate them is provided in Table 12.

Table 12 Summary of Key Issues, Their Impact and Strategy to Mitigate Risk

Potential risk Summary of data Impact- eligibility criteria

Strategy-monitoring/stopping criteria

Vascular lesions Dogs (4-week study): At 30mg/kg/day, 2 males had arterial lesions

One male: Heart – Coronary artery inflammation; Thymus –Arteriole inflammation with fibroplasia

One male: Epididymides – Artery degeneration/necrosis with inflammation

Dogs (3-month study): At 10 mg/kg/day, arterial lesions were observed in 2 dogs.One male: Epididymides (bilateral) -arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation

One female: Urinary bladder -arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation

Rats (7-day study): At 300 mg/kg/day, inflammation in an extra hepatic arterioleoccurred in one rat.

None The arterial lesions noted in heart, thymus and epididymides cannot be monitored directly. There is currently no human translation biomarker or understanding of the underlying mechanism.

Since these effects cannot be monitored directly in clinical studies, a coverage of ≥50-fold wasmaintained in humans from the no-effect dose (10mg/kg/day), and exposure did not exceed the average daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.

A ≥30-fold margin will be maintained based on the revised no-effect dose (3mg/kg/day); exposure will not exceed an AUC of 0.448hr*ug/mL and/or Cmax of 0.049ug/mL in any individual dosed after 10/31/2014.

Myocardial toxicity Dogs (4-week study): At 30mg/kg/day, myofiber degeneration/necrosis & inflammation (2 animals)

Rats (7-day study): At 300 mg/kg/day, epicardial myofibre degeneration and/or necrosis with mononuclearinflammatory cell infiltrate occurred in one rat.

Subjects with chronic angina, unstable angina, or history of acute coronarysyndromes, coronary angioplasty, or stenting within the past 6 months will be excluded (exclusion #2)

Troponin levels will be monitored throughout the study. Guidelines for stopping are in Section 5.3.3.1

A coverage of ≥50 fold will be maintained in humans from the no-effect dose (10mg/kg/day) observed in dogs.

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Mortality/moribund condition; poor viability

Dogs (4-week study): At 30 mg/kg/day one male terminated early (Day 6) due to poor clinical condition. Another male had transient whole body shaking on Days 8 and 9.

Dog (13-week study): At 10 mg/kg/day one male was terminated early (Day 74) due to welfare reasons.

Rats (micronucleus and comet study): mortality occurred following 1 to 3 doses at ≥600mg/kg/day

None Weight and adverse events reported by subjects will be monitored.

Gastrointestinal and/or hepatic toxicity

GI toxicity - ≥3mg/kg/day in dogs and at 300mg/kg/day in rats, consisting of mucosal erosion/ulceration in the stomach and/or duodenum.

Hepatic Toxicity: Biliary epithelial hypertrophy/hyperplasia and periductal mixed inflammatory cell infiltrate into the liver was observed at 300mg/kg/day in rat (7-day study) and focal hepatocellular degeneration in 1 male dog at 30mg/kg/day (4-week study)

Subjects with active ulcer disease or GI bleeding will be excluded (exclusion #6)

Subjects will be monitored for GI intolerance and sequential biochemistry analysis including liver enzymes.

Testicular toxicity Rats (4-week study): Spermatid retention at ≥10mg/kg/day. Not associated with degenerative changes in testes or epididymides.

No spermatogenic abnormalities were observed in dogs.

None A safety margin of ≥ 40 fold will be maintained from the no effect dose (10 mg/kg/day) in rats.

Skeletal muscle toxicity

Rat (4-week study): Myofiber necrosis: myofiber degeneration/regeneration; fibroplasia, at 300mg/kg/day in the soleus muscle

None CPK levels will be monitored throughout the study.

Seizures and convulsions

Rats (micronucleus and comet study): Convulsions observed at ≥600mg/kg/day. Convulsions were not related to Cmax, nor occurred at any predictable time from dose administration.

Dogs: No CNS findings at 12mg/kg/day in the dog 7-day EEG/CV study. In other compounds in the same series, convulsions have been observed.

Subjects with a history of seizure disorder or stroke within the last 5 years will be excluded from the study. (exclusion #5)

Due to presence of potential CNS effects of the compound, suicidality assessment by GSK standards will be included in the protocol.

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Low food consumption

Dogs (4-week study): 30mg/kg/day reduced food consumption. Two males were terminated early (Day 10) due to extremely reduced food consumption.

Rats (4-week study): 300mg/kg/day had decreased food consumption.

None Weight and appetite will be monitored.

Effects on macrophages (Phospholipid accumulation)

Rats (4-week study): 60mg/kg/day in the lung (prominent alveolar macrophages); 300mg/kg/day in the mesenteric lymph node (increased cellularity of sinus macrophages) and thymus (macrophage vacuolation; increased thymus weight). Consistent with phospholipid accumulation (phospholipidosis) based on ultrastructural appearance of mesenteric lymph nodes at 300mg/kg/day. Findings were not associated withdegenerative changes.


Renal toxicity with use of Gadolinum

Gadobutrol (Gd) (Gadovist; Bayer) has produced nephrogenic systemic fibrosis and fibrosing dermopathy in patients with renal disease. The incidence of NSF in dialysis and end-stage renal disease patients when exposed to Gd is in the range 3-5% [Marckmann, 2006; Kuo, 2008; However, there are no reports of NSF in subjects with normal renal function [Perazella, 2007; Deo, 2007; Chewning, 2007; Thomsen, 2006]. It is concluded that subjects dependent on dialysis and those with estimated glomerular filtration rate (eGFR) <30mL/min (chronic kidney disease stage 4/5) are at risk of developing NSF on exposure to Gd [Perazella, 2007].

As a result of this recent evidence, subjects in Cohort 4with creatinine clearance levels <40 mL/min will be excluded from this study and subjects in Cohort 4 with a creatinine clearance of < 30 mL/min within 48 hours prior to the MRI scan performed during the repeat dose session, will not be eligible to participate in that scan.

Based on updated guidance from the FDA, subjects with an eGFR >30mL/min have appear to have negligible risk of developing NSF/NFD [Kramer, 2007; FDA, 2015].

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Other theoretical risks:

Potential effects on vasoregulation: TRPV4 mediates prostaglandin release from isolated human endothelial cells and in vivo in rats, supporting the potential for TRPV4 blockade to modulate blood pressure via prostaglandin release. No effect of GSK2788745 on blood pressure was observed in preclinical studies. Blood pressure will be monitored throughout the study.

On-target effects suggested by literature reports: Genetic deletion of TRPV4 in mice has been shown to effect hearing. TRPV4 knockout mice at age 8 weeks exhibited normal hearing thresholds but at age 24 weeks, had delayed-onset hearing loss; additionally, the cochlea was found to be vulnerable to acoustic injury with sound overexposure [Tabuchi, 2005]. Patients with Charcot-Marie-Tooth disease Type 2C (CMT2C), an autosomal dominant axonal neuropathy related to TRPV4 gene mutations, demonstrate symptoms that include hearing loss caused by nerve damage in the inner ear (sensorineural hearing loss). Although the exact mechanism is unclear, it has been suggested that the TRPV4 channel plays an important role in peripheral nerve function and that the alterations in TRPV4 in CMT2C may be due to increased channel activity leading to excessive calcium influx and a calcium overload. In cells (HEK293) expressing the CMT2C mutant channel, inhibitors of the TRPV4 channel were found to block the increased intracellular calcium concentrations and resultant cell death [Landouré, 2009]. Although there is a lack of information on the direct effects of TRPV4 inhibitors on hearing, audiometry will be incorporated in the assessments for the repeat-dose phases of the study, Cohorts 3 and 4.

Miscellaneous: TRPV4 is a ubiquitous channel, and fluid movement across membranes is relevant in multiple tissues. Preclinical models have indicated substantial safety with the onset of TRPV4 blockade in these many tissues spaces, including that of renal function (within and outside the context of concomitant diuretic therapy). Given the importance of the kidney in heart failure patients, HF patients will be monitored in-house for renal function (estimated GFR) and urine specific gravity. Overall, physical examination reviews and daily attention to clinical history will offer some possible insights if man does not parallel the safety findings thus far in animals. Other than the risks listed in the table above there are no other preclinical concerns of which we are aware.

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Table 13 Risk Evaluation Related to Specific Study Procedures in Cohorts 3 and 4

Study Procedure Potential risksBicycle exercise Side effects of bicycle testing can include shortness of breath, light-

headedness, drop in blood pressure, or abnormal heart rhythm. In rare cases, these side effects can be serious or life-threatening. Also possible are direct injuries such as bruises, sprains, and strains and indirect problems such worsening of pain from arthritis.

DCE-MRI The relatively confined space of the MRI system may cause some subjects to experience claustrophobia. The time varying magnetic fieldsused in MRI can cause mild nerve stimulation and tissue heating, both of which are strictly controlled by both software and hardware controls implemented by the scanner manufacturer that cannot be bypassed. All scans will be conducted by experienced radiographers and radiologists in the nominated scanning sites. If a subject experiences claustrophobia, the subject will be withdrawn from the study if they are unable to tolerate it again. While lying supine in the MRI scanning system, a subject may develop an exacerbation of dyspnoea. If significant dyspnoea occurs, treatments available in the study area will include sitting upright and oxygen if required. If further therapies are required, best practice clinical management including transfer to hospital for further management will be undertaken.

4. STUDY POPULATION

4.1. Number of Subjects

A sufficient number of healthy volunteer subjects will be enrolled such that approximately 24 subjects will complete dosing and critical assessments (approximately 20 subjects will complete single dosing and 4 subjects will complete repeat dosing). At least 4 subjects will complete dosing and critical assessments in each dose group prior to dose escalation. Further, an additional group of 8 subjects may be enrolled to allow for the evaluation of another dose level with repeat dose administration.

A sufficient number of subjects with HF will be enrolled in Cohort 4 such that 18 subjects complete dosing and critical assessments. If required, the total number of subjects may be increased to 24. Approximately eighteen to twenty four additional subjects with HF may be enrolled in a separate group to allow for evaluation of an additional dose level for up to a maximum of 14 days of repeat dosing.

A sufficient number of subjects with HF will be enrolled in Cohort 5 such that at least 8 subjects complete dosing and assessments.

For single dosing (Cohorts 1 and 2), if subjects prematurely discontinue the study, additional subjects may be enrolled as replacement subjects and assigned to the same treatment sequence, at the discretion of the Sponsor in consultation with the Investigator. Replacement subjects in Cohort 1 of the study will not necessarily start on the lowest

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dose level tested within the cohorts and may start on the dose intended for the withdrawn subject.

All decisions on dosing of replacement subjects will be made following review of the emerging study data and in consultation with the Investigator.

4.2. Eligibility Criteria

Protocol waivers or exemptions are not allowed with the exception of immediate safety concerns. Therefore, adherence to the study design requirements, including those specified in the Time and Events Table (Section 6.1), is essential and required for study conduct.

4.2.1. Inclusion Criteria for Healthy Subjects Cohorts (1-3)

Specific information regarding warnings, precautions, contraindications, adverse events, and other pertinent information on the GSK investigational product or other study treatment that may impact subject eligibility is provided in the IB.

A subject will be eligible for inclusion in this study only if all of the following criteria apply:

1. Male or female 18-75 years of age inclusive, at the time of signing the informed consent

2. Healthy as determined by a responsible and experienced physician, based on an evaluation including medical history, physical examination, laboratory tests and cardiac evaluation including ECG and echocardiogram. A subject with a clinical abnormality or laboratory parameter(s) which is/are not specifically listed in the inclusion or exclusion criteria, outside the reference range for the population being studied may be included only if the Investigator in consultation with the GSK Medical Monitor agree and document that the finding is unlikely to introduce additional risk factors and will not interfere with the study procedures.

3. Body weight 50kg and BMI (body mass index) within the range 18-32kg/m2

(inclusive)

4. A female subject is eligible to participate if she is of:

Non-childbearing potential defined as pre-menopausal females with a documented tubal ligation or hysterectomy for this definition, “documented” refers to the outcome of the Investigator's/designee’s review of the subject's medical history for study eligibility, as obtained via a verbal interview with the subject or from the subject’s medical records; or postmenopausal defined as 12 months of spontaneous amenorrhea. In questionable cases a blood sample with simultaneous follicle stimulating hormone (FSH) > 40MlU/ml and estradiol < 40pg/ml (<147pmol/L) is confirmatory.

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5. Male subjects with female partners of child-bearing potential must agree to use one of the contraception methods listed in Section 4.3.1. This criterion must be followed from the time of the first dose of study medication until 2 weeks post-last dose.

6. Capable of giving written informed consent, which includes compliance with the requirements and restrictions listed in the consent form

7. ALT, alkaline phosphatase and bilirubin 1.5xULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is fractionated and direct bilirubin <35%)

8. Based on averaged QTc values of triplicate ECGs obtained over a brief recording period:

QTc < 450msec; or

QTc < 480msec in subjects with Bundle Branch Block

4.2.2. Inclusion Criteria for Subjects with Heart Failure (Cohort 4)

a. Established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) Class II or III on stable heart failure therapy for at least 1 month and was not hospitalized for HF during the last three months

b. Male or female 18 years or older, age inclusive, at the time of signing the informed consent

c. ALT, alkaline phosphatase and bilirubin 1.5xULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is fractionated and direct bilirubin <35%)

d. Based on averaged QTc values of triplicate ECGs obtained over a brief recording period:

a. QTc < 450msec; or

b. QTc < 480msec in subjects with Bundle Branch Block

e. Female subject is eligible to participate if she is of:

a. Non-childbearing potential defined as pre-menopausal females with a documented tubal ligation or hysterectomy for this definition, “documented” refers to the outcome of the Investigator's/designee’s review of the subject's medical history for study eligibility, as obtained via a verbal interview with the subject or from the subject’s medical records; or postmenopausal defined as 12 months of spontaneous amenorrhea. In questionable cases a blood sample with simultaneous follicle stimulating hormone (FSH) > 40MlU/ml and estradiol < 40pg/ml (<147pmol/L) is confirmatory.

f. Male subjects with female partners of child-bearing potential must agree to use one of the contraception methods listed in Section 4.3.1. This criterion must be followed from the time of the first dose of study medication until 2 weeks post-last dose.

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g. Body weight 50kg and BMI within the range 18-40kg/m2 (inclusive)

h. Capable of giving written informed consent, which includes compliance with the requirements and restrictions listed in the consent form

4.2.3. Inclusion Criteria for Subjects with Heart Failure (Cohort 5)

1. Established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) Class II or III; on stable heart failure therapy for at least 1 month and not hospitalized for HF during the last three months

2. Male or female 18 years or older, age inclusive, at the time of signing the informed consent





5. Female subject is eligible to participate if she is of:


6. Male subjects with female partners of child-bearing potential must agree to useone of the contraception methods listed in Section 4.3.1. This criterion must be followed from the time of the first dose of study medication until 2 weeks post-last dose.

7. Body weight 50kg and BMI within the range 18-40kg/m2 (inclusive)


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4.2.4. Exclusion Criteria That Apply to All Subjects (Healthy Subjects and HF Patients in Cohorts 1-4)

A subject will not be eligible for inclusion in this study if any of the following criteria apply:

Criteria Based Upon Medical History

1. Current or chronic history of liver disease, or known hepatic or biliary abnormalities (with the exception of Gilbert's syndrome or asymptomatic gallstones)

2. History of acute coronary syndromes (including unstable angina), coronary angioplasty, or stenting within the past 6 months

3. History of regular alcohol consumption within 6 months of the study defined as:

An average weekly intake of >21 units for males or >14 units for females. One unit is equivalent to 8g of alcohol: a half-pint (~240mL) of beer, 1 glass (125mL) of wine or 1 (25mL) measure of spirits

4. History of sensitivity to any of the study medications, or components thereof or a history of drug or other allergy that, in the opinion of the Investigator and/or GSK Medical Monitor, contraindicates their participation

5. History of seizure disorder and or stroke within the last 5 years

6. Active ulcer disease or GI bleeding

7. Current smokers

Criteria Based Upon Diagnostic Assessments

1. A positive pre-study Hepatitis B surface antigen or positive Hepatitis C antibody result within 3 months of screening

2. A positive pre-study drug/alcohol screen

3. A positive test for HIV antibody

4. A screening cardiac Troponin (cTn) level > ULN

5. Baseline presence of severe aortic stenosis

Other Criteria

1. The subject has participated in a clinical trial and has received an investigational product within the following time period prior to the first dosing day in the current study: 30 days, 5 half-lives or twice the duration of the biological effect of the investigational product (whichever is longer).

2. Exposure to more than four new chemical entities within 12 months prior to the first dosing day

3. Left ventricular ejection fraction < 50% (Healthy subjects only)

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4. Subject who, in the Investigator/designee's judgement, poses a significant suicide risk. Evidence of serious suicide risk may include any history of suicidal behaviour and/or any evidence of suicidal ideation on any questionnaires e.g., Type 4 or 5 on the C-SSRS in the last 5 years.

4.2.5. Exclusion Criteria for Subjects with Heart Failure (Cohort 4)

1. History of known primary pulmonary disease requiring current medication or other therapy

2. Orthopnoea of sufficient severity to preclude supine scanning as determined at screening

3. Uncontrolled hypertension (resting systolic BP > 160mmHg or resting diastolic BP > 100mmHg)

4. Resting hypoxia while breathing room air (SpO2 <88%)

5. Estimated creatinine clearance (Cockcroft-Gault) <40mL/minute

6. Contraindication to MRI contrast agents

7. Contraindication for MRI scanning (as assessed by local MRI safety questionnaire), which includes but is not limited to:

a. Intracranial aneurysm clips (except Sugita) or other metallic objects

b. Intra- orbital metal fragments that have not been removed

c. Pacemakers or other implanted cardiac rhythm management/monitoringdevices and non-MR conditional heart valves

d. Inner ear implants

e. History of claustrophobia








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Other Criteria



3. Subject who, in the Investigator/designee's judgement, poses a significant suicide risk. Evidence of serious suicide risk may include any history of suicidal behaviour and/or any evidence of suicidal ideation on any questionnaires (e.g., Type 4 or 5 on the C-SSRS in the last 5 years).

4.3. Lifestyle and/or Dietary Restrictions

4.3.1. Contraception Requirements

4.3.1.1. Male Subjects

Male subjects with female partners of child-bearing potential must use one of the following contraceptive methods after the first dose of study treatment and until 2 weeks post-last dose.

Abstinence, defined as sexual inactivity consistent with the preferred and usual lifestyle of the subject. Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception.

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Condom plus partner use of a highly effective contraceptive:

Contraceptive Methods with a Failure Rate of 1%

Oral contraceptive, either combined or progestogen alone

Injectable progestogen

Implants of etonogestrel or levonorgestrel

Estrogenic vaginal ring

Percutaneous contraceptive patches

Intrauterine device (IUD) or intrauterine system (IUS) that meets the <1% failure rate as stated in the product label

Documented male partner sterilization prior to the female subject's entry intothe study, and this male is the sole partner for that subject. For this definition, “documented” refers to the outcome of the Investigator's/designee’s review of the subject's medical history for study eligibility, as obtained via a verbal interview with the subject or from the subject’s medical records.

Male condom combined with a female diaphragm, either with or without a vaginal spermicide (foam, gel, cream or suppository).

Male condom combined with a vaginal spermicide (foam, gel, cream or suppository).

NOTE: These allowed methods of contraception are only effective when used consistently, correctly and in accordance with the product label. The Investigator is responsible for ensuring subjects understand how to properly use these methods of contraception.

4.3.2. Meals and Dietary Restrictions

Subjects are not permitted to consume red wine, Seville oranges, grapefruit or grapefruit juice and/or pummelos, exotic citrus fruits, grapefruit hybrids or fruit juices from 7 days prior to the first dose of study medication until their discharge from the unit after their last dose of study medication.

In the food effect arm subjects will fast from approximately midnight on the day prior to dosing and will receive a standard FDA high-fat, high calorie meal 30 minutes prior to dosing. Subjects will eat this meal in 30 minutes or less. Dose administration will occur approximately 30 minutes after the start of meal consumption. Subjects will not receive any further food until 4 hours post-dose.

In Cohorts 4 and 5, no meal restrictions will be placed with regard to drug administration. Subjects will be allowed to consume a standard breakfast prior to drug administration.

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4.3.3. Caffeine, Alcohol

During each dosing session, subjects will abstain from ingesting caffeine- or xanthine-containing products (e.g., coffee, tea, cola drinks, and chocolate) for 24 hours prior to the start of dosing until collection of the final PK and/or PD sample.

During each dosing session, subjects will abstain from alcohol for 24 hours prior to the start of dosing until collection of the final PK and/or PD sample.

4.3.4. Activity

Subjects should refrain from strenuous activity 48 hours prior to clinic visits and throughout the study (except when in the exercise portion of the study). Subjects may participate in light recreational activities during studies (e.g., watch television, read).

4.4. Screen and Baseline Failures

Data for screen and baseline failures will be collected in source documentation at the site, but will not be transmitted to GSK.

4.5. Withdrawal Criteria and Procedures

A subject may withdraw from study treatment at any time at his/her own request, or may be withdrawn at any time at the discretion of the Investigator for safety, behavioural or administrative reasons.

Should a subject fail to attend the clinic for a required study visit, the site should attempt to contact the subject and re-schedule the missed visit as soon as possible. The site should also counsel the subject on the importance of maintaining the assigned visit schedule and ascertain whether or not the subject wishes to and/or should continue in the study based on previous non-compliance. In cases where the subject does not return for the rescheduled visit or cannot be reached to reschedule the missed visit, the site should make every effort to regain contact with the subject so that they can appropriately be withdrawn from the study.

These contact attempts should be documented in the subject’s medical record. Should the subject continue to be unreachable, then and only then will he/she be considered to have withdrawn from the study with a primary reason of “Lost to Follow-up”. For all other subjects withdrawing from the study, an alternative reason for discontinuation should be recorded in the eCRF.

Refer to Section 5.3 for planned dose adjustment/stopping criteria, and subject specific dose adaptation/stopping criteria including Liver Chemistry and QTc.

Liver chemistry threshold stopping criteria have been designed to assure subject safety and to evaluate liver event etiology (in alignment with the FDA premarketing clinical liver safety guidance). See Section 5.3.1 for details.

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4.6. Subject Completion

A completed subject is one who has completed all phases of the study including the follow-up visit.

The end of the study is defined as the last subject’s last visit.

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5. STUDY TREATMENT

5.1. Investigational Product and Other Study Treatment Dosage/Administration

Study TreatmentProduct name: GSK2798745 Placebo

Formulation description API solution in aqueous citrate buffer with 4% captisol

Powder in a bottle for reconstitution

Granule filled capsule

Aqueous citrate buffer with 4% captisol

Hypromellose Acetate Succinate Powder in a bottle for reconstitution

Placebo blend filled capsule

Dosage form: Solution Suspension Capsule Solution Suspension Capsule

Unit dose strength(s)/Dosage level(s):

0.1-0.4mg ≥ 0.5mg ≥ 0.5mg NA NA NA

Route/Administration/Duration: Oral Oral Oral Oral Oral OralDosing instructions: Administer required

volume of oral solution for dose up to 0.4mg. Dose with 240mL water.

Dose with 240mL water.

Dose with 240mL water

Dose with 240mL water



Physical description: Clear, colourless solution White to almost white solid

Size one White Opaque capsule containing white to almost white solid

Clear, colourless solution

White to yellowish-white solid

Size oneWhite Opaque capsule containing white to almost white solid

Manufacturer/source of procurement:

GlaxoSmithKline GlaxoSmithKline GlaxoSmithKline GlaxoSmithKline GlaxoSmithKline GlaxoSmithKline

Method for individualizing dosage:

Site to assemble Site to assemble Site to assemble Site to assemble Site to assemble Site to assemble

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Details for the various formulations can be found in the SPM.

5.2. Treatment Assignment

Subjects will be assigned to treatments in accordance with the randomization schedule generated by Discovery Biometrics, prior to the start of the study, using validated internal software. Once additional centres are initiated, subjects in Cohorts 4 and 5 will be randomized into the study by means of an interactive web response (IWR) i.e. RAMOS NG, to receive one of the treatment regimens. See Appendix 5 for treatment regimen tables.

5.3. Planned Dose Adjustments and Stopping Criteria

This protocol allows some alteration from the currently outlined dosing schedule. However, in any case, the maximum daily exposure will not intentionally exceed Cmax of 0.09µg/mL and/or AUC of 1.01µg*hr/mL in subjects dosed prior to 10/31/2014.

In Cohorts 4 and 5 (or in any cohort where dosing occurs after 10/31/2014), the exposure will not exceed a daily AUC of 0.448 µg*h/mL or Cmax of 0.049 µg/mL in any individual.

The dosing schedule may also be adjusted to expand a dosing cohort to further evaluate safety, PK and/or PD findings at a given dose level or to add cohorts to evaluate up to 1 additional dose level. The study procedures for these additional subject(s) or cohort(s) will be the same as those described for other subjects.

5.3.1. Liver Chemistry Stopping Criteria

Liver chemistry threshold stopping criteria have been designed to assure subject safety and to evaluate liver event etiology (in alignment with the FDA premarketing clinical liver safety guidance).

Study treatment will be stopped for a subject if the following liver chemistry stopping criteria is met:

ALT 3xULN

NOTE: Refer to Appendix 1 for details of the required assessments if a subject meets the above criteria.

5.3.2. QTc Withdrawal Criteria

5.3.2.1. Healthy Subjects (Cohorts 1 thru 3)

A subject who meets either criterion below will be withdrawn from the study. The same QT correction formula (e.g., QTcB, QTcF) should be used to determine inclusion and discontinuation for any individual subject throughout the study.

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QTcB or QTcF > 500msec

or

Change from baseline: QTc >60msec

If a subject has underlying bundle branch block, the following withdrawal criteria should be used instead:

Baseline QTc value (with underlying bundle branch block)

QTc withdrawal criteria

<450msec >500msec450-480msec 530msec

Withdrawal of subjects is to be based on an average QTc value of triplicate ECGs. If an ECG demonstrates a prolonged QT interval, then obtain 2 more ECGs over a brief period of time and then use the averaged QTc values of the 3 ECGs to determine whether the subject should be discontinued from the study.

5.3.2.2. Heart Failure Patients (Cohorts 4 and 5)

QTc Withdrawal Criteria

A subject who meets any of the criteria below will be withdrawn from the study. The same QT correction formula (QTcB or QTcF) should be used to determine inclusion and discontinuation for any individual subject throughout the study.


uncorrected QT >600msec,





<450msec > 500msec450-480msec 530msec

Withdrawal of subjects is to be based on an average QTc value of triplicate ECGs. If an ECG demonstrates a prolonged QT interval, obtain 2 more ECGs over a brief period of time and then use the averaged QTc values of the 3 ECGs to determine whether the subject should be discontinued from the study.

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5.3.3. Other Dose Adjustment/Stopping Safety Criteria

For an individual study participant, stopping criteria include, but are not limited to:

Severe signs or symptoms or significant changes in any of the safety assessments (e.g., ECG, vital signs, laboratory tests) that put the safety of the individual at risk, as judged by the Principal Investigator in consultation with the Medical Monitor if necessary.

5.3.3.1. Troponin Stopping Criteria

If post-screening, the local cTn is >10% Coefficient of Variance (CV) for the assay (to be determined based on local laboratory assay), it is recommended that subjects undergo repeat Troponin testing and urgent evaluation if symptoms suggestive of cardiac ischemia are present.

5.3.3.2. Asymptomatic Subject

If the second value of cTn is ≤10% CV of assay; the subject can continue on study with close follow up of symptoms. ECG and further cTn measurements should be performed as clinically indicated.

If the second value of cTn remains >10% CV of assay, treatment with GSK2798745 should be interrupted. The subject should be evaluated by a cardiologist. Any re-start of study treatment must be discussed with the GSK Medical Monitor.

If the second value of cTn exceeds the threshold for MI according to local lab parameters, cardiology consultation should be obtained immediately, GSK2798745 should be discontinued permanently, and the subject should be withdrawn from the study.

5.3.3.3. Symptomatic Subject

Cardiology consultation should be obtained immediately for any subject with new signs or symptoms suggestive of cardiac ischemia, including chest pain, shortness of breath, diaphoresis, etc. GSK2798745 should be discontinued permanently in this setting, and the subject should be withdrawn from the study.

5.3.3.4. Stopping Criteria Related to Digoxin

The subjects in Cohorts 4 and 5 that are on digoxin will be monitored for digoxin levels pre-dose and for trough levels of digoxin. If the digoxin levels are observed to be significantly lower or higher post study drug administration, the dose of digoxin may be titrated if possible in consultation with the Medical Monitor and GP. In case the digoxin dose cannot be titrated, the subject may be withdrawn from the study or continue the study without administration of the study drug, or withdrawal of the digoxin as clinically appropriate. Any follow-up and safety observations will be collected and monitored in these subjects.

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5.3.3.5. Stopping Criteria Related to CrCl and MRI Scanning

For subjects in Cohort 4, the estimated creatinine clearance (Cockcroft-Gault) will be monitored within 48 hours prior to the DCE-MRI scan that occurs during the repeat dose session between Days 5-7. If the estimated creatinine clearance is <30mL/minute, the subject will not be eligible to participate in the repeat dose session MRI scan. The subject may continue the study and administration of the study drug.

5.4. Blinding

This will be a sponsor un-blinded study: Only the sponsor and the site pharmacist are un-blinded.

The Investigator or treating physician may un-blind a subject’s treatment assignment only in the case of an emergency or in the event of a serious medical condition when knowledge of the study treatment is essential for the appropriate clinical management or welfare of the subject as judged by the Investigator. Investigators have direct access to the subject’s individual study treatment. It is preferred (but not required) that the Investigator first contact the GSK Medical Monitor or appropriate GSK study personnel to discuss options before un-blinding the subject’s treatment assignment. If GSK personnel are not contacted before the un-blinding, the Investigator must notify GSK as soon as possible after un-blinding unless that information is important for the safety of subjects currently in the study. The date and reason for the un-blinding must be fully documented in the appropriate data collection tool.

5.5. Packaging and Labelling

The contents of the label will be in accordance with all applicable regulatory requirements.

5.6. Preparation/Handling/Storage/Accountability

A description of the detailed methods and materials required for preparation of GSK2798745 solution, suspension or capsule, and placebo are provided in the protocol.

The solution, suspension and capsules will be extemporaneously prepared at the clinical site as per instructions that will be reviewed and approved by GSK prior to use.

Study treatment must be dispensed or administered according to procedures described herein. Only subjects enrolled in the study may receive study treatment. Only authorized site staff may supply or administer study treatment. All study treatment must be stored in a secure area with access limited to the Investigator and authorized site staff. Study treatment is to be stored at 2-8C, protected from light and moisture. Maintenance of a temperature log (manual or automated) is required.

The Investigator, institution, or the head of the medical institution (where applicable) is responsible for study treatment accountability, reconciliation, and record maintenance. The Investigator or the head of the medical institution (where applicable), or designated

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site staff (e.g., storage manager, where applicable) must maintain study treatment accountability records throughout the course of the study. The responsible person(s) will document 1) the amount of bulk study drug received from and returned to GSK, 2) the amount used to prepare study drug as solution, suspension and filled capsules, and 3) the amount dispensed and administered to the study participants. The required accountability unit for this study will vary, depending on the stage of drug preparation and dispensing for which reconciliation is being conducted. Discrepancies are to be reconciled or resolved. Procedures for final disposition of unused study treatment are listed in the SPM.

Investigational product is not expected to pose significant occupational safety risk to site staff under normal conditions of use and administration. Adequate precaution should be taken to avoid direct eye or skin contact and the generation of aerosols or mists. In the case of unintentional occupational exposure notify the monitor, medical monitor and/or study manager. A Material Safety Data Sheet (MSDS)/equivalent document describing occupational hazards and recommended handling precautions either will be provided to the Investigator, where this is required by local laws, or is available upon request from GSK.

5.7. Assessment of Compliance

When the individual dose for a subject is prepared from a bulk supply, the preparation of the dose will be confirmed by a second member of the study site staff.

When subjects are dosed at the study site, they will receive study treatment directly from the Investigator or designee, under medical supervision. The date and time of each dose administered in the clinic will be recorded in the source documents. The dose of study treatment and study participant identification will be confirmed at the time of dosing by a member of the study site staff other than the person administering the study treatment. Study site personnel will examine each subject’s mouth to ensure that the study treatment was ingested.

5.8. Treatment of Study Treatment Overdose

GSK does not recommend specific treatment for an overdose. The Investigator [or physician in charge of the subject at the time] will use clinical judgment to treat any overdose.

5.9. Treatment after the End of the Study

The Investigator is responsible for ensuring that consideration has been given to the post-study care of the patient’s medical condition, whether or not GSK is providing specific post-study treatment.

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5.10. Concomitant Medications and Non-Drug Therapies

5.10.1. Permitted Medications for Healthy Subjects

Paracetamol at doses of 2 grams/day is permitted for use any time during the study. Other concomitant medication may be considered on a case by case basis by the Investigator in consultation with the GSK Medical Monitor.

5.10.2. Permitted Medications for Heart Failure Patients

Paracetamol at doses of 2 grams/day is permitted for use any time during the study. The patients may stay on all regular prescription medications (except those listed in Section 5.10.4). Digoxin is permitted, but with close monitoring to maintain the therapeutic window. Other concomitant medication may be considered on a case by case basis by the Investigator in consultation with the GSK Medical Monitor.

5.10.3. Prohibited Medications and Non-Drug Therapies for Healthy Subjects

Except for the permitted medications listed above, subjects must abstain from taking prescription or non-prescription drugs (including vitamins and dietary or herbal supplements), within 7 days (or 14 days if the drug is a potential enzyme inducer) or 5 half-lives (whichever is longer) prior to the first dose of study medication until completion of the follow-up visit, unless in the opinion of the Investigator and/ or sponsor the medication will not interfere with the study.

5.10.4. Prohibited Medications and Non-Drug Therapies for Heart Failure Subjects

Except for the permitted medications noted above (Section 5.10.2), subjects with HF must abstain from taking non-prescription drugs (including vitamins and dietary or herbal supplements), within 7 days (or 14 days if the drug is a potential enzyme inducer) or 5 half-lives (whichever is longer) prior to the first dose of study medication until completion of the follow-up visit, unless in the opinion of the Investigator and sponsor the medication will not interfere with the study.

Patients must avoid using drugs that are strong inhibitors or inducers of Cytochrome P450 (CYP) 3A4 or p-glycoprotein (Pgp) because they may alter GSK2798745. The list may be modified based on emerging data. These include, but are not limited to, those listed in Table 14: consider therapeutic substitutions for these medications.

GSK2798745 has a weak potential for CYP3A4 inhibition. There is the likelihood that the concentrations of drugs that are substrates of CYP3A4 may be increased. HMG-CoA reductase inhibitors such as atorvastatin and simvastatin are examples of CYP3A4 substrates that are likely to be taken by the eligible subjects as part of their medications. The concentrations of these statins will be monitored during the study.

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GSK2798745 systemic concentrations will be monitored to detect any drug interactions with moderate CYP3A4 inhibitors or PgP inhibitors (see SPM for a detailed list).

It is strongly recommended that patients avoid using drugs that are substrates of Cytochrome P450 (CYP) 3A4 and PgP or that have a low therapeutic index because concentrations of these substrates may be increased by GSK2798745. If co-administration of these medications is necessary, investigators should monitor subjects for loss of efficacy or consider substitutions of these medications. The list may be modified based on emerging data. These include, but are not limited to, those listed in Table 15: consider therapeutic substitutions for these medications.

All concomitant medications should be reviewed by the Medical Monitor and will be to the discretion of the Investigator and Medical Monitor whether the medication can be continued and/or the subject can participate in the study.

Table 14 Strong Inducers/Inhibitors of CYP3A and PgP

Antiretrovirals: atazanavir, indinavir, nelfinavir, ritonavir

Macrolide antibiotics: clarithromycin, telithromycin, troleandomycin

Oral antifungals: ketoconazole, itraconazole, vorconazole

Antidepressant: nefazadone (FYI - withdrawn from Canada 2003 due to hepatic failure and dangerous DDI)

Calcium channel blocker:

mibefradil (FYI - withdrawn from US market 1998 due to dangerous DDI, may be off international market as well)

Immunosuppressant Cyclosporine

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Table 15 Sensitive and Narrow Therapeutic Index Substrates of CYP3A and PgP

Antiretrovirals: saquinavir, indinavir, nelfinavir, ritonavir

Macrolide antibiotics: clarithromycin, erythromycin


Antidepressant: ariprazole, buspirone

Immunosuppressant cyclosporine, tacrolimus, everolimus, sirolimus

Analgesics Alfentanil, fentanyl,

Antimigraine agents Ergotamine, eletriptan

Antiarrhythmics Disopyramide, propafenone, quinidine

HMG CoA Reductase Inhibitors

Lovastatin

Others alfentanil, boceprevir, carbamazepine, cafergot, cilostazol, cocaine, dapsone, dexamethasone, dextromethorphan, docetaxel, domperidone, eplerenone, finasteride, gleevec, irinotecan, lidocaine, methadone, nateglinide, nevirapine, ondansetron, pimozide, propranolol, quetiapine, risperidone, romidepsin, salmeterol, sildenafil, sorafenib, sunitinib, tamoxifen, taxol, telaprevir, terfenadine, torisel, trazodone, vemurafenib, vincristine, zaleplon, ziprasidone, zolpidem

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6. STUDY ASSESSMENTS AND PROCEDURES

This section lists the procedures and parameters of each planned study assessment. The exact timing of each assessment is listed in the Time and Events Table Section 6.1.

The timing and number of planned study assessments, including safety, PK, PD/biomarker assessments may be altered during the course of the study based on newly available data (e.g., to obtain data closer to the time of peak plasma concentrations) to ensure appropriate monitoring. The change in timing or addition of time points for any planned study assessments must be documented in a Note to File which is approved by the relevant GSK study team member and then archived in the study sponsor and site study files, but this will not constitute a protocol amendment. The IRB/IEC (Institutional review board/ Institutional ethics committee) will be informed of any safety issues that require alteration of the safety monitoring scheme or amendment of the Informed Consent Form. No more than 500mL of blood will be collected over the duration of the study, including any extra assessments that may be required.

Whenever vital signs, 12-lead ECGs and blood draws are scheduled for the same nominal time, the assessments should occur in the following order: 12-lead ECG, vital signs, blood draws. The timing of the assessments should allow the blood draw to occur at the exact nominal time.

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6.1. Time and Events Table

Table 16 Single Dose Healthy Subjects and Heart Failure Patients (Cohorts 1, 2, and 4)

Procedure

Screening(up to 35 days prior to Day 1)

Study Day (each dosing session)Day -1

Day 1 Day 2 Day 3

Day 410

Day 5-7

Follow up11

(7-14 days post

dost)

Pre

-do

se

0 h

0.25

h 0.5 h

0.75

h 1 h

1.5 h 2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

Admission to Unit XInformed Consent/Demographics XFull Physical Examination XBrief Physical Examination X X XWeight X X X X X X X Medical/Medication/Drug/Alcohol/ Smoking History

X X X

12-lead ECG X1 X X1 X X X X X X X X X X X X XPulse Oximetry X X X X X X XVital Signs X X X2 X X X X X X X X X X X X XEchocardiogram3 XTelemetry4 Continuous from 1 hour pre-dose to 24-hour timepoint Holter Monitoring3 XUrine Drug/Alcohol BreathTest13 X X

Serum -hCG (women) X X X

HIV, Hep B and Hep C Screen XHema/Chem/UrinalysisTests X X X X XUrine Collection5 X5 X5 - - - - - - - - - X5 X5 - I/Os Continuous XTroponin X X X XDigoxin Level6 X X XCSSR (Suicidality Assessment) X X X

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Procedure



Day 1 Day 2 Day 3

Day 410

Day 5-7

Follow up11

(7-14 days post

dost)

Pre

-do

se

0 h

0.25

h 0.5 h

0.75

h 1 h

1.5 h 2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

Appetite Assessment X X XMeal7 XStudy Treatment Dosing XPD BloodSample12 X X X X X X X X X X X X X X XPharmacokinetic Sampling8 X X X X X X X X X X X X X X X XMRI X14 X15

Maximal Exercise X14

Constant Workload Exercise X14

DLco and DLno and Spirometry X14

Dyspnoea X14

NT-proBNP X XAudiometry X14

Pharmacogenetic (PGx) Sample9 For subjects who consent (only): collect one PGx sample after the start of dosing (preferably on Day 1)

Adverse Event Review X Continuous XConcomitant Medication Review X Continuous XDischarge10 XOutpatient Visit X X

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1. ECGs to be obtained in triplicate.

2. Vital signs will be taken in triplicate.3. Assessment may be conducted 7 days prior to Day 14. Telemetry is conducted from 1 hour pre-dose until 24 hours post-dose.5. Urine samples for metabolite identification will be collected and pooled over the time

intervals of 0-12 hours, 12-24 hours and 24-48 hours for Cohort 1 only. A single predose urine sample will also be collected for Cohort 1 only. Output measurements will be determined from samples collected over the 0-12 hour and the 12-24 hour intervals (combined). No urine samples will be collected for Cohort 2. Metabolite identification samples will not be collected in Cohort 4.

6. Only for subjects who are receiving digoxin.7. Subjects will be fasted from midnight of Day-1 until 4 hours after the first dose of

study medication. In Cohort 4, subjects meals will not be restricted Any other meal instructions will be detailed in the SPM

8. PK sampling time points may be modified based on emerging data. For HF subjects, serial sampling for Day 1 timepoints only and some of those timepoints may also be utilized to collect samples to determine concentrations of other medications (e.g. atorvastatin and/or simvastatin). See SRM for detailed information. The 72-hour sample may not be obtained in all groups, based on the estimated half-life of the drug.

9. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample.

10. Discharge may be at 48 or 72 hours following the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 3 or 4 will be conducted on the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 4) will not be performed.

11. Follow-up assessments will not be conducted in patients in Cohort 4 who continue to the repeat-dose Treatment Period.

12. Pharmacodynamic (PD) blood sampling to be drawn in Cohort 4 only and may be modified based on emerging data. See Section 6.6

13. For HF patients only who are unable to breath into the alcohol breath test apparatus or if technique issues occur urine ethanol test will be performed

14. Cohort 4 only. Assessment may be conducted within 7 days of Day 1 of the single-dose treatment period or the repeat dose period.

15. Cohort 4 only, only in case of technical failure of scanning at Day -1.

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Table 17 Repeat Dose Healthy Subjects (Cohort 3)

Day: Screening -1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Follow-up

Visit Window (relative to Day 1)

-45 to -1 days

7-14 days after last dose

Admission to Unit XInformed Consent XDemographics XComplete Physical Exam./Smoking History

X

Brief Physical Exam. X X X X X X X XWeight X X X X X X X X X X X X X X X X X X X XMedical/Medication/Drug/Alcohol/Smoking History

X X

12-lead ECG X1 X1 X X X X X X X X X X X X X X X XHolter Monitoring3 X

Vital Signs/Oximetry4 X X5 X X X X X X X X X X X X X X X X X X

Echocardiogram3 XAudiometry X6 X XUrine Drug/Alcohol Breath Test

X X

Serum -hCG (women)

X X X

HIV, Hep B and Hep C Screen

X

Hema/Chem/Urinalysis Tests2 X X X X X X X X X

Troponin X X X X X X X X XUrine Collection7 X7 X7 CSSR (Suicidality Assessment)

X X X X

Appetite Assessment X X X X

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-45 to -1 days


Exercise Testing X6 X8

DLco and DLno X6 X8

OGTT9 X6 X8

PD Blood Sample X16 X X X16 X X

T/M Blood Sample X17 X X

AE Assessment X Continuous XCon.Medication Review

X Continuous X

PK Blood Sample10 X11 X X X X X X11 X X XStudy Treatment Dosing12 X X13 X X X X X X X X X X X X

PGx14 for subjects who consent (only): collect one PGx sample after the start of dosing, preferably on Day 1Discharge15 XOutpatient Visit X X

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1. ECGs will be obtained in triplicate.2. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported3. Can be conducted in a separate screening visit. If the subject has had an Echocardiogram or Holter within the last 3 months, it does not need to be repeated for

participation in this particular cohort.4. Pulse oximetry will be conducted once daily excluding screening.

5. Vital signs will be taken in triplicate.6. Assessment may be conducted within 7 days of the start of the treatment period (Day 1).7. Urine samples for metabolite identification will be collected and pooled over the time intervals of 0-12 hours and 12-24 hours on Day 1. A single predose urine sample

will also be collected on Day 1. Urine samples will also be collected and pooled over the time intervals of 0-12 hours, 12-24 hours, and 24-48 hours starting on Day 14.

8. Assessment will be conducted once during Days 12 through 14.9. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT (fasting), and 60, 120 and 180min post-OGTT10. For a twice daily dosing regimen, PK sampling times will be adjusted and detailed accordingly in the SPM.11. Serial sampling (actual timpoints will be assigned after data from previous cohort(s) are available).12. Timing of food with respect to dosing will be determined based on information gained with previous cohorts. 13. Based on the PK profile obtained in Cohort 1, the Day 2 dose may be skipped to estimate the time invariance in PK.14. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample15. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 16 or 17 will be

conducted on the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 17) will not be performed.16. PD serial blood samples will be drawn only prior to dose administration and may be drawn at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours after the administration of drug

to correspond with PK sampling. Actual timepoints could change based on the PK sampling timepoints.17. Transcriptomic/Metabolomic Blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.

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Table 18 Repeat Dose Heart Failure Patients (Cohort 4 continued from single-dose Table 16)

Days Screening(up to 35 days prior to Day 1)17

-11,17 117 2 3 4 5 6 7 8 Follow-up (7-14 days after the last dose)

Re-Admission to Unit XFull Physical Examination XBrief Physical Examination X X X X X X X X X XWeight X X X X X X X X X X XMedical/Medication/Drug/Alcohol/Smoking History

X X

12-lead ECG X X2 X X X X X X X X XTelemetry3 XVital Signs/ Oximetry4 X X5 X X X X X X X X XRespiratory Rate X X X X XEchocardiogram X XAudiometry X17 X XUrine Drug/Alcohol Breath Test6 X X

Serum -hCG (women) X X XHema/Chem/Urinalysis Tests16 X X X X X X X XTroponin X X X X X X X

NT-Pro BNP and ANP X X X X X

Uroguanylin and Guanylin X X X X

Digoxin Concentration7 X X X X X

I/Os X X X X X X XAE Assessment ContinuousC-SSRS X X X XAppetite Assessment X X XCon. Medication Review X XConstant Workload Exercise X17 X8

Maximal Workload Exercise X17 X8

Dyspnoea Scale Scoring X17 X X X8 XDLco and DLno and Spirometry X17 X8

Orthopnea X X X X8 XMRI X17 X8

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T/M Blood Samples X15 XPK Blood Sample 10 X11 X X X X X X9 X12

PD Blood Sample X9 XStudy Treatment Dosing13 X X X X X X XSensiVest18 X X X X X X X X X

PGx14 for subjects who consent (only): collect one PGx sample after the start of dosing (preferably on Day 1 [if not previously collected during the SD treatment period]

Discharge XOutpatient Visit X X

1. First 6 subjects will return to the unit after a washout period of 7-21 days for the RD treatment period. Day 1 will then be the first day of dosing for the RD dose period.2. ECGs to be obtained in triplicate.3. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose4. Pulse oximetry will be conducted once daily.5. Vital signs will be taken in triplicate.6. Urine ethanol test will be performed if the patient is unable to perform the alcohol breath test due to breathlessness7. Only for subjects taking digoxin.8. Assessment may be completed between Days 5 to 7.9. Serial sampling will occur on days 7. Timepoints will be pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 4h, 5h, 6h, 8h, 12h, and 15h. Some of these timepoints may also be utilized

to collect samples to determine concentrations of other medications (e.g., atorvastatin and/or simvastatin). See the SRM for detailed information.10. On days 2 through 6 PK samples will be drawn pre dose11. On day 1 PK samples will be drawn predose, 2h, and 12h. For subjects who do not participate in the single dose period, PK samples will be drawn at the following timepoints:

pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 5h, 8h, 12h and 15 h. Some of these timepoints may also be utilized to collect samples to determine concentrations of other medications (e.g. atorvastatin and/or simvastatin). See SRM for detailed information.

12. On day 8, PK samples will be drawn at 24h post last dose and just prior to discharge (sample time will be noted in the eCRF).13. Meals will not be restricted in this cohort14. Informed consent for optional PGx (Pharmacogenetics) research must be obtained before collecting a sample.15. Transcriptomic/Metabolomic blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.16. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported17. For subjects who do not participate in the single dose session, screening, day -1 and day 1 will reflect timepoints shown in Table 16. MRI, Constant and Maximal Exercise,

DLco/DLno and Dyspnea scale scoring can be completed within 7 days prior to Day -1. Baseline assessment of MRI, constant and maximal Exercise, audiometry, DLco/DLno, spirometry and dyspnoea scale scoring can be performed either prior to the single dose session or the repeat dose session.

18. This non-invasive vest may be placed on the subject daily with the subject’s consent and will only be perfomed at GSK designated sites that have the capability. Timepoints may be changed based on feasibility.

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Table 19 Cohort 5: Repeat Dose Heart Failure Patients

Days Screening(up to 35 days prior to Day 1)

-1 1 2 3 4 5 6 7 8 Follow-up (7-14 days after the last dose)

Admission to Unit XFull Physical Examination XBrief Physical Examination X X X X X X XWeight X X X X X X X XMedical/Medication/Drug/Alcohol/Smoking History

X X

12-lead ECG X X1 X X X X X XTelemetry2 XVital Signs X X3 X X X X X X X X XPulse Oximetry4 X X X X X XEchocardiogram X XAudiometry X X XUrine Drug/Alcohol Breath Test5 X X

Serum -hCG (women) X X XHema/Chem/Urinalysis Tests X X X X X XTroponin X X X X X XDigoxin Concentration6 X X X X X

AE Assessment X X X X X X X X X XC-SSRS X X X XAppetite Assessment X X XCon. Medication Review X X XDyspnoea Scale Scoring X X X X X X XDLco, DLno and Spirometry X X XPK Blood Sample7 X8 X X X X X X9 XPD Blood Sample X8 X9 XTM Blood Sample X10 XStudy Treatment Dosing11 X X X X X X XBodyGuardian Monitor --------------------------------------------- Continuous----------------------------------------------


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Discharge from Unit XClinic Visit X XOutpatient Visit13 X X X X

1. ECGs to be obtained in triplicate.2. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose.3. Vital signs will be taken in triplicate.4. Pulse oximetry will be conducted once on scheduled days only.5. Urine ethanol test will be performed if the patient is unable to perform the alcohol breath test due to breathlessness.6. Only for subjects taking digoxin7. On Days 2 through 6, PK samples will be collected prior to administration of study medication and on Day 8 PK samples will be drawn at approximately 24 hours after the last

dose of study medication.8. Serial sampling will occur on Day 1 and will be drawn at the following timepoints: pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 5h, 8h and 12 hours. Some of these timepoints may

also be utilized to collect samples to determine concentrations of other medications (e.g. atorvastatin and/or simvastatin). See SRM for detailed information.9. Serial sampling will occur on Day 7 and will be drawn at the following timepoints: pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 5h and 8h. Some of these timepoints may also be

utilized to collect samples to determine concentrations of other medications (e.g. atorvastatin and/or simvastatin). See SRM for detailed information.10. Transcriptomic/Metabolomic blood samples will be obtained prior to administration and at 12 hours after administration of study medication on Day 1.11. Meals will not be restricted in this cohort.12. Informed consent for optional PGx (Pharmacogenetics) research must be obtained before collecting a sample.13. Days 5 and 6 will be outpatient visits where a nurse will collect vital signs, AEs, blood samples for PK, and administer study medication to subjects at the subjects’ home. Day

8 will also be an outpatient visit where a nurse will obtain blood samples for PK and PD analysis and record vital signs and AEs.

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6.2. Demographic/Medical History Assessments

The following demographic parameters will be captured: year of birth, gender, race and ethnicity.

Medical/medication/alcohol/ smoking history will be assessed as related to the eligibility criteria listed in Section 4.2. Cardiovascular medical history/risk factors will also be assessed at baseline.

For subjects with HF only, the following items pertaining to medical and medicationhistory will be recorded/assessed at Screening (See eligibility criteria listed in Section4.2):

Confirm heart failure class

Onset and type of symptoms

Years since diagnosis of HF

Degree of exercise intolerance: distance/ stairs/time prior to breathlessness

Presence of orthopnoea and/or paroxysmal nocturnal dyspnoea

Peripheral oedema: presence and height beyond ankle; presence of anasarca, recent weight gains, level of peripheral pitting edema

Significant past medical history including onset, aetiology, and results of any recent relevant investigations of heart failure, as applicable

Medication history

6.3. Safety

Planned time points for all safety assessments are listed in the Time and Events Table (Section 6.1). Additional time points for safety tests (such as vital signs, physical examinations and laboratory safety tests) may be added during the course of the study based on newly available data to ensure appropriate safety monitoring.

6.3.1. Physical Examinations

A complete physical examination will include assessments of the head, eyes, ears, nose, throat, skin, thyroid, neurological system, lungs, cardiovascular system, abdomen (liver and spleen), lymph nodes and extremities. Height and weight will also be measured and recorded.

A brief physical examination will include assessments of the skin, lungs, cardiovascular system, and abdomen (liver and spleen). In subjects with HF, peripheral oedema (height and severity above ankle, non-dependent limb), as well as JVP and presence of anasarca should be monitored

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Weight will be measured once daily as indicated in the Time and Events Tables. If applicable, metabolic scales will be utilized to collect daily weights per site SOP and recorded to nearest 100g.

The examinations will be performed by a qualified, licensed medical professional (i.e., physician, physician assistant, or nurse practitioner).

6.3.2. Vital Signs and Other Measures

Vital sign measurements will include systolic and diastolic blood pressure, heart rate, and respiratory rate.

Vital signs will be collected with the subject semi-supine and after the subject has been resting for 5 minutes.

For time points where vital signs are collected in triplicate, there should be a 5 minute interval between readings.

Resting pulse oximetry will be measured as indicated in the Time and Events Tables.

Subject-reported appetite assessments will be made prior to the administration of study medication and periodically as indicated in the Time and Events Tables.

Recording of 24-hour fluid input/output totals will be performed at the time of the 24-hour urine collection while the subject is in the unit (Cohorts 1-3)

Cohort 4: Recording of 24-hour fluid input/output totals will be performed while the subject is in the unit(both periods, if applicable)

6.3.3. Electrocardiogram (ECG)

12-lead ECGs will be obtained at each time point during the study using an ECG machine that automatically calculates the heart rate and measures PR, QRS, QT, and QTcF intervals.

ECGs will be obtained in the semi-supine position after the subject has been resting for at least 5 minutes.

For time points where ECGs are collected in triplicate at baseline, there should be approximately a 5 minute interval between readings.

Refer to Section 5.3.2 for QTc withdrawal criteria and additional QTc readings that may be necessary.

A transthoracic echocardiogram will be performed as specified in the Time and Events Table. Images will be obtained in standard views (e.g., long axis parasternal, short axis parasternal, and apical 2, 3, 4 and 5 chamber). The time to acquire images should not exceed 30 minutes.

6.3.4. Telemetry Monitoring

Continuous triple lead ECG monitoring (using telemetry or a bedside ECG monitor) will also be performed during the study as described in the Time and Events Tables.

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Abnormal findings on continuous ECG monitoring should be confirmed by 12-lead ECG.

6.3.5. Holter Monitoring

24-hour multi-channel continuous Holter monitoring will be performed during the screening period to assess for presence of any baseline arrhythmias.

6.3.6. Audiometry

A hearing assessment will be conducted prior to the administration of study medication and at the end of each treatment period as described in the Time and Events Tables for Cohorts 3, 4 (repeat dose period) and 5. Details of the audiometry testing may be found in the SPM.

6.3.7. Remote Monitoring

For subjects participating in Cohort 5, continuous remote monitoring will be performed during the 7-day repeat dose study period utilizing the Preventice BodyGuardian Remote Monitoring System. The cardiac monitoring system is a portable, wireless body sensor that measures ECG, heart rate, respiratory rate, and activity level. Data will be stored and transmitted to a 24-hour monitoring center. Subjects will be instructed to wear the sensor throughout the study period (Day -1 to Day 7).

6.3.8. SensiVest

For subjects participating in Cohort 4 who consent to this optional procedure, the SensiVest (Sensible Medical Innovations) will be placed on the subjects daily to assess lung fluid concentration at multiple timepoints each day. The vest utilizes noninvasive remote dielectric sensing (ReDS) technology to assess lung fluid concentration. The simple measurement takes 90 seconds to complete. GSK will designate which sites can perform this assessment according to capability.

6.3.9. Clinical Laboratory Assessments

Haematology, clinical chemistry, urinalysis and additional parameters to be tested are listed below. Details for the preparation and shipment of samples will be provided by the local laboratory or TDL laboratory.

If additional non-protocol specified laboratory assessments are performed at the site’s local laboratory and result in a change in subject management or are considered clinical significant by the Investigator, for example Serious Adverse Event (SAE) or AE or requiring dose modification, the results must be captured and sent to GSK along with other study data as defined in Appendix 3.

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Haematology, clinical chemistry, urinalysis and additional parameters to be tested are listed below:

HaematologyPlatelet Count RBC Indices: Automated WBC Differential:RBC Count MCV NeutrophilsWBC Count (absolute) MCH LymphocytesReticulocyte Count MCHC MonocytesHemoglobin EosinophilsHematocrit Basophiles

Clinical Chemistry

BUN Potassium AST (SGOT) Total and direct bilirubinCreatinine Chloride ALT (SGPT) Uric AcidGlucose, fasting Troponin GGT AlbuminSodium Calcium Alkaline phosphatise Total ProteinCPKA separate troponin sample to be drawn off the sample at timepoints in Section 6.1

NOTE: Details of Liver Chemistry Stopping Criteria and Follow-Up Procedures are given in Section 5.3.1.

Routine UrinalysisSpecific gravitypH, glucose, protein, blood and ketones by dipstickMicroscopic examination (if blood or protein is abnormal)

Other screening testsHIVHepatitis B (HBsAg)Hepatitis C (Hep C antibody)FSH and estradiol (as needed in women of non-child bearing potential only)Digoxin levels (only for subjects treated with Digoxin)Alcohol and drug screen (to include at minimum: amphetamines, barbiturates, cocaine, opiates, cannabinoids and benzodiazepines)

Biomarkers (As Indicated)B-Type Natriuretic Peptide (NT- proBNP)Atrial natriuretic peptide (ANP)UroguanylinGuanylin

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All laboratory tests with values that are significantly abnormal during participation in the study or within 14 days after the last dose of study treatment should be repeated until the values return to normal or baseline. If such values do not return to normal within a period judged reasonable by the Investigator, the etiology should be identified and the Sponsor notified.

6.3.10. Safety Laboratory Samples

6.3.10.1. Sample Collection

Blood samples should be collected by appropriately trained staff.

All sample handling and analysis will be carried out according to local laboratory SOPs.

Any clinical laboratory results outside the normal range will be repeated at the discretion of the Principal Investigator.

6.3.11. Blood Sample Collection for Troponin

The blood sample for troponin analysis will be drawn off of the safety labs scheduled at the timepoints in Section 6.1. Troponin samples are stable at 20-25C.

6.3.12. Blood Sample Collection for Digoxin

For patients taking digoxin, blood samples will be drawn at the timepoints in Section 6.1, 6 to 8 hours post-dose. Collect blood sample into a properly labeled 2.5mL SST blood collection tube (supplied by GSK). Record the date and exact time that each sample is collected in the CRF.

Clot for approx 30mins before centrifuging at 3000rpm 10mins at 4°C, then aliquot serum into an OLA tube. Send ambient on the day of collection. Shipping instructions are located in the SPM.

6.3.13. Suicidality (C-SSRS) and Possible Suicidality Related Adverse Event(s)

Based on preclinical studies that have been conducted GSK2798745 is considered to be a CNS-active drug. There has been some concern that some CNS-active drugs may be associated with an increased risk of suicidal thinking or behaviour when given to some patients with certain conditions. Although this drug has not been shown to be associated with an increased risk of suicidal thinking or behaviour when given to this patient population, GSK considers it important to monitor for such events before or during clinical studies with compounds such as this.

Subjects being treated with GSK2798745 should be assessed and monitored appropriately for suicidality and unusual changes in behaviour. Consideration should be given to

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discontinuing GSK2798745 in subjects who experience signs of suicidal ideation or behaviour.

The C-SSRS is a measure of suicidal ideation and behavior, with demonstrated predictive validity and reliability. Improved assessments of suicidal ideation and behavior are necessary to better understand the relationship between suicidal AEs and medication treatment. The FDA recommends the use of suicidality assessment instruments that map to the Columbia Classification Algorithm for Suicide Assessment (C-CASA). One such instrument is the C-SSRS. Sections of the C-SSRS include suicidal ideation, intensity of ideation, suicidal behavior, and actual suicide attempt(s). The C-SSRS assesses lifetime and current suicidal thoughts and behaviors across these categories based on an increasing severity of a 1- to 5-rating scale. The semi-structured questionnaire is completed by a trained and experienced neurologist, psychiatrist, or neuropsychologist, or another trained and experienced person approved by the Sponsor, who may be the Principal Investigator or a sub-investigator for the study. See Appendix 7 for details of the scale.

The PSRAE eCRF form should be completed (in addition to the AE or SAE pages, as appropriate) if there is an occurrence of an adverse event which, in the Investigator’s opinion, is possibly related to suicidality. This may include, but is not limited to, an event that involves suicidal ideation, a preparatory act toward imminent suicidal behavior, a suicide attempt, or a completed suicide. The Investigator will exercise his or her medical and scientific judgment in deciding whether an event is possibly related to suicidality. The Investigator will record this information in the source document and the PSRAE eCRF. The PSRAE form should be completed in its entirety as soon as the information is available and updated with any additional follow-up information received. If the adverse event meets the definition of an SAE, the Investigator must ensure that there are no discrepancies between the PSRAE and SAE forms. Both forms (PSRAE and SAE) should be updated with any follow-up information.

6.4. Pharmacokinetics

6.4.1. Blood Sample Collection for Pharmacokinetics

Blood samples for pharmacokinetic analysis of GSK2798745 and for circulatingmetabolite analysis will be collected at the time points indicated in Section 6.1 Time and Events Table. Metabolite identification samples will not be collected in Cohort 4. The actual date and time of each blood sample collection will be recorded. The timing of PK samples may be altered and/or PK samples may be obtained at additional time points to ensure thorough PK monitoring.

Where possible, PK monitoring of relevant co-administered drugs and their metabolites may also be undertaken (e.g. atorvastatin and/or simvastatin). For monitoring of simvastatin, blood samples will be collected into sodium heparin tubes. For monitoring of atorvastatin, blood samples will be collected into lithium heparin tubes. The actual date and time of each blood sample collection will be recorded. Details of PK sample collection, processing, storage, and shipment are provided in the SPM.

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6.4.2. Urine Sample Collection

Urine samples for metabolite identification will be collected at the time points listed in Section 6.1 Time and Events Table. The timing of urine samples may be altered and/or samples may be obtained at additional time points. Urine samples for metabolite identification will not be collected in Cohort 4.

Details of urine sample collection, processing, storage and shipping procedures are provided in the SPM.

6.4.3. Sample Analysis

Plasma analysis will be performed under the management of Bioanalytical Science and Toxicokinetics, DMPK (Drug Metabolism and Pharmacokinetics), GlaxoSmithKline. Concentrations of GSK2798745 will be determined in plasma samples using the currently approved analytical methodology. Raw data will be stored in the GLP (Good Laboratory Practice) Archives, GlaxoSmithKline.

Once the plasma has been analyzed for GSK2798745 any remaining plasma may be analyzed qualitatively for other circulating metabolites and the results reported under a separate DMPK protocol.

The urine samples may be analyzed for compound-related metabolites and the results will be reported under a separate DMPK protocol.

6.5. Pharmacodynamic Profile

An ex vivo cell-based impedance assay has been established with cultured human endothelial cells to measure the pharmacodynamic effect of varying concentrations of the TRPV4 channel blocker, GSK2798745, in samples of whole blood [Kustermann, 2014]. By obtaining serial blood samples at times correlated with samples taken for pharmacokinetic analysis of drug concentration, a pharmacokinetic-pharmacodynamic relationship will be established.

In Cohort 3, blood samples will be obtained on Days 1 and 14 prior to dose administration and at the times designated for pharmacokinetic sampling through the first 12 hours. If pharmacokinetic samples are specified to be taken at intervals of less than 30 minutes, those timepoints may be skipped when obtaining samples for pharmacodynamic analysis. It is anticipated that samples will be at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10, 12, 24 and 48 hours after the administration of drug. Timepoints may be adjusted during the study based on emerging data.

In Cohort 4, serial blood samples will be obtained on Day 1 of the single-dose period and on Day 7 of the repeat dose period as listed in the Time and Events Table. In Cohort 5, serial blood samples will be collected on Days 1 and 7 at the timepoints indicated in the Time and Events Table. Timepoints may be adjusted during the study based on emerging data.

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At each timepoint, samples for this pharmacodynamic analysis will be taken after the sample for pharmacokinetic analysis is obtained. The date and time of each sample will be recorded. Details of sample collection, processing storage, and shipment are provided in the SPM. These results will be reported under a separate study report.

6.6. Transcriptomic and Metabolomic Profiles

With administration of GSK2798745, the transcriptomic profile, which identifies mRNAtranscripts, may be altered, reflecting changes in gene expression in response to drug treatment. Similarly, the metabolomic profiles will provide information on any changes in the metabolites, hormones and signalling molecules present in the plasma following drug administration. Blood samples obtained in Cohorts 3 and 4 will be screened to characterize these profiles.

In Cohort 3, blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1. Samples will also be obtained on Day 7 and Day 14.

In the repeat-dose phase of Cohort 4 and in Cohort 5, blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1. Blood samples will also be obtained on Day 7 prior to administration of study medication.

The date and time of each sample will be recorded. Details of sample collection, processing storage, and shipment are provided in the SPM. These results will be reported under a separate study report.

6.7. Biomarkers

Biomarker samples will be collected for B-Type Natriuretic Peptide (NT- pro BNP), Atrial Natriuretic Peptide (ANP), uroguanylin, and guanylin analysis, as indicated in the Time and Events Tables.

6.7.1. Blood Sample Collection for Biomarkers

Blood samples for biomarkers will be drawn at the timepoints specified in Section 6.1.

Collect each serial whole blood biomarker sample as close as possible to the planned time relative to dosing. Collect whole blood into a properly labeled 5mL SST blood collection tube (supplied by GSK). Record the date and exact time that each sample is collected in the eCRF.

Immediately after collection, gently invert (DO NOT SHAKE) the evacuated blood collection tube 5 times to mix and place upright at room temperature for 30 – 120 minutes (or at 2 – 8 °C for 12 -16 hours) to clot. Centrifuge the tube (1200 – 1400 x g for 10 minutes at room temperature) and collect 3 x 500 ul of supernatant into correctly labeled vials. Transfer serum to storage in a -80 °C freezer within 30 minutes of collection.

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6.8. Efficacy

6.8.1. Exercise Tolerance for Cohort 3 and Cohort 4

Rationale: TRPV4 channel blockade may decrease pulmonary oedema produced in the setting of exercise-induced increases in PVP, resulting in improved exercise capacity and/or oxygen uptake.

Description: Peak Oxygen Uptake

Peak oxygen uptake will be measured at baseline and during the repeat-dose treatment period as outlined in the Time and Events Tables for Cohorts 3 and 4 (Section 6.1).

Maximal Exercise Test Limited by Dyspnoea or Fatigue

Subjects will first be asked to perform a maximal exercise test limited by dyspnoea or fatigue on a cycle ergometer. Baseline measurements (heart rate, blood pressure, respiratory rate, and breath-by-breath gas exchange measurements: oxygen consumption(VO2), ventilation/carbon dioxide production (VE/VCO2) slope, respiratory exchange ratio (RER), and VO2 and time at ventilator threshold) will be performed with subjects seated on the cycle ergometer for approximately 3 minutes. Subjects will then be asked to commence cycling. The workloads will be increased in a stepwise fashion until volitional fatigue. Breath-by-breath gas measurements and heart rate will be recorded throughout exercise. At the end of each 3-minute workload, Borg Rating of Perceived Exertion (RPE) and blood pressure will be obtained. At peak exercise, heart rate, blood pressure, Borg RPE, and breath-by-breath gas exchange measurements including peak VO2 will be recorded. Respiratory rate at the end of exercise will also be recorded.

Constant Workload Exercise Test

Subjects will be asked to perform cycle exercise for 10 minutes at a workload between75% to 80% of the peak work rate achieved during the maximal exercise to exhaustiontest described above. Breath-by-breath gas measurements (VO2, RER, exercise time) andheart rate will be measured throughout the exercise period. Blood pressure andrespiratory rate will also be measured.

Full details of the exercise test protocols are included in the SPM.

6.8.2. DLco and DLno

Diffusion of oxygen across the pulmonary alveolar barrier is impaired at rest in patients with chronic heart failure (CHF) and has been implicated in the generation of symptoms and exercise intolerance. It is hypothesized that by affecting the permeability of the lung, and thus reducing the amount of interstitial water, TRPV4 inhibition will increase absorption into the bloodstream of inhaled carbon monoxide (CO). This is based on the alveolar:vascular membrane conductance as well as the affinity for hemoglobin. To better characterize the membrane conductance alone, nitrogen oxide (NO) absorption will

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also be tested, as it is mostly dependent on the membrane itself. This is due to its profound affinity for hemoglobin; well beyond that of CO.

In Cohort 4, DLco and DLno measurements will be made before and after the constant workload exercise test.

Details of the pulmonary testing methodology including diffusing capacity and measured components are included in the SPM. Refer to the instruction manual(s) for the equipment for further details.

6.8.3. Magnetic Resonance Imaging (Cohort 4)

Each subject in Cohort 4 will have two MRI scans taken: at baseline (before single dose) and after steady-state has been reached during repeat dosing. If a technical failure occurs at the baseline scan, a baseline rescan may be attempted prior to repeat dosing following washout of the single dose. If a technical failure occurs during the MRI scan during repeat dosing, a rescan of the MRI scan may be attempted schedule permitting. See Section 5.3.3.5 for stopping criteria related to CrCl and the MRI scan during the repeatdose session.

6.8.3.1. Subject Scanning Procedures

Subjects will undergo MRI scanning using a 1.5 T system. On attendance at the Radiology Department, subjects will be placed supine in the scanner and will be prepared for intravenous contrast agent administration.

The scanning protocol will include routine localisers followed by T1 measurement sequences and a dynamic time series. The T1 measurement sequences will consist of 3D spoiled gradient echo (3D-SPGR) with constant echo time (TE) and repetition time (TR)and varying flip angles. The dynamic series will also consist of 3D-SPGR acquisitions with constant TE, TR and constant flip angle. Contrast agent will be administered intravenously as a bolus using a power injector during the dynamic series. Scanner gains will be controlled manually between all of the 3D-SPGR acquisitions to allow subsequent DCE-MRI parameter quantification.

Further details of scanning site training procedures and scanning protocols will be provided in a dedicated Imaging Manual.

All MRI scans will be reported (non-anonymised) for clinical abnormalities as per normal NHS Clinical Governance requirements for subject safety purposes.

6.8.3.2. Phantom Scanning

In order to maximise image quality and data consistency throughout the study, regular scanning of a Eurospin TO5 phantom will be required. The same scanning protocol as used in study subjects will be repeated using the phantom at intervals of no less than once every 6 weeks and immediately after any software or hardware upgrade or maintenance.

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6.8.3.3. Data Transfer

All MRI data will be anonymised at site and transferred to Bioxydyn Limited. Details for image transfer will be provided in the Imaging Manual.

6.8.3.4. DCE-MRI Data Analysis

All DCE-MRI data analysis will take place at Bioxydyn Limited. DCE-MRI data will be corrected for breathing motion using registration and the lungs will be segmented from the image volume. An arterial input function (AIF) will be extracted from the pulmonary artery or right ventricle; if not available a population AIF will be substituted. The ‘extended Tofts’ tracer kinetic model will be applied to the data to provide measurements of ktrans (capillary transfer coefficient of contrast agent - /min), ve (leakage space -fraction) and vp (plasma volume - fraction). Median values of ktrans and ve will be provided from each lung (total lung, apical and basal) for subsequent statistical analysis. All values will be corrected for the individual’s haematocrit value. If not available, a typical haematocrit value will be assumed. Normalized proton density will additionally be measured using patient muscle as an internal reference.

6.8.4. Oral Glucose Tolerance Test (OGTT)

The oral glucose tolerance test (OGTT) measures the body's ability to use glucose, the body's main source of energy. It has been demonstrated in preclinical models that TRPV4 inhibition improves glucose utilization [Ye, 2012]. A dose-dependent change in this parameter could offer a simpler metric to assess target engagement. On days specified in Section 6.1, subjects in Cohort 3 will be administered a fasting 75g oral glucose tolerance test (OGTT) approximately 2h after dosing to assess the PD effects of GSK2798745 and placebo. The 75g glucose OGTT must be completely consumed in 5 minutes. Breakfast will be omitted on days when the OGTT is administered. A fasting blood sample will be collected prior to OGTT, and blood sampling will then be collected every 60min up to 180min.

6.8.5. Dyspnoea Scale Scoring

A standardised, validated absolute dyspnoea 5-point Likert scale [Mebazaa, 2009] will be administered before and after bicycle exercise (both the maximal and constant exercise tests) in the seated position, at the time points in Section 6.1. With more modest dyspnea, the change when supine will be captured. Additional details are in the SPM.

6.9. Pharmacogenetics

Information regarding Pharmacogenetic (PGx) research is included in Appendix 2. The IRB/IEC and, where required, the applicable regulatory agency must approve the PGx assessments before these can be conducted at the site. In some cases, approval of the PGx assessments can occur after approval is obtained for the rest of the study. If so, then the written approval will clearly indicate approval of the PGx assessments is being deferred and in most cases, the study, except for PGx assessments, can be initiated.

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When PGx assessments will not be approved, then the approval for the rest of the study will clearly indicate this and therefore, PGx assessments will not be conducted.

7. ADVERSE EVENTS, SERIOUS ADVERSE EVENTS, PREGNANCY AND MEDICAL DEVICE INCIDENTS

7.1. Adverse Events (AE) and Serious Adverse Events (SAEs)

The Investigator or site staff is responsible for detecting, documenting and reporting events that meet the definition of an AE or SAE.

7.1.1. Time Period for Collecting AE and SAE Information

AEs will be collected from the start of study treatment and until the follow-up contact. Medical occurrences that begin prior to the start of study treatment but after obtaining informed consent may be recorded on the Medical History/Current Medical Conditions eCRF.

SAEs will be collected over the same time period as stated above for AEs. However, any SAEs assessed as related to study participation (e.g., protocol-mandated procedures, invasive tests, or change in existing therapy) or related to a GSK product will be recorded from the time a subject consents to participate in the study up to and including any follow-up contact. All SAEs will be recorded and reported to GSK within 24 hours, as indicated in Appendix 3.

Investigators are not obligated to actively seek AEs or SAEs in former study participants. However, if the Investigator learns of any SAE, including a death, at any time after a subject has been discharged from the study, and he/she considers the event reasonably related to the study treatment or study participation, the Investigator would promptly notify GSK.

NOTE: The method of, recording, evaluating and follow-up of AEs and SAEs plus procedures for completing and transmitting SAE reports to GSK are provided in Appendix 3.

7.1.2. Method of Detecting AEs and SAEs

Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended and non-leading verbal questioning of the subject is the preferred method to inquire about AE occurrence. Appropriate questions include:

“How are you feeling?”

“Have you had any (other) medical problems since your last visit/contact?”

“Have you taken any new medicines, other than those provided in this study, since your last visit/contact?”

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7.1.3. Definition of Adverse Events

An AE is any untoward medical occurrence in a patient or clinical investigation subject, temporally associated with the use of a medicinal product, whether or not considered related to the medicinal product.

NOTE: An AE can therefore be any unfavourable and unintended sign (including an abnormal laboratory finding), symptom, or disease (new or exacerbated) temporally associated with the use of a medicinal product.

Events meeting the definition of an AE include:

Any abnormal laboratory test results (haematology, clinical chemistry, or urinalysis) or other safety assessments (e.g., ECGs, radiological scans, vital signs measurements), including those that worsen from baseline, and felt to be clinically significant in the medical and scientific judgement of the Investigator.

Exacerbation of a chronic or intermittent pre-existing condition including either an increase in frequency and/or intensity of the condition.

New conditions detected or diagnosed after study treatment administration even though it may have been present prior to the start of the study.

Signs, symptoms, or the clinical sequelae of a suspected interaction.

Signs, symptoms, or the clinical sequelae of a suspected overdose of either study treatment or a concomitant medication (overdose per se will not be reported as an AE/SAE unless this is an intentional overdose taken with possible suicidal/self-harming intent. This should be reported regardless of sequelae.).

Events that do not meet the definition of an AE include:

Any clinically significant abnormal laboratory findings or other abnormal safety assessments that are associated with the underlying disease, unless judged by the Investigator to be more severe than expected for the subject’s condition.

The disease/disorder being studied or expected progression, signs, or symptoms of the disease/disorder being studied, unless more severe than expected for the subject’s condition.

Medical or surgical procedure (e.g., endoscopy, appendectomy); the condition that leads to the procedure is an AE.

Situations where an untoward medical occurrence did not occur (social and/or convenience admission to a hospital).

Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present or detected at the start of the study that do not worsen.

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7.1.4. Definition of Serious Adverse Events

If an event is not an AE per Section 7.1.3, then it cannot be an SAE even if serious conditions are met (e.g., hospitalization for signs/symptoms of the disease under study, death due to progression of disease, etc).

An SAE is any untoward medical occurrence that, at any dose:

a. Results in death

b. Is life-threatening

NOTE: The term 'life-threatening' in the definition of 'serious' refers to an event in which the subject was at risk of death at the time of the event. It does not refer to an event, which hypothetically might have caused death, if it were more severe.

c. Requires hospitalization or prolongation of existing hospitalization

NOTE: In general, hospitalization signifies that the subject has been detained (usually involving at least an overnight stay) at the hospital or emergency ward for observation and/or treatment that would not have been appropriate in the physician’s office or out-patient setting. Complications that occur during hospitalization are AEs. If a complication prolongs hospitalization or fulfils any other serious criteria, the event is serious. When in doubt as to whether “hospitalization” occurred or was necessary, the AE should be considered serious.

Hospitalization for elective treatment of a pre-existing condition that did not worsen from baseline is not considered an AE.

d. Results in disability/incapacity, or

NOTE: The term disability means a substantial disruption of a person’s ability to conduct normal life functions. This definition is not intended to include experiences of relatively minor medical significance such as uncomplicated headache, nausea, vomiting, diarrhoea, influenza, and accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday life functions but do not constitute a substantial disruption.

e. Is a congenital anomaly/birth defect

f. Medical or scientific judgment should be exercised in deciding whether reporting is appropriate in other situations, such as important medical events that may not be immediately life-threatening or result in death or hospitalization but may jeopardize the subject or may require medical or surgical intervention to prevent one of the other outcomes listed in the above definition. These should also be considered serious. Examples of such events are invasive or malignant cancers, intensive treatment in an emergency room or at home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in hospitalization, or development of drug dependency or drug abuse.

g. Is associated with liver injury and impaired liver function defined as:

ALT 3xULN and total bilirubin* 2xULN (>35% direct), or

ALT 3xULN and INR** > 1.5.

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*Serum bilirubin fractionation should be performed if testing is available; if unavailable, measure urinary bilirubin via dipstick. If fractionation is unavailable and ALT 3xULN and total bilirubin 2xULN, then the event is still to be reported as an SAE.

**INR testing not required per protocol and the threshold value does not apply to subjects receiving anticoagulants. If INR measurement is obtained, the value is to be recorded on the SAE form.

Refer to Appendix 1 for the required liver chemistry follow-up instructions.

7.1.5. Cardiovascular Events

Investigators will be required to fill out event specific data collection tools for the following AEs and SAEs:

Myocardial infarction/unstable angina

Congestive heart failure

Arrhythmias

Valvulopathy

Pulmonary hypertension

Cerebrovascular events/stroke and transient ischemic attack

Peripheral arterial thromboembolism

Deep venous thrombosis/pulmonary embolism

Revascularization

This information should be recorded in the specific cardiovascular electronic case report form (eCRF) within one week of when the AE/SAE(s) are first reported.

7.1.6. Death Events

In addition, all deaths, whether or not they are considered SAEs, will require a specific death data collection tool to be completed. The death data collection tool includes questions regarding cardiovascular (including sudden cardiac death) and noncardiovascular death.

This information should be recorded in the specific death eCRF within one week of when the death is first reported.

7.1.7. Prompt Reporting of SAEs to GSK

Once the Investigator determines that an event meets the protocol definition of an SAE, the SAE will be reported to GSK within 24 hours. Any follow-up information on a previously reported SAE will also be reported to GSK within 24 hours.

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If the Investigator does not have all information regarding an SAE, he/she will not wait to receive additional information before notifying GSK of the event and completing the appropriate data collection tool. The Investigator will always provide an assessment of causality at the time of the initial report as described in Appendix 3.

7.1.8. Regulatory Reporting Requirements for SAEs

Prompt notification of SAEs by the Investigator to GSK is essential so that legal obligations and ethical responsibilities towards the safety of subjects are met.

GSK has a legal responsibility to notify both the local regulatory authority and other regulatory agencies about the safety of a product under clinical investigation. GSK will comply with country specific regulatory requirements relating to safety reporting to regulatory authorities, IRBs/IECs and investigators.

Investigator safety reports are prepared for suspected unexpected serious adverse reactions according to local regulatory requirements and GSK policy and are forwarded to investigators as necessary. An investigator who receives an investigator safety report describing an SAE(s) or other specific safety information (e.g., summary or listing of SAEs) from GSK will file it with the IB and will notify the IRB/IEC, if appropriate according to local requirements.

7.2. Pregnancy

7.2.1. Time Period for Collecting Pregnancy Information

All pregnancies in female partners of male subjects will be collected after the start of dosing and until follow up visit.

7.2.2. Action to be taken if pregnancy occurs in a female partner of amale study subject

The Investigator will attempt to collect pregnancy information on any female partner of a male study subject who becomes pregnant while participating in this study. This applies only to subjects who are randomized to receive study medication. After obtaining the necessary written informed consent from the female partner directly, the Investigator will record pregnancy information on the appropriate form and submit it to GSK within 2 weeks of learning of the partner’s pregnancy. The partner will also be followed to determine the outcome of the pregnancy. Information on the status of the mother and child will be forwarded to GSK. Generally, follow-up will be no longer than 6 to 8 weeks following the estimated delivery date. Any premature termination of the pregnancy will be reported.

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8. DATA MANAGEMENT

For this study subject data will be entered into GSK-defined electronic case report forms (eCRFs) in a validated data system and transmitted electronically to GSK. These data will be combined with data provided from other sources (e.g., diary data, laboratory data) to deliver datasets which support the clinical objectives. Subject initials will not be collected or transmitted to GSK according to GSK policy.

Management of clinical data will be performed in accordance with applicable GSK standards and data cleaning procedures to ensure the integrity of the data, e.g., removing errors and inconsistencies in the data. Adverse events and concomitant medications terms will be coded using MedDRA (Medical Dictionary for Regulatory Activities) and an internal validated medication dictionary, GSKDrug. The eCRFs (including queries and audit trails) will be retained by GSK, and copies will be sent to the Investigator to maintain as the Investigator copy.

9. DATA ANALYSIS AND STATISTICAL CONSIDERATIONS

9.1. Hypotheses and Treatment Comparisons

The primary objective of this study is to assess the safety and tolerability of single and repeat oral doses of GSK2798745 in healthy volunteers and in heart failure patients.

Given this is a first time in human study and no previous clinical data exist for this compound, no formal hypotheses are to be tested. Where appropriate, an estimation approach will be taken, and point estimates and confidence intervals (CI’s) on the endpoints of interest will be constructed.

9.2. Sample Size Considerations

For all cohorts, the sample size is based on feasibility; no formal power calculations were performed.

9.2.1. Cohorts 1-2 (Healthy Subjects Single Dose)

The sample size of 8 subjects for Cohort 1 is considered adequate to provide a preliminary assessment of PK and safety prior to progression into the repeat dose cohort.

The sample size of 12 subjects for the bioequivalence (BE) and food effect Cohort 2 is considered adequate to provide a preliminary assessment of PK bioavailability and food effect.

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9.2.2. Cohort 3 (Healthy Subjects Repeat Dose)

The repeat dose cohort may study 2 dose levels. Up to 8 subjects (6 on active and 2 on placebo) will be assigned to each dose level. All subjects will also participate in an exercise capacity and provide Peak VO2 related measures, along with DLco and DLno.

9.2.3. Cohort 4 (Heart Failure Patients Single and Repeat Dose)

The main goal of this cohort is to study the safety and tolerability in the patient population, targeting a total sample size of approximately 18 subjects with stable heart failure [randomized 1:1 (treatment:placebo)]. Sample size for the exploratory measurements is based on feasibility, and is supported by the information regarding interstitial volume (ve) measured by DCE-MRI in Section 9.2.5.

9.2.4. Cohort 5 (Heart Failure Patients Repeat Dose)

The main goal of this cohort is to study the safety and pharmacokinetics in the patient population targeting a total sample size of approximately 8 subjects with heart failure [randomized 3:1 (treatment:placebo)]. A sample size of 8 subjects is considered adequate to generate a pharmacokinetic profile in subjects with heart failure.

9.2.5. Interstitial volume (ve)

The difference of interstitial volume ve between smokers and non-smokers was 0.06 [Naish 2008]. The estimation on the variance of change from baseline for ve was 0.041 (SD). If we assume that the effect size observed between smokers and non-smoker will be similar to the expected difference between placebo and treatment at the end of this study and that the subject variance of change from baseline for ve is valid for this study population, the half-width of 95% CI for the mean difference in change from baseline ve

between treatment and placebo is estimated to be 0.05 with 9 subjects per arm. That is, if the observed difference between treatment and placebo for the mean change from baseline for ve is 0.06, then the 95% CI would be (0.01, 0.11).

9.2.6. Sample Size Re-estimation

The number of subjects in Cohort 4 will be re-evaluated based on the variance of change ve after 12 subjects (6:6) complete the study. A maximum of 24 subjects will be enrolled with a 1:1 ratio, as needed.

9.3. Data Analysis Considerations

9.3.1. Interim Analysis

Interim PK analyses will be performed on plasma concentration-time data available from the conduct of the single dose:

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(1) prior to dose escalation decisions in Cohort 1 to decide the active dose level for the next period.

(2) right after the PK food and bioavailability assessment result when Cohort 2 is completed to decide the starting dose formula for repeated dose study.

(3) right after the treatment of first dose level cohort in the repeated dose Cohort 3 to decide the dose level for the next repeated dose cohort.

For these analyses in Cohort 1, plasma concentration- time data will be analyzed using nominal times. The decision to proceed to higher doses will be made by the study team with consultation from the Investigator based on assessment of safety/tolerability and actual PK data at the preceding dose.

The PK and safety data that are reviewed for the dose escalations in Cohort 1 (along with data for Cohort 2), will also be used to determine appropriate doses and dosing regimen for the repeat dose cohorts.

Upon completion of Cohort 3, a formal interim analysis will be performed to report the results from Cohort 1, 2 and 3. If a lower dose is studied in Cohort 3, it will be reported out with Cohort 4.

Cohort 4: Safety, tolerability, and efficacy data from Cohort 4 will be reviewed in-stream by the sponsor. A formal interim review will be performed after 12 subjects complete the study with respect to safety, PK and efficacy parameters. Sample size re-estimation will be performed to determine if the study will be complete when 18 or 24 subjects complete the study.

Cohort 5: A review of safety, tolerability and efficacy data will be performed after 8 subjects complete all assessments in Cohort 5.

9.3.2. Final Analyses

9.3.2.1. Safety Analyses

No formal statistical analysis of the safety data is planned. Safety data, including Troponin, NT Pro-BNP, ANP, uroguanylin, guanylin (GI markers [Frederik, 2013]), triple lead telemetry monitoring, 12-lead ECGs, vital signs, safety laboratory tests and AE assessments will be reviewed and summarized on an ongoing basis during the study.

Any clinically relevant abnormalities or values of potential clinical concern will be described. Safety data will be presented in tabular and/or graphical format and summarized descriptively according to GSK’s Integrated Data Standards Library (IDSL) standards. Placebo data will be combined and summarized across periods and cohorts.

9.3.2.2. Pharmacokinetic Analyses

Plasma concentration-time data will be analyzed by non-compartmental methods with WinNonlin 5.2 or higher. Calculations will be based on the actual sampling times recorded during the study. From the plasma concentration-time data, the following PK

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parameters will be determined, as data permit: maximum observed plasma concentration (Cmax), time to Cmax (Tmax), area under the plasma concentration-time curve [AUC (0-t) and AUC (0-∞)], and apparent terminal phase half-life (t1/2).

PK parameters mentioned above will be listed and summarised descriptively by treatment dose (and day for repeat dose). Details of the analyses to evaluate the effect of meal and formulation on exposures will be listed in the reporting and analysis plan (RAP).

If data permit, dose proportionality, accumulation ratio, time invariance and steady state of GSK2798745 will be estimated where appropriate. In addition, the effect of food on PK will be assessed by comparing AUC and Cmax values from fed vs. fasted periods. The details for these analyses will be fully described in the statistical Reporting and Analysis Plan (RAP).

9.3.2.3. Pharmacodynamic Analyses

9.3.2.3.1. Cohort 4 and Cohort 5

DCE-MRI measurements ve, and ktrans (and other physiologic variables to be explored including endpoints measured during exercise testing) in Cohort 4 will be fitted using a mixed effect model with treatment as a fixed effect and baseline as a covariate. Point estimates and associated 95% confidence intervals will be constructed to provide a plausible range of values for the true comparisons of interest, such as the mean difference between treatment and placebo. If model assumptions appear grossly violated, alternative methods (e.g., use of raw data with log transformation or non-parametric methods) will be considered.

Other PD endpoints (including DLco and DLno) may also be statistically analysed, using a model appropriate to the study design and data. All PD data will be descriptively summarised and presented in graphical displays, as appropriate and will be described in more detail in the Reporting and Analysis Plan (RAP).

10. STUDY GOVERNANCE CONSIDERATIONS

10.1. Posting of Information on Publicly Available Clinical Trial Registers

Study information from this protocol will be posted on publicly available clinical trial registers before enrolment of subjects begins.

10.2. Regulatory and Ethical Considerations, Including the Informed Consent Process

Prior to initiation of a study site, GSK will obtain favourable opinion/approval from the appropriate regulatory agency to conduct the study in accordance with ICH Good Clinical Practice (GCP) and applicable country-specific regulatory requirements.

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The study will be conducted in accordance with all applicable regulatory requirements.

The study will also be conducted in accordance with ICH Good Clinical Practice (GCP), all applicable subject privacy requirements, and, the guiding principles of the 2008 Declaration of Helsinki. This includes, but is not limited to, the following:

IRB/IEC review and favourable opinion/approval to conduct the study and of any subsequent relevant amended documents

Written informed consent (and any amendments) to be obtained for each subject before participation in the study

Investigator reporting requirements (e.g. reporting of AEs/SAEs/protocol deviations to IRB/IEC)

Written informed consent must be obtained from each subject prior to participation in the study.

Information regarding pharmacogenetic (PGx) research is included in Appendix 2. In approving the clinical protocol the IEC/IRB and, where required, the applicable regulatory agency must also approve the PGx assessments (i.e., approval of Appendix 3), unless otherwise indicated. Where permitted by regulatory authorities, approval of the PGx assessments can occur after approval is obtained for the rest of the study. If so, then the written approval will clearly indicate approval of the PGx assessments is being deferred and the study, except for PGx assessments, can be initiated. When PGx assessments are not approved, then the approval for the rest of the study will clearly indicate this and therefore, PGx assessments will not be conducted.

10.2.1. Urgent Safety Measures

If an event occurs that is related to the conduct of the study or the development of the study treatment, and this new event is likely to affect the safety of subjects, the sponsor and the Investigator will take appropriate urgent safety measures to protect subjects against any immediate hazard.

The Sponsor will work with the Investigator to ensure the IEC/IRB is notified.

10.3. Quality Control (Study Monitoring)

In accordance with applicable regulations including GCP, and GSK procedures, GSK monitors will contact the site prior to the start of the study to review with the site staff the protocol, study requirements, and their responsibilities to satisfy regulatory, ethical, and GSK requirements. When reviewing data collection procedures, the discussion will also include identification, agreement and documentation of data items for which the PIMS record for studies conducted at a GSK Phase I unit will serve as the source document.

GSK will monitor the study and site activity to verify that the:

Data are authentic, accurate, and complete.

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Safety and rights of subjects are being protected.

Study is conducted in accordance with the currently approved protocol and any other study agreements, GCP, and all applicable regulatory requirements.

The Investigator and the head of the medical institution (where applicable) agrees to allow the monitor direct access to all relevant documents.

10.4. Quality Assurance

To ensure compliance with GCP and all applicable regulatory requirements, GSK may conduct a quality assurance assessment and/or audit of the site records, and the regulatory agencies may conduct a regulatory inspection at any time during or after completion of the study. In the event of an assessment, audit or inspection, the Investigator (and institution) must agree to grant the advisor(s), auditor(s) and inspector(s) direct access to all relevant documents and to allocate their time and the time of their staff to discuss the conduct of the study, any findings/relevant issues and to implement any corrective and/or preventative actions to address any findings/issues identified.

10.5. Study and Site Closure

Upon completion or premature discontinuation of the study, the monitor will conduct site closure activities with the Investigator or site staff, as appropriate, in accordance with applicable regulations including GCP, and GSK procedures.

In addition, GSK reserves the right to temporarily suspend or prematurely discontinue this study at any time for reasons including, but not limited to, safety or ethical issues or severe non-compliance. For multicenter studies, this can occur at one or more or at all sites. If GSK determines such action is needed, GSK will discuss this with the Investigator or the head of the medical institution (where applicable), including the reasons for taking such action. When feasible, GSK will provide advance notification to the Investigator or the head of the medical institution, where applicable, of the impending action prior to it taking effect.

If the study is suspended or prematurely discontinued for safety reasons, GSK will promptly inform investigators or the head of the medical institution (where applicable) and the regulatory authorities of the suspension or premature discontinuation of the study and the reason(s) for the action. If required by applicable regulations, the Investigator or the head of the medical institution (where applicable) must inform the IRB/IEC promptly and provide the reason for the suspension or premature discontinuation.

10.6. Records Retention

Following closure of the study, the Investigator or the head of the medical institution (where applicable) must maintain all site study records, except for those required by local regulations to be maintained by someone else, in a safe and secure location. The records must be maintained to allow easy and timely retrieval, when needed (e.g., audit or inspection), and, whenever feasible, to allow any subsequent review of data in

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conjunction with assessment of the facility, supporting systems, and staff. Where permitted by local laws/regulations or institutional policy, some or all of these records can be maintained in a format other than hard copy (e.g., microfiche, scanned, electronic); however, caution needs to be exercised before such action is taken. The Investigator must assure that all reproductions are legible and are a true and accurate copy of the original and meet accessibility and retrieval standards, including re-generating a hard copy, if required. Furthermore, the Investigator must ensure there is an acceptable back-up of these reproductions and that an acceptable quality control process exists for making these reproductions.

GSK will inform the Investigator of the time period for retaining these records to comply with all applicable regulatory requirements. The minimum retention time will meet the strictest standard applicable to that site for the study, as dictated by any institutional requirements or local laws or regulations, or GSK standards/procedures; otherwise, the retention period will default to 15 years.

The Investigator must notify GSK of any changes in the archival arrangements, including, but not limited to, archival at an off-site facility or transfer of ownership of the records in the event the Investigator leaves the site.

10.7. Provision of Study Results to Investigators, Posting of Information on Publically Available Clinical Trials Registers and Publication

Where required by applicable regulatory requirements, an Investigator signatory will be identified for the approval of the clinical study report. The Investigator will be provided reasonable access to statistical tables, figures, and relevant reports and will have the opportunity to review the complete study results at a GSK site or other mutually-agreeable location.

GSK will also provide the Investigator with the full summary of the study results. The Investigator is encouraged to share the summary results with the study subjects, as appropriate.

GSK will provide the Investigator with the randomization codes for their site only after completion of the full statistical analysis.

The results summary will be posted to the Clinical Study Register no later than eight months after the final primary completion date, the date that the final subject was examined or received an intervention for the purposes of final collection of data for the primary outcome. In addition, a manuscript will be submitted to a peer reviewed journal for publication no later than 18 months after the last subject’s last visit (LSLV). When manuscript publication in a peer reviewed journal is not feasible, a statement will be added to the register to explain the reason for not publishing.

A manuscript will be progressed for publication in the scientific literature if the results provide important scientific or medical knowledge.

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12. APPENDICES

12.1. Appendix 1: Liver Safety Process

Scenario 1 Healthy Volunteer Studies

The procedures listed below are to be followed if a subject meets the liver chemistry stopping criteria defined in Section 5.3.1:

Immediately withdraw the subject from study treatment

Notify the GSK medical monitor within 24 hours of learning of the abnormality to confirm the subject’s study treatment cessation and follow-up.

Complete the “Safety Follow-Up Procedures” listed below.

Complete the liver event case report forms. If the event also meets the criteria of an SAE (see Section 7.1.4), the SAE data collection tool will be completed separately with the relevant details.

Upon completion of the safety follow-up withdraw the subject from the study unless further safety follow up is required

Do not restart study treatment

Refer to the Flow chart for a visual presentation of the procedures listed below.

Safety Follow-Up Procedures for subjects with ALT 3xULN:

Monitor subjects weekly until liver chemistries (ALT, AST, alkaline phosphatase, bilirubin) resolve, stabilize or return to within baseline values.

Safety Follow-Up Procedures for subjects with ALT 3xULN and total bilirubin 2xULN (>35% direct bilirubin); or ALT 3xULN and INR1 > 1.5:

This event is considered an SAE (see Section 7.1.4). Serum bilirubin fractionation should be performed if testing is available. If fractionation is unavailable, urinary bilirubin is to be measured via dipstick (a measurement of direct bilirubin, which would suggest liver injury).

Make every reasonable attempt to have subjects return to the clinic within 24 hours for repeat liver chemistries, additional testing, and close monitoring (with specialist or hepatology consultation recommended).

Monitor subjects twice weekly until liver chemistries (ALT, AST, alkaline phosphatase, bilirubin) resolve, stabilize or return to within baseline values.

In addition, for all subjects with ALT 3xULN, every attempt must be made to also obtain the following:

1 INR testing not required per protocol and the threshold value does not apply to subjects receiving

anticoagulants.

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Viral hepatitis serology including:

Hepatitis A IgM (Immunoglobulin) antibody.

Hepatitis B surface antigen and Hepatitis B Core Antibody (IgM).

Hepatitis C RNA (ribonucleic acid).

Cytomegalovirus IgM antibody.

Epstein-Barr viral capsid antigen IgM antibody (or if unavailable, obtain heterophile antibody or monospot testing).

Hepatitis E IgM antibody.

Blood sample for pharmacokinetic (PK) analysis, obtained within 24 hours of last dose. Record the date/time of the PK blood sample draw and the date/time of the last dose of study treatment prior to blood sample draw on the case report form (CRF). If the date or time of the last dose is unclear, provide the subject’s best approximation. If the date/time of the last dose cannot be approximated OR a PK sample cannot be collected in the time period indicated above, do not obtain a PK sample. Instructions for sample handling and shipping are included in the SPM.

Serum creatine phosphokinase (CPK) and lactate dehydrogenase (LDH).

Fractionate bilirubin, if total bilirubin 2xULN.

Assess eosinophilia.

Record the appearance or worsening of clinical symptoms of hepatitis (fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash or eosinophilia) on the AE CRF.

Record use of concomitant medications, acetaminophen, herbal remedies, other over the counter medications, or putative hepatotoxins on the Concomitant Medications CRF.

Record alcohol use on the Liver Events CRF.

The following are required for subjects with ALT 3xULN and bilirubin 2xULN (>35% direct) but are optional for other abnormal liver chemistries:

Anti-nuclear antibody, anti-smooth muscle antibody, and Type 1 anti-liver kidney microsomal antibodies.

Serum acetaminophen adduct HPLC assay (quantifies potential acetaminophen contribution to liver injury in subjects with definite or likely acetaminophen use in the preceding week [James, 2009]).

Liver imaging (ultrasound, magnetic resonance, or computerized tomography) to evaluate liver disease.

The Liver Imaging and/or Liver Biopsy CRFs are also to be completed if these tests are performed.

The Liver Imaging and/or Liver Biopsy CRFs are also to be completed if these tests are performed.

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Refer to the diagram below for a visual presentation of the procedures listed above.

ALT≥3xULN ?

Bilirubin ≥ 2xULN

(or INR > 1.5 if measured)* ?

No

No

Yes

Yes

Continue investigational product (IP)

Instruct subject to stop IP Notify GSK within 24 hrs Obtain weekly liver chemistries until resolved, stabilized or returned

to baseline values Perform liver event follow up assessments (serology, PK sample, etc

as in protocol) Complete liver event CRF Withdraw subject from study after liver chemistry monitoring

complete + do not re-challenge with IP

Instruct subject to stop IP Notify GSK and arrange clinical followup within 24 hrs Perform liver event follow up assessments (serology, PK sample etc

as in protocol) Report as SAE (excl. hepatic impairment or cirrhosis studies);

complete SAE & liver event CRF + liver imaging and biopsy CRFs (if these tests are performed)

Obtain twice weekly liver chemistries until resolved, stabilized or returned to baseline values

Consultation with hepatologist/specialist recommended Withdraw subject from study after liver chemistry monitoring

complete + do not re-challenge with IP*INR threshold does not apply to subjects receiving anticoagulants.

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12.2. Appendix 2: Pharmacogenetic Research

Pharmacogenetics – Background

Pharmacogenetics (PGx) is the study of variability in drug response due to hereditary factors in populations. There is increasing evidence that an individual's genetic background (i.e., genotype) may impact the pharmacokinetics (absorption, distribution, metabolism, elimination), pharmacodynamics (relationship between concentrations and pharmacologic effects or the time course of pharmacologic effects) and/or clinical outcome (in terms of efficacy and/or safety and tolerability). Some reported examples of PGx associations with safety/adverse events include:

Drug Disease Gene Variant OutcomeAbacavir HIV

[Hetherington, 2002; Mallal, 2002; Mallal, 2008]

HLA-B* 57:01 (Human Leukocyte Antigen B)

Carriage of the HLA-B*57:01 variant has been shown to increase a patient's risk for experiencing hypersensitivity to abacavir. Prospective HLA-B*57:01 screening and exclusion of HLA-B*57:01 positive patients from abacavir treatment significantly decreased the incidence of abacavir hypersensitivity. Treatment guidelines and abacavir product labeling in the United States and Europe now recommend (US) or require (EU) prospective HLA-B*57:01 screening prior to initiation of abacavir to reduce the incidence of abacavir hypersensitivity. HLA-B*57:01screening should supplement but must never replace clinical risk management strategies for abacavir hypersensitivity.

Carbamazepine

Seizure, Bipolar disorders & Analgesia Chung, 2010; Ferrell, 2008

HLA-B*15:02 Independent studies indicated that patients of East Asian ancestry who carry HLA-B*15:02are at higher risk of Stevens-Johnson Syndrome and toxic epidermal necrolysis. Regulators, including the US FDA and the Taiwanese TFDA, have updated the carbamazepine drug label to indicate that patients with ancestry in genetically at risk populations should be screened for the presence of HLA-B*15:02 prior to initiating treatment with carbamazepine.

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Drug Disease Gene Variant OutcomeIrinotecan Cancer

[Innocenti, 2004; Liu, 2008; Schulz, 2009]

UGT1A1*28 Variations in the UGT1A1 gene can influence a patient’s ability to break down irinotecan, which can lead to increased blood levels of the drug and a higher risk of side effects. A dose of irinotecan that is safe for one patient with a particular UGT1A1 gene variation might be too high for another patient without this variation, raising the risk of certain side-effects that include neutropenia following initiation of Irinotecan treatment. The irinotecan drug label indicates that individuals who have two copies of the UGT1A1*28 variant are at increased risk of neutropenia. A genetic blood test is available that can detect variations in the gene.

A key component to successful PGx research is the collection of samples during the conduct of clinical studies.

Collection of whole blood samples, even when no a priori hypothesis has been identified, may enable PGx analysis to be conducted if at any time it appears that there is a potential unexpected or unexplained variation in response to GSK2798745.

Pharmacogenetic Research Objectives

The objective of the PGx research (if there is a potential unexpected or unexplained variation) is to investigate a relationship between genetic factors and response to GSK2798745. If at any time it appears there is potential variability in response in this clinical study or in a series of clinical studies with GSK2798745, the following objectives may be investigated – the relationship between genetic variants and study treatment with respect to:

Pharmacokinetics and/or pharmacodynamics of study treatment

Safety and/or tolerability

Study Population

Any subject, who is enrolled in the clinical study, can participate in PGx research. Any subject who has received an allogeneic bone marrow transplant must be excluded from the PGx research.

Subject participation in the PGx research is voluntary and refusal to participate will not indicate withdrawal from the clinical study or result in any penalty or loss of benefits to which the subject would otherwise be entitled.

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Study Assessments and Procedures

Blood samples can be taken for Deoxyribonucleic acid (DNA) extraction and used in PGx assessments.

If taking blood samples: in addition to any blood samples taken for the clinical study, a whole blood sample (~6ml) will be collected for the PGx research using a tube containing EDTA. It is recommended that the blood sample be taken at the first opportunity after a subject has been randomized and provided informed consent for PGx research, but may be taken at any time while the subject is participating in the clinical study.

The PGx sample is labelled (or “coded”) with a study specific number that can be traced or linked back to the subject by the Investigator or site staff. Coded samples do not carry personal identifiers (such as name or social security number). The blood sample is taken on a single occasion unless a duplicate sample is required due to inability to utilize the original sample.

The DNA extracted from the blood sample may be subjected to sample quality control analysis. This analysis will involve the genotyping of several genetic markers to confirm the integrity of individual samples. If inconsistencies are noted in the analysis, then those samples may be destroyed.

The need to conduct PGx analysis may be identified after a study (or a set of studies) of GSK2798745has been completed and the clinical study data reviewed. In some cases, the samples may not be studied. e.g., no questions are raised about how people respond to GSK2798745.

Samples will be stored securely and may be kept for up to 15 years after the last subject completes the study or GSK may destroy the samples sooner. GSK or those working with GSK (for example, other researchers) will use samples collected from the study for the purpose stated in this protocol and in the informed consent form.

Subjects can request their sample to be destroyed at any time.

Subject Withdrawal from Study

If a subject who has consented to participate in PGx research withdraws from the clinical study for any reason other than being lost to follow-up, the subject will be given a choice of one of the following options concerning the PGx sample, if already collected:

Continue to participate in the PGx research with the PGx sample retained for analysis.

Withdraw from the PGx research and destroy the PGx sample.

If a subject withdraws consent for PGx research or requests sample destruction for any reason, the Investigator must complete the appropriate documentation to request sample destruction within the timeframe specified by GSK and maintain the documentation in the site study records. The Investigator should forward the Pharmacogenetic Sample Destruction Request Form to GSK as directed on the form. This can be done at any time

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when a subject wishes to withdraw from the PGx research or have their sample destroyed whether during the study or during the retention period following close of the main study.

Screen and Baseline Failures

If a blood sample for PGx research has been collected and it is determined that the subject does not meet the entry criteria for participation in the clinical study, then the Investigator should instruct the participant that their PGx sample will be destroyed. No forms are required to complete this process as it will be completed as part of the consent and sample reconciliation process. In this instance a sample destruction form will not be available to include in the site files.

Pharmacogenetics Analyses

1. Specific genes may be studied that encode the drug targets, or drug mechanism of action pathways, drug metabolizing enzymes, drug transporters or which may underpin adverse events, disease risk or drug response. These candidate genes may include a common set of ADME (Absorption, Distribution, Metabolism and Excretion) genes that are studied to determine the relationship between gene variants or treatment response and/or tolerance.

In addition, continuing research may identify other enzymes, transporters, proteins or receptors that may be involved in response to GSK2798745. The genes that may code for these proteins may also be studied.

2. Genome-wide scans involving a large number of polymorphic markers (e.g., single nucleotide polymorphisms) at defined locations in the genome, often correlated with a candidate gene, may be studied to determine the relationship between genetic variants and treatment response or tolerance. This approach is often employed when a definitive candidate gene(s) does not exist and/or the potential genetic effects are not well understood.

If applicable and PGx research is conducted, appropriate statistical analysis methods will be used to evaluate pharmacogenetic data in the context of the other clinical data. Results of PGx investigations will be reported either as part of the main clinical study report or as a separate report. Endpoints of interest from all comparisons will be descriptively and/or graphically summarized as appropriate to the data. A detailed description of the analysis to be performed will be documented in the study reporting and analysis plan (RAP) or in a separate pharmacogenetics RAP, as appropriate.

Informed Consent

Subjects who do not wish to participate in the PGx research may still participate in the clinical study. PGx informed consent must be obtained prior to any blood being taken for PGx research.

Provision of Study Results and Confidentiality of Subject’s PGx Data

GSK may summarize the PGx research results in the clinical study report, or separately, or may publish the results in scientific journals.

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GSK does not inform the Investigator, subject, or anyone else (e.g., family members, study investigators, primary care physicians, insurers, or employers) of individual genotyping results that are not known to be relevant to the subject’s medical care at the time of the study, unless required by law. This is due to the fact that the information generated from PGx studies is generally preliminary in nature, and therefore the significance and scientific validity of the results are undetermined.

References

Chung WH, Hung SL, Chen YT. Genetic predisposition of life-threatening antiepileptic-induced skin reactions. Expert Opin. Drug Saf. 2010; 9: 15-21.

Ferrell PB, McLeod HL. Carbamazepine, HLA-B*1502 and risk of Stevens-Johnson syndrome and toxic epidermal necrolysis: US FDA recommendations. Pharmacogenomics. 2008; 9: 1543-46.

Hetherington S, Hughes AR, Mosteller M, Shortino D, Baker KL, Spreen W, Lai E, Davies K, Handley A, Dow DJ, Fling ME, Stocum M, Bowman C, Thurmond LM, Roses AD. Genetic variations in HLA-B region and hypersensitivity reactions to abacavir. Lancet. 2002; 359:1121-2.

Innocenti F, Undevia SD, Iyer L, Chen PX, Das S, Kocherginsky M, Karrison T, Janisch L, Ramirez J, Rudin CM, Vokes EE, Ratain MJ. Genetic variants in the UDP-glucuronosyltransferase 1A1 gene predict the risk of severe neutropenia of irinotecan. J Clin Oncol 2004; 22: 1382-1388.

Liu CY, Chen PM, Chiou TJ, Liu JH, Lin JK, Lin TC, Chen WS, Jiang JK, Wang HS, Wang WS. UGT1A1*28 polymorphism predicts irinotecan-induced severe toxicities without affecting treatment outcome and survival in patients with metastatic colorectal carcinoma. Cancer. 2008; 112: 1932-40.

Mallal S, Nolan D, Witt C, Masel G, Martin AM, Moore C, Sayer D, Castley A, Mamotte C, Maxwell D, James I. Association between presence of HLA-B*5701, HLA-DR7, and HLA-DQ3 and hypersensitivity to HIV-1 reverse-transcriptase inhibitor abacavir. Lancet. 2002; 359:727-32.

Mallal S, Phillips E, Carosi G, Molina JM, Workman C, Tomazic J, Jägel-Guedes E, Rugina S, Kozyrev O, Cid JF, Hay P, Nolan D, Hughes S, Hughes A, Ryan S, Fitch N, Thorborn D, Benbow A; PREDICT-1 Study Team. HLA-B*5701 screening for hypersensitivity to abacavir. N Engl J Med. 2008; 358; 568-78

Schulz C, Heinemann V, Schalhorn A, Moosmann N, Zwingers T, Boeck S, Giessen C, Stemmler HJ. UGT1A1 gene polymorphism: Impact on toxicity and efficacy of irinotecan-based regimens in metastatic colorectal cancer. World J. Gastroenterol. 2009; 15: 5058-66.

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12.3. Appendix 3: Procedures for Detection, Evaluation, Follow-Up and Reporting of Adverse Events Recording of AEs and SAEs

When an AE/SAE occurs, it is the responsibility of the Investigator to review all documentation (e.g., hospital progress notes, laboratory, and diagnostics reports) relative to the event. The Investigator will then record all relevant information regarding an AE/SAE in the appropriate data collection tool.

It is not acceptable for the Investigator to send photocopies of the subject’s medical records to GSK in lieu of completion of the GSK, AE/SAE data collection tool. However, there may be instances when copies of medical records for certain cases are requested by GSK. In this instance, all subject identifiers, with the exception of the subject number, will be blinded on the copies of the medical records prior to submission of to GSK.

The Investigator will attempt to establish a diagnosis of the event based on signs, symptoms, and/or other clinical information. In such cases, the diagnosis will be documented as the AE/SAE and not the individual signs/symptoms.

Subject-completed health outcomes questionnaires and the collection of AE data are independent components of the study. Responses to each question in the health outcomes questionnaire will be treated in accordance with standard scoring and statistical procedures detailed by the scale’s developer. The use of a single question from a multidimensional health survey to designate a cause-effect relationship to an AE is inappropriate.

Evaluating AEs and SAEs

Assessment of Intensity

The Investigator will make an assessment of intensity for each AE and SAE reported during the study and will assign it to one of the following categories:

Mild: An event that is easily tolerated by the subject, causing minimal discomfort and not interfering with everyday activities.

Moderate: An event that is sufficiently discomforting to interfere with normal everyday activities.

Severe: An event that prevents normal everyday activities.

An AE that is assessed as severe will not be confused with an SAE. Severity is a category utilized for rating the intensity of an event; and both AEs and SAEs can be assessed as severe. An event is defined as ‘serious’ when it meets at least one of the pre-defined outcomes as described in the definition of an SAE.

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Assessment of Causality

The Investigator is obligated to assess the relationship between study treatment and the occurrence of each AE/SAE. A "reasonable possibility" is meant to convey that there are facts/evidence or arguments to suggest a causal relationship, rather than a relationship cannot be ruled out. The Investigator will use clinical judgment to determine the relationship. Alternative causes, such as natural history of the underlying diseases, concomitant therapy, other risk factors, and the temporal relationship of the event to the study treatment will be considered and investigated. The Investigator will also consult the Investigator Brochure (IB) and/or Product Information, for marketed products, in the determination of his/her assessment.

For each AE/SAE the Investigator must document in the medical notes that he/she has reviewed the AE/SAE and has provided an assessment of causality.

There may be situations when an SAE has occurred and the Investigator has minimal information to include in the initial report to GSK. However, it is very important that the Investigator always make an assessment of causality for every event prior to the initial transmission of the SAE data to GSK. The Investigator may change his/her opinion of causality in light of follow-up information, amending the SAE data collection tool accordingly. The causality assessment is one of the criteria used when determining regulatory reporting requirements.

Follow-up of AEs and SAEs

After the initial AE/SAE report, the Investigator is required to proactively follow each subject at subsequent visits/contacts. All AEs and SAEs will be followed until resolution, until the condition stabilizes, until the event is otherwise explained, or until the subject is lost to follow-up.

The Investigator is obligated to perform or arrange for the conduct of supplemental measurements and/or evaluations as may be indicated or as requested by GSK to elucidate as fully as possible the nature and/or causality of the AE or SAE. The Investigator is obligated to assist. This may include additional laboratory tests or investigations, histopathological examinations or consultation with other health care professionals. If a subject dies during participation in the study or during a recognized follow-up period, the Investigator will provide GSK with a copy of any post-mortem findings, including histopathology.

New or updated information will be recorded in the originally completed data collection tool. The Investigator will submit any updated SAE data to GSK within the designated reporting time frames.

Reporting of SAEs to GSK

The primary mechanism for reporting SAEs to GSK will be the paper SAE data collection tool and fax it to the GSK Medical Monitor. Then the site will enter the serious adverse event data into the electronic system.

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After the study is completed at a given site, the electronic data collection tool (e.g., InForm system) will be taken off-line to prevent the entry of new data or changes to existing data. If a site receives a report of a new SAE from a study participant or receives updated data on a previously reported SAE after the electronic data collection tool has been taken off-line, the site can report this information on a paper SAE form or to their GSK protocol contact by telephone.

GSK contacts for SAE receipt can be found at the beginning of this protocol on the Sponsor/Medical Monitor Contact Information page.

Facsimile transmission of the SAE data collection tool is the preferred method to transmit this information to the project contact for SAE receipt. In rare circumstances and in the absence of facsimile equipment, notification by telephone is acceptable, with a copy of the SAE data collection tool sent by overnight mail. Initial notification via the telephone does not replace the need for the Investigator to complete and sign the SAE data collection tool within the designated reporting time frames.

GSK contacts for SAE receipt can be found at this beginning of the protocol on the Sponsor/Medical Monitor Contact Information page.

Facsimile transmission of the following PIMS listings for the corresponding subject is the preferred method to transmit SAE information to the GSK Medical Monitor:

SAE listing

Demographic listing

Study treatment listing

In rare circumstances and in the absence of facsimile equipment, notification by telephone is acceptable, with a copy of all required information sent by overnight mail.

If the PIMS system is unavailable when the SAE occurs, the site will use the paper SAE form and fax that to the GSK medical Monitor. The site will enter the SAE data into PIMS as soon as the system becomes available.

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12.4. Appendix 4: Treatment Sequences for Cohort 1

The treatment sequence for Cohort 1 is presented in Table 20

Table 20 Treatment Sequences for Cohort 1 (Single Dose)

Number of subjects Period 1 Period 2 Period 3 Period 4

Cohort 2 P B C D

2 0.25mg P C D

2 0.25mg B P D

2 0.25mg B C P

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12.5. Appendix 5 Treatment Regimens

Table 21 Planned Treatment Regimen Table for Cohorts 1 and 2

Treatment Regimen

Description

A 0.25mg GSK2798745 Fasted solution (single dose)B 1.0 mg GSK2798745 Fasted suspension (single dose)C 5.0 mg GSK2798745 Fasted suspension (single dose)D 12.5 mg GSK2798745 Fasted suspension (single dose)G 5.0 GSK2798745 Fasted suspension (single dose)H 5.0 GSK2798745 Fasted capsule (single dose)I 5.0 GSK2798745 Fed capsule (single dose)P Matched Placebo suspension(s) (single dose)

Table 22 Planned Treatment Regimen Table for Cohorts 3

Treatment Regimen

Description

J TBD mg GSK2798745 suspension/capsule (repeat dose )K TBD mg GSK2798745 suspension/capsule (repeat dose)

P1 matched Placebo suspension/capsule(s) (repeat dose)

Table 23 Planned Treatment Regimen Table for Cohort 4

Treatment Regimen

Description

L 2.4mg GSK2798745 capsule (single/repeat dose )M X.Xmg GSK2798745 capsule (single/repeat dose)P2 matched Placebo suspension/capsule(s) (repeat dose)

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12.6. Appendix 6: Dose Rationale Background

The predicted pharmacokinetic parameters in Table 6 were derived from the pre-clinical experiments listed below. The data from the in vitro studies measuring the intrinsic drug clearance is presented in Table 24.

Table 24 Intrinsic Clearance (Clint) of GSK2256294 – (in vitro) in Various Preclinical Species

Clint (ml/min/kg)

Human 8.5

Dog 11.0

Rat 15.0

Prediction of Clearance (Cl) and Volume of Distribution (Vd)

Table 25 lists the predicted Vd based on various approaches using data generated from pre-clinical species with GSK2798745 [Davies, 1993; Iwatsubo, 1997; Obach, 1997; Lave, 1999]. Similarly the predicted clearance in human is listed in Table 26. These methods include scaling predictions based on differences in protein binding, maximum life span potential, body weight in different species.

Table 25 Predicted Human Volume of Distribution

SpeciesExperimentally measured Vd in Vivo (L/kg)

Predicted Vd (L/kg)Avg. Fraction unbound in

tissueProportionality

Allometryw/o binding

Allometryw/binding

Human 0.99 1.04 2.30 0.87Dog 2.17 ± 0.25Rat 1.93 ± 0.49

Table 26 Predicted Human Clearance

Experimentally measured Cl in vivo(ml/min/kg)

Predicted Clearance (ml/min/kg)Allometry

w/o fu, w/o MLP

Allometryw/ fu, w/o

MLP

Allometryw/o fu, w/

MLP

Allometryw/ fu, w/

MLP*

FCIM**

Human 0.88 0.33 0.41 0.15 2.14Dog 1.77 ± 0.15Rat 6.53 ± 0.32*MLP – Maximum Lifespan potential ** FCIM Fraction Corrected Intercept Method

The ranges of PK predictions from Table 24 are summarized in Table 6. The drug half life is estimated based on the predicted volume of distribution and clearance in man. The

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oral bioavailability in Table 6 is based on the expression F = 1 – (Clp/Q) where Q is the liver blood flow [Obach, 1997]. This method does not account for potential limitations on absorption from GI tract nor first pass extraction by gut wall tissue. The observed oral bioavailability (F) in animals ranges between 55 to 70 %. Table 6 suggests GSK2798745 to be a drug with low clearance (CL) of approximately 4L/hr and volume of distribution (Vd) of 60 – 161L.

Preliminary Analyses of PK data from Cohorts 1 through 3

The PK data from single and repeat doses of GSK2798745 administered as suspension in fasted state to healthy volunteers in Cohorts 1 through 3 was used to build a preliminary population PK (POP-PK) model. The analysis was performed using non-linear mixed effects modelling approach in NONMEM software (ref). A 2-comp PK model with lag time in absorption adequately described the observed PK data and was used for simulation. The POP-PK model parameters are listed in Table 27 below.

Table 27 POP PK parameters for GSK2798745

Parameter Population Estimate Between subject variability (%CV)Absorption Rate – Ka (1/hr) 0.38 9.3

Clearance – CL/F (L/hr) 18.2 34.5Apparent Vol of distribution of central

compartment – V2/F (L)59 53.8

Intercompartment Clearance – Q/F (L/hr)

32.4 NE

Apparent Vol of distribution of peripheral compartment – V3/F (L)

197 NE

Lag Time – ALAG (hr) 0.22 NEF (bioavailability) NE 14.1

Residual variability – (% Coeff of Var) 28.0NE = not estimated

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12.7. Appendix 7 Example Copy Suicidality Scale

The forms to be used will be supplied to the site by GSK. This is an example of the form.

COLUMBIA SUICIDE-SEVERITY RATING SCALE (C-SSRS)

Baseline/Screening

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COLUMBIA SUICIDE-SEVERITY RATING SCALE (C-SSRS)

Since Last Visit

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12.8. Appendix 8: Protocol Amendment Changes

AMENDMENT 1

Where the Amendment Applies

This amendment applies to all sites (this study is single SITE).

Summary of Amendment Changes with Rationale

This amendment incorporates the changes requested during MHRA review, and corrects minor discrepancies that were in the original protocol.

List of Specific Changes


ADDED TEXT

CMT2C Charcot-Marie-Tooth disease Type 2C

CYP Cytochrome P450 enzyme

HEK Human embryonic kidney cells

Section 3.1 Study Schematic

ADDED TEXT

The order of conduct of Cohorts 2 and 3 may be changed or the two cohorts may be conducted in parallel.


PREVIOUS TEXT

1. Doses may change based on safety and exposure data. These doses are for estimation purposes only. 2. Doses greater than or equal to 0.5 mg will be given as a suspension and below 0.5mg will be given as a solution.3. Dosing will not exceed the daily average AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in any individual.4. There may be an additional dose added to either Cohort 1 or 3.5. The formulation used will depend on the results of the relative bioavailability being tested in Cohort 2.

REVISED TEXT

1. Doses may change based on safety and exposure data. These doses are for estimation purposes only. 2. Doses greater than or equal to 0.5 mg will be given as a suspension and below 0.5mg will be given as a solution.3. Dosing will not exceed the daily average AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in any individual.4. There may be an additional dose added to either Cohort 1 or 3.

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5. The formulation used will depend on the results of the relative bioavailability being tested in Cohort 2. If Cohort 3 or 4 is conducted concurrently or prior to Cohort 2, the liquid formulation utilized in Cohort 1 will be administered.

Figure 2 Study Design for Healthy Subjects Single Dose (Cohorts 1 and 2)

PREVIOUS TEXT

REVISED TEXT

Table 2 Healthy Subjects Single Dose Study Duration

PREVIOUS TEXT

Total Duration Cohort 1 (screening within 35 days + 4x (treatment + washout) + follow up of 7-14 days) = ~80 days

Cohort 2 (screening within 35 days + 3x (treatment + washout) + follow up of 7-14 days) = ~71 days

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REVISED TEXT

Total Duration Cohort 1 (screening within 35 days + 4x (treatment periods +with washout) + follow up of 7-14 days) = approximately 17 weeks ~80 days

Cohort 2 (screening within 35 days + 3x ( treatment periods withwashout) + follow up of 7-14 days) = approximately 11 weeks~71 days

Single Dose Escalation - Cohort 1

PREVIOUS TEXT

In Cohort 1, a sufficient number of subjects will be enrolled such that 8 evaluable subjects will be randomized to 1 of 4 placebo-controlled dose sequences with 2 subjects in each sequence and each subject having four dose periods (3 active dose + 1 placebo dose). The subjects will be fasting from midnight to four hours post-dose.

Sentinel dosing: For each dose escalation level, only 2 subjects will be dosed on Day 1, separated by at least 1 hour. If there are no safety or tolerability concerns, the rest of the cohort may be dosed at least 24 hours after the first dose was given at appropriate intervals.

The first cohort of single dose subjects will aim to achieve an escalation from a low starting dose to a maximum, safe and well-tolerated dose. The average daily exposure (24hr) across a cohort at any planned single dose will not intentionally exceed the composite outcome of both of the following parameters; Cmax of 0.09ug/mL in addition to (AUC) of 1.01hr*ug/mL (hereafter referred to as Cmax and/ or AUC) (see Section 3.4). If either of these exposures is exceeded, this will trigger dose considerations. Dose escalation will be stopped if stopping criteria for exposure (Cmax and/or AUC0-24) are met. While the average daily Cmax of 0.09ug/mL and/or AUC of 1.01hr*ug/mL will not be exceeded, if any individual reaches 1.5 times the stopping Cmax and/or AUC (Cmax of 0.135ug/mL and/or AUC of 1.52ug*hr/mL), that individual may be given a lower dose in the next dosing period. If an individual is projected to exceed 1.5 times the stopping Cmax and/or AUC in the next dosing period during the dose escalation step, that individual may be given the same current dose or a lower dose in next dosing period.

Progression from one dose in a given group to the next higher dose (or lower dose if needed) in the following period within Cohort 1 will be based on acceptable safety, tolerability and systemic exposure data as reviewed during a dose escalation meeting. The reviewed datasets will at a minimum consist of the listings of any adverse events, liver function test results, flagged vital signs, and flagged findings during continuous cardiac monitoring (telemetry), ECG, laboratory findings and PK results derived from 24-hour plasma profiles.

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REVISED TEXT

In Cohort 1, a sufficient number of subjects will be enrolled such that 8 evaluable subjects will be randomized to 1 of 4 placebo-controlled dose sequences with 2 subjects in each sequence and each subject having four dose periods (3 active dose + 1 placebo dose). In each Treatment Period, subjects will be fasting from midnight to four hours post-dose (Day 1).

Sentinel dosing: For each dose escalation level, only 2 subjects will be dosed on Day 1, separated by at least 1 hour; one subject will receive drug and one subject will receive placebo. If there are no safety or tolerability concerns, the rest of the cohort will may be dosed at least 24 hours after the first dose was given at appropriate intervals.

The objective of Cohort 1 The first cohort of single dose subjects will aim to achieve an escalation from a low starting dose to a maximum, safe and well-tolerated dose. For each planned single dose, tThe average daily exposure in any individual (24hr) across a cohort at any planned single dose will not intentionally exceed a the composite outcome of both of the following parameters; Cmax of 0.09ug/mL in addition to (or an AUC) of 1.01hr*ug/mL (hereafter referred to as Cmax and/ or AUC) (see Section 3.4). If either of these exposures is exceeded, this will trigger dose considerations. Dose escalation will be stopped if stopping criteria for exposure (Cmax and/or AUC0-24) are met. While the average daily Cmax of 0.09ug/mL and/or AUC of 1.01hr*ug/mL will not be exceeded, if any individual reaches 1.5 times the stopping Cmax and/or AUC (Cmax of 0.135ug/mL and/or AUC of 1.52ug*hr/mL), that individual may be given a lower dose in the next dosing period. If an individual is projected to exceed 1.5 times the stopping Cmax and/or AUC in the next dosing period during the dose escalation step, that individual may be given the same current dose or a lower dose in next dosing period.

If any individual is projected to exceed the limiting Cmax and/or AUC in the next Treatment Period during the dose escalation step, that individual may be administered the same current dose or a lower dose in next dosing period. The other subjects not projected to exceed the stopping criteria will be escalated to the next dose accordingly. Dose escalation will be stopped if either criterion for exposure (Cmax and/or AUC0-24) is met.

Progression from one dose in a given group to the next higher dose (or lower dose if needed) in the following period within Cohort 1 will be based on acceptable safety, tolerability and systemic exposure data as reviewed during a dose escalation meeting. The reviewed datasets will at a minimum consist of the listings of any adverse events, liver function test results, flagged vital signs, and flagged findings during continuouscardiac monitoring (telemetry), ECG, laboratory findings and PK results derived from 24-hour plasma profiles.

Progression to the next higher dose level will be stopped if 1 or more subjects experience a serious adverse event considered as having a reasonable probability of being related to drug. Additionally, progression to the next higher dose level will be stopped if 2 or more subjects experience a severe or significant non-serious adverse event considered as having a reasonable probability of being related to drug.

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Section 12.8.1.1. Relative Bioavailability and Food Effect - Cohort 2

ADDED TEXT

Period 1- Reference Dose: Subjects will receive a liquid dose (suspension or solution). Subjects will be fasting from midnight to four hours post-dose.

Period 2- Relative Bioavailability: Subjects will receive a capsule formulation (filled in by the pharmacy) in order to assess the relative bioavailability of the capsule formulation as compared to the liquid formulation. The subjects will be fasting from midnight to four hours post-dose.

Period 3- Food Effect: Subjects will receive GSK2798745 following a standard high fat/high calorie meal. The formulation is planned to be the capsule unless the liquid formulation is selected based on available data.

Section 3.2.2.1 Dose Considerations - Cohort 3

PREVIOUS TEXT

The maximum daily dose in this repeat dosing arm will not intentionally exceed an average daily exposure of AUC of 1.01μg*hr/mL or a Cmax of 0.09μg/mL in this cohort. Doses and food intake timing will be determined based on data from Cohorts 1 and 2. Two doses will be tested (8 subjects each). The first dose will be lower and a dose escalation meeting will be conducted following the first dose to determine the dose in the second group of subjects.

Doses will be administered on Days 1-14 inclusive. It is currently planned to dose once daily, however based on emergent data [e.g., half-life (T1/2)] from the initial study cohorts, dosing may be altered to twice daily. If needed, refer to the study procedures manual (SPM) for a twice-daily dosing time and event table and dose schedule.

REVISED TEXT

The maximum daily dose in this repeat dosing arm will not intentionally exceed an average daily exposure of AUC of 1.01μg*hr/mL or a Cmax of 0.09μg/mL in any individual this cohort. Doses and fFood intake timing will be determined based on data from Cohorts 1 ands 1 and 2 (if Cohort 2 is conducted before Cohort 3). Two doses will be tested (8 subjects each). The first dose will be lower and a dose escalation meeting will be conducted following the first dose to determine the dose in the second group of subjects.

Progression to a higher dose level will be stopped if 1 or more subjects experience a serious adverse event considered as having a reasonable probability of being related to drug. Additionally, progression to a higher dose level will be stopped if 2 or more subjects experience a severe or significant non-serious adverse event considered as having a reasonable probability of being related to drug.

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Doses will be administered on Days 1 through-14. Based on data from Cohort 1, the second dose in the repeat-dose period may be skipped to estimate the time invariance in PK inclusive. It is currently planned to dose once daily, however based on emergent data [e.g., half-life (T1/2)] from the initial study cohorts, dosing may be altered to twice daily. If needed, refer to the study procedures manual (SPM) for a twice-daily dosing time and event table and dose schedule. Subjects will be fasted from midnight to 4 hours after dosing on Day 1 and Day 14 that entail serial PK sampling. Meal timings on other days will be based on previous cohort data.


PREVIOUS TEXT

Screening within 35 days + treatment (17 days) + follow up of 7-14 days) = ~65 days.

Timing and dosing regimen may change pending safety and PK data from Cohorts 1 and 2. Total treatment duration is Day -1+ 14 days dosing+ 2 days (discharge is up to 72 hours post dose).

REVISED TEXT

Screening within 35 days + treatment (17 days) + follow up of 7-14 days) = approximately 10 weeks ~65 days.

Timing and dosing regimen may change pending safety and PK data from Cohorts 1 and 2. Total treatment duration is Day -1+ 14 days dosing+ 2 days (discharge is up to 72 hours post dose).

Section 3.2.3. Heart Failure Patients Single and Repeat Dose - Cohort 4

PREVIOUS TEXT

Dose considerations: The maximum daily dose in the repeat dosing periodarm will not intentionally exceed an average daily exposure of AUC of 1.01μg*hr/mL or a Cmax of 0.09μg/mL in this cohort. The decision of food intake timing will be determined based on data from Cohorts 1 and 2. The decision of the dose will be determined from Cohorts 1 through 3. The highest safe and well tolerated dose will be evaluated in the Cohort 4.

REVISED TEXT

Dose considerations: The maximum daily dose in the repeat dosing periodarm will not intentionally exceed an average daily exposure of AUC of 1.01μg*hr/mL or a Cmax of 0.09μg/mL in any individualthis cohort. The decision of food intake timing will be determined based on data from Cohorts 1 and 2. The decision of the dose will be determined from Cohorts 1 through 3. The highest safe and well tolerated dose will be evaluated in the Cohort 4.

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Section 3.3 Section Drug Formulation

ADDED TEXT

All doses in Cohort 1 will be administered either as a suspension or a solution depending on the dose. Cohort 2 will also employ the capsule formulation (filled in by the pharmacy) in order to assess the relative bioavailability of the capsule formulation as compared to the liquid formulation. Cohorts 3 and 4 will employ one of the formulations used in Cohorts 1 or 2. The relative exposure data from Cohort 2 will determine the formulation for Cohorts 3 and 4. The formulation that will provide the best exposure profile (i.e., the least variable profile) will be used in Cohort 3 and 4. In the event that Cohort 3 is conducted concurrently with Cohort 2, the liquid formulation will be administered in the repeat-dose Cohort 3.

Section 3.4.2.2 Dog

PREVIOUS TEXT

As the dog exposure levels provide a more conservative stopping limit as compared to the exposure in rat, the tentative doses for this FTIH will be selected to not knowingly exceed the daily average AUC of 1.01µg*hr/mL and/or Cmax of 0.09µg/mL in any cohort.

REVISED TEXT

As the dog exposure levels provide a more conservative stopping limit as compared to the exposure in rat, the tentative doses for this FTIH will be selected to not knowingly exceed a the daily average AUC of 1.01µg*hr/mL and/or a Cmax of 0.09µg/mL in any individual in any cohort.

Section 3.4.5 Safety Cover Based on Predicted Exposure and NOAEL from the Pre-Clinical Species

PREVIOUS TEXT

If exposures are less than predicted, doses higher than the currently planned 4mg may be used. However, in any case, the average daily exposure will not intentionally exceed Cmax of 0.09µg/mL and/or AUC of 1.01g*hr/mL in any cohort.

REVISED TEXT

If exposures are less than predicted, doses higher than the currently planned 4mg may be used. However, in any case, the average daily exposure will not intentionally exceed Cmax of 0.09µg/mL and/or AUC of 1.01g*hr/mLin any individual cohort.

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Section 3.4.6 Dosing and Randomization

PREVIOUS TEXT

In Cohort 2, all 12 subjects will assigned to one fixed sequence with each subject having three dose periods: GHI, where G is capsule with food, H is liquid formulation without food and I is capsule without food.

REVISED TEXT

In Cohort 2, all 12 subjects will assigned to one fixed sequence with each subject having three dose periods: GHI, where G is capsule with food, H is liquid formulation without food and I is capsule without food.In Cohort 2, all 12 subjects will assigned to one fixed sequence with each subject having three dose periods: GHI, where G is liquid formulation without food and H is capsule without food and I is capsule with food.

Section 3.5 Risk Management

PREVIOUS TEXT

On-target effects suggested by literature reports: TRPV4 blockers and genetic deletion of TRPV4 in mice were shown to effect hearing. TRPV4 knockout mice at age 24 weeks have delayed-onset hearing loss and their cochlea were found to be vulnerable to acoustic injury [Tabuchi, 2005]. Patients with Charcot-Marie-Tooth Type 2C due to TRPV4 gene mutations, demonstrate symptoms that include hearing loss caused by nerve damage in the inner ear (sensorineural hearing loss). Although the mechanism is unclear it is suggested to be a gain (rather than loss) of function [Landouré, 2009].

REVISED TEXT

On-target effects suggested by literature reports: GTRPV4 blockers and genetic deletion of TRPV4 in mice has been were shown to effect hearing. TRPV4 knockout mice at age 8 weeks exhibited normal hearing thresholds but at age 24 weeks, hadve delayed-onset hearing loss; additionally,and their cochlea waserefound to be vulnerable to acoustic injury with sound overexposure [Tabuchi, 2005]. Patients with Charcot-Marie-Tooth disease Type 2C (CMT2C), an autosomal dominant axonal neuropathy related due to TRPV4 gene mutations, demonstrate symptoms that include hearing loss caused by nerve damage in the inner ear (sensorineural hearing loss). Although the exact mechanism is unclear, it has been suggested that the TRPV4 channel plays an important role in peripheral nerve function and that the alterations in TRPV4 in CMT2C may be due to increased channel activity leading to excessive calcium influx and a calcium overload. In cells (HEK293) expressing the CMT2C mutant channel, inhibitors of the TRPV4 channel were found to block the increased intracellular calcium concentrations and resultant cell death [Landouré, 2009]. Although there is a lack of information on the direct effects of TRPV4 inhibitors on hearing,

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audiometry will be incorporated in the assessments for the repeat-dose phases of the study, Cohorts 3 and 4.

Section 4.2.3. Exclusion Criteria That Apply to All Subjects (Healthy Subjects and HF Patients in Cohorts 1-4)

PREVIOUS TEXT

2. Chronic angina, unstable angina, or istory of acute coronary syndromes, coronary angioplasty, or stenting within the past 6 months

REVISED TEXT

2. Chronic angina, unstable angina, or History of acute coronary syndromes(including unstable angina), coronary angioplasty, or stenting within the past 6 months

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Section 5.1 Investigational Product and Other Study Treatment Dosage/Administration

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0.1-0.4mg ≥ 2.5mg 0.5-4mg NA NA NA

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0.1-0.4mg ≥ 0.5mg 0.5-4mg NA NA NA

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PREVIOUS TEXT

Procedure



Day 1 Day 2 Day 3

Day 4100

Follow up1

(7-14 days post dose)

Pre

-do

se

0 h

0.25

h

0.5

h

0.75

h 1 h

1.5

h

2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

Admission to Unit XInformed Consent/Demographics XFull Physical Examination XBrief Physical Examination X X XMedical/Medication/Drug/Alcohol/ Smoking History

X X X

12-lead ECG X1 X X1, 2 X X X X X X X X X X X X XVital Signs X X X23 X X X X X X X X X X X X XEchocardiogram334 X

Telemetry44 Continuous from 1 hour pre-dose to 24-hour timepoint

Holter Monitoring33 XAudiometry X X XUrine Drug/Alcohol BreathTest X X


HIV, Hep B and Hep C Screen XHema/Chem/UrinalysisTests X X X X X X

Urine Collection55 X55 X55 - - - - - - - - - X55 X55

Troponin X X X X XDigoxin Level66 X X XCSSR (Suicidality Assessment) X

Meal/ Breakfast77 X XStudy Treatment Dosing X

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Procedure



Day 1 Day 2 Day 3

Day 4100

Follow up1


Pre

-do

se

0 h

0.25

h

0.5

h

0.75

h 1 h

1.5

h

2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

Pharmacokinetic SamplingFor healthy subjects only 88 X X X X

XX X X X X X X X X X

XX

Pharmacogenetic (PGx) Sample99

For subjects who consent (only): collect one PGx sample after the start of dosing (preferably on Day 1)

Adverse Event Review X Continuous XConcomitant Medication Review X Continuous XDischarge100 XOutpatient Visit X X1. ECGs to be obtained in triplicate.

2. ECGs will be taken at the time points listed in Section 6.3.3.3. Vital signs will be taken at the time points listed in Section 6.3.2.Can be conducted in a separate screening visit4. Telemetry is conducted from 1 hour pre-dose until 24 hours post-dose. Only for subjects who are receiving digoxin.5. Other meal instructions will be detailed in the SPM6. For HF subjects, serial sampling for Day 1 timepoints only.7. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample.8. Discharge may be at 48 or 72 hours following the last dose of study medication, depending on the half-life of the drug.

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REVISED TEXT

Procedure

Screening

(up to 35 days prior to Day 1)

Study Day (each dosing session)

Day -1

Day 1 Day 2 Day 3

Day 410

Follow up11


Pre

-do

se

0 h

0.25

h

0.5

h

0.75

h

1 h

1.5

h2

h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

Admission to Unit X

Informed Consent/Demographics X

Full Physical Examination XBrief Physical Examination X X XWeight X X X X X X X Medical/Medication/Drug/Alcohol/ Smoking History

X X X

12-lead ECG X1 X X1 X X X X X X X X X X X X XPulse Oximetry X X X X X X XVital Signs X X X2 X X X X X X X X X X X X XEchocardiogram3 X


Holter Monitoring3 XUrine Drug/Alcohol BreathTest X X



Urine Collection5 X5 X5 - - - - - - - - - X5 X5 -

Troponin X X X X XDigoxin Level6 X X XCSSR (Suicidality Assessment) X X X

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Procedure

Screening

(up to 35 days prior to Day 1)

Study Day (each dosing session)

Day -1

Day 1 Day 2 Day 3

Day 410

Follow up11


Pre

-do

se

0 h

0.25

h

0.5

h

0.75

h

1 h

1.5

h2

h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

Appetite Assessment X X XMeal/ Breakfast7 X X XStudy Treatment Dosing XPharmacokinetic Sampling8

For Healthy Subjects OnlyX X X X X X X X X X X X X X X X X

Pharmacogenetic (pgx) Sample9 For subjects who consent (only): collect one PGx sample after the start of dosing (preferably on Day 1)


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1. ECGs to be obtained in triplicate.

2. Vital signs will be taken in triplicate.3. Can be conducted in a separate screening visit4. Telemetry is conducted from 1 hour pre-dose until 24 hours post-dose.5. Urine samples for metabolite identification will be collected and pooled over the time intervals of 0-12 hours, 12-24 hours and 24-48 hours for Cohort 1 only. A single

predose urine sample will also be collected for Cohort 1 only. Output measurements will be determined from samples collected over the 0-12 hour and the 12-24 hour intervals (combined). No urine samples will be collected for Cohort 2. Output measurements will be determined from urine samples collected over the 0-12 hour and the 12-24 hour intervals (combined) for Cohort 4.

6. Only for subjects who are receiving digoxin.7. Subjects will be fasted from midnight of Day-1 until 4 hours after the first dose of study medication. Any other meal instructions will be detailed in the SPM8. PK sampling time points may be modified based on emerging data. For HF subjects, serial sampling for Day 1 timepoints only. The 72-hour sample may not be

obtained in all groups, based on the estimated half-life of the drug9. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample.10. Discharge may be at 48 or 72 hours following the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 3 or 4

will be conducted on the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 4) will not be performed.11. Follow-up assessments will not be conducted in patients in Cohort 4 who continue to the repeat-dose Treatment Period


PREVIOUS TEXT



-35 to -1 days


Admission to Unit X

Informed Consent XDemographics XComplete Physical Exam./Smoking History

X

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-35 to -1 days


Brief Physical Exam. X X X X X X X XMedical/Medication/Drug/Alcohol/Smoking History

X X

12-lead ECG X1 X1 X X X X X X X X X X X X X X X XTelemetry2 X XHolter Monitoring3 X

Vital Signs4 x X5 X X X X X X X X X X X X X X X X X

Echocardiogram3 X

Urine Drug/Alcohol Breath Test

X X

Serum -hCG (women)

X X X


X

Hema/Chem/Urinalysis Tests

X X X X X X X X X

Troponin X X X X X X X X XUrine Collection5 X X5 5 X7

CSSR (Suicidality Assessment)

X X X X

Exercise Testing 6 X X7

DLco and DLno X X

OGTT8 X X


X Continuous X

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-35 to -1 days


PK Blood Sample9 X1

0 X X X X X X10 XX X

Study Treatment Dosing

X X11 X X X X X X X X X X X X

PGx12 for subjects who consent (only): collect one PGx sample after the start of dosing (preferably on Day 1

Discharge13 XOutpatient Visit X X1. ECGs will be obtained in triplicate.2. Telemetry is performed from1 hour pre-dose until 48 hours post-dose3. Can be conducted in a separate screening visit

4. Vital signs will be taken in triplicate.5. Urine samples will be collected and pooled over the time intervals of 0-12 hours and 12-24 hours on Days 1 and 15. A single predose urine sample will also be

collected also, and 24-48 hours starting.6. Exercise testing will be conducted once during Days 12 through 14.7. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT (fasting), and 60, 120 and 180min post-OGTT8. Timing of food with respect to dosing will be determined based on information gained with previous cohorts. For a twice daily dosing regimen, PK sampling times will

be adjusted and detailed accordingly in the SPM. 9. Serial sampling (actual timpoints will be assigned after data from previous cohort(s) are available).10. Based on the PK profile obtained in Cohort1, the Day 2 dose may be skipped.11. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample12. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug..

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REVISED TEXT



-35 to -1 days



X


X X

12-lead ECG X1 X1 X X X X X X X X X X X X X X X XTelemetry2 X XHolter Monitoring3 X

Vital Signs/Oximetry4 x X5 X X X X X X X X X X X X X X X X X X

Echocardiogram5 X

Audiometry X6 X XUrine Drug/Alcohol Breath Test

X X

Serum -hCG (women)

X X X


X


X X X X X X X X X

Troponin X X X X X X X X XUrine Collection7 X X7 X7

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-35 to -1 days



X X X X



DLco and DLno X6 X8

OGTT9 X6 X X8


X Continuous X

PK Blood Sample10X1

1 X X X X X X11 XX X

Study Treatment Dosing12 X X13 X X X X X X X X X X X X


Discharge15 XOutpatient Visit X X

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1. ECGs will be obtained in triplicate.2. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose3. Can be conducted in a separate screening visit4. Pulse oximetry will be conducted once daily.

5. Vital signs will be taken in triplicate.6. Asseement may be conducted within 7 days of the start of the treatment period (Day 1). 7. Urine samples for metabolite identification will be collected and pooled over the time intervals of 0-12 hours and 12-24 hours on Day 1. A single predose

urine sample will also be collected on Day 1. Urine samples will also be collected and pooled over the time intervals of 0-12 hours, 12-24 hours, and 24-48 hours starting on Day 14.

8. Assessment will be conducted once during Days 12 through 14.9. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT (fasting), and 60, 120 and 180min post-OGTT10. For a twice daily dosing regimen, PK sampling times will be adjusted and detailed accordingly in the SPM. 11. Serial sampling (actual timpoints will be assigned after data from previous cohort(s) are available).12. Timing of food with respect to dosing will be determined based on information gained with previous cohorts. 13. Based on the PK profile obtained in Cohort 1, the Day 2 dose may be skipped to estimate the time invariance in PK.14. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample15. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 16 or

17 will be conducted on the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 17) will not be performed.


PREVIOUS TEXT

Days -11 1 2 3 4 5 6 7 8 9 10 Follow-up (7-14 days after the last dose)

Re-Admission to Unit XBrief Physical Examination X X X X X X X X X X XWeight X X X X X X X X X X X XMedical/Medication/Drug/Alcohol/Smoking History

X

12-lead ECG X2 X X X X X X X X

Telemetry3 XXX

Vital Signs X3 X X X X X X X X X X

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Respiratory Rate X X X X XEchocardiogram X

Urine Drug/Alcohol Breath Test X

Serum -hCG (women) X XHema/Chem/Urinalysis Tests X X X X X X XTroponin X X X X X


Uroguanylin and Guanylin X X X X X


AE Assessment ContinuousC-SSRS (Suicidality Assessment) X X X

Concomitant Medication Review X XExercise Testing4 X X6

Dyspnea Scale Scoring X X X6 X

DLco and DLno X X6

Orthopnea X X X X XOGTT7 X XMeal served (breakfast) X X X X X X X XPK Blood Sample 8, 9 X X X X X X X XStudy Treatment Dosing X X X X X X X


Discharge11 xOutpatient Visit X X

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1. Day 1 will then be the first day of dosing for the RD dose period.2. ECGs to be obtained in triplicate.3. Vital signs will be taken in triplicate.4. Only for subjects taking digoxinAssessment may be completed between Days 5 to 7.5. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT(fasting), and 60, 120 and 180min post-OGTT.6. Trough sample only, actual timpoints will be assigned after data from previous Cohorts 1-3 are available7. For a twice daily dose regimen, PK sampling times will be adjusted and detailed accordingly in SPM.8. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample.9. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug.

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REVISED TEXT



X

12-lead ECG X2 X X X X X X X XTelemetry3 XVital Signs/ Oximetry4 X5 X X X X X X X X X X XRespiratory Rate X X X X XEchocardiogram XAudiometry X6 X XUrine Drug/Alcohol Breath Test X





AE Assessment ContinuousC-SSRS (Suicidality Assessment) X X XAppetite Assessment X X XConcomitant Medication Review X XExercise Testing X6 X8


DLco and DLno X6 X8

Orthopnea X X X X8 XOGTT9 X6 X8

PK Blood Sample 10, 11 X X X X X X X XStudy Treatment Dosing12 X X X X X X X

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Discharge14 xOutpatient Visit X

1. Subjects will return to the unit after a washout period of ≥7 days for the repeat-dose treatment period. Day 1 will then be the first day of dosing for the RD dose period.2. ECGs to be obtained in triplicate.3. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose.4. Pulse oximetry will be conducted once daily.5. Vital signs will be taken in triplicate.6. Assement may be conducted within 7 days of Day 1 of the repeat-dose treatment period.7. Only for subjects taking digoxin.8. Assessment may be completed between Days 5 to 7.9. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT(fasting), and 60, 120 and 180min post-OGTT.10. Only trough samples are currently planned; PK sampling timepoints may be changed based on emerging data.11. For a twice daily dose regimen, PK sampling times will be adjusted and detailed accordingly in SPM. 12. Timing of food with respect to dosing will be determined based on information gained with previous cohorts 13. Informed consent for optional PGx (Pharmacogenetics) research must be obtained before collecting a sample.14. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug. Assessments noted as either Day 9 or 10 will be conducted on

the day of discharge. If discharge is on Day 9, any assessments designated for Day 10 will not be conducted.

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Section 6.3.1 Physical Examinations

ADDED TEXT

Weight will be measured once daily as indicated in the Time and Events Tables.

Section 6.3.2 Vital Signs and Other Measures [New Section Name]

ADDED TEXT



ADDED SECTION

Section 12.8.1 Audiometry

A hearing assessment will be conducted prior to the administration of study medication and at the end of each treatment period as described in the Time and Events Tables for Cohorts 3 and 4 (repeat dose period). Details of the audiometry testing may be found in the SPM.

Section 6.6.1. Exercise Tolerance for Cohort 3 and Cohort 4

PREVIOUS TEXT


Peak oxygen uptake will be measured at baseline and post-dose as outlined in the Time and Events Tables for Cohorts 4 and 5 (Section 6.1). Patients will perform a maximal exercise test limited by dyspnea or fatigue on a cycle ergometer. After a rest period, the workloads will be increased in a step-wise fashion by 25 watts every 3 minutes. Breath by breath gas exchange and heart rate will be measured throughout exercise. During each 3 minute workload, Borg RPE and blood pressure will be obtained. At peak exercise, heart rate, blood pressure, and Borg RPE will be recorded. Gas exchange endpoints included peak VO2, Ve/VCO2 slope, RER, exercise time, and VO2 and time at ventilator threshold.

REVISED TEXT


Peak oxygen uptake will be measured at baseline and during the repeat-dose treatment period post-dose as outlined in the Time and Events Tables for Cohorts 3 and 4 (Section 6.1). Patients will perform a maximal exercise test limited by symptoms such as dyspnea or fatigue on a cycle ergometer. After a rest period, the workloads will be

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increased in a step-wise or ramp pattern fashion by 25 watts every in 3-minute stages. An additional constant work-rate period may also be incorporated in the exercise testing. Full details of the exercise protocol and planned measurements are included in the SPM. Breath by breath gas exchange and heart rate will be measured throughout exercise. During each 3-minute workload, Borg RPE and blood pressure will be obtained. Peak work rate will be determined. At peak exercise, heart rate, blood pressure, and Borg RPE will be recorded. Gas exchange endpoints will included peak VO2, Ve/VCO2 slope, RER, exercise time, and VO2 and time at ventilatory threshold.

Section 6.6.2. DLco and DLno

ADDED TEXT



PREVIOUS TEXT

Treatment Regimen

Description

A 0.25mg GSK2798745 Fasted solution (single dose)B TBD mg GSK2798745 Fasted suspension (single dose)C TBD mg GSK2798745 Fasted suspension (single dose)D TBD mg GSK2798745 Fasted suspension (single dose)G TBD GSK2798745 Fed capsule (single dose)H TBD GSK2798745 Fasted suspension (single dose)I TBD GSK2798745 Fasted capsule (single dose)P Matched Placebo suspension(s) (single dose)

REVISED TEXT

Treatment Regimen

Description

A 0.25mg GSK2798745 Fasted solution (single dose)B TBD mg GSK2798745 Fasted suspension (single dose)C TBD mg GSK2798745 Fasted suspension (single dose)D TBD mg GSK2798745 Fasted suspension (single dose)G TBD GSK2798745 Fasted suspension (single dose)H TBD GSK2798745 Fasted capsule (single dose)I TBD GSK2798745 Fed capsule (single dose)P Matched Placebo suspension(s) (single dose)

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AMENDMENT 2


This amendment applies to all sites (this study is single site).


This amendment incorporates the addition of new assessments for Cohort 3 and 4 and corrects minor discrepancies in the protocol amendment 01.


Section 5.3.2.1 Healthy Subjects (Cohorts 1 thru 3)

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QTc, QTcB, QTcF > 500msec

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QTc, QTcB, QTcF > 500msec

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Section 6.1 Time and Events Table


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Procedure



Day 1 Day 2 Day 3

Day 410

Follow up11


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se

0 h

0.25

h

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h

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h 1 h

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h

2 h

3 h

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X X X







Troponin X X X X XDigoxin Level6 X X X

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Procedure



Day 1 Day 2 Day 3

Day 410

Follow up11


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0 h

0.25

h

0.5

h

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h 1 h

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h

2 h

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6 h

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10 h

12 h

15 h

24 h

36 h

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72 h

CSSR (Suicidality Assessment) X X XAppetite Assessment X X XMeal7 XStudy Treatment Dosing XPharmacokinetic Sampling8 X X X X X X X X X X X X X X X XPharmacogenetic (PGx) Sample9



2. Vital signs will be taken in triplicate.3. Can be conducted in a separate screening visit4. Telemetry is conducted from 1 hour pre-dose until 24 hours post-dose.5. Urine samples for metabolite identification will be collected and pooled over the time intervals of 0-12 hours, 12-24 hours and 24-48 hours for Cohort 1 only. A single predose

urine sample will also be collected for Cohort 1 only. Output measurements will be determined from samples collected over the 0-12 hour and the 12-24 hour intervals (combined). No urine samples will be collected for Cohort 2. Output measurements will be determined from urine samples collected over the 0-12 hour and the 12-24 hour intervals (combined) for Cohort 4.

6. Only for subjects who are receiving digoxin.7. Subjects will be fasted from midnight of Day-1 until 4 hours after the first dose of study medication. Any other meal instructions will be detailed in the SPM8. PK sampling time points may be modified based on emerging data. For HF subjects, serial sampling for Day 1 timepoints only. The 72-hour sample may not be obtained in all

groups, based on the estimated half-life of the drug.9. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample.10. Discharge may be at 48 or 72 hours following the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 3 or 4 will be

conducted on the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 4) will not be performed.11. Follow-up assessments will not be conducted in patients in Cohort 4 who continue to the repeat-dose Treatment Period.

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REVISED TEXT

Procedure



Day 1 Day 2 Day 3

Day 410

Follow up11


Pre

-do

se

0 h

0.25

h

0.5

h

0.75

h 1 h

1.5

h

2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h


X X X







Troponin X X X X XDigoxin Level6 X X XCSSR (Suicidality Assessment) X X XAppetite Assessment X X XMeal7 XStudy Treatment Dosing XPharmacodynamic Blood Sample12 X X X X X X X X X X X

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Procedure



Day 1 Day 2 Day 3

Day 410

Follow up11


Pre

-do

se

0 h

0.25

h

0.5

h

0.75

h 1 h

1.5

h

2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

Pharmacokinetic Sampling8 X X X X X X X X X X X X X X X XPharmacogenetic (PGx) Sample9







conducted on the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 4) will not be performed.11. Follow-up assessments will not be conducted in patients in Cohort 4 who continue to the repeat-dose Treatment Period.12. Pharmacodynamic (PD) blood sampling to be drawn in Cohort 4 only and may be modified based on emerging data. See Section 6.6

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PREVIOUS TEXT



-35 to -1 days



X


X X

12-lead ECG X1 X1 X X X X X X X X X X X X X X X XTelemetry2 XHolter Monitoring3 X


Echocardiogram3 X


X X

Serum -hCG (women)

X X X


X


X X X X X X X X X

Troponin X X X X X X X X XUrine Collection7 X X7 X7

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-35 to -1 days



X X X X



DLco and DLno X6 X8

OGTT9 X6 X8


X Continuous X




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conducted on the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 17) will not be performed.

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REVISED TEXT



-35 to -1 days7-14 days after last dose


X


X X



Echocardiogram3 X


X X

Serum -hCG (women) X X XHIV, Hep B and Hep C Screen

X


X X X X X X X X X

Troponin X X X X X X X X XUrine Collection7 X X7 X7 CSSR (Suicidality Assessment)

X X X X


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-35 to -1 days7-14 days after last dose


DLco and DLno X6 X8

OGTT9 X6 X8

PD Blood Sample X16



X Continuous X


PGx14 for subjects who consent (only): collect one PGx sample after the start of dosing (preferably on Day 1 Discharge15 XOutpatient Visit X X

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5. Vital signs will be taken in triplicate.6. Assessment may be conducted within 7 days of the start of the treatment period (Day 1).7. Urine samples for metabolite identification will be collected and pooled over the time intervals of 0-12 hours and 12-24 hours on Day 1. A single predose urine sample will also be

collected on Day 1. Urine samples will also be collected and pooled over the time intervals of 0-12 hours, 12-24 hours, and 24-48 hours starting on Day 14.8. Assessment will be conducted once during Days 12 through 14.9. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT (fasting), and 60, 120 and 180min post-OGTT10. For a twice daily dosing regimen, PK sampling times will be adjusted and detailed accordingly in the SPM.11. Serial sampling (actual timpoints will be assigned after data from previous cohort(s) are available).12. Timing of food with respect to dosing will be determined based on information gained with previous cohorts. 13. Based on the PK profile obtained in Cohort 1, the Day 2 dose may be skipped to estimate the time invariance in PK.14. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample15. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 16 or 17 will be conducted on

the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 17) will not be performed.16. PD serial blood samples will be drawn only prior to dose administration and may be drawn at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours after the administration of drug to

correspond with PK sampling. Actual timepoints could change based on the PK sampling timepoints.17. Transcriptomic/Metabolomic Blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.

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ADDED SECTION

Section 6.5 Pharmacodynamic Profile

An ex vivo cell-based impedance assay has been established with cultured human endothelial cells to measure the pharmacodynamic effect of varying concentrations of the TRPV4 channel blocker, GSK2798745 , in samples of whole blood [Kustermann, 2014]. By obtaining serial blood samples at times correlated with samples taken for pharmacokinetic analysis of drug concentration, a pharmacokinetic-pharmacodynamic relationship will be established.

In Cohort 3, blood samples will be obtained on Day 1 prior to dose administration and at the times designated for pharmacokinetic sampling through the first 12 hours. If pharmacokinetic samples are specified to be taken at intervals of less than 30 minutes, those timepoints may be skipped when obtaining samples for pharmacodynamic analysis. It is anticipated that samples will be at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours after the administration of drug. Timepoints may be adjusted during the study based on emerging data.

In Cohort 4, blood samples will be obtained on Day 1 of the single-dose period. Samples will be obtained prior to dose administration and at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours. Timepoints may be adjusted during the study based on emerging data.

At each timepoint, samples for this pharmacodynamic analysis will be taken after the sample for pharmacokinetic analysis is obtained. The date and time of each sample will be recorded. Details of sample collection, processing storage, and shipment are provided in the SPM.

ADDED SECTION

Section 6.6 Transcriptomic and Metabolomic Profiles

With administration of GSK2798745, the transcriptomic profile, which identifies mRNAtranscripts, may be altered, reflecting changes in gene expression in response to drug treatment. Similarly, the metabolomic profiles will provide information on any changesin the metabolites, hormones and signaling molecules present in the plasma following drug administration. Blood samples obtained in Cohorts 3 and 4 will be screened to characterize these profiles.

In Cohort 3, blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1. Samples will also be obtained on Day 7, and Day 14.

In the repeat-dose phase of Cohort 4, blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1. Blood samples will also be obtained on Day 7.

The date and time of each sample will be recorded. Details of sample collection, processing storage, and shipment are provided in the SPM.

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SECTION 11 REFERENCES

ADDED TEXT

Kustermann, S, Manigold T, Ploix C, Skubatz M, Heckel T, Hinton H,Weiser T, Singer T, Suter L, Roth A. A real-time impedance-based screening assay for drug-induced vascular leakage. Toxicol Sci 2014; 138:333-343.

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AMENDMENT 3




This amendment incorporates the addition of a new endpoint and assessment for Cohort 3 as well as clarification of minor details.


TABLE OF CONTENTS

AVP Arginine VasopressinNa SodiumNaCl Sodium Chloride

SECTION 2 OBJECTIVE(S) AND ENDPOINT(S)

ADDED TEXT

Exploratory tests

Determine the effect of repeat administration of GSK2798745 on the plasma concentration of AVP after an osmotic challenge in healthy volunteers

Plasma concentration of AVP following a NaCl challenge

Table 1 Study DesignADDED TEXT

Healthy subjects repeat dose3

Cohort 3n= 16


Safety, tolerability, PK, exploratory tests for feasibility: exercise parameters, lung permeability (DLco and DLno), AVP

0.5, 1.5mg4

Section 3.2.2 Healthy Subjects Repeat Dose - Cohort 3

PREVIOUS TEXT

This cohort is constructed as a sponsor un-blinded, randomized, placebo-controlled, 14-day repeat-dose evaluation of GSK2798745. It is planned that up to two doses will be studied based on the safety, tolerability and the systemic exposure data obtained from the

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single dose studies. A sufficient number of subjects will be enrolled such that 16 evaluable subjects will be randomized to 2 repeat dose cohorts with 8 subjects in each cohort in a ratio of 6:2 (treatment: placebo). The effect of TRPV4 channel inhibition on exercise performance will be evaluated as noted above. Glucose tolerance will also be evaluated by an oral glucose tolerance test (OGTT). In a TRPV4 knock-out preclinical model, body weight was reduced in the setting of improved glucose handling [Ye, 2012]. This measurement may represent a tool to estimate target engagement in these early studies.

REVISED TEXT

This cohort is constructed as a sponsor un-blinded, randomized, placebo-controlled, 14-day repeat-dose evaluation of GSK2798745. It is planned that up to two doses will be studied based on the safety, tolerability and the systemic exposure data obtained from the single dose studies. A sufficient number of subjects will be enrolled such that 16 evaluable subjects will be randomized to 2 repeat dose cohorts with 8 subjects in each cohort in a ratio of 6:2 (treatment: placebo). The effect of TRPV4 channel inhibition on exercise performance will be evaluated as noted above. In addition, arginine vasopressin (AVP) concentration will also be evaluated by a hypertonic NaCl challenge. The osmotic regulation of AVP secretion may involve the TRPV4 channel. [Sladek, 2013] Glucose tolerance will also be evaluated by an oral glucose tolerance test (OGTT). In a TRPV4 knock-out preclinical model, body weight was reduced in the setting of improved glucose handling [Ye, 2012]. Theseis measurementsmay represent a tools to estimate target engagement in these early studies.

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PREVIOUS TEXT


Treatment Period Each subject will take part in only one period and will be dosed for 14 days.

During the study period, subjects will be in-house from Day -1 until all post-dose assessments have been completed in each period (48 or 72hrs post dose depending on the half life).

Subjects will have exploratory measurements on Day -1 and between Days 12- 14. The measurements will include exercise testing and lung permeability assay (DLco and DLno), see Section 6.1 for PD assessments.


If warranted, additional follow-up visits may be scheduled.Total Duration Screening within 35 days + treatment (17 days) + follow up of 7-14

days = approximately 10 weeks

REVISED TEXT

Screening All screening assessments to be completed within 45 35 days prior to the first dose.



Subjects will have exploratory measurements on Day -1 and between Days 12- 14. The measurements will include exercise testing, OGTT and lung permeability assay (DLco and DLno), see Section 6.1 for PD assessments.

In the second dose group of Cohort 3, subjects will have an exploratory measurement on Day -1 (within day -14 and day -3) and between Days 9-11. AVP will be measured in response to a NaCl challenge, see Section 6.1.


If warranted, additional follow-up visits may be scheduled.Total Duration Screening within 35 45days + treatment (17 days) + follow up of 7-14

days = approximately 10 weeks

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ADDED TEXT

NaCl (2.7%) challenge Side effects of a peripheral infusion of NaCl may include pain or redness at the infusion site and peripheral vein trauma (vein thrombosis, or extravasation of hypertonic saline and local tissue damage). Subjects may also experience symptoms such as significant thirst, generalized swelling, and an increase in urine output, Additionally, plasma concentrations of sodium may be elevated for a period of time. In extremely rare cases, seizure or central pontine myelinolysis could theoretically occur which could lead to permanent neurologic impairment. This risk is based on reports in patients experiencing rapid reversal of significant baseline hyponatremia, and not in health volunteers with normal baseline sodium level. These risks are being mitigated by the utilization of the lower concentration of saline (2.7%) in comparison to the literature, and ensuring normal sodium levels at screening. Females are also being excluded from participation as their risk of neurologic complications may be greater than in males [Ayus, 1992].

Section 4.2.1 Inclusion Criteria for Healthy Subject Cohorts (1-3)

PREVIOUS TEXT






(inclusive)

4. A female subject is eligible to participate if she is of:

Non-childbearing potential defined as pre-menopausal females with a documented tubal ligation or hysterectomy for this definition,

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“documented” refers to the outcome of the Investigator's/designee’s review of the subject's medical history for study eligibility, as obtained via a verbal interview with the subject or from the subject’s medical records; or postmenopausal defined as 12 months of spontaneous amenorrhea. In questionable cases a blood sample with simultaneous follicle stimulating hormone (FSH) > 40MlU/ml and estradiol < 40pg/ml (<147pmol/L) is confirmatory.





QTc < 450msec; or


REVISED TEXT




Only males 18-75 years of age inclusive, at the time of signing the informed consent will be recruited for Cohort 3, dosing group 2.



(inclusive)

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4. A female subject is eligible to participate (with the exclusion of Cohort 3 dosing group 2) if she is of:






QTc < 450msec; or


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Section 5.1 Investigational Product and Other Study Treatment Dosage/Administration

PREVIOUS TEXT


0.1-0.4mg ≥ 0.5mg 0.5-4mg NA NA NA

REVISED TEXT


0.1-0.4mg ≥ 0.5mg ≥ 0.5mg-4mg NA NA NA

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Section 5.3.2.2 Heart Failure Patients (Cohort 4)

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A subject who meets any of the criteria below will be withdrawn from the study. The same QT correction formula should be used to determine inclusion and discontinuation for any individual subject throughout the study.

[QTc] > 500msec



REVISED TEXT


A subject who meets any of the criteria below will be withdrawn from the study. The same QT correction formula (QTcF) should be used to determine inclusion and discontinuation for any individual subject throughout the study.

[QTcF] > 500msec


Change from baseline: QTcF >60msec

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PREVIOUS TEXT



-35 to -1 days



X


X X




X X


X


X X X X X X X X X

Troponin X X X X X X X X XUrine Collection7 X7 X7

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-35 to -1 days



X X X X



DLco and DLno X6 X8

OGTT9 X6 X8

PD Blood Sample X16



X Continuous X



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to correspond with PK sampling. Actual timepoints could change based on the PK sampling timepoints.17. Transcriptomic/Metabolomic Blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.

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REVISED TEXT



-35 45 to -1 days



X


X X




X X


X


X X X X X X X X X


X X X X


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-35 45 to -1 days



DLco and DLno X6 X8

OGTT9 X6 X8

PD Blood Sample X16 X16


AVP18 X19 X20


X Continuous X



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1. ECGs will be obtained in triplicate.2. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose3. Can be conducted in a separate screening visit. If the subject has had an Echocardiogram or Holter within the last 3 months, it does not need to be repeated

for participation in this particular cohort.4. Pulse oximetry will be conducted once daily excluding screening.



8. Assessment will be conducted once during Days 12 through 14.9. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT (fasting), and 60, 120 and 180min post-OGTT10. For a twice daily dosing regimen, PK sampling times will be adjusted and detailed accordingly in the SPM.11. Serial sampling (actual timpoints will be assigned after data from previous cohort(s) are available). Blood samples for AVP concentrations may be drawn along

with PK samples (details will be outlined in the SPM).12. Timing of food with respect to dosing will be determined based on information gained with previous cohorts. 13. Based on the PK profile obtained in Cohort 1, the Day 2 dose may be skipped to estimate the time invariance in PK.14. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample15. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 16 or 17 will be


to correspond with PK sampling. Actual timepoints could change based on the PK sampling timepoints.17. Transcriptomic/Metabolomic Blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1. 18. To be performed only in male healthy volunteers in the second repeat dose period of Cohort 3 only. Sequential blood samples for the measurement of

AVP concentrations, Na levels, and serum osmolality will be outlined in the SPM19. Assessment may be conducted within 14 days of the start of treatment period and prior to Day -3.20. Assessment will be conducted once during days 9 through 11

Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported

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X








DLco and DLno X6 X8


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T/M Blood Sample X15 XPK Blood Sample 10, 11 X X X X X X X XStudy Treatment Dosing12 X X X X X X X



1. Subjects will return to the unit after a washout period of ≥7 days for the repeat-dose treatment period. Day 1 will then be the first day of dosing for the RD dose period.2. ECGs to be obtained in triplicate.3. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose4. Pulse oximetry will be conducted once daily.. 5. Vital signs will be taken in triplicate.6. Assessment may be conducted within 7 days of Day 1 of the repeat-dose treatment period.7. Only for subjects taking digoxin.8. Assessment may be completed between Days 5 to 7.9. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT(fasting), and 60, 120 and 180min post-OGTT.10. Only trough samples are currently planned; PK sampling timepoints may be changed based on emerging data.11. For a twice daily dose regimen, PK sampling times will be adjusted and detailed accordingly in SPM. 12. Timing of food with respect to dosing will be determined based on information gained with previous cohorts 13. Informed consent for optional PGx (Pharmacogenetics) research must be obtained before collecting a sample.14. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug. Assessments noted as either Day 9 or 10 will be conducted on the

day of discharge. If discharge is on Day 9, any assessments designated for Day 10 will not be conducted.15. Transcriptomic/Metabolomic blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.

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REVISED TEXT



X

12-lead ECG X2 X X X X X X X XTelemetry3 XVital Signs/ Oximetry4 X5 X X X X X X X X X X XRespiratory Rate X X X X XEchocardiogram XAudiometry X6 X XUrine Drug/Alcohol Breath Test

X

Serum -hCG (women) X XHema/Chem/Urinalysis Tests16 X X X X X

XX

Troponin X X X X X




AE Assessment ContinuousC-SSRS (Suicidality Assessment)

X X X

Appetite Assessment X X XConcomitant Medication Review

X X



DLco and DLno X6 X8

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day of discharge. If discharge is on Day 9, any assessments designated for Day 10 will not be conducted.15. Transcriptomic/Metabolomic blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.16. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported

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PREVIOUS TEXT


A brief physical examination will include assessments of the skin, lungs, cardiovascular system, and abdomen (liver and spleen).


The examinaitons will be performed by a qualified, licensed medical professional (i.e., physician, physician assistant, or nurse practitioner).

REVISED TEXT


A brief physical examination will include assessments of the skin, lungs, cardiovascular system, and abdomen (liver and spleen).


The examinations examinaitons will be performed by a qualified, licensed medical professional (i.e., physician, physician assistant, or nurse practitioner).

ADDED SECTION

Section 6.5 Vasopressin Secretion

As recently reviewed by [Sladek, 2013], the osmotic regulation of arginine-vasopressin (AVP) secretion may involve the TRPV channel. Studies in TRPV4 knock-out mice demonstrated that plasma concentrations of AVP were reduced following a hypertonic saline challenge, suggesting that TRPV4 is necessary for the normal response to changes in osmotic pressure and functions as the osmotic sensor in the central nervous system [Liedtke, 2003]. Studies in rats indicate that administration of a TRPV4 antagonist, GSK2193874, attenuates the elevation of AVP concentration in the blood following a NaCl challenge.

In defining the target engagement of the drug, it is of interest to determine whether GSK2798745 can similarly inhibit AVP secretion in response to an osmotic stimulus in man. Many studies have demonstrated that an infusion of hypertonic saline (3% to 5%) provides an adequate stimulus for AVP secretion, and that the challenge was well tolerated [Seckl, 1989; Manner, 1989; Pedersen, 2001; Graffe, 2012; Jensen, 2013]. In studies that employed a 3% hypertonic saline challenge [Pedersen, 2001; Graffe, 2012; Jensen, 2013], the increases in plasma osmolality and plasma sodium concentration were

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within the normal range. The infusion procedure used in this study will be based on the methods described in these studies that utilized the lower 3% saline challenge [Pederson, 2001; Graffe, 2012; Jensen, 2013].

Subjects in the higher dose group(s) of Cohort 3 will undergo a NaCl challenge within the 14 days prior to the start of drug administration and once again during the Day 9 to Day 11 period. Subjects will receive an intravenous infusion of 2.7% saline. Subjects will receive 7 mL/kg of hypertonic saline, which represents 14.7 g of sodium or 503 mOsm for a 70 kg individual, through a peripheral intravenous line inserted into the antecubital vein. Infusions would be limited to no more than 2 hours.

Subjects will be maintained in a supine position prior to the start of the infusion and throughout the infusion period. Blood samples for the measurement of AVP concentrations will be obtained prior to the start of the infusion and at periodic intervals after the start of the saline infusion. In addition, plasma osmolality and plasma sodium concentrations will be determined periodically.

Additional details of the vasopressin secretion testing are provided in the SPM.


PREVIOUS TEXT


In Cohort 3, blood samples will be obtained on Day 1 prior to dose administration and at the times designated for pharmacokinetic sampling through the first 12 hours. If pharmacokinetic samples are specified to be taken at intervals of less than 30 minutes, those timepoints may be skipped when obtaining samples for pharmacodynamic analysis. It is anticipated that samples will be at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours after the administration of drug. Timepoints may be adjusted during the study based on emerging data.

In Cohort 4, blood samples will be obtained on Day 1 of the single-dose period. Samples will be obtained prior to dose administration and at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours. Timepoints may be adjusted during the study based on emerging data.

At each timepoint, samples for this pharmacodynamic analysis will be taken after the sample for pharmacokinetic analysis is obtained. The date and time of each sample will be recorded. Details of sample collection, processing storage, and shipment are provided in the SPM.

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REVISED TEXT


In Cohort 3, blood samples will be obtained on Days 1 and 14 prior to dose administration and at the times designated for pharmacokinetic sampling through the first 12 hours. If pharmacokinetic samples are specified to be taken at intervals of less than 30 minutes, those timepoints may be skipped when obtaining samples for pharmacodynamic analysis. It is anticipated that samples will be at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours after the administration of drug. Timepoints may be adjusted during the study based on emerging data.

In Cohort 4, blood samples will be obtained on Days 1 and 14 of the single-dose period. Samples will be obtained prior to dose administration and at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours. Timepoints may be adjusted during the study based on emerging data.



PREVIOUS TEXT




The date and time of each sample will be recorded. Details of sample collection, processing storage, and shipment are provided in the SPM.

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REVISED TEXT




The date and time of each sample will be recorded. Details of sample collection, processing storage, and shipment are provided in the SPM. These results will be reported under a separate study report.

Section 9.3.1 Interim Analysis

ADDED TEXT

Upon completion of Cohort 3, a formal interim analysis will be performed to report the results from Cohort 1, 2 and 3.

Section 9.3.2.3.1 Cohort 3 and 4

PREVIOUS TEXT

Peak VO2 (and other physiologic variables measure in the exercise testing) will be fitted using a mixed effect model with repeated measures, with time included as a fixed effect and baseline as a covariate. Point estimates and associated 95% confidence intervals will be constructed to provide a plausible range of values for the true comparisons of interest, such as the mean difference between baseline of GSK2798745 and the end of treatment. If model assumptions appear grossly violated, alternative methods (e.g., use of raw data with log transformation or non-parametric methods) will be considered.

Other PD endpoints (including DLco and DLno) may be statistically analysed, using a model appropriate to the study design and data. All PD data will be descriptivelysummarised and presented in graphical displays, as appropriate and will be described in more detail in the Reporting and Analysis Plan (RAP).

REVISED TEXT

Peak VO2 (and other physiologic variables measure in the exercise testing) will be fitted using a mixed effect model with repeated measures, with time included as a fixed effect and baseline as a covariate. Point estimates and associated 95% confidence intervals will

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be constructed to provide a plausible range of values for the true comparisons of interest, such as the mean difference between baseline of GSK2798745 and the end of treatment. If model assumptions appear grossly violated, alternative methods (e.g., use of raw data with log transformation or non-parametric methods) will be considered.

Other PD endpoints (including DLco and DLno and AVP) may be statistically analysed, using a model appropriate to the study design and data. All PD data will be descriptively summarised and presented in graphical displays, as appropriate and will be described inmore detail in the Reporting and Analysis Plan (RAP).

Section 11 References

ADDED TEXT

Ayus JC, Wheeler JM, Arieff AI. Postoperative Hyponatremic Encephalopathy in Menstruant Women. Ann Intern Med. 1992;117:891-897.

Graffe CC, Bech JN, Pedersen EB. Effect of high and low sodium intake on urinary aquaporin-2 excretion in healthy humans Am J Physiol Renal Physiol 2012; 302: F264–F275.

Liedtke W, Friedman JM. Abnormal osmotic regulation in trpv4-/- mice. Proc Natl Acad Sci USA 2003; 100:13698–13703.

Jensen J, Frank H Mose FH, Bech JN, Nielsen S, Pedersen EB. Effect of volume expansion with hypertonic and isotonic saline and isotonic glucose on sodium and water transport in the principal cells in the kidney. BMC Nephrology 2013;14:202.

Manner T, Kanto J, Ruskoaho H, Karhuvaara S, Vunamaki O, Viilimiiki M, Scheinin M. Hormonal, haemodynamic, and subjective effects of intravenously infused indomethacin: no change in the physiological response to hypertonic saline challenge. Pharmacol Toxicol 1989;65:231-235.

Pedersen RS, Bentzen H, Bech JN, Pedersen EB. Effect of water deprivation and hypertonic saline infusion on urinary AQP2 excretion in healthy humans. Am J Physiol Renal Physiol 2001; 280: F860–F867.

Seckl JR, Johnson MR, Lightman SL. Vasopressin and oxytocin responses tohypertonic saline infusion: effect of the opioid antagonist naloxone. Clin Endocrinol 1989; 30:513-518.

Sladek CD, Johnson AK. Integration of thermal and osmotic regulation of water homeostasis: the role of TRPV channels. Am J Physiol Regul Integr Comp Physiol 2013; 305: R669–R678.

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AMENDMENT 4




This amendment incorporates changes to the dose rationale, the addition of new exploratory endpoints, changes to Cohort 3 and additional assessments for Cohort 4.



ADDED TEXT

3D SPGR 3D Spoiled Gradient EchoDCE Dynamic Contrast EnhancedGd GadoliniumKtrans Exchange RateMRI Magnetic Resonance ImagingNSF/NFD Nephrogenic Systemic Fibrosis/Nephrogenic Fibrosing

DermopathyPACS Picture Archiving and Communication SystemRIS Radiology Information SystemTETRVeVpWBC

Echo Time Repetition TimeInterstitial VolumeVolume of oxygenWhite Blood Cells

Section 1 Introduction

PREVIOUS TEXT

This study is the First Time in Human Study (FTIH) for GSK2798745 and will evaluate the safety, tolerability, and pharmacokinetics (PK) of single and repeat oral doses of GSK2798745 administered to healthy subjects (Cohorts 1 through 3) and stable heart failure subjects (Cohort 4). In addition, this study will interrogate evidence for a functional effect of transient receptor potential vanilloid 4 (TRPV4) channel blockade on exercise tolerance and lung gas permeability parameters in the cohort of stable heart failure patients.

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REVISED TEXT

This study is the First Time in Human Study (FTIH) for GSK2798745 and will evaluate the safety, tolerability, and pharmacokinetics (PK) of single and repeat oral doses of GSK2798745 administered to healthy subjects (Cohorts 1 through 3) and stable heart failure subjects (Cohort 4). In addition, this study will interrogate evidence for a functional effect of transient receptor potential vanilloid 4 (TRPV4) channel blockade on exercise tolerance, and lung gas permeability parameters, pulmonary oedema, and vascular permeability in the cohort of stable heart failure patients.

Section 1.1 Study Rationale

PREVIOUS TEXT

GSK2798745 has never been administered to humans. Accordingly, the first phase of this study will address the safety, tolerability, and the pharmacokinetics (PK) of GSK2798745 in healthy adult subjects in single and repeat ascending doses. In addition, the relative bioavailability of GSK2798745 administered via capsule as compared to liquid formulation and effect of food on systemic exposure of GSK2798745 will be evaluated through different cohorts as outlined in Table 1 and study schematics in Section 3. Exercise tolerability will be evaluated in the healthy subjects in the repeat dose cohort (Cohort 3) to further establish safety during exercise as explained above. Further, given the potential interstitial fluid excess and thus compromise in gas exchange in healthy subjects during exercise, there may be a beneficial effect.

Upon completion of the evaluation of the healthy subjects, his study will progress to a stable heart failure cohort. Stable heart failure is defined as patients with an established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) class II or III. This definition includes the maintenance of stable heart failure therapy and lack of heart failure hospitalization for at least 3 months. In this cohort we will evaluate the effects of GSK2798745 primarily on safety, including clinical assessments and exercise tolerance. However, despite the small numbers, an exploratory assessment of efficacy will be performed, which will include assessment of respiratory rates, exercise capacity and alveolar:vascular gas transfer. These assessments will test directly or indirectly for the potential reduction in lung interstitial fluid with GSK2798745 and the functional benefit in the setting of exercise (both in healthy subjects and HF patients).

REVISED TEXT

Prior to this study, GSK2798745 has never been administered to humans. Accordingly, the first phase of this study will address the safety, tolerability, and the pharmacokinetics (PK) of GSK2798745 in healthy adult subjects within single and repeat administration ascending doses. In addition, the relative bioavailability of GSK2798745 administered via capsule as compared to liquid formulation and effect of food on systemic exposure of GSK2798745 will be evaluated through different cohorts as outlined in Table 1 and study schematics in Section 3. Exercise tolerability will be evaluated in the healthy subjects in the repeat dose cohort (Cohort 3) to further establish safety during exercise as explained

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above. Further, given the potential interstitial fluid excess and thus compromise in gas exchange in healthy subjects during exercise, there may be a beneficial effect.

Upon completion of the evaluation of the healthy subjects, This study will thenprogress to a stable heart failure cohort. Stable heart failure is defined as patients with an established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) class II or III. This definition includes the maintenance of stable heart failure therapy and lack of heart failure hospitalization for at least 3 months. In this cohort we will evaluate the effects of GSK2798745 primarily on safety, including clinical assessments and exercise tolerance. However, despite the small numbers, an exploratory assessment of effecticacy will be performed, which will include assessment of respiratory rates, exercise capacity,andalveolar:vascular gas transfer, pulmonary oedema, and vascular permeability. These assessments will test directly or indirectly for the potential reduction in lung interstitial fluid with GSK2798745 and the functional benefit in the setting of exercise(both in healthy subjects and HF patients).

Dynamic contrast enhanced (DCE) MRI is an established technique for assessing changes in vascular permeability and interstitial water volume. DCE-MRI measures the exchange of an extracellular MRI contrast agent as it travels between the intravascular space and the interstitial space. Pharmacokinetic modeling of DCE-MRI enables quantification of the plasma volume (vp), interstitial volume (ve), and exchange rate (ktrans), a parameter strongly dependent on vascular permeability. DCE-MRI is frequently used within oncology studies (O’Connor 2007), and is used increasingly in other indications such as renal disease (Buckley, 2006) and rheumatoid arthritis (Hodgson, 2007). DCE-MRI has been used to detect alterations in vascular permeability and interstitial water volume in the lungs of smokers relative to healthy controls (Naish, 2008). An exploratory study (201137) in both healthy volunteers and patients with heart failure has been undertaken to develop DCE-MRI to detect increased interstitial lung fluid via measurement of ve

or altered vascular permeability via measurement of ktrans. Preliminary analysis of this study suggests that DCE-MRI may be a useful modality to characterize vascular permeability and interstitial water volume in patients with heart failure.

Section 1.2.1 GSK2798745

ADDED TEXT

GSK2798745 is a potent and selective human TRPV4 channel blocker, with an IC50 = 2.0nM (nanomolar), assessed by measuring Ca2+ influx induced by the TRPV4 agonist GSK634775 (also numbered SB-436488) in HEK cells transduced with recombinant human TRPV4 channels. In addition, GSK2798745 inhibits hypotonicity-evoked human TRPV4 Ca2+ influx in transduced BHK cells with an IC50 of 1.7nM. GSK2798745 displays a similar potency at rat, mouse, dog and monkey TRPV4. GSK2798745 demonstrates no agonist activity (EC50 > 25uM) against human TRPV4. Administration of GSK2798745 in vivo inhibited the increase in lung wet weight (edema) and decrease in mean arterial pressure induced by a TRPV4 agonist in urethane anesthetized rats.

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For detailed information please refer to the Investigator’s Brochure for GSK2798745 [GlaxoSmithKline Document Number 2013N162862_00].

To date, GSK2798745 has been administered to healthy volunteers as single doses of 0.25, 1.0, 5.0 and 12.5 mg. In Cohort 1, 8 subjects were to receive 3 single doses of GSK2798745 and one dose of placebo (fasted). One subject was withdrawn from thesecond treatment period prior to dose administration due to vasovagal syncope after intravenous cannulation; therefore, only 7 subjects participated in the second period. A replacement subject was enrolled for subsequent treatment periods. Preliminary review of the blinded data including adverse events, electrocardiographic parameters, telemetry, vital sign measures, clinical laboratory parameters, pulse oximetry, and Holter recordings as well as weight and appetite assessments indicates that there were no clinically significant safety concerns.

In Cohort 2, 12 subjects were to receive 3 single doses of GSK2798745 5mg. However, one subject withdrew for personal reasons after completing the first treatment period. This subject was not replaced and therefore, 11 subjects completed the remaining treatment periods. No clinically significant safety concerns were noted.

In Cohort 3, 8 subjects were to receive repeat doses of GSK2798745 5mg once daily or placebo (6:2 ratio) for 14 days. Four subjects completed 14-days of dosing; however, the second group of 4 subjects only completed 8 days of dosing before the study was placed on temporary halt due to the receipt of new information from the 3-month dog toxicity study. Preliminary review of the blinded data including adverse events, electrocardiographic parameters, telemetry, vital sign measures, clinical laboratory parameters, pulse oximetry, and audiometry as well as weight and appetite assessments indicates that there were no clinically significant safety concerns with repeat administration of GSK2798745.

Section 2 Objectives and Endpoints

PREVIOUS TEXT

Exploratory tests

Characterize the effects of repeat dosing with GSK2798745 on exercise capacity in healthy subjects and subjects with HF

Characterize the effects of repeat dosing with GSK2798745 on DLco and DLno in healthy subjects and stable heart failure patients


Gas exchange endpoints including peak VO2, Ve/VCO2 slope, RER, exercise time, and VO2 and time at ventilator threshold



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REVISED TEXT

Exploratory

Characterize the effects of repeat administrationdosing ofwithGSK2798745 on exercise capacity in healthy subjects and subjects with HF

Characterize the effects of repeat administrationdosing ofwithGSK2798745 on DLco and DLno in healthy subjects and stable heart failure patients


Characterize the effect of repeat administration of GSK2798745 on DCE-MRI measures of pulmonary oedema and vascular permeability at rest (Cohort 4 only)

Characterize the effect of repeat administration of GSK2798745 on DCE-MRI measures of pulmonary oedema and vascular permeability following exercise (Cohort 4 only)

Characterize the effect of repeat administration of GSK2798745 on exercised-induced changes in DCE-MRI measures of pulmonary oedema and vascular permeability (Cohort 4 only)

Examine plasma volume and MRI physical properties influenced by the tissue microenvironment relaxation rate,and proton density in heart failure patients before and after repeat administration of GSK2798745 (Cohort 4 only)

Determine the effect of repeat administration of GSK2798745 on the plasma concentrations of NT-pro BNP in heart failure patients (Cohort 4 only)




Difference in the interstitial volume (ve) and exchange rate (ktrans) before and after repeat dosing measured at rest (before exercise).

Difference in the interstitial volume (ve) and exchange rate (ktrans) before and after repeat dosing measured following exercise

Difference in the exercise-induced change (post-exercise minus pre-exercise) in interstitial volume (ve) and exchange rate (ktrans) before and after repeat dosing



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PREVIOUS TEXT





Cohort Phase Assessments Predicted dose or dose range1

Healthy subjects single doseCohort 1n=8


Safety , tolerability and PK 0.25-4mg4

Cohort 2n=12

Single dose (liquid2

and capsule formulation) with and without food


0.5-4.0mg

Healthy subjects repeat dose3

Cohort 3n= 16



0.5, 1.5mg4

Heart failure patients single dose followed by repeat dose 3

Cohort 4n=~15 (4:1 active/ placebo)

Single dose, Repeat doseliquid formulation or capsule5 for 7 days

Safety, tolerability PK, exploratory tests for feasibility: exercise parameters, lung permeability (DLco and DLno), OGTT

1.5mg

1. Doses may change based on safety and exposure data. These doses are for estimation purposes only. 2. Doses greater than or equal to 0.5 mg will be given as a suspension and below 0.5mg will be given as a solution.3. Dosing will not exceed the daily AUC of 1.01hr*ug/mL or Cmax of 0.09ug/mL in any individual.4. There may be an additional dose added to either Cohort 1 or 3.5. The formulation used will depend on the results of the relative bioavailability being tested in Cohort 2. . If Cohort 3

or 4 is conducted concurrently or prior to Cohort 2, the liquid formulation utilized in Cohort 1 will be administered.

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REVISED TEXT






Phase Assessments Dose or Dose Range1,2

Healthy subjects single dose3

Cohort 1(n=8)


Safety , tolerability and PK 0.25mg-12.5mg0.25-4mg

Cohort 2(n=12)



0.5-4.0mg5mg


Cohort 3(n=8[3:1 ratio]164 / dose group)



0.5, 1.5mg5mg


Cohort 4(n=~185)(1:1 ratio)

Single dose, Repeat doseliquid formulation or capsule5 for 7 days

Safety, tolerability PK, exploratory tests for feasibility: exercise parameters, lung permeability (DLco and DLno), OGTT DCE-MRI, NT-proBNP

1.5mg-2.4mg (initial)

1. Doses may change based on safety and exposure data. 2. Doses greater than or equal to 0.5 mg will be given as a suspension and below 0.5mg will be given as a solution.3. Exposure Dosing will not exceed the daily AUC of 1.01hr*ug/mL or Cmax of 0.09ug/mL in any individual in

Cohorts 1-3. Any new dose investigated in Cohort 3 will be selected so as to not intentionally exceed the daily AUC of 0.448 µg*h/mL or Cmax of 0.049 µg/mL in any individual.

4. There may be an additional dose added to either Cohort 1, or 3, or 4.5. The formulation used will depend on the results of the relative bioavailability being tested in Cohort 2. If Cohort 3

or 4 is conducted concurrently or prior to Cohort 2, the liquid formulation utilized in Cohort 1 will be administered.6. Exposure will not intentionally exceed a daily AUC of 0.448 µg*h/mL or Cmax of 0.049 µg/mL in any

individual participating in Cohort 4.

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Section 3.2.2 Healthy Subjects Repeat Dose

PREVIOUS TEXT

This cohort is constructed as a sponsor un-blinded, randomized, placebo-controlled, 14-day repeat-dose evaluation of GSK2798745. It is planned that up to two doses will be studied based on the safety, tolerability and the systemic exposure data obtained from the single dose studies. A sufficient number of subjects will be enrolled such that 16 evaluable subjects will be randomized to 2 repeat dose cohorts with 8 subjects in each cohort in a ratio of 6:2 (treatment: placebo). The effect of TRPV4 channel inhibition on exercise performance will be evaluated as noted above. In addition, arginine vasopressin (AVP) concentration will also be evaluated by a hypertonic NaCl challenge. The osmotic regulation of AVP secretion may involve the TRPV4 channel. [Sladek, 2013] Glucose tolerance will also be evaluated by an oral glucose tolerance test (OGTT). In a TRPV4 knock-out preclinical model, body weight was reduced in the setting of improved glucose handling [Ye, 2012]. These measurements may represent tools to estimate targetengagement in these early studies.

REVISED TEXT

This cohort is constructed as a sponsor un-blinded, randomized, placebo-controlled, 14-day repeat-dose evaluation of GSK2798745. It is planned that up to two doses may willbe studied based on the safety, tolerability and the systemic exposure data obtained from the single dose studies. A sufficient number of subjects will be enrolled such that up to16 subjects in a ratio of 6:2 (treatment: placebo) willmay be evaluated in each planned cohort. However, only 4 subjects completing 14 days of dosing will be deemed sufficient to move into either the next cohort of 8 healthy volunteers or directly into heart failure patients (Cohort 4) without any further testing in healthy volunteers. The effect of TRPV4 channel inhibition on exercise performance will be evaluated as noted above. In addition, arginine vasopressin (AVP) concentration will may also be evaluated by a hypertonic NaCl challenge. The osmotic regulation of AVP secretion may involve the TRPV4 channel. [Sladek, 2013] Glucose tolerance will also be evaluated by an oral glucose tolerance test (OGTT). In a TRPV4 knock-out preclinical model, body weight was reduced in the setting of improved glucose handling [Ye, 2012]. These measurements may represent tools to estimate target engagement in these early studies.

Section 3.2.2.1 Dose Considerations - Cohort 3

PREVIOUS TEXT

The maximum daily dose in this repeat dosing arm will not intentionally exceed an daily exposure of AUC of 1.01μg*hr/mL or a Cmax of 0.09μg/mL in any individual. Food intake timing will be determined based on data from Cohorts 1 and 2 (if Cohort 2 is conducted before Cohort 3). Two doses will be tested (8 subjects each). The first dose will be lower and a dose escalation meeting will be conducted following the first dose to determine the dose in the second group of subjects.

Progression to a higher dose level will be stopped if 1 or more subjects experience a serious adverse event considered as having a reasonable probability of being related to

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drug. Additionally, progression to a higher dose level will be stopped if 2 or more subjects experience a severe or significant non-serious adverse event considered as having a reasonable probability of being related to drug.

Doses will be administered on Days 1 through14. Based on data from Cohort 1, the second dose in the repeat-dose period may be skipped to estimate the time invariance in PK. It is currently planned to dose once daily, however based on emergent data [e.g., half-life (T1/2)] from the initial study cohorts, dosing may be altered to twice daily. If needed, refer to the study procedures manual (SPM) for a twice-daily dosing time and event table and dose schedule. Subjects will be fasted from midnight to 4 hours after dosing on Day 1 and Day 14 that entail serial PK sampling. Meal timings on other days will be based on previous cohort data.

Figure 3 Study Design for Healthy Subjects Repeat Dose (Cohort 3)






and DLno), see Section 6.1 for PD assessments. In the second dose group of Cohort 3, subjects will have an

exploratory measurement on Day -1 (within day -14 and day -3) and between Days 9-11. AVP will be measured in

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response to a NaCl challenge, see Section 6.1.

Follow-up 7-14 days after last study drug administration.If warranted, additional follow-up visits may be scheduled.

Total Duration Screening within 45days + treatment (17 days) + follow up of 7-14 days = approximately 10 weeks

REVISED TEXT

The maximum daily dose in this repeat dosing arm will was to not intentionally exceed a daily exposure of AUC of 1.01μg*hr/mL or a Cmax of 0.09μg/mL in any individual. Based on the newly available data from the dog toxicity study, any further dosing events will not intentionally exceed daily exposure of AUC of 0.448 1μg*hr/mL or a Cmax of 0.049 μg/mL in any individual.

Food intake timing will be determined based on data from Cohorts 1 and 2 (if Cohort 2 is conducted before Cohort 3).

Two doses will be tested (8 subjects each). The first dose will be lower and a dose escalation meeting will be conducted following the first dose to determine the dose in the second group of subjects.

Progression to a higher dose level will be stopped if 1 or more subjects experience a serious adverse event considered as having a reasonable probability of being related to drug. Additionally, progression to a higher dose level will be stopped if 2 or more subjects experience a severe or significant non-serious adverse event considered as having a reasonable probability of being related to drug.

Doses will be administered on Days 1 through14. Based on data from Cohort 1, the second dose in the repeat-dose period may be skipped to estimate the time invariance in PK. It is currently planned to dose once daily, however based on emergent data [e.g., half-life (T1/2)] from the initial study cohorts, dosing may be altered to twice daily. If needed, refer to the study procedures manual (SPM) for a twice-daily dosing time and event table and dose schedule. Subjects will may be fasted from midnight to 4 hours after dosing on Day 1 and Day 14 that entail serial PK sampling. Meal timings on other days will be based on previous cohort data.

Figure 3 Study Design for Cohort 3: Repeat Dose Administration in Healthy Subjects

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Treatment Period Each subject will take part in only one treatment period and will be dosed for 14 days.



and DLno); see Section 6.1 for PD assessments. Ifn the second dose group of Cohort 3 is initiated, subjects

will have an exploratory measurement on Day -1 (within day -14 and day -3) and between Days 9-11. AVP may be measured in response to a NaCl challenge, see Section 6.1.

Follow-up 7-14 days after last study drug administration. If warranted, additional follow-up visits may be scheduled.

Total Duration Screening within 45days + treatment (17 days) + follow up of 7-14 days = approximately 10 weeks

Two doses of GSK2798745 may be evaluated. A review meeting will be conducted following the first dose level to determine the dose in any proposed second group of subjects. Progression to a higher dose level will not occur if 1 or more subjects experience a serious adverse event considered as having a reasonable probability of being related to drug. Additionally, progression to a higher dose level will not occur if 2 or more subjects experience a severe or significant non-serious adverse event considered as having a reasonable probability of being related to drug. Alternately, a lower dose may be studied if additional information may be gained.

Section 3.2.3 Heart Failure Patients Single and Repeat Dose - Cohort 4

PREVIOUS TEXT

The HF patient cohort will be a sponsor un-blinded, randomized, placebo-controlled, single dose followed by a 7-day repeat dose, in-house evaluation of GSK2798745. This cohort will enroll patients with mild to moderate dyspnea on exertion (i.e., NYHA Class II or III), thereby including those likely to have some excess fluid in their lungs. The dose will be based on the safety, tolerability and PK data obtained from the single-dose and repeat-dose healthy subject cohorts. A sufficient number of patients will be enrolled such that 15 patients will be randomized to the cohort with a treatment:placebo ratio of 12:3. The main focus of this cohort is the evaluation of safety and tolerability, including safety biochemical testing and assessment of physical examination throughout the 7 days and follow-up.

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In addition, we will interrogate these subjects for efficacy. Respiratory rates will be quantified over time. Orthopnea will be assessed at the beginning and end of the study. Maximal exercise capacity will be assessed using a standardized bike protocol (see Section 6.9.1), at the early and latter part of the 7 days of treatment. Degree of ventilation (Ve) can be compared to the ambient level of CO2, a ratio which is notably high in HF patients, and possibly reduced with the test agent. This will be supplemented by measures of gas transfer (carbon monoxide and nitric oxide; DLco and DLno) before and immediately after exercise at baseline and after reaching steady state with GSK2798745. The profound elevation in pulmonary venous pressures during exercise (often observed in HF patients) will likely exacerbate the movement of fluid into the lung tissue, and thereby decrease alveolar: vascular membrane gas transfer. We hypothesize a TRPV4 blocker will limit this exercise-induced change.

Dose considerations: The maximum daily dose in the repeat dosing period will not intentionally exceed a daily exposure of AUC of 1.01μg*hr/mL or a Cmax of 0.09μg/mL in any individual. The decision of food intake timing will be determined based on data from Cohorts 1 and 2. The decision of the dose will be determined from Cohorts 1 through 3. The highest safe and well tolerated dose will be evaluated in the Cohort 4.

Figure 4 Study Design for HF Patients Single and Repeat Doses (Cohort 4)


Screening Identification and basic screening assessment will be done throughout the study. If the screening assessment is conducted more than 35 days prior to first dose it will need to be repeated.

Treatment Period

For single dose followed by repeat dose

Single dose period: patients will be in-house from Day -1 until all post-dose assessments have been completed (48 or 72hrs post dose depending on the half-life).

Subject will return to the unit after a washout period ≥7 days for the 7 day repeat dose period.

Repeat dose period: patients will be in-house from Day -1 until all post-dose assessments have been completed (48 or 72hrs post

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final dose depending on the half-life).

Each patient will be dosed for 7 days.

Subjects will have exploratory measurements on Day -1 and Day 7. The measurements will include exercise testing and lung permeability assay (DLco; DLno) and OGTT (see Section 6.1 for PD assessments).


If warranted, additional follow-up visits may be scheduled.

Total Duration Screening within 35 days + single dose + washout + repeat dose treatment (7 days) + follow up (7-14 days) = approximately 10 weeks

REVISED TEXT

Cohort 4 will be a sponsor un-blinded, randomized, placebo-controlled study in patients with heart failure including a single dose and a subsequent 7-day repeat dose evaluation of GSK2798745. This cohort will enroll patients with mild to moderate dyspnea on exertion (i.e., NYHA Class II or III), thereby including those likely to have some excess fluid in their lungs. The dose will be based on the safety, tolerability and PK data obtained from the single-dose and repeat-dose healthy subject cohorts. A sufficient number of patients will be enrolled such that 185 patients are planned be randomized to the cohort with a treatment:placebo ratio of 1:112:3. The main focus of this cohort is the evaluation of safety, pharmacokinetics and tolerability, including safety biochemical testing and assessment of physical examination throughout the 7 days and follow-up.

In addition, we will evaluate the potential effect of GSK2798745 in patients with heart failure. Respiratory rates will be quantified over time. Orthopnea will be assessed at the beginning and end of the study. Maximal exercise capacity will be assessed using a standardized bicycle protocol (see Section 6.9.1), prior to repeat-dose administration and during the latter part of the 7 days of treatment. Degree of ventilation (VEe) can be compared to the ambient level of CO2, a ratio, which is notably high in HF patients, and possibly reduced with the test agent. This will be supplemented by measures of gas transfer (carbon monoxide and nitric oxide; DLco and DLno) before and immediately after exercise both at baseline and after reaching steady state with GSK2798745. DCE MRI measures of pulmonary edema (ve) and vascular permeability (ktrans) will also be assessed at baseline and after reaching steady state with GSK2798745. The profound elevation in pulmonary venous pressures during exercise (often observed in HF patients) will likely exacerbate the movement of fluid into the lung tissue, and thereby decrease alveolar: vascular membrane gas transfer. We hypothesize a TRPV4 blocker will limit this exercise-induced change.

Dose considerations: The maximum daily dose in the repeat dosing period will not intentionally exceed a daily exposure of AUC of 0.448 1.01μg*hr/mL or a Cmax of

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0.090.049 μg/mL in any individual. The decision of food intake timing will be determined based on data from Cohorts 1 and 2. The decision of the dose will be determined from Cohorts 1 through 3.Based on data from the previous cohorts, the dose will be 2.4mg in the first group utilizing the capsule formulation administered with or without food.(see Section 3.4.5 for dose rationale). Based on the emerging PK data from these HF patients, the dose level may be modified if needed as long as the dose would not intentionally exceed a daily exposure of AUC of 0.448 μg*hr/mL or a Cmax of 0.049 μg/mL in any individual. Further, two dose levels of GSK2798745 may be evaluated in Cohort 4 and additional patients may be recruited for a second dose group to allow up to a maximum of 14-day repeatdosing. The highest safe and well tolerated dose will be evaluated in the Cohort 4.

Figure 4 Study Design for Cohort 4: HF Patients Single and Repeat Dose Administration in Patients with HFs



Treatment Period


Single dose period: subjectpatients will be in-house from Day -1 until all post-dose assessments have been completed (48 or72hrs post dose depending on the half-life).

Subjects will return to the unit after a washout period ≥7 days for the 7day repeat dose period.

Repeat dose period: subjects will be in-house from Day -1 until all post-dose assessments have been completed (48 or 72hrs post final dose depending on the half-life).

Each subject will be administered GSK2798745 or placebodosed (based on randomization) for 7 days.

Subjects will have exploratory measurements on Day -1 and between Days 5-77. The measurements will include exercise testing and lung permeability assay (DLco; DLno) and , OGTT(see Section 6.1 for PD assessments), and DCE-MRI.and NT-pro BNP levels will also be measured

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throughout the period.


If warranted, additional follow-up visits may be scheduled.

Total Duration Screening within 35 days + single dose period + washout + 7-day repeat dose treatment (7 days) period + follow up (7-14 days after last dose of study medication) = approximately 10 weeks

Section 3.3 Drug Formulation

ADDED TEXT

All doses in Cohort 1 will be administered either as a suspension or a solution depending on the dose. Cohort 2 will also employ the capsule formulation (filled in by the pharmacy) in order to assess the relative bioavailability of the capsule formulation as compared to the liquid formulation. Cohorts 3 and 4 will employ one of the formulations used in Cohorts 1 or 2. The relative exposure data from Cohort 2 will determine the formulation for Cohorts 3 and 4. The formulation that will provide the best exposure profile (i.e., the least variable profile) will be used in Cohort 3 and 4. In the event that Cohort 3 is conducted concurrently with Cohort 2, the liquid formulation will be administered in the repeat-dose Cohort 3. Based on all the data available from the previous cohorts in this study, Cohort 4 will employ capsule formulation.

Section 3.4.1 Pharmacokinetic Predictions for GSK2798745

PREVIOUS TEXT

The human exposure predictions for GSK2798745 were based on the exposure data collected from preclinical studies in rat and dog. Allometric scaling with and without corrections for factors such as protein binding and maximum life span potential differences between species was employed for these predictions [Davies, 1993; Iwatsubo, 1997, Obach, 1997; Lave, 1999]. After applying these various scaling methods, the range of predicted clearance, volume of distribution and half-life are summarized in Table 5.



Volume of Distribution [Vd] (L/kg)



0.88 – 1.07 0.87 – 2.30 9 – 30 80 – 100

REVISED TEXT

InitialThe human exposure predictions for GSK2798745 were based on the exposure data collected from preclinical studies in rat and dog. Allometric scaling with and

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without corrections for factors such as protein binding and maximum life span potential differences between species was employed for these predictions [Davies, 1993; Iwatsubo, 1997, Obach, 1997; Lave, 1999]. After applying these various scaling methods, the range of predicted clearance, volume of distribution and half-life are summarized in Table 5.



Volume of Distribution [Vd] (L/kg)



0.88 – 1.07 0.87 – 2.30 9 – 30 80 – 100

Section 3.4.2 No Observed Adverse Effect Level (NOAEL) Dose

PREVIOUS TEXT

Four week toxicology studies (rats and dogs) were conducted to assess the toxicity of GSK2798745.

REVISED TEXT

Four-week (rats and dogs) and 3-month (dog) toxicology studies toxicology studies (rats and dogs) were conducted to assess the toxicity of GSK2798745.

PREVIOUS TEXT

Section 3.4.2.1 Rat

REVISED TEXT

Section 3.4.2.1 Rat 4-Week Toxicity Study

PREVIOUS TEXT

Section 3.4.2.2 Dog

The dose levels studied in the oral dog 4-week toxicity study were 0 (vehicle), 3, 10 and 30mg/kg/day. There were various toxicological findings at different doses that are summarized in Table 8. Based on the adverse toxicological findings at the 30mg/kg/day dose group, the 10mg/kg/day dose was selected as the NOAEL dose level. Given that the arterial and cardiac findings at 30mg/kg/day cannot be easily monitored for in clinical studies and the mechanism by which they occur is not understood, a 50X exposure margin below the NOAEL dose of 10mg/kg/day was considered the maximum exposure to be achieved in humans in this study, consistent with regulatory guidelines [ICH, 2009]. The Day 1 mean exposures in dogs at 10mg/kg/day were used as this provided the most conservative approach. The mean AUC was 50.4hr*µg/mL and Cmax was 4.51µg/mL at this dose. Applying the 50-fold safety margin, an AUC of 1.01µg*hr/mL and Cmax of

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0.09µg*hr/mL were used to estimate the safety margins with respect to the dog species. These safety margins are listed in Table 7.

As the dog exposure levels provide a more conservative stopping limit as compared to the exposure in rat, the tentative doses for this FTIH will be selected to not knowingly exceed a daily AUC of 1.01µg*hr/mL and/or a Cmax of 0.09µg/mL in any individual in any cohort.

REVISED TEXT

Section 3.4.2.2 Dog 4-Week Toxicity Study

The dose levels studied in the oral dog 4-week toxicity study were 0 (vehicle), 3, 10 and 30mg/kg/day. There were various toxicological findings at different doses that are summarized in Table 8. Based on the adverse toxicological findings at the 30mg/kg/day dose group, the 10mg/kg/day dose was selected as the NOAEL dose level. Given that the arterial and cardiac findings at 30mg/kg/day cannot be easily monitored for in clinical studies and the mechanism by which they occur is not understood, a 50X exposure margin below the NOAEL dose of 10mg/kg/day was considered the maximum exposure to be achieved in humans in this study, consistent with regulatory guidelines [ICH, 2009]. The Day 1 mean exposures in dogs at 10mg/kg/day were used as this provided the most conservative approach. The mean AUC was 50.4hr*µg/mL and Cmax was 4.51µg/mL at this dose. Applying the 50-fold safety margin, an AUC of 1.01µg*hr/mL and Cmax of 0.09µg*hr/mL were used to estimate the safety margins with respect to the dog species. These safety margins are listed in Table 7.

As the dog exposure levels provide a more conservative stopping limit as compared to the exposure in rat, the tentative doses for this FTIH will be selected to not knowingly exceed a daily AUC of 1.01µg*hr/mL and/or a Cmax of 0.09µg/mL in any individual in any cohort. This information and exposure limits were utilized in Cohorts 1 through 3 to establish appropriate doses for administration to healthy volunteers. Subsequently, new information has been obtained from the 3-month dog toxicity study.

ADDED SECTION

Section 3.4.2.3 Dog 3-Month Toxicity Study

3.4.2.3.1 Findings

GSK2798745 was given, by oral gavage, to male and female dogs (4/sex/group), at

doses of 1, 3 or 10 mg/kg/day for 3 months. A control group received the vehicle

alone. The peer-reviewed microscopic pathology data identified vascular toxicity in

2 dogs given 10 mg/kg/day. Specifically, arteriolar degeneration/necrosis,

accompanied by lymphocytic inflammation, was observed in the epididymides

(bilateral) in a male and in the urinary bladder of a female. Neither dog presented

clinical abnormalities, and each survived the scheduled duration of the study. No

evidence of vascular toxicity was observed in other tissues of these dogs, and no

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vascular lesions were seen in any tissues of dogs given 1 or 3 mg/kg/day. Such

vascular lesions are not considered a new finding with GSK2798745 since lesions

like these were seen previously in the 1-month dog study at 30 mg/kg/day. However,

the lesions are now being observed at a lower dose. In dogs given 10 mg/kg/day,

mean AUC and Cmax (gender-averaged, Day 1) was 48.8 µg.h/mL and 4.09 µg/mL,

respectively. In dogs given 3 mg/kg/day (the no-effect dose for vascular toxicity in

this study), mean AUC and Cmax (gender-averaged, Day 1) was 13.5 µg.h/mL and

1.46 µg/mL, respectively.

3.4.2.3.2 Risk Assessment

The original clinical exposure cap was based on one fiftieth of exposure at the

NOAEL of 10 mg/kg/day identified in the 1-month dog study. A clinical exposure

cap based on one fiftieth of exposure at the 3 mg/kg/day dog NOAEL would

translate to AUC 0.269 µg.h/mL and Cmax 0.029 µg/mL.

GSK has critically reviewed the vascular findings from the 1-month and the 3-

month dog studies. GSK believes it is unlikely that the lesions are attributable to

some effect of TRPV4 channel blockage in the dog. Estimates based on the plasma

concentration of GSK2798745 that causes full channel blockade in rats (TRPV4-

induced lung edema model; refer to the GSK2798745 Investigator’s Brochure),

corrected for cross-species differences in in vitro potency and plasma protein

binding between rat and dog, suggest that full inhibition of TRPV4 is achieved in

the dog at plasma concentrations less than one hundredth of Cmax at the

3 mg/kg/day NOAEL. Although TRPV4 channel blockade can affect vascular

function, we are not aware of any evidence that would link to a potential

detrimental vascular effect. Our further thought is that the lesions appear to

resemble those caused by vasodilators (discussed below). In that context, however,

we have no data to suggest that TRPV4 blockade results in systemic vasodilation or

hypotension in healthy animals. Rather, this notion is paradoxical in that TRPV4

activation consistently results in profound endothelium-dependent vasodilation and

hypotension (Willette, 2007; Mendoza, 2010).

Some further aspects of the vascular lesions seen in these dogs that are considered

noteworthy:

Dose-response: Based on the pooled data from the month 1- and 3-month studies,

the incidence of dogs with vascular lesions shows a dose response with 10 mg/kg/day

at the low end (2/6 at 30 mg/kg/day [33%]; 2/14 at 10 mg/kg/day [14%]; 0/14 at

3 mg/kg/day (0%]). Although the incidence increased with dose, the lesions were

similar in severity and not associated with resultant organ damage at either dose.

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Similarity to lesions caused by vasodilators: The character of the lesions, particularly

the focal necrosis of arterioles, resembles that of lesions described in animals given

high doses of vasodilating agents of various classes (Louden and Morgan, 2001). In

dogs, such lesions are situated more typically in the heart, but can occur randomly

at multiple other sites (Louden and Morgan, 2001), including the urinary bladder

(the site of the lesion in one of the dogs given of GSK2798745 10 mg/kg/day) as

reported with endothelin receptor antagonists (Jones, 2003) and with an adenosine

agonist (Metz, 1991). These lesions associated with vasodilators have been regarded

as a species-sensitive response in the dog that may not be of predictive value in

humans at therapeutic doses (Tesfamariam, 2007).

In considering the points above, GSK proposes a lower clinical exposure cap based on exposure at one thirtieth of the 3 mg/kg/day dog NOAEL, which translates to AUC 0.448 µg.h/mL and Cmax 0.049 µg/mL. This also represents approximately one hundredth and one eightieth of mean AUC and Cmax, respectively, at 10 mg/kg/day (the low end of the dose response for vascular lesions). While recognizing the serious nature and non-monitorability of this non-clinical hazard, these are still substantial safety margins.

Section 3.4.3 TRPV4 Channel Inhibition

PREVIOUS TEXTThe clinical dose of GSK2798745 is targeted to achieve greater than 80% inhibition of TRPV4 channel over a major fraction of the dosing interval. It assumes that such a high level of TRPV4 channel inhibition will be sufficient to elicit the anticipated physiologic activity of GSK2798745.

REVISED TEXT

The clinical dose of GSK2798745 is was targeted to achieve greater than 80% inhibition of TRPV4 channel over a major fraction of the dosing interval. It assumes that such a high level of TRPV4 channel inhibition will be sufficient to elicit the anticipated physiologic activity of GSK2798745. Based on the new NOAEL level, the targeted exposures should achieve sufficiently high TRPV4 channel inhibition to evaluate the activity of GSK2798745.

Section 3.4.5 Safety Cover Based on Predicted Exposure and NOAEL from the Pre-Clinical Species

PREVIOUS TEXT


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If exposures are less than predicted, doses higher than the currently planned 4mg may be used. However, in any case, the daily exposure will not intentionally exceed Cmax of 0.09µg/mL and/or AUC of 1.01g*hr/mLin any individual.


Table 7 represents the planned dose range and predicted exposure for clinical evaluation of single doses of GSK2798745.



Cmax (µg/mL)


of 0.09ug/mL**



Rat# Dog* Rat# Dog*

0.25 0.001-0.004 3301-10481 23-74 0.044-0.068 1843-2801 15-23

0.50 0.002-0.008 1650-5240 12-37 0.089-0.135 921-1401 8-11

0.75 0.004-0.012 1100-3494 8-25 0.133-0.203 614-934 5-8

1.50 0.007-0.023 550-1747 4-12 0.267-0.405 307-467 3-4

2.50 0.012-0.039 330-1048 2-7 0.444-0.676 184-280 2-2

3.50 0.017-0.054 236-749 2-5 0.622-0.946 132-200 1-2

4.0 0.019-0.062 206-655 2-5 0.711-1.081 115-175 1-1

**The stopping AUC and Cmax provide 50X cover from the NOAEL dose (10mg/kg/day) exposure in the dog study* Exposure values from day 1 of the dog study used given the toxicological findings# Exposure values from day 28 of the rat study used given the toxicological findingsThe range of exposures at doses planned for the current study was estimated using the predicted PK parameters in human as listed in Table 6.

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REVISED TEXT




If exposures are less than predicted, doses higher than the currently planned 4mg may be used. However, in any case, the daily exposure will not intentionally exceed Cmax of 0.09µg/mL and/or AUC of 1.01g*hr/mL in any individual (Cohorts 1 through 3). If another group of subjects is initiated in Cohort 3, the exposure will not intentionally exceed a daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL in any individual.


Table 7 represents the initially planned dose range and predicted exposures for clinical evaluation of single doses of GSK2798745 (Cohorts 1 and 2).



Cmax (µg/mL)


of 0.09ug/mL**



Rat# Dog* Rat# Dog*

0.25 0.001-0.004 3301-10481 23-74 0.044-0.068 1843-2801 15-23

0.50 0.002-0.008 1650-5240 12-37 0.089-0.135 921-1401 8-11

0.75 0.004-0.012 1100-3494 8-25 0.133-0.203 614-934 5-8

1.50 0.007-0.023 550-1747 4-12 0.267-0.405 307-467 3-4

2.50 0.012-0.039 330-1048 2-7 0.444-0.676 184-280 2-2

3.50 0.017-0.054 236-749 2-5 0.622-0.946 132-200 1-2

4.0 0.019-0.062 206-655 2-5 0.711-1.081 115-175 1-1

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**The stopping AUC and Cmax provide 50X cover from the NOAEL dose (10mg/kg/day) exposure in the 4-week dog study* Exposure values from day 1 of the dog study used given the toxicological findings# Exposure values from day 28 of the rat study used given the toxicological findingsThe range of exposures at doses planned for the current study was estimated using the predicted PK parameters in human as listed in Table 6.

3.4.5.1 Doses based on clinical data from Cohorts 1-3 in FTIH study

Doses from 0.25 to 12.5 mg were administered in the single dose ascending cohort 1 of the FTIH study in healthy volunteers. Based on the exposure data from these doses, the 5 mg dose was evaluated to characterize the effect of capsule formulation and food on GSK2798745 exposure in cohort 2 in healthy volunteers. A 5 mg once daily repeat dose was also evaluated in 8 healthy volunteers (6 active + 2 placebo) in cohort3. Of these 6 subjects on GSK2798745, 3 completed 2 weeks of dosing while remaining 3 completed 8 days of dosing. No SAEs were observed in any of the subjects dosed with GSK2798745.

All the available data was used to develop a preliminary population PK model and simulate exposures for the heart failure subjects in cohort 4. The tentative doses and predicted exposure at these doses are listed in Table 8. This was primarily done to explore tentative doses for the cohort 4 subjects to limit exposure to a lower threshold based on the new preclinical data obtained from the 3 month dog safety study. The new lower threshold of daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL provides a 30X cover from the revised no-effect dose level of 3mg/kg/day exposures observed in the 3 month dog safety study.

Table 8 Predicted Exposure and Safety Margin for the Repeat-Dose Administration in Subjects with Heart Failure (Cohort 4)

Dose (mg)



Safety Margin from AUC of 0.448 ug*hr/mL

Median (90% PredictionInterval)



Safety Margin from Cmax of 0.049 ug/mL

Median (90% prediction Interval)

3.0 0.17 (0.09 – 0.29) 79X (46X – 149X) 0.018 (0.011 – 0.028) 81 (52 – 133)

3.5 0.20 (0.11 – 0.35) 67X (38X – 122X) 0.021 (0.013 – 0.033) 70 (44 – 113)

4.25 0.24 (0.13 – 0.42) 56X (32X – 103X) 0.026 (0.015 – 0.041) 56 (36 – 98)

4.5 0.25 (0.14 – 0.44) 54X (31X – 96X) 0.027 (0.016 – 0.043) 54 (34 – 92)

Simulations were also performed to predict the probability that 1 or more subjects in the next cohort of subjects (9 active + 9 placebo) achieve exposures greater than a daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL. The results from these simulations are listed in Table 9. Based on these analyses, a 3 mg dose can be recommended for cohort 4. The population parameter estimates for the PK model used for simulations are listed in Appendix 6.

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Table 9 Predicted Exposure and Probability of exceeding threshold AUC and Cmax in future cohorts

Dose (mg)





% Probability that ≥ 1 out of 9 subjects exceed threshold AUC (0.448

ug*hr/mL)

% Probability that ≥ 1 out of 9 subjects exceed

threshold Cmax (0.049 ug*hr/mL)

3.0 0.17 (0.09 – 0.29) 0.018 (0.011 – 0.028) 4.3 2.03.5 0.20 (0.11 – 0.35) 0.021 (0.013 – 0.033) 14.3 6.3

4.25 0.24 (0.13 – 0.42) 0.026 (0.015 – 0.041) 39.0 25.74.5 0.25 (0.14 – 0.44) 0.027 (0.016 – 0.043) 45.0 37.0

The simulations were based on assumption that GSK2798745 will be administered as a suspension formulation in fasted state, similar to cohort 1. However, preliminary analyses of the data from cohort 2 indicated small increases in the systemic exposure of GSK2798745 when the drug was administered in the capsule formulation and with food (high fat meal). These preliminary results are listed in Table 10. Consequently, a 2.4 mg dose in capsule formulation (without any meal restrictions) is recommended for the subjects in cohort 4. A 25% increase in exposure of 2.4 mg (when administered in capsule and without meal restrictions) would result in exposures comparable to 3 mg dose (when administered as suspension and fasted state) and within the stopping criteria of daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL. Additionally, if needed, the dose may be adjusted based on emerging PK and safety data. Any dose selected will not intentionally exceed daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL.

Table 10 Impact of capsule and meal on systemic exposure of GSK2798745 (preliminary results)

Comparison AUC Ratio (90%CI) Cmax Ratio (90%CI)Capsule Fasted Vs Suspension

Fasted1.12 (1.00 – 1.25) 1.05 (0.9 – 1.23)


To summarize, based on the revised NOAEL established in the 3-month dog toxicity study and a 30-fold safety margin, the planned dose for single and repeat administration of GSK2798745 in Cohort 4 will be 2.4mg once daily administered in capsule without any meal restrictions. The daily exposure will not intentionally exceed a Cmax of 0.049µg/mL and/or a AUC of 0.448g*hr/mL in any individual.


PREVIOUS TEXT

In Cohort 1, 8 subjects receiving single doses will be randomized to one of the following four sequences with each subject having four dose periods and two subjects in each

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sequence: PBCD, APCD, ABP D and ABCP, where placebo (P) and ABCD are active doses of GSK2798745.


In Cohort 3, 16 subjects will be randomized to two repeated dose cohorts with 8 subjects in each cohort in a treatment:placebo ratio of 6:2.

In Cohort 4, 15 patients will be randomized to a cohort with a treatment:placebo ratio of 12:3.

Detailed randomization tables and doses can be found in Appendix 4 and Appendix 5 .

REVISED TEXT



In Cohort 3, up to 8 subjects will be randomized to treatment at a treatment:placebo ratio of 3:116 subjects will be randomized to two repeated dose cohorts with 8 subjects in each cohort in a treatment:placebo ratio of 6:2.. An additional dose group of another 8 subjects may be randomized at the same ratio.

In Cohort 4, 185 patients will be randomized to treatment at a treatment:placebo ratio of 12:31:1. An additional dose group of approximately 18 subjects may be randomized to GSK2798745 or placebo to gain additional safety, tolerability, pharmacokinetic and pharmacodynamic information if needed.



PREVIOUS TEXT


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Rats: No vascular lesions observed.


Since these effects cannot be monitored directly in clinical studies, a coverage of ≥50 fold will be maintained in humans from the no-effect dose (10mg/kg/day), and dosing will not exceed the average daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL.

Myocardial toxicity

Dogs (4-week study): At 30mg/kg/day, myofiber degeneration/necrosis & inflammation (2 animals)

Rats: No myocardial toxicity observed.

Subjects with chronic angina, unstable angina, or history of acute coronary syndromes, coronary angioplasty, or stenting within the past 6 months will be excluded (exclusion #2)


A coverage of ≥50 fold will be maintained in humans from the no-effect dose (10mg/kg/day), and dosing will not exceed the average daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL





A coverage of ≥50 fold will be maintained in humans, and dosing will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL.

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Subjects with history of active ulcer disease or GI bleeding will be excluded (exclusion #6)



None A coverage of ≥50 fold will be maintained in humans to the NOAEL dose (10mg/kg/day) as exposures will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL.







Subjects with a history of seizure disorder or stroke will be excluded from the study. (exclusion #5)

A coverage of >50 fold will be maintained in humans and dosing will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mLDue to presence of potential CNS effects of the compound, suicidality assessment by GSK standards will be included in the protocol.






Rats (4-week study): 60mg/kg/day in the lung (prominent alveolar macrophages); 300mg/kg/day in the mesenteric lymph node (increased cellularity of sinus

None A coverage of ≥50 fold will be maintained in human to the no effect dose (10mg/kg/day) as exposures will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of

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macrophages) and thymus (macrophage vacuolation; increased thymus weight). Consistent with phospholipid accumulation (phospholipidosis) based on ultrastructural appearance of mesenteric lymph nodes at 300mg/kg/day. Findings were not associated with degenerative changes.

0.09ug/mL

REVISED TEXT


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Dogs (3-month study): At 10 mg/kg/day, arterial lesions were observed in 2 dogs.

One male: Epididymides (bilateral) - arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation,

One female: Urinary bladder -arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation



Since these effects cannot be monitored directly in clinical studies, a coverage of ≥50-fold will be maintained in humans from the no-effect dose (10mg/kg/day), and dosing will not exceed the average daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.

A ≥30-fold margin will be maintained from the no-effect dose (3mg/kg/day); exposure will not exceed an AUC of 0.448hr*ug/mL and/or Cmax of 0.049ug/mL in any individual dosed after 10/31/2014.

Myocardial toxicity





A coverage of ≥50 fold will be maintained in humans from the no-effect dose (10mg/kg/day), and dosing will not exceed the average daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.


Mortality/moribund condition; poor

Dogs (4-week study): At 30 mg/kg/day one male terminated

None Weight and adverse events reported

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viability early (Day 6) due to poor clinical condition. Another male had transient whole body shaking on Days 8 and 9.


by subjects will be monitored.

A coverage of ≥50 fold will be maintained in humans, and dosing will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.

A ≥30-fold margin will be maintained from the no-effect dose (3mg/kg/day); exposure will not exceed an AUC of 0.448hr*ug/mL and/or Cmax of 0.049ug/mL in any individualdosed after 10/31/2014.







None A coverage of ≥50-fold will be maintained in humans to the NOAEL dose (10mg/kg/day) as exposures will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.






Rats (micronucleus and comet study): Convulsions observed at ≥600mg/kg/day. Convulsions were not related to Cmax, nor

Subjects with a history of seizure disorder or stroke will be excluded

A coverage of >50-fold will be maintained in humans and dosing will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of

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occurred at any predictable time from dose administration.


from the study. (exclusion #5)

0.09ug/mL in subjects dosed prior to 10/31/2014.








Rats (4-week study): 60mg/kg/day in the lung (prominent alveolar macrophages); 300mg/kg/day in the mesenteric lymph node (increased cellularity of sinus macrophages) and thymus (macrophage vacuolation; increased thymus weight). Consistent with phospholipid accumulation (phospholipidosis) based on ultrastructural appearance of mesenteric lymph nodes at 300mg/kg/day. Findings were not associated with degenerative changes.

None A coverage of ≥50-fold will be maintained in human to the no effect dose (10mg/kg/day) as exposures will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.



Gadobutrol (Gd) (Gadovist; Bayer) has produced nephrogenic systemic fibrosis and fibrosing dermopathy in patient swith renal disease. The incidence of NSF in dialysis and end-stage renal disease patients when exposed to Gd is in the range 3-5% [Marckmann, 2006; Kuo, 2008; However, there are no reports of NSF in subjects with normal renal function [Perazella, 2007; Deo, 2007; Chewning, 2007;

As a result of this recent evidence, subjects with creatinine clearance levels < 60mL/min will be excluded from this study.

Patients with normal renal function appear to have negligible risk of developing NSF/NFD [Kramer, 2007].

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Thomsen, 2006]. It is concluded that subjects dependent on dialysis and those with estimated glomerular filtration rate (eGFR) <30mL/min (chronic kidney disease stage 4/5) are at risk of developing NSF on exposure to Gd [Perazella, 2007].

PREVIOUS TEXT


Study Procedure Potential risksBicycle exercise Side effects of bicycle testing can include shortness of breath, light- headedness, drop in

blood pressure, or abnormal heart rhythm. In rare cases, these side effects can be serious or life-threatening. Also possible are direct injuries such as bruises, sprains, and strains and indirect problems such worsening of pain from arthritis.

NaCl (2.7%) challenge Side effects of a peripheral infusion of NaCl may include pain or redness at the infusion site and peripheral vein trauma (vein thrombosis, or extravasation of hypertonic saline and local tissue damage). Subjects may also experience symptoms such as significant thirst, generalized swelling, and an increase in urine output, Additionally, plasma concentrations of sodium may be elevated for a period of time. In extremely rare cases, seizure or central pontine myelinolysis could theoretically occur which could lead to permanent neurologic impairment. This risk is based on reports in patients experiencing rapid reversal of significant baseline hyponatremia and not in health volunteers with normal baseline sodium level. These risks are being mitigated by the utilization of the lower concentration of saline (2.7%) in comparison to the literature, and ensuring normal sodium levels at screening. Females are also being excluded from participation as their risk of neurologic complications may be greater than in males [Ayus, 1992].

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REVISED TEXT


Study Procedure Potential risksBicycle exercise Side effects of bicycle testing can include shortness of breath, light- headedness, drop in

blood pressure, or abnormal heart rhythm. In rare cases, these side effects can be serious or life-threatening. Also possible are direct injuries such as bruises, sprains, and strains and indirect problems such worsening of pain from arthritis.

DCE-MRI The relatively confined space of the MRI system may cause some subjects to experience claustrophobia. The time varying magnetic fields used in MRI can cause mild nerve stimulation and tissue heating, both of which are strictly controlled by both software and hardware controls implemented by the scanner manufacturer that cannot be bypassed. All scans will be conducted by experienced radiographers and radiologists in the nominated scanning sites. If a subject experiences claustrophobia, the subject will be withdrawn from the study if they are unable to tolerate it again. While lying supine in the MRI scanning system, a subject may develop an exacerbation of dyspnoea. If significant dyspnoea occurs, treatments available in the study area will include sitting upright and oxygen if required. If further therapies are required, best practice clinical management including transfer to hospital for further management will be undertaken.

NaCl (2.7%) challenge Side effects of a peripheral infusion of NaCl may include pain or redness at the infusion site and peripheral vein trauma (vein thrombosis, or extravasation of hypertonic saline and local tissue damage). Subjects may also experience symptoms such as significant thirst, generalized swelling, and an increase in urine output, Additionally, plasma concentrations of sodium may be elevated for a period of time. In extremely rare cases, seizure or central pontine myelinolysis could theoretically occur which could lead to permanent neurologic impairment. This risk is based on reports in patients experiencing rapid reversal of significant baseline hyponatremia and not in health volunteers with normal baseline sodium level. These risks are being mitigated by the utilization of the lower concentration of saline (2.7%) in comparison to the literature, and ensuring normal sodium levels at screening. Females are also being excluded from participation as their risk of neurologic complications may be greater than in males [Ayus, 1992].

Section 4.1 Number of Subjects

PREVIOUS TEXT

A sufficient number of healthy volunteer subjects will be enrolled such that approximately 36 subjects will complete dosing and critical assessments (20 subjects will complete single dosing and 16 subjects will complete repeat dosing). At least 4 subjects will complete dosing and critical assessments in each dose prior to dose escalation. A sufficient number of patients diagnosed with HF will be enrolled such that approximately 15 subjects complete dosing and critical assessments.

Additional subjects/cohorts may be enrolled to allow for evaluation of additional dose levels up to a maximum of 16 additional subjects (or another two standard cohorts of 8 each, single and/or repeat dose).

For single dosing (Cohorts 1and 2), if subjects prematurely discontinue the study, additional subjects may be enrolled as replacement subjects and assigned to the same

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treatment sequence, at the discretion of the Sponsor in consultation with the Investigator. Replacement subjects in Cohort 1 of the study will not necessarily start on the lowest dose level tested within the cohorts and may start on the dose intended for the withdrawn subject.


REVISED TEXT


A sufficient number of patients diagnosed with HF will be enrolled such that approximately 185 subjects complete dosing and critical assessments. Additional subjects/cohorts may be enrolled to allow for evaluation of additional dose levels up to a maximum of 16 additional subjects (or another two standard cohorts of 8 each, single and/or repeat dose). Approximately eighteen additional patients with HF may be enrolled to allow for evaluation of an additional dose level for up to a maximum of 14 days of repeat dosing.

For single dosing (Cohorts 1 and 2), if subjects prematurely discontinue the study, additional subjects may be enrolled as replacement subjects and assigned to the same treatment sequence, at the discretion of the Sponsor in consultation with the Investigator. Replacement subjects in Cohort 1 of the study will not necessarily start on the lowest dose level tested within the cohorts and may start on the dose intended for the withdrawn subject.


Section 4.2.2 Inclusion Criteria for Heart Failure Patients (Cohort 4)

PREVIOUS TEXT

1. Established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) Class II or III on stable heart failure therapy for at least 3 months and was not hospitalized for HF during the last three months



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REVISED TEXT








a. Non-childbearing potential defined as pre-menopausal females with a documented tubal ligation or hysterectomy for this definition, “documented” refers to the outcome of the Investigator's/designee’s

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review of the subject's medical history for study eligibility, as obtained via a verbal interview with the subject or from the subject’s medical records; or postmenopausal defined as 12 months of spontaneous amenorrhea. In questionable cases a blood sample with simultaneous follicle stimulating hormone (FSH) > 40MlU/ml and estradiol < 40pg/ml (<147pmol/L) is confirmatory.




Section 4.2.3 Exclusion Criteria That Apply to All Subjects (Healthy Subjects and HF Patients in Cohorts 1-4)

PREVIOUS TEXT








5. History of seizure disorder and or stroke

6. History of active ulcer disease or GI bleeding

7. Current smokers



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Other Criteria



3. Patients who are taking > 20mg of any statin (HF patients only)



REVISED TEXT










14. Current smokers

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Other Criteria



6. Patients who are taking > 20mg of any statingreater than 40 mg of atorvastatin or greater than 20 mg of simvastatin (HF patients only)



ADDED SECTION

Section 4.2.4 Exclusion Criteria for Subjects with Heart Failure (Cohort 4)




4. Resting hypoxia while breathing room air (SaO2 <88%)




h. Intracranial aneurysm clips (except Sugita) or other metallic objects

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i. Intra- orbital metal fragments that have not been removed

j. Pacemakers or other implanted cardiac rhythm management/monitoring devices and non-MR conditional heart valves

k. Inner ear implants

l. History of claustrophobia

Section 4.3.2 Meals and Dietary Restrictions

ADDED TEXT

In Cohort 4, no meal restrictions will be placed with regard to drug administration. Subjects will be allowed to consume a standard breakfast prior to drug administration.

Section 5.2 Planned Dose Adjustments and Stopping Criteria

ADDED TEXT


In Cohort 4 (or in any cohort where dosing occurs after 10/31/2014), the exposure will not exceed a daily AUCof 0.448 µg*h/mL or Cmax of 0.049 µg/mL in any individual.


Section 5.10.2 Permitted Medications for Heart Failure Patients

PREVIOUS TEXT

Paracetamol at doses of 2 grams/day is permitted for use any time during the study. The patients may stay on all regular prescription medications. Patients on statin may be enrolled in this study only if the dose is ≤ 20mg or lower. Other concomitant medication may be considered on a case by case basis by the Investigator in consultation with the GSK Medical Monitor.

REVISED TEXT

Paracetamol at doses of 2 grams/day is permitted for use any time during the study. The patients may stay on all regular prescription medications. Patients on statin may be enrolled in this study only if the dose is ≤ 20mg or lowera simvastatin dose of 20 mg or less or an atorvastatin dose of 40 mg or less may be enrolled in this study. Digoxin

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is permitted, but with close monitoring to maintain the therapeutic window. Other concomitant medication may be considered on a case by case basis by the Investigator in consultation with the GSK Medical Monitor.

Section 5.10.4 Prohibited Medications and Non-Drug Therapies for Heart Failure Patients

PREVIOUS TEXT


Patients must avoid using a strong Cytochrome P450 (CYP) 3A4 inhibitor (Table 10) from screening to the follow up visit. GSK2798745 systemic concentrations will be monitored to detect any drug interactions with moderate CYP3A4 inhibitors or PgP inhibitors (see SPM for a detailed list). Digoxin is permitted, but with close monitoring as described above to maintain the therapeutic window.

Table 10 Strong CYP3A4 Inhibitors







Immunosuppressant cyclosporin

REVISED TEXT

Except for the permitted medications noted above (Section 5.10.2), subjects with HF must abstain from taking non-prescription drugs (including vitamins and dietary or herbal supplements), within 7 days (or 14 days if the drug is a potential enzyme inducer) or 5 half-lives (whichever is longer) prior to the first dose of study medication until

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completion of the follow-up visit, unless in the opinion of the Investigator and sponsor the medication will not interfere with the study.

Patients must avoid using drugs that are strong inhibitors or inducers of Cytochrome P450 (CYP) 3A4, p-glycoprotein (Pgp) or Bcrp transporters because they may alter GSK2798745. The list may be modified based on emerging data. These include, but are not limited to, those listed in Table 13: consider therapeutic substitutions for these medications.


It is strongly recommended that patients avoid using drugs that are substrates of Cytochrome P450 (CYP) 3A4 and/or Bcrp transporter or that have a low therapeutic index because concentrations of these substrates may be increased by GSK2798745. If co-administration of these medications is necessary, investigators should monitor subjects for loss of efficacy or consider substitutions of these medications. The list may be modified based on emerging data. These include,but are not limited to, those listed in Table 14: consider therapeutic substitutions for these medications.


Patients must avoid using a strong Cytochrome P450 (CYP) 3A4 inhibitor (Table 10) from screening to the follow up visit. GSK2798745 systemic concentrations will be monitored to detect any drug interactions with moderate CYP3A4 inhibitors or PgP inhibitors (see SPM for a detailed list). Digoxin is permitted, but with close monitoring as described above to maintain the therapeutic window.

Table 1013 Strong inducers/inhibitors of CYP3A, Pgp and BcrpCYP3A4 Inhibitors







Immunosuppressant cyclosporine

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Table 14 Sensitive and narrow therapeutic index substrates of CYP3A, Pgp and Bcrp




Antidepressant: aripiprazole, buspirone


Analgesics alfentanil, fentanyl,

Antimigraine agents ergotamine, eletriptan

Antiarrhythmics disopyramide, propafenone, quinidine


lovastatin, rosuvastatin, cerivastatin (removed from the market in the US in 2001)

Others alfentanil, boceprevir, carbamazepine, cafergot, cilostazol, cocaine, dapsone, dexamethasone, dextromethorphan, docetaxel, domperidone, eplerenone, , finasteride, gleevec, , irinotecan, lidocaine, methadone, nateglinide, nevirapine, ondansetron, pimozide, propranolol, quetiapine, risperidone, romidepsin, salmeterol, sildenafil, sorafenib, sunitinib, tamoxifen, taxol, telaprevir, terfenadine, torisel, trazodone, vemurafenib, vincristine, zaleplon, ziprasidone, zolpidem

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PREVIOUS TEXT


Procedure



Day 1 Day 2 Day 3

Day 410

Follow up11


Pre

-do

se

0 h

0.25

h

0.5

h

0.75

h 1 h

1.5

h

2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

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X X X







Troponin X X X X XDigoxin Level6 X X XCSSR (Suicidality Assessment) X X XAppetite Assessment X X X

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Procedure



Day 1 Day 2 Day 3

Day 410

Follow up11


Pre

-do

se

0 h

0.25

h

0.5

h

0.75

h 1 h

1.5

h

2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

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Meal7 XStudy Treatment Dosing XPharmacodynamic Blood Sample12 X X X X X X X X X X X

Pharmacokinetic Sampling8 X X X X X X X X X X X X X X X XPharmacogenetic (PGx) Sample9







conducted on the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 4) will not be performed.11. Follow-up assessments will not be conducted in patients in Cohort 4 who continue to the repeat-dose Treatment Period.12. Pharmacodynamic (PD) blood sampling to be drawn in Cohort 4 only and may be modified based on emerging data. See Section 6.7

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-45 to -1 days



X


X X




X X

Serum -hCG (women)

X X X


X

Hema/Chem/Urinalysis Tests21

X X X X X X X X X


X X X X

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-45 to -1 days




DLco and DLno X6 X8

OGTT9 X6 X8

PD Blood Sample X16 X16


AVP18 X19 X20


X Continuous X


PGx14 for subjects who consent (only): collect one PGx sample after the start of dosing, preferably on Day 1Discharge15 XOutpatient Visit X X1. ECGs will be obtained in triplicate.2. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose3. Can be conducted in a separate screening visit. If the subject has had an Echocardiogram or Holter within the last 3 months, it does not need to be repeated for participation in

this particular cohort.4. Pulse oximetry will be conducted once daily excluding screening.


collected on Day 1. Urine samples will also be collected and pooled over the time intervals of 0-12 hours, 12-24 hours, and 24-48 hours starting on Day 14.8. Assessment will be conducted once during Days 12 through 14.9. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT (fasting), and 60, 120 and 180min post-OGTT10. For a twice daily dosing regimen, PK sampling times will be adjusted and detailed accordingly in the SPM.11. Serial sampling (actual timpoints will be assigned after data from previous cohort(s) are available). Blood samples for AVP concentrations may be drawn along with PK samples

(details will be outlined in the SPM).

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12. Timing of food with respect to dosing will be determined based on information gained with previous cohorts. 13. Based on the PK profile obtained in Cohort 1, the Day 2 dose may be skipped to estimate the time invariance in PK.14. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample15. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 16 or 17 will be conducted on

the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 17) will not be performed.16. PD serial blood samples will be drawn only prior to dose administration and may be drawn at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours after the administration of drug to

correspond with PK sampling. Actual timepoints could change based on the PK sampling timepoints.17. Transcriptomic/Metabolomic Blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1. 18. To be performed only in male healthy volunteers in the second repeat dose period of Cohort 3 only. Sequential blood samples for the measurement of AVP concentrations, Na

levels, and serum osmolality will be outlined in the SPM19. Assessment may be conducted within 14 days of the start of treatment period and prior to Day -3.20. Assessment will be conducted once during days 9 through 1121. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported

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Table 13 Repeat Dose Heart Failure Patients (Cohort 4)



X


Serum -hCG (women) X XHema/Chem/Urinalysis Tests16 X X X X X X XTroponin X X X X XNT-Pro BNP and ANP X X X X X




Dyspnoea Scale Scoring X X X8 X

DLco and DLno X6 X8



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day of discharge. If discharge is on Day 9, any assessments designated for Day 10 will not be conducted.15. Transcriptomic/Metabolomic blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.16. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported

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REVISED TEXT


Procedure



Day 1 Day 2 Day 3

Day

410

Day 5-7

Follow up11

(7-14 days post dost)

Pre

-do

se

0 h

0.25

h 0.5 h

0.75

h 1 h

1.5 h 2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h


X X X



HIV, Hep B and Hep C Screen XHema/Chem/UrinalysisTests X X X X XUrine Collection5 X5 X5 - - - - - - - - - X5 X5 - Troponin X X X XDigoxin Level6 X X XCSSR (Suicidality Assessment) X X XAppetite Assessment X X XMeal7 X

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Procedure



Day 1 Day 2 Day 3

Day

410

Day 5-7

Follow up11


Pre

-do

se

0 h

0.25

h 0.5 h

0.75

h 1 h

1.5 h 2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

Study Treatment Dosing XPD PharmacodyamicBloodSample12 X X X X X X X X X X X X X X X X

Pharmacokinetic Sampling8 X X X X X X X X X X X X X X X XMRI14 X15 X16



DLco and DLno X15

Audiometry X15



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1. ECGs to be obtained in triplicate.2. Vital signs will be taken in triplicate.3. Assessment may be conducted 7 days prior to Day 14. Telemetry is conducted from 1 hour pre-dose until 24 hours post-dose.5. Urine samples for metabolite identification will be collected and pooled over the time

intervals of 0-12 hours, 12-24 hours and 24-48 hours for Cohort 1 only. A single predose urine sample will also be collected for Cohort 1 only. Output measurements will be determined from samples collected over the 0-12 hour and the 12-24 hour intervals (combined). No urine samples will be collected for Cohort 2. Output measurements will be determined from urine samples collected over the 0-12 hour and the 12-24 hour intervals (combined) for Cohort 4.


study medication. In Cohort 4, subject’s meals will not be restricted. Any other meal instructions will be detailed in the SPM

8. PK sampling time points may be modified based on emerging data. For HF subjects, serial sampling for Day 1 timepoints only. The 72-hour sample may not be obtained in all groups, based on the estimated half-life of the drug.

9. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample.10. Discharge may be at 48 or 72 hours following the last dose of study medication,

depending on the half-life of the drug. Assessments indicated for either Day 3 or 4 will be conducted on the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 4) will not be performed.

11. Follow-up assessments will not be conducted in patients in Cohort 4 who continue to the repeat-dose Treatment Period.12. Pharmacodynamic (PD) blood sampling to be drawn in Cohort 4 only and may be modified based on emerging data. See Section 6.713. For HF patients only who are unable to breath into the alcohol breath test apparatus or if technique issues occur urine ethanol test will be performed14. Cohort 4 only. MRI scans will require scanning pre- and post- constant workload exercise which can be conducted on separate consecutive days.15. Cohort 4 only. Assessment may be conducted within 7 days of Day 1 of the single-dose treatment period.16. Cohort 4 only, only in case of technical failure of scanning at Day -1.

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Table 1612 Repeat Dose Healthy Volunteers (Cohort 3)

Day: Screening -1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Follow-upVisit Window (relative to Day 1)

-45 to -1 days



X


X X




X X


X


X X X X X X X X X


X X X X



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Day: Screening -1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Follow-upVisit Window (relative to Day 1)

-45 to -1 days


DLco and DLno X6 X8

OGTT9 X6 X8



AVP18 X19 X20


X Continuous X


PGx14 for subjects who consent (only): collect one PGx sample after the start of dosing, preferably on Day 1Discharge15 XOutpatient Visit X X1. ECGs will be obtained in triplicate.2. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose3. Can be conducted in a separate screening visit. If the subject has had an Echocardiogram or Holter within the last 3 months, it does not need to be repeated for participation in

this particular cohort.4. Pulse oximetry will be conducted once daily excluding screening.


collected on Day 1. Urine samples will also be collected and pooled over the time intervals of 0-12 hours, 12-24 hours, and 24-48 hours starting on Day 14.8. Assessment will be conducted once during Days 12 through 14.9. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT (fasting), and 60, 120 and 180min post-OGTT10. For a twice daily dosing regimen, PK sampling times will be adjusted and detailed accordingly in the SPM.11. Serial sampling (actual timpoints will be assigned after data from previous cohort(s) are available). Blood samples for AVP concentrations may be drawn along with PK

samples (details will be outlined in the SPM).12. Timing of food with respect to dosing will be determined based on information gained with previous cohorts. 13. Based on the PK profile obtained in Cohort 1, the Day 2 dose may be skipped to estimate the time invariance in PK.14. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample

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15. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 16 or 17 will be conducted on the day of discharge. If discharge is at 48 hours, assessments indicated for 72 hours (Day 17) will not be performed.

16. PD serial blood samples will be drawn only prior to dose administration and may be drawn at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours after the administration of drug to correspond with PK sampling. Actual timepoints could change based on the PK sampling timepoints.

17. Transcriptomic/Metabolomic Blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1. 18. To be performed only in male healthy volunteers in the second repeat dose period of Cohort 3 only. Sequential blood samples for the measurement of AVP concentrations, Na

levels, and serum osmolality will be outlined in the SPM19. Assessment may be conducted within 14 days of the start of treatment period and prior to Day -3.20. Assessment will be conducted once during days 9 through 1121. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported

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Table 1713 Repeat Dose Heart Failure Patients (Cohort 4)



X

12-lead ECG X2 X X X X X X X XTelemetry3 XVital Signs/ Oximetry4 X5 X X X X X X X X X X XRespiratory Rate X X X X XEchocardiogram XAudiometry X XUrine Drug/Alcohol Breath Test6 X

Serum -hCG (women) X XHema/Chem/Urinalysis Tests17 X X X X X X XTroponin X X X X X




AE Assessment ContinuousC-SSRS (Suicidality Assessment) X X XAppetite Assessment X X XConcomitant Medication Review X XConstant Workload Exercise X8


DLco and DLno X6 X8

Orthopnea X X X X8 XMRI X8, 18

T/M Blood Samples X16 XPK Blood Sample 10 X11 X X X X X X9 X12 X X

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PD Blood Sample X9 X XStudy Treatment Dosing13 X X X X X X X


Discharge15 XOutpatient Visit X

1. Subjects will return to the unit after a washout period of ≥7 days for the repeat-dose treatment period. Day 1 will then be the first day of dosing for the RD dose period.2. ECGs to be obtained in triplicate.3. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose4. Pulse oximetry will be conducted once daily.5. Vital signs will be taken in triplicate.6. Assessment may be conducted within 7 days of Day 1 of the repeat-dose treatment period. Urine ethanol test will be performed if the patient is unable to perform the

alcohol breath test due to breathlessness7. Only for subjects taking digoxin.8. Assessment may be completed between Days 5 to 7.9. Serial sampling will occur on days 7. Timepoints will be pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 4h, 5h, 6h, 8h, and 12h, and 15h10. On days 2 through 6 PK samples will be drawn pre dose11. On day 1 PK samples will be drawn predose, 2h, and 12h 12. On day 8, PK samples will be drawn at 24h and 36h post last dose 13. Meals will not be restricted in this cohort14. Informed consent for optional PGx (Pharmacogenetics) research must be obtained before collecting a sample.15. Discharge will be either 48 or 72 hours after the last dose of study medication. Assessments noted as either Day 9 or 10 will be conducted on the day of discharge. 16. Transcriptomic/Metabolomic blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.17. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported18. MRI scans being performed during treatment period will require scanning pre and post exercise which can be conducted on separate consecutive days.

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Section 6.2 Demographic/Medical History Assessments

ADDED TEXT

The following demographic parameters will be captured: year of birth, gender, race and ethnicity.

Medical/medication/alcohol/ smoking history will be assessed as related to the eligibility criteria listed in Section 4.2. Cardiovascular medical history/risk factors will also be assessed at baseline.

For subjects with HF only, the following items pertaining to medical and medicationhistory will be recorded/assessed at Screening (See eligibility criteria listed in Section 4.2):

Confirm heart failure class

Onset and type of symptoms

Years since diagnosis of HF

Degree of exercise intolerance: distance/ stairs/time prior to breathlessness

Presence of orthopnoea and/or paroxysmal nocturnal dyspnoea

Peripheral oedema: presence and height beyond ankle; presence of anasarca, recent weight gains, level of peripheral pitting edema

Significant past medical history including onset, aetiology, and results of any recent relevant investigations of heart failure, as applicable

Medication history


ADDED TEXT


A brief physical examination will include assessments of the skin, lungs, cardiovascular system, and abdomen (liver and spleen). In subjects with HF, peripheral oedema (height and severity above ankle, non-dependent limb), as well as JVD and presence of anasarca should be monitored.



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Section 6.4.1 Blood Sample Collection for Pharmacokinetics

ADDED TEXT

Blood samples for pharmacokinetic analysis of GSK2798745 and for circulatingmetabolite analysis will be collected at the time points indicated in Section 6.1 Time and Events Table. Metabolite identification samples will not be collected in Cohort 4.The actual date and time of each blood sample collection will be recorded. The timing of PK samples may be altered and/or PK samples may be obtained at additional time points to ensure thorough PK monitoring.

Details of PK sample collection, processing, storage, and shipment are provided in the SPM.


PREVIOUS TEXT

As recently reviewed by [Sladek, 2013], the osmotic regulation of arginine-vasopressin (AVP) secretion may involve the TRPV channel. Studies in TRPV4 knock-out mice demonstrated that plasma concentrations of AVP were reduced following a hypertonic saline challenge, suggesting that TRPV4 is necessary for the normal response to changes in osmotic pressure and functions as an osmotic sensor in the central nervous system [Liedtke, 2003]. Studies in rats indicate that administration of a TRPV4 antagonist, GSK2193874, attenuates the elevation of AVP concentration in the blood following a NaCl challenge.

In defining the target engagement of the drug, it is of interest to determine whether GSK2798745 can similarly inhibit AVP secretion in response to an osmotic stimulus in man. Many studies have demonstrated that an infusion of hypertonic saline (3% to 5%) provides an adequate stimulus for AVP secretion, and that the challenge was well tolerated [Seckl, 1989; Manner, 1989; Pedersen, 2001; Graffe, 2012; Jensen, 2013]. In studies that employed a 3% hypertonic saline challenge [Pedersen, 2001; Graffe, 2012; Jensen, 2013], the increases in plasma osmolality and plasma sodium concentration were within the normal range. The infusion procedure used in this study will be based on the methods described in these studies that utilized the lower 3% saline challenge [Pedersen, 2001; Graffe, 2012; Jensen, 2013].

Subjects in the higher dose group(s) of Cohort 3 will undergo a NaCl challenge within the 14 days prior to the start of drug administration and once again during the Day 9 to Day 11 period. Subjects will receive an intravenous infusion of 2.7% saline. Subjects will receive 7 mL/kg of hypertonic saline, which represents 14.7 g of sodium or 503 mOsm for a 70 kg individual, through a peripheral intravenous line inserted into the antecubital vein. Infusions would be limited to no more than 2 hours.

Subjects will be maintained in a supine position prior to the start of the infusion and throughout the infusion period. Blood samples for the measurement of AVP concentrations will be obtained prior to the start of the infusion and at periodic intervals

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after the start of the saline infusion. In addition, plasma osmolality and plasma sodium concentrations will be determined periodically.


REVISED TEXT



Subjects in the higher second dose group(s) of Cohort 3 (if initiated) will undergo a NaCl challenge within the 14 days prior to the start of drug administration and once again during the Day 9 to Day 11 period. Subjects will receive an intravenous infusion of 2.7% saline. Subjects will receive 7 mL/kg of hypertonic saline, which represents 14.7 g of sodium or 503 mOsm for a 70 kg individual, through a peripheral intravenous line inserted into the antecubital vein. Infusions would be limited to no more than 2 hours.




PREVIOUS TEXT

An ex vivo cell-based impedance assay has been established with cultured human endothelial cells to measure the pharmacodynamic effect of varying concentrations of the TRPV4 channel blocker, GSK2798745 , in samples of whole blood [Kustermann, 2014].

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By obtaining serial blood samples at times correlated with samples taken for pharmacokinetic analysis of drug concentration, a pharmacokinetic-pharmacodynamic relationship will be established.

In Cohort 3, blood samples will be obtained on Days 1 and 14 prior to dose administration and at the times designated for pharmacokinetic sampling through the first 12 hours. If pharmacokinetic samples are specified to be taken at intervals of less than 30 minutes, those timepoints may be skipped when obtaining samples for pharmacodynamic analysis. It is anticipated that samples will be at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours after the administration of drug. Timepoints may be adjusted during the study based on emerging data.

In Cohort 4, blood samples will be obtained on Days 1 of the single-dose period. Samples will be obtained prior to dose administration and at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12 hours. Timepoints may be adjusted during the study based on emerging data.


REVISED TEXT


In Cohort 3, blood samples will be obtained on Days 1 and 14 prior to dose administration and at the times designated for pharmacokinetic sampling. If pharmacokinetic samples are specified to be taken at intervals of less than 30 minutes, those timepoints may be skipped when obtaining samples for pharmacodynamic analysis. It is anticipated that samples will be at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12, 24 and 48 hours after the administration of drug. Timepoints may be adjusted during the study based on emerging data.

In Cohort 4, blood samples will be obtained on Days 1 of the single-dose period and onday 7 of the repeat dose period. Samples will be obtained prior to dose administration and at 0.25, 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10 and 12, 15hours, 24, and 48 hours. Timepoints may be adjusted during the study based on emerging data.


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Section 6.9.1 Exercise Tolerance for Cohort 3 and 4

PREVIOUS TEXT



Peak oxygen uptake will be measured at baseline and during the repeat-dose treatment period as outlined in the Time and Events Tables for Cohorts 3 and 4 (Section 6.1). Patients will perform a maximal exercise test limited by symptoms such as dyspnea or fatigue on a cycle ergometer. After a rest period, the workloads will be increased in a step-wise or ramp pattern in 3-minute stages. An additional constant work-rate period may also be incorporated in the exercise testing. Full details of the exercise protocol and planned measurements are included in the SPM. Breath by breath gas exchange and heart rate will be measured throughout exercise. During each 3-minute workload, Borg RPE and blood pressure will be obtained. Peak work rate will be determined. At peak exercise, heart rate, blood pressure, and Borg RPE will be recorded. Gas exchange endpoints will include peak VO2, Ve/VCO2 slope, RER, exercise time, and VO2 and time at ventilatory threshold.

REVISED TEXT



Peak oxygen uptake will be measured at baseline and during the repeat-dose treatment period as outlined in the Time and Events Tables for Cohorts 3 and 4 (Section 6.1). Patients will perform a maximal exercise test limited by symptoms such as dyspnea or fatigue on a cycle ergometer. After a rest period, the workloads will be increased in a step-wise or ramp pattern in 3-minute stages. An additional constant work-rate period may also be incorporated in the exercise testing. Full details of the exercise protocol and planned measurements are included in the SPM. Breath by breath gas exchange and heart rate will be measured throughout exercise. During each 3-minute workload, Borg RPE and blood pressure will be obtained. Peak work rate will be determined. At peak exercise, heart rate, blood pressure, and Borg RPE will be recorded. Gas exchange endpoints will include peak VO2, Ve/VCO2 slope, RER, exercise time, and VO2 and time at ventilatory threshold.

Maximal Exercise Test Limited by Dyspnoea or Fatigue

Subjects will first be asked to perform a maximal exercise test limited by dyspnoea or fatigue on a cycle ergometer. Baseline measurements (heart rate, blood pressure,

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respiratory rate, and breath-by-breath gas exchange measurements: oxygen consumption (VO2), ventilation/carbon dioxide production (VE/VCO2) slope, respiratory exchange ratio (RER), and VO2 and time at ventilator threshold) will be performed with subjects seated on the cycle ergometer for approximately 3 minutes. Subjects will then be asked to commence cycling. The workloads will be increased in a stepwise fashion until volitional fatigue. Breath-by-breath gas measurements and heart rate will be recorded throughout exercise. At the end of each 3-minute workload, Borg Rating of Perceived Exertion (RPE) (See Appendix 3) and blood pressure will be obtained. At peak exercise, heart rate, blood pressure, Borg RPE, and breath-by-breath gas exchange measurements including peak VO2 will be recorded. Respiratory rate at the end of exercise will also be recorded.

Constant Workload Exercise Test

Subjects will be asked to perform cycle exercise for 10 minutes at a workload between 75% to 80% of the peak work rate achieved during the maximal exercise to exhaustion test described above. Breath-by-breath gas measurements (VO2, RER, exercise time) and heart rate will be measured throughout the exercise period. Blood pressure and respiratory rate will also be measured.

Full details of the exercise test protocols are included in the SPM.

Section 6.9.2 DLco and DLno

ADDED TEXTIn Cohort 4, DLco and DLno measurements will be made after each MRI scan has been completed and prior to the constant workload exercise test.

ADDED SECTIONS

Section 6.9.3 Magnetic Resonance Imaging (Cohort 4)

Each subject in Cohort 4 will have four MRI exams; pre- and post- constant workload exercise both at baseline (before single dose) and after steady state has been reached during repeat dosing. If a technical failure occurs at the baseline scan, a baseline rescan may be attempted prior to repeat dosing following washout of the single dose. If a technical failure occurs during the pre-exercise MRI scan during repeat dosing, a rescan of the pre-exercise MRI scan may be attempted schedule permitting.

Section 6.9.3.1 Subject Scanning Procedures

Subjects will undergo MRI scanning at Addenbrooke’s Radiology Department using a 1.5 T system. On attendance at the Radiology Department, subjects will be placed supine in the scanner and will be prepared for intravenous contrast agent administration.

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The scanning protocol will include routine localisers followed by T1 measurement sequences and a dynamic time series. The T1 measurement sequences will consist of 3D spoiled gradient echo (3D-SPGR) with constant echo time (TE) and repetition time (TR) and varying flip angles. The dynamic series will also consist of 3D-SPGR acquisitions with constant TE, TR and constant flip angle. Contrast agent will be administered intravenously as a bolus using a power injector during the dynamic series. Scanner gains will be controlled manually between all of the 3D-SPGR acquisitions to allow subsequent DCE-MRI parameter quantification.



Section 6.9.3.2 Phantom Scanning

In order to maximise image quality and data consistency throughout the study, regular scanning of a Eurospin TO5 phantom will be required. The same scanning protocol as used in study subjects will be repeated using the phantom at intervals of no less than once every 6 weeks and immediately after any software or hardware upgrade or maintenance.

Section 6.9.3.3 Data Transfer

All MRI data will be anonymised at site and transferred to Bioxydyn Limited. Details for image transfer will be provided in the Imaging Manual.

Section 6.9.3.4 DCE-MRI Data Analysis

All DCE-MRI data analysis will take place at Bioxydyn Limited. DCE-MRI data will be corrected for breathing motion using registration and the lungs will be segmented from the image volume. An arterial input function (AIF) will be extracted from the pulmonary artery or right ventricle; if not available a population AIF will be substituted. The ‘extended Tofts’ tracer kinetic model will be applied to the data to provide measurements of ktrans (capillary transfer coefficient of contrast agent - /min), ve (leakage space - fraction) and vp (plasma volume - fraction). Median values of ktrans and ve will be provided from each lung (total lung, apical and basal) for subsequent statistical analysis. All values will be corrected for the individual’s haematocrit value. If not available, a typical haematocrit value will be assumed. Normalized proton density will additionally be measured using patient muscle as an internal reference.

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Section 6.9.4 Oral Glucose Tolerance Test

DELETED TEXT

The oral glucose tolerance test (OGTT) measures the body's ability to use glucose, the body's main source of energy. It has been demonstrated in preclinical models that TRPV4 inhibition improves glucose utilization [Ye, 2012]. A dose-dependent change in this parameter could offer a simpler metric to assess target engagement. On days specified in Section 6.1, subjects in Cohorts 3 and 4 will be administered a fasting 75g oral glucose tolerance test (OGTT) approximately 2h after dosing to assess the PD effects of GSK2798745 and placebo. The 75g glucose OGTT must be completely consumed in 5 minutes. Breakfast will be omitted on days when the OGTT is administered. A fasting blood sample will be collected prior to OGTT, and blood sampling will then be collected every 60min up to 180min.

Section 6.9.5 Dyspnea Scale Scoring

DELETED TEXT

A standardised, validated absolute dyspnoea 5-point Likert scale and a visual analog scale [Mebazaa, 2009] will be administered before and after bicycle exercise in the seated position, at the time points in Section 6.1. With more modest dyspnea, the change when supine will be captured. Additional details are in the SPM.

Section 9.2.2 Cohort 3 (Healthy Subject Repeat Dose)

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The repeat dose cohort will study 2 dose levels. 8 subjects (6 on active and 2 on placebo) will be assigned to each dose level. All subjects will also participate in an exercise capacity and provide Peak VO2 related measures, along with DLco and DLno

REVISED TEXT

The repeat dose cohort maywill study 2 dose levels. Up to 8 subjects (6 on active and 2 on placebo) will be assigned to each dose level. All subjects will also participate in an exercise capacity and provide Peak VO2 related measures, along with DLco and DLno

Section 9.2.3 Cohort 4 (Heart Failure Patients Single and Repeat Dose)

PREVIOUS TEXT

The main goal of this cohort is to study safety and tolerability, targeting a total sample size of 15 subjects with stable heart failure [randomized 4:1 (treatment:placebo)]. Sample size for the exploratory measurements is based on feasibility, utilizing baseline as comparator, and is supported by the following information regarding peak VO2

measurement and DLco.

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REVISED TEXT

The main goal of this cohort is to study safety and tolerability in the patient population,, targeting a total sample size of 15 18 subjects with stable heart failure [randomized 41:1 (treatment:placebo)]. Sample size for the exploratory measurements is based on feasibility, utilizing baseline as comparator, and is supported by the following information regarding interstitial volume (ve) measured by DCE-MRIpeak VO2

measurement and DLco.

PREVIOUS TEXT

Section 9.2.4 Peak Oxygen Update VO2

A 1.5mL/kg/min improvement in peak VO2 compared to placebo treatment would be considered a borderline clinically significant result [Bensimhon, 2008]. The estimated between subject variance for peak VO2 is SD=1.5.

So for the current study with 15 subjects randomised 12:3 to GSK 2798745 and placebo comparing the predose and post dose treatment, if we assume within-subject variability SDw=1.2 (30% reduction in variability), the half-width of 95% CI for the mean difference in peak VO2 between baseline and the end of treatment is estimated to be 0.54 for 12 subjects on treatment. That is, if the observed mean peak VO2 difference between baseline and the end of treatment is 1.5mL/kg/min, then the 95% CI would be (0.96, 2.0).

REVISED TEXT

Section 9.2.4 Interstitial volume (ve)Peak Oxygen Uptake VO2

The difference of interstitial volume ve between smokers and non-smokers was 0.06 in the paper by Naish in 2008. The estimation on the variance of change from baseline ve is 0.041 (SD). If we assume same effect size between smokers and non-smoker is to be expected in our study between placebo and treatment at the end of study and same between subject variance of change from baseline ve is valid for the study population, the half-width of 95% CI for the mean difference in change from baseline ve between treatment and placebo is estimated to be 0.05. That is, if the observed mean change from baseline ve difference between treatment and placebo is 0.06, then the 95% CI would be (0.01, 0.11).

A1.5mL/kg/min improvement in peak VO2 compared to placebo treatment would be considered a borderline clinically significant result [Bensimhon, 2008]. The estimated between subject variance for peak VO2 is SD=1.5.

So for the current study with 15 subjects randomised 12:3 to GSK 2798745 and placebo comparing the predose and post dose treatment, if we assume within-subject variability SDw=1.2 (30% reduction in variability), the half-width of 95% CI for the mean difference in peak VO2 between baseline and the end of treatment is estimated to be 0.54 for 12 subjects on treatment. That is, if the observed mean

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peak VO2 difference between baseline and the end of treatment is 1.5mL/kg/min, then the 95% CI would be (0.96, 2.0).

DELETED TEXT

Section 9.2.5 DLco

An increase in diffusion of carbon dioxide (Dlco) by 15% is of clinical benefit in chronic heart failure patients [Agostoni, 2006]. While the between subject variance for the % predicted endpoint demonstrates an SD of 22%, given our use of baseline measures for each individual patient, we assume within-subject variability SDw=14.4%. For a sample size of 12 subjects per arm, the half-width of 95% CI for the mean difference in DLco between baseline and the end of treatment is estimated to be 6.7%. That is, if the observed mean DLco difference between baseline and the end of treatment is 15%, then the 95% CI would be (9.3%, 21.7%).

Section 9.2.6 Sample Size Sensitivity

To be conservative, assuming within-subject variability SDw=1.5, for a sample size of 12 subjects per arm, the half-width of 95% CI for the mean difference in peak VO2 between baseline and the end of treatment is estimated to be 0.67. That is, if the observed mean peak VO2 difference between baseline and the end of treatment is 1.5ml/kg/min, the 95% CI would be (0.83, 2.17).


ADDED TEXT







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An informal interim review may be performed after approximately 6 patients in Cohort 4 (~3 treatment, ~3 placebo) complete all required MRI scanning.

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Peak VO2 (and other physiologic variables measure the exercise testing) will be fitted using a mixed effect model with repeated measures, with time included as a fixed effect and baseline as a covariate. Point estimates and associated 95% confidence intervals will be constructed to provide a plausible range of values for the true comparisons of interest, such as the mean difference between baseline of GSK2798745 and the end of treatment. If model assumptions appear grossly violated, alternative methods (e.g., use of raw data with log transformation or non-parametric methods) will be considered.

Other PD endpoints (including DLco and DLno and AVP) may be statistically analysed, using a model appropriate to the study design and data. All PD data will be descriptively summarised and presented in graphical displays, as appropriate and will be described in more detail in the Reporting and Analysis Plan (RAP).

REVISED TEXT


DCE-MRI measurements ve, and ktransPeak VO2 (and other physiologic variables measure to be explored including endpoints measured duringthe exercise testing) will be fitted using a mixed effect model with repeated measures, with time includedtreatment as a fixed effect and baseline as a covariate. Point estimates and associated 95% confidence intervals will be constructed to provide a plausible range of values for the true comparisons of interest, such as the mean difference between baseline of GSK2798745 and the end of treatmentand placebo. If model assumptions appear grossly violated, alternative methods (e.g., use of raw data with log transformation or non-parametric methods) will be considered.

Other PD endpoints (including DLco and DLno and AVP) may also be statistically analysed, using a model appropriate to the study design and data. All PD data will be descriptively summarised and presented in graphical displays, as appropriate and will be described in more detail in the Reporting and Analysis Plan (RAP).

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ADDED TEXT







Louden C, Morgan DG, 2001. Pathology and pathophysiology of drug-induced arterial injury in laboratory animals and its implications on the evaluation of novel chemical entities for human clinical trials. Pharm. Tox., 89:150-170.

Marckmann P, Skov L, Rossen K, Dupont A, Damholt MB, Heaf JG, et al. Nephrogenic systemic fibrosis: suspected causative role of gadodiamide used for contrast-enhanced magnetic resonance imaging. J Am Soc Nephrol. 2006 Sep;17(9):2359–62.Mebazaa, A; Pang,P; Tavares, M et al. The impact of early standard therapy on dyspnoea in patients with acute heart failure: the URGENT-dyspnoea study. European Heart Journal, 2009.

Mendoza SA et al., 2010. TRPV4-mediated endothelial Ca2 influx and vasodilation in response to shear stress. Am. J. Physiol. Heart. Circ. Physiol. 298: H466–H476, 2010.

Metz AL et al., 1991. Acute cardiovascular toxicity induced by an adenosine agonist-antihypertensive in beagles. Tox Path, 19:98-107.


Tesfamariam B, DeFelice AF, 2007. Endothelial injury in the initiation and progression of vascular disorders. Vasc. Pharmacol., 46:229-237.

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Willette RN et al., 2007. Systemic activation of the transient receptor potential vanilloid subtype 4 channel causes endothelial failure and circulatory collapse: Part 2. J. Pharm Exp. Ther., 326:443-452.

APPENDIX 5 Treatment Regimens

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Treatment Regimen

Description

A 0.25mg GSK2798745 Fasted solution (single dose)B TBD mg GSK2798745 Fasted suspension (single dose)C TBD mg GSK2798745 Fasted suspension (single dose)D TBD mg GSK2798745 Fasted suspension (single dose)G TBD GSK2798745 Fasted suspension (single dose)H TBD GSK2798745 Fasted capsule (single dose)I TBD GSK2798745 Fed capsule (single dose)P Matched Placebo suspension(s) (single dose)


Treatment Regimen

Description

select from A-D TBD mg GSK2798745 suspension/capsule (repeat dose )select from G-I TBD mg GSK2798745 suspension/capsule (repeat dose)

P matched Placebo suspension/capsule(s) (repeat dose)

REVISED TEXT


Treatment Regimen

Description

A 0.25mg GSK2798745 Fasted solution (single dose)B 1.0 TBD mg GSK2798745 Fasted suspension (single dose)C 5.0 TBD mg GSK2798745 Fasted suspension (single dose)D 12.5 TBD mg GSK2798745 Fasted suspension (single dose)G 5.0 mg TBD GSK2798745 Fasted suspension (single dose)H 5.0 mg TBD GSK2798745 Fasted capsule (single dose)I 5.0 mg TBD GSK2798745 Fed capsule (single dose)P Matched Placebo suspension(s) (single dose)

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Table 20 Planned Treatment Regimen Table for Cohorts 3

Treatment Regimen

Description

J select from A-D TBD mg GSK2798745 suspension/capsule (repeat dose )K select from G-I TBD mg GSK2798745 suspension/capsule (repeat dose)

P1 matched Placebo suspension/capsule(s) (repeat dose)

Table 21 Planned Treatment Regimen Table for Cohort 4

Treatment Regimen

Description

L 2.4mg GSK2798745 capsule (single/repeat dose )M TBD mg GSK2798745 capsule (single/repeat dose)P2 matched Placebo suspension/capsule(s) (repeat dose)

APPENDIX 6

ADDED TEXT

Preliminary Analyses of PK data from Cohorts 1 through 3

The PK data from single and repeat doses of GSK2798745 administered as suspension in fasted state to healthy volunteers in cohorts 1 through 3 was used to build a preliminary population PK (POP-PK) model. The analysis was performed using non-linear mixed effects modelling approach in NONMEM software (ref). A 2-comp PK model with lag time in absorption adequately described the observed PK data and was used for simulation. The POP-PK model parameters are listed in Table 20 below.

Table 25: POP PK parameters for GSK2798745

Parameter Population Estimate Between subject variability (%CV)Absorption Rate – Ka (1/hr) 0.38 9.3

Clearance – CL/F (L/hr) 18.2 34.5Apparent Vol of distribution of central compartment – V2/F (L)

59 53.8

Intercompartment Clearance – Q/F (L/hr)

32.4 NE

Apparent Vol of distribution of peripheral compartment – V3/F (L)

197 NE

Lag Time – ALAG (hr) 0.22 NEF (bioavailability) NE 14.1

Residual variability – (% Coeff of Var)

28.0

NE = not estimated

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AMENDMENT 5

Where this Amendment Applies

This amendment applies to all sites.

Summary of Amendment Changes

This amendment allows for the change to a multi-centre study, changes to the eligibility criteria, and changes to the design of Cohort 4.


Title

DELETED TEXT

A single-centre sponsor un-blinded, placebo-controlled study to evaluate the safety, tolerability, pharmacokinetics, and pharmacodynamics of single and repeat, ascending doses of GSK2798745 in healthy subjects and stable heart failure patients.

Table of Contents

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AVP Arginine Vasopressin

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SECTION 2 Objectives and Endpoints

DELETED TEXT

Exploratory

Characterize the effects of repeat administration of GSK2798745 on exercise capacity in healthy subjects and subjects with HF

Characterize the effects of repeat administration of GSK2798745 on DLco and DLno in healthy subjects and stable heart failure patients


Characterize the effect of repeat administration of GSK2798745 on DCE-MRI measures of pulmonary oedema and vascular permeability at rest (Cohort 4 only)

Characterize the effect of repeat administration of GSK2798745 on DCE-MRI measures of pulmonary oedema and vascular permeability following exercise (Cohort 4 only)

Characterize the effect of repeat administration of GSK2798745 on exercised-induced changes in DCE-MRI measures of pulmonary oedema and vascular permeability (Cohort 4 only)

Examine plasma volume and MRI physical properties influenced by the tissue microenvironment relaxation rate, and proton density in heart failure patients before and after repeat administration of GSK2798745 (Cohort 4 only)

Determine the effect of repeat administration of GSK2798745 on the




Difference in the interstitial volume (ve) and exchange rate (ktrans) before and after repeat dosing measured at rest (before exercise).

Difference in the interstitial volume (ve) and exchange rate (ktrans) before and after repeat dosing measured following exercise

Difference in the exercise-induced change (post-exercise minus pre-exercise) in interstitial volume (ve) and exchange rate (ktrans) before and after repeat dosing


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Exploratoryplasma concentrations of NT-pro BNP in heart failure patients (Cohort 4 only)


SECTION 3.1 Study Schematic

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Cohort 2(n=12)



5mg




Safety, tolerability, PK, exploratory tests for feasibility: exercise parameters, lungpermeability (DLco and DLno), AVP

5mg


Cohort 4(n=18)(1:1 ratio)

Single dose, Repeat dosecapsule for 7 days


2.4mg (initial)





participating in Cohort 4

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REVISED TEXT









Cohort 2(n=12)



5mg





5mg


Cohort 4(n=18up to 24)(1:1 ratio)



2.4mg (initial)


Any new dose investigated in Cohort 3 will be selected so as to not intentionally exceed the daily AUC of 0.448µg*h/mL or Cmax of 0.049 µg/mL in any individual.




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Section 3.2.2 Healthy Subjects Repeat Dose – Cohort 3

DELETED TEXT

This cohort is constructed as a sponsor un-blinded, randomized, placebo-controlled, 14-day repeat-dose evaluation of GSK2798745. It is planned that up to two doses may be studied based on the safety, tolerability and the systemic exposure data obtained from the single dose studies. A sufficient number of subjects will be enrolled such that up to 16 subjects in a ratio of 6:2 (treatment: placebo) may be evaluated in each planned cohort. However, only 4 subjects completing 14 days of dosing will be deemed sufficient to move into either the next cohort of 8 healthy volunteers or directly into heart failure patients (Cohort 4) without any further testing in healthy volunteers. The effect of TRPV4 channel inhibition on exercise performance will be evaluated. In addition, arginine vasopressin (AVP) concentration may also be evaluated by a hypertonic NaCl challenge. The osmotic regulation of AVP secretion may involve the TRPV4 channel. [Sladek, 2013] Glucose tolerance will also be evaluated by an oral glucose tolerance test (OGTT). In a TRPV4 knock-out preclinical model, body weight was reduced in the setting of improved glucose handling [Ye, 2012]. These measurements may represent tools to estimate target engagement in these early studies.



Treatment Period Each subject will take part in only one treatment period and will be dosed for 14 days.



and DLno); see Section 6.1 for PD assessments. If the second dose group of Cohort 3 is initiated, subjects

will have an exploratory measurement on Day -1 (within day -14 and day -3) and between Days 9-11. AVP may be measured in response to a NaCl challenge, see Section 6.1.

Follow-up 7-14 days after last study drug administration. If warranted, additional follow-up visits may be scheduled.

Total Duration Screening within 45 days + treatment (17 days) + follow up of 7-14 days = approximately 10 weeks

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Section 3.2.3 Heart Failure Patients Single and Repeat Dose – Cohort 4

PREVIOUS TEXT

Cohort 4 will be a sponsor un-blinded, randomized, placebo-controlled study in patients with heart failure including a single dose and a subsequent 7-day repeat dose evaluation of GSK2798745. This cohort will enroll patients with mild to moderate dyspnea on exertion (i.e., NYHA Class II or III), thereby including those likely to have some excess fluid in their lungs. The dose will be based on the safety, tolerability and PK data obtained from the single-dose and repeat-dose healthy subject cohorts. A sufficient number of patients will be enrolled such that 18 patients are planned be randomized to the cohort with a treatment:placebo ratio of 1:1. The main focus of this cohort is the evaluation of safety, pharmacokinetics and tolerability, including safety biochemical testing and assessment of physical examination throughout the 7 days and follow-up.

In addition, we will evaluate the potential effect of GSK2798745 in patients with heart failure. Respiratory rates will be quantified over time. Orthopnea will be assessed at the beginning and end of the study. Maximal exercise capacity will be assessed using a standardized bicycle protocol (see Section 6.9.1), prior to repeat-dose administration and during the latter part of the 7 days of treatment. Degree of ventilation (VE) can be compared to the ambient level of CO2, a ratio, which is notably high in HF patients, and possibly reduced with the test agent. This will be supplemented by measures of gas transfer (carbon monoxide and nitric oxide; DLco and DLno) before and immediately after exercise both at baseline and after reaching steady state with GSK2798745. DCE MRI measures of pulmonary edema (ve) and vascular permeability (ktrans) will also be assessed at baseline and after reaching steady state with GSK2798745. The profound elevation in pulmonary venous pressures during exercise (often observed in HF patients) will likely exacerbate the movement of fluid into the lung tissue, and thereby decrease alveolar: vascular membrane gas transfer. We hypothesize a TRPV4 blocker will limit this exercise-induced change.

Dose considerations: The maximum daily dose in the repeat dosing period will not intentionally exceed a daily exposure of AUC of 0.448 μg*hr/mL or a Cmax of 0.049 μg/mL in any individual. Based on data from the previous cohorts, the dose will be 2.4mg in the first group utilizing the capsule formulation administered with or without food. (See Section 3.4.5 for dose rationale). Based on the emerging PK data from these HF patients, the dose level may be modified if necessary as long as the dose would not intentionally exceed a daily exposure of AUC of 0.448 μg*hr/mL or a Cmax of 0.049 μg/mL in any individual. Further, two dose levels of GSK2798745 may be evaluated in Cohort 4 and additional patients may be recruited for a second dose group to allow up to a maximum of 14-day repeat dosing.

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Treatment Period


Single dose period: subjects will be in-house from Day -1 until all post-dose assessments have been completed (72hrs post dose).

Subjects will return to the unit after a washout period ≥7 days for the 7-day repeat dose period.

Repeat dose period: subjects will be in-house from Day -1 until all post-dose assessments have been completed (72hrs post final dose).


Subjects will have exploratory measurements on Day -1 and between Days 5 through 7. The measurements will include exercise testing and lung permeability assay (DLco; DLno), (see Section 6.1 for PD assessments), DCE-MRI and NT-pro BNP levels will also be measured throughout the period.


If warranted, additional follow-up visits may be scheduled.Total Duration Screening within 35 days + single dose period + washout + 7-

day repeat dose treatment period + follow up (7-14 days after last dose of study medication) = approximately 10 weeks

REVISED TEXT

Cohort 4 will be a sponsor un-blinded, randomized, placebo-controlled study in patients with heart failure including a single dose and a subsequent 7-day repeat dose evaluation of GSK2798745. If the first 6 HF subjects tolerate the single dose safely, the single dose portion of Cohort 4 may be discontinued for the remaining HF subjects

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enrolled into this cohort. The decision to remove the single dose period from Cohort 4 for the remaining subjects enrolled will be made by the Study Team including the Medical Monitor and the Investigator based on safety and tolerability once 6 patients with HF have completed both the single and repeat dose sessions. This cohort will enroll patients with mild to moderate dyspnea on exertion (i.e., NYHA Class II or III), thereby including those likely to have some excess fluid in their lungs. The dose will be based on the safety, tolerability and PK data obtained from the single-dose and repeat-dose healthy subject cohorts. A sufficient number of patients will be enrolled such that 18 patients subjects and possibly up to 24 subjects are planned be randomized to the cohort with a treatment or: placebo at a ratio of 1:1. The main focus of this cohort is the evaluation of safety, pharmacokinetics and tolerability, including safety biochemical testing and assessment of physical examination throughout the 7 days and follow-up.

In addition, we will evaluate the potential pharmacodynamic effect of GSK2798745 in patients with heart failure. Respiratory rates will be quantified over time. Orthopnea will be assessed at the beginning and end of the study. Maximal exercise capacity will be assessed using a standardized bicycle protocol (see Section 6.9.1), prior to repeat-dose administration and during the latter part of the 7 days of treatment. Degree of ventilation (VE) can be compared to the ambient level of CO2, a ratio, which is notably high in HF patients, and possibly reduced with the test agent. This will be supplemented by measures of gas transfer (carbon monoxide and nitric oxide; DLco and DLno) before and immediately after exercise both at baseline and after reaching steady state with GSK2798745. DCE MRI measures of pulmonary edema (ve) and vascular permeability (ktrans) will also be assessed at baseline and after reaching steady state with GSK2798745. The profound elevation in pulmonary venous pressures during exercise (often observed in HF patients) will likely exacerbate the movement of fluid into the lung tissue, and thereby decrease alveolar: vascular membrane gas transfer. We hypothesize a TRPV4 blocker will limit this exercise-induced change. DCE MRI measures of pulmonary edema (ve) and vascular permeability (ktrans) will also be assessed at baseline and after reaching steady state with GSK2798745.

Dose considerations: The maximum daily dose in the repeat dosing period will not intentionally exceed a daily exposure of AUC of 0.448 μg*hr/mL or a Cmax of 0.049 μg/mL in any individual. Based on data from the previous cohorts, the dose will be 2.4mg in the first group utilizing the capsule formulation administered with or without food. (See Section 3.4.5 for dose rationale). Based on the emerging PK data from these HF patients, the dose level may be modified if necessary as long as the dose would not intentionally exceed a daily exposure of AUC of 0.448 μg*hr/mL or a Cmax of 0.049 μg/mL in any individual. Further, two dose levels of GSK2798745 may be evaluated in Cohort 4 and additional patients may be recruited for a second dose group to allow (up to a maximum of 14-day repeat doseing administration).

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Treatment Period

For single dose (at least the first 6 subjects) followed by repeat dose

Single dose period: subjects (at least the first 6 subjects) will be in-house from Day -1 until all post-dose assessments have been completed (72hrs post dose).

Subjects will return to the unit after a washout period ≥7 to 21days for the 7-day repeat dose period.

Repeat dose period: subjects will be in-house from Day -1 until all post-dose assessments have been completed on Day 8 (72hrs post final dose).


Subjects will have exploratory measurements on Day -1 and between Days 5 through 7. The measurements will include exercise testing and lung permeability assay (DLco; DLno), (see Section 6.1 for PD assessments), DCE-MRI and NT-pro BNP levels will also be measured throughout the period.


If warranted, additional follow-up visits may be scheduled.Total Duration Subjects participating in SD and RD: Screening within 35

days + single dose period + washout + 7-day repeat dose treatment period + follow up (7-14 days after last dose of study medication) = approximately 10 weeks

Subjects participating in RD only: Screening within 35 days + 7-day repeat dose treatment period + follow up (7-14 days after last dose of study medication) = approximately 8 weeks

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PREVIOUS TEXT




In Cohort 4, 18 patients will be randomized to treatment at a treatment:placebo ratio of 1:1. An additional dose group of approximately 18 subjects may be randomized to GSK2798745 or placebo to gain additional safety, tolerability, pharmacokinetic and pharmacodynamic information if needed.


REVISED TEXT




In Cohort 4, 18 subjects patients will be randomized to treatment at a treatment:placebo ratio of 1:1. If required, an additional number of subjects (up to 24 total) will be randomized in Cohort 4. An additional separate dose group of approximately 18 subjects may be randomized to GSK2798745 or placebo to gain additional safety, tolerability, pharmacokinetic and pharmacodynamic information if needed.


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PREVIOUS TEXTA summary of potential risk factors and the strategy to mitigate them is provided in Table 11.







Dogs (3-month study): At 10 mg/kg/day, arterial lesions were observed in 2 dogs.One male: Epididymides (bilateral) -arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation,

One female: Urinary bladder -arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation,





Myocardial toxicity





A coverage of ≥50 fold will be maintained in humans from the no-effect dose (10mg/kg/day), and dosing will not exceed the average daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.


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A coverage of ≥50 fold will be maintained in humans, and dosing will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.








None A coverage of ≥50-fold will be maintained in humans to the NOAEL dose (10mg/kg/day) as exposures will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.






Rats (micronucleus and comet study): Convulsions observed at ≥600mg/kg/day. Convulsions were not related to Cmax, nor occurred at any predictable time

Subjects with a history of seizure disorder or stroke will be excluded from the study.

A coverage of >50-fold will be maintained in humans and dosing will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior

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from dose administration.


(exclusion #5) to 10/31/2014.









None A coverage of ≥50-fold will be maintained in human to the no effect dose (10mg/kg/day) as exposures will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.



Gadobutrol (Gd) (Gadovist; Bayer) has produced nephrogenic systemic fibrosis and fibrosing dermopathy in patient swith renal disease. The incidence of NSF in dialysis and end-stage renal disease patients when exposed to Gd is in the range 3-5% [Marckmann, 2006; Kuo, 2008; However, there are no reports of NSF in subjects with normal renal function [Perazella, 2007; Deo, 2007; Chewning, 2007; Thomsen, 2006]. It is concluded that subjects dependent on dialysis and those with estimated



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glomerular filtration rate (eGFR) <30mL/min (chronic kidney disease stage 4/5) are at risk of developing NSF on exposure to Gd [Perazella, 2007].





NaCl (2.7%) challenge

Side effects of a peripheral infusion of NaCl may include pain or redness at the infusion site and peripheral vein trauma (vein thrombosis, or extravasation of hypertonic saline and local tissue damage). Subjects may also experience symptoms such as significant thirst, generalized swelling, and an increase in urine output, Additionally, plasma concentrations of sodium may be elevated for a period of time. In extremely rare cases, seizure or central pontine myelinolysis could theoretically occur which could lead to permanent neurologic impairment. This risk is based on reports in patients experiencing rapid reversal of significant baseline hyponatremia and not in health volunteers with normal baseline sodium level. These risks are being mitigated by the utilization of the lower concentration of saline (2.7%) in comparison to the literature, and ensuring normal sodium levels at screening. Females are also being excluded from participation as their risk of neurologic complications may be greater than in males [Ayus, 1992].

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REVISED TEXT





Vascular lesions Dogs (4-week study): At 30mg/kg/day, 2 males had arterial lesionsOne male: Heart – Coronary artery inflammation; Thymus –Arteriole inflammation with fibroplasia One male: Epididymides – Artery degeneration/necrosis with inflammationDogs (3-month study): At 10 mg/kg/day, arterial lesions were observed in 2 dogs.One male: Epididymides (bilateral) -arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation, One female: Urinary bladder -arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation,Rats: No vascular lesions observed.

None The arterial lesions noted in heart, thymus and epididymides cannot be monitored directly. There is currently no human translation biomarker or understanding of the underlying mechanism.Since these effects cannot be monitored directly in clinical studies, a coverage of ≥50-fold will be maintained in humans from the no-effect dose (10mg/kg/day), and dosing will not exceed the average daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.A ≥30-fold margin will be maintained from the no-effect dose (3mg/kg/day); exposure will not exceed an AUC of 0.448hr*ug/mL and/or Cmax of 0.049ug/mL in any individual dosed after 10/31/2014.

Myocardial toxicity





A coverage of ≥50 fold will be maintained in humans from the no-effect dose (10mg/kg/day) observed in dogs., and dosing will not exceed the average daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.



Dogs (4-week study): At 30 mg/kg/day one male terminated early (Day 6) due to poor clinical condition. Another male had


A coverage of ≥50 fold will be

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transient whole body shaking on Days 8 and 9.


maintained in humans, and dosing will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.








None A safety margin of ≥ 40 fold will be maintained from the no effect dose (10 mg/kg/day) in rats. A coverage of ≥50-fold will be maintained in humans to the NOAEL dose (10mg/kg/day) as exposures will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.






Rats (micronucleus and comet study): Convulsions observed at ≥600mg/kg/day. Convulsions were not related to Cmax, nor

Subjects with a history of seizure disorder or stroke within the last 5

A coverage of >50-fold will be maintained in humans and dosing will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of

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occurred at any predictable time from dose administration.


years will be excluded from the study. (exclusion #5)

0.09ug/mL in subjects dosed prior to 10/31/2014.









None A safety margin of ≥ 40 fold will be maintained from the no effect dose (10 mg/kg/day) in rats. A coverage of ≥50-fold will be maintained in human to the no effect dose (10mg/kg/day) as exposures will not exceed the daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.



Gadobutrol (Gd) (Gadovist; Bayer) has produced nephrogenic systemic fibrosis and fibrosing dermopathy in patient swith renal disease. The incidence of NSF in dialysis and end-stage renal disease patients when exposed to Gd is in the range 3-5% [Marckmann, 2006; Kuo, 2008; However, there are no reports of NSF in subjects with normal renal



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function [Perazella, 2007; Deo, 2007; Chewning, 2007; Thomsen, 2006]. It is concluded that subjects dependent on dialysis and those with estimated glomerular filtration rate (eGFR) <30mL/min (chronic kidney disease stage 4/5) are at risk of developing NSF on exposure to Gd [Perazella, 2007].





NaCl (2.7%) challenge

Side effects of a peripheral infusion of NaCl may include pain or redness at the infusion site and peripheral vein trauma (vein thrombosis, or extravasation of hypertonic saline and local tissue damage). Subjects may also experience symptoms such as significant thirst, generalized swelling, and an increase in urine output, Additionally, plasma concentrations of sodium may be elevated for a period of time. In extremely rare cases, seizure or central pontine myelinolysis could theoretically occur which could lead to permanent neurologic impairment. This risk is based on reports in patients experiencing rapid reversal of significant baseline hyponatremia and not in health volunteers with normal baseline sodium level. These risks are being mitigated by the utilization of the lower concentration of saline (2.7%) in comparison to the literature, and ensuring normal sodium levels at screening. Females

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Study Procedure Potential risksare also being excluded from participation as their risk of neurologic complications may be greater than in males [Ayus, 1992].


PREVIOUS TEXT


A sufficient number of patients diagnosed with HF will be enrolled such that approximately 18 subjects complete dosing and critical assessments. Approximately eighteen additional patients with HF may be enrolled to allow for evaluation of an additional dose level for up to a maximum of 14 days of repeat dosing.



REVISED TEXT


A sufficient number of patients diagnosed with HF will be enrolled such that approximately 18 subjects complete dosing and critical assessments. If required, the total number of subjects may be increased to 24. Approximately eighteen additional subjects patients with HF may be enrolled in a separate group to allow for evaluation of an additional dose level for up to a maximum of 14 days of repeat dosing.

For single dosing (Cohorts 1 and 2), if subjects prematurely discontinue the study, additional subjects may be enrolled as replacement subjects and assigned to the same treatment sequence, at the discretion of the Sponsor in consultation with the Investigator. Replacement subjects in Cohort 1 of the study will not necessarily start on the lowest

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dose level tested within the cohorts and may start on the dose intended for the withdrawn subject.


Section 4.2 Eligibility Criteria

PREVIOUS TEXT

Protocol waivers or exemptions are not allowed with the exception of immediate safety concerns. Therefore, adherence to the study design requirements, including those specified in the Time and Events table (Section 6.1), is essential and required for study conduct.

4.2.1 Inclusion Criteria for Healthy Subject Cohorts (1-3)

Specific information regarding warnings, precautions, contraindications, adverse events, and other pertinent information on the GSK investigational product or other studytreatment that may impact subject eligibility is provided in the IB.






(inclusive)


Non-childbearing potential defined as pre-menopausal females with a documented tubal ligation or hysterectomy for this definition, “documented” refers to the outcome of the Investigator's/designee’s review of the subject's medical history for study eligibility, as obtained via a verbal interview with the subject or from the subject’s medical records; or postmenopausal defined as 12 months of spontaneous amenorrhea. In

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questionable cases a blood sample with simultaneous follicle stimulating hormone (FSH) > 40MlU/ml and estradiol < 40pg/ml (<147pmol/L) is confirmatory.





QTc < 450msec; or


4.2.2 Inclusion Criteria for Heart Failure Patients (Cohort 4)









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4.2.3 Exclusion Criteria That Apply to All Subjects (Healthy Subjects and HF Patients in Cohorts 1-4)










7. Current smokers

Criteria based Upon Diagnostic Assessments:






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Other Criteria



3. Patients who are taking greater than 40 mg of atorvastatin or greater than 20 mg of simvastatin (HF patients only)



4.2.4 Exclusion Criteria for Subjects with Heart Failure (Cohort 4)








m. Intracranial aneurysm clips (except Sugita) or other metallic objects

n. Intra- orbital metal fragments that have not been removed

o. Pacemakers or other implanted cardiac rhythm management/monitoringdevices and non-MR conditional heart valves

p. Inner ear implants

q. History of claustrophobia

REVISED TEXT

Protocol waivers or exemptions are not allowed with the exception of immediate safety concerns. Therefore, adherence to the study design requirements, including those specified in the Time and Events table (Section 6.1), is essential and required for study conduct.

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4.2.1 Inclusion Criteria for Healthy Subject Cohorts (1-3)







(inclusive)







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QTc < 450msec; or


4.2.2 Inclusion Criteria for Heart Failure Patients (Cohort 4)

1. Established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) Class II or III on stable heart failure therapy for at least 1 3 months and was not hospitalized for HF during the last three months











4.2.3 Exclusion Criteria That Apply to All Subjects (Healthy Subjects and HF Patients in Cohorts 1-4)


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6. History of aActive ulcer disease or GI bleeding

7. Current smokers

Criteria based Upon Diagnostic Assessments:






Other Criteria



3. Patients who are taking greater than 40 mg of atorvastatin or greater than 20 mg of simvastatin (HF patients only)



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4.2.4 Exclusion Criteria for Subjects with Heart Failure (Cohort 4)








r. Intracranial aneurysm clips (except Sugita) or other metallic objects

s. Intra- orbital metal fragments that have not been removed

t. Pacemakers or other implanted cardiac rhythm management/monitoringdevices and non-MR conditional heart valves

u. Inner ear implants

v. History of claustrophobia

Section 5.2 Treatment Assignment

PREVIOUS TEXT

Subjects will be assigned to treatments in accordance with the randomization schedule generated by Discovery Biometrics, prior to the start of the study, using validated internal software. See Appendix 5 for treatment regimen tables.

ADDED TEXT

Subjects will be assigned to treatments in accordance with the randomization schedule generated by Discovery Biometrics, prior to the start of the study, using validated internal software. Once additional centres are initiated, subjects in Cohort 4 will be randomized into the study by means of an interactive web response (IWR) i.e. RAMOS NG, to receive one of the treatment regimens. See Appendix 5 for treatment regimen tables.

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Section 5.3.2 QTc Withdraw Criteria

PREVIOUS TEXT

5.3.2.1 Healthy Subjects (Cohorts 1 thru 3)


QTcF > 500msec

or


If a subject has underlying bundle branch block the following withdrawal criteria should be used instead:





5.3.2.2 Heart Failure Patients (Cohort 4)


A subject who meets any of the criteria below will be withdrawn from the study. The same QT correction formula (QTcF) should be used to determine inclusion and discontinuation for any individual subject throughout the study.

QTcF > 500msec



If a subject has underlying bundle branch block the following withdrawal criteria should be used instead.




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REVISED TEXT

5.3.2.1 Healthy Subjects (Cohorts 1 thru 3)



or


If a subject has underlying bundle branch block the following withdrawal criteria should be used instead:





5.3.2.2 Heart Failure Patients (Cohort 4)







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Section 5.10.2 Permitted Medications for Heart Failure Patients

PREVIOUS TEXT

Paracetamol at doses of 2 grams/day is permitted for use any time during the study. The patients may stay on all regular prescription medications. Patients on a simvastatin dose of 20 mg or less or an atorvastatin dose of 40 mg or less may be enrolled in this study. Digoxin is permitted, but with close monitoring to maintain the therapeutic window. Other concomitant medication may be considered on a case by case basis by the Investigator in consultation with the GSK Medical Monitor.

REVISED TEXT

Paracetamol at doses of 2 grams/day is permitted for use any time during the study. The patients may stay on all regular prescription medications (except those listed in Section 5.10.4). Patients on a simvastatin dose of 20 mg or less or an atorvastatin dose of 40 mg or less may be enrolled in this study. Digoxin is permitted, but with close monitoring to maintain the therapeutic window. Other concomitant medication may be considered on a case by case basis by the Investigator in consultation with the GSK Medical Monitor.

Section 5.10.4 Prohibited Medications and Non-Drug Therapies for Heart Failure Patients

PREVIOUS TEXT


Patients must avoid using drugs that are strong inhibitors or inducers of Cytochrome P450 (CYP) 3A4, p-glycoprotein (Pgp) or Bcrp transporters because they may alter GSK2798745. The list may be modified based on emerging data. These include, but are not limited to, those listed in Table 13: consider therapeutic substitutions for these medications.


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It is strongly recommended that patients avoid using drugs that are substrates of Cytochrome P450 (CYP) 3A4 and/or Bcrp transporter or that have a low therapeutic index because concentrations of these substrates may be increased by GSK2798745. If co-administration of these medications is necessary, investigators should monitor subjects for loss of efficacy or consider substitutions of these medications. The list may be modified based on emerging data. These include,but are not limited to, those listed in Table 14: consider therapeutic substitutions for these medications.


Table 13 Strong inducers/inhibitors of CYP3A, Pgp, and Bcrp








Table 14 Sensitive and narrow therapeutic index substrates of CYP3A, Pgp and Bcrp









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Lovastatin, rosuvastatin, Cerivastatin (removed from the market in the US in 2001)


REVISED TEXT


Patients must avoid using drugs that are strong inhibitors or inducers of Cytochrome P450 (CYP) 3A4, or p-glycoprotein (Pgp) or Bcrp transporters because they may alter GSK2798745. The list may be modified based on emerging data. These include, but are not limited to, those listed in Table 13: consider therapeutic substitutions for these medications.

GSK2798745 has a weak potential for CYP3A4 inhibition. There is the likelihood that the concentrations of drugs that are substrates of CYP3A4 may be increased. HMG-CoA reductase inhibitors such as atorvastatin and simvastatin are examples of CYP3A4 substrates that are likely to be taken by the eligible subjects as part of their medications. The concentrations of these statins will be monitored during the study.


It is strongly recommended that patients avoid using drugs that are substrates of Cytochrome P450 (CYP) 3A4 and PgP/or Bcrp transporter or that have a low therapeutic index because concentrations of these substrates may be increased by GSK2798745. If co-administration of these medications is necessary, investigators should monitor subjects for loss of efficacy or consider substitutions of these medications. The list may be modified based on emerging data. These include, but are not limited to, those listed in Table 14: consider therapeutic substitutions for these medications.


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Table 13 Strong inducers/inhibitors of CYP3A, and PgPp, and Bcrp








Table 14 Sensitive and narrow therapeutic index substrates of CYP3A, and PgPp and Bcrp










Lovastatin, rosuvastatin, Cerivastatin (removed from the market in the US in 2001)


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PREVIOUS TEXT


Procedure



Day 1 Day 2 Day 3

Day 410

Day 5-

7

Follow up11


Pre

-do

se

0 h

0.25

h 0.5 h

0.75

h 1 h

1.5 h 2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36h

48 h

72 h


X X X



HIV, Hep B and Hep C Screen XHema/Chem/UrinalysisTests X X X X XUrine Collection5 X5 X5 - - - - - - - - - X5 X5 - Troponin X X X XDigoxin Level6 X X XCSSR (Suicidality Assessment) X X XAppetite Assessment X X XMeal7 XStudy Treatment Dosing X

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Procedure



Day 1 Day 2 Day 3

Day 410

Day 5-

7

Follow up11


Pre

-do

se

0 h

0.25

h 0.5 h

0.75

h 1 h

1.5 h 2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36h

48 h

72 h

PD BloodSample12 X X X X X X X X X X X X X X XPharmacokinetic Sampling8 X X X X X X X X X X X X X X X X

MRI14 X15 X16



DLco and DLno X15

Audiometry X15

Pharmacogenetic (PGx) Sample9



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intervals of 0-12 hours, 12-24 hours and 24-48 hours for Cohort 1 only. A single predose urine sample will also be collected for Cohort 1 only. Output measurements will be determined from samples collected over the 0-12 hour and the 12-24 hour intervals (combined). No urine samples will be collected for Cohort 2. Output measurements will be determined from urine samples collected over the 0-12 hour and the 12-24 hour intervals (combined) for Cohort 4.

6. Only for subjects who are receiving digoxin.7. Subjects will be fasted from midnight of Day-1 until 4 hours after the first dose of study

medication. In Cohort 4, subjects meals will not be restricted Any other meal instructions will be detailed in the SPM

8. PK sampling time points may be modified based on emerging data. For HF subjects, serial sampling for Day 1 timepoints only. The 72-hour sample may not be obtained in all groups, based on the estimated half-life of the drug.



11. Follow-up assessments will not be conducted in patients in Cohort 4 who continue to the repeat-dose Treatment Period.12. Pharmacodynamic (PD) blood sampling to be drawn in Cohort 4 only and may be modified based on emerging data. See Section 6.713. For HF patients only who are unable to breath into the alcohol breath test apparatus or if technique issues occur urine ethanol test will be performed14. Cohort 4 only. MRI scans will require scanning pre- and post- constant workload exercise which can be conducted on separate consecutive days.15. Cohort 4 only. Assessment may be conducted within 7 days of Day 1 of the single-dose treatment period.16. Cohort 4 only, only in case of technical failure of scanning at Day -1.




-45 to -1 days



X


X X

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-45 to -1 days





X X

Serum -hCG (women)

X X X


X

Hema/Chem/Urinalysis Tests2 X X X X X X X X X


X X X X



DLco and DLno X6 X8

OGTT9 X6 X8



AVP18 X19 X20


X Continuous X

PK Blood Sample10 X11 X X X X X X11 X X X

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-45 to -1 days


Study Treatment Dosing12 X X13 X X X X X X X X X X X X


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8. Assessment will be conducted once during Days 12 through 14.9. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT (fasting), and 60, 120 and 180min post-OGTT10. For a twice daily dosing regimen, PK sampling times will be adjusted and detailed accordingly in the SPM.11. Serial sampling (actual timpoints will be assigned after data from previous cohort(s) are available)..12. Timing of food with respect to dosing will be determined based on information gained with previous cohorts. 13. Based on the PK profile obtained in Cohort 1, the Day 2 dose may be skipped to estimate the time invariance in PK.14. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample15. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 16 or 17 will be


to correspond with PK sampling. Actual timepoints could change based on the PK sampling timepoints.17. Transcriptomic/Metabolomic Blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1. 18. To be performed only in male healthy volunteers in the second repeat dose period of Cohort 3 only. Sequential blood samples for the measurement of AVP

concentrations, Na levels, and serum osmolality will be outlined in the SPM19. Assessment may be conducted within 14 days of the start of treatment period and prior to Day -3.20. Assessment will be conducted once during days 9 through 11



Re-Admission to Unit XBrief Physical Examination X X X X X X X X X X XWeight X X X X X X X X X X X X

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Medical/Medication/Drug/Alcohol/Smoking History

X

12-lead ECG X2 X X X X X X X XTelemetry3 XVital Signs/ Oximetry4 X5 X X X X X X X X X X XRespiratory Rate X X X X XEchocardiogram XAudiometry X XUrine Drug/Alcohol Breath Test6 X

Serum -hCG (women) X XHema/Chem/Urinalysis Tests17 X X X X X X XTroponin X X X X X




AE Assessment ContinuousC-SSRS (Suicidality Assessment) X X XAppetite Assessment X X XConcomitant Medication Review X XConstant Workload Exercise X8


DLco and DLno X8

Orthopnea X X X X8 XMRI X8, 18

T/M Blood Samples X16 XPK Blood Sample 10 X11 X X X X X X9 X12 X XPD Blood Sample X9 X XStudy Treatment Dosing13 X X X X X X X

PGx14 for subjects who consent (only): collect one PGx sample after the start of dosing (preferably on

Day 1 [if not previously collected during the SD treatment period] Discharge15 XOutpatient Visit X

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1. Subjects will return to the unit after a washout period of ≥7 days for the repeat-dose treatment period. Day 1 will then be the first day of dosing for the RD dose period.2. ECGs to be obtained in triplicate.3. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose4. Pulse oximetry will be conducted once daily.5. Vital signs will be taken in triplicate.6. Urine ethanol test will be performed if the patient is unable to perform the alcohol breath test due to breathlessness7. Only for subjects taking digoxin.8. Assessment may be completed between Days 5 to 7.9. Serial sampling will occur on days 7. Timepoints will be pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 4h, 5h, 6h, 8h, 12h, and 15h10. On days 2 through 6 PK samples will be drawn pre dose11. On day 1 PK samples will be drawn predose, 2h, and 12h 12. On day 8, PK samples will be drawn at 24h and 36h post last dose 13. Meals will not be restricted in this cohort14. Informed consent for optional PGx (Pharmacogenetics) research must be obtained before collecting a sample.15. Discharge will be 72 hours after the last dose of study medication. Assessments noted as either Day 9 or 10 will be conducted on the day of discharge. 16. Transcriptomic/Metabolomic blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.17. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported18. MRI scans being performed during treatment period will require scanning pre and post exercise which can be conducted on separate consecutive days.

REVISED TEXT

Table 15 Single Dose Healthy Subjects and Heart Failure Patients (Cohorts 1,2 and 4)

Procedure



Day 1 Day 2 Day 3

Day 410

Day 5-7

Follow up11


Pre

-do

se

0 h

0.25

h 0.5 h

0.75

h 1 h

1.5 h 2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

Admission to Unit XInformed Consent/Demographics XFull Physical Examination X

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Procedure



Day 1 Day 2 Day 3

Day 410

Day 5-7

Follow up11


Pre

-do

se

0 h

0.25

h 0.5 h

0.75

h 1 h

1.5 h 2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

Brief Physical Examination X X XWeight X X X X X X X Medical/Medication/Drug/Alcohol/ Smoking History

X X X



HIV, Hep B and Hep C Screen XHema/Chem/UrinalysisTests X X X X X XUrine Collection5 X5 X5 - - - - - - - - - X5 X5 - I/Os Continuous XTroponin X X X XDigoxin Level6 X X XCSSR (Suicidality Assessment) X X XAppetite Assessment X X XMeal7 XStudy Treatment Dosing XPD BloodSample12 X X X X X X X X X X X X X X XPharmacokinetic Sampling8 X X X X X X X X X X X X X X X XMRI X145 X156



DLco and DLno and Spirometry X145

Dyspnoea X14

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Procedure



Day 1 Day 2 Day 3

Day 410

Day 5-7

Follow up11


Pre

-do

se

0 h

0.25

h 0.5 h

0.75

h 1 h

1.5 h 2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

72 h

NT-proBNP X XAudiometry X145



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intervals of 0-12 hours, 12-24 hours and 24-48 hours for Cohort 1 only. A single predose urine sample will also be collected for Cohort 1 only. Output measurements will be determined from samples collected over the 0-12 hour and the 12-24 hour intervals (combined). No urine samples will be collected for Cohort 2. Metabolite identification samples will not be collected in Cohort 4. Output measurements will be determined from urine samples collected over the 0-12 hour and the 12-24 hour intervals (combined) for Cohort 4.


study medication. In Cohort 4, subjects meals will not be restricted Any other meal instructions will be detailed in the SPM

8. PK sampling time points may be modified based on emerging data. For HF subjects, serial sampling for Day 1 timepoints only and some of those timepoints may also be utilized to collect samples to determine concentrations of other medications (e.g. atorvastatin and/or simvastatin). See SRM for detailed information. The 72-hour sample may not be obtained in all groups, based on the estimated half-life of the drug.



11. Follow-up assessments will not be conducted in patients in Cohort 4 who continue to the repeat-dose Treatment Period.12. Pharmacodynamic (PD) blood sampling to be drawn in Cohort 4 only and may be modified based on emerging data. See Section 6.713. For HF patients only who are unable to breath into the alcohol breath test apparatus or if technique issues occur urine ethanol test will be performed14. Cohort 4 only. MRI scans will require scanning pre- and post- constant

workload exercise which can be conducted on separate consecutive days.15. Cohort 4 only. Assessment may be conducted within 7 days of Day 1 of the single-dose treatment period.16. Cohort 4 only, only in case of technical failure of scanning at Day -1.




-45 to -1 days


Admission to Unit XInformed Consent XDemographics X

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-45 to -1 days


Complete Physical Exam./Smoking History

X


X X




X X

Serum -hCG (women)

X X X


X


X X X X X X X X X


X X X X



DLco and DLno X6 X8

OGTT9 X6 X8


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-45 to -1 days



AVP18 X19 X20


X Continuous X



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8. Assessment will be conducted once during Days 12 through 14.9. OGTT will be conducted in the fasted state. Blood samples for OGTT will be drawn at pre-OGTT (fasting), and 60, 120 and 180min post-OGTT10. For a twice daily dosing regimen, PK sampling times will be adjusted and detailed accordingly in the SPM.11. Serial sampling (actual timpoints will be assigned after data from previous cohort(s) are available)..12. Timing of food with respect to dosing will be determined based on information gained with previous cohorts. 13. Based on the PK profile obtained in Cohort 1, the Day 2 dose may be skipped to estimate the time invariance in PK.14. Informed consent for optional PGx (Pharmacogenetic) research must be obtained before collecting a sample15. Discharge will be 48 or 72 hours after the last dose of study medication, depending on the half-life of the drug. Assessments indicated for either Day 16 or 17 will be


to correspond with PK sampling. Actual timepoints could change based on the PK sampling timepoints.17. Transcriptomic/Metabolomic Blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1. 18. To be performed only in male healthy volunteers in the second repeat dose period of Cohort 3 only. Sequential blood samples for the measurement of

AVP concentrations, Na levels, and serum osmolality will be outlined in the SPM19. Assessment may be conducted within 14 days of the start of treatment period and prior to Day -3.20. Assessment will be conducted once during days 9 through 11


Days Screening(up to 35

days prior to Day 1)17

-11,17 117 2 3 4 5 6 7 8 9 10 Follow-up (7-14 days after the last dose)

Re-Admission to Unit XBrief Physical Examination X X X X X X X X X X X

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Full Physical Examination XWeight X X X X X X X X X X X X XMedical/Medication/Drug/Alcohol/Smoking History

X X

12-lead ECG X X2 X X X X X X X X XTelemetry3 XVital Signs/ Oximetry4 X X5 X X X X X X X X X X XRespiratory Rate X X X X XEchocardiogram X XAudiometry X17 X XUrine Drug/Alcohol Breath Test6 X X

Serum -hCG (women) X X XHema/Chem/Urinalysis Tests167 X X X X X X X X XTroponin X X X X X X X

NT-Pro BNP and ANP X X X X X X



I/Os X X X X X X XAE Assessment ContinuousC-SSRS (Suicidality) X X X XAppetite Assessment X X XCon Med Review X XConstant Workload Exercise X17 X8


Dyspnoea Scale Scoring X17 X X X8 X XDLco and DLno and Spirometry X17 X8

Orthopnea X X X X8 XMRI X17 X8, 18

T/M Blood Samples X156 X

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PK Blood Sample 10 X11 X X X X X X9 X12 X XPD Blood Sample X9 X XStudy Treatment Dosing13 X X X X X X X



1. First 6 sSubjects will return to the unit after a washout period of ≥7-21 days for the repeat-dose treatment period. Day 1 will then be the first day of dosing for the RD dose period.

2. ECGs to be obtained in triplicate.3. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose4. Pulse oximetry will be conducted once daily.5. Vital signs will be taken in triplicate.6. Urine ethanol test will be performed if the patient is unable to perform the alcohol breath test due to breathlessness7. Only for subjects taking digoxin.8. Assessment may be completed between Days 5 to 7.9. Serial sampling will occur on days 7. Timepoints will be pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 4h, 5h, 6h, 8h, 12h, and 15h. Some of these timepoints may be

utilized to collect samples to determine concentrations of other medications (e.g., atorvastatin and/or simvastatin). See the SRM for detailed information.10. On days 2 through 6 PK samples will be drawn pre dose11. On day 1 PK samples will be drawn predose, 2h, and 12h. For subjects who do not participate in the single dose period, PK samples will be drawn at the

following timepoints: pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 5h, 8h, 12h and 15 h. Some of these timepoints may also be utilized to collect samples to determine concentrations of other medications (e.g. atorvastatin and/or simvastatin). See SRM for detailed information.

12. On day 8, PK samples will be drawn at 24h and 36h post last dose and just prior to discharge (sample time will be noted in the eCRF). 13. Meals will not be restricted in this cohort14. Informed consent for optional PGx (Pharmacogenetics) research must be obtained before collecting a sample.15. Discharge will be 72 hours after the last dose of study medication. Assessments noted as either Day 9 or 10 will be conducted on the day of discharge. 16. Transcriptomic/Metabolomic blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.17. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported18. MRI scans being performed during treatment period will require scanning pre and post exercise which can be conducted on separate consecutive days.17. For subjects who do not participate in the single dose session, screening, day -1 and day 1 will reflect timepoints shown in Table 15. MRI, Constant and Maximal

Exercise, DLco/DLno and Dyspnea scale scoring can be completed within 7 days prior to Day -1.

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A brief physical examination will include assessments of the skin, lungs, cardiovascular system, and abdomen (liver and spleen). In subjects with HF, peripheral oedema (height and severity above ankle, non-dependent limb), as well as JVD and presence of anasarca should be monitored


The examinations will be performed by a qualified, licensed medical professional(i.e., physician, physician assistant, or nurse practitioner).

REVISED TEXT


A brief physical examination will include assessments of the skin, lungs, cardiovascular system, and abdomen (liver and spleen). In subjects with HF, peripheral oedema (height and severity above ankle, non-dependent limb), as well as JVPD and presence of anasarca should be monitored

Weight will be measured once daily as indicated in the Time and Events Tables. If applicable, metabolic scales will be utilized to collect daily weights per site SOP and recorded to nearest 100g.


Section 6.3.2 Vital Signs and Other Measures

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Recording of 24-hour fluid input/output totals will be performed at the time of the 24-hour urine collection while the subject is in the unit.

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Recording of 24-hour fluid input/output totals will be performed at the time of the 24-hour urine collection while the subject is in the unit (Cohorts 1-3)

Cohort 4: Recording of 24-hour fluid input/output totals will be performed while the subject is in the unit.(both periods, if applicable)

Section 6.4.1 Blood Sample Collection for Pharmacokinetics

ADDED TEXT

Blood samples for pharmacokinetic analysis of GSK2798745 and for circulatingmetabolite analysis will be collected at the time points indicated in Section 6.1 Time and Events Table. Metabolite identification samples will not be collected in Cohort 4. The actual date and time of each blood sample collection will be recorded. The timing of PK samples may be altered and/or PK samples may be obtained at additional time points to ensure thorough PK monitoring.

Where possible, PK monitoring of relevant co-administered drugs and their metabolites may also be undertaken (e.g. atorvastatin and/or simvastatin). For monitoring of simvastatin, blood samples will be collected into sodium heparin tubes. For monitoring of atorvastatin, blood samples will be collected into lithium heparin tubes. The actual date and time of each blood sample collection will be recorded.

Details of PK sample collection, processing, storage, and shipment are provided in the SPM.

Section 6.4.2 Urine Sample Collection

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Urine samples for metabolite identification will be collected at the time points listed in Section 6.1 Time and Events Table. The timing of urine samples may be altered and/or samples may be obtained at additional time points.


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Urine samples for metabolite identification will be collected at the time points listed in Section 6.1 Time and Events Table. The timing of urine samples may be altered and/or samples may be obtained at additional time points. Urine samples for mMetabolite identification sample will not be collected in Cohort 4.


DELETED TEXT




Subjects in the second dose group(s) of Cohort 3 (if initiated) will undergo a NaCl challenge within the 14 days prior to the start of drug administration and once again during the Day 9 to Day 11 period. Subjects will receive an intravenous infusion of 2.7% saline. Subjects will receive 7 mL/kg of hypertonic saline, which represents 14.7 g of sodium or 503 mOsm for a 70 kg individual, through a peripheral intravenous line inserted into the antecubital vein. Infusions would be limited to no more than 2 hours.



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In Cohort 4, blood samples will be obtained on Day 1 of the single-dose period and on day 7 of the repeat dose period. Samples will be obtained prior to dose administrationand at 0.25, 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 15, 24, and 48 hours Timepoints may be adjusted during the study based on emerging data.


REVISED TEXT


In Cohort 3, blood samples will be obtained on Days 1 and 14 prior to dose administration and at the times designated for pharmacokinetic sampling through the first 12 hours. If pharmacokinetic samples are specified to be taken at intervals of less than 30 minutes, those timepoints may be skipped when obtaining samples for pharmacodynamic analysis. It is anticipated that samples will be at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10, 12, and 24 and 48 hours after the administration of drug. Timepoints may be adjusted during the study based on emerging data.

In Cohort 4, blood samples will be obtained on Day 1 of the single-dose period and on day 7 of the repeat dose period. Samples will be obtained prior to dose administration and at 0.25, 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 15, 24, and 48 hours Timepoints may be adjusted during the study based on emerging data.

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Section 6.8.2 DLco and DLno

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Diffusion of oxygen across the pulmonary alveolar barrier is impaired at rest in patients with chronic heart failure (CHF) and has been implicated in the generation of symptoms and exercise intolerance. It is hypothesized that by affecting the permeability of the lung, and thus reducing the amount of interstitial water, TRPV4 inhibition will increase absorption into the bloodstream of inhaled carbon monoxide (CO). This is based on the alveolar: vascular membrane conductance as well as the affinity for hemoglobin. To better characterize the membrane conductance alone, nitrogen oxide (NO) absorption will also be tested, as it is mostly dependent on the membrane itself. This is due to its profound affinity for hemoglobin; well beyond that of CO.

In Cohort 4, DLco and DLno measurements will be made after each MRI scan has been completed and prior to the constant workload exercise test.


REVISED TEXT

Diffusion of oxygen across the pulmonary alveolar barrier is impaired at rest in patients with chronic heart failure (CHF) and has been implicated in the generation of symptoms and exercise intolerance. It is hypothesized that by affecting the permeability of the lung, and thus reducing the amount of interstitial water, TRPV4 inhibition will increase absorption into the bloodstream of inhaled carbon monoxide (CO). This is based on the alveolar: vascular membrane conductance as well as the affinity for hemoglobin. To better characterize the membrane conductance alone, nitrogen oxide (NO) absorption will also be tested, as it is mostly dependent on the membrane itself. This is due to its profound affinity for hemoglobin; well beyond that of CO.

In Cohort 4, DLco and DLno measurements will be made after each MRI scan has been completed and prior to the before and after the constant workload exercise test.


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Section 6.8.3 Magnetic Resonance Imaging (Cohort 4)

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Each subject in Cohort 4 will have four MRI exams; pre- and post- constant workload exercise both at baseline (before single dose) and after steady state has been reached during repeat dosing. If a technical failure occurs at the baseline scan, a baseline rescan may be attempted prior to repeat dosing following washout of the single dose. If a technical failure occurs during the pre-exercise MRI scan during repeat dosing, a rescan of the pre-exercise MRI scan may be attempted schedule permitting.

6.8.3.1 Subject Scanning Procedures


The scanning protocol will include routine localisers followed by T1 measurement sequences and a dynamic time series. The T1 measurement sequences will consist of 3D spoiled gradient echo (3D-SPGR) with constant echo time (TE) and repetition time (TR) and varying flip angles. The dynamic series will also consist of 3D-SPGR acquisitions with constant TE, TR and constant flip angle. Contrast agent will be administered intravenously as a bolus using a power injector during the dynamic series. Scanner gains will be controlled manually between all of the 3D-SPGR acquisitions to allow subsequent DCE-MRI parameter quantification.



REVISED TEXT

Each subject in Cohort 4 will have two four MRI exams; pre- and post- constant workload exercise both taken at baseline (before single dose) and after steady state has been reached during repeat dosing. If a technical failure occurs at the baseline scan, a baseline rescan may be attempted prior to repeat dosing following washout of the single dose. If a technical failure occurs during the pre-exercise MRI scan during repeat dosing, a rescan of the pre-exercise MRI scan may be attempted schedule permitting.

6.8.3.1 Subject Scanning Procedures


The scanning protocol will include routine localisers followed by T1 measurement sequences and a dynamic time series. The T1 measurement sequences will consist of 3D

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spoiled gradient echo (3D-SPGR) with constant echo time (TE) and repetition time (TR) and varying flip angles. The dynamic series will also consist of 3D-SPGR acquisitions with constant TE, TR and constant flip angle. Contrast agent will be administered intravenously as a bolus using a power injector during the dynamic series. Scanner gains will be controlled manually between all of the 3D-SPGR acquisitions to allow subsequent DCE-MRI parameter quantification.



Section 6.8.5 Dysponea Scale Scoring

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A standardised, validated absolute dyspnoea 5-point Likert scale [Mebazaa, 2009] will be administered before and after bicycle exercise in the seated position, at the time points in Section 6.1. With more modest dyspnea, the change when supine will be captured. Additional details are in the SPM.

REVISED TEXT

A standardised, validated absolute dyspnoea 5-point Likert scale [Mebazaa, 2009] will be administered before and after bicycle exercise (both the maximal and constant exercise tests) in the seated position, at the time points in Section 6.1. With more modest dyspnea, the change when supine will be captured. Additional details are in the SPM.

Section 9.2 Sample Size Considerations

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9.2.1 Cohorts 1-2 (Healthy Subject Single Dose)



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9.2.2 Cohort 3 (Healthy Subject Repeat Dose)

The repeat dose cohort may study 2 dose levels. Up to 8 subjects (6 on active and 2 on placebo) will be assigned to each dose level. All subjects will also participate in an exercise capacity and provide Peak VO2 related measures, along with DLco and DLno

9.2.3 Cohort 4 (Heart Failure Patients Single and Repeat Dose)

The main goal of this cohort is to study safety and tolerability in the patient population, targeting a total sample size of approximately 18 subjects with stable heart failure [randomized 1:1 (treatment:placebo)]. Sample size for the exploratory measurements is based on feasibility, and is supported by the following information regarding interstitial volume (ve) measured by DCE-MRI.

9.2.4 Interstitial volume (ve)

The difference of interstitial volume ve between smokers and non-smokers was 0.06 in the paper by Naish in 2008. The estimation on the variance of change from baseline ve is 0.041 (SD). If we assume same effect size between smokers and non-smoker is to be expected in our study between placebo and treatment at the end of study and same between subject variance of change from baseline ve is valid for the study population, the half-width of 95% CI for the mean difference in change from baseline ve between treatment and placebo is estimated to be 0.05. That is, if the observed mean change from baseline ve difference between treatment and placebo is 0.06, then the 95% CI would be (0.01, 0.11).

9.2.5 Sample Size Re-estimation

No sample size re-estimation will be performed.

REVISED TEXT


9.2.1 Cohorts 1-2 (Healthy Subject Single Dose)



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9.2.2 Cohort 3 (Healthy Subject Repeat Dose)

The repeat dose cohort may study 2 dose levels. Up to 8 subjects (6 on active and 2 on placebo) will be assigned to each dose level. All subjects will also participate in an exercise capacity and provide Peak VO2 related measures, along with DLco and DLno

9.2.3 Cohort 4 (Heart Failure Patients Single and Repeat Dose)

The main goal of this cohort is to study the safety and tolerability in the patient population, targeting a total sample size of approximately 18 subjects with stable heart failure [randomized 1:1 (treatment:placebo)]. Sample size for the exploratory measurements is based on feasibility, and is supported by the following information regarding interstitial volume (ve) measured by DCE-MRI.

9.2.4 Interstitial volume (ve)

The difference of interstitial volume ve between smokers and non-smokers was 0.06 in the paper by [Naish in 2008]. The estimation on the variance of change from baseline for ve was is 0.041 (SD). If we assume that the same effect size observed between smokers and non-smoker is to be expected in our study will be similar to the expected difference between placebo and treatment at the end of this study and that the same between subject variance of change from baseline for ve is valid for this study population, the half-width of 95% CI for the mean difference in change from baseline ve

between treatment and placebo is estimated to be 0.05 with 9 subjects per arm. That is, if the observed mean change from baseline ve difference between treatment and placebo for the mean change from baseline for ve is 0.06, then the 95% CI would be (0.01, 0.11).

9.2.5 Sample Size Re-estimation

No sample size re-estimation will be performed.

The number of subjects in Cohort 4 will be re-evaluated based on the variance of ve

after 12 subjects (6:6) complete the study. A maximum of 24 subjects will be enrolled with a 1:1 ratio, as needed.


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Cohort 4: Safety, tolerability, and efficacy data from Cohort 4 will be reviewed in-stream by the sponsor. A formal interim review will be performed after 18 subjects

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complete the study with respect to safety, PK and efficacy parameters. Sample size re-estimation will be performed to determine if the study will be completed when 18 subjects or 24 subjects complete the study.


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Davies, B. and Morris, T. 1993. Physiological parameters in laboratory animals and humans. Pharm Res 10(7): 1093-5.Deo A, Fogel M, Cowper SE. Nephrogenic systemic fibrosis: a population study examining the relationship of disease development to gadolinium exposure. Clin J Am Soc Nephrol. 2007 Mar;2(2):264–7.



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GlaxoSmithKline Document Number 2013N162862_00. Investigator’s Brochure for GSK2798745, December 2013.

Graffe CC, Bech JN, Pedersen EB. Effect of high and low sodium intake on urinary aquaporin-2 excretion in healthy humans Am J Physiol Renal Physiol 2012; 302: F264–F275.Hodgson RJ, Connolly S, Barnes T, Eyes B, Campbell RSD, Moots R. Pharmacokinetic modeling of dynamic contrast-enhanced MRI of the hand and wrist in rheumatoid arthritis and the response to anti-tumor necrosis factor-alpha therapy. Magn Reson Med. 2007 Sep;58(3):482–9.










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Seckl JR, Johnson MR, Lightman SL Vasopressin and oxytocin responses to . hypertonic saline infusion: effect of the opioid antagonist naloxone. Clinl Endocrinol 1989; 30:513-518.







Ve´roniqueL. Roger. Heart Disease and Stroke Statistics- 2012 Update: A report from the American Heart Association. Circulation. 2012; 125:e2-e220.



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Ye L, Kleiner S, Wu J, Sah R, Gupta RK, Banks AS, Cohen P, Khandekar MJ, Boström P, Mepani RJ, Laznik D, Kamenecka TM, Song X, Liedtke W, Mootha VK, Puigserver P, Griffin PR, Clapham DE, Spiegelman BM. TRPV4 is a regulator of adipose oxidative metabolism, inflammation, and energy homeostasis. Cell. 2012 Sep 28;151(1):96-110. doi: 10.1016/j.cell.2012.08.034.

REVISED TEXT






Davies, B. and Morris, T. 1993. Physiological parameters in laboratory animals and humans. Pharm Res 10(7): 1093-5.Deo A, Fogel M, Cowper SE. Nephrogenic systemic fibrosis: a population study examining the relationship of disease development to gadolinium exposure. Clin J Am Soc Nephrol. 2007 Mar;2(2):264–7.



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GlaxoSmithKline Document Number 2013N162862_001. Investigator’s Brochure for GSK2798745, December 2013 June 2015.

Graffe CC, Bech JN, Pedersen EB. Effect of high and low sodium intake on urinary aquaporin-2 excretion in healthy humans Am J Physiol Renal Physiol 2012; 302: F264–F275.











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Seckl JR, Johnson MR, Lightman SL Vasopressin and oxytocin responses to . hypertonic saline infusion: effect of the opioid antagonist naloxone. Clinl Endocrinol 1989; 30:513-518.







Ve´ronique L. Roger. Heart Disease and Stroke Statistics- 2012 Update: A report from the American Heart Association. Circulation. 2012; 125:e2-e220.



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Ye L, Kleiner S, Wu J, Sah R, Gupta RK, Banks AS, Cohen P, Khandekar MJ, Boström P, Mepani RJ, Laznik D, Kamenecka TM, Song X, Liedtke W, Mootha VK, Puigserver P, Griffin PR, Clapham DE, Spiegelman BM. TRPV4 is a regulator of adipose oxidative metabolism, inflammation, and energy homeostasis. Cell. 2012 Sep 28;151(1):96-110. doi: 10.1016/j.cell.2012.08.034.

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AMENDMENT 6




This amendment incorporates the addition of new Cohort (Cohort 5).


Note: Tables were added to the document starting with Table 5 and therefore all subsequent table numbers were increased accordingly throughout the document.

List of Abbreviations

ADDED TEXT

ReDS Remote dielectric sensing

Section 1 Introduction

PREVIOUS TEXT

This study is the First Time in Human Study (FTIH) for GSK2798745 and will evaluate the safety, tolerability, and pharmacokinetics (PK) of single and repeat oral doses of GSK2798745 administered to healthy subjects (Cohorts 1 through 3) and stable heart failure subjects (Cohort 4). In addition, this study will interrogate evidence for a functional effect of transient receptor potential vanilloid 4 (TRPV4) channel blockade on exercise tolerance, lung gas permeability parameters, pulmonary oedema, and vascular permeability in the cohort of stable heart failure patients.


TPRV4 is an ion channel expressed in the pulmonary vasculature distributed through the alveolar septum. Multiple lines of evidence from animal models have identified an important role for TRPV4 in mediating the development of cardiogenic pulmonary edema. Using a TRPV4 blocker prior to or after the induction of high pulmonary venous pressure in preclinical models leads to amelioration of the anticipated increase in lung edema, accompanied by an improvement in PO2 [Thorneloe, 2012].

Based on the role of TRPV4 in the mediation of fluid associated with cardiogenic pulmonary edema, it is postulated that inhibition of this channel may provide therapeutic benefits in patients presenting with pulmonary edema. Such an apparent improvement in the alveolar septal barrier, leading to a reduction in extravascular lung fluid, may lead to better symptom relief, allowing these patients to increase their exercise tolerance, to reduce orthopnoea and paroxysmal nocturnal dyspnoea, and/or to have less frequent need for hospitalization or acute care. These symptoms and their complications are all thought

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to be related to high pulmonary venous pressure resulting from left ventricular dysfunction. The extravasation of fluid into pulmonary tissue can lead to enhanced lung stiffness, abnormal gas exchange, and ultimately a sense of dyspnoea.


Prior to this study, GSK2798745 has never been administered to humans. Accordingly, the first phase of this study will address the safety, tolerability, and the pharmacokinetics (PK) of GSK2798745 in healthy adult subjects with single and repeat administration. In addition, the relative bioavailability of GSK2798745 administered via capsule as compared to liquid formulation and effect of food on systemic exposure of GSK2798745 will be evaluated through different cohorts as outlined in Table 1 and study schematics in Section 3. Exercise tolerability will be evaluated in the healthy subjects in the repeat dose cohort (Cohort 3) to further establish safety during exercise as explained above. Further, given the potential interstitial fluid excess and thus compromise in gas exchange in healthy subjects during exercise, there may be a beneficial effect.

This study will then progress to a stable heart failure cohort. Stable heart failure is defined as patients with an established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) class II or III. This definition includes the maintenance of stable heart failure therapy and lack of heart failure hospitalization for at least 3 months. In this cohort we will evaluate the effects of GSK2798745 primarily on safety, including clinical assessments and exercise tolerance. However, despite the small numbers, an exploratory assessment of effect will be performed, which will include assessment of respiratory rates, exercise capacity, alveolar:vascular gas transfer, pulmonary oedema, and vascular permeability. These assessments will test directly or indirectly for the potential reduction in lung interstitial fluid with GSK2798745 and the functional benefit in the setting of exercise.

Dynamic contrast enhanced (DCE) MRI is an established technique for assessing changes in vascular permeability and interstitial water volume. DCE-MRI measures the exchange of an extracellular MRI contrast agent as it travels between the intravascular space and the interstitial space. Pharmacokinetic modeling of DCE-MRI enables quantification of the plasma volume (vp), interstitial volume (ve), and exchange rate (ktrans), a parameter strongly dependent on vascular permeability. DCE-MRI is frequently used within oncology studies (O’Connor, 2007), and is used increasingly in other indications such as renal disease (Buckley, 2006) and rheumatoid arthritis (Hodgson, 2007). DCE-MRI has been used to detect alterations in vascular permeability and interstitial water volume in the lungs of smokers relative to healthy controls (Naish, 2008). An exploratory study (201137) in both healthy volunteers and patients with heart failure has been undertaken to

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develop DCE-MRI to detect increased interstitial lung fluid via measurement of ve or altered vascular permeability via measurement of ktrans. Preliminary analysis of this study suggests that DCE-MRI may be a useful modality to characterize vascular permeability and interstitial water volume in patients with heart failure.

REVISED TEXT

This study is the First Time in Human Study (FTIH) for GSK2798745 and will evaluate the safety, tolerability, and pharmacokinetics (PK) of single and repeat oral doses of GSK2798745 administered to healthy subjects (Cohorts 1 through 3) and subjects with stable heart failure (Cohorts 4 and 5). In addition, this study will interrogate evidence for a functional effect of transient receptor potential vanilloid 4 (TRPV4) channel blockade on exercise tolerance, lung gas permeability parameters, pulmonary oedema, and vascular permeability in patients with stable heart failure.


TPRV4 is an ion channel expressed in the pulmonary vasculature distributed through the alveolar septum. Multiple lines of evidence from animal models have identified an important role for TRPV4 in mediating the development of cardiogenic pulmonary edema. Using a TRPV4 blocker prior to or after the induction of high pulmonary venous pressure in preclinical models leads to amelioration of the anticipated increase in lung edema, accompanied by an improvement in PO2 [Thornloe, 2012].

Based on the role of TRPV4 in the mediation of fluid associated with cardiogenic pulmonary edema, it is postulated that inhibition of this channel may provide therapeutic benefits in patients presenting with pulmonary edema. Such an apparent improvement in the alveolar septal barrier, leading to a reduction in extravascular lung fluid, may lead to better symptom relief, allowing these patients to increase their exercise tolerance, to reduce orthopnoea and paroxysmal nocturnal dyspnoea, and/or to have less frequent need for hospitalization or acute care. These symptoms and their complications are all thought to be related to high pulmonary venous pressure resulting from left ventricular dysfunction. The extravasation of fluid into pulmonary tissue can lead to enhanced lung stiffness, abnormal gas exchange, and ultimately a sense of dyspnoea.


Prior to this study, GSK2798745 has never been administered to humans. Accordingly, the first phase of this study will address the safety, tolerability, and the pharmacokinetics (PK) of GSK2798745 in healthy adult subjects with single and repeat administration. In addition, the relative bioavailability of GSK2798745 administered via capsule as compared to liquid formulation and effect of food on systemic exposure of GSK2798745

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will be evaluated through different cohorts as outlined in Table 1 and study schematics in Section 3. Exercise tolerability will be evaluated in the healthy subjects in the repeat dose cohort (Cohort 3) to further establish safety during exercise as explained above. Further, given the potential interstitial fluid excess and thus compromise in gas exchange in healthy subjects during exercise, there may be a beneficial effect.

This study will then progress into patients withto a stable heart failurecohort. Stable heart failure is defined as patients with an established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) class II or III. This definition includes the maintenance of stable heart failure therapy for 1 month and lack of heart failure hospitalization for at least 3 months. In this cohort we will evaluate the effects of GSK2798745 primarily on safety, including clinical assessments and exercise tolerance. However, despite the small numbers, an exploratory assessment of effect will be performed, which will include assessment of respiratory rates, exercise capacity, alveolar:vascular gas transfer, pulmonary oedema, and vascular permeability. These assessments will test directly or indirectly for the potential reduction in lung interstitial fluid with GSK2798745 and the functional benefit in the setting of exercise.

Dynamic contrast enhanced (DCE) MRI is an established technique for assessing changes in vascular permeability and interstitial water volume. DCE-MRI measures the exchange of an extracellular MRI contrast agent as it travels between the intravascular space and the interstitial space. Pharmacokinetic modeling of DCE-MRI enables quantification of the plasma volume (vp), interstitial volume (ve), and exchange rate (ktrans), a parameter strongly dependent on vascular permeability. DCE-MRI is frequently used within oncology studies (O’Connor, 2007), and is used increasingly in other indications such as renal disease (Buckley, 2006) and rheumatoid arthritis (Hodgson, 2007). DCE-MRI has been used to detect alterations in vascular permeability and interstitial water volume in the lungs of smokers relative to healthy controls (Naish, 2008). An exploratory study (201137) in both healthy volunteers and patients with heart failure has been undertaken to develop DCE-MRI to detect increased interstitial lung fluid via measurement of ve or altered vascular permeability via measurement of ktrans. Preliminary analysis of this study suggests that DCE-MRI may be a useful modality to characterize vascular permeability and interstitial water volume in patients with heart failure.

Section 1.2.1 GSK2798745

ADDED TEXT

A preliminary review of the healthy volunteer QT data from Cohorts 1-3 was performed, after exposure to single doses of 0.1mg, 1mg, 5mg, and 12.5mg, and repeat dose exposure of 5mg daily. Categorical analysis demonstrated that no subjects experienced an increase in QTc from baseline of 30-60ms, or >60ms, and no subjects had a QTc value of 480-500ms, or >500ms while on therapy. Exposure response analysis demonstrated no evidence of a relationship between concentration of GSK2798745 and QTc prolongation. In consideration of the lack of pre-clinical signal for effect on cardiac repolarization, and the negative healthy volunteer clinical data, extended QT eligibility and stopping criteria will be implemented in

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Cohorts 4 and 5 (See Section 4.2 and Section 5.3.2.2 for updated eligibility and stopping criteria).


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Cohort 2(n=12)



5mg





5mg


Cohort 4(n=up to 24)(1:1 ratio)



2.4mg (initial)






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REVISED TEXT



The order of conduct of Cohorts 2 and 3 may be changed or the two cohorts may be conducted in parallel. Cohorts 4 and 5 may overlap.







Cohort 2(n=12)



5mg





5mg


Cohort 4(n=up to 24)(1:1 ratio)



2.4mg (initial)

Heart failure patients repeat dose6

Cohort 5(n=8 [3:1 ratio])

Repeat dose (capsule) for 7 days

Safety, pharmacokinetics and lung permeability (DLco and DLno)

2.4mg





participating in Cohorts 4 or 5.

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ADDED SECTION

Section 3.2.4 Heart Failure Patients – Cohort 5

Cohort 5 will be a sponsor un-blinded, randomized, placebo-controlled, 7-day repeat dose evaluation of GSK2798745 in patients with heart failure. To gain additional information on the profile of GSK2798745, this cohort will evaluate safety, pharmacokinetics, and lung permeability (DLco and DLno) in a broader, more general population of patients with heart failure, NYHA Class II or III. Exclusions specifically included in Cohort 4 relevant for MRI scanning have been removed for Cohort 5. A sufficient number of patients will be enrolled such that up to 8 subjects complete the cohort with a treatment to placebo randomization ratio of 3 to 1.

Prior to the initiation of Cohort 5, all available safety data from Cohort 4 will be reviewed by the sponsor. As Cohort 4 will continue to recruit subjects with heart failure into the single dose and repeat dose regimens as outlined in Section 3.2.3, the review of accrued safety data will permit Cohort 5 to avoid the single dose, and immediately initiate the cohort only employing a repeat dose regimen. The repeatdose periods of Cohorts 4 and 5 will constitute our primary evaluation of safety for this early phase study.

Subjects with heart failure participating in Cohort 5 will be required to stay inhouse for the first 4 days of the period. Fitted with a remote monitoring device (which provides 24 hour continuous remote monitoring of ECG, HR, RR and activity level – see Section 6.3.7), they will return to their homes where they will receive visits from registered nurses the mornings of Days 5 and 6 to administer study medication, assess vital signs and dyspnea, collect blood samples for pharmacokinetic analysis, and obtain information on any adverse events.

Dose considerations: The maximum daily dose in the repeat dosing period will not intentionally exceed a daily exposure of AUC of 0.448 μg*hr/mL or a Cmax of 0.049 μg/mL in any individual. Based on data from the previous cohorts, the dose will be 2.4mg utilizing the capsule formulation administered with or without food. (See Section 3.4.5 for dose rationale).

Figure 5 Study Design for Cohort 5

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Table 5 Study Duration for Cohort 5

Screening All screening assessments are to be completed within 35 days prior to the first dose.

Treatment Period Each subject will be administered GSK2798745 or placebo (based on randomization) for 7 days.

Subjects will have safety assessments and other measurements, including DLco and DLno, and PK duringthe study period.

Subjects will remain in house from Day -1 until Day 4. Day 5, 6, and 8 visits will be outpatient only. For the Day 7 Visit, subjects will return to the clinic.


If warranted, additional follow-up visits may be scheduled.Total Duration Screening within 35 days + 7-day repeat dose study period +

follow up (7-14 days after last dose of study medication) = approximately 8 weeks

ADDED TEXT

Section 3.3 Drug Formulation

All doses in Cohort 1 will be administered either as a suspension or a solution depending on the dose. Cohort 2 will also employ the capsule formulation (filled in by the pharmacy) in order to assess the relative bioavailability of the capsule formulation as compared to the liquid formulation. Cohorts 3 and 4 will employ one of the formulations used in Cohorts 1 or 2. The relative exposure data from Cohort 2 will determine the formulation for subsequent cohorts. In the event that Cohort 3 is conducted concurrently with Cohort 2, the liquid formulation will be administered in the repeat-dose Cohort 3. Based on all the data available from the previous cohorts in this study, Cohorts 4 and 5 will employ capsule formulation.

Please refer to Appendix 5 for more details.

Section 3.4.2.1 Rat 4-Week Toxicity Study

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The dose levels in the oral rat 4-week toxicity study were 0 (vehicle), 10, 60 and 300mg/kg/day. There were various toxicological findings at different doses that are summarized in Table 12. Based on the adverse toxicological findings at the 300mg/kg/day dose group, the 60mg/kg dose was selected as the NOAEL dose level. The mean AUC and Cmax from this 60mg/kg/day dose group were used to estimate the safety margins with respect to the rat species and are listed in Table 8.

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REVISED TEXT

The dose levels in the oral rat 4-week toxicity study were 0 (vehicle), 10, 60 and 300mg/kg/day. There were various toxicological findings at different doses that are summarized in Table 11Table 12. Based on the adverse toxicological findings at the 300mg/kg/day dose group, and 60mg/kg/day dose groups in the 4-week study and effects observed at 30mg/kg/day in the 7-day study, the 60 10mg/kg dose was selected as the NOAEL dose level. The mean AUC and Cmax from this the 60mg/kg/day dose group were previously used to estimate the safety margins with respect to the rat species and are listed in Table 7 Table 8

Section 3.4.2.2. Dog 4-Week Toxicity Study

PREVIOUS TEXT

The dose levels studied in the oral dog 4-week toxicity study were 0 (vehicle), 3, 10 and 30mg/kg/day. There were various toxicological findings at different doses that are summarized in Table 12. Based on the adverse toxicological findings at the 30mg/kg/day dose group, the 10mg/kg/day dose was selected as the NOAEL dose level. Given that the arterial and cardiac findings at 30mg/kg/day cannot be easily monitored for in clinical studies and the mechanism by which they occur is not understood, a 50X exposure margin below the NOAEL dose of 10mg/kg/day was considered the maximum exposure to be achieved in humans in this study, consistent with regulatory guidelines [ICH, 2009]. The Day 1 mean exposures in dogs at 10mg/kg/day were used as this provided the most conservative approach. The mean AUC was 50.4hr*µg/mL and Cmax was 4.51µg/mL at this dose. Applying the 50-fold safety margin, an AUC of 1.01µg*hr/mL and Cmax of 0.09µg*hr/mL were used to estimate the safety margins with respect to the dog species. These safety margins are listed in Table 8.

REVISED TEXT

The dose levels studied in the oral dog 4-week toxicity study were 0 (vehicle), 3, 10 and 30mg/kg/day. There were various toxicological findings at different doses that are summarized in Table 11 Table 12. Based on the adverse toxicological findings at the 30mg/kg/day dose group, the 10mg/kg/day dose was selected as the NOAEL dose level. Given that the arterial and cardiac findings at 30mg/kg/day cannot be easily monitored for in clinical studies and the mechanism by which they occur is not understood, a 50X exposure margin below the NOAEL dose of 10mg/kg/day was considered the maximum exposure to be achieved in humans in this study, consistent with regulatory guidelines [ICH, 2009]. The Day 1 mean exposures in dogs at 10mg/kg/day were used as this provided the most conservative approach. The mean AUC was 50.4hr*µg/mL and Cmax was 4.51µg/mL at this dose. Applying the 50-fold safety margin, an AUC of 1.01µg*hr/mL and Cmax of 0.09µg*hr/mL were used to estimate the safety margins with respect to the dog species. These safety margins are listed in Table 7 Table 8.

As the dog exposure levels provide a more conservative stopping limit as compared to the exposure in the rat, the tentative doses for this FTIH will be selected to not knowingly exceed a daily AUC of 1.01µg*hr/mL and/or a Cmax of 0.09µg/mL in any individual in

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any cohort. This information and exposure limits were utilized in Cohorts 1 through 3 to establish appropriate doses for administration to healthy volunteers. Subsequently, new information has been obtained from the 3-month dog toxicity study and the NOAEL reassessed as 3 mg/kg/day (see below).

Section 3.4.2.3.1. Findings

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GSK2798745 was given, by oral gavage, to male and female dogs (4/sex/group), at doses of 1, 3 or 10 mg/kg/day for 3 months. A control group received the vehicle alone. The peer-reviewed microscopic pathology data identified vascular toxicity in 2 dogs given 10 mg/kg/day. Specifically, arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation, was observed in the epididymides (bilateral) in a male and in the urinary bladder of a female. Neither dog presented with clinical abnormalities, and each survived the scheduled duration of the study. No evidence of vascular toxicity was observed in other tissues of these dogs, and no vascular lesions were seen in any tissues of dogs given 1 or 3 mg/kg/day. Such vascular lesions are not considered new findings with GSK2798745 since lesions like these were seen previously in the 1-month dog study at 30 mg/kg/day. However, the lesions are now being observed at a lower dose. In dogs given 10 mg/kg/day, mean AUC and Cmax (gender-averaged, Day 1) was 48.8 µg.h/mL and 4.09 µg/mL, respectively. In dogs given 3 mg/kg/day (the no-effect dose for vascular toxicity in this study), mean AUC and Cmax (gender-averaged, Day 1) was 13.5 µg.h/mL and 1.46 µg/mL, respectively.

REVISED TEXT

GSK2798745 was given, by oral gavage, to male and female dogs (4/sex/group), at doses of 1, 3 or 10 mg/kg/day for 3 months. A control group received the vehicle alone. The peer-reviewed microscopic pathology data identified vascular toxicity in 2 dogs given 10 mg/kg/day. Specifically, arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation, was observed in the epididymides (bilateral) in a male and in the urinary bladder of a female. Neither dog presented with clinical abnormalities, and each survived the scheduled duration of the study. No evidence of vascular toxicity was observed in other tissues of these dogs, and no vascular lesions were seen in any tissues of dogs given 1 or 3 mg/kg/day. Such vascular lesions are not considered new findings with GSK2798745 since lesions like these were seen previously in the 1-month dog study at 30 mg/kg/day. However, the lesions are now being observed at a lower dose. In dogs given 10 mg/kg/day, mean AUC and Cmax (gender-averaged, Day 1) was 48.8 µg.h/mL and 4.09 µg/mL, respectively. In dogs given 3 mg/kg/day (the no-effect dose for vascular toxicity in this study and hence the new NOAEL), mean AUC and Cmax (gender-averaged, Day 1) was 13.5 µg.h/mL and 1.46 µg/mL, respectively.

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Section 3.4.5. Safety Cover Based on Predicted Exposure and NOAEL from the Pre-Clinical Species

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Cmax (µg/mL)


of 0.09ug/mL**



Rat# Dog* Rat# Dog*

0.25 0.001-0.004 3301-10481 23-74 0.044-0.068 1843-2801 15-23

0.50 0.002-0.008 1650-5240 12-37 0.089-0.135 921-1401 8-11

0.75 0.004-0.012 1100-3494 8-25 0.133-0.203 614-934 5-8

1.50 0.007-0.023 550-1747 4-12 0.267-0.405 307-467 3-4

2.50 0.012-0.039 330-1048 2-7 0.444-0.676 184-280 2-2

3.50 0.017-0.054 236-749 2-5 0.622-0.946 132-200 1-2

4.0 0.019-0.062 206-655 2-5 0.711-1.081 115-175 1-1

**The stopping AUC and Cmax provide 50X cover from the NOAEL dose (10mg/kg/day) exposure in the 4-week dog study* Exposure values from day 1 of the dog study used given the toxicological findings# Exposure values from day 28 of the rat study used given the toxicological findingsThe range of exposures at doses planned for the current study was estimated using the predicted PK parameters in human as listed in Table 7.

REVISED TEXT

Table 7 8 Predicted Exposure with Safety Cover over the Proposed SD Dose Range


Cmax (µg/mL)


of 0.09ug/mL**



Rat# Dog* Rat# Dog*

0.25 0.001-0.004 3301-10481 23-74 0.044-0.068 1843-2801 15-23

0.50 0.002-0.008 1650-5240 12-37 0.089-0.135 921-1401 8-11

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Cmax (µg/mL)


of 0.09ug/mL**



Rat# Dog* Rat# Dog*

0.75 0.004-0.012 1100-3494 8-25 0.133-0.203 614-934 5-8

1.50 0.007-0.023 550-1747 4-12 0.267-0.405 307-467 3-4

2.50 0.012-0.039 330-1048 2-7 0.444-0.676 184-280 2-2

3.50 0.017-0.054 236-749 2-5 0.622-0.946 132-200 1-2

4.0 0.019-0.062 206-655 2-5 0.711-1.081 115-175 1-1

**The stopping AUC and Cmax provide 50X cover from the NOAEL dose (10mg/kg/day) exposure in the 4-week dog study* Exposure values from day 1 of the dog study used given the toxicological findings# Exposure values from day 28 of the rat study used given the toxicological findings. Note: these values were determined based on exposure determined in the 60mg/kg/day group.The range of exposures at doses planned for the current study was estimated using the predicted PK parameters in human as listed in Table 6 Table 8

Section 3.4.5.1 Doses based on clinical data from Cohorts 1-3 in FTIH study

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The simulations were based on assumption that GSK2798745 will be administered as a suspension formulation in fasted state, similar to cohort 1. However, preliminary analyses of the data from cohort 2 indicated small increases in the systemic exposure of GSK2798745 when the drug was administered in the capsule formulation and with food (high fat meal). These preliminary results are listed in Table 11. Consequently, a 2.4 mg dose in capsule formulation (without any meal restrictions) is recommended for the subjects in cohort 4. A 25% increase in exposure of 2.4 mg (when administered in capsule and without meal restrictions) would result in exposures comparable to 3 mg dose (when administered as suspension and fasted state) and within the stopping criteria of daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL. Additionally, if needed, the dose may be adjusted based on emerging PK and safety data. Any dose selected will not intentionally exceed daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL.

Table 10 Impact of capsule and meal on systemic exposure of GSK2798745 (preliminary results)




To summarize, based on the revised NOAEL established in the 3-month dog toxicity study and a 30-fold safety margin, the planned dose for single and repeat administration

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of GSK2798745 in Cohort 4 will be 2.4mg once daily administered in capsule without any meal restrictions. The daily exposure will not intentionally exceed a Cmax of 0.049µg/mL and/or a AUC of 0.448g*hr/mL in any individual.

REVISED TEXT

The simulations were based on assumption that GSK2798745 will be administered as a suspension formulation in fasted state, similar to cohort 1. However, preliminary analyses of the data from cohort 2 indicated small increases in the systemic exposure of GSK2798745 when the drug was administered in the capsule formulation and with food (high fat meal). These preliminary results are listed in Table 10 Table 11. Consequently, a 2.4 mg dose in capsule formulation (without any meal restrictions) is recommended for the subjects in Cohorts 4 and 5. A 25% increase in exposure of 2.4 mg (when administered in capsule and without meal restrictions) would result in exposures comparable to 3 mg dose (when administered as suspension and fasted state) and within the stopping criteria of daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL. Additionally, if needed, the dose may be adjusted based on emerging PK and safety data. Any dose selected will not intentionally exceed daily AUC of 0.448 ug*hr/mL or Cmax of 0.049 ug/mL.

Table 10 11 Impact of capsule and meal on systemic exposure of GSK2798745 (preliminary results)




To summarize, based on the revised NOAEL established in the 3-month dog toxicity study and a 30-fold safety margin, the planned dose for single and repeat administration of GSK2798745 in Cohorts 4 and 5 will be 2.4mg once daily administered in capsule without any meal restrictions. The daily exposure will not intentionally exceed a Cmax of 0.049µg/mL and/or a AUC of 0.448g*hr/mL in any individual.

Section 3.4.6. Dosing and Randomization

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In Cohort 5, 8 subjects will be randomized to treatment at a treatment:placebo ratio of 3:1.



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Dogs (3-month study): At 10 mg/kg/day, arterial lesions were observed in 2 dogs.One male: Epididymides (bilateral) -arteriolar degeneration/necrosis,accompanied by lymphocytic inflammation,

One female: Urinary bladder -arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation,





Myocardial toxicity








Rats (micronucleus and comet study): mortality occurred following 1 to 3 doses at


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≥600mg/kg/day




















Effects on macrophages (Phospholipid

Rats (4-week study): 60mg/kg/day in the lung (prominent alveolar macrophages); 300mg/kg/day in


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accumulation) the mesenteric lymph node (increased cellularity of sinus macrophages) and thymus (macrophage vacuolation; increased thymus weight). Consistent with phospholipid accumulation (phospholipidosis) based on ultrastructural appearance of mesenteric lymph nodes at 300mg/kg/day. Findings were not associated with degenerative changes.


Gadobutrol (Gd) (Gadovist; Bayer) has produced nephrogenic systemic fibrosis and fibrosing dermopathy in patient swith renal disease. The incidence of NSF in dialysis and end-stage renal disease patients when exposed to Gd is in the range 3-5% [Marckmann, 2006; Kuo, 2008; However, there are no reports of NSF in subjects with normal renal function [Perazella, 2007; Deo, 2007; Chewning, 2007; Thomsen, 2006]. It is concluded that subjects dependent on dialysis and those with estimated glomerular filtration rate (eGFR) <30mL/min (chronic kidney disease stage 4/5) are at risk of developing NSF on exposure to Gd [Perazella, 2007].





On-target effects suggested by literature reports: Genetic deletion of TRPV4 in mice has been shown to effect hearing. TRPV4 knockout mice at age 8 weeks exhibited normal hearing thresholds but at age 24 weeks, had delayed-onset hearing loss; additionally, the cochlea was found to be vulnerable to acoustic injury with sound overexposure [Tabuchi, 2005]. Patients with Charcot-Marie-Tooth disease Type 2C (CMT2C), an autosomal dominant axonal neuropathy related to TRPV4 gene mutations, demonstrate symptoms that include hearing loss caused by nerve damage in the inner ear (sensorineural hearing loss). Although the exact mechanism is unclear, it has been suggested that the TRPV4 channel plays an important role in

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peripheral nerve function and that the alterations in TRPV4 in CMT2C may be due to increased channel activity leading to excessive calcium influx and a calcium overload. In cells (HEK293) expressing the CMT2C mutant channel, inhibitors of the TRPV4 channel were found to block the increased intracellular calcium concentrations and resultant cell death [Landouré, 2009]. Although there is a lack of information on the direct effects of TRPV4 inhibitors on hearing, audiometry will be incorporated in the assessments for the repeat-dose phases of the study, Cohorts 3 and 4.


REVISED TEXT

A summary of potential risk factors and the strategy to mitigate them is provided in Table 11 12.

Table 11 12 Summary of Key Issues, Their Impact and Strategy to Mitigate Risk






Dogs (3-month study): At 10 mg/kg/day, arterial lesions were observed in 2 dogs.One male: Epididymides (bilateral) -arteriolar degeneration/necrosis, accompanied by lymphocytic inflammation,

One female: Urinary bladder -arteriolar degeneration/necrosis,

None The arterial lesions noted in heart, thymus and epididymides cannot be monitored directly. There is currently no human translation biomarker or understanding of theunderlying mechanism.

Since these effects cannot be monitored directly in clinical studies, a coverage of ≥50-fold will be wasmaintained in humans from the no-effect dose (10mg/kg/day), and dosing will exposure will not exceed the average daily AUC of 1.01hr*ug/mL and/or Cmax of 0.09ug/mL in subjects dosed prior to 10/31/2014.

A ≥30-fold margin will be maintained from based on therevised no-effect dose (3mg/kg/day); exposure will not exceed an AUC of 0.448hr*ug/mL

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accompanied by lymphocytic inflammation,

Rats (7-day study): No vascular lesions observed. At 300mg/kg/day, inflammation in an extra hepatic arteriole occurred in one rat.

and/or Cmax of 0.049ug/mL in any individual dosed after 10/31/2014.

Myocardial toxicity


Rats: No myocardial toxicity observed. Rats (7-day study): At 300 mg/kg/day, epicardial myofibre degeneration and/or necrosis with mononuclearinflammatory cell infiltrate occurred in one rat.






Dog (13-week study): At 10 mg/kg/day one male was terminated early (Day 74) due to welfare reasons.



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No spermatogenic abnormalities were observed in dogs.














Effects on macrophages

Rats (4-week study): 60mg/kg/day in the lung

None A safety margin of ≥ 40 fold will be maintained from the no effect dose

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(Phospholipid accumulation)

(prominent alveolar macrophages); 300mg/kg/day in the mesenteric lymph node (increased cellularity of sinus macrophages) and thymus (macrophage vacuolation; increased thymus weight). Consistent with phospholipid accumulation (phospholipidosis) based on ultrastructural appearance of mesenteric lymph nodes at 300mg/kg/day. Findings were not associated with degenerative changes.

(10 mg/kg/day) in rats.


Gadobutrol (Gd) (Gadovist; Bayer) has produced nephrogenicsystemic fibrosis and fibrosing dermopathy in patient swith renal disease. The incidence of NSF in dialysis and end-stage renal disease patients when exposed to Gd is in the range 3-5% [Marckmann, 2006; Kuo, 2008; However, there are no reports of NSF in subjects with normal renal function [Perazella, 2007; Deo, 2007; Chewning, 2007; Thomsen, 2006]. It is concluded that subjects dependent on dialysis and those with estimated glomerular filtration rate (eGFR) <30mL/min (chronic kidney disease stage 4/5) are at risk of developing NSF on exposure to Gd [Perazella, 2007].

As a result of this recent evidence, subjects in Cohort 4 with creatinine clearance levels < 60 40mL/min will be excluded from this study and subjects in Cohort 4 with a creatinine clearance of <30mL/min within 48 hours prior to the MRI scan performed during the repeat dose session will not be eligible to participate in that scan .

Based on updated guidance from the FDA, subjects with an eGFR > 30 mL/min Patients with normal renal function appear to have negligible risk of developing NSF/NFD [Kramer, 2007; FDA, 2010].



On-target effects suggested by literature reports: Genetic deletion of TRPV4 in mice has been shown to effect hearing. TRPV4 knockout mice at age 8 weeks exhibited normal hearing thresholds but at age 24 weeks, had delayed-onset hearing loss; additionally, the cochlea was found to be vulnerable to acoustic injury with sound overexposure [Tabuchi, 2005]. Patients with Charcot-Marie-Tooth disease Type 2C (CMT2C), an autosomal dominant axonal neuropathy related to TRPV4 gene mutations, demonstrate symptoms that include hearing loss caused by nerve damage in the inner ear (sensorineural hearing loss). Although the exact mechanism is unclear, it has been suggested that the TRPV4 channel plays an important role in

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peripheral nerve function and that the alterations in TRPV4 in CMT2C may be due to increased channel activity leading to excessive calcium influx and a calcium overload. In cells (HEK293) expressing the CMT2C mutant channel, inhibitors of the TRPV4 channel were found to block the increased intracellular calcium concentrations and resultant cell death [Landouré, 2009]. Although there is a lack of information on the direct effects of TRPV4 inhibitors on hearing, audiometry will be incorporated in the assessments for the repeat-dose phases of the study, Cohorts 3 and 4.



PREVIOUS TEXT


A sufficient number of subjects with HF will be enrolled such that 18 subjects complete dosing and critical assessments. If required, the total number of subjects may be increased to 24. Approximately eighteen to twenty four additional subjects with HF may be enrolled in a separate group to allow for evaluation of an additional dose level for up to a maximum of 14 days of repeat dosing.

For single dosing (Cohorts 1 and 2), if subjects prematurely discontinue the study,additional subjects may be enrolled as replacement subjects and assigned to the same treatment sequence, at the discretion of the Sponsor in consultation with the Investigator. Replacement subjects in Cohort 1 of the study will not necessarily start on the lowest dose level tested within the cohorts and may start on the dose intended for the withdrawn subject.


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REVISED TEXT


A sufficient number of subjects with HF will be enrolled in Cohort 4 such that 18 subjects complete dosing and critical assessments. If required, the total number of subjects may be increased to 24. Approximately eighteen to twenty four additionalsubjects with HF may be enrolled in a separate group to allow for evaluation of an additional dose level for up to a maximum of 14 days of repeat dosing.

A sufficient number of subjects with HF will be enrolled in Cohort 5 such that 8 subjects complete dosing and assessments.



Section 4.2.2. Inclusion Criteria for Subjects with Heart Failure (Cohort 4)

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1. Established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) Class II or III on stable heart failure therapy for at least 1 month and was not hospitalized for HF during the last three months






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REVISED TEXT




4. QTc < 480 msec based on averaged QTc values of triplicate ECGs obtained over a brief recording history

Based on averaged QTc values of triplicate ECGs obtained over a brief recording period:



ADDED SECTION

Section 4.2.3 Inclusion Criteria for Subjects with Heart Failure (Cohort 5)

1. Established diagnosis of mild or moderate heart failure of any aetiology with symptoms defined as corresponding to the New York Heart Association (NYHA) Class II or III; on stable heart failure therapy for at least 1 month and not hospitalized for HF during the last three months



4. QTc < 480msec based on averaged QTc values of triplicate ECGs obtained over a brief recording history



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ADDED SECTION











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Other Criteria



3. Subject who, in the Investigator/designee's judgement, poses a significant suicide risk. Evidence of serious suicide risk may include any history of suicidal behaviour and/or any evidence of suicidal ideation on any questionnaires (e.g., Type 4 or 5 on the C-SSRS in the last 5 years).

Section 4.3.2 Meal and Dietary Restriction

ADDED TEXT

In Cohorts 4 and 5, no meal restrictions will be placed with regard to drugadministration. Subjects will be allowed to consume a standard breakfast prior to drug administration.

Section 5.2 Treatment Assignment

PREVIOUS TEXT

Subjects will be assigned to treatments in accordance with the randomization schedule generated by Discovery Biometrics, prior to the start of the study, using validated internal software. Once additional centres are initiated, subjects in Cohort 4 will be randomized into the study by means of an interactive web response (IWR) i.e. RAMOS NG, to receive one of the treatment regimens. See Appendix 5 for treatment regimen tables.

REVISED TEXT

Subjects will be assigned to treatments in accordance with the randomization schedule generated by Discovery Biometrics, prior to the start of the study, using validated internal

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software. Once additional centres are initiated, subjects in Cohorts 4 and 5 will be randomized into the study by means of an interactive web response (IWR) i.e. RAMOS NG, to receive one of the treatment regimens. See Appendix 5 for treatment regimen tables.

Section 5.3 Planned Dose Adjustments and Stopping Criteria

PREVIOUS TEXT


In Cohort 4 (or in any cohort where dosing occurs after 10/31/2014), the exposure will not exceed a daily AUCof 0.448 µg*h/mL or Cmax of 0.049 µg/mL in any individual.


REVISED TEXT


In Cohorts 4 and 5 (or in any cohort where dosing occurs after 10/31/2014), the exposure will not exceed a daily AUCof 0.448 µg*h/mL or Cmax of 0.049 µg/mL in any individual.


Section 5.3.2.2. Heart Failure Patients (Cohort 4)

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5.3.2.2. Heart Failure Patients (Cohort 4)





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REVISED TEXT

5.3.2.2. Heart Failure Patients (Cohorts 4 and 5)



QTcB or QTcF > 500 530msec








Section 5.3.3.4 Stopping Criteria Related to Digoxin

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The subjects in Cohort 4 that are on digoxin will be monitored for digoxin levels pre-dose and for trough levels of digoxin. If the digoxin levels are observed to be significantly lower or higher post study drug administration, the dose of digoxin may be titrated if

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possible in consultation with the Medical Monitor and GP. In case the digoxin dose cannot be titrated, the subject may be withdrawn from the study or continue the study without administration of the study drug, or withdrawal of the digoxin as clinically appropriate. Any follow-up and safety observations will be collected and monitored in these subjects.

REVISED TEXT

The subjects in Cohorts 4 and 5 that are on digoxin will be monitored for digoxin levels pre-dose and for trough levels of digoxin. If the digoxin levels are observed to be significantly lower or higher post study drug administration, the dose of digoxin may be titrated if possible in consultation with the Medical Monitor and GP. In case the digoxin dose cannot be titrated, the subject may be withdrawn from the study or continue the study without administration of the study drug, or withdrawal of the digoxin as clinically appropriate. Any follow-up and safety observations will be collected and monitored in these subjects.

ADDED SECTION

Section 5.3.3.5 Stopping Criteria Related to CrCl and MRI Scanning

For subjects in Cohort 4, the estimated creatinine clearance (Cockcroft-Gault) will be monitored within 48 hours prior to the DCE-MRI scan that occurs during the repeat dose session between Days 5-7. If the estimated creatinine clearance is <30mL/minute, the subject will not be eligible to participate in the repeat dose session MRI scan. The subject may continue the study and administration of the study drug.


ADDED TEXT

Table 15 Bullet number 14: added “or the repeat dose period.” To the end of the bullet

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PREVIOUS TEXT

Table 17 Repeat Dose Heart Failure Patients (Cohort 4 continued from single-dose Table 15)Days Screening

(up to 35 days prior to Day 1)17



X X








Dyspnoea Scale Scoring X17 X X X8 X

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DLco and DLno and Spirometry X17 X8



PD Blood Sample X9 XStudy Treatment Dosing13 X X X X X X X



1. First 6 subjects will return to the unit after a washout period of 7-21 days for the RD treatment period. Day 1 will then be the first day of dosing for the RD dose period.

2. ECGs to be obtained in triplicate.3. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose4. Pulse oximetry will be conducted once daily.5. Vital signs will be taken in triplicate.6. Urine ethanol test will be performed if the patient is unable to perform the alcohol breath test due to breathlessness7. Only for subjects taking digoxin.8. Assessment may be completed between Days 5 to 7.9. Serial sampling will occur on days 7. Timepoints will be pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 4h, 5h, 6h, 8h, 12h, and 15h. Some of these timepoints may also

be utilized to collect samples to determine concentrations of other medications (e.g., atorvastatin and/or simvastatin). See the SRM for detailed information.10. On days 2 through 6 PK samples will be drawn pre dose11. On day 1 PK samples will be drawn predose, 2h, and 12h. For subjects who do not participate in the single dose period, PK samples will be drawn at the


12. On day 8, PK samples will be drawn at 24h post last dose and just prior to discharge (sample time will be noted in the eCRF).13. Meals will not be restricted in this cohort14. Informed consent for optional PGx (Pharmacogenetics) research must be obtained before collecting a sample.15. Transcriptomic/Metabolomic blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.16. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported17. For subjects who do not participate in the single dose session, screening, day -1 and day 1 will reflect timepoints shown in Tablet 15. MRI, Constant and Maximal

Exercise, DLco/DLno and Dyspnea scale scoring can be completed within 7 days prior to Day -1.

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REVISED TEXT

Table 17 18 Repeat Dose Heart Failure Patients (Cohort 4 continued from single-dose Table 15 16




X X








Dyspnoea Scale Scoring X17 X X X8 X

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DLco and DLno and Spirometry X17 X8



PD Blood Sample X9 XStudy Treatment Dosing13 X X X X X X XSensiVest18 X X X X X X X X X



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1. First 6 subjects will return to the unit after a washout period of 7-21 days for the RD treatment period. Day 1 will then be the first day of dosing for the RD dose period.

2. ECGs to be obtained in triplicate.3. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose4. Pulse oximetry will be conducted once daily.5. Vital signs will be taken in triplicate.6. Urine ethanol test will be performed if the patient is unable to perform the alcohol breath test due to breathlessness7. Only for subjects taking digoxin.8. Assessment may be completed between Days 5 to 7.9. Serial sampling will occur on days 7. Timepoints will be pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 4h, 5h, 6h, 8h, 12h, and 15h. Some of these timepoints

may also be utilized to collect samples to determine concentrations of other medications (e.g., atorvastatin and/or simvastatin). See the SRM for detailed information.

10. On days 2 through 6 PK samples will be drawn pre dose11. On day 1 PK samples will be drawn predose, 2h, and 12h. For subjects who do not participate in the single dose period, PK samples will be drawn at the


12. On day 8, PK samples will be drawn at 24h post last dose and just prior to discharge (sample time will be noted in the eCRF).13. Meals will not be restricted in this cohort14. Informed consent for optional PGx (Pharmacogenetics) research must be obtained before collecting a sample.15. Transcriptomic/Metabolomic blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1.16. Laboratory assessments of CPK in the 48 hour interval following exercise testing will not be reported17. For subjects who do not participate in the single dose session, screening, day -1 and day 1 will reflect timepoints shown in Table 15. MRI, Constant and

Maximal Exercise, DLco/DLno and Dyspnea scale scoring can be completed within 7 days prior to Day -1. Baseline assessment of MRI, constant and maximal Exercise, audiometry, DLco/DLno, spirometry and dyspnoea scale scoring can be performed either prior to the single dose session or the repeat dose session.

18. This non-invasive vest may be placed on the subject daily with the subject’s consent and will only be perfomed at GSK designated sites that have the capability. Timepoints may be changed based on feasibility.

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ADDED TABLE

Table 19 Cohort 5: Repeat Dose Heart Failure Patients



Admission to Unit XFull Physical Examination XBrief Physical Examination X X X X X X XWeight X X X X X X X XMedical/Medication/Drug/Alcohol/Smoking History

X X

12-lead ECG X X1 X X X X X XTelemetry2 XVital Signs X X3 X X X X X X X X XPulse Oximetry4 X X X X X XEchocardiogram X XAudiometry X X XUrine Drug/Alcohol Breath Test5 X X

Serum -hCG (women) X X XHema/Chem/Urinalysis Tests X X X X X XTroponin X X X X X XDigoxin Concentration6 X X X X X

AE Assessment X X X X X X X X X XC-SSRS X X X XAppetite Assessment X X XCon. Medication Review X X XDyspnoea Scale Scoring X X X X X X XDLco, DLno and Spirometry X X XPK Blood Sample7 X8 X X X X X X9 XPD Blood Sample X8 X9 XTM Blood Sample X10 XStudy Treatment Dosing11 X X X X X X XBodyGuardian Monitor --------------------------------------------- Continuous------------------------------------------------

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PGx12

for subjects who consent (only): collect one PGx sample after the start of dosing (preferably on Day 1 [if not previously collected during the SD treatment period]

Discharge from Unit XClinic Visit X XOutpatient Visit13 X X X X

1. ECGs to be obtained in triplicate.2. Telemetry is performed from 1 hour pre-dose until 48 hours post-dose.3. Vital signs will be taken in triplicate.4. Pulse oximetry will be conducted once on scheduled days only.5. Urine ethanol test will be performed if the patient is unable to perform the alcohol breath test due to breathlessness.6. Only for subjects taking digoxin7. On Days 2 through 6, PK samples will be collected prior to administration of study medication and on Day 8 PK samples will be drawn at approximately 24 hours

after the last dose of study medication.8. Serial sampling will occur on Day 1 and will be drawn at the following timepoints: pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 5h, 8h and 12 hours. Some of these

timepoints may also be utilized to collect samples to determine concentrations of other medications (e.g. atorvastatin and/or simvastatin). See SRM for detailed information.

9. Serial sampling will occur on Day 7 and will be drawn at the following timepoints: pre-dose, 0.25h, 0.5h, 1h, 1.5h, 2h, 3h, 5h and 8h. Some of these timepoints may also be utilized to collect samples to determine concentrations of other medications (e.g. atorvastatin and/or simvastatin). See SRM for detailed information.

10. Transcriptomic/Metabolomic blood samples will be obtained prior to administration and at 12 hours after administration of study medication on Day 1.11. Meals will not be restricted in this cohort.12. Informed consent for optional PGx (Pharmacogenetics) research must be obtained before collecting a sample.13. Days 5 and 6 will be outpatient visits where a nurse will collect vital signs, AEs, blood samples for PK, and administer study medication to subjects at the

subjects’ home. Day 8 will also be an outpatient visit where a nurse will obtain blood samples for PK and PD analysis and record vital signs and AEs..

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Section 6.3.6. Audiometry

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A hearing assessment will be conducted prior to the administration of study medication and at the end of each treatment period as described in the Time and Events Tables for Cohorts 3 and 4 (repeat dose period). Details of the audiometry testing may be found in the SPM.

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A hearing assessment will be conducted prior to the administration of study medication and at the end of each treatment period as described in the Time and Events Tables for Cohorts 3, and 4 (repeat dose period) and 5. Details of the audiometry testing may be found in the SPM.

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Section 6.3.7. Remote Monitoring

For subjects participating in Cohort 5, continuous remote monitoring will be performed during the 7-day repeat dose study period utilizing the Preventice BodyGuardian Remote Monitoring System. The cardiac monitoring system is a portable, wireless body sensor that measures ECG, heart rate, respiratory rate, and activity level. Data will be stored and transmitted to a 24-hour monitoring center. Subjects will be instructed to wear the sensor throughout the study period (Day -1 to Day 7).

6.3.8. SensiVest

For subjects participating in Cohort 4 who consent to this optional prcoedure, the SensiVest (Sensible Medical Innovations) will be placed on the subjects daily to assess lung fluid concentrations at multiple timepoints each day. The vest utilizes noninvasive remote dielectric sensing (ReDS) technology to assess lung fluid concentration. The simple measurement takes 90 seconds to complete. GSK will designate which sites can perform this assessment according to capability.


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In Cohort 4, blood samples will be obtained on Day 1 of the single-dose period and on day 7 of the repeat dose period. Samples will be obtained prior to dose administration and at 0.25, 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 15, 24 and 48 hours (48 hour timepoint only collected on Day 1). Timepoints may be adjusted during the study based on emerging data.


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In Cohort 4, serial blood samples will be obtained on Day 1 of the single-dose period and on day Day 7 of the repeat dose period as listed in the Time and Events Table. In Cohort 5, serial blood samples will be collected on Days 1 and 7 at the timepoints indicated in the Time and Events Table. Samples will be obtained prior to dose administration and at 0.25, 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 15, 24 and 48 hours (48 hour timepoint only collected on Day 1). Timepoints may be adjusted during the study based on emerging data.


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In the repeat-dose phase of Cohort 4 and in Cohort 5, blood samples will be obtained prior to dose administration and at 12 hours after drug administration on Day 1. Blood samples will also be obtained on Day 7 prior to administration of study medication.

Section 6.8.3. Magnetic Resonance Imaging (Cohort 4)

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Each subject in Cohort 4 will have two MRI scans taken: at baseline (before single dose) and after steady-state has been reached during repeat dosing. If a technical failure occurs at the baseline scan, a baseline rescan may be attempted prior to repeat dosing following washout of the single dose. If a technical failure occurs during the MRI scan during repeat dosing, a rescan of the MRI scan may be attempted schedule permitting.

REVISED TEXTEach subject in Cohort 4 will have two MRI scans taken: at baseline (before single dose) and after steady-state has been reached during repeat dosing. If a technical failure occurs at the baseline scan, a baseline rescan may be attempted prior to repeat dosing following washout of the single dose. If a technical failure occurs during the MRI scan during

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repeat dosing, a rescan of the MRI scan may be attempted schedule permitting. See Section 5.3.3.5 for stopping criteria related to CrCl and the MRI scan during the repeat dose session.

Section 9.2.3. Cohort 4 (Heart Failure Patients Single and Repeat Dose)

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The main goal of this cohort is to study the safety and tolerability in the patient population, targeting a total sample size of approximately 18 subjects with stable heart failure [randomized 1:1 (treatment:placebo)]. Sample size for the exploratory measurements is based on feasibility, and is supported by the following information regarding interstitial volume (ve) measured by DCE-MRI.

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The main goal of this cohort is to study the safety and tolerability in the patient population, targeting a total sample size of approximately 18 subjects with stable heart failure [randomized 1:1 (treatment:placebo)]. Sample size for the exploratory measurements is based on feasibility, and is supported by the following information regarding interstitial volume (ve) measured by DCE-MRI in Section 9.2.5.

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Section 9.2.4. Cohort 5 (Heart Failure Patients Repeat Dose)

The main goal of this cohort is to study the safety and pharmacokinetics in the patient population targeting a total sample size of approximately 8 subjects with heart failure [randomized 3:1 (treatment:placebo)]. A sample size of 8 subjects is considered adequate to generate a pharmacokinetic profile in subjects with heart failure.

Section 9.3.1. Interim Analysis

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For these analyses in Cohort 1, plasma concentration- time data will be analyzed using nominal times. The decision to proceed to higher doses will be made by the study team

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with consultation from the Investigator based on assessment of safety/tolerability and actual PK data at the preceding dose.




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Cohort 5: A review of safety, tolerability and efficacy data will be performed after 8 subjects complete all assessments in Cohort 5.

Section 9.3.2.3.1 Cohort 4 and Cohort 5

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9.3.2.3.1. Cohort 4

DCE-MRI measurements ve, and ktrans (and other physiologic variables to be explored including endpoints measured during exercise testing) will be fitted using a mixed effect model with treatment as a fixed effect and baseline as a covariate. Point estimates and associated 95% confidence intervals will be constructed to provide a plausible range of values for the true comparisons of interest, such as the mean difference between treatment and placebo. If model assumptions appear grossly violated, alternative methods (e.g., use of raw data with log transformation or non-parametric methods) will be considered.

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9.3.2.3.1. Cohort 4 and Cohort 5

DCE-MRI measurements ve, and ktrans (and other physiologic variables to be explored including endpoints measured during exercise testing) in Cohort 4 will be fitted using a mixed effect model with treatment as a fixed effect and baseline as a covariate. Point estimates and associated 95% confidence intervals will be constructed to provide a plausible range of values for the true comparisons of interest, such as the mean difference between treatment and placebo. If model assumptions appear grossly violated, alternative methods (e.g., use of raw data with log transformation or non-parametric methods) will be considered.


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Food and Drug Administration. FDA Drug Safety Communication: New warnings for using gadolinium-based contrast agents in patients with kidney dysfunction. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm223966.htm. Accessed: September 18, 2015

Updated GlaxoSmithKline Investigator’s Brochure to document number 2013N162862_02

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AMENDMENT 7




This amendment revises the QTc eligibility and withdrawal criteria for Cohorts 4 and 5.


Section 1.2.1 GSK2798745 (last paragraph)

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A preliminary review of the healthy volunteer QT data from Cohorts 1-3 was performed, after exposure to single doses of 0.1mg, 1mg, 5mg, and 12.5mg, and repeat dose exposure of 5mg daily. Categorical analysis demonstrated that no subjects experienced an increase in QTc from baseline of 30-60ms, or >60ms, and no subjects had a QTc value of 480-500ms, or >500ms while on therapy. Exposure response analysis demonstrated no evidence of a relationship between concentration of GSK2798745 and QTc prolongation. In consideration of the lack of pre-clinical signal for effect on cardiac repolarization and the negative healthy volunteer clinical data, extended QT eligibility and stopping criteria will be implemented in Cohorts 4 and 5 (See Section 4.2 and Section 5.3.2.2 for updated eligibility and stopping criteria).

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A preliminary review of the healthy volunteer QT data from Cohorts 1-3 was performed, after exposure to single doses of 0.1mg, 1mg, 5mg, and 12.5mg, and repeat doseexposure of 5mg daily. Categorical analysis demonstrated that no subjects experienced an increase in QTc from baseline of 30-60ms, or >60ms, and no subjects had a QTc value of 480-500ms, or >500ms while on therapy. Exposure response analysis demonstrated no evidence of a relationship between concentration of GSK2798745 and QTc prolongation.


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7. Body weight 50kg and BMI within the range 18-40kg/m2 (inclusive) :

8. Capable of giving written informed consent, which includes compliance with the requirements and restrictions listed in the consent form:

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a. Non-childbearing potential defined as pre-menopausal females with a documented tubal ligation or hysterectomy for this definition,

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“documented” refers to the outcome of the Investigator's/designee’s review of the subject's medical history for study eligibility, as obtained via a verbal interview with the subject or from the subject’s medical records; or postmenopausal defined as 12 months of spontaneous amenorrhea. In questionable cases a blood sample with simultaneous follicle stimulating hormone (FSH) > 40MlU/ml and estradiol < 40pg/ml (<147pmol/L) is confirmatory.





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c. QTc < 450msec; or

d. QTc < 480msec in subjects with Bundle Branch Block


b. Non-childbearing potential defined as pre-menopausal females with a documented tubal ligation or hysterectomy for this definition, “documented” refers to the outcome of the Investigator's/designee’s review of the subject's medical history for study eligibility, as obtained via a verbal interview with the subject or from the subject’s medical records; or postmenopausal defined as 12 months of spontaneous amenorrhea. In questionable cases a blood sample with simultaneous follicle stimulating hormone (FSH) > 40MlU/ml and estradiol < 40pg/ml (<147pmol/L) is confirmatory.




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Section 5.3.2.2. Heart Failure Patients (Cohorts 4 and 5)


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A subject who meets any of the criteria below will be withdrawn from the study. The same QT correction formula (QTcB or QTcF) should be used to determine inclusion anddiscontinuation for any individual subject throughout the study.







<450msec > 500msec450-480msec 530msec


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