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Clinical Study Protocol

Protocol ID: BCD-131-2

CONFIDENTIAL Version 1.0 of June 15, 2017 of 163

CLINICAL STUDY PROTOCOL

Protocol Title:

An International, Multicenter, Randomized, Open-Label,

Comparative Clinical Study of the Efficacy and Safety of

BCD-131 (JSC BIOCAD, Russia) and Mircera® (F.

Hoffmann-La Roche Ltd, Switzerland) in the Treatment of

Anemia in Dialysis Patients with Chronic Kidney Disease

Protocol ID: BCD-131-2, NCT03519243 Protocol Date: June 15, 2017

Protocol Amendment

Number:

Not applicable.

Protocol Amendment Date: Not applicable.

Protocol Version: 1.0

Study Sponsor/Monitor:

JSC BIOCAD, Russia

Legal address: 34-A, Ul. Svyazi, Strelna, Petrodvortsoviy

District, Saint Petersburg, Russian Federation, 198515

Postal address: Petrovo-Dalnee, Krasnogorskiy District,

Moscow Region, Russian Federation, 143422

Tel.: +7 (495) 992-66-28, Fax: +7 (495) 992-82-98

Sponsor’s Contact Person Responsible for Signing the

Protocol and Protocol

Amendments:

Roman Alexeevich Ivanov, Vice President for Research &

Development

Address: JSC BIOCAD, Petrovo Dalnee, Krasnogorskiy

District, Moscow Region,

Russian Federation, 143422

e-mail: [email protected]

Tel.: + 7 (495) 992-66-28 (ext. 154)

Sponsor’s Responsible Medical Expert:

Arina Valeryevna Zinkina-Orikhan, Medical Expert, Category

II

JSC BIOCAD, 34-A, Ul. Svyazi, Strelna, Petrodvortsoviy

District, Saint Petersburg, Russian Federation, 198515

e-mail: [email protected]

Tel.: +7 (812) 380-49-33, ext. 744

The information contained in this document is confidential and intended to be used solely by investigators, ethics

committee members and health authorities. This information may not be transferred to any third party without the

prior written permission of JSC BIOCAD, except when necessary for obtaining the patient’s consent to participate in the study. The above-mentioned requirements become effective upon the signing of this Protocol.




TABLE OF CONTENTS

TABLE OF CONTENTS .............................................................................................................................. 2

SIGNATURE SHEET ................................................................................................................................... 7

ABBREVIATIONS ....................................................................................................................................... 8

TERMS AND DEFINITIONS .................................................................................................................... 10

DOCUMENT HISTORY ............................................................................................................................ 12

SYNOPSIS .................................................................................................................................................. 17

1. BACKGROUND AND RATIONALE ................................................................................................... 37

1.1 Introduction ....................................................................................................................................... 37

1.2. Name and description of investigational products ........................................................................... 39

1.3. Summary of findings from nonclinical studies that have potential clinical significance and

summary of relevant clinical research ..................................................................................................... 42

1.3.1. Preclinical studies ................................................................................................................. 42

1.3.1.1. Overview of physicochemical studies ................................................................................ 43

1.3.1.2. Preclinical studies in laboratory animals ............................................................................ 43

1.3.1.2.1. Pharmacodynamics of a single subcutaneous injection of BCD-131 in mice ............. 43

1.3.1.2.2. Pharmacokinetics of a single subcutaneous injection of BCD-131 in mice ................ 45

1.3.1.2.3. Acute toxicity of BCD-131 ......................................................................................... 45

1.3.1.2.4. Non-clinical repeat-dose toxicity of BCD-131 ........................................................... 46

1.3.1.2.5. Local tolerance study during repeat-dose toxicity study of BCD-131 ........................ 48

1.3.1.2.6. Immunogenicity assessment of BCD-131 ................................................................... 48

1.3.2. Clinical studies of BCD-131 ................................................................................................ 48

1.3.2.1. Results of the PK study of BCD-131 in healthy volunteers ............................................... 50

1.3.2.1.1. Discussion of PD results.................................................................................................. 52

1.3.2.1.2. Discussion of safety results ............................................................................................. 53

1.3.2.1.4. Discussion of results of the Phase I study ....................................................................... 55

1.3.3. Conclusions and study rationale ........................................................................................... 56

1.4. Brief description of known and potential risks and benefit for study subjects (benefit/risk ratio) .. 58

1.4.1. Benefit evaluation ................................................................................................................. 58

1.4.2. Risk evaluation ..................................................................................................................... 58

1.4.3. Conclusions .......................................................................................................................... 60

1.5. Description and justification of administration mode, doses, dosage regimen and treatment course

................................................................................................................................................................. 61

1.5.1. Description and justification of administration mode, doses, dosage regimen and treatment

course ............................................................................................................................................. 61

1.5.2. The rationale for the selection of the reference drug ............................................................ 68

1.6. Compliance of the clinical study with regulatory requirements ....................................................... 69

1.7. Description of study population ....................................................................................................... 69

1.8. References ........................................................................................................................................ 69

2. STUDY PURPOSE AND OBJECTIVES ............................................................................................... 72




2.1 Study aims ......................................................................................................................................... 72

2.2 Study objectives ................................................................................................................................ 72

3. STUDY HYPOTHESIS .......................................................................................................................... 72

4. STUDY DESIGN .................................................................................................................................... 72

4.1. Primary and secondary endpoints .................................................................................................... 72

4.1.1 Primary endpoint ................................................................................................................... 72

4.1.2 Secondary endpoints .............................................................................................................. 73

4.2. Description of the study type/design, flow-chart, procedures and periods ...................................... 74

4.3. Measures to minimize/exclude bias ................................................................................................. 85

4.3.1. Distribution of patients to study sites ................................................................................... 85

4.3.2. Procedure of assigning study IDs ......................................................................................... 85

4.3.3. Stratification procedure ........................................................................................................ 86

4.3.4. Randomization procedure ..................................................................................................... 86

4.3.5. Blinding ................................................................................................................................ 91

4.4. Study therapy, doses and dosage regimens of investigational products Pharmaceutical form,

packaging and labeling of investigational products ................................................................................ 91

4.4.1. Study therapy, doses, and dosage regimens of investigational products .............................. 91

4.4.2. Pharmaceutical form, packaging and labeling of investigational products .......................... 92

4.4.2.1. Test drug ............................................................................................................................. 92

4.4.2.2. Reference drug ................................................................................................................... 92

4.5. Expected duration of the study and subjects’ participation in the study .......................................... 92

4.6. Study periods .................................................................................................................................... 92

4.6.1 Study schedule ....................................................................................................................... 92

4.2.6. Procedures of individual visits ............................................................................................. 98

4.7. Description of individual study procedures.................................................................................... 106

4.7.1. Collecting complaints, demographics and patients’ medical history ................................. 112

4.7.2. Physical examination .......................................................................................................... 112

4.7.3. Vital signs ........................................................................................................................... 112

4.7.4. Laboratory tests .................................................................................................................. 113

4.7.4.1. Compete blood count ....................................................................................................... 113

4.7.4.2. Blood biochemistry .......................................................................................................... 113

4.7.4.3. Blood test for intact parathyroid hormone (iPTH) .......................................................... 114

4.7.4.4. Serological tests ................................................................................................................ 114

4.7.4.5. Urinalysis ......................................................................................................................... 115

4.7.4.6. Pregnancy test. ................................................................................................................. 115

4.7.5. ECG .................................................................................................................................... 116

4.7.6. Chest X-ray/fluorography ................................................................................................... 116

4.7.7. Blood sampling for PK, PD and immunogenicity assessment .......................................... 116

4.7.8. Storage and shipping of biospecimens ............................................................................... 123

4.7.9. Procedure for determination of analyte in the serum ......................................................... 123

4.7.10. Unscheduled visits ............................................................................................................ 123

4.7.11. Filling in electronic CRFs ................................................................................................ 124




4.8. Stop rules and criteria for premature withdrawal for study subjects, study periods, and study as a

whole ..................................................................................................................................................... 124

4.8.1. Stop rules for study as a whole ........................................................................................... 124

4.8.2. Premature withdrawal criteria for study subjects ............................................................... 124

4.9. Drug accountability ........................................................................................................................ 124

4.9.1. Handling of investigational products ................................................................................. 125

4.10. Procedure for keeping and unblinding randomization codes ....................................................... 126

4.11. List of all data recorded in CRF (without previous recording in written or electronic form) and

considered as source data. ..................................................................................................................... 126

5. ELIGIBILITY AND EXCLUSION OF STUDY SUBJECTS .............................................................. 126

5.1. Inclusion Criteria ............................................................................................................................ 126

5.2. Exclusion Criteria ........................................................................................................................... 127

5.2. Exclusion criteria ........................................................................................................................... 128

5.4. Follow-up of subjects withdrawn from the study/study therapy .................................................... 129

5.4.1. Follow-up of patients who received at least one dose of the investigational products ....... 129

5.4.2. Follow-up of subjects who did not receive a single dose of the investigational products .. 130

6. TREATMENT OF STUDY SUBJECTS .............................................................................................. 131

6.1 Study therapy .................................................................................................................................. 131

6.1.1. Therapy regimen and duration ............................................................................................ 131

6.1.2. Correction and adjustment of study therapy ....................................................................... 132

6.1.3. Overdose of the test/reference drug ............................................................................... 133

6.2. Concomitant therapy, medications allowed and prohibited by the Protocol .................................. 134

6.2.1. Allowed concomitant therapy............................................................................................. 134

6.2.2. Allowed concomitant therapy that requires special precautions for use and/or some

measures ....................................................................................................................................... 134

6.2.3. Prohibited concomitant therapy .......................................................................................... 134

6.2.4. Therapy in special populations. .......................................................................................... 135

6.3. Compliance with study procedures ................................................................................................ 135

6.3.1. Compliance assessment ...................................................................................................... 136

7. EFFICACY EVALUATION ................................................................................................................. 136

7.1. Efficacy endpoints ................................................................................................................. 136

7.2 Methods and time frames for assessment, documenting, and analysis of efficacy variables .......... 137

7.2.1 Time frames for analysis of efficacy variables .................................................................... 137

7.2.2 Methods, time frames for assessment and documenting of efficacy variables .................... 137

8. SAFETY EVALUATION ..................................................................................................................... 137

8.1. List of safety variables ................................................................................................................... 137

8.1.1. Definitions of terms ............................................................................................................ 137

8.1.1.1. Adverse events ................................................................................................................. 137

8.1.1.2. Serious adverse events ..................................................................................................... 138

8.1.1.3. Unexpected adverse reactions .......................................................................................... 139

8.1.2. Safety endpoints ................................................................................................................. 139

8.1.3. Immunogenicity assessment ............................................................................................... 140




8.2. Methods and time frames for assessment, documenting, and analysis of safety variables ............ 140

8.2.1. Time frames for analysis of safety variables ...................................................................... 140

8.2.2. Methods, time frames for assessment and documenting of safety variables ...................... 140

8.3. Requirements for reports. Documenting and reporting AEs and completing AE Report Forms ... 141

8.3.1. Documenting AEs/SAEs .................................................................................................... 141

8.3.2. Reporting AE/SAE ............................................................................................................. 143

8.3.3. Reporting pregnancy .......................................................................................................... 146

8.3.4. Reporting improper administration of the investigational product. .................................... 146

8.3.5. Reporting drug overdose. ................................................................................................... 147

8.4. Methods and duration of follow-up for study subjects who had an AE/SAE ................................ 147

9. STATISTICS ......................................................................................................................................... 148

9.1. Description of statistical methods to be used ................................................................................. 148

9.1.2 Statistical methods for the assessment of safety of the test and reference drugs ......................... 149

9.1.3 Methods of Calculation of PK and PD parameters.............................................................. 150

9.1.4 Calculation of PD parameters of the test and reference drugs ............................................ 151

9.2. Stages of statistical analysis, timelines for preparing reports ......................................................... 152

9.3. Planned number of study subjects, justification of sample size, including reasoning or calculations

to justify statistical power and clinical justification of the study, and suitable significance level ........ 152

9.4. Suitable level of significance ......................................................................................................... 154

9.5. Statistical criteria for stopping and terminating the study .............................................................. 154

9.6. Handling missing, not evaluable or uncertain data ........................................................................ 154

9.7. Reporting any deviations from the statistical plan ......................................................................... 155

9.8. Selection of subjects for analysis ................................................................................................... 155

10. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS ................................................................. 156

11. QUALITY CONTROL AND ASSURANCE ..................................................................................... 156

11.1. Data quality assurance .................................................................................................................. 156

11.2. Investigator’s adherence to the Protocol ...................................................................................... 157

11.3. Investigator’s responsibility for protocol compliance .................................................................. 157

11.4. Study monitoring .......................................................................................................................... 158

11.5. Data management and quality control ................................................................................... 158

11.6. Study termination ......................................................................................................................... 159

12. ETHICS ............................................................................................................................................... 159

12.1. Ethics aspects of the study ........................................................................................................... 159

12.2. Confidentiality of study subjects .................................................................................................. 160

13. DATA HANDLING AND RECORD KEEPING ............................................................................... 160

13.1. Record keeping at the study site ................................................................................................... 160

13.2. Confidentiality of data .................................................................................................................. 161

13.3. Collection of data ......................................................................................................................... 161

14. FINANCE AND INSURANCE .......................................................................................................... 162




15. PUBLICATIONS ................................................................................................................................ 163




SIGNATURE SHEET

To Protocol version 1.0 of June 15, 2017: “An International, Multicenter, Randomized, Open-Label, Comparative

Clinical Study of the Efficacy and Safety of BCD-131 (JSC BIOCAD, Russia) and Mircera® (F. Hoffmann-La Roche

Ltd, Switzerland) in the Treatment of Anemia in Dialysis Patients with Chronic Kidney Disease”.

I, the undersigned, agree with the following:

1. I have read all provisions of this Protocol, I accept them, and I agree to conduct the study in compliance with

this Protocol, ICH Guideline for Good Clinical Practice (GCP), and requirements of the regulatory authorities

of the participating countries.

2. I will ensure no deviations from the Protocol to take place without the prior written permission of the Sponsor

approved by regulatory authorities, local ethics committees of participating countries, except when necessary

for protecting the study subject from an immediate danger.

3. I confirm that all staff members are appropriately qualified to conduct the study, the study site has all

necessary equipment, and I, the study investigator, have sufficient time to conduct this study in compliance

with the Protocol

4. I will take all due measures to ensure that all the staff members involved in the study have read and

understood this Protocol and correctly perform their duties during the study.

5. I agree to fully cooperate with audits and inspections conducted in accordance with the rules established by

the Sponsor and the state regulatory authorities.

6. I understand that the text of this Protocol, all other materials, and the results of this study are confidential and

proprietary information of the Sponsor. I agree not to disclose this information to a third party except when

required by the local legislation.

Principal Investigator: ______________________________ Signature

______________________________ Full Name

______________________________ Date

R.A. Ivanov, Vice-President, R&D, JSC BIOCAD: ______________________________

Signature

______________________________ Date




ABBREVIATIONS

AC-Emax Maximum absolute reticulocyte count after the first injection

AUC Area under the concentration vs. time curve

AUEC Total area under the effect vs. time curve

BCD-131 Pegylated darbepoetin, JSC BIOCAD

Cl Total clearance

Cmax Maximum concentration

CTCAE Common Toxicity Criteria for Adverse Events

FDA Food and Drug Administration

GCP Good Clinical Practice

GMP Good Manufacturing Practice

HbsAg Hepatitis B surface antigen

HBV Hepatitis B virus

HCV Hepatitis C virus

HED Human equivalent dose

ICН International Conference on Harmonization

MRSD Maximum recommended starting dose

MRT Mean residence time

NOAEL No-Observed-Adverse-Effect Level

CL Total clearance

Kel Elimination rate constant

T½ Half-life

Vd Volume of distribution

BP Blood pressure

ALT Alanine aminotransferase

AST Aspartate aminotransferase

VAS Visual analogue scale

ULN Upper limit of normal

HIV Human Immunodeficiency Virus

WHO World Healthcare Organization

NOAEL No-Observed-Adverse-Effect Level

DLT Dose-limiting toxicity




DNA Deoxyribonucleic acid

JSC Joint Stock Company

IMU Instruction for Medical Use

BMI Body Mass Index

CRF Case Report Form

ELISA Enzyme-Linked Immunosorbent Assay

DSMC Data Safety Monitoring Committee

LDH Lactate dehydrogenase

INN International Nonproprietary Name

MTD Maximum tolerated dose

MRSD Maximum recommended starting dose

AE Adverse event

TO Thoracic organs

PEG Polyethylene glycol

RAMS Russian Academy of Medical Sciences

SAE Serious adverse event

ESR Erythrocyte sedimentation rate

PD Pharmacodynamics

PK Pharmacokinetics

HR Heart rate

AP Alkaline phosphatase




TERMS AND DEFINITIONS

Term Definition

Investigational

product

This term includes the test drug and the reference drug. It is a

pharmaceutical form of an active ingredient being tested or used as a

reference in a clinical study, including an authorized product when

used or assembled (formulated or packaged) in a way different from

the approved form, or when used for an unapproved indication, or

when used to gain further information about an approved use.

Study/test

product/drug

A pharmaceutical form being tested in the clinical study.

Comparator/reference

product/drug

An active control being tested as a control in the clinical study to

reduce the bias of assessments, keep the study therapy blind, and assess

the internal validity of the study and/or comparative effects of the

study product.

Case Report Form

(CRF)

A printed or electronic document designed to record all the protocol-

required information to be reported to the Sponsor on each study

subject.

Investigator’s Brochure

A compilation of the clinical and nonclinical data on the

investigational product that is relevant to the study of the

investigational product in human subjects.

Subject Identification

Code (subject ID)

|__|__|-|__|__|__|

A unique identifier assigned by the Investigator to each study subject

to protect the subject’s identity and used instead of the subject’s name when the Investigator reports adverse events and/or other study-related

data.

Usually, the subject ID is a five-digit code where the first two digits

are the site number and the last three digits are assigned sequentially

to each participant as he/she enters the study.

Screening Number

|__|__|-|__|__|__|

A unique code assigned to each study subject who have signed the

informed consent. The first two digits are the site number, and the last

three digits are assigned sequentially to each patient as he/she gets

enrolled at this particular study site.

Evaluation A procedure used to obtain data required in the study.

Inclusion in the study A time point when the study subject signs the Patient Information

Sheet and the Informed Consent Form.

Any other therapy

during the study

Any medications other than the investigational product(s) that are used

to perform the study procedures. This includes, for example, the drugs

used as part of the combination therapy.

Early discontinuation /

withdrawal / dropout

A time point when the patient discontinues participation in the study

before the planned investigational treatment is completed and/or

assessments are performed. No further assessments are performed

beyond this point except for monitoring the survival and/or disease

progression in certain studies. If the patient discontinues the study due

to an event planned by the Protocol (for example, a complete

response), he/she is considered a dropout anyway.

Completion of the

study

A time point when the patient makes his/her last study visit.




Term Definition

Study therapy Any drug product or a combination of drug products, including

concomitant medication, used in any treatment group to perform the

study procedures.

Concomitant therapy Treatment with any drugs included in the study therapy, except for

the test drug and reference drug. For example, drugs used for

combination therapy, pre-medication etc.

Discontinuation of

study therapy

A time point corresponding to the permanent discontinuation of the

study therapy regardless of the reason. It can correspond (or not) to the

time point of the patient’s early withdrawal Variable An identifier used for the data analysis and derived directly or

indirectly from the protocol-specified assessments at pre-determined

time points.




DOCUMENT HISTORY

N/A.

Names/positions of investigators responsible for conducting the study. Contact information

of the study sites

No

.

Name/ Position of

Principal Investigator

Name of Study (Clinical)

Site

Address and Contacts of the

Study (Clinical) Site

Medical institutions in the Russian Federation

1. Vladimir Petrovich

Babich, Nephrologist,

Medical Director, Black

Sea Branch Offices of

Limited Liability

Company “Nephros” Medical Center

Limited Liability Company

“Nephros” Medical Center (“Nephros” Medical Center LLC), Department 9 of the

“Nephros” Dialysis Center.

Address: 28, 28/1, 28/4, Ul.

Shosse Neftyanikov, Krasnodar,

Russian Federation, 350051;

Study Site Address: 15-B, Ul.

Krasina, Novorossiysk, Krasnodar

Krai, Russian Federation, 353915;

Telephone:

+7 (861) 217-02-45,

+7 918 370-43-18,

+7 (8617) 760063,

Fax:

+7 (8617) 760063,

e-mail:

[email protected],

[email protected],

[email protected]

2. Konstantin Alexandrovich

Vishnevsky, Head of

Department of Chronic

Hemodialysis, Saint

Petersburg State

Budgetary Healthcare

Institution “City Hospital 15”

Saint Petersburg State


Institution “City Hospital 15” (SPb SBHI “City Hospital 15”)

4, Ul. Avangardnaya, Saint

Petersburg, Russian Federation,

198205,

Telephone:

+7 (812) 735-96-98,

+7 (812) 736-93-42,

Fax:

+7 (812) 735-07-66,

+7 (812) 736-93-42,

e-mail:

[email protected],

[email protected]

3. Alexander Vasilievich

Zuev, Head of

Hemodialysis Department,

State Budgetary

Healthcare Institution of

the Republic of Karelia

“V.A. Baranov Republican Hospital”

State Budgetary Healthcare

Institution of the Republic

of Karelia “V.A. Baranov Republican Hospital” (SBHI RK “V.A. Baranov Republican Hospital”),

3, Ul. Pirogova, Petrozavodsk,

Russian Federation, 185000,

Telephone:

+7-(814)-2-76-44-40,

+7-(814)-2-764-285,

Fax:

+7-(814)-2-76-03-71,

+7-(814)-2-764-440,

mailto:[email protected]





e-mail:

[email protected],

[email protected]

4. Lidiya Ivanovna Kotova,

MD, PhD, Head of

Nephrology and Dialysis

Department, Budgetary

Healthcare Institution of

Omsk Region “Regional Clinical Hospital”


Institution of Omsk Region

“Regional Clinical Hospital” (BHI OR “Regional Clinical Hospital”)

3, Ul. Berezovaya, Omsk, Russian

Federation, 644111,

Telephone:

+7 (3812) 23-26-74,

+7 (3812) 35-92-83,

Fax:

+7 (3812) 25-66-68,

e-mail:

[email protected]

u,

[email protected]

5. Anton Borisovich Legotin,

Nephrologist,




Institution “St. Elizabeth City Hospital”



Institution “St. Elizabeth City Hospital” (SPb SBHI “St. Elizabeth City Hospital”)

14-A, Ul. Vavilovykh, Saint


197706,

Telephone:

+7 (812) 555-57-73,

+7 (812) 555-14-84,

Fax:

+7 (812) 555-15-05,

e-mail:

[email protected],

[email protected]

6. Anastasiya Borisovna

Sabodash, MD, PhD, Head

of Dialysis Department,

Limited Liability

Company “B. Braun

Avitum Russland Clinics”


“B. Braun Avitum Russland

Clinics”

(“B. Braun Avitum

Russland Clinics” LLC), Dialysis Center of Separate

Subdivision 1, Saint

Petersburg

Address:

Room 24-A, 34-A, 7th Liniya

V.O., Saint Petersburg, Russian

Federation, 199004; Study Site

Address:

Bld. 1-A, 1, Ul. Badaeva, Saint


193318, Telephone:

+7 (812) 640-13-04,

Fax:

+7 (812) 640-13-04,

e-mail:

[email protected],

[email protected],

[email protected]

7. Viktor Nikolaevich

Suchkov, Nephrologist,




Institution “Mariinsky Hospital”



Institution “Mariinsky Hospital” (SPb SBHI “Mariinsky Hospital”)

56, Liteyny Prospect, Saint

Petersburg,

Russian Federation 191104,

Telephone:

+7 (812) 275-74-46,

+7 (812) 275-73-28,

Fax:

+7 (812) 275-73-36,

e-mail:




tel:88125555773






[email protected],

[email protected]

8. Galina Yurievna

Timokhovskaya, Head of

Dialysis Treatment

Department, Saint

Petersburg State


Institution “City Clinical Hospital 31”



Institution “City Clinical Hospital 31” (SPb SBHI “City Clinical Hospital 31”)

3, Dinamo Prospect, Saint

Petersburg,


Telephone:

+7 (812) 235-11-04,

+7 (812) 230-47-98,

Fax:

+7 (812) 235-21-11,

+7 (812) 230-47-98,

e-mail:

[email protected],

[email protected]

9. Leisan Ildarovna

Fakhrutdinova,

Nephrologist,


State Autonomous

Healthcare Institution

“Republican Clinical Hospital of the Ministry of

Health of the Republic of

Tatarstan”

State Autonomous


“Republican Clinical Hospital of the Ministry of


Tatarstan” (SAHI “Republican Clinical

Hospital of the Ministry of


Tatarstan”)

138, Orenburgsky Tract, Kazan,

Republic of Tatarstan,


Telephone:

+7 (843)-231-21-09,

+7 (843)-231 21 38,

Fax:

+7 (843)-235-33-22,

e-mail:

[email protected],

[email protected]

10. Larisa Alexeevna

Fedotova, Medical

Director, Nephrologist,

Limited Liability

Company “Nephroline-

Novosibirsk”


“Nephroline-Novosibirsk” (“Nephroline-Novosibirsk” LLC)

Address:

1, Ul. Syzranskaya, Novosibirsk,

Russian Federation, 630025 Study

Site Address:

143/1, Ul. Nemirovicha-

Danchenko,

Novosibirsk, Russian Federation,

630087,

Telephone:

+7 (383) 314-22-00,

+7 (383) 314-22-00,

+7 (383) 314-45-05,

Fax:

+7 (383) 314-20-50,

e-mail:

[email protected],

[email protected]

11. Nadezhda Georgievna

Khadikova, MD, PhD,

Deputy Medical Director

for Organizational and

Methodical Work, Saint

Petersburg State



Institution “Nikolaevsky Hospital” (SPb SBHI “Nikolaevsky Hospital”)

1, Ul. Konstantinovskaya,

Peterhof, Russian Federation,

198510

Telephone:

+7 (812) 450-63-79,

+7 (812) 450-65-61,








Institution “Nikolaevsky Hospital”

Fax:

+7 (812) 450-66-30,

+7 (812) 450-65-61,

e-mail:

[email protected],

[email protected]

Medical institutions in the Republic of Belarus

1. Dmitry Mikhailovich

Toropilov, Deputy

Medical Director,


“N. E. Savchenko City

Clinical Hospital 4”


“N. E. Savchenko City

Clinical Hospital 4” (HI “N. E. Savchenko City

Clinical Hospital 4”)

110, Ul. Rosy Luxemburg,

Minsk, Republic of Belarus,

220036,

Telephone:

+375 (17) 286-19-93,

+375 (17) 208-95-73,

Fax:

+375 (17) 208-95-74,

e-mail:

[email protected],

[email protected],

[email protected]

2. Oleg Valentinovich

Kalachik, Head of

Nephrology, Renal

Replacement Therapy and

Kidney Transplantation

Department, Healthcare

Institution “City Clinical Hospital 9”

Healthcare Institution “City Clinical Hospital 9” (HI “City Clinical Hospital 9”)

8, Ul. Semashko,

Minsk, Republic of Belarus,

220045,

Telephone:

+375 (17) 272-73-90,

+375 (17) 277-21-03,

Fax:

+375 (017) 272-41-63,

e-mail:

[email protected],

[email protected]

3. Sergey Vitalievich

Prilutsky, Head of



“Minsk Regional Clinical Hospital”


“Minsk Regional Clinical Hospital” (HI “Minsk Regional Clinical Hospital”)

Lesnoy Agro-town, Minsk

Region, Republic of Belarus,

223041

Telephone:

+375 (17) 265-21-68,

+375 (17) 265-48-64,

Fax:

+375 (17) 265-21-26,

e-mail:

[email protected],

[email protected]










Names and addresses of clinical or other medical and/or technical services and/or

organizations involved in the study

No. Name of

Institution

Position in

the Study

Person in

Charge

Position of the

Person in

Charge

Address of

Institution

Telephone,

Fax, Email

1. Bioanalytical

Laboratory,

Analytical

Development

Division

JSC BIOCAD

Central

Analytical

Laboratory

Aleksandr

Valeryevich

Novikov

Head of

Analytical

Development

Division, JSC

BIOCAD, MD,

PhD

34-A, Ul.

Svyazi,

Strelna,

Petrodvortso

viy District,

Saint

Petersburg,

Russian

Federation,

198515

Telephone: +7

(812) 380-49-

33, ext.

928/906,

Fax: +7 (812)

380-49-34,

Email:

novikov@bio

cad.ru

callto:928906




SYNOPSIS

Protocol ID BCD-131-2

Study Title An International, Multicenter, Randomized, Open-Label,

Comparative Clinical Study of the Efficacy and Safety of BCD-131

(JSC BIOCAD, Russia) and Mircera® (F. Hoffmann-La Roche

Ltd, Switzerland) in the Treatment of Anemia in Dialysis Patients

with Chronic Kidney Disease.

Phase II

Study Sponsor JSC BIOCAD

Postal address: Petrovo-Dalnee, Krasnogorskiy District, Moscow

Region, Russian Federation, 143422

Legal address: 34-A, Ul. Svyazi, Strelna, Petrodvortsoviy District,

Saint Petersburg, Russian Federation, 198515

Test drug BCD-131 — pegylated darbepoetin (JSC BIOCAD, Russia),

solution for injection.

Description of the Test

Drug

BCD-131 is a covalent conjugate of darbepoetin with the low

content of sialic acids and linear methoxy-polyethylene glycol with

the molecular weight of 30 kDa. Pegylated darbepoetin is expected

to have a longer half-life and higher in vivo activity than the

available authorized drugs. As a result, the drug will be

administered to patients less often, the blood concentration of the

active ingredient will be more stable thus promoting further

improvement of the patient’s prognosis and quality of life. Pegylated darbepoetin (BCD-131) developed by JSC

BIOCAD is an innovative biotechnology product. To date, a

comprehensive study of structural, physico-chemical and

biological properties of BCD-131 has been conducted. The amino

acid profile, three-dimensional structure, sialylated form profile,

purity and homogeneity, in vivo potency and stimulating activity of

pegylated darbepoetin in TF-1 cells have been studied.

The first step of clinical development of BCD-131 was the

evaluation of its effects in healthy volunteers in the Phase I study:

“Open-Label Single Ascending Dose Clinical Trial to Evaluate the

Pharmacokinetics, Pharmacodynamics, Tolerability, Safety and

Immunogenicity of BCD-131 in Healthy Volunteers as Compared

to Mircera® (F. Hoffman-La Roche Ltd., Switzerland) and

Aranesp® (Amgen Europe B.V., Netherlands)”. According to the results of the Phase I study, the anticipated therapeutic dose range

of BCD-131 was selected based on the evaluation of the drug

pharmacodynamic (PD) effect on stimulation of erythropoiesis.

The pharmacodynamic response reflected by the increased

reticulocyte count, which was very similar to that due to the




SYNOPSIS

comparator Mircera®, was observed in the cohorts of volunteers

receiving BCD-131 at a dose of 1.05 µg/kg, 1.7 µg/kg, and

2.75 µg/kg. The further development of BCD-131 includes the

study of its efficacy and safety for the treatment of renal anemia

due to the end-stage chronic renal failure (CKD (chronic kidney

disease) stage 5D) in epoetin or darbepoetin alfa-treated patients.

Reference Drug Mircera® — methoxy polyethylene glycol-epoetin beta

(F. Hoffmann-La Roche Ltd., Switzerland) solution for intravenous

and subcutaneous injection.

Study Aims and

Objectives

Study aim:

To determine an effective and safe therapeutic dose of

BCD-131 upon repeated administration of the drug to dialysis

patients with chronic kidney disease treated for anemia.

Study objectives

1. Determine and compare the efficacy variables of 3 different

doses of BCD-131 upon multiple administration of the test

drug with those of Mircera®.

2. Study and compare the adverse event profile of 3 different

doses of BCD-131 upon multiple administration of the test

drug with that of Mircera®.

3. Determine and compare the pharmacokinetics (PK) and

pharmacodynamics (PD) of 3 different doses of BCD-131

upon multiple administration of the test drug with those of

Mircera®.

4. Determine and compare the proportion of BAb- and NAb-

positive patients in the BCD-131 and Mircera® groups.

Study Design Clinical study BCD-131-2 is an international, multicenter,

randomized, open-label, comparative two-stage clinical study to

determine an effective and safe therapeutic dose of BCD-131 upon

multiple administration of the drug to dialysis patients with chronic

kidney disease treated for anemia.

The study will include up to 100 dialysis patients with

stage 5D chronic kidney disease (end-stage chronic renal failure),

established efficacy of dialysis and renal anemia without other

causes of anemia development (such as anemia of chronic disease,

vitamin B12 deficiency, folic acid deficiency, iron deficiency),

receiving erythropoiesis-stimulating agents (ESA) and reaching

target hemoglobin levels. This study is a study of the maintenance

treatment of anemia; therefore, the study population includes

patients:




SYNOPSIS

− receiving recombinant erythropoietin (EPO)

(epoetin alfa or epoetin beta, or darbepoetin alfa)

for at least 3 months before signing the Informed

Consent (IC);

− receiving a stable dose of recombinant EPO

(epoetin alfa or epoetin beta, qw, biw, tiw, or

darbepoetin alfa, qw or q2w) for at least 2 weeks

before signing the Informed Consent and during the

screening period;

− with hemoglobin levels within target values (100-

120 g/L) for at least 2 weeks before signing the

Informed Consent and at screening.

Randomization and Stratification

The study plans to include 4 groups: 3 groups will receive

the test drug BCD-131 at a dose of 1.05 µg/kg, 1.7 µg/kg and 2.75

µg/kg x conversion ratio (CR)1 based on the previous therapy and

one group will receive the reference drug Mircera®.

Before inclusion in the study, all patients will be provided

with the full information about the clinical study, its aims, and the

risks associated with the participation in the study. After signing

the Informed Consent, patients will undergo a screening

examination (within the screening period of max 4 calendar weeks)

to confirm that they meet the eligibility criteria.

After the investigator has decided to include the patient in

the study, they will be stratified based on the previous therapy

(epoetin alfa / epoetin beta / darbepoetin alfa) and risk factors for

AE development due to rHuEPO therapy: age (<60 years / ≥60 years), availability / absence of vascular implants, need/no need for

hypoglycemic agents or insulin.

Study Stages:

The study will include the following two stages:

Stage I

1 The dose calculations for BCD-131 and Mircera® are provided in section “Study Therapy” of the Synopsys

and in section 1.5.1 “Description and Justification of Administration Mode, Doses, Dosage Regimen and Treatment Course” of the Study Protocol.

Monthly doses of BCD-131 and Mircera® depend on a stable dose of recombinant EPO (epoetin alfa or epoetin

beta, or darbepoetin alfa) received by the patient for at least 2 weeks before signing the Informed Consent and during

the screening period.




SYNOPSIS

At stage I, patients will be included successively in each of

the groups to receive BCD-131. At the same time, patients will be

included in the reference group to receive Mircera®. Patients will

be included in the groups in a 3:1 ratio (BCD-131 group : Mircera®

group).

First, 9 patients will be included in Group 1 (BCD-131,

1.05 µg/kg x CR depending on the dose of the previous therapy)

and 3 patients will be included in the Mircera® group (in a 3:1 ratio).

After all the enrolled patients from these groups (Group 1 and the

reference group) have received 2 injections of the test/reference

drug and completed a 2-week follow-up period after the second

injection (i.e. 1.5 months (42 days) after the first injection or 14

days after the second injection), the investigators will consider a

possibility of including the next 9 patients in Group 2 (BCD-131,

1.7 µg/kg x CR depending on the dose of the previous therapy).

At stage I, the Data Safety Monitoring Committee (DSMC)

will take a decision on a possibility of including the next group of

patients to receive a higher dose (1.7 µg/kg x CR)2. The decision

will be based on the pooled data on the safety and

pharmacodynamics of BCD-131 obtained in patients from Group 1

for the first 1.5 months (i.e. after two injections and a 2-week

follow-up period after the second injection). The safety evaluation

of the test drug will be based on the incidence of Grade 3 AEs,

having a reasonable suspected causal relationship to the study drug

(according to the DSMB), in patients from Group 1. To perform the

preliminary evaluation of the PD effect of the indicated dose of the

drug product, DSMC members will be additionally provided with

the data on hemoglobin levels and reticulocyte counts in complete

blood counts of the patients included in Group 1 at stage I.

The treatment of patients in Group 1 at stage I and in the

reference group will not be interrupted and continue according to

the Study Protocol.

After the DSMC members have taken a decision about

further dose escalation, 9 patients will be randomized to Group 2 at

stage I to receive BCD-131 at a dose of 1.7 µg/kg x CR, and 3

patients will be randomized to the reference group to receive

Mircera® (randomization in a 3:1 ratio)3.

2 The DSMC will include principal investigators (4 persons) and a medical expert assigned for this study. 3 If the DSMC members have taken a decision about the risk of including patients in the next dose levels of

BCD-131 (1.7 µg/kg and 2.75 µg/kg x CR) based on the safety data obtained in Group 1 at stage I, new patients will

not be enrolled in groups to receive the next dose levels of BCD-131.




SYNOPSIS

After all the patients in Group 2 and 3 patients in the

reference group (enrolled simultaneously with the patients

receiving BCD-131 at a dose of 1.7 µg/kg) have received 2

injections of either BCD-131 at a dose of 1.7 µg/kg x CR or the

reference drug and completed a 2-week follow-up period after the

second injection (i.e. 1.5 months (42 days) after the first injection

or 14 days after the second injection), the investigators will

consider a possibility of including the next 9 patients in Group 3

(BCD-131, 2.75 µg/kg x CR depending on the dose of the previous

therapy).

At stage I, the decision on a possibility of including the next

group of patients to receive a higher dose (2.75 µg/kg x CR) will

be taken in the same way as described for the previous dose level.

The treatment of patients in Group 2 at stage I and in the

reference group (the next 3 patients) will not be interrupted and

continue according to the study protocol. The patients will go on

receiving the relevant drugs at the same dose or, according to the

DSMC decision, at a lower dose if the treatment with the same dose

of BCD-131 does not benefit the patient for safety reasons.

After the DSMC members have taken a decision about

further dose escalation, 9 patients will be randomized to Group 3 at

stage I to receive BCD-131 at a dose of 2.75 µg/kg x CR, and 3

patients will be randomized to the reference group to receive

Mircera® (randomization in a 3:1 ratio)4.

The terms and parameters of safety evaluation of BCD-131

at a dose of 2.75 µg/kg x CR in patients in Group 3 at stage I will

be the same as those in Group 1 and Group 2 at stage I.

Stage II

In any of the above-mentioned situations, patients will be

further enrolled in stage II of the study according to the conditions

of the screening period and stratification described above for stage

I. The total number of patients in each group, approved by the

DSMC for participation in stage II, should be 25 patients including

those randomized to the relevant group at stage I of the study. At

stage I, more patients will be enrolled in the reference group to

4 If the DSMC members have taken a decision about the risk of including patients in the next dose level of

BCD-131 (2.75 µg/kg x CR) based on the safety data obtained in Group 2 at stage I, new patients will not be enrolled

in groups to receive the next dose levels of BCD-131.




SYNOPSIS

achieve the total number of 25 patients, including those randomized

to the relevant group at stage I of the study.

If, based on the decision of the DSMC, all the three dose

levels (1.05, 1.7, and 2.75 µg/kg x CR) of BCD-131 have

acceptable safety profiles at stage I, more patients will be enrolled

in each of these three groups and in the reference group at stage II

to compare the efficacy and safety of the selected treatment

regimen for 21 weeks. In this case, stage II of the study will include

the following groups:

Planned study groups provided the DSMC has approved

the further study of the three dose levels of BCD-131:

• Group 1: Patients in this group (25 patients

including those randomized to this group at stage I)

will receive a subcutaneous injection of BCD-131,

1.05 µg/kg x CR5, depending on the dose of the

previous therapy, once a month until Week 21.




1.7 µg/kg x CR, depending on the dose of the









will receive a subcutaneous injection of Mircera®

once a month until Week 21, at a dose depending on

that of the previously administered recombinant

EPO in accordance with the SmPC for Mircera®6.

If, based on the decision of the DSMC, the first two dose

levels (1.05 and 1.7 µg/kg x CR) of BCD-131 have acceptable

5 The dose calculations for BCD-131 and Mircera® are provided in Section 1.5.1 “Description and Justification

of Administration Mode, Doses, Dosage Regimen and Treatment Course” of the Study Protocol.



the screening period. 6 http://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=24dc1990-f2f5-4991-996b-b4ef599ba2a6&t=

http://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=24dc1990-f2f5-4991-996b-b4ef599ba2a6&t




SYNOPSIS

safety profiles at stage I, more patients will be enrolled only in

Group 1 and Group 2 of the test drug and in the reference group at

stage II to compare the efficacy and safety of the selected treatment

regimen for 21 weeks. Patients who at stage I had received BCD-

131 at a dose of 2.75 µg/kg x CR, which later was not approved by

the DSMC for stage II, will further receive BCD-131 at a dose of

1.7 µg/kg x CR (i.e. the preceding dose level) until Week 21; their

data will be used for additional safety evaluation. In this case, stage

II of the study will include the following groups:


the further study of BCD-131, 1.05 and 1.7 µg/kg x CR:











• Group 3: Patients in this group (only 9 patients who

have been randomized to this group at stage I and

received BCD-131, 2.75 µg/kg x CR) will receive a

subcutaneous injection of BCD-131, 1.7 µg/kg x

CR, depending on the dose of the previous therapy,

once a month until Week 21, for the purpose of

additional safety evaluation.








of Administration Mode, Doses, Dosage Regimen and Treatment Course” of the Study Protocol. Monthly doses of BCD-131 and Mircera® depend on a stable dose of recombinant EPO (epoetin alfa or epoetin







SYNOPSIS

If, based on the decision of the DSMC, only the first dose

level (1.05 µg/kg x CR) of BCD-131 has an acceptable safety

profile at stage I, more patients will be enrolled only in Group 1 of

the test drug and in the reference group at stage II to compare the

efficacy and safety of the selected treatment regimen for 21 weeks.

Patients who at stage I had received BCD-131 at a dose of

1.7 µg/kg x CR, which later was not approved by the DSMC for

stage II, will receive BCD-131 at a dose of 1.05 µg/kg x CR (i.e.

the preceding dose level) until Week 21; their data will be used for

additional safety evaluation. In this case, stage II of the study will

include the following groups:


the further study of BCD-131, 1.05 µg/kg x CR:






• Group 2: Patients in this group (only 9 patients who

have been randomized to this group at stage I and

received BCD-131, 1.7 µg/kg x CR) will receive a

subcutaneous injection of BCD-131, 1.05 µg/kg x

CR, depending on the dose of the previous therapy,

once a month until Week 21, for the purpose of

additional safety evaluation.







Study Periods

The study will include the following periods:









SYNOPSIS

1. Screening period (up to 28 days from the moment of signing

the Patient Information Sheet and the Informed Consent

Form, inclusive);

2. Treatment period (Week 1 – Week 21, inclusive);

3. Follow-up (28 days from the last injection of the

test/reference drug at Week 21 of the study).

Study Population Adult dialysis patients with renal anemia due to the end-

stage chronic renal failure (stage 5D CKD), aged 18 to 75 years

(inclusive) on the day of signing the ICF, with the established

efficacy of dialysis (dialysis dose (Kt/v) ≥1.2 for patients on hemodialysis and Kt/v ≥1.7 for patients on peritoneal dialysis)11.

For dialysis patients, the need for the standard hemodialysis

procedure should be at least 12 hours per week.

Patients receiving recombinant EPO therapy (epoetin alfa

or epoetin beta, or darbepoetin alfa) for at least 3 months before

signing the Informed Consent, with the stable recombinant EPO

dosing (epoetin alfa or epoetin beta, qw, biw, tiw, or darbepoetin

alfa, qw or q2w) for at least 2 weeks before signing the Informed

Consent and during the screening period, with the hemoglobin level

within target values (100-120 g/L, inclusive) for at least 2 weeks

before signing the Informed Consent and at screening, will be

eligible for inclusion.

Planned Sample Size Maximum number of patients: 100 patients

Inclusion Criteria 1. Signed ICF to participate in the study.

2. Men and women aged 18 to 75 years inclusive at the

moment of signing the ICF.

3. Documented end-stage renal failure.

4. Need for dialysis for at least 3 months before signing the

ICF.

5. For dialysis patients, according to the investigator, the need

for the standard hemodialysis procedure should be at least

12 hours per week.

6. Documented treatment with recombinant EPO (epoetin

alfa, epoetin beta, or darbepoetin alfa) for at least 3 months

before signing the ICF.

11 Kt/V = -Ln (R - 0.008 x t) + (4 - 3.5 x R) x UF/W

where Ln - natural logarithm; R - post-dialysis to pre-dialysis blood urea nitrogen (BUN) (or urea) ratio; t - dialysis

duration in h; UF - ultrafiltration volume in L; W - post-dialysis weight of the patient.




SYNOPSIS

7. Documented stable dose of recombinant EPO (epoetin alfa

or epoetin beta, qw, biw, tiw, or darbepoetin alfa, qw or

q2w) for at least 2 weeks before signing the ICF and during


8. Documented target hemoglobin level (100-120 g/L

inclusive) for 2 weeks before signing the ICF and at

screening.

9. Efficacy of dialysis established at screening (dialysis dose

(Kt/v) ≥1.2 for patients on hemodialysis, and Kt/v ≥1.7 for patients on peritoneal dialysis)12.

10. Transferrin saturation ≥20%, ferritin level > 100 ng/mL at screening.

11. Willingness of patients and their sexual partners with

preserved reproductive function to use reliable

contraception starting from signing the ICF and up to 4

weeks after the final dose of the drug product given within

the clinical study. This requirement does not apply to

patients after surgical sterilization or ≥ 2 years post-

menopausal. Reliable methods of contraception include one

barrier method in combination with one of the following

methods: spermicides, intrauterine device/oral

contraceptives.

12. Patient’s ability (in the investigator’s opinion) to follow the Protocol procedures.

Exclusion Criteria: 1. Any other diagnosed forms of anemia, except for renal

anemia, including anemia of chronic disease (C-reactive

protein (CRP) level >20 mg/L at screening).

2. Proven diagnosis of lupus nephritis or CKD due to systemic

vasculitis13.

3. Platelet count <100х109/L at screening.

4. Planned (i.e. there are data on a tentative date of surgery

and/or availability of a suitable donor) kidney transplant

surgery during the expected period of participation in the

study.

5. History of allergies (anaphylactic shock or multiple drug

allergy syndrome) as told by the patient, and

12 Kt/V = -Ln (R - 0.008 x t) + (4 - 3.5 x R) x UF/W



13 A note of the absence of this pathology should be made by the investigator in the source documents.




SYNOPSIS

hypersensitivity to darbepoetin alfa or any components of

the study drugs, or iron(III)-hydroxide sucrose complex.

6. Vaccination within 8 weeks prior to signing the ICF (as told

by the patient).

7. Diagnosed liver cirrhosis complicated with portal

hypertension and/or splenomegaly and/or ascites.

8. HIV-infection, acute hepatitis В, С, syphilis14.

9. ALT, AST levels >3xULN at screening.

10. Decompensated heart disorders (chronic heart failure

(CHF), NYHA Class IV).

11. Resistant hypertension15.

12. Unstable angina pectoris.

13. Proven diagnosis of hemoglobinopathies, myelodysplastic

syndrome, malignant blood or lymphoid disorders, pure red

cell aplasia.

14. Severe secondary hyperparathyroidism (intact parathyroid

hormone (PTH)>1000 pg/mL at screening).

15. Documented episodes of gastrointestinal bleeding within 3

weeks prior to signing the ICF.

16. Documented episodes of thrombosis in past medical history

(acute myocardial infarction, stroke, transient ischemic

attacks, deep venous thrombosis, pulmonary embolism)

within 6 months prior to signing the ICF.

17. Seizure disorders, including a history of epilepsy.

18. Documented major surgery within 1 month prior to signing

the ICF.

19. Documented blood transfusion within 3 months prior to

signing the ICF.

20. Any acute infections, relapses of chronic infections or any

other chronic diseases that are present on the day of signing

the Informed Consent and can, as judged by the

14 The patient with anti-HCV antibodies detected at screening can be included in the study if all of the following

conditions are met: negative qualitative PCR results for HCV RNA (this test is performed only if anti-HCV antibodies

have been detected); no increased transaminase and bilirubin concentrations shown by blood biochemistry tests; the

medical infections specialist has provided a documented conclusion that the patient has no HCV/cured HCV; and the

Sponsor has approved the enrollment of this particular patient.

HBsAg test is performed during the examination for hepatitis B. In case of positive results for HBsAg, the patient

cannot be included in the study.

In case of a positive reaction for syphilis, the patient can be included in the study by the decision of the Sponsor if the

Dermatologist/Venerologist has provided a documented conclusion that the patient has no syphilis/cured syphilis.

Additional examination may be required to confirm the diagnosis (at the discretion of dermatologist). 15 Resistant hypertension is defined as high blood pressure above the target range despite the concurrent use of three

anti-hypertensive drugs of different classes. In case blood pressure can be controlled using four or more

antihypertensive drugs, such hypertension is still considered to be resistant.




SYNOPSIS

Investigator, negatively affect the patient’s safety during the

study treatment.

21. History of severe depression, suicidal thoughts or suicide

attempts16.

22. Documented malignancies except for cured basal-cell

carcinoma and/or cervical cancer in situ.

23. Known alcoholic or drug dependence or signs of present

alcoholic/drug dependence that, in the investigator's

opinion, can be contraindications for the treatment with the

test/reference drug products or limit the treatment

compliance.

24. Participation in other clinical studies within 90 calendar

days prior to signing the Informed Consent.

25. Pregnancy and breastfeeding.

Study Therapy BCD-131 will be administered to patients in 3 of 4 groups.

Patients in Group 1 will receive BCD-131 at a dose of 1.05 µg/kg

х CR, in Group 2 – 1.7 µg/kg х CR, in Group 3 – 2.75 µg/kg х CR. In all the BCD-131 groups, a conversion ratio will be additionally

used to calculate a monthly dose depending on the previous dose of

epoetin (alfa or beta) or darbepoetin alfa.

The calculated doses of BCD-131, the frequency (once a

month) and route of administration (subcutaneous) have been

selected based on the data from non-clinical studies and a Phase I

clinical study of BCD-131 as well as on their comparison with the

data and recommendations for use available for other recombinant

epoetins. The ease of administration and applicability in clinical

practice have been taken into account as well.

BCD-131 and Mircera® will be injected on Day 1 of

Week 1, Day 1 of Week 5, Day 1 of Week 9, Day 1 of Week 13,

Day 1 of Week 17, Day 1 of Week 21, i.e. each patient will receive

6 injections of the test or reference drug.

It should be noted that during the discussion of this clinical

study design with leading Russian experts having extensive

practical experience in using erythropoietins in dialysis patients

with CKD, this approach was found to be optimal in terms of

patients’ safety and prevention of potential adverse events.

The table below shows the starting doses of BCD-131 in

Groups 1, 2, 3 and the dose of Mircera® in the Mircera® group

depending on the type and dose of previous treatment.

16 This exclusion criterion can be confirmed or rejected on the basis of documents or as told by the patient.




SYNOPSIS

Dose

Level

Previous

dose of

epoetin

Previous dose

of darbepoetin

alfa

Mircera®

dose

BCD-131 dose

in Group 1

(1.05 µg/kg x

CR),

subcutaneously

BCD-131 dose

in Group 2

(1.7 µg/kg x

CR),

subcutaneously

BCD-131 dose

in Group 3

(2.75 µg/kg x

CR),

subcutaneously

No. IU/week µg/week µg/month µg/month µg/month µg/month

1 1000 - 2000 5 - 10 40 40 60 80

2 >2000 - 4000 > 10 - 20 75 60 100 160

3 > 4000 - 6000 > 20 - 30 120 100 160 260

4 > 6000 - 8000 > 30 - 40 150 120 200 340

5 > 8000 -

10000 > 40 - 50 200 160 280 440

6 > 10000 -

12000 > 50 - 60 250 200 340 560

7 > 12000 -

14000 > 60 - 70 300 260 420 680

8 > 14000 -

16000 > 70 - 80 350 300 480 800

9 > 16000 > 80 >350 >300 >480 >800

Dose Management:

Due to intra-patient variability, occasional individual

hemoglobin values for a patient above and below the desired

hemoglobin level may be observed. Hemoglobin variability should

be addressed through dose management (adjustment) with

consideration for the hemoglobin target range of 100 to 120 g/L,

inclusive.

In this clinical study, 9 dose levels have been calculated for

each of the BCD-131 and Mircera® groups depending on the

dose/type of the previous treatment received by the participant.

When situations described in the table below occur, dose

adjustment is required (i.e. the dose of the drug product used should

be increased or decreased by one level). For example, if the starting

monthly dose of BCD-131 given to a patient in Group 1 (1.05 µg/kg

x CR) was set as 100 µg/month (third dose level), then when the

hemoglobin level increases from >125 to <130 g/L, it is necessary

to reduce the dose of the drug product to the previous dose level i.e.

to 60 µg/month (second dose level). Or, for example, when a patient

in Group 2 (BCD-131, 1.7 µg/kg x CR) receives the drug product

at a dose of 200 µg/month (fourth dose level) and two sequential

blood tests show the variation in the hemoglobin level from ≥95 to <100 g/L, it is necessary to increase the product dose to the next

dose level, i.e. the next injected dose should be 280 µg/month (fifth

dose level).

If, according to the investigator, a situation requiring a

different approach to dose adjustment of the test/reference drug

occurs, this should be discussed with the Sponsor.




SYNOPSIS

The dose adjustment of the test/reference drug is required,

if one of the situations described in the table below occur:

Hemoglobin level

in complete blood

count (CBC), g/L

Change in hemoglobin level

since the last CBC Required measures

<75 Any change over time

Repeat the CBC. If hemoglobin level remains <75 g/L, it is recommended

that the dose is increased to the next

dose level.

75 to <95 Decreased level or without

change

It is recommended that the dose is

increased to the next dose level.

75 to <95 Increased level Maintenance dose (no dose

adjustment is required)

≥95 до <100

during two

sequential complete blood counts

Decreased level or without

change



≥100 to ≤120 Any change over time Maintenance dose (no dose


>120 to ≤125

during two

sequential complete

blood counts

Increased level or without

change

Maintenance dose (no dose


>125 to <130 Decreased level Maintenance dose (no dose


>125 to <130 Increased level or without

change


decreased to the previous dose level

≥130 Any change over time

Repeat the CBC. If the hemoglobin

of ≥130 g/L is confirmed, the dose

should be temporarily withheld until

the hemoglobin decreases to

115 g/L, at which point therapy should be reinitiated at one dose

level lower than the previous one.

Any

Increase by >20 g/L from the

baseline for 4 weeks (or by

>10 g/L for 2 weeks)

Repeat the CBC. It is recommended

that the dose is decreased to the

previous dose level

Any

Reduction by >20 g/L from

the baseline for 4 weeks (or by

>10 g/L for 2 weeks)

Repeat the CBC. It is recommended

that the dose is increased to the next

dose level.

Study Procedures Patients will be given the injections of the test/reference

drug during their visits to the study site. During the clinical study,

dialysis sessions will be conducted as scheduled according to the

recommendations approved by the treating physician.

The efficacy of the drug products will be evaluated upon the

completion of all the study periods based on the comparison of

hemoglobin values obtained throughout the evaluation period vs.

baseline (primary efficacy endpoint) and based on secondary

endpoints. Secondary efficacy endpoints will include changes in the

hemoglobin over time, a proportion of patients with the target

hemoglobin maintained throughout the entire study, a proportion of

patients who required dose adjustment or blood transfusion, and the

mean hemoglobin throughout the entire study.




SYNOPSIS

Safety evaluation will be based on the frequency and

severity of AEs and SAEs in the treatment groups, laboratory and

instrumental findings, and the analysis of the vital signs. The

investigators will monitor main hematology and biochemistry

markers, ECG results, vital signs as well as the results of general

examination of the patients. Safety parameters will be analyzed

throughout the study.

To evaluate the immunogenicity of the study drugs,

patients will take blood tests for binding or neutralizing antibodies

to BCD-131 or Mircera®, depending on the treatment group. To

detect antibodies to pegylated darbepoetin / methoxy polyethylene

glycol-epoetin beta and analyze changes in their production over

time, blood sampling will be performed before the first injection at

Visit 1/Day 1, then at Week 9 and Week 23, and when pure red cell

aplasia (PRCA) is suspected17.

A limited number of patients (not more than 15 patients in

each group) will have additional blood samples collected to study

pharmacokinetics (PK) (serum concentrations of the drug product)

and pharmacodynamics (PD) (absolute reticulocyte count). Based

on the investigator’s decision, during the period of intensive blood sampling for PK analysis (after injection 1), patients in the PK/PD

subset may be hospitalized to the study site (this hospitalization will

not be reported as a SAE). Since patients included in the PK/PD

subset will have to make multiple additional visits to the study site

for blood sampling, this may cause certain inconveniences.

Therefore, the study provides compensation to these patients.

Overall Duration of the

Study

The expected duration of the study is 30 months, including

the periods of enrollment (12 months), treatment and follow-up as

well as data collection and statistical analysis of the results.

Each subject is expected to participate in the study for 28

weeks maximum, including the screening (4 weeks), treatment and

follow-up periods.

17 Diagnostic criteria for pure red cell aplasia

Main signs:

rHuEPO therapy for at least 3 weeks;

Hemoglobin reduction by at least 1 g/L/day without blood transfusions;

Reticulocyte count below 10x109/L;

No significant reduction in WBC and platelets.

Additional signs:

Skin and/or systemic allergic reactions.

Supporting assessment:

Bone marrow aspiration shows normal cellularity and <5% erythroblasts with evidence of a maturation block;

Serum assay shows the presence of anti-erythropoietin NAbs.




SYNOPSIS

Efficacy Evaluation Primary endpoint:

• Change in the hemoglobin vs. baseline during the

evaluation period.

The baseline hemoglobin will be calculated as the

arithmetic mean of hemoglobin values obtained at screening and at

Visit 1. The final hemoglobin value during the evaluation period

will be calculated as the arithmetic mean of hemoglobin values

obtained at Week 21 and Week 23.

Secondary endpoints:

• Relative number of patients (%) with the target hemoglobin

level (100-120 g/L, inclusive) during Weeks 1-23;

• Relative number of patients (%) who required dose

adjustment during Weeks 1-23;

• Relative number of patients (%) who required blood

transfusion during Weeks 1-23;

• Mean hemoglobin level during Weeks 1-23.

Methods of efficacy assessment:

The efficacy analysis will be based on the comparison of

hemoglobin values obtained throughout the evaluation period vs.

baseline, a proportion of patients with the target hemoglobin, a

proportion of patients who required blood transfusion and dose

adjustment, and the mean hemoglobin.

To evaluate the efficacy of BCD-131 and Mircera®, patients

will take CBC tests to determine hemoglobin levels. The first test

for hemoglobin will be taken at screening. During the treatment

period, the hemoglobin will be determined once every 2 weeks

during the first 2 months of the study, and then every 4 weeks.

The primary efficacy endpoint will be analyzed after the

clinical study completion.

Safety Evaluation Safety endpoints:

• The proportion of patients who developed AEs/SAEs

that were treatment-emergent in the opinion of the

investigator;

• The proportion of patients in each group who developed

Grade 3-4 AEs (СТСАЕ v.4.03) that were treatment-emergent in the opinion of the investigator;

• The proportion of patients in each group who

discontinued the study due to AEs/SAEs.

The safety endpoints will be analyzed after the completion

of all periods of the study.




SYNOPSIS

Methods of safety evaluation:

The safety assessment will include periodic evaluation of

vital signs (blood pressure, pulse, body temperature), hematology

(RBC, Hb, reticulocytes, platelets, WBC differential etc.) and

biochemistry (glucose, total bilirubin, AST, ALT, ferritin,

transferrin saturation etc.), ECG monitoring, AE/SAE reporting.

Immunogenicity

Assessment

• The proportion of BAb- and NAb-positive patients.

Blood sampling for immunogenicity assessment (BAbs and

NAbs) will be performed in all the patients included in the study

before the first injection and then at Week 9 and Week 23.

Immunogenicity endpoints will be analyzed after the study

completion.

PK and PD Assessment

(for a limited number of

patients, max n=60)

1) PK/PD endpoints:

PK endpoints:

✓ AUC0–672 h (area under the concentration vs. time curve

from the moment of injection to 672 h [28 days]) and AUC0-

∞ (to infinity) after the first injection of the test/reference

drug,

✓ Cmax (maximum serum concentration of the drug product)

after the first injection of the test/reference drug,

✓ Cmin (minimum serum concentration of the drug product) at

Weeks 5, 9, 13, 17, 21,

✓ Тmax (time to maximum serum concentration) after the first

injection of the test/reference drug,

✓ Т½ (half-life) after the first injection of the test/reference

drug,

✓ Кel (elimination rate constant) after the first injection of the

test/reference drug,

✓ CL (total clearance) after the first injection of the

test/reference drug.

PD endpoints:

✓ AUEC0-672 h (area under the effect vs. time curve from the

moment of injection to 672 h [28 days]) based on the change

in the absolute reticulocyte count after the first injection of

BCD-131/Mircera®,

✓ AC-Emax (maximum absolute reticulocyte count after the

first injection of BCD-131/Mircera®).

The PK analysis of the test drug will be based on the serum

concentration of BCD-131 (pegylated darbepoetin). The PD




SYNOPSIS

analysis of BCD-131 will be based on the absolute reticulocyte

count.

The PK/PD study will include a limited number of patients

(max 60 patients, i.e. 15 patients per group). Additional blood

samples will be collected in these patients for PK/PD study.

Blood sampling points for PK assessment:

• 2 h, 1 h and 5 min before injection 1 (Day 1 of Week 1),

• 3, 6, 12, 24, 48, 72, 96, 168, 336, 504 h after injection 1,

• 672 h after injection 1 (i.e. immediately before injection 2

at Week 5),

• Before injections 3, 4, 5, 6 (Weeks 9, 13, 17, 21).

Blood sampling points for PD assessment:

• 5 min before injection 1 (Week 1),

• 3, 6, 12, 24, 48, 72, 96, 168, 336, 504 h after injection 1,

• 672 h after injection 1 (i.e. immediately before injection 2

at Week 5).

Based on the investigator’s decision, during the period of intensive blood sampling for PK/PD analysis (after injection 1),

patients in the PK/PD subset may be hospitalized to the study site

(this hospitalization will not be reported as a SAE).

The PK/PD endpoints will be analyzed after the completion of

all periods of the study.

Statistical Analysis Calculation of sample size

The number of patients to be enrolled in the study was

calculated using literature data on the therapeutic efficacy of

Mircera® obtained from a multicenter, randomized, open-label

clinical study of the maintenance treatment of anemia in dialysis

patients with chronic kidney disease18.

While the study was being planned, a hypothesis about the

equivalent efficacy of the test and reference drugs (H0: |ε| ≥ 𝛿, H1:

|ε| < δ, where ε is the true difference in the mean efficacy between the groups, δ is the equivalence margin of the efficacy of the test

and reference drugs) was tested using the following values of

errors: type I error: 5% (α=0.05), type II error: 20% (β=0.2), with the 80% power. The efficacy variable used to calculate the sample

18 F.Locatelli, G.Villa, A.L.M. de Francisco, et al. Effect of a continuous erythropoietin receptor activator

(C.E.R.A.) on stable haemoglobin in patients with CKD on dialysis: once monthly administration. Current medical

research and opinion, 2007, Vol. 23, No., 2007, 969–979




SYNOPSIS

size was set as the change in the hemoglobin level throughout the

treatment in patients participating in the above-mentioned Phase II

study19.

To calculate the sample size, the investigators estimated the

sample mean value and standard deviation for the efficacy

parameter using median values and quartiles given in the above-

mentioned study. The estimate was based on the approach

described in the article by X.Wan, W.Wang20.

The calculated number of patients was 10 subjects per

group. Taking into account the evaluation of the primary efficacy

endpoint of the test drug with the dose selection for subsequent

phases and high probability of patient’s early withdrawal (due to the main disease), 25 patients will be included in each group to get

more accurate and relevant efficacy data. Thus, the study will

include up to 100 patients (25 patients in each group of BCD-131,

if all the three groups are formed, and 25 patients in the reference

group).

Selection of populations for analysis

Efficacy analysis

The per-protocol analysis will be used to assess the efficacy

of treatment using the primary endpoint. This analysis will include

all the patients who completed the treatment according to the

Protocol.

The mITT-analysis will be used to evaluate the efficacy of

treatment using secondary endpoints. The mITT-analysis will

include all the patients who were randomized to receive at least one

dose of the study drugs and were not withdrawn at the beginning of

the study due to serious violations of the Protocol rules and

inclusion/exclusion criteria.

Safety analysis

The safety population will include all the patients who

received at least one dose of the test/reference drug.

Immunogenicity analysis

The immunogenicity analysis will include all the patients

who received at least one dose of the test/reference drugs and who



research and opinion, 2007, Vol. 23, No., 2007, 969–979. 20 X.Wan, W.Wang, J. Liu, T.Tong. Estimating the sample mean and standard deviation from the sample size,

median, range and/or interquartile range. BMC Medical Research Methodology, 2014.




SYNOPSIS

have samples (suitable for analysis) taken before the first injection

and at least at one of the subsequent visits.

PK/PD Analysis

The PK/PD analysis will include patients with no missed /

lost / damaged blood samples as follows:

• Samples taken before injection 1 (at least 1 blood

sample);

• Not more than 2 blood samples taken after injection

1 to 672 h, inclusive;

• Not more than 2 blood samples taken at visits of

Week 9, Week 13, Week 17, Week 21 (for PK

analysis).

Methods of Statistical Analysis

The efficacy analysis for the primary endpoint will be

performed by calculating the 95% confidence interval for the

difference in the frequencies and by its comparison with the

selected equivalence margin of 10 g/L.

Statistical methods for other variables will be selected based

on the type and distribution of raw data. The following tests will be

used to compare quantitative data with normal distribution: two-

tailed Student's test, Welch's test, ANOVA. The non-normally

distributed quantitative data will be analyzed using the Mann-

Whitney test, Wilcoxon test, Kruskal-Wallis test, and the Friedman

test. The categorical data will be processed with frequency tables,

contingency tables, exact Fisher’s test, test for equality of frequencies, 𝜒2 Pearson’s test, and Cochran-Mantel-Haenszel test.

Reporting:

Upon the completion of all the study periods, the final report

will be prepared. It will contain the data on the efficacy and safety

of BCD-131 obtained in this study.




1. BACKGROUND AND RATIONALE

1.1 Introduction

Treatment with erythropoietin (EPO) analogues (or erythropoiesis-stimulating agents,

ESA) has become one of the most valuable advances in the treatment of patients with a number of

diseases accompanied by anemia. These drugs have been actively used for the treatment of chronic

renal failure patients who developed anemia due to erythropoietin deficiency and for the treatment

of cancer patients with the massive death of RBC caused by concomitant chemotherapy. In a

number of cases, ESAs are used in HIV patients who initially received antiviral treatment, in

patients with myelodysplastic anemia, in premature babies, and also before and after major surgery

[1]. Anemia significantly affects the quality of patients’ lives and worsens their prognosis. It has

been shown that the risk of death in patients with chronic kidney disease increases by 14% each

time when the hemoglobin decreases by 10 g/L [2, 3].

The first generation of recombinant erythropoietin drugs (ESAs) showed the impressive

results in the treatment of patients with chronic renal failure and became an alternative to

traditional blood transfusions used to raise the hemoglobin. However, those drugs had to be given

to a patient 2 or 3 times a week. Considering that most of these patients have to receive ESAs all

their lives, a reduction in the frequency of injections would significantly improve their quality of

life as well as compliance with the treatment.

One of the ways to increase the half-lives of ESAs was to change the glycosylation profile

of the erythropoietin molecule. Darbepoetin alfa has 5 N-linked carbohydrate chains whereas

recombinant human erythropoietins (r-HuEPO) have three. Due to its increased carbohydrate

(sialic acids) content, darbepoetin alfa has a longer terminal half-life than r-HuEPO (25 h vs. 6–

9 h) [4]. Darbepoetin may be administered to patients once weekly or once every two weeks.

Another way to increase the half-life of erythropoietin is pegylation, i.e. the attachment of

polyethylene glycol, a molecule which by itself has no properties. Pegylated erythropoietin

belongs to a new class of third-generation erythropoiesis-stimulating agents (ESAs), also called

C.E.R.A. (continuous erythropoietin receptor activator). The name was chosen because the

molecule of pegylated erythropoietin is characterized by a slower association to and faster

dissociation from the receptor of erythropoietin [5, 6, 7]. Pegylated erythropoietin has shown its

efficacy in clinical practice and has been characterized by a longer half-life (about 130–140 h),

which allowed for using the drug once every 2–4 weeks [8].




Literature data indicate that the glycosylation profile affects the half-life of both

recombinant erythropoietin and its pegylated derivative [9].

Additional glycosylation (sialylation) of erythropoietin is known to result in an increased

half-life as well as an increased activity in vivo. However, there is every reason to suppose that

isoforms having lower carbohydrate content (i.e. with lower sialic acid content) have higher

affinity for the receptor of erythropoietin and increased in vitro biological effect [19, 20], although

their in vivo biological activity may be reduced due to a faster clearance by the liver [21].

BCD-131 is an original drug product developed by JSC BIOCAD. It is a chemically-

synthesized covalent conjugate of darbepoetin with the low content of sialic acids (as compared to

darbepoetin alfa (BCD-066, JSC BIOCAD)) and linear methoxy-polyethylene glycol with the

molecular weight of 30 kDa. Pegylated darbepoetin is expected to have a longer half-life and

higher in vivo activity than the available authorized drugs. As a result, the drug will be

administered to patients less often, the blood concentration of the active ingredient will be more

stable thus promoting further improvement of the patient’s prognosis and quality of life. Also,

clinical implementation of pegylated darbepoetin, developed and produced in Russia, would make

it possible to provide patients with more affordable innovative recombinant erythropoietin with a

long-lasting therapeutic effect, the efficacy of which can be compared to that of existing ESAs.

Pegylated darbepoetin (BCD-131) developed by JSC BIOCAD is an innovative

biotechnology product. To date, a comprehensive study of structural, physico-chemical and

biological properties of BCD-131 has been conducted. The amino acid profile, three-dimensional

structure, sialylated form profile, purity and homogeneity, in vivo potency and stimulating activity

of pegylated darbepoetin in TF-1 cells have been studied. In a number of non-clinical studies,

BCD-131 has been shown to have potency in vitro and in vivo and specifically increase the

hemoglobin level and erythrocyte count through specific interaction with the erythropoietin

receptors. Also, BCD-131 has shown no unexpected toxicity, significant immunogenicity or local

intolerance, being characterized by sufficient purity.

The extent and results of non-clinical studies of BCD-131 allowed for conducting a Phase I

clinical study in humans.

The first step of clinical development of BCD-131 was the evaluation of its effects in

healthy volunteers in the Phase I study: “Open-Label Single Ascending Dose Clinical Trial to

Evaluate the Pharmacokinetics, Pharmacodynamics, Tolerability, Safety and Immunogenicity of

BCD-131 in Healthy Volunteers as Compared to Mircera® (F. Hoffman-La Roche Ltd.,

Switzerland) and Aranesp® (Amgen Europe B.V., Netherlands)”. According to the results of the




Phase I study, the therapeutic dose range of BCD-131 was selected based on the evaluation of the

drug pharmacodynamic (PD) effect on stimulating the erythropoiesis. The pharmacodynamic

response reflected by the increased reticulocyte count, which was very similar to that due to the

comparator Mircera®, was observed in the cohorts of volunteers receiving BCD-131 at a dose of

1.05 µg/kg, 1.7 µg/kg, and 2.75 µg/kg.

Therefore, the following doses have been chosen for the further development and efficacy

studies of BCD-131 in the treatment of patients with renal anemia due to the end-stage chronic

renal failure (stage 5D CKD) receiving epoetin or darbepoetin alfa: 1.05 µg/kg, 1.7 µg/kg, and

2.75 µg/kg given as subcutaneous injections once a month.

1.2. Name and description of investigational products

Investigational products used in this study include the test drug and the reference drug.

1.2.1. Test drug.

Trade Name: N/A. Product code — BCD-131.

International Nonproprietary Name: N/A at the time of study.

Dosage Form: solution for injection

Composition per 1 mL:

Active ingredient: methoxy polyethylene glycol-darbepoetin — 200 µg.

Excipients: sodium phosphate monobasic monohydrate — 2.118 mg, sodium phosphate dibasic*

— 0.45 mg, L-methionine — 0.1 mg, mannitol — 40 mg, polysorbate 80 — 0.05 mg, water for

injections — up to 1.0 mL.

*anhydrous

Manufacturer: JSC BIOCAD, Russia.

Shelf life: 2 years. Do not use after the expiry date specified on packaging.

Storage and transportation conditions: Store at 2 to 8 °C, protected from light in the received

packaging. Do not freeze. Keep out of the sight and reach of children.

Packaging:

One 2R colorless Type I glass vial with a rubber stopper and an aluminum flip-off seal contains

2 mL of the drug product at a concentration of 200 µg/mL (400 µg). Each vial has a self-adhesive

label.

Posology and method of administration: During the study, the drug product will be administered

once a month as a subcutaneous injection. BCD-131 will be given at three different doses




depending on the randomized group: 1.05 µg/kg in Group 1, 1.7 µg/kg in Group 2, 2.75 µg/kg in

Group 3. In all the BCD-131 groups, a conversion ratio will be additionally used21 to calculate a

monthly dose depending on the previous dose of epoetin (alfa or beta) or darbepoetin alfa (see

section 6.1.1 “Study Therapy”).

Labeling:

According to Article 46 of Federal Law 61-FZ of April 12, 2010 “On the Circulation of

Medicinal Products” and regulatory requirements of the participating countries, the primary

packaging of the investigational product should contain the following information (printed in the

national language using an easily readable font):

The primary packaging of the investigational product will contain the following information

(printed using an easily readable font):

- BCD-131,

- Dosage,

- Date of manufacture,

- Shelf life,

- Batch of the drug product,

- Dosage form.

The secondary packaging of the investigational product will contain the following information

(printed using an easily readable font):

- BCD-131,

- Dosage,

- Name of manufacturer: JSC BIOCAD

- Batch of the drug product,

- Date of manufacture,

- Shelf life,

- Method of administration,

- Dosage form,

- Storage conditions,

- Warnings and precautions.

The secondary packaging will also contain the Protocol ID and the following information

added by the investigator: study site No., subject ID, date of administration of the drug product.

21 A detailed description of dose calculation using the CR is provided in Section 1.5.1 “Description and

Justification of Administration Mode, Doses, Dosage Regimen and Treatment Course” of the Study Protocol.




Both primary and secondary packaging will have the “For clinical trials only” label as well.

Also, see section 4.4.2. “Pharmaceutical form, packaging and labeling of investigational

products”, subsection 4.4.2.1. “Test drug”.

1.2.2. Reference product.

Trade Name: Mircera®.

International Nonproprietary Name: methoxy polyethylene glycol-epoetin beta.

Dosage Form: solution for intravenous and subcutaneous injection.

Manufacturer: F. Hoffmann-La Roche, Switzerland22.

Active Ingredient: methoxy polyethylene glycol-epoetin beta 30 µg/0.3 mL.

AND / OR

Active Ingredient: methoxy polyethylene glycol-epoetin 40 µg/0.3 mL.

AND / OR


AND / OR


AND / OR


AND / OR


AND / OR


AND / OR


AND / OR

22 In case the drug product is not available and/or difficult to buy in the Russian Federation, it will be purchased

in other countries.





Excipients: L-methionine, sodium sulphate anhydrous, sodium dihydrogen phosphate

monohydrate, mannitol, poloxamer 188, diluted hydrochloric acid or sodium hydroxide solution,

water for injections.

Shelf life: 2 years. Do not use after the expiry date specified on packaging.

Storage and transportation conditions: Store at 2 to 8 °C. Protect from light. Do not freeze.

Keep out of the sight and reach of children!

Packaging: Mircera® is manufactured in disposable pre-filled syringes.

One pre-filled syringe and one container with a needle for injection are contained in a clear sealed

blister pack. One blister pack and a PIL are contained in a carton.

Posology and method of administration: During the study, the drug product will be

administered once a month as a subcutaneous injection. The starting dose of Mircera® will be

calculated on an individual basis for each study subject depending on a stable dose of recombinant

erythropoietin (epoetin alfa or epoetin beta, or darbepoetin alfa) received by the patient for at least

2 weeks before signing the Informed Consent and during the screening period.

Labeling:

The drug product has been authorized; the labeling should comply with the approved

SmPC.

The secondary packaging will also contain the following information added by the

Investigator: Protocol ID, study center No., and subject ID.

Both primary and secondary packaging will have the “For clinical trials only” label as well.

Also, see section 4.4.2. “Pharmaceutical form, packaging and labeling of investigational

products”, subsection 4.4.2.2. “Reference product”.

1.3. Summary of findings from nonclinical studies that have potential clinical significance

and summary of relevant clinical research

1.3.1. Preclinical studies


biotechnology product. Its physicochemical, biological, PK, and toxicological properties have

been characterized in a range of preclinical studies. It has been shown that BCD-131 has potency

in vitro and in vivo, has no toxicity, and is characterized by sufficient purity, which makes it




possible to use it in clinical studies in humans. The extent and duration of the toxicity studies are

also sufficient to initiate clinical studies of BCD-131 in humans.

1.3.1.1. Overview of physicochemical studies

According to data obtained in the preclinical physicochemical studies of BCD-131, the

drug product is characterized by the following properties:

✓ The amino acid composition and amino acid sequence of BCD-131 are similar to

those of darbepoetin alfa. The identity of polyethylene glycol in BCD-131 has

been confirmed by SDS-PAGE with iodine staining in the presence of barium

chloride.

✓ The molecular weight of BCD-131 is about 65 kDa.

✓ The BCD-131 sialylation profile is as follows: monosialylated forms — 2.46%;

disialylated forms — 5.93%, trisialylated forms — 29.45%; tetrasialylated forms

— 62.16%.

✓ The purity of BCD-131 is as follows: total impurities — 2.11% (reducing

conditions). The content of high-molecular impurities in pegylated darbepoetin

determined by size-exclusion HPLC is 4.44%. The content of monomer conjugate

is 95.56%. The content of oxidized forms in BCD-131 is 3.7%, while the content

of deamidated forms is 2.17%. Therefore, according to its purity characteristics,

BCD-131 can be used as a test drug in clinical studies in humans.

✓ The potency of BCD-131 in vitro (the proliferative activity of the drug product

against TF-1 cells) can be compared to that of Mircera®, but is much lower than

that of Aranesp®, which is due to the absence of the PEG molecule in the latter.

✓ The potency of BCD-131 in vivo on Day 6 is 85.97% as compared to that of

Mircera®, and 121.79% as compared to that of Aranesp®. Therefore, the findings

obtained from the experiments suggest that the potency in vivo of pegylated

darbepoetin is higher than that of Aranesp® and is similar to that of Mircera®.

1.3.1.2. Preclinical studies in laboratory animals

1.3.1.2.1. Pharmacodynamics of a single subcutaneous injection of BCD-131 in mice

The PD of BCD-131 was investigated by evaluating the effect of the drug product on

reticulocyte count in the peripheral blood of mice after a single subcutaneous injection. The effect

of BCD-131 was compared to that of Aranesp® (darbepoetin alfa, Amgen Europe B. V., the




Netherlands). The blood sampling from the retro-orbital sinus of each mouse was performed on

Days 0, 3, 4, 5, 6, 8, 10, 13, 14, 16 and 20 (11 points) after the injection of the study drugs. The

blood was taken to analyze the reticulocyte count by flow cytometry.

Results: At baseline, the relative reticulocyte count in this animal species was 4±0.4%

(Day 0, before injection). On Day 3 following the administration of the study drugs, an increased

reticulocyte count was reported in all the experimental groups. The maximum reticulocyte count

was achieved on Day 5 of the study (see Table 10). The statistically significant differences between

BCD-131 at a dose of 20 µg/kg and Aranesp® were observed on Days 5, 6 and 8 after dosing

(p≤0.05, Newman-Keuls test, Table 10). On Day 8, the relative reticulocyte count in the group

receiving BCD-131 at a dose of 20 µg/kg was 3.8-fold higher than in the group given Aranesp® at

the same dose.

Table 10. Relative Reticulocyte Count (%) in the Groups of Mice Given a Single Dose of BCD-

131 or Aranesp® (mean — M, standard error of mean — m).

Days

BCD-131

5 µg/kg

(n=55)

BCD-131

10 µg/kg

(n=55)

BCD-131

20 µg/kg

(n=55)

Aranesp®

20 µg/kg

(n=55)

M m M m M m M m

0 3.37 0.21 3.95 0.3 4.04 0.37 3.28 0.19

3 9.46 0.51 9.37 0.76 9.23 1.61 11.46 0.19

4 9.76 0.52 10.41 0.75 12.75 0.36 12.19 0.84

5 10.37 0.24 12.20 0.61 14.56 0.33 14.16 0.53

6 10.03 0.43 10.20 0.67 13.62 0.51 11.31 0.64

8 3.70 0.25 6.15 0.32 8.81 0.31 2.30 0.12

10 2.00 0.12 2.96 0.28 4.06 0.17 1.77 0.19

13 1.57 0.34 1.40 0.30 1.55 0.18 0.97 0.24

14 2.01 0.27 0.91 0.19 0.94 0.12 1.15 0.23

16 1.89 0.14 0.97 0.11 0.94 0.11 0.67 0.14

20 2.80 0.07 1.62 0.19 1.43 0.28 2.56 0.29

Therefore, the administration of BCD-131 at all the studied doses resulted in similar

changes related to the specific effect of the drug. Moreover, these changes were dose-dependent.

On Day 3 after dosing, an increased reticulocyte count in the peripheral blood was observed in all

study groups. The maximum reticulocyte count was achieved on Day 5 of the study and was

reported in all study groups. The statistically significant differences between BCD-131 at a dose

of 20 µg/kg and Aranesp® given at the same dose were observed on Days 5, 6 and 8 after dosing

(p≤0.05).




1.3.1.2.2. Pharmacokinetics of a single subcutaneous injection of BCD-131 in mice

The PK of BCD-131 was investigated by determining its concentration in the peripheral

blood of mice after single ascending doses of the drug product. During the study, the effect of

BCD-131 was compared to that of Mircera® and Aranesp®. The blood samples for the PK analysis

were taken from the tail vein of each mouse before the administration of the study drugs and at 12,

24, 36, 48, 72, 96, 120, 144, 168 and 240 h after dosing.

Results: The serum concentration of the drug product in mice given single ascending doses

of subcutaneous BCD-131 was dose-dependent; the changes in Сmax and AUC were dose-

dependent as well. Cmax was 16.8311.10 ng/mL (100 ng/mouse) and 45.548.72 ng/mL

(400 ng/mouse). An increase in AUC was also dose-dependent and equaled 1542.56±550.13 and

3730.93±1246.33 with doses of 100 ng/mouse and 400 ng/mouse, respectively. Depending on a

dose, the total clearance (Cl) of the drug product was 0.071±0.024 and 0.125±0.067 mL/h/kg

with doses of 100 ng/mouse and 400 ng/mouse, respectively. The mean residence time (MRT)

and the half-life (T1/2) of the drug almost did not depend on a dose. The MRT was 96.45±17.31 h

and 89.1±13.77 h with doses of 100 ng/mouse and 400 ng/mouse, respectively. The T1/2 was

51.44±15.38 h and 48.44±10.82 h with doses of 100 ng/mouse and 400 ng/mouse, respectively.

The comparative study of PK parameters upon single subcutaneous administration of BCD-

131 and Aranesp® showed that the total clearance of BCD-131 was lower as compared to that

of Aranesp® (0.125±0.067 mL/h vs. 0.73±0.365 mL/h). The delayed clearance resulted in a 4-

fold increase in the half-life (T1/2) of BCD-131 as compared to that of Aranesp® (48.4410.82 h

vs. 11.723.18 h) and in a 3-fold increase in the MRT (89.113.77 h vs. 27.543.23 h). The

concentration of Aranesp® in the blood of the experimental animals reduced to zero over 72 h

while BCD-131 was detected over 168–240 h after dosing.

The clearance of a single subcutaneous injection of BCD-131 to mice was lower than that

of Mircera® (0.1250.067 mL/h/kg vs. 0.2150.115 mL/h/kg) while the T1/2 and MRT were higher

(48.4410.82 h vs. 38.6518.5 h) and (89.113.77 h vs 76.7125.44 h), respectively. However,

these differences were not statistically significant.

1.3.1.2.3. Acute toxicity of BCD-131

The toxicity of a single-dose subcutaneous administration of BCD-131 was studied for the

following doses: 50 µg/kg, 100 µg/kg, and 200 µg/kg vs. placebo. These doses were calculated

from the mean therapeutic doses of Mircera® (the closest analogue of BCD-131) for humans,

taking into account the interspecies scaling factor (for rats). The lowest (minimal) dose




investigated in this study is equivalent to approximately 12 anticipated therapeutic doses; the

medium dose is equivalent to 25 anticipated therapeutic doses; the highest (maximum) dose is

equivalent to 50 anticipated therapeutic doses. The experiment was conducted in mice

(40 animals) and rats (40 animals) of both sexes.

Results: During the experiment, no cases of animal death or clinical signs of intoxication

were reported. No changes in animal behavior, appearance, the condition of their eyes, noses or

pelage were observed. The changes in stool, appetite or breathing patterns were not reported either.

The statistical analysis revealed no significant difference in the body weight of the animals

(either mice or rats) receiving BCD-131 and the body weight of the control animals.

The findings of histological examination across all the groups of animals revealed similar

changes mainly related to the specific effect of the test drug and the reference drugs. The revealed

abnormalities included dyscirculatory changes in the liver, myocardium, spleen, brain as well as

the dystrophic and necrotic changes in the liver and kidneys. The engorged blood vessels and

stromal edema were observed in most body organs, which was related to the specific effect of the

study drugs.

Thus, the studies of BCD-131 at doses of 50 µg/kg, 100 µg/kg and 200 µg/kg did not reveal

lethal doses. The lethal dose of BCD-131 for mice and rats is >200 µg/kg.

1.3.1.2.4. Non-clinical repeat-dose toxicity of BCD-131

The repeat-dose toxicity of BCD-131 was investigated in 120 rats using three dose levels

of the test drug. These doses were calculated from the mean therapeutic doses of Mircera® (the

closest analogue of BCD-131) for humans, taking into account the interspecies scaling factor (for

rats). The lowest (minimal) dose investigated in this study is equivalent to one anticipated

therapeutic dose for humans; the medium dose is equivalent to 2 anticipated therapeutic doses; the

highest (maximum) dose is equivalent to 5 anticipated therapeutic doses.

The animals were distributed to 6 groups (depending on the drug product and its dose):

• BCD-131 (20 animals: 10 females and 10 males), at a dose of 4 µg/kg;



• Placebo (20 animals: 10 females and 10 males).

BCD-131 was given as a subcutaneous injection once every 6 days for 30 days. The choice

of the dosing regimen was based on the PK analysis. The volume of injection both for the study

drugs and placebo was 1.0 mL.

The recovery period was 14 days.




The blood samples for hematological and biochemical tests were taken on Day 30 and after

a 14-day recovery period. Before blood sampling, the animals were anesthetized with CO2. The

blood was taken from the subclavian artery.

During the experiment, no cases of animal death or clinical signs of intoxication were

reported. No changes in animal behavior, appearance, the condition of their eyes, noses or pelage

were observed. The changes in stool, appetite or breathing patterns were not reported either.

The administration of BCD-131 at all the studied doses resulted in similar changes related

to the specific effect of the drug. Hematological findings revealed erythrocytosis, increased

hemoglobin and RBC microcytosis and hypochromia during the entire study period. At the same

time, no changes in WBC were observed. Biochemical tests were performed in rats from the test

groups receiving BCD-131 at a dose of 4 µg/kg, 8 µg/kg or 20 µg/kg, or the reference drug at a

dose of 20 µg/kg. A 1.5-2.5-fold increase in AST levels was observed in all female animals from

the test drug groups vs. placebo. At the same time, AST levels in rats receiving BCD-131 at a dose

of 4 µg/kg were within normal limits. It should be said that these abnormalities were not observed

in male rats from the groups receiving BCD-131 or the reference drugs.

All the above-mentioned changes were reversible. Upon the completion of a 14-day

recovery period, serum levels of glucose in experimental animals returned to the target values.

After the recovery period, AST levels in animals across all the test and reference groups were

similar to those in the placebo group. The detected deviations in other blood biochemistry

parameters were within the range of target values for this animal species.

The results of the histological examination performed on Day 30 after dosing in the groups

of male and female rats receiving BCD-131 revealed mainly engorged blood vessels of

parenchymatous organs, intermuscular edema of the cardiac stroma, and vasodilatation. The

macroscopic examination carried out in animals given either three different doses of BCD-131 or

reference drugs at a dose of 20 µg/kg revealed marked splenomegaly with a 2-fold difference in

the relative weight of the spleen in all animals of both sexes as compared to the controls. After the

14-day recovery period, these changes were less pronounced.

Therefore, the studies of BCD-131 in rats revealed its specific effects on hematological and

biochemical parameters of the blood as well as on organs and tissues of animals. All the changes

were reversible. After the 14-day recovery period they were less pronounced. The study showed

that BCD-131 had low toxicity and, therefore, it can be recommended for clinical investigations.




1.3.1.2.5. Local tolerance study during repeat-dose toxicity study of BCD-131

The local tolerance of BCD-131 was assessed on Day 30 of the study. It was based on the

results of general examination and on histological findings obtained during the chronic toxicity

study. Tissue samples from the injection sites and regional lymph nodes were taken for histology.

Thus, the repeated-dose subcutaneous administration of BCD-131 at a dose of 4 µg/kg,

8 µg/kg and 20 µg/kg did not result in local intolerance. The examination of regional lymph nodes

of animals from the test and reference groups revealed that the tissues and nodes were of regular

histological composition similar to that of control animals.

1.3.1.2.6. Immunogenicity assessment of BCD-131

During the process of blood sampling performed on Day 30 of the study and after the 14-

day recovery period, the serum was taken to determine BCD-131 antibodies.

On Day 30 of the study, anti-BCD-131 antibodies were revealed in one of the female

animals in the group receiving BCD-131 at a dose of 20 µg/kg (1.84 µg/mL) and in one of the

male animals in the group receiving BCD-131 at a dose of 8 µg/kg (0.32 µg/mL).

The level of antibodies in the sera of other animals, assessed at the specified time points,

was below the lower limit of detection.

Therefore, the experiment showed that BCD-131 at a dose of 4 µg/kg, 8 µg/kg and

20 µg/kg had low immunogenic potential.

1.3.1.2.7. Reproductive toxicity of BCD-131

The studies of BCD-131 did not reveal its embryotoxic or teratogenic effects.

The study of embryotoxic and teratogenic effects of BCD-131 showed that the repeated-

dose subcutaneous administration of the drug product at a dose of 3.6 µg/kg and 7.2 µg/kg to

pregnant female outbred white rats did not result in significantly increased post-implantation loss

and did not affect changes in the body weight of laboratory animals or the weight and craniocaudal

size of embryos. The drug product did not cause any significant fetal malformations (body, organs

or skeleton).

1.3.2. Clinical studies of BCD-131

At the moment of this Protocol preparation, a Phase I clinical study of BCD-131 has been

completed. In order to evaluate the use of BCD-131 (JSC BIOCAD) in humans, the investigators




studied the single-dose PK, PD, tolerability and safety of the drug product in healthy volunteers as

compared to Aranesp® and Mircera®. The study was conducted according to Clinical Trial

Authorization No. 261 of April 18, 2016 of the Ministry of Health of the Russian Federation.

The study included two stages.

The first stage of the study included 34 healthy volunteers in accordance with the approved

study design (including volunteers who withdrew from the study for any reason).

The study involved:

• Cohort 1: 3 volunteers receiving BCD-131 as a single subcutaneous injection at a dose of

0.05 µg/kg;

• Cohort 2: 3 volunteers receiving BCD-131 as a single subcutaneous injection at a dose

of 0.15 µg/kg;


of 0.40 µg/kg;


of 1.05 µg/kg;


of 1.70 µg/kg;


of 2.75 µg/kg;


of 4.45 µg/kg;

• Cohort 8: 6 volunteers receiving Mircera® as a single subcutaneous injection at a dose of

1.20 µg/kg;

• Cohort 9: 7 volunteers receiving Aranesp® as a single subcutaneous injection at a dose of

0.45 µg/kg.

The first stage of the study aimed to evaluate the PK, PD, immunogenicity, tolerability and

safety of single ascending doses of subcutaneous BCD-131 in healthy volunteers as compared to

those of standard therapeutic doses of Mircera® and Aranesp® given as single subcutaneous

injections to healthy volunteers.

One of the objectives of the second stage of the study was to evaluate the PK, PD,

tolerability and safety of single-dose intravenous and subcutaneous injections of BCD-131 at the

anticipated maximum dose estimated at stage I.




Stage II of the study involved 12 healthy volunteers (including volunteers who withdrew

from the study for any reason) randomized to 2 cohorts. One of them received BCD-131 as a

single-dose intravenous injection at a dose of 2.75 µg/kg, established at Stage I; the other received

BCD-131 as a single-dose subcutaneous injection at the same dose.

Cohort 10: 6 volunteers receiving BCD-131 as a single-dose intravenous injection at the

anticipated maximum dose of 2.75 µg/kg;

Cohort 11: 6 volunteers receiving BCD-131 as a single-dose subcutaneous injection at the

anticipated maximum dose of 2.75 µg/kg.

1.3.2.1. Results of the PK study of BCD-131 in healthy volunteers

The PK endpoints in this study were as follows:

• AUC0–1176 h (area under the concentration vs. time curve from the moment of injection

to 1176 h [Day 50 of the follow-up]);

• AUC0-∞ (to infinity);

• Cmax (maximum serum concentration);

• Тmax (time to Cmax);

• Т½ (half-life);

• Кel (elimination constant);

• CL (total clearance).

All the obtained concentrations were normalized to the baseline level determined before

dosing. Due to the fact that volunteers in Cohort 1 and Cohort 2 received low doses of the drug

product, the PK values calculated and provided for these groups are unlikely to reflect true PK

values of the drug product because of possible significant effects of intrasubject variability of

endogenous erythropoietin levels in volunteers from these cohorts.

The results of the PK evaluation performed at Stage I demonstrated that the concentrations

of pegylated darbepoetin after a single-dose subcutaneous administration of BCD-131 reached the

maximum values over 72-120 h (Cohorts 3-7). Cmax depended on the administered dose of the

drug product. The Cmax values in Cohorts 2-7 were higher than in the reference group receiving

Aranesp® while the Cmax values in Cohorts 4-7 were higher than in the groups receiving Mircera®

or Aranesp®.

All the calculated values of AUC0-1176 in Cohorts 3-7 receiving BCD-131 were higher than

those in cohorts treated with Mircera® and Aranesp®. The results of the regression analysis showed

that the AUC values in cohorts receiving BCD-131 were dose-dependent.




Time to Cmax and half-life of BCD-131 were not dose-dependent. The half-life of BCD-

131 was highly variable being in the range between 181 h and 416 h. In some volunteers it was

not possible to calculate this parameter due to the absence of linear terminal elimination phase in

these subjects.

At Stage II, the PK of BCD-131 was evaluated after a single-dose intravenous or

subcutaneous injection of the drug product at a dose of 2.75 µg/kg (i.e. the highest of the three

doses chosen at Stage I). The Tmax values were a bit higher in the group receiving subcutaneous

BCD-131 while the AUC(0-1176) and Cmax values were higher in the group receiving intravenous

BCD-131. The mean Tmax value for PEG-darbepoetin was 3 days (80 h) after a single-dose

subcutaneous injection of the test drug and 45 min after a single-dose intravenous injection. The

Cmax values were 87526 pg/mL and 10588 pg/mL in the groups receiving intravenous BCD-131

and subcutaneous BCD-131, respectively. The AUC0-1176 values were 6382389.188 (pg/mL х h)

and 2089193.125 (pg/mL х h) in the same groups, respectively.

One of the objectives of Stage II was to compare the PK parameters of the maximum

anticipated therapeutic dose of BCD-131 given as single-dose intravenous and subcutaneous

injections with those of Mircera® and Aranesp® given as single-dose subcutaneous injections. Like

at Stage I, BCD-131 at a dose of 2.75 µg/kg showed higher AUC(0-1176) values as compared to

those of Mircera® and Aranesp®.

Therefore, based on the findings obtained at Stage II of the study, the PK of both

intravenous and subcutaneous modes of administration of BCD-131 was evaluated.

It should be noted that the main decision on the choice of the therapeutic dose range of

BCD-131 was based on the PD response with reference to an increase in the reticulocyte count.

The reason why this decision was made without taking into account the PK parameters was related

to different specific potencies of BCD-131 and the reference drugs, which had been demonstrated

in preclinical studies of BCD-131. Thus, the data provided in the report “The Effects of BCD-131

(JSC BIOCAD, Russia) vs. Mircera® (F. Hoffmann-La Roche Ltd., Switzerland) on the Ability of

Myelocariocytes (Hematopoietic Stem Cells, HSCs) of the Umbilical Cord Blood to Stimulate the

Production of Colony-Forming Unit-Erythroid (CFU-e) Cells when Culturing Umbilical Cord

Blood HSCs In Vitro Using Methylcellulose Media” have shown that the erythropoietic activity

of BCD-131 with reference to Mircera® is 81.15%.




1.3.2.1.1. Discussion of PD results

The study used the following primary endpoints for the assessment of PD markers

(reticulocyte count, hemoglobin):

• AUEC0-1176,

• AC-Emax,

• Тmax.

Overall, the administration of BCD-131 resulted in increased reticulocyte counts in the

blood of volunteers across all study groups. The intensity of PD effects, assessed by the area under

the concentration-time curve, increased as the dose increased.

After administration of a single-dose subcutaneous injection of BCD-131 to healthy

volunteers, the response achieved in the majority of cohorts (except for Cohort 1 (0.05 µg/kg) and

Cohort 2 (0.15 µg/kg) was characterized by a rapid increase in the reticulocyte count, which

reached its maximum on Days 8-14 (depending on the dose injected) and returned to the baseline

values on Days 21-24. Despite some changes in reticulocyte counts in cohorts receiving the test

drug at a dose of 0.05 µg/kg and 0.15 µg/kg, considering low doses of BCD-131 and insignificant

variations in this PD marker, the findings are likely to reflect individual changes in the reticulocyte

count rather than PD effects of BCD-131.

Therefore, when assessing the PD effects of BCD-131 by an increase in the reticulocyte

count, the response similar to that achieved with Mircera® was reported in cohorts receiving PEG-

darbepoetin at a dose of 1.05 µg/kg, 1.7 µg/kg and 2.75 µg/kg.

The hemoglobin assessment following a single-dose injection of BCD-131 or the reference

drugs (Mircera® and Aranesp®) showed no significant increase in this parameter. Its values were

within normal limits, which is typical of erythropoietins since this PD effect can be observed only

upon repeated-dose administration of this kind of drugs.

No evidence of DLT was observed during dose escalation of BCD-131. Considering a poor

PD response in cohorts receiving BCD-131 at a dose range from 0.05 µg/kg to 0.40 µg/kg, these

doses were not chosen as potential therapeutic doses. When given at a dose of 4.45 µg/kg, BCD-

131 resulted in a significant increase in the reticulocyte count, which, hypothetically, can lead to

red bone marrow cell hyperstimulation and, as a result, to a negative effect of the drug product.

Therefore, this dose can also be excluded from a range of doses intended for use at Stage II of the

study.

Since DLT was not achieved in the range of the studied doses, the choice was made

between three doses of 1.05 µg/kg, 1.70 µg/kg and 2.75 µg/kg which had similar safety parameters




and PD profiles. Considering a favorable safety profile of BCD-131, the highest of the three doses

(2.75 µg/kg) was chosen for the second stage of the study.

After administration of a single-dose intravenous injection of BCD-131 2.75 µg/kg and a

single-dose subcutaneous injection of BCD-131 2.75 µg/kg to healthy volunteers, the response

achieved was characterized by a rapid increase in the reticulocyte count, which reached its

maximum on Day 5 and Day 6, respectively, and returned to the baseline values on Day 30.

The maximum reticulocyte count in volunteers given BCD-131 as an intravenous injection

was achieved 1-2 days sooner than in volunteers given subcutaneous BCD-131, which correlated

with the systemic exposure of BCD-131 that was observed a bit sooner in intravenous

administration.

Changes in hemoglobin levels were additionally studied during the PK evaluation of BCD-

131. According to literature data, an increase in the reticulocyte count is followed by an increase

in hemoglobin, hematocrit and total RBC as a result of multiple-dose administration of

recombinant erythropoietins. Therefore, a single-dose administration of BCD-131 was not

expected to have a significant effect on these parameters. Since hemoglobin concentrations were

highly variable and did not demonstrate similar trends in any of the cohorts receiving BCD-131,

the PD evaluation based on hemoglobin levels was narrative.

1.3.2.1.2. Discussion of safety results

BCD-131 demonstrated a favorable safety and tolerability profile upon a single-dose

administration to healthy volunteers.

In accordance with the Study Protocol, the investigators reported all clinical and laboratory

abnormalities emerged during the study as AEs, with the exception of laboratory abnormalities

reflective of the main pharmacodynamic effect of the drug product. Those abnormalities included

increased levels of reticulocytes, RBC, hemoglobin and hematocrit, and were not reported as AEs.

No evidence of dose-limiting toxicity (i.e. Grade 3-4 AEs) was reported at Stage I. All the

AEs were related to laboratory abnormalities revealed during CBC and blood biochemistry tests.

No SAEs were reported at Stage I of the study. No cases of early withdrawal due to AEs were

reported either. The majority of the recorded reactions were deemed expected and had been

observed before in patients treated with other erythropoietin drugs.

All AEs, regardless of their severity, had no clinical signs or symptoms and resolved

without treatment with no sequelae.




Overall, the safety profile of the test drug used at different doses was comparable to the

safety data on erythropoietins and on the reference drugs (Mircera® and Aranesp®) in particular.

The incidence of AEs in all the cohorts receiving subcutaneous injections of the test drug and in

the reference groups was comparable. Besides, no evidence of dose-limiting toxicity was reported

at Stage I of the study.

Table 1. Assessment of Safety Endpoints in Healthy Volunteers Receiving BCD-131 (n = 21,

Cohorts 01-07), Mircera® (n=6, Cohort 08) and Aranesp® (n=7, Cohort 09).

Endpoint Cohorts 01-07 (n=21)

Cohort 08

(n=6)

Cohort 09

(n=7)

n % n % n %

Total SAEs 0 0.00 0 0.00 0 0.00

Total AEs 6 28.57% 2 33.33% 4 57.14%

Grade 3-4 AEs and SAEs 0 0.00 0 0.00 1 14.3%

Administration site reactions 0 0.00 0 0.00 0 0.00

Early withdrawal due to AEs

and SAEs. 0 0.00 0 0.00 0 0.00

At Stage I, the immunogenicity assessment in healthy volunteers revealed no BAbs to

pegylated darbepoetin, methoxy polyethylene glycol-epoetin beta, or darbepoetin alfa in any

subject. The analysis for NAbs was not conducted.

At Stage II, the investigators assessed the safety of a single-dose intravenous (Cohort 10)

and subcutaneous (Cohort 11) injection of BCD-131 given at the highest (2.75 µg/kg) of the three

anticipated therapeutic doses established at Stage I.

The table below shows the results of safety evaluation at Stage II of the study.

Table 2. Safety and Tolerability Endpoints at Stage II.

Endpoint

Group

р-value1 Cohort 10

(n=6)

Cohort 11

(n=6)

Total AEs 4 (66.67%) 5 (83.33%) 1.00

Total SAEs 0 0 -

Grade 3-4 AEs and SAEs 0 0 -

Administration site reactions 0 0 -

Early withdrawal due to AEs and SAEs. 0 0 -




Endpoint

Group

р-value1 Cohort 10

(n=6)

Cohort 11

(n=6)

Note: 1 two-tailed exact Fisher’s test.

At Stage II of the study, AEs were reported in a total of 75% of volunteers who received

the test drug either as an intravenous or subcutaneous injection. However, no evidence of dose-

limiting toxicity (Grade 3-4 AEs) was reported. The majority of AEs were related to CBC and

blood biochemistry abnormalities. No SAEs were reported at Stage II of the study. No cases of

early withdrawal due to AEs were reported either. The majority of the recorded reactions were

expected and had been observed before in patients treated with other erythropoietin drugs.

Like at Stage I, the immunogenicity assessment in healthy volunteers included in the

second stage of the study revealed no BAbs to pegylated darbepoetin in any subject. As a result,

the analysis for NAbs was not conducted.

Therefore, the safety profiles of BCD-131 in intravenous and subcutaneous administration

at a dose of 2.75 μg/kg were comparable. The use of BCD-131 in either mode of administration

was characterized by the comparable frequency of AEs, which allows for suggesting that the safety

profiles of the drug product in intravenous and subcutaneous administration were similar.

Thus, the analysis showed that the test drug in the dose range of 0.05 μg/kg to 4.45 μg/kg

was generally well-tolerated and that its safety profile was comparable to those of Mircera® and

Aranesp®, which allows for further investigation of BCD-131 in the target population.

1.3.2.1.4. Discussion of results of the Phase I study

The study aimed to evaluate the safety, tolerability, PK and PD of single ascending doses of

BCD-131 (pegylated darbepoetin, JSC BIOCAD) including the comparison of these parameters

with those of Mircera® (methoxy polyethylene glycol-epoetin beta (pegylated epoetin)) and

Aranesp® (darbepoetin alfa). The study consisted of 2 stages. At Stage I, study subjects received

ascending doses of BCD-131, which followed by determination of a dose to be used in healthy

volunteers at Stage II of the study. The dose of 2.75μg/kg was chosen. This dose (2.75 μg/kg) was

the highest one of the three potential therapeutic doses (1.05 μg/kg, 1.7 μg/kg, 2.75 μg/kg) that,

according to the PD parameters, were most similar to those of the reference drug Mircera®.

The analysis of the findings demonstrated a favorable safety profile of BCD-131 when used

at doses ranging from 0.05 μg/kg to 4.45 μg/kg. No evidence of dose-limiting toxicity (i.e.

treatment-emergent Grade 3-4 AEs) was reported in any of the seven cohorts included in the study.




The majority of the reported AEs were expected and comparable to the safety profiles of other

erythropoietins (Mircera® and Aranesp®). No anti-BCD-131 antibodies (BAbs or NAbs) were

detected throughout the entire study period.

The AEs reported at Stage I and Stage II of the study included only Grade 1-2 (СТСАЕ

v.4.03) laboratory abnormalities (elevated liver enzymes, neutropenia, thrombocytosis), which,

along with the absence of administration site reactions, allows for predicting good tolerability of

BCD-131 when used for the treatment of patients.

The PK study of a single-dose subcutaneous injection of BCD-131 demonstrated that the

PK parameters of the drug product were dose-dependent: an increase in AUC was directly

proportional to the dose injected. It should be noted that the main decision on the choice of the

therapeutic dose range of BCD-131 was based on the PD response with reference to an increase in

the reticulocyte count. The reason why this decision was made without taking into account the PK

parameters was related to different specific potencies of BCD-131 and the reference drugs, which

had been demonstrated in preclinical studies of BCD-131.

The hemoglobin assessment following a single-dose injection of BCD-131 or the reference

drugs (Mircera® and Aranesp®) showed no significant increase in this parameter. Its values were

within normal limits, which is typical of erythropoietins since this PD effect can be observed only

upon repeated-dose administration of this kind of drugs. Therefore, the PD evaluation, followed

by the selection of the therapeutic dose range of BCD-131, was performed based on an increase in

the reticulocyte count while the PD evaluation based on hemoglobin levels was narrative.

An increase in the reticulocyte count was reported for all studied doses. However, the best

PD response, which was very similar to that due to the comparator Mircera®, was observed in the

cohorts of volunteers receiving BCD-131 at a dose of 1.05 µg/kg, 1.7 µg/kg, and 2.75 µg/kg. When

given at a dose of 4.45 µg/kg, BCD-131 resulted in a significant increase in the reticulocyte count,

which, hypothetically, can lead to red bone marrow cell hyperstimulation and, as a result, to a

negative effect of the drug product. Therefore, this dose can also be excluded from a range of

doses intended for use at Stage II of the study.

1.3.3. Conclusions and study rationale

Chronic kidney disease (CKD) is a severe chronic disorder secondary to many common

diseases. The prevalence of CKD around the world is increasing every year. Anemia is an

inevitable complication of CKD.




Renal, nephrogenic anemia is observed in the majority of patients on dialysis and has

numerous causes characterized mainly by the combination of deficiency in the production of

endogenous erythropoietin (EPO), depletion of the iron pool immediately available for

erythropoiesis, and resistance of the bone marrow to EPO. Just a few decades ago, the only

approach to the treatment of anemia in hemodialysis patients included multiple blood transfusions.

In the 1980s, recombinant human erythropoietins (rHuEPO) were developed. The use of

those drugs allowed for effective treatment of anemia, improved quality of life in CKD patients

and increased survival. One of the disadvantages of the first generation of epoetins was the

necessity for frequent administration of those drugs (three times a week). This problem was solved

to a large extent after the development of Aranesp® (darbepoetin alfa) in 2001. Aranesp® had a

better PK profile as compared to the first generation of epoetins, which allowed for using the drug

once a week or once every two weeks. However, a common disadvantage of all epoetins (and

darbepoetin alfa in particular) is their high cost.

Despite the significant progress in the treatment of nephrogenic anemia, there are still a lot

of problems to solve. Treatment with short-acting rHuEPO is burdensome both for patients and

healthcare professionals. Considering an epidemic-like increase in the incidence of CKD around

the world and a constantly increasing number of patients who require dialysis, there is a clinical

need for drugs having a convenient dosing regimen. Another reason for creating long-acting ESAs

is cyclic variability of hemoglobin, when its level often falls outside the target range. As a result,

it requires constant dose adjustment. These fluctuations in the hemoglobin level can be explained

by the use of short-acting ESAs.

BCD-131 is a covalent conjugate of darbepoetin with the low content of sialic acids and

linear methoxy-polyethylene glycol with the molecular weight of 30 kDa. Pegylated darbepoetin

is expected to have a longer half-life and higher in vivo activity than the available authorized drugs.

As a result, the drug will be administered to patients less often, the blood concentration of the

active ingredient will be more stable thus promoting further improvement of the patient’s

prognosis and quality of life.


biotechnology product. To date, a comprehensive study of structural, physico-chemical and

biological properties of BCD-131 has been conducted. The amino acid profile, three-dimensional

structure, sialylated form profile, purity and homogeneity, in vivo potency and stimulating activity

of pegylated darbepoetin in TF-1 cells have been studied.




The first step of clinical development of BCD-131 was the evaluation of its effects in

healthy volunteers in the Phase I study: “Open-Label Single Ascending Dose Clinical Trial to

Evaluate Pharmacokinetics, Pharmacodynamics, Tolerability, Safety and Immunogenicity of

BCD-131 in Healthy Volunteers as Compared to Mircera® (F. Hoffman-La Roche Ltd.,

Switzerland) and Aranesp® (Amgen Europe B.V., Netherlands)”. According to the results of the

Phase I study, the therapeutic dose range of BCD-131 was selected based on the evaluation of the

drug pharmacodynamic (PD) effect on stimulating the erythropoiesis. The pharmacodynamic

response reflected by the increased reticulocyte count, which was very similar to that due to the

comparator Mircera®, was observed in the cohorts of volunteers receiving BCD-131 at a dose of

1.05 µg/kg, 1.7 µg/kg, and 2.75 µg/kg.

Therefore, BCD-131 can be recommended for further clinical investigation of its efficacy

in the treatment of patients with renal anemia due to the end-stage chronic renal failure (stage 5D

CKD) receiving epoetin or darbepoetin alfa.

1.4. Brief description of known and potential risks and benefit for study subjects (benefit/risk

ratio)

1.4.1. Benefit evaluation

Based on the available information on the biological effects of human erythropoietin and

on the properties of authorized ESAs, having similar mechanisms of action (e.g. Mircera®) and

PD effects, it can be assumed that the use of BCD-131 in the target population (patients with

anemia secondary to chronic kidney disease) will result in increased hemoglobin values, increased

blood oxygen levels and improved oxygen delivery to body tissues.

According to the findings of preclinical studies and a Phase I study in healthy volunteers,

the selected doses of BCD-131 allow for maintaining (for one month) its PD effects similar to

those of Mircera®, a long-acting ESA used for the treatment of anemia in patients with stage 5

CKD. As a result, it is reasonable to suggest that the therapeutic efficacy of BCD-131 has been

demonstrated for all dosing regimens and is comparable to that of Mircera®. Therefore, the use of

BCD-131 at the specified dose is ethically acceptable.

1.4.2. Risk evaluation

BCD-131 demonstrated a favorable safety and tolerability profile in a Phase I clinical study

where it was administered to healthy volunteers as a single-dose injection.




Similar results were obtained following the evaluation of the safety, tolerability and

immunogenicity of the test drug at Stage I and Stage II of the Phase I study.

Thus, no evidence of dose-limiting toxicity (Grade 3-4 AEs) was reported either at Stage I

or Stage II of the study. Throughout the entire study period, just one Grade 3 AE (increased

bilirubin) was reported in a patient receiving Aranesp® 0.45 µg/kg. No other cases of Grade 3-4

AEs were observed. Also, no SAEs or cases of early withdrawal due to AEs were reported.

The most common AEs included laboratory abnormalities in CBC and biochemistry tests.

Those AEs had no clinical signs or symptoms and required no treatment. Cases of administration

site reactions were not reported either.

The majority of the reported reactions were deemed expected considering the mechanism

of action of the test drug and literature data on previously observed side reactions in patients treated

with erythropoietins.

Overall, the AEs emerged through the entire study period were as follows:

• Blood and lymphatic system disorders: decreased / increased platelet level,

decreased WBC level, decreased neutrophil level, increased monocyte level, increased basophil

level, increased eosinophil level.

• Hepatobiliary disorders: elevated AST, increased total bilirubin.

• Metabolism and nutrition disorders: decreased glucose level.

The most frequent of the above-mentioned AEs was neutropenia; other AEs were reported

as single cases (≤2).

The immunogenicity assessment during this Phase I study revealed no BAbs to pegylated

darbepoetin in any subject at either of the two stages of the study; as a result, the analysis for NAbs

was not conducted.

Therefore, the safety profiles of BCD-131 in intravenous and subcutaneous administration

were comparable. The use of BCD-131 in either mode of administration was characterized by the

comparable frequency of AEs, which allows for suggesting that the safety profiles of the drug

product in intravenous and subcutaneous administration were similar. The changes in the

laboratory findings observed both with intravenous and subcutaneous administration showed no

progression (the medians of all the studied parameters were within normal limits).

Since BCD-131 is a novel drug product, its effects in the target population (patients with

CKD) are unknown.

However, based on the literature data on AEs reported after administration of authorized

ESAs, presumably having similar mechanisms of action and PD effects (e.g. Mircera®), it cannot




be excluded that the use of BCD-131 in CKD patients may be associated with the risk for the

development of the following conditions: common - arterial hypertension, uncommon— shunt

thrombosis, headache, rare — flushing, hypertensive encephalopathy, hypersensitivity reactions,

maculopapular rash.

Therefore, the most common and expected side effect occurred in patients treated with

epoetins is increased blood pressure or a worsening of pre-existing arterial hypertension. The effect

is dose-dependent and is most commonly observed in patients with renal failure.

This study will take into account the specific inclusion/exclusion criteria that are

considered to be contraindications for the treatment with ESAs. The monitoring of CBC and blood

biochemistry parameters as well as questions asked at every visit and physical examination of

patients will allow for early detection of AEs that typically develop due to ESAs. As a result,

treatment can be adjusted, if necessary.

Also, risks for patients participating in the study are minimized with regard to the chosen

study design. For example, the process of inclusion in the study as well as dose escalation of BCD-

131 will be of gradual, step-by-step nature. At Stage I, the decision on a possibility of including

the next group of patients to receive a higher dose of BCD-131 will be taken by the DSMC based

on the pooled data on the safety and pharmacodynamics of BCD-131 in patients from the previous

dose group.

1.4.3. Conclusions

Thus, considering that the comparative physicochemical studies, preclinical studies, and a

clinical study of the PK, PD and safety of BCD-131 in healthy volunteers revealed no significant

differences between BCD-131 and Mircera® (a drug product presumably having a similar

mechanism of action), the PK parameters as well as the safety and tolerability profiles of BCD-

131, when used in further clinical studies for the treatment of anemia in CKD patients, are expected

to be similar to those described above.

Risks for patients participating in the study have been minimized due to the study design,

according to which the process of inclusion in the study as well as dose escalation of BCD-131

will be of gradual, step-by-step nature. At Stage I, the decision on a possibility of including the

next group of patients to receive a higher dose of BCD-131 will be taken by the DSMC based on

the pooled data on the safety and pharmacodynamics of BCD-131 in patients from the previous

dose group.




The risks of adverse effects are well known and not associated with any severe or life-

threatening conditions. The immunogenicity of BCD-131 is expected to be rather low. At the same

time, the data obtained from multiple international studies of Mircera® as well as known

advantages of long-acting ESAs indicate that patients can benefit from this study. Therefore, the

overall risk/benefit ratio for patients treated with BCD-131 is favorable.

1.5. Description and justification of administration mode, doses, dosage regimen and

treatment course

1.5.1. Description and justification of administration mode, doses, dosage regimen and

treatment course

BCD-131 is a potential therapeutic candidate for the treatment of anemia in patients with

chronic kidney disease who need long-term or even long-life therapy.

When choosing a dose and the frequency of administration of BCD-131 for this clinical

study, the investigators considered the results of the Phase I clinical study of BCD-131 as well as

the available data on two authorized ESAs (Mircera® and Aranesp®), the efficacy of which had

been confirmed for a number of diseases accompanied by anemia.

Thus, the Phase I clinical study aimed to evaluate the tolerability, safety, PK, PD and

immunogenicity of single ascending doses of BCD-131 in healthy volunteers as compared to

Mircera® and Aranesp®. Since the PD properties of BCD-131 studied in healthy volunteers without

anemia are difficult to extrapolate to patients with anemia, the Phase I clinical study also

investigated the PK and PD properties of Mircera® and Aranesp®, which had been used in clinical

practice for some time and for which the mean therapeutic dose was known.

It should be noted that the main decision on the choice of the therapeutic dose range upon

the completion of Phase I of the study was based on the evaluation of the BCD-131

pharmacodynamic (PD) effect on stimulation of erythropoiesis. The reason why this decision was

made without taking into account the comparative analysis of PK parameters was related to

different specific potencies of BCD-131 and the reference drugs (the erythropoietic activity of

BCD-131 with reference to Mircera® is 81.15%), which had been demonstrated in preclinical

studies of BCD-13123. During the Phase I study, the PD effects of BCD-131 were assessed by an

increase in the reticulocyte count. As a result, the PD response similar to that achieved with

23 “The Effects of BCD-131 (JSC BIOCAD, Russia) vs. Mircera® (F. Hoffmann-La Roche Ltd., Switzerland)

on the Ability of Myelocariocytes (Hematopoietic Stem Cells, HSCs) of the Umbilical Cord Blood to Stimulate the

Production of Colony-Forming Unit-Erythroid (CFU-e) Cells when Culturing Umbilical Cord Blood HSCs In Vitro

Using Methylcellulose Media”.




Mircera® 1.2 µg/kg was reported in cohorts receiving BCD-131 at a dose of 1.05 µg/kg, 1.7 µg/kg

and 2.75 µg/kg.

Therefore, the following doses have been chosen for further development of BCD-131 as

well as for the studies of its efficacy and safety in the treatment of patients with renal anemia due

to the end-stage chronic renal failure (stage 5D CKD) receiving epoetin or darbepoetin alfa:

1.05 µg/kg, 1.7 µg/kg, and 2.75 µg/kg given as subcutaneous injections once a month.

However, taking into account the data available for the authorized erythropoietins used for

the treatment of patients with renal anemia due to the end-stage chronic renal failure (stage 5D

CKD) receiving epoetin or darbepoetin alfa, the doses used in healthy volunteers and/or in

treatment-naive patients and/or in patients converted to another ESA should be recalculated. It

means that the starting dose of the drug product for dialysis patients currently receiving some other

ESAs depends on the dose of the previously used ESAs. The relevant information is provided in

the SmPCs for Aranesp® (darbepoetin alfa)24 and Mircera® (methoxy polyethylene glycol-epoetin

beta)25.

Considering that Mircera® is most likely to be a drug product whose mechanism of action

and dosing regimen are most similar to those of BCD-131, it would be most reasonable to take

into account recommendations and literature data related to the practical use of Mircera® when

justifying the algorithm of BCD-131 dose recalculation depending on the type and dose of previous

treatment. Also, the results of the Phase I study showed that BCD-131 and Mircera® had

comparable profiles of the PD effects targeting the stimulation of erythropoiesis. During the

Phase II study, the therapeutic efficacy and safety of different doses of BCD-131 will also be

compared with those of Mircera®.

According to the information provided in the SmPC for Mircera®, a conversion from short-

acting recombinant erythropoietins (rHuEPO) is performed in accordance with the doses shown in

the table below:

Table 3. Starting doses of Mircera®.

Previous weekly dose of

epoetin (U/week)


darbepoetin alfa

(µg/week)

Dose of Mircera®

Once a month

(µg/month)

Once 2 weeks (µg/2

weeks)

<8000 <40 120 60

24 https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=6a984fd4-843e-4238-ace8-

d1b2006cda46&t= 25 https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=24dc1990-f2f5-4991-996b-b4ef599ba2a6&t=

https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=6a984fd4-843e-4238-ace8-d1b2006cda46&t

https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=6a984fd4-843e-4238-ace8-d1b2006cda46&t

https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=24dc1990-f2f5-4991-996b-b4ef599ba2a6&t





epoetin (U/week)


darbepoetin alfa

(µg/week)

Dose of Mircera®

Once a month

(µg/month)

Once 2 weeks (µg/2

weeks)

8000-16000 40-80 200 100

>16000 >80 360 180

As can be seen from the table above, the starting dose of Mircera® in the SmPC for the

drug product was calculated based on the three dose levels of the previous treatment. To minimize

the risk of complications for patients and thoroughly study the safety profile of BCD-131, it would

be optimal, for all practical purposes, to introduce an additional detailed description of each dose

level depending on the dose received by the patient at the moment of conversion to another drug

product.

It should be noted that during the discussion of this clinical study design with leading

Russian experts having extensive practical experience in using erythropoietins in dialysis patients

with CKD, this approach was found to be optimal in terms of patients’ safety and prevention of

potential adverse events.

The algorithm, according to which the starting (initial) doses of Mircera® and BCD-131 in

Groups 1, 2 and 3 were calculated, is provided below:

1. Considering that the study plans to include patients receiving epoetins (alfa or beta)

or darbepoetin alfa, the dose levels of the relevant drug products were calculated. The calculations

were done in accordance with the information provided in the SmPC for Aranesp®: “The initial

weekly dose of Aranesp® (µg/week) can be determined by dividing the total weekly dose of

rHuEPO (IU/week) by 200” (i.e. if a patient receives rHuEPO at a dose of 1000 IU/week, then the

weekly dose of Aranesp® will be 1000 IU/week / 200 = 5 µg/week).

2. After that, the initial dose of the reference drug Mircera® was calculated depending

on the type and dose of the previous treatment (erythropoietin alfa/beta or darbepoetin alfa) and

using the conversion ratio of 0.8. To determine the values of the conversion ratio, the investigators

analyzed and summarized the data obtained from clinical studies of Mircera® as well as the

available data related to the practical experience of conversion from short-acting ESAs to long-

acting ESAs, since neither the IMU26, nor the Summary of product characteristics (SmPC)27 for

Mircera® contain any clearly defined algorithm using which the dose modification for additional

dose levels could be performed.

26 https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=24dc1990-f2f5-4991-996b-b4ef599ba2a6&t= 27 http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-

_Product_Information/human/000739/WC500033672.pdf


http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000739/WC500033672.pdf

http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000739/WC500033672.pdf




Thus, the efficacy of Mircera® for the treatment of anemia in dialysis patients with CKD

previously treated with erythropoietins alfa or beta was investigated in a multicenter randomized

open-label Phase II study28. The study involved a total of 137 patients. One of the inclusion criteria

was the target Hb of 110 – 130 g/L. During the study, the patients were distributed to three groups

depending on the conversion ratio applied for the calculation of the initial dose of Mircera® based

on a weekly dose of erythropoietin received by each patient. The conversion ratios (CR) used in

the study were as follows: 0.4/150, 0.8/150 and 1.2/150. It means that if the patient had been

receiving erythropoietin at a dose of 2000 IU/week, the dose of Mircera® calculated using the CR

of 0.4/150 was: 2000 х 0.4 / 150 = 5.3 µg/week29. Also, each of the three groups was divided into

additional dosing regimens: once a week, three times a week and once a month. The findings

obtained from this study showed that the median change in Hb levels was the lowest in the group

in which the CR used was 0.8/150 as compared to the CR of 0.4/150 with which decreased Hb

levels were observed, or as compared to the CR of 1.2/150 with which increased Hb levels were

observed(“Hb levels decreased in group A (–0.62 g/dL), remained stable in group B (–0.11 g/dL)

and increased in group C (0.31 g/dL”) 30. At the same time, the effect did not depend on a dosing

regimen (i.e. on the frequency of injections, including the once a month dosing regimen).

This clinical study is most similar to the planned clinical study BCD-131-2 because the

former was conducted in a homogenous target population of patients with anemia secondary to

chronic kidney disease who, prior to inclusion in the study, had been receiving treatment with

short-acting ESAs. Another similarity was that patients received subcutaneous injections of a

relevant drug once a month.

Therefore, to calculate the initial dose of Mircera® based on the previously received dose

of erythropoietin alfa or beta, the conversion ratio of 0.8/150 was chosen. For example, if a patient

had been treated with short-acting erythropoietin at a dose of 1000 IU/week, the initial dose of

Mircera® was: 1000 х 0.8 / 150 = 5 µg/week. To calculate the monthly dose of Mircera®, the

obtained value was multiplied by 4 weeks: 5 µg/week х 4 = 20 µg / once a month. A similar

approach was used to calculate doses of Mircera® for all dose levels (see the table below).

28 https://www.accessdata.fda.gov/drugsatfda_docs/nda/2007/125164TOC.cfm 29 «To determine the weekly starting dose of C.E.R.A., the weekly dose of epoetin (alfa or beta) the patient

received during the run-in period was multiplied by one of three ratios (0.4/150, 0.8/150 or 1.2/150 for groups A, B

and C, respectively). For example, if a patient had been receiving epoetin at a dose of 100 IU/kg/week, his C.E.R.A.

dose would have been 0.27 μg/kg/week if assigned to group A; 0.53 μg/kg/week if assigned to group B and 0.8 μg/kg/week if assigned to group C»




https://www.accessdata.fda.gov/drugsatfda_docs/nda/2007/125164TOC.cfm




Since clinical study BCD-131-2 plans to include patients who will be able to receive

treatment with darbepoetin alfa as well, the initial dose of Mircera® was also calculated for this

patient population using the conversion ratio of 0.8.

This value of the CR was chosen based on the literature data obtained from a number of

international studies.

Thus, based on the findings of one clinical study, which evaluated the switching of patients

from darbepoetin alfa to Mircera®, a conclusion was made that the starting dose of Mircera®, used

to maintain a stable Hb level, had to be 80-90% of the previously received dose of darbepoetin

(“This finding is evidence that CERA should be started at approximately 80% - 90% of the DA

dose to maintain equivalent Hb levels when the switching ESA from DA to CERA, suggesting that

the CERA dose is reducible during the maintenance phase of the CERA therapy”)31.

Another multicenter, observational study (TRANSFORM), which aimed to investigate

changes in Hb levels and other parameters in hemodialysis patients in clinical practice, evaluated

the reverse switching from Mircera® to darbepoetin alfa. In this study, the geometric mean (95%

CI) dose ratio at switching was 1.06 (1.01, 1.11), and more than three-quarters of patients (77.8%)

had a dose ratio of ≥ 0.8 32. It should be noted that 6 months after switching to another drug product,

the mean geometric dose ratio decreased to 0.88 (0.83; 0.93).

Also, the study in dialysis patients switching from Mircera® to darbepoetin alfa established

that33, on average, 1 μg of Mircera® was equivalent to 0.7-0.9 μg of darbepoetin alfa (“On the

basis of these data, Meier suggested conversion ratio in the range of 1 lg PEG-Epo to 0.7–0.9 lg

DA”), i.e. approximately 0.8.

Therefore, to calculate the initial dose of Mircera® based on the previously received dose

of darbepoetin alfa, the conversion ratio of 0.8 was chosen. In case when a patient had been treated

with darbepoetin at a dose of 5 μg/week, the initial dose of Mircera® was: 5 / 0.8 = 6 μg/week. To

calculate the monthly dose of Mircera®, the obtained value was multiplied by 4 weeks: 6 µg/week

х 4 = 24 µg / once a month. A similar approach was used to calculate doses of Mircera® for all

dose levels (see the table below).

31 Sayaka Takahashi, Yoshiko Tanaka, Mari Takano. Hemoglobin Level Stability after a Switch from

Darbepoetin Alfa to Epoetin Beta Pegol for the Treatment of Renal Anemia in Hemodialysis Patients. International

Journal of Clinical Medicine, 2015, 6, 652-660. 32 Jan Donck, Lourdes Gonzalez, Tabares Jacques. Preservation of Anemia Control and Weekly ESA Dosage After

Conversion from PEG-Epoetin Beta to Darbepoetin Alfa in Adult Hemodialysis Patients: The TRANSFORM Study.

Adv Ther (2014) 31:1155–1168 33 Meier P. Switch of ESA therapy from CERA to darbepoetin-alpha in chronic hemodialysis patients: a multicenter

experience (Abstract THPO441:presented at the American Society of Nephrology Renal Week, Denver, CO, USA,

16–21 November 2010). J Am Soc Nephrol. 2010;21:211A.




After the calculations were made, the investigators obtained the initial doses of Mircera®

which were based on the previous treatment (epoetins or darbepoetin alfa). The obtained initial

doses at one dose level were comparable both when switching from epoetins and from darbepoetin

alfa. As a result, to make the administration of the drug product in clinical practice simple and

more convenient, a monthly dose was found by calculating the mean of the monthly doses based

on the dose/type of the previous treatment. When calculating a monthly dose of Mircera®, the

investigators also considered a possible pharmaceutical form of the original Mircera® provided in

the SmPC for the drug product34 (see the table below).

Table 4. Calculation of the Monthly Dose of Mircera® Based on the Previous Treatment

Previous dose of

epoetin

Previous dose of

darbepoetin alfa

Dose of Mircera® (once a

month) based on the

previous dose of epoetin

Dose of Mircera® (once a

month) based on the

previous dose of

darbepoetin alfa

Mean dose of

Mircera® based

on the previous

treatment with

epoetins /

darbepoetin

alfa

IU/week µg/week µg/week µg/month µg/week µg/month µg/month

1000 - 2000 5 - 10 5 – 11 20 - 44 6-13 24 - 52 40

>2000 - 4000 > 10 - 20 > 11 – 21 > 44 – 84 > 13 – 25 > 52 – 100 75

> 4000 - 6000 > 20 - 30 > 21 – 32 > 84 – 128 > 25 – 38 > 100 – 152 120

> 6000 - 8000 > 30 - 40 > 32 – 43 > 128 – 172 > 38 – 50 > 152 - 200 150

> 8000 - 10000 > 40 - 50 > 43 – 53 > 172 – 212 > 50 – 63 > 200 - 252 200

> 10000 - 12000 > 50 - 60 > 53 – 64 > 212 – 256 > 63 – 75 > 252 – 300 250

> 12000 - 14000 > 60 - 70 > 64 – 75 > 256 – 300 > 75 – 88 > 300 – 352 300

> 14000 - 16000 > 70 - 80 > 75 – 85 > 300 – 340 > 88 – 100 > 352 – 400 350

> 16000 > 80 > 85 > 340 > 100 > 400 >350

3. After that, based on the obtained doses of Mircera®, which depended on the

dose/type of the previous treatment, the investigators calculated the initial doses of BCD-131 for

groups receiving 1.05 µg/kg; 1.7 µg/kg and 2.75 µg/kg of the test drug.

As it was mentioned before, during Phase I of the clinical study in healthy volunteers, the

use of BCD-131 at various doses and Mircera® at a dose of 1.2 µg/kg was investigated. According

to the SmPC for the drug product, the chosen dose of Mircera® was used in patients previously not

treated with ESAs. Based on the study results, the investigators chose the doses of BCD-131

(1.05 µg/kg; 1.7 µg/kg and 2.75 µg/kg), the PD effect of which was comparable to that of Mircera®

at a dose of 1.2 µg/kg.

34 https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=24dc1990-f2f5-4991-996b-b4ef599ba2a6&t=





Considering that the mean body weight of a healthy volunteer in the study was 70 kg, the

mean dose of Mircera® received by one volunteer was 1.2 µg/kg х 70 kg = 84 µg.

For a volunteer with the body weight of 70 kg, receiving BCD-131 at a dose of 1.05 µg/kg,

the mean dose of BCD-131 was 1.05 µg/kg х 70 kg = 73.5 µg.


the mean dose of BCD-131 was 1.7 µg/kg х 70 kg = 119 µg.


the mean dose of BCD-131 was 2.75 µg/kg х 70 kg = 192.5 µg.

Therefore, to calculate the anticipated therapeutic dose of BCD-131 when switching from

other erythropoietins, it was assumed that:

• 84 µg of Mircera® ≈ 73.5 µg of BCD-131 (for the dose level of 1.05 µg/kg),

• 84 µg of Mircera® ≈ 119 µg of BCD-131 (for the dose level of 1.7 µg/kg),

• 84 µg of Mircera® ≈ 192.5 µg of BCD-131 (for the dose level of 2.75 µg/kg).

Furthermore, according to the calculations provided in the table above, the mean dose of

Mircera®, for example, with the previous use of epoetin at a dose of 1000-2000 IU/week or

darbepoetin at a dose of 5-10 µg/week is 40 µg/month. Using a proportion where 84 µg of

Mircera® is equivalent to 73.5 µg of BCD-131 (for the dose level of 1.05 µg/kg, Group 1), the

mean dose of BCD-131 for the specified case can be calculated: 84 µg of Mircera®73.5 µg of 𝐵𝐶𝐷 − 131 (𝑓𝑜𝑟 𝐺𝑟𝑜𝑢𝑝 1) = 40 µg of Mircera®Х µg of 𝐵𝐶𝐷 − 131 (𝑓𝑜𝑟 𝐺𝑟𝑜𝑢𝑝 1) Х = 73.5 х 4084 = 35 µg of 𝐵𝐶𝐷 − 131 (for Group 1)

It means that a patient previously treated with epoetin at a dose of 1000-2000 IU/week or

darbepoetin at a dose of 5-10 µg/week should be given 35 µg of BCD-131 (in Group 1).

When used a similar approach for Group 2 (1.7 µg/kg х CR), the dose of BCD-131 for a

patient previously treated with epoetin at a dose of 1000-2000 IU/week or darbepoetin at a dose

of 5-10 µg/week is 56.6 µg (≈60 µg); for Group 3, the dose of BCD-131 (2.75 µg/kg х CR) is

91.6 µg (≈90 µg).

Also, to calculate a monthly dose of BCD-131, it was assumed that 1 mL of the test drug

BCD-131 contained 200 µg of the active ingredient and, therefore, a possible dosing increment

would be 20 µg. Considering this, when calculating the starting dose, its value was rounded down

to minimize the risk for patients.




The table below shows the starting doses of BCD-131 in Groups 1, 2, 3 and the dose of

Mircera® in the Mircera® group depending on the type and dose of previous treatment.

Table 5. Initial Monthly Doses of BCD-131 and Mircera® Used in the Clinical Study.

Dose

Level

Previous dose

of epoetin

Previous dose

of darbepoetin

alfa

Dose of

Mircera®

BCD-131 dose in

Group 1

(1.05 µg/kg x

CR),

subcutaneously

BCD-131 dose in

Group 2 (1.7

µg/kg x CR),

subcutaneously

BCD-131 dose in

Group 3 (2.75

µg/kg x CR),

subcutaneously


1 1000 - 2000 5 - 10 40 40 60 80

2 >2000 - 4000 > 10 - 20 75 60 100 160

3 > 4000 - 6000 > 20 - 30 120 100 160 260

4 > 6000 - 8000 > 30 - 40 150 120 200 340

5 > 8000 - 10000 > 40 - 50 200 160 280 440

6 > 10000 -

12000 > 50 - 60 250 200 340 560

7 > 12000 -

14000 > 60 - 70 300 260 420 680

8 > 14000 -

16000 > 70 - 80 350 300 480 800

9 > 16000 > 80 >350 >300 >480 >800

Thus, the calculated doses of BCD-131, the frequency (once a month) and route of

administration (subcutaneous) have been selected based on the data from non-clinical studies and

a Phase I clinical study of BCD-131 as well as on their comparison with the data and

recommendations for use available for other recombinant epoetins. The ease of administration and

applicability in clinical practice have been taken into account as well.

1.5.2. The rationale for the selection of the reference drug

The original Mircera® methoxy polyethylene glycol-epoetin beta was chosen as the

reference drug in this study. This drug product has demonstrated its efficacy in the treatment of

anemia in patients with chronic kidney disease35.

35 https://www.accessdata.fda.gov/drugsatfda_docs/nda/2007/125164TOC.cfm

https://www.accessdata.fda.gov/drugsatfda_docs/nda/2007/125164TOC.cfm




1.6. Compliance of the clinical study with regulatory requirements

This clinical study will be conducted according to this Protocol developed in full

compliance with the current law of the Russian Federation (Federal Law No. 61-FZ of April 12,

2012: On the Circulation of Medicines; National Standard of the Russian Federation GOST R

52379-2005 Good Clinical Practice; Constitution of the Russian Federation; and Federal Law No.

323-FZ of November 21, 2011: On Public Health Protection in the Russian Federation), the WMA

Declaration of Helsinki (Fortaleza 2013), the GCP principles, and the current law and regulations

of the participating countries.

1.7. Description of study population

Adult dialysis patients with renal anemia, due to the end-stage chronic renal failure (stage

5D CKD), aged 18 to 75 years (inclusive) on the day of signing the ICF, with the established

efficacy of dialysis (dialysis dose (Kt/v) ≥1.2 for patients on hemodialysis and Kt/v ≥1.7 for

patients on peritoneal dialysis)36. For dialysis patients, the need for the standard hemodialysis


Patients receiving recombinant EPO therapy (epoetin alfa or epoetin beta, or darbepoetin

alfa) for at least 3 months before signing the Informed Consent, with the stable recombinant EPO

dosing (epoetin alfa or epoetin beta, qw, biw, tiw, or darbepoetin alfa, qw or q2w) for at least

2 weeks before signing the Informed Consent and during the screening period, with the

hemoglobin level within target values (100-120 g/L, inclusive) for at least 2 weeks before signing

the Informed Consent and at screening, will be eligible for inclusion.

1.8. References

1. Bunn H.F. Erythropoietin. // Cold Spring Harbor Perspectives in Medicine. —2013. — V. 3.

—No.3. — a011619.

2. A.V. Vatazina, E.M. Shilova The use of Eprex® (epoetin alfa) for the treatment of anemia in

patients with end-stage chronic renal failure. / Study guide – 2nd edition. — M.: Practical

Medicine, 2006.

36 Kt/V = -Ln (R - 0.008 x t) + (4 - 3.5 x R) x UF/W






3. Papatheofanis F. J. Dosing patterns, hematologic outcomes, and costs of erythropoietic agents

in predialysis chronic kidney disease patients with anemia. // Current Medical Research and

Opinion. — 2006. — Vol. 22. — No.5. — P. 837–842.

4. Hörl W.H. Differentiating factors between erythropoiesis-stimulating agents: an update to

selection for anaemia of chronic kidney disease. // Drugs. — 2013. — Vol. 73. — No.2. — P.

117-130.

5. MacDougall I.C. CERA (continuous erythropoietin receptor activator): a new erythropoiesis-

stimulating agent for the treatment of anemia. // Curr. Hematol. Rep. — 2005. — Vol. 4. — P.

436–440.

6. MacDougall I.C. Novel erythropoiesis-stimulating agents: a new era in anemia management.

// Clin. J. Am. Soc. Nephrol. — 2008. — Vol. 3. — P. 200–207.

7. Panchapakesan U., Sumual S., Pollock C. Nanomedicines in the treatment of anemia in renal

disease: focus on CERA (continuous erythropoietin receptor activator). // Int. J. Nanomed. —

2007. — Vol. 2. — P. 33–38.

8. Instruction for Medical Use for Mircera® ЛСР-002182\08.

9. Liu L., Li H., Hamilton S.R., Gomathinayagam S., Rayfield W.J., van Maanen M., Yin K.C.,

Hong L., Prueksaritanont T. The impact of sialic acids on the pharmacokinetics of a PEGylated

erythropoietin. // J. Pharm. Sci. — 2012. — Vol. 101. — No.12. — P. 4414–4418.

10. Henke M., Laszig R., Rübe C., Schäfer U., Haase K.D., Schilcher B., Mose S., Beer K.T.,

Burger U., Dougherty C., Frommhold H. Erythropoietin to treat head and neck cancer patients

with anaemia undergoing radiotherapy: randomised, double-blind, placebo-controlled trial. //

Lancet. — 2003. — Vol. 362. — No.9392. — P. 1255–1260.

11. Mohyeldin A., Lu H., Dalgard C., Lai S.Y., Cohen N., Acs G., Verma A. Erythropoietin

signaling promotes invasiveness of human head and neck squamous cell carcinoma. //

Neoplasia. — 2005. — Vol. 7. — No.5. — P. 537–543.

12. Sinclair A.M., Rogers N., Busse L., Archibeque I., Brown W., Kassner P.D., Watson J.E.,

Arnold G.E., Nguyen K.C., Powers S., Elliott S. Erythropoietin receptor transcription is neither

elevated nor predictive of surface expression in human tumour cells. // Br. J. Cancer. — 2008.

— Vol. 98. — No.6. — P. 1059–1067.

13. Bohlius J., Wilson J., Seidenfeld J., Piper M., Schwarzer G., Sandercock J., Trelle S., Weingart

O., Bayliss S., Djulbegovic B., Bennett C.L., Langensiepen S., Hyde C., Engert A.

Recombinant human erythropoietins and cancer patients: updated meta-analysis of 57 studies

including 9353 patients. // J. Natl. Cancer Inst. — 2006. — Vol. 98. — No.10. — P. 708–714.




14. Bennett C.L., Silver S.M., Djulbegovic B., Samaras A.T., Blau C.A., Gleason K.J., Barnato

S.E., Elverman K.M., Courtney D.M., McKoy J.M., Edwards B.J., Tigue C.C., Raisch D.W.,

Yarnold P.R., Dorr D.A., Kuzel T.M., Tallman M.S., Trifilio S.M., West D.P., Lai S.Y., Henke

M. Venous thromboembolism and mortality associated with recombinant erythropoietin and

darbepoetin administration for the treatment of cancer-associated anemia. // JAMA. — 2008.

— Vol. 299. — No.8. — P. 914–924.

15. A.Yu. Kulikov, E.E. Arnina Cost-minimization analysis in the treatment of nephrogenic

anemia with erythropoiesis-stimulating agents (ESAs) in patients with chronic kidney disease

not on dialysis // Pharmacoeconomics. — 2009. — V. 2. — No.4. — P.34–37.

16. Yu.B. Belousov, S.K. Zyryanov, D.Yu. Belousov Pharmacoeconomic evaluation of the use of

short-acting (Eprex®) and long-acting (Aranesp®, Mircera®) erythropoietins for the treatment

of anemia in patients with chronic kidney disease. In: Hospital drugs: [collected volume /

edited by R. I. Yagudina]. — M.: Pharm Media, 2012. — P. 39–50.

17. Green M.D. Clinical Pharmacology Review of Novel Erythropoiesis Stimulating Protein

NESP.

http://www.fda.gov/downloads/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelope

dandApproved/ApprovalApplications/TherapeuticBiologicApplications/ucm086020.pdf

18. EMEA. Scientific discussion.

http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-

_Scientific_Discussion/human/000739/WC500033669.pdf

19. V.Yu. Shilo The novel erythropoiesis-stimulating agent Aranesp® (darbepoetin alfa) in the

management of renal anemia // Nephrology and dialysis. — 2007. — V. 9. — No.3. — P. 1–

9.

20. Macdougall I. C., Padhi D., Jang G. Pharmacology of darbepoetin alfa // Nephrol. Dial.

Transplant. — 2007. — Vol. 22. — Suppl 4. — P. iv2 – iv9.

21. L.G. Babicheva, I.V. Poddubnaya Treatment of anemia in oncology patients: a role of the

novel erythropoiesis-stimulating agent Aranesp® (darbepoetin alfa) // Modern Oncology. —

2007. — Т. 9. — No.3. — P. 69–74.

http://www.fda.gov/downloads/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/TherapeuticBiologicApplications/ucm086020.pdf

http://www.fda.gov/downloads/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/TherapeuticBiologicApplications/ucm086020.pdf

http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Scientific_Discussion/human/000739/WC500033669.pdf

http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Scientific_Discussion/human/000739/WC500033669.pdf




2. STUDY PURPOSE AND OBJECTIVES

2.1 Study aims

To determine an effective and safe therapeutic dose of BCD-131 upon multiple

administration of the drug to dialysis patients with chronic kidney disease treated for anemia.

2.2 Study objectives

1. Determine and compare the efficacy variables of 3 different doses of BCD-131 upon multiple

administration of the drug with those of Mircera®.

2. Study and compare the adverse event profile of 3 different doses of BCD-131 upon multiple

administration of the drug with that of Mircera®.

3. Determine and compare the pharmacokinetics (PK) and pharmacodynamics (PD) of 3

different doses of BCD-131 upon multiple administration of the drug with those of

Mircera®.

4. Determine and compare the proportion of BAb- and NAb-positive patients in the BCD-131

and Mircera® groups.

3. STUDY HYPOTHESIS

This clinical study is based on the following hypothesis:

The efficacy of the test drug (BCD-131) is equivalent to that of the reference drug

(Mircera®) based on the analysis of the primary endpoint (changes in the Hb level over the period

of evaluation as compared to the baseline Hb level37) during the 21-week period of treatment.

4. STUDY DESIGN

4.1. Primary and secondary endpoints

4.1.1 Primary endpoint

Efficacy evaluation:

• Change in the hemoglobin vs. baseline during the evaluation period.

37 The baseline hemoglobin will be calculated as the arithmetic mean of hemoglobin values obtained at

screening and at Visit 1. The final hemoglobin value during the evaluation period will be calculated as the arithmetic

mean of hemoglobin values obtained at Week 21 and Week 23.




The baseline hemoglobin will be calculated as the arithmetic mean of hemoglobin values

obtained at screening and at Visit 1. The final hemoglobin value during the evaluation period will

be calculated as the arithmetic mean of hemoglobin values obtained at Week 21 and Week 23.

4.1.2 Secondary endpoints

Efficacy endpoints:


• Relative number of patients (%) with the target hemoglobin level (100-120 g/L,

inclusive) during Weeks 1-23;

• Relative number of patients (%) who required dose adjustment during Weeks 1-23;

• Relative number of patients (%) who required blood transfusion during Weeks 1-

23;


The primary efficacy endpoint will be analyzed after the completion of all periods of the

study.

Tolerability and safety endpoints:

Safety evaluation:

• The proportion of patients who developed AEs/SAEs that were treatment-emergent in

the opinion of the investigator;

• The proportion of patients in each group who developed Grade 3-4 AEs (СТСАЕ

v.4.03) that were treatment-emergent in the opinion of the investigator;

• The proportion of patients in each group who discontinued the study due to

AEs/SAEs.

The safety endpoints will be analyzed after the completion of all periods of the study.

Immunogenicity assessment:


Blood sampling for immunogenicity assessment (BAbs and NAbs) will be performed in all

the patients included in the study before the first injection and then at Week 9 and Week 23.

The immunogenicity endpoints will be analyzed after the completion of all periods of the

study.

Pharmacokinetics/pharmacodynamics endpoints:




PK endpoints

• AUC0–672 h (area under the concentration vs. time curve from the moment of injection

to 672 h [28 days]) and AUC0-∞ (to infinity) after the first injection of the test/reference

drug,

• Cmax (maximum serum concentration of the drug product) after the first injection of the


• Cmin (minimum serum concentration of the drug product) at Weeks 5, 9, 13, 17, 21,

• Тmax (time to maximum serum concentration) after the first injection of the


• Т½ (half-life) after the first injection of the test/reference drug,

• Кel (elimination rate constant) after the first injection of the test/reference drug,

• CL (total clearance) after the first injection of the test/reference drug.

PD endpoints:

• AUEC0-672 h (area under the effect vs. time curve from the drug injection to 672 h [28

days]) based on the change in the absolute reticulocyte count after the first injection of

the test/reference drug,

• AC-Emax (maximum absolute reticulocyte count after the first injection of BCD-

131/Mircera®).

The PK analysis of the test drug will be based on the serum concentration of BCD-131

(pegylated darbepoetin). The PD analysis of BCD-131 will be based on the absolute reticulocyte

count.

The PK/PD endpoints will be analyzed after the completion of all periods of the study.

4.2. Description of the study type/design, flow-chart, procedures and periods

Study design

Clinical study BCD-131-2 is an international, multicenter, randomized, open-label,

comparative two-stage clinical study to determine an effective and safe therapeutic dose of BCD-

131 upon multiple administration of the drug to dialysis patients with chronic kidney disease

treated for anemia.

The study will include up to 100 dialysis patients with stage 5D chronic kidney disease

(end-stage chronic renal failure), established efficacy of dialysis and renal anemia without other

causes of anemia development (such as anemia of chronic disease, vitamin B12 deficiency, folic




acid deficiency, iron deficiency), receiving erythropoiesis-stimulating agents (ESA) and reaching

target hemoglobin levels. This study is a study of the maintenance treatment of anemia; therefore,

the study population includes patients:

− receiving recombinant erythropoietin (EPO) (epoetin alfa or epoetin beta, or

darbepoetin alfa) for at least 3 months before signing the Informed Consent (IC);

− receiving a stable dose of recombinant EPO (epoetin alfa or epoetin beta, qw, biw,

tiw, or darbepoetin alfa, qw or q2w) for at least 2 weeks before signing the

Informed Consent and during the screening period;

− with hemoglobin levels within target values (100-120 g/L) for at least 2 weeks

before signing the Informed Consent and at screening.

Randomization and stratification

The study plans to include 4 groups: 3 groups will receive the test drug BCD-131 at a dose

of 1.05 µg/kg, 1.7 µg/kg and 2.75 µg/kg x conversion ratio (CR) 38 based on the previous therapy

and one group will receive the reference drug Mircera®.

Before inclusion in the study, all patients will be provided with the full information about

the clinical study, its aims, and the risks associated with the participation in the study. After signing

the Informed Consent, patients will undergo a screening examination (within the screening period

of max 4 calendar weeks) to confirm that they meet the eligibility criteria.

After the investigator has decided to include the patient in the study, they will be stratified

based on the previous therapy (epoetin alfa / epoetin beta / darbepoetin alfa) and risk factors for

AE development due to rHuEPO therapy: age (<60 years / ≥60 years), availability / absence of

vascular implants, need/no need for hypoglycemic agents or insulin.

Study stages:

The study will include the following two stages:

Stage I

At stage I, patients will be included successively in each of the groups to receive BCD-

131. At the same time, patients will be included in the reference group to receive Mircera®. Patients

will be included in the groups in a 3:1 ratio (BCD-131 group : Mircera® group).

38 The dose calculations for BCD-131 and Mircera® are provided in section “Study Therapy” of the Synopsys

and in section 1.5.1 “Description and Justification of Administration Mode, Doses, Dosage Regimen and Treatment Course” of the Study Protocol.







First, 9 patients will be included in Group 1 (BCD-131, 1.05 µg/kg x CR depending on the

dose of the previous therapy) and 3 patients will be included in the Mircera® group (in a 3:1 ratio).

After all the enrolled patients from these groups (Group 1 and the reference group) have received

2 injections of the test/reference drug and completed a 2-week follow-up period after the second

injection (i.e. 1.5 months (42 days) after the first injection or 14 days after the second injection),

the investigators will consider a possibility of including the next 9 patients in Group 2 (BCD-131,

1.7 µg/kg x CR depending on the dose of the previous therapy).

At stage I, the Data Safety Monitoring Committee (DSMC) will take a decision on a

possibility of including the next group of patients to receive a higher dose (1.7 µg/kg x CR)39. The

decision will be based on the pooled data on the safety and pharmacodynamics of BCD-131 in

patients from Group 1 for the first 1.5 months (i.e. after two injections and a 2-week follow-up

period after the second injection). The safety evaluation of the test drug will be based on the

incidence of Grade 3 AEs, having a reasonable suspected causal relationship to the study drug

(according to the DSMB), in patients from Group 1. To perform the preliminary evaluation of the

PD effect of the indicated dose of the drug product, DSMC members will be additionally provided

with the data on hemoglobin levels and reticulocyte counts in complete blood counts of the patients

included in Group 1 at stage I.

The treatment of patients in Group 1 at stage I and in the reference group will not be

interrupted and continue according to the study protocol.

After the DSMC members have taken a decision about further dose escalation, 9 patients

will be randomized to Group 2 at stage I to receive BCD-131 at a dose of 1.7 µg/kg x CR, and 3

patients will be randomized to the reference group to receive Mircera® (randomization in a 3:1

ratio)40.

After all the patients in Group 2 and 3 patients in the reference group (enrolled

simultaneously with the patients in Group 2) have received 2 injections of either BCD-131 at a

dose of 1.7 µg/kg x CR or the reference drug and completed a 2-week follow-up period after the

second injection (i.e. 1.5 months (42 days) after the first injection or 14 days after the second

injection), the investigators will consider a possibility of including the next 9 patients in Group 3

(BCD-131, 2.75 µg/kg x CR depending on the dose of the previous therapy).

39 The DSMC will include principal investigators (4 persons) and a medical expert assigned for this study. 40 If the DSMC members have taken a decision about the risk of including patients in the next dose levels of






At stage I, the decision on a possibility of including the next group of patients to receive a

higher dose (2.75 µg/kg x CR) will be taken in the same way as described for the previous dose

level.

The treatment of patients in Group 2 at stage I and in the reference group (the next 3

patients) will not be interrupted and continue according to the study protocol. The patients will go

on receiving the relevant drugs at the same dose or, according to the DSMC decision, at a lower

dose if the treatment with the same dose of BCD-131 does not benefit the patient for safety reasons.




ratio)41.

The terms and parameters of safety evaluation of BCD-131 at a dose of 2.75 µg/kg x CR

in patients in Group 3 at stage I will be the same as those in Group 1 and Group 2 at stage I.

Stage II

In any of the above-mentioned situations, patients will be further enrolled in stage II of the

study according to the conditions of the screening period and stratification described above for

stage I. The total number of patients in each group, approved by the DSMC for participation in

stage II, should be 25 patients including those randomized to the relevant group at stage I of the

study. At stage I, more patients will be enrolled in the reference group to achieve the total number

of 25 patients, including those randomized to the relevant group at stage I of the study.

If, based on the decision of the DSMC, all the three dose levels (1.05, 1.7, and 2.75 µg/kg

x CR) of BCD-131 have acceptable safety profiles at stage I, more patients will be enrolled in each

of these three groups and in the reference group at stage II to compare the efficacy and safety of

the selected treatment regimen for 21 weeks. In this case, stage II of the study will include the

following groups:

Planned study groups provided the DSMC has approved the further study of the three

dose levels of BCD-131:

• Group 1: Patients in this group (25 patients including those randomized to this

group at stage I) will receive a subcutaneous injection of BCD-131, 1.05 µg/kg x

CR42, depending on the dose of the previous therapy, once a month until Week 21.



in groups to receive the next dose levels of BCD-131. 42 The dose calculations for BCD-131 and Mircera® are provided in Section 1.5.1 “Description and Justification

of Administration Mode, Doses, Dosage Regimen and Treatment Course” of the Study Protocol.






CR, depending on the dose of the previous therapy, once a month until Week 21.





group at stage I) will receive a subcutaneous injection of Mircera® once a month

until Week 21, at a dose depending on that of the previously administered

recombinant EPO in accordance with the SmPC for Mircera®43.

If, based on the decision of the DSMC, the first two dose levels (1.05 and 1.7 µg/kg x CR)

of BCD-131 have acceptable safety profiles at stage I, more patients will be enrolled only in

Group 1 and Group 2 of the test drug and in the reference group at stage II to compare the efficacy

and safety of the selected treatment regimen for 21 weeks. Patients who at stage I had received

BCD-131 at a dose of 2.75 µg/kg x CR, which later was not approved by the DSMC for stage II,

will further receive BCD-131 at a dose of 1.7 µg/kg x CR (i.e. the preceding dose level) until Week

21; their data will be used for additional safety evaluation. In this case, stage II of the study will

include the following groups:

Planned study groups provided the DSMC has approved the further study of BCD-

131, 1.05 and 1.7 µg/kg x CR:









the screening period. 43 http://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=24dc1990-f2f5-4991-996b-b4ef599ba2a6&t= 44 The dose calculations for BCD-131 and Mircera® are provided in Section 1.5.1 “Description and Justification








• Group 3: Patients in this group (only 9 patients who have been randomized to this

group at stage I and received BCD-131, 2.75 µg/kg x CR) will receive a

subcutaneous injection of BCD-131, 1.7 µg/kg x CR, depending on the dose of the

previous therapy, once a month until Week 21, for the purpose of additional safety

evaluation.





If, based on the decision of the DSMC, only the first dose level (1.05 µg/kg x CR) of BCD-

131 has an acceptable safety profile at stage I, more patients will be enrolled only in Group 1 of

the test drug and in the reference group at stage II to compare the efficacy and safety of the selected

treatment regimen for 21 weeks. Patients who at stage I had received BCD-131 at a dose of

1.7 µg/kg x CR, which later was not approved by the DSMC for stage II, will receive BCD-131 at

a dose of 1.05 µg/kg x CR (i.e. the preceding dose level) until Week 21; their data will be used for

additional safety evaluation. In this case, stage II of the study will include the following groups:

Planned study groups provided the DSMC has approved the further study of BCD-

131, 1.05 µg/kg x CR:




• Group 2: Patients in this group (only 9 patients who have been randomized to this

group at stage I and received BCD-131, 1.7 µg/kg x CR) will receive a

subcutaneous injection of BCD-131, 1.05 µg/kg x CR, depending on the dose of

the previous therapy, once a month until Week 21, for the purpose of additional

safety evaluation.



45 http://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=24dc1990-f2f5-4991-996b-b4ef599ba2a6&t= 46 The dose calculations for BCD-131 and Mircera® are provided in Section 1.5.1 “Description and Justification










Study periods

Overall, the study will include the following periods:

1. Screening period (up to 28 days from the moment of signing the Patient Information Sheet

and the Informed Consent Form, inclusive);


3. Follow-up (28 days from the last injection of the test/reference drug at Week 21 of the

study).

The study flow-chart is shown in the figure below.

47 http://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=24dc1990-f2f5-4991-996b-b4ef599ba2a6&t=





Figure 1. Study Flow-Chart.




Treatment

BCD-131 will be administered to patients in 3 of 4 groups. Patients will receive BCD-131

at a dose of 1.05 µg/kg (Group 1), 1.7 µg/kg (Group 2), 2.75 µg/kg (Group 3). In all the BCD-131

groups, a conversion ratio will be additionally used48 to calculate a monthly dose depending on the

previous dose of epoetin (alfa or beta) or darbepoetin alfa (see the table below). The patients will

receive the drug product as subcutaneous injections given once a month for 21 weeks.

The patients in the reference group will receive Mircera® as subcutaneous injections given

once a month for 21 weeks. The injected dose of Mircera® will be calculated on an individual basis

for each study subject depending on a stable dose of recombinant erythropoietin (epoetin alfa or

epoetin beta, or darbepoetin alfa) received by the patient for at least 2 weeks before signing the

Informed Consent and during the screening period (see the table below).

Table 6. Starting Doses of BCD-131 in Groups 1, 2, 3 and the Dose of Mircera® in the Mircera®

Group Depending on the Dose of the Previous Treatment.

Dose Level Previous dose of

epoetin

Previous dose of

darbepoetin alfa

Dose of

Mircera®

BCD-131 dose in

Group 1

(1.05 µg/kg x

CR),

subcutaneously

BCD-131 dose in

Group 2 (1.7

µg/kg x CR),

subcutaneously

BCD-131 dose in

Group 3 (2.75

µg/kg x CR),

subcutaneously


1 1000 - 2000 5 - 10 40 40 60 80

2 >2000 - 4000 > 10 - 20 75 60 100 160

3 > 4000 - 6000 > 20 - 30 120 100 160 260

4 > 6000 - 8000 > 30 - 40 150 120 200 340

5 > 8000 -

10000 > 40 - 50 200 160 280 440

6 > 10000 -

12000 > 50 - 60 250 200 340 560

7 > 12000 -

14000 > 60 - 70 300 260 420 680

8 > 14000 -

16000 > 70 - 80 350 300 480 800

9 > 16000 > 80 >350 >300 >480 >800

BCD-131 and Mircera® will be injected on Day 1 of Week 1, Day 1 of Week 5, Day 1 of

Week 9, Day 1 of Week 13, Day 1 of Week 17, Day 1 of Week 21, i.e. each patient will receive 6

injections of the test or reference drug.


Justification of Administration Mode, Doses, Dosage Regimen and Treatment Course”.




Regardless of a group to which a patient was assigned, subcutaneous injections will be

given by an authorized member of the study team right at the study site. Injections can be given

under the skin in the anterior abdominal wall, hip, shoulder. The distance between the sites of

injections should be at least 5 cm. In case when the day of injection coincides with the day of

dialysis, the injection of BCD-131/Mircera® should be given after the dialysis session.

Due to intra-patient variability, occasional individual hemoglobin values for a patient

above and below the desired hemoglobin level may be observed. Hemoglobin variability should

be addressed through dose management (adjustment) with consideration for the hemoglobin target

range of 100 to 120 g/L, inclusive.

The injected dose will be further adjusted based on the Hb level in accordance with the

algorithm provided in section 6.1.2 of the Study Protocol.

Throughout the entire study period, the therapy will be open-label.

Management of patients after the study completion

During the follow-up period, the management of patients, who completed the study in

accordance with the Protocol, is determined by the treating physician.

If the subject discontinues the study after receiving at least one dose of the investigational

product, an Early Withdrawal Visit is performed on the day of withdrawal. At this visit, the

following procedures are performed:

• Collecting the information about concurrent therapy;

• Physical examination;

• Evaluation of vital signs (BP; heart rate; body temperature);

• CBC and blood biochemistry, urinalysis;

• AEs/SAEs reporting.

- On Day 28±2 after withdrawal, the patient should attend the Follow-up Visit for an Early

Withdrawn Subject (procedures were described above).

The specified procedures are mandatory for all subjects who prematurely withdrew from

the study, except for the subjects who are lost to follow-up or are physically unable to attend the

visit. All records must be supported with appropriate source documents and the CRF.

If the subject discontinues the study due to an AE/SAE, the investigator should conduct

further treatment and follow-up after the Early Withdrawal Visit in accordance with the study site

standards for the treatment of a certain AE or SAE.

Also, see section 5.4 “Follow-up of subjects withdrawn from the study/study therapy”.

Study procedures




Patients will be given the injections of the test/reference drug during their visits to the study

site. During the clinical study, dialysis sessions will be conducted as scheduled according to the

recommendations approved by the treating physician.

The efficacy of the drug products will be evaluated upon the completion of all the study

periods by all the study subjects based on the comparison of hemoglobin values obtained

throughout the evaluation period vs. baseline (primary efficacy endpoint) and based on secondary

endpoints. Secondary efficacy endpoints will include changes in the hemoglobin over time, a

proportion of patients with the target hemoglobin maintained throughout the entire study, a

proportion of patients who required dose adjustment or blood transfusion, and the mean

hemoglobin throughout the entire study.

Safety evaluation will be based on the frequency and severity of AEs and SAEs in the

treatment groups, laboratory and instrumental findings, and the analysis of the vital signs. The

investigators will monitor main hematology and biochemistry markers, ECG results, vital signs as

well as the results of general examination of the patients. Safety parameters will be analyzed

throughout all the periods of the study.

To evaluate the immunogenicity of the study drugs, patients will take blood tests for

binding or neutralizing antibodies to BCD-131 or Mircera®, depending on the treatment group. To

detect antibodies to pegylated darbepoetin / methoxy polyethylene glycol-epoetin beta and analyze

changes in their production over time, blood sampling will be performed before the first injection

at Visit 1/Day 1, then at Week 9 and Week 23, and when pure red cell aplasia (PRCA) is

suspected49.

A limited number of patients (not more than 15 patients in each group) will have additional

blood samples collected to study pharmacokinetics (PK) (serum concentrations of the drug

product) and pharmacodynamics (PD) (absolute reticulocyte count). Based on the investigator’s

decision, during the period of intensive blood sampling for PK/PD analysis (after injection 1),

patients in the PK/PD subset may be hospitalized to the study site (this hospitalization will not be

49 Diagnostic criteria for pure red cell aplasia

Main signs:

rHuEPO therapy for at least 3 weeks;

Hemoglobin reduction by at least 1 g/L/day without blood transfusions;

Reticulocyte count below 10x109/L;

No significant reduction in WBC and platelets.

Additional signs:

Skin and/or systemic allergic reactions.

Supporting assessment:

Bone marrow aspiration shows normal cellularity and <5% erythroblasts with evidence of a maturation block;

Serum assay shows the presence of anti-erythropoietin NAbs.




reported as a SAE). Since patients included in the PK/PD subset will have to make multiple

additional visits to the study site for blood sampling, this may cause certain inconveniences.

Therefore, the study provides compensation to these patients.

4.3. Measures to minimize/exclude bias

4.3.1. Distribution of patients to study sites

The recruitment of patients at the study sites will be performed on a competitive basis.

4.3.2. Procedure of assigning study IDs

Patients will be randomized, stratified, and assigned ID numbers according to in-house

procedures of JSC BIOCAD.

Each study site will be assigned a 2-digit ID number. For example, the first site will be

numbered 01, the second – 02, the third – 03, etc.

After signing the informed consent form, each patient will be assigned a 5-digit screening

ID with the first two digits being the number of the study site and the next three digits showing the

order in which the patient was included in the study. The screening ID will be recorded in the

source documents and in the screening log. For example, the first patient who signed the Informed

Consent at study site 02, gets the screening ID 02-001.

When all the screening procedures are completed, and the investigator has decided that the

patient is eligible for the study, the investigator fills in a Screening Form and adds all the necessary

information on the Screening Visit to the eCRF. After that, the Sponsor receives a notification that

the relevant tabs have been filled in. If JSC BIOCAD confirms the inclusion of the patient in the

study, this patient is stratified, randomized and assigned a subject ID and a treatment group. The

Investigator receives the information on the assigned subject ID and the treatment group of the

enrolled patient. The Investigator records the information on the subject ID and the treatment group

in the source documents and in the eCRF.

Paper screening logs may be used as well. In this case the Investigator sends the screening

form to the clinical study project manager (Monitor) of JSC BIOCAD via e-mail (BCD-131-

[email protected]) or fax:

+7 (495) 992 82 98 (ext. 116). If JSC BIOCAD confirms the inclusion of the patient in the study,

this patient is stratified, randomized and assigned a subject ID and a treatment group. The

Investigator receives the information on the assigned subject ID and the treatment group of the






enrolled patient. The Investigator records the information on the subject ID and the treatment group

in the source documents and in the eCRF.

Patients can also be randomized using the Interactive Voice Response System (IVRS). In

this case, after having filled in the eCRF and/or having sent the completed screening form (in paper

form) and having received the confirmation of the patient’s inclusion in the study from JSC

BIOCAD, the Investigator stratifies and randomizes the patient with the Interactive Voice

Response System (IVRS), which will assign a subject ID and a treatment group to this patient.

The subject ID is a five-digit code where the first two digits are the study site number and

the last three digits are assigned sequentially to each participant as he/she enters the study.

For example, subject ID “01-090”:

- “01” – study site number,

- “090” – sequential subject ID in the study.

4.3.3. Stratification procedure

Prior to randomization, to ensure the similarity of the groups, the patients are stratified

based on the previous therapy (epoetin alfa / epoetin beta / darbepoetin alfa) and risk factors for

AE development due to rHuEPO therapy: age (<60 years / ≥60 years), availability / absence of

vascular implants, need/no need for the administration of hypoglycemic agents or insulin. The

common algorithm of patient stratification at Stage I and Stage II of the study is shown in the

figure below (Fig. 2).

4.3.4. Randomization procedure

Randomization in the study will be centralized.

The study plans to include 4 groups: 3 groups will receive the test drug BCD-131 at a dose

of 1.05 µg/kg, 1.7 µg/kg and 2.75 µg/kg x conversion ratio (CR) based on the previous therapy

and one group will receive the reference drug Mircera®.

Before inclusion in the study, all patients will be provided with the full information about

the clinical study, its aims, and the risks associated with the participation in the study. After signing

the Informed Consent, patients will undergo a screening examination (within the screening period

of max 4 calendar weeks) to confirm that they meet the eligibility criteria.

After the Investigator has decided that the patient is eligible for the study (i.e. s/he meets

all the inclusion/exclusion criteria specified in the Study Protocol) and is ready to receive the study

treatment, the treating physician informs the patient about this decision and makes sure that the




patient is ready to participate in the study (by asking the patient about his/her final decision and

adding this information to the source documents). After that, the randomization procedure is

performed.

Since this is a two-stage study, patients will be included in the study in a successive order.

Stage 1

At stage I, patients will be included successively in each of the groups to receive BCD-

131. At the same time, patients will be included in the reference group to receive Mircera®. Patients

will be included in the groups in a 3:1 ratio (BCD-131 group : Mircera® group).

First, 9 patients will be included in Group 1 (BCD-131, 1.05 µg/kg x CR depending on the

dose of the previous therapy) and 3 patients will be included in the Mircera® group (in a 3:1 ratio).

After all the enrolled patients from these groups (Group 1 and the reference group) have received

2 injections of the test/reference drug and completed a 2-week follow-up period after the second

injection (i.e. 1.5 months (42 days) after the first injection or 14 days after the second injection),

the investigators will consider a possibility of including the next 9 patients in Group 2 (BCD-131,

1.7 µg/kg x CR depending on the dose of the previous therapy). At stage I, the decision on a

possibility of including the next group of patients to receive a higher dose (1.7 µg/kg x CR) will

be taken by the DSMC. The treatment of patients in Group 1 at stage I and in the reference group

will not be interrupted and continue according to the study protocol.




ratio)50.

After all the patients in Group 2 and 3 patients in the reference group (enrolled

simultaneously with the patients in Group 2) have received 2 injections of either BCD-131 at a

dose of 1.7 µg/kg x CR or the reference drug and completed a 2-week follow-up period after the

second injection (i.e. 1.5 months (42 days) after the first injection or 14 days after the second

injection), the investigators will consider a possibility of including the next 9 patients in Group 3

(BCD-131, 2.75 µg/kg x CR depending on the dose of the previous therapy).

At stage I, the decision on a possibility of including the next group of patients to receive a

higher dose (2.75 µg/kg x CR) will be taken in the same way as described for the previous dose

level.

50 If the DSMC members have taken a decision about the risk of including patients in the next dose levels of






The treatment of patients in Group 2 at stage I and in the reference group (the next 3

patients) will not be interrupted and continue according to the study protocol. The patients will go

on receiving the relevant drugs at the same dose or, according to the DSMC decision, at a lower

dose if the treatment with the same dose of BCD-131 does not benefit the patient for safety reasons.




ratio)51.

See the detailed description of stage I of the study in section 4.2. “Description of study

type/design, flow-chart, procedures and stages”.

Stage 2

Patients will be further enrolled in stage II of the study according to the conditions of the

screening period and stratification described above for stage I. The total number of patients in each

group, included in the study, should be 25 patients including those randomized to the relevant

group at stage I of the study.

Therefore, the study will have a total of 24 strata. Each stratum will contain its own block

sequence (block randomization). The patients included in the study will be randomized within each

block using a random number generator.

During randomization, each patient is distributed to the relevant stratum, to the first free

group in a block. After randomization, JSC BIOCAD / the Interactive Voice Response System

(IVRS) will assign a subject ID and a treatment group to each patient. The Investigator will only

be provided with the information on the subject ID and his/her treatment group.

For example, the first patient in the study from study site 02 will be distributed to stratum 1

(i.e. this patient has been treated with epoetin alfa, s/he is <60 years old, s/he has vascular implants

and needs treatment with hypoglycemic agents or insulin). The first block in a random sequence

for stratum 1 is block 04 (mentioned as an example). The first free number in block 04 is 1

(mentioned as an example), which determines the distribution of the patient to Group 1 (BCD-131

at a dose of 1.05 µg/kg x CR).

The subject ID in the study is a five-digit code where the first two digits are the study site

number (in this example, it is 02) and the last three digits are a sequential number assigned to



in groups to receive the next dose levels of BCD-131.




each patient in the study (in this example, it is 001). As a result, the subject ID looks as follows:

|__|__|-|__|__|__|. In this example, the subject ID is 02-001.

The Investigator will be informed about the subject ID, which consists of the study site

number and a sequential number assigned to each patient in the study. In this example, the subject

ID is 02-001, the treatment group is Group 1 (BCD-131 at a dose of 1.05 µg/kg x CR).

The investigator records the information on the subject ID and the treatment group in the

source documents and in the eCRF. After that, the study doctor will set the date of the first visit.

The patient is informed about the date of the first visit after randomization. The investigator either

calls the patient or says about it in person if the patient is at the study site. Also, the Investigator

should tell the patient at what time exactly the latter should come to the study site for Visit 1 (the

patient should come to the study site at least 30 minutes before the scheduled time to take

laboratory tests; in case when the patient has agreed to be in the subgroup for PK/PD analysis, s/he

should come to the study site at least 2 hours before the first injection). Besides, the patient should

be informed about other requirements (e.g. the patient should fast for 8 h (i.e. no food including

sweet drinks) before the visit, s/he should not drink alcohol for 24 h before the visit and s/he should

not smoke for 1 h before the visit). If the study doctor plans to randomize the patient on the same

day when the first injection of the test/reference drug is given, s/he should tell the patient about

the above-mentioned requirements (by phone or in person if the patient is at the study site; the

doctor should add an appropriate record to the source documents as well). The first injection of

the test/reference drug should be given no later than 5 days after randomization.

JSC BIOCAD should keep lists of screening IDs and subject IDs of all the enrolled patients

including the information on the groups to which those patients were randomized. The batch

numbers of the investigational products should be kept as well.

During randomization, a representative of JSC BIOCAD will monitor the total number of

enrolled patients.




Figure 2. Stratification Algorithm.




4.3.5. Blinding

N/A. The therapy will be open-label throughout the entire study period.

4.4. Study therapy, doses and dosage regimens of investigational products Pharmaceutical

form, packaging and labeling of investigational products

4.4.1. Study therapy, doses, and dosage regimens of investigational products

BCD-131 will be administered to patients in 3 of 4 groups. Patients in Group 1 will receive

BCD-131 at a dose of 1.05 µg/kg х CR, in Group 2 – 1.7 µg/kg х CR, in Group 3 – 2.75 µg/kg х

CR. In all the BCD-131 groups, a conversion ratio will be additionally used to calculate a monthly

dose depending on the previous dose of epoetin (alfa or beta) or darbepoetin alfa. The injected

dose of Mircera® will be calculated on an individual basis for each study subject depending on a

stable dose of recombinant erythropoietin (epoetin alfa or epoetin beta, or darbepoetin alfa)

received by the patient for at least 2 weeks before signing the Informed Consent and during the

screening period (see the table below).

The test/reference drug will be given to patients for 21 weeks.

Table 7. Starting Doses of BCD-131 in Groups 1, 2, 3 and the dose of Mircera® in Group 4

Depending on the Dose of the Previous Treatment.


epoetin

Previous dose of

darbepoetin alfa

Dose of

Mircera®

BCD-131 dose in

Group 1

(1.05 µg/kg x

CR),

subcutaneously

BCD-131 dose in

Group 2 (1.7

µg/kg x CR),

subcutaneously

BCD-131 dose in

Group 3 (2.75

µg/kg x CR),

subcutaneously


1 1000 - 2000 5 - 10 40 40 60 80

2 >2000 - 4000 > 10 - 20 75 60 100 160

3 > 4000 - 6000 > 20 - 30 120 100 160 260

4 > 6000 - 8000 > 30 - 40 150 120 200 340

5 > 8000 -

10000 > 40 - 50 200 160 280 440

6 > 10000 -

12000 > 50 - 60 250 200 340 560

7 > 12000 -

14000 > 60 - 70 300 260 420 680

8 > 14000 -

16000 > 70 - 80 350 300 480 800

9 > 16000 > 80 >350 >300 >480 >800




Thus, BCD-131 and Mircera® will be injected on Day 1 of Week 1, Day 1 of Week 5,

Day 1 of Week 9, Day 1 of Week 13, Day 1 of Week 17, Day 1 of Week 21, i.e. each patient will

receive 6 injections of the test or reference drug.










The injected dose will be further adjusted based on the Hb level in accordance with the

algorithm provided in section 6.1.2 of the Study Protocol.

Throughout the entire study period, the therapy will be open-label.

4.4.2. Pharmaceutical form, packaging and labeling of investigational products

4.4.2.1. Test drug

See section 1.2.1 “Test drug”.

4.4.2.2. Reference drug

See section 1.2.2 “Reference drug”.

4.5. Expected duration of the study and subjects’ participation in the study

The expected duration of the study is 30 months, including the periods of enrollment (12

months), treatment and follow-up as well as data collection and statistical analysis of the results.

Each subject is expected to participate in the study for 28 weeks maximum, including the

screening (4 weeks), treatment and follow-up periods.

4.6. Study periods

4.6.1 Study schedule

Overall, the study includes the following periods:




1. Screening period (up to 28 days from the moment of signing the Patient Information Sheet

and the Informed Consent Form, inclusive);


3. Follow-up (28 days from the last injection of the test/reference drug at Week 21 of the

study).

Table 8 presents all the assessments/evaluations to be performed in the study (except for

visits to be made only by patients included in the PK/PD subset, see Table 9). All data obtained

during these assessments should be confirmed by relevant records in the source documents.

Prior results may be used for certain screening tests and exams (see section 4.7 for details).

During the screening period, blood biochemistry testing and urinalysis can be repeated one more

time if the first results did not meet the inclusion/exclusion criteria. The repeated sampling of

biological material can be performed if the previously taken samples were lost, or some violations

at the pre-analytical phase were observed (i.e. violations related to the sampling procedure, storage

or transportation of samples), or if the biological material was considered not suitable for analysis

(e.g., hemolysis, chylous serum etc.). All additional procedures must be approved by the Sponsor.

All scheduled visits (except for the visits for PK/PD evaluation) allow for a ±3-day interval

to perform evaluations with no shift in the following scheduled visits (i.e. the dates of all the

following visits are calculated starting from the previously scheduled date and not from the actual

date of the visit). If a scheduled visit falls on a state or religious holiday or in case of force majeure,

it can be postponed up to ±10 days, which must be approved by the Sponsor. In this case, all the

following scheduled visits are shifted (i.e. the dates of all the following visits will be calculated

starting from the actual date and not from the scheduled date of the visit).

The study plans to conduct the screening period, 8 scheduled visits during the treatment

period as well as 1 visit and 1 phone contact during the follow-up period.

The visits scheduled for the PK subset to perform blood sampling for the PK/PD analysis

cannot be postponed. During the collection of blood samples for the PK/PD analysis, changes in

the time of blood sampling can be made; however, they should be within permissible deviations

provided in Table 14.




Table 8. Study procedures and visits.

Visit

Procedure

Scr

een

ing

Wee

k 1

/ D

ay

1

Wee

k 3

Wee

k 5

Wee

k 7

Wee

k 9

Wee

k 1

3

Wee

k 1

7

Wee

k 2

1

Wee

k 2

3

Ph

on

e co

nta

ct

Day of visit - 28 - 0 1 15±3 29±3 43±3 57±3 85±3 113±3 141±3 155±3 169±3

Visit No. 152 2 3 4 5 6 7 8 9 10

Signing of the Informed Consent Form +

Collection of demographic data +

Collection of medical history and complaints +

Collection of information on comorbidities +

Collection of information on concurrent therapy53 + + + + + + + + + + +

Physical examination + + + + + + +

Evaluation of vital signs54 + + + + + + + + + +

Complete blood count55 + + + + + + + + + +

52 Scheduled visits, starting from Week 2, can be performed within the interval of ±3 days from the scheduled visit date counted from the date of the first injection (except

for patients in the PK/PD subsets) 53 At screening, the investigators collect the detailed information on recombinant EPO (epoetin alfa, epoetin beta, or darbepoetin alfa), received by the patient for at least

3 months prior to signing the Informed Consent. The dose of recombinant EPO (epoetin alfa or epoetin beta, qw, biw, tiw, or darbepoetin alfa, qw or q2w) received by the patient

should be stable for at least 2 weeks before signing the ICF and during the screening period (see the inclusion criteria). 54 Blood pressure, heart rate, body temperature, body weight (the weight is measured only at screening). 55 Starting from Visit 1 / Week 1, the analysis can be performed within 1-3 days before the scheduled visit date. The analysis is always performed before the following

injection. At visits “Week 5”, “Week 9”, “Week 13”, “Week 17” and “Week 21”, during which patients should receive the scheduled injections of BCD-131 / Mircera® in

accordance with the Study Protocol, the CBC results should be interpreted before dosing so that the investigator can make a decision on the dose adjustment, if necessary.




Visit

Procedure

Scr

een

ing

Wee

k 1

/ D

ay

1

Wee

k 3

Wee

k 5

Wee

k 7

Wee

k 9

Wee

k 1

3

Wee

k 1

7

Wee

k 2

1

Wee

k 2

3

Ph

on

e co

nta

ct

Day of visit - 28 - 0 1 15±3 29±3 43±3 57±3 85±3 113±3 141±3 155±3 169±3

Visit No. 152 2 3 4 5 6 7 8 9 10

Blood biochemistry56 +57 +58 + + + + + + + +

C-reactive protein (CRP)59 +60

Ferritin, transferrin saturation61 +62 + + + + + + +

Urinalysis +63 + + + + + + +

Blood sampling for HIV, hepatitis В and С, syphilis64,65 +

Blood test for intact parathyroid hormone (iPTH) +

56 Blood biochemistry tests analyze the following parameters: total protein, total bilirubin, ALT, AST, glucose, urea, creatinine, potassium 57 At screening, blood biochemistry tests can be repeated once if the first results did not meet the inclusion/exclusion criteria. All additional procedures must be approved by

the Sponsor. If some test is repeated, the results of both tests should be included in the source documents; however, only the results of the repeated test are included in the eCRF. 58 Starting from Visit 1 / Week 1, the analysis can be performed within 1-3 days before the scheduled visit date. The analysis is always performed before the following

injection. 59 CRP is evaluated only at screening. This parameter is analyzed during blood biochemistry testing, as an additional parameter. 60 At screening, the evaluation of CRP during blood biochemistry testing can be repeated just once if the first results did not meet the inclusion/exclusion criteria. All

additional procedures must be approved by the Sponsor. If some test is repeated, the results of both tests should be included in the source documents; however, only the results of

the repeated test are included in the eCRF. 61 These parameters (ferritin, transferrin saturation) are analyzed during blood biochemistry testing, as an additional parameter. 62 At screening, a blood biochemistry test to determine the serum iron can be repeated once if the first results did not meet the inclusion/exclusion criteria. All additional

procedures must be approved by the Sponsor. If some test is repeated, the results of both tests should be included in the source documents; however, only the results of the repeated

test are included in the eCRF. 63 At screening, the urinalysis can be repeated once, if the first results did not meet the inclusion/exclusion criteria. All additional procedures must be approved by the

Sponsor. If some test is repeated, the results of both tests should be included in the source documents; however, only the results of the repeated test are included in the eCRF.

64 At screening, only the test results obtained within 2 months prior to signing the Informed Consent are taken into account. The analyses for these chronic infections can be

performed by methods typically used at the study site.

65 Antibodies to HIV (HIV Ag/Ab Combo); HBsAg; Anti-HCV; RPR or a hemagglutination test.




Visit

Procedure

Scr

een

ing

Wee

k 1

/ D

ay

1

Wee

k 3

Wee

k 5

Wee

k 7

Wee

k 9

Wee

k 1

3

Wee

k 1

7

Wee

k 2

1

Wee

k 2

3

Ph

on

e co

nta

ct

Day of visit - 28 - 0 1 15±3 29±3 43±3 57±3 85±3 113±3 141±3 155±3 169±3

Visit No. 152 2 3 4 5 6 7 8 9 10

Blood sampling for immunogenicity assessment +66 + +

ECG + + +

Pregnancy test (a urine test for HCG, for women only)67 +

Chest X-ray/fluorography68 +

Assessment of compliance with the inclusion/exclusion criteria +

Administration of the drug product69 + + + + + +

AEs/SAEs reporting70 + + + + + + + + + + +

66 At Visit 1, blood sampling for immunogenicity assessment is performed before dosing. 67 A pregnancy test should be taken only by women of childbearing potential. If needed, this test can be performed at any subsequent visit. 68 At screening, only the test results obtained within 2 months prior to signing the Informed Consent are taken into account. 69 In case when the day of injection coincides with the day of dialysis, the injection of the test/reference drug should be given after the dialysis session. 70 Only SAEs are recorded at screening.




Table 9. Schedule of Additional Procedures in Patients Included in the PK/PD subset.

Visit No. Week of visit

Day of

visit

Blood sampling for PK

analysis

Blood sampling for

PD analysis

AEs/SAEs

reporting

Visit 1 Week 1 (Day 1)1 1 + + +

Visit 1a Week 1 (Day 2) 2 + + +

Visit 1b Week 1 (Day 3) 3 + + +

Visit 1c Week 1 (Day 4) 4 + + +

Visit 1d Week 1 (Day 5) 5 + + +

Visit 1e Week 2 (Day 1) 8 + + +

Visit 2 Week 3 (Day 1) 15 + + +

Visit 2а Week 4 (Day 1) 22 + + +

Visit 3 Week 5 (Day 1) (immediately before

injection 2) 29 + + +

Visit 5 Week 9 (immediately before

injection 3) 57 + +


injection 4) 85 + +


injection 5) 113 + +


injection 6) 141 + +

Note: 1 Multiple blood sampling is performed (see Table 14 for details).




4.2.6. Procedures of individual visits

Screening visit (up to 28 days from the moment of signing the Patient Information Sheet and the

Informed Consent Form, inclusive):

1. Signing of the Informed Consent Form;

2. Collection of demographic data;

3. Collection of medical history and complaints;

4. Collection of information on comorbidities;

5. Collection of information on concurrent therapy71;

6. Physical examination;

7. Evaluation of vital signs (BP; heart rate; body temperature; body weight);

8. Complete blood count;

9. Blood biochemistry72,73;

10. C-reactive protein (CRP) 74,75;

11. Ferritin, transferrin saturation76,77;

12. Urinalysis78;

13. HIV, hepatitis B and C, syphilis markers79;

71 At screening, the investigators collect the detailed information on recombinant EPO (epoetin alfa, epoetin

beta, or darbepoetin alfa), received by the patient for at least 3 months prior to signing the Informed Consent. The

dose of recombinant EPO (epoetin alfa or epoetin beta, qw, biw, tiw, or darbepoetin alfa, qw or q2w) received by the

patient should be stable for at least 2 weeks before signing the ICF and during the screening period (see the inclusion

criteria). 72 At screening, blood biochemistry tests can be repeated once if the first results did not meet the

inclusion/exclusion criteria. All additional procedures must be approved by the Sponsor. If some test is repeated, the

results of both tests should be included in the source documents; however, only the results of the repeated test are

included in the eCRF. 73 Blood biochemistry tests analyze the following parameters: total protein, total bilirubin, ALT, AST,

glucose, urea, creatinine, potassium 74 CRP is evaluated only at screening. This parameter is analyzed during blood biochemistry testing, as an

additional parameter. 75 At screening, the evaluation of CRP during blood biochemistry testing can be repeated just once if the first

results did not meet the inclusion/exclusion criteria. All additional procedures must be approved by the Sponsor. If

some test is repeated, the results of both tests should be included in the source documents; however, only the results

of the repeated test are included in the eCRF. 76 These parameters (ferritin, transferrin saturation) are analyzed during blood biochemistry testing, as an

additional parameter. 77 At screening, a blood biochemistry test to determine the serum iron can be repeated once if the first results

did not meet the inclusion/exclusion criteria. All additional procedures must be approved by the Sponsor. If some test

is repeated, the results of both tests should be included in the source documents; however, only the results of the

repeated test are included in the eCRF. 78 At screening, the urinalysis can be repeated once, if the first results did not meet the inclusion/exclusion

criteria. All additional procedures must be approved by the Sponsor. If some test is repeated, the results of both tests

should be included in the source documents; however, only the results of the repeated test are included in the eCRF. 79 At screening, only the test results obtained within 2 months prior to signing the Informed Consent are taken

into account. The analyses for these chronic infections can be performed by methods typically used at the study site.




14. Blood test for intact parathyroid hormone (iPTH);

15. ECG;

16. Pregnancy test (a human chorionic gonadotropin (hCG) urine test, only for women of

childbearing potential) 80;

17. Chest x-ray/fluorography 81;

18. Assessment of compliance with the inclusion/exclusion criteria

19. Randomization of the patient to the study after s/he was found to be eligible for the study;

20. SAEs reporting.

The total volume of the blood taken during the visit: 22 mL.

Visit 1 / “Week 1 Day 1”:

1. Collection of information on concurrent therapy;

2. Evaluation of vital signs (BP; heart rate; body temperature);

3. Complete blood count82;

4. Blood biochemistry8384;

5. Ferritin, transferrin saturation85

6. Urinalysis;

7. Blood sampling for immunogenicity assessment (BAbs, NAbs) 86;

8. Administration of the test/reference drug87;

9. Blood sampling for the PK/PD analysis in patients from the PK/PD subset (for the PK

analysis: 2 h, 1 h and 5 min before injection 1; for the PD analysis: 5 min before

injection 1) and then for the PK/PD analysis 3 h ± 5 min, 6 h ± 10 min, 12 h ± 10 min after

administration;

10. AEs/SAEs reporting.

80 A pregnancy test should be taken only by women of childbearing potential. If needed, this test can be

performed at any subsequent visit. 81 At screening, only the test results obtained within 2 months prior to signing the Informed Consent are taken

into account. 82 The analysis can be performed within 1-3 days before the scheduled visit date. The analysis is always

performed before the injection. 83 The analysis can be performed within 1-3 days before the scheduled visit date. The analysis is always

performed before the injection. 84 Blood biochemistry tests analyze the following parameters: total protein, total bilirubin, ALT, AST, glucose,

urea, creatinine, potassium 85 These parameters (ferritin, transferrin saturation) are analyzed during blood biochemistry testing, as an

additional parameter. 86 At Visit 1, blood sampling for immunogenicity assessment is performed before dosing. 87 In case when the day of injection coincides with the day of dialysis, the injection of the test/reference drug

should be given after the dialysis session.




The total volume of the blood taken during the visit: 19 mL; for patients in the PK/PD subset:

81 mL.

Visit 1а/ Week 1 Day 2 - 1e/ Week 2 Day 1 (only for the patients in the PK/PD subset):

Visit 1а/ Week 1 Day 2:

1. Blood sampling for the PK/PD analysis 24 h ± 10 min after injection 1;



Based on the decision of the Principal Investigator and in accordance with the patient’s

will, the patient can be hospitalized to the study site for the purpose of blood sampling for the

PK/PD analysis during visits Week 1 Day 1 and Week 1 Day 2. This hospitalization will not be

reported as a SAE.

Visit 1b/ Visit Week 1 Day 3:




Visit 1c/ Visit Week 2 Day 4:




Visit 1d/ Visit Week 1 Day 5:

1. Blood sampling for the PK (the concentration of the test/reference drug in the blood)) and PD

(the absolute reticulocyte count) analysis 96 h ± 20 min after injection 1;



Visit 1e/ Visit Week 2 Day 1:


2.3. AEs/SAEs reporting.





Visit 2 / Week 3:





5. In patients from the PK/PD subset, blood sampling for the PK/PD analysis 336 h ± 30 min

after injection 1;



21 mL.

Visit 2а/ Week 4 Day 1 (only for the patients in the PK/PD subset):

Visit 2а/ Week 4 Day 1:




Visit 3/ Week 5






6. Ferritin, transferrin saturation93;

7. Urinalysis;

8. In patients from the PK/PD subset, blood sampling for the PK/PD analysis 672 h ± 30 min

after injection 1 (i.e. immediately before injection 2);

88 The analysis can be performed within 1-3 days before the scheduled visit date. 89 The analysis can be performed within 1-3 days before the scheduled visit date. 90 The analysis can be performed within 1-3 days before the scheduled visit date.

91 The analysis can be performed within 1-3 days before the scheduled visit date. 92 Blood biochemistry tests analyze the following parameters: total protein, total bilirubin, ALT, AST, glucose,


additional parameter.







21 mL.

Visit 4 / Week 7







Visit 5 / Week 9







7. Urinalysis;

8. ECG;

9. Blood sampling for immunogenicity assessment (BAbs, NAbs);

10. In patients from the PK subset, blood sampling for the PK analysis before administration of

the drug product (i.e. 5 min before injection 3);

94 In case when the day of injection coincides with the day of dialysis, the injection of the test/reference drug

should be given after the dialysis session. 95 The analysis can be performed within 1-3 days before the scheduled visit date. The CBC results should be

interpreted before dosing so that the investigator can make a decision on the dose adjustment, if necessary. 96 The analysis can be performed within 1-3 days before the scheduled visit date. 97 The analysis can be performed within 1-3 days before the scheduled visit date. The CBC results should be

interpreted before dosing so that the investigator can make a decision on the dose adjustment, if necessary. 98 The analysis can be performed within 1-3 days before the scheduled visit date. 99 Blood biochemistry tests analyze the following parameters: total protein, total bilirubin, ALT, AST, glucose,








The total volume of the blood taken during the visit: 19 mL; for patients in the PK subset:

28 mL.

Visit 6 / Week 13







7. Urinalysis;






19 mL.

Visit 7 / Week 17





101 In case when the day of injection coincides with the day of dialysis, the injection of the test/reference drug




additional parameter. 106 In case when the day of injection coincides with the day of dialysis, the injection of the test/reference drug


interpreted before dosing so that the investigator can make a decision on the dose adjustment, if necessary.






7. Urinalysis;





The total volume of the blood taken during the visit: 10 mL; for patients in the PK subset: 19 mL.

Visit 8 / Week 21







7. Urinalysis;






19 mL.

108 The analysis can be performed within 1-3 days before the scheduled visit date. 109 Blood biochemistry tests analyze the following parameters: total protein, total bilirubin, ALT, AST, glucose,



should be given after the dialysis session. 112 The analysis can be performed within 1-3 days before the scheduled visit date. The CBC results should

be interpreted before dosing so that the investigator can make a decision on the dose adjustment, if necessary. 113 The analysis can be performed within 1-3 days before the scheduled visit date. 114 Blood biochemistry tests analyze the following parameters: total protein, total bilirubin, ALT, AST, glucose,



should be given after the dialysis session.




Visit 9 / Week 23







7. Urinalysis;

8. ECG;

9. Blood sampling for immunogenicity assessment (BAbs, NAbs);



Visit 10 / Phone Contact (performed 28 days after injection 6 of the test/reference drug)



Procedures of the Early Withdrawal Visit





5. Blood biochemistry;

6. Urinalysis;


Procedures of the Follow-up Visit for an Early Withdrawn Subject


117 The analysis can be performed within 1-3 days before the scheduled visit date. The CBC results should be


urea, creatinine, potassium. 120 These parameters (ferritin, transferrin saturation) are analyzed during blood biochemistry testing, as an









6. Urinalysis;


Procedures of unscheduled visits (if AE occurs)






6. Urinalysis

4.7. Description of individual study procedures

All scheduled clinical and laboratory procedures and their frequency are provided in the

table below:

Table 10. Frequency of Clinical and Laboratory Tests in the Study.

Test/Examination Test variable Frequency Locatio

n

Physical examination • General health state

• Skin and mucous membranes

• Peripheral lymph nodes

• Auscultation of the heart and lungs

• GIT status

• Urogenital system status

• Liver palpation

×6:

- at visits: Screening, Week 5,

Week 9, Week 13, Week 17,

Week 21, Week 23

Study

site

Vital signs121 • BP,

• HR,

• Body temperature

• Body weight

×10:




Week 21, Week 23

Study

site

Compete blood count

• Hemoglobin (g/L)

• RBC ( ×1012/L)

• Hematocrit (%)

• Reticulocytes (×109/L)

• Platelets ( ×109/L)

×10:




Week 21, Week 23

Study

site/Cen

tral lab

121 The body weight is measured only at screening





n

• WBC (×109/L)

• Neutrophils (×109/L)

• Lymphocytes (×109/L)

• Monocytes (×109/L)

(Blood volume: 3 mL)

Blood biochemistry

• Total protein (g/L)

• Total bilirubin (µmol/L)

• ALT (U/L)

• AST (U/L)

• Glucose (mmol/L)

• Urea (mmol/L)

• Creatinine (µmol/L)

• Potassium (mmol/L)


×10:




Week 21, Week 23

Study

site/Cen

tral lab

• C-reactive protein (mg/L) (screening)

(performed as part of biochemistry

testing)

Х1: - at visit: Screening

• Ferritin (µg/L)

• Transferrin saturation (%)) (performed

as part of biochemistry testing)

×8:



Week 17, Week 21, Week 23

Blood test for intact

parathyroid hormone

(iPTH)

• Intact parathyroid hormone (iPTH)


×1:

- at visit: Screening

Study

site/Cen

tral lab

Markers of HBV,

HCV, HIV,

syphilis122,123

• Antibodies to HIV (HIV Ag/Ab

Combo),

• Anti-HCV,

×1:

- at visit: Screening

Study

site/Cen

tral lab

122 At screening, only the test results obtained within 2 months prior to signing the Informed Consent are

taken into account and / or within 3 months before the estimated date of the first injection of the test/reference drug.

The analyses for these chronic infections can be performed by methods typically used at the study site. 123The patient with anti-HCV antibodies detected at screening can be included in the study if all of the

following conditions are met: negative qualitative PCR results for HCV RNA (this test is performed only if anti-HCV

antibodies have been detected); no increased transaminase and bilirubin concentrations shown by blood biochemistry

tests; the medical infections specialist has provided a documented conclusion that the patient has no HCV/cured HCV;

and the Sponsor has approved the enrollment of this particular patient.

HBsAg test should be performed as part of the analysis for hepatitis B. In case of positive results for HBsAg, the

patient cannot be included in the study.

In case of positive results for syphilis, the patient can be included in the study by the decision of the Sponsor

if the dermatologist/venerologist has provided a documented conclusion that the patient has no syphilis/cured syphilis.

Additional examination may be required to confirm the diagnosis (at the discretion of dermatologist).





n

• HBsAg,

• Rapid Plasma Reagin (RPR) or direct

hemagglutination to T. pallidum124.


Urinalysis • General properties (color, clarity,

specific gravity, pH, protein, glucose);

• Urinary sediment microscopy

(epithelium, erythrocytes, leukocytes,

cylinders, bacteria, salts).

×8:

- at visits: Screening,



Week 23

Study

site/Cen

tral lab

Pregnancy test (only

for women of

childbearing potential)

• A urine test for HCG ×1:

at visi: Screening125

Study

site

Instrumental

examinations

• 12-lead ECG ×3:

at visits: Screening, Week 9,

Week 23

Study

site

Immunogenicity

assessment

• Determination of serum NAbs and

BAbs (blood volume: 9 mL)

x 3:

at visits: Week 1, Week 9,

Week 23

Central

lab of

JSC

BIOCA

D

PK and PD

Assessment

• Determination of serum concentration

of the test/reference drug (blood

volume: 9 mL)

• Determination of the absolute

reticulocyte count in the blood (blood

volume: 2 mL)

A detailed schedule is provided in

Table 16 (the study is conducted

only in patients included in the

PK/PD subset)

Central

lab of

JSC

BIOCA

D /

Central

lab

The table below gives the estimated volume of blood to be taken at each visit and during

the entire study.

The blood volume required for additional serological tests (in case there is need for additional

testing/examination) should not exceed 20 mL. 124 Other tests can be used as well. 125 If needed, this test can be performed at any subsequent visit.




Table 11. Volume of blood to be taken from each subject in the study.

Visit No. Week of visit Laboratory tests (frequency/blood volume per 1 sample) Total blood volume

Screening Screening

• CBC (1 / 3 mL) 126

• Blood biochemistry127 (1 / 7 mL)

• iPTH (1 / 2 mL)

• Blood sampling for HIV, hepatitis, syphilis markers (1/

10 mL) 128

22 mL

Visit 1 Week 1 (Day 1)

• CBC (1 / 3 mL)

• Blood biochemistry (1 / 7 mL)

• IG (1 / 9 mL)

19 mL

Visit 2 Week 3 (Day 5±3) • CBC (1 / 3 mL)

• Blood biochemistry (1 / 7 mL) 10 mL





Visit 5 Week 9 (Day 57±3)

• CBC (1 / 3 mL)


• IG (1 / 9 mL)

19 mL







Visit 9 Week 23 (Day 155±3)

• CBC (1 / 3 mL)


• IG (1 / 9 mL)

19 mL

126 A CBC can be repeated once at screening. In this case, the additional amount of blood taken from the patient will be not more than 3 mL. 127 Biochemical tests can be repeated once at screening. In this case, the amount of blood taken from the patient will be not more than 7 mL. 128The additional amount of blood drawn for serological tests (in case when additional tests are required) will not exceed 20 mL.




Visit No. Week of visit Laboratory tests (frequency/blood volume per 1 sample) Total blood volume

Total volume of blood taken in one subject over the entire study 139129 mL

Table 12. The additional amount of blood drawn in one subject (for patients included in the PK/PD subset).

Visit No. Week of visit Laboratory tests (frequency/blood volume per 1 sample) Total blood

volume

Visit 1 Week 1 Day 1

✓ Determination of the concentration of the test/reference drug 2 h,

1 h and 5 min before injection 1

✓ Determination of the absolute reticulocyte count 5 min before

injection 1.

✓ Determination of the concentration of the test/reference drug and

the content of the absolute reticulocyte count 3 h, 6 h and 12 h

after injection 1

62 mL

Visit 1a Week 1 Day 2 ✓ Determination of the concentration of the test/reference drug and

the content of the absolute reticulocyte count 24 h after injection 1 11 mL

Visit 1b Week 1 Day 3 ✓ Determination of the concentration of the test/reference drug and


Visit 1c Week 1 Day 4 ✓ Determination of the concentration of the test/reference drug and


Visit 1d Week 1 Day 5 ✓ Determination of the concentration of the test/reference drug and


Visit 1e Week 2 Day 1 ✓ Determination of the concentration of the test/reference drug and

the content of the absolute reticulocyte count 168 h after

injection 1

11 mL

Visit 2 Week 3 Day 1 ✓ Determination of the concentration of the test/reference drug and


injection 1

11 mL

129 The total volume of blood can be increased if additional tests are needed.




Visit No. Week of visit Laboratory tests (frequency/blood volume per 1 sample) Total blood

volume

Visit 2а Week 4 Day 1 ✓ Determination of the concentration of the test/reference drug and


injection 1

11 mL

Visit 3 Week 5 Day 1 ✓ Determination of the concentration of the test/reference drug and


injection 1 (i.e. immediately before injection 2).

11 mL

Visit 5 Week 9 ✓ Determination of the concentration of the test/reference drug

immediately before injection 3 9 mL







Additional amount of blood drawn in one subject over the entire study (the PK/PD subset) 186 mL




4.7.1. Collecting complaints, demographics and patients’ medical history

The following parameters will be recorded based on the patient’s medical records and

interview:

1. Main demographics including date of birth, age, sex, race/ethnic background,

occupation;

2. Medical and surgery history, including past diseases.

3. Gynecological history;

4. History of allergies and intolerance to medication;

5. Information on the previous treatment: the investigator will record all the drug

products received by the patient currently or in the past (within previous 90 days).

4.7.2. Physical examination

The following organs and systems must be assessed during the physical examination:

− General health state

− Skin and mucous membranes

− Peripheral lymph nodes

− Auscultation of the heart and lungs

− GIT status

− Urogenital system status

− Liver palpation

Frequency and timing:

Physical examination will be performed at the following visits: Screening, Week 5,

Week 9, Week 13, Week 17, Week 21, Week 23.

4.7.3. Vital signs

The evaluation of vital signs includes the following: axillary body temperature (ºC), blood

pressure (one arm, mm Hg), heart rate (wrist pulse) as well as the patient’s body weight (kg)

measured only at screening visit.


The vital signs will be evaluated at the following visits: Screening, Week 1, Week 3,

Week 5, Week 7, Week 9, Week 13, Week 17, Week 21, Week 23. If the scheduled date of

examination coincides with the day of dialysis, the blood pressure should be measured after the

dialysis session.




4.7.4. Laboratory tests

Laboratory tests include a CBC, blood biochemistry testing, an intact parathyroid hormone

test and urinalysis. The markers for HIV, hepatitis B and C and syphilis should be determined as

well.

4.7.4.1. Compete blood count

A CBC should be performed before the dialysis session in accordance with the standard

procedure as a fasting blood test (i.e. the patient must not have any food including sweet or alcohol

drinks within 8 h before the test). This study includes the following CBC parameters:

− Hemoglobin (g/L)

− RBC (×1012/L)

− Hematocrit (%)

− Reticulocytes (×109/L)

− Platelets (×109/L)

− WBC (×109/L)

− Neutrophils (×109/L)

− Lymphocytes (×109/L)

− Monocytes (×109/L)

Volume of blood taken: 3 mL.

Blood sampling is performed using standard procedures.


Blood sampling for a CBC will be performed at the following visits: Screening, Week 1,

Week 3, Week 5, Week 7, Week 9, Week 13, Week 17, Week 21, Week 23.

4.7.4.2. Blood biochemistry

Blood biochemistry testing is performed before the dialysis session in accordance with the

standard procedure as a fasting blood test (i.e. the patient must not have any food including sweet

or alcohol drinks within 8 h before the test).

A standard analysis includes the evaluation of the following parameters:

− Total protein (g/L)

− Total bilirubin (µmol/L)




− ALT (U/L)

− AST (U/L)

− Glucose (mmol/L)

− Urea (mmol/L)

− Creatinine (µmol/L)

− Potassium (mmol/L)


Blood sampling for blood biochemistry testing will be performed at the following visits:

Screening, Week 1, Week 3, Week 5, Week 7, Week 9, Week 13, Week 17, Week 21, Week 23.

At screening, blood biochemistry testing will also include the evaluation of the following

parameters:

− C-reactive protein (mg/L)

The study plans to determine the following parameters of iron metabolism:

− Ferritin (µg/L)

− Transferrin saturation (%).

These parameters will be assessed as part of blood biochemistry testing at the following

visits in accordance with the Study Protocol: Screening, Week 1, Week 5, Week 9, Week 13,

Week 17, Week 21, Week 23.



4.7.4.3. Blood test for intact parathyroid hormone (iPTH)

A test for intact parathyroid hormone should be performed in accordance with the standard

procedure as a fasting blood test (i.e. the patient must not have any food within 8 h before the test).

The patient must not drink alcohol for 24 h before the test and s/he should not smoke for 1 h before

the test. The patient should rest for 30 min before blood sampling.




Blood sampling for the intact parathyroid hormone test will be performed only at screening.

4.7.4.4. Serological tests




The test for HIV-infection detects antibodies to HIV-1 and HIV-2 (HIV Ag/Ab Combo) in

the serum or plasma.

Syphilis is determined by the Rapid Plasma Reagin (RPR) test or direct hemagglutination

to T. pallidum. Other tests can be used as well.

HBsAg test should be performed as part of the analysis for hepatitis B. In case of positive

results for HBsAg, the patient cannot be included in the study.

Hepatitis С is assessed by the results of determination of anti-HCV antibodies (total IgM

and IgG). If the patient is positive for anti-HCV antibodies, qualitative PCR for HCV RNA should

be performed, and the patient should be consulted by an infectious disease specialist.

Patients positive for anti-HBC antibodies can be included in the study if all of the following

conditions are met:

• Negative qualitative PCR results for HCV RNA,

• No abnormalities found in blood biochemistry results (ALT, AST, total bilirubin),

• The infectious disease specialist has provided a documented conclusion that the

patient has no HCV/cured HCV (the conclusion should be sent to the Sponsor, and saved in the

source documents and in the Investigator’s File),

• The Sponsor has approved the inclusion of the patient in the study.

All these tests are performed using routine procedures of the study site or central

laboratory. To prepare for the tests, the patient should fast for 8 hours before blood sampling.


4.7.4.5. Urinalysis

Urine sampling and urinalysis will be performed using standard procedures.


Urinalysis will be performed at the following visits: Screening, Week 1, Week 5, Week 9,

Week 13, Week 17, Week 21, Week 23.

4.7.4.6. Pregnancy test.

The hCG pregnancy test strips are used to determine hCG in urine specimens taken in

women of childbearing potential.


This test is performed at screening and then, if needed, at any subsequent visit.




4.7.5. ECG

12-lead ECG is recorded using a commonly used procedure.


The ECG test will be performed at the following visits: Screening, Week 9, Week 23.

4.7.6. Chest X-ray/fluorography

Chest X-ray is performed in accordance with the standard procedure used at the study site

to exclude tuberculosis or other lung diseases. If necessary, the Sponsor’s representative may

request the images (if the subject develops active tuberculosis while being in the study).


The study will be conducted at screening only. If the patient had an X-ray scan done within

2 months before signing the Informed Consent, its results can be used at screening. In this case,

the patient does not have to take this test again.

4.7.7. Blood sampling for PK, PD and immunogenicity assessment

In this study, additional blood samples will be collected in a limited number of patients (a

total of 60 patients, 15 patients per group) for the PK/PD analysis. The PK evaluation of the test

drug will be performed based on the serum concentration of BCD-131 (pegylated darbepoetin). In

the reference group, the PK evaluation will be based on the serum concentration of Mircera®

(methoxy polyethylene glycol-epoetin beta). The PD analysis of BCD-131 will be based on the

absolute reticulocyte count.

The procedures for the PK and PD evaluation will be conducted at blood sampling points

established by the Study Protocol.

In this study, blood sampling for immunogenicity assessment will be performed in all

patients. Immunogenicity assessment will be a necessary part of the drug safety monitoring. It will

be performed before the administration of the test drug on Day 1 of Week 1, and also at Week 9

and Week 23.

The study of the concentration of BCD-131 and its immunogenicity will be conducted in

the central laboratory of JSC BIOCAD (Bioanalytical Laboratory, Analytical Development

Department).

The evaluation of the absolute reticulocyte count will be conducted in the central

laboratory.




Determination of BCD-131 concentration (pharmacokinetics evaluation)

The concentrations of the active ingredients of BCD-131 and Mircera® will be determined

by a validated method of ELISA using the Erythropoietin-IFA-Best commercial test-system

manufactured by Vector Best. The limit of quantification of the test systems is as follows:

0.2 ng/mL for BCD-131 and 0.2 ng/mL for Mircera®.

Test specimen: venous serum.

Collect venous blood samples (at least 9 mL) into labeled clot activator tubes containing

no anticoagulants. Rotate the tube with a sample so the blood contacts the clot activator. Let it

stand for 20-30 min at room temperature in an upright position. To complete the clotting process,

allow the tube to stand for 20-30 min at 2-8°С in an upright position. Spin the tube at 2000 rpm

(approx. 700 G for 20 min). If needed, the tube can be spun at 1500G for 10 min. After spinning,

take the sample out of the centrifuge. The precipitate contains debris of blood cells and cell

elements. Serum is above the clot. No shaking or inverting is allowed. Divide 4 mL of serum

without a clot into two aliquots (A and B) and transfer them at a volume of at least 2 mL to dry

labeled plastic Eppendorf/cylindrical cryotubes. Immediately place the cryotubes for storage at -

20 °C (storage at -80 °C is also allowed). Store the tubes at –20оС at the study site for no longer

than 30 days. The tubes containing serum can be stored at -70 оС at the study site until requested

by the Sponsor’s representative or until the site close-down (but no longer than for 1 year).

Determination of the absolute reticulocyte count (pharmacodynamics evaluation).

Test specimen: venous blood.

Collect venous blood samples (at least 2 mL) into special tubes containing anticoagulant

(EDTA).

Send the samples from the study site on the day of sampling or within 24 h after blood

sampling. Assess the analysis results within 48 h after blood sampling.

Store the tubes containing samples at 2 - 8 ºС.

Immunogenicity assessment

Immunogenicity will be assessed by detecting binding (BAbs) and neutralizing (NAbs)

antibodies in the serum samples of patients. Serum levels of BAbs to BCD-131 will be determined

by using validated methods of ELISA; BAbs will be detected by using a standard procedure

(screening, confirmatory analysis and titer). The assay for neutralizing anti-BCD-131 antibodies

will be performed only if the test for binding antibodies shows positive results. NAbs will be

detected using a cell assay.

Test specimen: venous serum.




To determine BAbs/NAbs, venous blood is used at a volume of at least 9 mL. After

sampling, process the blood samples in the same way as for PK evaluation. Divide the serum

sample into 3 aliquots (A, B, and C), at least 1 mL each. Perform blood sampling no sooner than

2 h after the last meal.

Labeling of blood samples for PK, PD and immunogenicity assessment

Each tube should be labeled so that labeling cannot be wiped off/erased. The tubes should

be labeled with the following information: study code, subject ID, and sample's identifier. Each

sample’s identifier is unique and consists of letters and digits. The first two letters refer to the

purpose of the sample (i.e. PK refers to the analysis of the concentration of the test/reference drug;

PD refers to the content of absolute reticulocyte count; IG refers to the BAbs/NAbs detection).

Digits refer to the sequential number of the sample (which consists of the week number and the

time of blood sampling). They are followed by a letter (A for PD evaluation; А or B for PK

evaluation; А or B or С for IG assessment), which defines an aliquot of the sample. For example,

IG-1-B. To ensure correct labeling, appropriate sticky labels will be supplied to each study site.

Also, individual kits of tubes can be used to perform the above-mentioned evaluations. In this case,

the protocol code, subject ID, kit number and time of blood sampling should be indicated on these

tubes.

A test system used for the assay of anti-BCD-131 (pegylated darbepoetin) binding

antibodies.

The presence of anti-BCD-131 BAbs will be determined by ELISA; BAbs will be detected

by using a standard procedure (screening, confirmatory analysis and titer). The linearity range for

determination of anti-BCD-131 BAbs will be between 15.63 ng/mL and 1000 ng/mL.

The test-system will employ the plates (No. 3590, Corning Costar), to the wells of which

BCD-131 (JSC BIOCAD) will be applied. As standards to generate a calibration curve, known

concentrations of polyclonal rabbit anti-BCD-131 (JSC BIOCAD) antibodies, diluted in buffer

with pooled serum, will be applied to the wells after acid dissociation of antigen-antibody

complexes. To maintain the pH and form bridges with binding antibodies presented in samples,

1M Tris will be preliminary applied to the wells of the plate.

After incubation and washing, biotin-conjugated darbepoetin (JSC BIOCAD) will be added

to the wells. After incubation with biotinylated darbepoetin and washing, horseradish peroxidase-

labeled streptavidin will be added to the wells.




After incubation and washing, the amount of bound conjugate will be determined by a color

test using horseradish peroxidase-labeled streptavidin – hydrogen peroxide and chromoge –

tetramethylbenzidine. The reaction will be stopped by adding 1N H2SO4 and the absorbance (OD)

of solutions in the wells will be measured at 450 nm. The intensity of yellow staining will be

proportional to the content of anti-BCD-131 BAbs in the sample.

During the screening analysis, the ELISA method will detect patients' serum samples with

absorbance higher than the pre-specified cut point (CP). It is assumed that the serum samples of

these patients may contain anti-BCD-131 BAbs. Samples with signal lower than the CP are

considered negative, i.e. containing no BAbs. Samples considered positive during screening are

re-tested in the confirmatory analysis. During this analysis, serum samples are incubated with an

excess of an investigational product to detect signal changes. If the signal of the sample incubated

with an excess of the investigational product is < CP, this shows the specificity of the signal and

the presence of BAbs in the sample. In this case, the sample is considered true positive. If the

signal in the confirmatory analysis does not decrease or decreases insignificantly, the sample is

considered negative for BAbs.

NAbs to pegylated darbepoetin (BCD-131).

The presence of anti-BCD-131 NAbs in the serum samples of patients will be determined

by a proliferative assay in TF-1 cell culture, a human erythroblast cell line.

Control and test solutions will be added to the TF-1 cell culture. The fluorescent dye

(Alamar Blue) will be added 70-72 h after incubation. The resulting solutions will be incubated

for 20-22 h. After that, the fluorescence (RFU) will be measured at 544/590 nm excitation-

emission wavelength using the Tecan InfiniteM200Pro microplate reader. Samples with signal

lower than the CP (cutpoint) will be considered positive, i.e. containing anti-BCD-131 NAbs.

Samples with signal higher than the CP (cutpoint) will be considered negative, i.e. containing no

anti-BCD-131 NAbs. Polyclonal rabbit anti-BCD-131 antibodies will be used as a reference

standard.

Table 13. Unique Labeling of Tubes for Immunogenicity Assessment.

Visit Immunogenicity

Week 1 Day 1 (prior to the drug product

administration)

IG-1-A

IG-1-B

IG-1-С

Week 9 (prior to the drug product administration)

IG-2-A

IG-2-B

IG-2-С




Visit Immunogenicity

Week 23 (prior to the drug product

administration)

IG-3-A

IG-3-B

IG-3-С




Table 14. Unique Labeling of Tubes for PK, PD Evaluation in Patients Included in the PK/PD subset.

Visit Sample collection time PK PD Acceptable deviation

Week 1 / Day 1

(Visit 1)

2 h before dosing РК-1-А РК-1-В

Before injection 1

1 h before dosing РК-2-А РК-2-В

Before injection 1

5 min before dosing РК-3-А РК-3-В

PD-1-А Before injection 1

3 h after injection 1 РК-4-А РК-4-В

PD-2-А +/- 5 min


PD-3-А +/- 10 min


PD-4-А +/- 10 min

Week 1 Day 2

(Visit 2) 24 h after injection 1

РК-7-А РК-7-В

PD-5-А +/- 10 min

Week 1 Day 3

(Visit 1b) 48 h after injection 1

РК-8-А РК-8-В

PD-6-А +/- 20 min

Week 1 Day 4

(Visit 1c) 72 h after injection 1

РК-9-А РК-9-В

PD-7-А +/- 20 min

Week 1 Day 5

(Visit 1d) 96 h after injection 1

РК-10-А РК-10-В

PD-8-А +/- 20 min

Week 2 Day 1

(Visit 1e) 168 h after injection 1


PD-9-А +/- 30 min

Week 3 Day 1

(Visit 2) 336 h after injection 1

РК-12-А

РК-12-В PD-10-А +/- 30 min

Week 4 Day 1

(Visit 2a)


PD-11-А +/- 30 min




Visit Sample collection time PK PD Acceptable deviation

Week 5 Day 1

(Visit 3)


PD-12-А 672 h after injection 1 (i.e. immediately before injection 2) *

Week 9

(Visit 5)

5 min before injection 3 РК-15-А РК-15-В

Immediately before injection 3*

Week 13

(Visit 6)

5 min before injection 4 РК-16-А РК-16-В


Week 17

(Visit 7) 5 min before injection 5



Week 21

(Visit 8) 5 min before injection 6



Note: * - insignificant deviation in the time of blood sampling is allowed but not more than 30 min before the injection




4.7.8. Storage and shipping of biospecimens

Blood samples for the PK and immunogenicity evaluation are kept at the study site before

being sent to the central laboratory. Samples are sent to the central laboratory in lots, i.e. from

several patients at a time. Before sending samples, the study site should notify the Clinical Study

Manager/Monitor and agree upon the shipping date by phone. The first shipping takes only

aliquots A of each specimen. Aliquots B are stored at the study site until JSC BIOCAD confirms

that the test results are obtained. In case of the samples used for BAbs/NAbs detection, aliquots A

and B should be sent for analysis. Aliquot C is stored at the study site.

Samples should be shipped in containers with dry ice to keep them frozen for 72 hours. All

shipments to the laboratory will be made via a delivery service. Contact details of the delivery

service are provided by the clinical study manager/monitor. Contact details of the central

laboratory to which the samples are sent are provided in Section “Other institutions involved in

the study (clinical laboratories and other medical and/or technical services)”.

Blood samples for the PD evaluation are sent to the central laboratory on the day of

sampling or within 24 h after blood sampling. The tubes containing samples should be stored at 2

- 8 ºС.

4.7.9. Procedure for determination of analyte in the serum

The presence of anti-BCD-131 BAbs in the serum samples of patients will be determined

by ELISA. This method has been validated and developed in the laboratory of JSC BIOCAD130.

The presence of anti-BCD-131 NAbs will be determined by a validated cell assay.

The concentrations of the active ingredients of BCD-131 and Mircera® will be determined

by a validated method of ELISA using the Erythropoietin-IFA-Best commercial test-system

manufactured by Vector Best131.

4.7.10. Unscheduled visits

At the discretion of the investigator, the patient can come to the study site for an

unscheduled visit to undergo additional safety tests (repeated laboratory tests, AE assessment,

etc.).

130 Validation report “Determination of BAbs to pegylated darbepoetin (BCD-131), methoxy polyethylene

glycol-epoetin beta (Mircera®) and darbepoetin alfa (Aranesp®) in the serum samples by the validated method of

ELISA.” 131 Validation reports “Determination of methoxy polyethylene glycol-epoetin beta (Mircera®) concentration

in human serum by ELISA” and “Determination of pegylated darbepoetin concentration in human serum by ELISA”




Procedures of unscheduled visits (if an AE occurs)




4. CBC and blood biochemistry, urinalysis.

4.7.11. Filling in electronic CRFs

The principal investigator and the study team members will be provided with logins and

passwords to enter the eCRF system.

The eCRF should be filled in within 5 working days after the visit. All screening data

should be entered at once after the screening.

In the eCRF system, patients are identified only by their unique subject IDs.

4.8. Stop rules and criteria for premature withdrawal for study subjects, study periods, and

study as a whole

4.8.1. Stop rules for study as a whole

The study can be terminated due to the following reasons:

1. By the decision of JSC BIOCAD due to safety reasons, ethical considerations,

compliance issues, or any other reasons.

2. By the decision of LECs or regulatory authorities.

4.8.2. Premature withdrawal criteria for study subjects

See section 5.2.

4.9. Drug accountability

The investigator is responsible for the investigational product accountability at the study

site. Throughout the study, the investigator must ensure proper accountability of the investigational

product as required by regulatory authorities. The investigator must maintain accurate records

regarding the receipt of the investigational product from JSC BIOCAD and its dispensing to/ return

by study subjects.

When the investigator or the pharmacist receives the investigational products, he/she

should check the delivery, sign and date a receipt form for the investigational products and




documentation provided by JSC BIOCAD, then return it to JSC BIOCAD. A copy of this

documentation should be stored in the Investigator's File.

The amount of investigational product delivered to the study site must be recorded in the

receipt form provided by JSC BIOCAD. This form will be used as an investigational product

accountability record.

Accurate accountability records should be available to the Monitor during each monitoring

visit. Accounting records should include:

• Confirmation of delivery of the investigational products to the study site;

• Inventory at the study site;

• Use of investigational product by each study subject;

• Return of unused drug product to JSC BIOCAD.

Records should include dates, amounts, batch numbers, and expiry dates of the

investigational product (if applicable). The investigator should keep records to ensure that:

• Study subjects get the investigational product at doses specified by the

Protocol/Amendment;

• The total amount of the investigational product provided by JSC BIOCAD is accurately

checked and delivered undamaged.

The unused investigational product must not be used for any other purpose except this

study. The test/reference drug that was dispensed to the patient and returned unused cannot be

dispensed to another patient.

4.9.1. Handling of investigational products

The drug delivered from the Sponsor should be stored 2°С to 8°С, protected from light. All

medicinal products supplied by the Sponsor must be stored in a limited access area. Only the

principal investigator, co-investigators, and an authorized representative of the site administration

will have access to the storage area.

The investigational product may be stored only at the study sites authorized for this clinical

study. The investigator must ensure safe storage of the investigational drug to prevent loss, theft,

or improper environmental conditions (temperature) specified by the Sponsor and described in the

Investigator’s Brochure. The investigator must maintain a temperature log.

Patients should be informed on storage conditions of the investigational product: a supply

of the drug must be stored at 2 - 8°С in the refrigerator. Do not freeze.




4.10. Procedure for keeping and unblinding randomization codes

There is no blinding in this study (i.e. it is an open-label trial), thus there is no procedure for

unblinding of randomization codes.

The screening and study IDs of all enrolled patients will be kept at JSC BIOCAD.

4.11. List of all data recorded in CRF (without previous recording in written or electronic

form) and considered as source data.

All data entered to the eCRF must be recorded in the source documentation.

In this study, no data will be entered directly to eCRF without prior entering to the source

documents.

5. ELIGIBILITY AND EXCLUSION OF STUDY SUBJECTS

5.1. Inclusion Criteria

1. Signed ICF to participate in the study.

2. Men and women aged 18 to 75 years inclusive at the moment of signing the ICF.

3. Documented end-stage renal failure.

4. Need for dialysis for at least 3 months before signing the ICF.

5. For dialysis patients, according to the investigator, the need for the standard hemodialysis


6. Documented treatment with recombinant EPO (epoetin alfa, epoetin beta, or darbepoetin alfa)

for at least 3 months before signing the ICF.

7. Documented stable dose of recombinant EPO (epoetin alfa or epoetin beta, qw, biw, tiw, or

darbepoetin alfa, qw or q2w) for at least 2 weeks before signing the ICF and during the

screening period.

8. Documented target hemoglobin level (100-120 g/L inclusive) for 2 weeks before signing the

ICF and at screening.

9. Efficacy of dialysis established at screening (dialysis dose (Kt/v) ≥1.2 for patients on

hemodialysis, and Kt/v ≥1.7 for patients on peritoneal dialysis)132.

10. Transferrin saturation ≥20%, ferritin level > 100 ng/mL at screening.

132 Kt/V = -Ln (R - 0.008 x t) + (4 - 3.5 x R) x UF/W






11. Willingness of patients and their sexual partners with preserved reproductive function to use

reliable contraception starting from signing the ICF and up to 4 weeks after the final dose of

the drug product given within the clinical study. This requirement does not apply to patients

after surgical sterilization or ≥ 2 years post-menopausal. Reliable methods of contraception

include one barrier method in combination with one of the following methods: spermicides,

intrauterine device/oral contraceptives.

12. Patient’s ability (in the investigator’s opinion) to follow the Protocol procedures.

5.2. Exclusion Criteria

1. Any other diagnosed forms of anemia, except for renal anemia, including anemia of chronic

disease (C-reactive protein (CRP) level >20 mg/L at screening).

2. Proven diagnosis of lupus nephritis or CKD due to systemic vasculitis133.

3. Platelet count <100х109/L at screening.

4. Planned (i.e. there are data on a tentative date of surgery and/or availability of a suitable

donor) kidney transplant surgery during the expected period of participation in the study.

5. History of allergies (anaphylactic shock or multiple drug allergy syndrome) as told by the

patient, and hypersensitivity to darbepoetin alfa or any components of the study drugs, or

iron(III)-hydroxide sucrose complex.

6. Vaccination within 8 weeks prior to signing the ICF (as told by the patient).

7. Diagnosed liver cirrhosis complicated with portal hypertension and/or splenomegaly

and/or ascites.

8. HIV-infection, acute hepatitis В, С, syphilis134.

9. ALT, AST levels >3xULN at screening.

10. Decompensated heart disorders (chronic heart failure (CHF), NYHA Class IV).

11. Resistant hypertension135.

133 A record on the absence of this pathology should be made by the investigator in the source documents. 134 The patient with anti-HCV antibodies detected at screening can be included in the study if all of the following

conditions are met: negative qualitative PCR results for HCV RNA (this test is performed only if anti-HCV antibodies

have been detected); no increased transaminase and bilirubin concentrations shown by blood biochemistry tests; the

medical infections specialist has provided a documented conclusion that the patient has no HCV/cured HCV; and the

Sponsor has approved the enrollment of this particular patient.

HBsAg test should be performed as part of the analysis for hepatitis B. In case of positive results for HBsAg, the

patient cannot be included in the study.

In case of positive results for syphilis, the patient can be included in the study by the decision of the Sponsor if the

dermatologist/venerologist has provided a documented conclusion that the patient has no syphilis/cured syphilis.

Additional examination may be required to confirm the diagnosis (at the discretion of dermatologist). 135 Resistant hypertension is defined as high blood pressure above the target range despite the concurrent use of three

anti-hypertensive drugs of different classes. In case blood pressure can be controlled using four or more

antihypertensive drugs, such hypertension is still considered to be resistant.




12. Unstable angina pectoris.

13. Proven diagnosis of hemoglobinopathies, myelodysplastic syndrome, malignant blood or

lymphoid disorders, pure red cell aplasia.

14. Severe secondary hyperparathyroidism (intact parathyroid hormone (PTH)>1000 pg/mL at

screening).

15. Documented episodes of gastrointestinal bleeding within 3 weeks prior to signing the ICF.

16. Documented episodes of thrombosis in past medical history (acute myocardial infarction,

stroke, transient ischemic attacks, deep venous thrombosis, pulmonary embolism) within

6 months prior to signing the ICF.

17. Seizure disorders, including a history of epilepsy.

18. Documented major surgery within 1 month prior to signing the ICF.

19. Documented blood transfusion within 3 months prior to signing the ICF.

20. Any acute infections, relapses of chronic infections or any other chronic diseases that are

present on the day of signing the Informed Consent and can, as judged by the Investigator,

negatively affect the patient’s safety during the study treatment.

21. History of severe depression, suicidal thoughts or suicide attempts136.

22. Documented malignancies except for cured basal-cell carcinoma and/or cervical cancer in

situ.

23. Known alcoholic or drug dependence or signs of present alcoholic/drug dependence that,

in the investigator's opinion, can be contraindications for the treatment with the

test/reference drug products or limit the treatment compliance.

24. Participation in other clinical studies within 90 calendar days prior to signing the Informed

Consent.

25. Pregnancy or breastfeeding.

5.2. Exclusion criteria

Patients will be withdrawn from the study in the following cases:

1. Major violations of the inclusion/exclusion criteria revealed after signing the Informed

Consent (by the decision of JSC BIOCAD)137;

2. The patient recalls his/her informed consent;

3. The patient develops adverse events or serious adverse events, laboratory abnormalities or

136 This exclusion criterion can be confirmed or rejected on the basis of documents or as told by the patient. 137 Violations of the inclusion/exclusion criteria justified by the Investigator and approved by the Sponsor cannot be

a reason to withdraw the patient from the study.




concomitant conditions that, in the opinion of the Investigator/Sponsor, make his/her

further participation in the study impossible, dangerous or non-beneficial regarding the

patient’s well-being/safety;

4. The patient has been diagnosed as having pure red cell aplasia (PRCA);

5. The patient has missed more than 2 injections in a row (in this case, the patient’s withdrawal

must be approved by the representatives of JSC BIOCAD, see section 6.3.1 “Compliance

assessment”); or the patient has missed 2 consecutive visits or a total of 3 visits;

6. The patient gets pregnant. If pregnancy is suspected, the urine test for HCG is performed.

If it is positive, the patient must be withdrawn from the study;

7. The study is terminated by the decision of JSC BIOCAD, local ethics committees or

regulatory authorities;

8. Use of medications prohibited by the Protocol;

9. The patient dies.

The investigator must inform JSC BIOCAD within 24 h about a patient’s early

withdrawal and specify the reason.

If the subject discontinues the study, an Early Withdrawal Form in the eCRF should be

filled in. The follow-up procedures for the discontinued subjects are described in section 5.4 (“List

of procedures at individual visits”).

See section 11.6 “Study termination” for details.

5.4. Follow-up of subjects withdrawn from the study/study therapy

5.4.1. Follow-up of patients who received at least one dose of the investigational products

The following should be done if the patient who received at least one dose of the test drug

discontinues the study early:

- On the day of withdrawal, the Early Withdrawal Visit must be performed. At this visit,

the following procedures are performed:

• Collection of information on concurrent therapy;

• Physical examination;

• Evaluation of vital signs (BP; heart rate; body temperature);

• CBC and blood biochemistry, urinalysis;

• AEs/SAEs reporting.

- On Day 28±2 after withdrawal, the patient should attend the Follow-up Visit for an Early

Withdrawn Subject (procedures were described above).




The specified procedures are mandatory for all subjects who prematurely withdrew from

the study, except for the subjects who are lost to follow-up or are physically unable to attend the

visit. All records must be supported with appropriate source documents and the CRF.


further treatment and follow-up after the Early Withdrawal Visit in accordance with the study site

standards for the treatment of a certain AE or SAE. The patient should be followed up until the

AE or SAE resolves completely. On Day 28±2 after withdrawal, the patient should attend the

Follow-up Visit for an Early Withdrawn Subject (procedures were described above).

If the subject discontinues the study, an Early Withdrawal Form in the eCRF should be

filled in by the investigator.

A female patient who discontinued the trial because of pregnancy should be monitored

through the entire pregnancy and for 6 months after delivery to evaluate the mother’s and child’s

health. Information on pregnancy course and outcome should be recorded in the source documents

and in the Pregnancy Report Form (see section 8.3.3). During the entire pregnancy period, the

investigator in collaboration with the attending Ob/Gyn specialist (if it is possible to contact

him/her) should monitor woman’s general health, the course of pregnancy, and the results of

laboratory and instrumental investigations including ultrasound. When the child is born, the

investigator together with the attending pediatrician (if it is possible to contact him/her) should

monitor the newborn for 6 months evaluating the child’s clinical status and the

laboratory/instrumental findings.

Information about the health state of the patient withdrawn from the study should be

recorded in the source documentation and eCRF.

5.4.2. Follow-up of subjects who did not receive a single dose of the investigational products

If the patient discontinues the study before being randomized and before getting the first

dose of the test/reference drug (screenout), the investigator must fill in all the screening procedures

in the eCRF of this patient.

If the patient was randomized but did not receive a single dose of the test/reference drug,

the investigator must also fill in the Early Withdrawal Form in the eCRF.

Non-dosed patients are followed-up only if they discontinue the study because of

AEs/SAEs. In this case, the follow up is performed according to the study site standards.

If the subject discontinues the study due to any reason after receiving a dose of the

test/reference drug, his/her data will be included in the analysis. If the subject discontinues the




study before the first dose of the investigational product, his/her information will be removed from

the analysis.

6. TREATMENT OF STUDY SUBJECTS

6.1 Study therapy

6.1.1. Therapy regimen and duration

BCD-131 will be administered to patients in 3 of 4 groups. Patients will receive BCD-131

at a dose of 1.05 µg/kg (Group 1), 1.7 µg/kg (Group 2), 2.75 µg/kg (Group 3). In all the BCD-131

groups, a conversion ratio will be additionally used to calculate a monthly dose depending on the

previous dose of epoetin (alfa or beta) or darbepoetin alfa138 (see the table below). The patients

will receive the drug product as subcutaneous injections given once a month for 21 weeks.

The patients in the reference group will receive Mircera® as subcutaneous injections given

once a month for 21 weeks. The injected dose of Mircera® will be calculated on an individual basis

for each study subject depending on a stable dose of recombinant erythropoietin (epoetin alfa or

epoetin beta, or darbepoetin alfa) received by the patient for at least 2 weeks before signing the

Informed Consent and during the screening period (see the table below).

Table 15. Starting Doses of BCD-131 in Groups 1, 2, 3 and the Dose of Mircera® in the Mircera®

Group Depending on the Dose of the Previous Treatment.


epoetin

Previous dose of

darbepoetin alfa

Dose of

Mircera®

BCD-131 dose in

Group 1

(1.05 µg/kg x

CR),

subcutaneously

BCD-131 dose in

Group 2 (1.7

µg/kg x CR),

subcutaneously

BCD-131 dose in

Group 3 (2.75

µg/kg x CR),

subcutaneously


1 1000 - 2000 5 - 10 40 40 60 80

2 >2000 - 4000 > 10 - 20 75 60 100 160


Justification of Administration Mode, Doses, Dosage Regimen and Treatment Course”.





epoetin

Previous dose of

darbepoetin alfa

Dose of

Mircera®

BCD-131 dose in

Group 1

(1.05 µg/kg x

CR),

subcutaneously

BCD-131 dose in

Group 2 (1.7

µg/kg x CR),

subcutaneously

BCD-131 dose in

Group 3 (2.75

µg/kg x CR),

subcutaneously

3 > 4000 - 6000 > 20 - 30 120 100 160 260

4 > 6000 - 8000 > 30 - 40 150 120 200 340

5 > 8000 -

10000 > 40 - 50 200 160 280 440

6 > 10000 -

12000 > 50 - 60 250 200 340 560

7 > 12000 -

14000 > 60 - 70 300 260 420 680

8 > 14000 -

16000 > 70 - 80 350 300 480 800

9 > 16000 > 80 >350 >300 >480 >800

Thus, BCD-131 and Mircera® will be injected on Day 1 of Week 1, Day 1 of Week 5,

Day 1 of Week 9, Day 1 of Week 13, Day 1 of Week 17, Day 1 of Week 21, i.e. each patient will

receive 6 injections of the test or reference drug.






6.1.2. Correction and adjustment of study therapy





In this clinical study, 9 dose levels have been calculated for each of the BCD-131 and

Mircera® groups depending on the previous therapy dose/type received by the participant. When

situations described in the table below occur, dose adjustment is required (i.e. the dose of the drug

product used should be increased or decreased by one level). For example, if the starting monthly

dose of BCD-131 given to a patient in Group 1 (1.05 µg/kg x CR) was set as 100 µg/month (third

dose level), then when the hemoglobin level increases from >125 to <130 g/L, it is necessary to

reduce the dose of the drug product to the previous dose level i.e. to 60 µg/month (second dose

level). Or, for example, when a patient in Group 2 (BCD-131, 1.7 µg/kg x CR) receives the drug




product at a dose of 200 µg/month (fourth dose level) and two sequential blood tests show the

variation of hemoglobin level from ≥95 to <100 g/L, it is necessary to increase the product dose

to the next dose level, i.e. the next injected dose should be 280 µg/month (fifth dose level).

If, according to the investigator, a situation requiring a different approach to dose

adjustment of the test/reference drug occurs, this should be discussed with the Sponsor.

The dose adjustment of the test/reference drug is required, if one of the situations described

in the table below occur:

Table 16. Dose Adjustment of BCD-131 and Mircera®

Hemoglobin level in

complete blood count

(CBC), g/L

Change in hemoglobin level since the

last CBC Recommendations/measures

<75 Any change over time

Repeat the CBC. If hemoglobin level remains

<75 g/L, it is recommended that the dose is


75 to <95 Decreased level or without change It is recommended that the dose is increased to

the next dose level.

75 to <95 Increased level Maintenance dose (no dose adjustment is

required)

≥95 до <100 during two sequential complete blood

counts

Decreased level or without change It is recommended that the dose is increased to

the next dose level.

≥100 to ≤120 Any change over time Maintenance dose (no dose adjustment is

required)

>120 to ≤125

during two sequential

complete blood counts

Increased level or without change Maintenance dose (no dose adjustment is

required)

>125 to <130 Decreased level Maintenance dose (no dose adjustment is

required)

>125 to <130 Increased level or without change It is recommended that the dose is decreased to

the previous dose level

≥130 Any change over time

Repeat the CBC. If the hemoglobin of ≥130 g/L

is confirmed, the dose should be temporarily

withheld until the hemoglobin decreases to

115 g/L, at which point therapy should be

reinitiated at one dose level lower than the

previous one.

Any Increase by >20 g/L from the baseline

for 4 weeks (or by >10 g/L for 2 weeks)

Repeat the CBC. It is recommended that the dose

is decreased to the previous dose level

Any Reduction by >20 g/L from the baseline

for 4 weeks (or by >10 g/L for 2 weeks)

Repeat the CBC. It is recommended that the dose

is increased to the next dose level.

6.1.3. Overdose of the test/reference drug

Erythropoiesis-stimulating agents (ESA) have a wide therapeutic index; therefore, when

initiating treatment with ESAs, an individual response to therapy should be taken into account.

Therapy with ESAs can result in hyperstimulation of erythropoiesis if the hemoglobin is not

carefully monitored and the dose is not appropriately adjusted. In case of a high Hb level, the




treatment should be discontinued (see section 6.1.2. “Correction and adjustment of study

therapy”).

In the event of polycythemia, darbepoetin alfa should be temporarily withheld. If clinically

indicated, phlebotomy may be performed.

Considering the variability in the dosing of the study drugs and, as specified in the Study

Protocol, a possibility of dose adjustment depending on a clinical situation, in this study overdose

is considered to be accidental dose excess as compared to the dose indicated by the investigator

for an individual patient at each particular visit.

See also section 8.3.5. “Reporting drug overdose”

6.2. Concomitant therapy, medications allowed and prohibited by the Protocol

6.2.1. Allowed concomitant therapy

Study subjects should tell the study team about any new medications that they have

received after the initiation of the study therapy. All medications (except for the test drug) and

significant non-medication therapies (including physiotherapy, herbal medicines/agents of natural

origin) used during the study should be recorded in section “Concomitant therapy” of the eCRF.

In case of using any concomitant therapy, the patient should continue it at the same dose

and regimen throughout the entire study (if it is possible from the medical point of view).

All drugs that the patient has been receiving before the study and all drugs used in addition

to the investigational drug during the study (including biologically active dietary supplements)

will be recorded in the Case Report Form.

Supplementary iron therapy is recommended for all patients with serum ferritin values

below 100 µg/l or whose transferrin saturation is below 20%. This therapy should be intravenous

(iron(III)-hydroxide sucrose complex) and may be provided by JSC BIOCAD.

6.2.2. Allowed concomitant therapy that requires special precautions for use and/or some

measures

N/A.

6.2.3. Prohibited concomitant therapy

Treatments prohibited in this study:

− Any other unauthorized products;




− Any other (except for the study drugs) recombinant erythropoietins or any other ESAs (e.g.,

androgens);

− Vaccinations;

− Oral iron supplementation given simultaneously with iron(III)-hydroxide sucrose complex.

A study participant who received or requires any prohibited treatment must be withdrawn

from the study.

The investigator must notify JSC BIOCAD within 10 business days about patient

withdrawal due to a prohibited treatment.

6.2.4. Therapy in special populations.

PRCA

If the patient develops PRCA, the test/reference drug should be discontinued. In future,

such patients should not be treated with recombinant erythropoietins. Peginesatide can be further

used to stimulate erythropoiesis. If PRCA is suspected, the tests should include the following: a

complete blood count along with the determination of absolute reticulocyte count, myelogram and

determination of anti-darbepoetin BAbs and NAbs. For the treatment of PRCA, patients are

typically indicated glucocorticoids and/or immunosuppressive drugs. If it is necessary to maintain

the Hb level, blood transfusions may be performed.

Stroke

If the patient develops an acute cerebrovascular accident, s/he should be further monitored

in the intensive care unit by a neurologist.

Need for blood transfusions

The need for blood transfusions is typically defined not by the Hb level in a patient, but by

his/her health condition and clinical benefit. According to KDIGO Clinical Practice Guideline for

Anemia in Chronic Kidney Disease (2012), blood transfusions in CKD patients with anemia are

recommended in such acute clinical situations as unstable angina, acute severe hemorrhage or

when rapid pre-operative Hb correction is required, and also in case of ESA resistance.

6.3. Compliance with study procedures

The information on each administration of the investigational product and doses will be

recorded during the study.

The Clinical Research Associate (CRA) will inspect the study documentation during

monitoring visits and upon completion of the study.




6.3.1. Compliance assessment

Non-compliance criteria (if the patient meets these criteria, s/he must be excluded from

the study):

- The patient has missed more than 2 injections in a row (in this case, the patient’s

withdrawal must be approved by the representatives of JSC BIOCAD), or

- the patient has missed 2 consecutive visits or a total of 3 visits.

All visits are conducted within the interval of ±3 days from the scheduled visit date counted

from the date of the first injection (except for patients in the PK/PD subset). In the case of force

majeure, or if the visit falls on a public holiday or other important event when the patient cannot

attend the study site, the visit can be rescheduled within 10 days if appropriately justified by the

investigator and approved by the Sponsor. The scheduled visit may be rescheduled within 7 days

by the decision of the investigator if the patient develops an AE. If none of this applies, the

violation of the visits schedule is considered a non-compliance.

According to the Study Protocol, patients included in the PK/PD subset can be replaced by

another patient in the following cases:

- The patient has been withdrawn from the study before the first injection of the


7. EFFICACY EVALUATION

7.1. Efficacy endpoints


Primary endpoint:


The baseline hemoglobin will be calculated as the arithmetic mean of hemoglobin values

obtained at screening and at Visit 1. The final hemoglobin value during the evaluation period will

be calculated as the arithmetic mean of hemoglobin values obtained at Week 21 and Week 23.

Secondary endpoints:

• Relative number of patients (%) with the target hemoglobin level (100-120 g/L, inclusive)

during Weeks 1-23;


• Relative number of patients (%) who required blood transfusion during Weeks 1-23;





7.2 Methods and time frames for assessment, documenting, and analysis of efficacy variables

7.2.1 Time frames for analysis of efficacy variables

The primary efficacy endpoint will be analyzed after Week 23 of the study.

7.2.2 Methods, time frames for assessment and documenting of efficacy variables

The efficacy analysis will be based on the comparison of hemoglobin values obtained

throughout the evaluation period vs. baseline, a proportion of patients with the target hemoglobin,

a proportion of patients who required blood transfusion and dose adjustment, and the mean

hemoglobin.

To evaluate the efficacy of BCD-131 and Mircera®, patients will take CBC tests to

determine hemoglobin levels. The first test for hemoglobin will be taken at screening. During the

treatment period, the hemoglobin will be determined once every 2 weeks during the first 2 months

of the study, and then every 4 weeks. Also, according to the Study Protocol, the reticulocyte count

will be assessed as part of the PD analysis in a limited number of patients (15 patients per group).

The per-protocol analysis will be used to assess the efficacy of treatment using the primary

endpoint. This analysis will include all the patients who completed the treatment according to the

Protocol.

The mITT-analysis will be used to evaluate the efficacy of treatment using secondary

endpoints. The mITT-analysis will include all the patients who were randomized to receive at least

one dose of the study drugs and were not withdrawn at the beginning of the study due to serious

violations of the Protocol rules and inclusion/exclusion criteria.

8. SAFETY EVALUATION

8.1. List of safety variables

8.1.1. Definitions of terms

8.1.1.1. Adverse events

Adverse Event (AE) is any untoward medical occurrence in a patient or clinical

investigation subject administered a pharmaceutical product and which does not necessarily have

to have a causal relationship with this treatment.




An AE can, therefore, be any unfavorable and unintended sign (including an abnormal

laboratory finding), symptom, or disease temporally associated with the use of a medicinal

product, whether or not related to the medicinal product: from the first dose of the investigational

product and until the end of the protocol-specified follow-up, inclusive, upon completion of the

therapy by the patient.

Based on this definition, untoward medical events developed prior to the administration of

the drug product (including events detected at Visit 1 but before dosing) do not refer to AEs. These

conditions are considered to be baseline for this patient.

8.1.1.2. Serious adverse events

Serious Adverse Event (SAE) is any untoward medical occurrence that at any dose:

• Results in death;

• Is life-threatening;

• Requires hospitalization or its prolongation;

• Results in persistent or significant incapacitation or disability;

• Is a congenital anomaly or birth defect.

In case of any uncertainty whether the event meets the seriousness criteria or not, it should

be treated as a serious adverse event.

An immediate risk of death from a reported event is considered life-threatening. A life-

threatening event does not include an adverse event that, had it occurred in a more severe form,

might have caused death, but is not associated with an immediate risk of death in the form it

occurred. For example, hepatitis that resolved without any signs of hepatic failure will not be

considered life-threatening, although more severe hepatitis can lead to fatal outcome. Similarly,

an allergic reaction resulting in face angioedema will not be considered life-threatening, although

larynx angioedema, allergic bronchospasm or anaphylaxis can lead to a fatal outcome.

Hospitalization is an official admission to hospital. Hospitalization or its prolongation is

a criteria of AE seriousness; however, hospitalization itself is not a serious adverse event.

Hospitalization or its prolongation not associated with an AE should not be reported by the

investigator as a serious adverse event. This is applicable (including but not limited) to the

following cases:

• Hospitalization or its prolongation is necessary to perform procedures required

by the Protocol.




• Hospitalization or its prolongation is a part of routine procedures at this study site

(for example, stent removal after a surgery). An appropriate confirmation should

be stored in a study file.

• Hospitalization due to a pre-existing (before signing the Informed Consent)

condition which did not aggravate (e.g. 1. Hospitalization for kidney transplant

surgery due to availability of a suitable donor; 2. A surgery of cataract diagnosed

before signing the Informed Consent etc.)

Disability is persistent or significant incapacity of the patient due to a disease, injury or its

sequelae or any other reasons over a particular period of time (temporary disability) or over a long-

term, uncertain period of time.

Other reportable information. Certain information which is not considered to be a SAE should

be recorded, presented in the report and followed as a SAE in accordance with the requirements

for expedited reporting. This includes:

• Maladministration of the drug product, such as unintentional or accidental use of the

investigational product, medication errors, whether or not considered related to an AE

(including confusion or possible confusion during the administration of investigational

products).

• Overdose (see criteria for expedited reporting of overdose in section 8.3.5. “Reporting drug

overdose”

• Cases of pregnancy

8.1.1.3. Unexpected adverse reactions

Unexpected Adverse Drug Reaction (Unexpected ADR) is an adverse reaction, the nature

or severity of which is not consistent with the available product information (e.g., Investigator’s

Brochure).

8.1.2. Safety endpoints

• The proportion of patients who developed AEs/SAEs that were treatment-emergent in the

opinion of the investigator;

• The proportion of patients in each group who developed Grade 3-4 AEs (СТСАЕ v.4.03)

that were treatment-emergent in the opinion of the investigator;

• The proportion of patients in each group who discontinued the study due to AEs/SAEs.




The safety endpoints will be analyzed after the completion of all periods of the study.

8.1.3. Immunogenicity assessment


Blood sampling for immunogenicity assessment (BAbs and NAbs) will be performed in

all the patients included in the study before the first injection and then at Week 9 and Week 23.

The immunogenicity endpoints will be analyzed after the completion of all periods of the

study.

8.2. Methods and time frames for assessment, documenting, and analysis of safety variables

8.2.1. Time frames for analysis of safety variables

Information about serious adverse events will include data on SAEs developed from the

moment of drug product administration until the completion (planned or premature) of the study

by the patient.

SAEs developed at screening will be assessed separately. Technically, these events do not

refer to AEs since they develop prior to the administration of the test product; however, they can

characterize the safety of screening procedures or be the reason for the patient’s withdrawal at

screening. Therefore, they must be reported as well.

The information on AEs that do not meet the seriousness criteria will be reported from the

first dose of the investigational product and until the end of the protocol-specified follow-up

period, inclusive, upon completion (planned or premature) of the therapy by the patient.

Drug Safety Division of JSC BIOCAD will analyze information about each SAE just after

receiving a report about it, provided that the Investigator has sent the report within the due time

window. The cumulative analysis will be performed during the preparation of the final study

report.

AEs not meeting the seriousness criteria will be analyzed routinely during the preparation

of the final study report.

8.2.2. Methods, time frames for assessment and documenting of safety variables

The safety analysis will include all patients who received at least one dose of the


Safety will be analyzed based on the information about:

- Reported AEs and SAEs,




- Physical examination data and vital signs assessment;

- CBC, blood biochemistry testing, urinalysis, blood test for iPTH.

- ECG results.

The frequency of these procedures is specified in section 4.6.1 “Schedule of study visits

and procedures”. AEs/SAEs are recorded in accordance with the guide provided by the Sponsor.

The investigator is responsible for documenting adverse events in the clinical study.

AEs will be reported from the first dose of the investigational product and until the end of

the protocol-specified follow-up period, inclusive, upon completion (planned or premature) of the

therapy by the patient. SAEs will be reported from the moment of signing the Informed Consent

until the completion (planned or premature) of the study by the patient. SAEs reported at screening

will not be included in the overall safety analysis. The investigator can record a SAE after the

period specified by the Study Protocol if s/he considers this SAE to be related to the study

treatment or procedures.

An AE is considered to be resolved if the laboratory / physiological variable or symptom

returned to baseline. The baseline values will be considered to be the values/manifestations of all

the variables obtained/observed in the patient before the first injection of the test/reference drug

given at the first scheduled visit in accordance with the Study Protocol. In case of long-

lasting/chronic AEs (including SAEs), the resolution will be seen as stabilization of the patient’s

condition (e.g., AE “Relapse of chronic bronchitis” will be considered resolved if remission is

achieved).

The study investigator must document non-serious AEs in the source documents and in the

eCRF and show them to the CRA at the next monitoring visit. Serious adverse events (SAEs) must

be reported to the Sponsor immediately, i.e. within 24 h by filling in and submitting the SAE

Report Form. SAE reports must be immediately (within 24 h) sent to the Sponsor via email at

[email protected] (put “To Pharmacovigilance Officer” in the subject field). The investigator

should receive a receipt/delivery confirmation.

8.3. Requirements for reports. Documenting and reporting AEs and completing AE Report

Forms

8.3.1. Documenting AEs/SAEs

At every visit, a record was made whether or not any AEs occurred during the period from

the previous visit. Any adverse event reported for a patient should be recorded in source documents





and in the Adverse Event Report Form (in the eCRF). AEs will be documented in accordance with

the guide provided by the Sponsor.

AEs are recorded and numbered consecutively as they occur. Each AE is reported in the

Adverse Event Report Form. Rules for reporting AE/SAE are described in detail in the guide

provided by the Sponsor.

Adverse events must be recorded regardless of their seriousness and causal relationship

with the study therapy. If the same adverse event re-emerges, it must be recorded as a new AE

with a new number assigned.

Laboratory/vital sign abnormalities

Laboratory/vital sign abnormalities considered to be adverse events (assessed as clinically

significant, including those of CTCAE 4.03 Grade 1, i.e. inducing clinical symptoms or

complaints, requiring concomitant therapy or changes in study therapy) must be recorded in

section “Adverse Events” of the eCRF. It is preferable to specify diagnosis rather than individual

symptoms (for example, leukopenia instead of decreased leukocyte count). Laboratory

abnormalities meeting the criteria of adverse events should be followed up until they return to

baseline values or until their adequate explanation is obtained.

Based on the safety evaluation of ESAs and considering the target population that will be

included in the study as well as individual patterns of chronic renal failure, a number of specific

rules for AE recording have been introduced to the study.

Specific rules for AE recording:

The following should not be reported as AEs:

• Clinical signs and symptoms of the main disease in the absence of worsening of CKD

(e.g., 1. Fluctuating edema with no clinically significant increase in its severity; 2.

Increased blood pressure before a dialysis session in the absence of clinically significant

change in the BP level as compared to BP values typical of this patient or previously

observed).

• Fluctuating laboratory abnormalities typical of CKD in the absence of a clinically

significant increase in these parameters as compared to the values previously observed

in this patient. In this study, these parameters include urea, creatinine, potassium.

In terms of other laboratory / physiological and clinical parameters in the absence of

any abnormalities in these variables at Visit 1 before the first injection of the test drug, the

following should be reported:

• All abnormalities of Grade 2 (CTCAE 4.03) and higher.




• Grade 1 abnormalities should be documented as AEs only if they are clinically

significant, i.e. if the investigator considers the abnormality to be substantial with

account of the main and concurrent illnesses. Single abnormalities found among

multiple laboratory test results or incidental low values should not be reported as AEs,

except for events that are clinically relevant.

In case of any laboratory, physiological or instrumental abnormalities observed between

visits, i.e. in the period between scheduled visits specified by the Study Protocol (e.g., when the

patient comes to the study site for a dialysis session), such AEs may be recorded by the investigator

in the eCRF if they are clinically significant (regardless of their severity). In this case, the

investigator should indicate the time of AE onset, add a note that the AE developed between visits

and make a comment explaining why this or that AE was recorded (e.g., by indicating the values

of laboratory and/or physiological variables).

8.3.2. Reporting AE/SAE

The AE Report Form should be filled in during the study visit (or the investigator can do it

later on the same day), except for data not available/not known at that moment. All sections of the

form must be filled in. If data are not available, the following should be entered: "Data not

available" or "N/A”. However, all actions should be taken to receive all necessary data on

emerging adverse events.

The following information must be recorded in source documents and the AE Report Form

of the eCRF:

- AE No.,

- Visit No.,

- Brief description of AE

- Seriousness (yes/no)

- Seriousness criteria,

- CTCAE 4.03 grade,

- Onset date,

- Date of resolution,

- Outcome,

- Actions taken due to AE

- Causality,




- Comments specifying any clinically relevant (in the investigator’s opinion) information

related to AE development or its therapy.

If any medication therapy is prescribed, all drugs should be listed in the relevant section of

the eCRF, with a note that they were used to manage the AE.

Columns “Grade”, “Outcome”, “Measures”, and “Causal Relationship” are filled in using

digital codes explained in the notes. If the Investigator considers an AE to be a serious adverse

event, he/she must fill in a SAE Report Form in addition to an AE Report From (printed copies).

For each SAE, one SAE Report Form is filled in. If the SAE remains unresolved at the next

visit after its recording, a checkbox in section “Adverse Events” of the eCRF should be ticked for

the corresponding visit and marked as “unresolved”. If any new important information is obtained,

the investigator should fill in another SAE Report Form and submit it to the Sponsor. In the

absence of completely new information on SAEs, the frequency of submitting a Follow-Up SAE

Report Form is recommended to be once every 14 days.

The following information must be included in the SAE Report Form:

1) Study information:

- Protocol code;

2) SAE information:

- SAE name

- Initial/Follow Up

- Internal SAE code assigned by the Sponsor (this field is filled in by the Sponsor)

3) Information on the investigator who reported the SAE, and information on the study site:

- Name of the investigator

- Contact information (phone number and e-mail)

- Study site name and code

- Name of the Principal Investigator

4) Information on the study subject:

- Subject ID

- Sex

- Body weight

- Birth date

- Renal/hepatic impairment

- Allergies

5) Information on the test drug:




- Code of the drug product (or trade name for the reference drug)

- Indication

- Date of the first injection of the test drug

- Batch of the drug product due to which the SAE developed

- Dose (with which the SAE developed)

- Treatment start date and time (followed by the SAE)

- Treatment stop date and time (followed by the SAE)

- Administration mode

- Dose and dosing frequency

6) Information about recent (within 3 months) concomitant therapy or the one used at the

time of the SAE onset:

- INNs and trade names of concomitant medications

- Indication

- Treatment start date

- Treatment stop date

- Dosages, frequency and route of administration

- Any suspected causal relationship between the SAE and concomitant medications

7) SAE narrative:

- SAE description with all symptoms and laboratory/instrumental abnormalities and time

frames indicated

- Time after the last dose of the test drug

- Autopsy data if the subject died (specifying the cause of death according to postmortem

conclusion). If no autopsy findings are available, the cause of death should be specified according

to the clinical conclusion

- Time of hospitalization (if applicable)

8) Severity (CTCAE 4.03)

9) Seriousness

10) Medical history (with dates provided)

11) Investigations of particular interest at onset of the SAE

- Investigation

- Normal limits

- Date

- Results




12) Actions taken to resolve the SAE

- Medication / non-medication

For medication therapy, the following should be specified: INNs and trade names of drugs,

treatment start and stop dates, dosages, frequencies and routes of administration.

13) Actions taken regarding the suspected drug

- Drug discontinued/dose reduced/dose maintained, etc.

- Dechallenge/rechallenge test results (if applicable)

14) SAE outcome

15) Signatures

The investigator must sign (with a signature and full name) each page of the SAE Report

Form to verify his/her responsibility for the reported information. The signed SAE Report Form is

then submitted to the Sponsor.

8.3.3. Reporting pregnancy

In this study, all cases of pregnancy developed during the treatment period and during the

follow-up period after the last injection of the test/reference drug must be recorded.

A report form should be filled in in the following cases:

– When the initial information on the patient’s pregnancy is obtained;

– When new important information (FU-report) related to complications in pregnancy or

delivery is obtained;

– 6 months after the baby is born to evaluate the child’s health.

A pregnancy report NOT associated with a SAE must be sent to the Sponsor via email at

[email protected] within 5 working days.

In case the pregnant patient develops a SAE, the completed Pregnancy Report and the

enclosed documents reflecting information on the SAE must be submitted to the Sponsor within

24 h after obtaining the information on the SAE.

8.3.4. Reporting improper administration of the investigational product.

Violation of investigational product administration refers to any violation of dosing, route

or procedure of administration described in the Study Protocol. This also includes violation

(prolongation) of the interval between the doses of the investigational product, except for cases

specified by the Study Protocol.





This Report Form should be filled in if any of the specified violations is observed except

for overdose.

If the violation of investigational product administration is accompanied by a SAE

development, the SAE Report Form should be filled in as well.

If the violation of investigational product administration is NOT associated with a SAE,

the completed Report Form must be sent to the Sponsor via email at [email protected] within

5 working days.

If the violation of investigational product administration is associated with a SAE, the

investigator should fill in two Report Forms (“The SAE Report Form” and “The Report Form on

Improper Administration of the Investigational Product”). Both reports must be submitted to the

Sponsor within 24 h after obtaining the information on the SAE.

8.3.5. Reporting drug overdose.

In this study, overdose is considered to be accidental dose excess as compared to the dose

indicated by the investigator for an individual patient at each particular visit.

Criteria for expedited reporting of overdose:

– Overdose two or more times exceeding the dose indicated by the investigator must be

reported regardless of AE/SAE development;

– Overdose less than two times the indicated dose, which has a temporal association with

AE/SAE, must be reported as well;

– Overdose less than two times the indicated dose, which is not associated with the

development of AE/SAE, may be submitted to the Sponsor as expedited reporting if this event is

considered to be significant in the opinion of the investigator;

– In case overdose is less than two times the indicated dose and the investigator decides

not to report this event as expedited, the revealed violation must be added by the Monitor only to

the violation log.

8.4. Methods and duration of follow-up for study subjects who had an AE/SAE


further treatment and follow-up in accordance with the study site standards for the treatment of a

certain AE or SAE. The patient should be followed up until the AE or SAE resolves completely,

the baseline values are obtained or until his/her condition is stabilized in case of long-lasting /

chronic conditions. See section 5.4. for details.





9. STATISTICS

9.1. Description of statistical methods to be used

The statistical analysis will be performed using two-tailed hypothesis tests. The statistical

significance level is 0.05.

The following tests will be used to compare quantitative data with normal distribution: two-

tailed Student's test, Welch's test, ANOVA.

The non-normally distributed quantitative data will be analyzed using the Mann-Whitney

test, Wilcoxon test, Kruskal-Wallis test, and the Friedman test.

The quantitative data:

Efficacy:



Safety:

• CBC results,

• Blood biochemistry results,

• iPTH results.

PK and PD

Demographic data

The Shapiro-Wilk test will be used to test the demographic data for normality.

The quantitative data will be described using the mean values, the geometric mean (for PK

and PD parameters), standard deviation, coefficients of variation (CoV), medians, quartiles,

minimal and maximum values.

The categorical data:

Efficacy:

• Relative number of patients (%) with the target hemoglobin level (100-120 g/L)

during Weeks 1-23;


• Relative number of patients (%) who required blood transfusion during Weeks 1-

23.

Safety and tolerability:

• ECG results,

• Urinalysis results,




• The percentage of patients with an AE/SAE in each group,

• The percentage of patients with a Grade 3/4 AE/SAE in each group.

• The percentage of patients who discontinued the study early due to AEs/SAEs.

Immunogenicity:

• The percentage of BAb- and NAb-positive patients.

The categorical data will be processed with frequency tables, exact Fisher’s test, test for

equality of frequencies, 𝜒2 Pearson’s test, and Cochran-Mantel-Haenszel test. The categorical data

will be described using percentages or proportions.

For multiple comparisons, the Benjamini-Yekutieli procedure will be used.

Regression will be used to assess the effect of factors other than the study treatment on

study results.

Statistical methods will be selected based on the type and distribution of raw data.

Applicability of certain statistical tests will be evaluated after all the data are collected because it

is impossible to predict the distribution pattern, data homogeneity and other data characteristics in

advance. A list of methods can be expanded if necessary for conducting a high-quality analysis.

9.1.2 Statistical methods for the assessment of safety of the test and reference drugs

To assess the treatment safety, the data obtained in the clinical study will be statistically

processed.

The quantitative data will be tested for normality (Shapiro-Wilk test) and then compared

using ANOVA (for normally distributed data) or the Friedman test for dependent variables (for

non-normally distributed data). For non-normally distributed independent samples the Kruskal-

Wallis test will be used. If there are significant differences between the means, additional pair-

wise comparison by study stages will be performed using the t-test for dependent samples (for

normally distributed data) or non-parametric Wilcoxon test for dependent samples (for non-

normally distributed data). The independent samples will be compared using the Mann-Whitney

test (for non-normally distributed data) and Student’s t-test, Welch's test (for normally distributed

data).

Categorical data will be compared using the χ2 or exact Fisher’s test, and the Cochran-

Mantel-Haenszel test. The categorical data will be described using frequencies and percentages.

The between-group comparison of quantitative data obtained at one of the study stages will

be performed using the t-test, Welch's test (for normally distributed data) or using the non-




parametric Mann-Whitney test (for non-normally distributed data). The normality will be tested

using the Shapiro-Wilk test.

The intra-group comparison of quantitative data obtained at different stages of the study

will be performed using the t-test for dependent variables (for normally distributed data) or the

non-parametric Wilcoxon test (for non-normally distributed data). The normality will be tested

using the Shapiro-Wilk test.

For multiple comparisons, the Benjamini-Yekutieli procedure will be used.

Statistical methods will be selected based on the type and distribution of raw data.

Applicability of certain statistical tests will be evaluated after all the data are collected because it

is impossible to predict the distribution pattern, data homogeneity and other data characteristics in

advance. A list of methods can be expanded if necessary for conducting a high-quality analysis.

Statistical analysis will be performed using R programming language and the Statistica

10.0 software package (StatSoft, USA).

9.1.3 Methods of Calculation of PK and PD parameters

1. AUC(0-672) is area under concentration-time curve of BCD-131 / Mircera® from the

moment of injection to 672 h with the first full dose:

𝐴𝑈𝐶(0−672) = ∑ (𝐶𝑝 + 𝐶𝑝−1) ∗ (𝑡𝑝 − 𝑡𝑝−1)212𝑝=2 ,

𝑤ℎ𝑒𝑟𝑒 𝐶𝑝 is concentration of BCD-131/Mircera® in blood at time point tp (h)

tp{ 0∗; 3; 6; 12; 24; 48; 72; 96; 168; 336; 504; 672}; p=1,…,12

*- concentrations at the initial time point will be calculated as the mean of the concentrations

obtained 2 h, 1 h and 5 min before injection 1

2. AUMC(0-672) is the total area under the first moment curve from 0 to 672 h. AUMC0-672 is

calculated using the following formula:

𝐴𝑈𝑀𝐶(0−672) = ∑ (𝐶𝑝 ∗ 𝑡𝑝 + 𝐶𝑝−1 ∗ 𝑡𝑝−1) ∗ (𝑡𝑝 − 𝑡𝑝−1)212𝑝=2 ,

𝑤ℎ𝑒𝑟𝑒 С𝑝 − 𝑏𝑙𝑜𝑜𝑑 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑡ℎ𝑒 𝑑𝑟𝑢𝑔 𝑎𝑡 𝑡𝑖𝑚𝑒 𝑝𝑜𝑖𝑛𝑡 𝑡𝑝,

tp{ 0∗; 3; 6; 12; 24; 48; 72; 96; 168; 336; 504; 672}p=1,…,12

*- concentrations at the initial time point will be calculated as the mean of the concentrations

obtained 2 h, 1 h and 5 min before injection 1




3. Mean retention time (MRT) is calculated as a AUMC0-672 to AUC0-672 ratio: MRT = AUMC0−672AUC0−672

4. Cmax is the maximum concentration of BCD-131 / Mircera® with the first full dose.

5. Tmax is the time to Cmax of BCD-131 / Mircera® with the first full dose.

6. Elimination rate constant (kel) of BCD-131 / Mircera® will be calculated using regression

analysis with the specified number of points in the terminal log phase used for evaluation.

7. Half-life (T1/2) of BCD-131/Mircera® will be calculated using the following formula: 𝑇1/2 = ln (2)𝑘𝑒𝑙

8. CL- total clearance of BCD-131/Mircera® will be calculated using the following formula:

𝐶𝐿 = 𝑑𝑜𝑠𝑒𝐴𝑈𝐶0−672, where dose is the administered dose of BCD-131/Mircera®

9. Cmin is the minimum concentration of BCD-131 / Mircera® with the first full dose at Weeks

9, 13, 17, 21.

10. Area under concentration vs. time curve from 0 to infinity (AUC0-∞). 𝐴𝑈𝐶𝟎−∞ = 𝐴𝑈𝐶0−672 + 𝐶𝟔𝟕𝟐𝑘𝒆𝒍 , where

C672 is the concentration of the drug product in blood at 672 h after administration at the first full

dose.

9.1.4 Calculation of PD parameters of the test and reference drugs

1. AUEC(0-672 h) is the area under the effect vs. time curve from the moment of injection to

672 h based on the change in the absolute reticulocyte count after the first injection of BCD-

131/Mircera®.

𝐴𝑈𝐸𝐶(0−672) = ∑ (𝐶𝑝 + 𝐶𝑝−1) ∗ (𝑡𝑝 − 𝑡𝑝−1)212𝑝=2 ,

𝐶𝑝 is the absolute reticulocyte count in blood after the first injection of BCD-131/Mircera®

at time point tp (h)tp{ 0; 3; 6; 12; 24; 48; 72; 96; 168; 336; 504; 672}; p=1,…,12




2. AC-Emax is the maximum absolute reticulocyte count after the first injection of BCD-

131/Mircera®.

9.2. Stages of statistical analysis, timelines for preparing reports

The statistical analysis will be performed upon the completion of all periods of the study.

9.3. Planned number of study subjects, justification of sample size, including reasoning or

calculations to justify statistical power and clinical justification of the study, and suitable

significance level

The number of patients to be enrolled in the study was calculated using literature data on

the therapeutic efficacy of Mircera® obtained from a multicenter, randomized, open-label clinical

study of the maintenance treatment of anemia in dialysis patients with chronic kidney disease139.

While the study was being planned, a hypothesis about the equivalent efficacy of the test

and reference drugs (H0: |ε| ≥ 𝛿, H1: |ε| < δ, where ε is the true difference in the mean efficacy

between the groups, δ is the equivalence margin of the efficacy of the test and reference drugs)

was tested using the following values of errors: type I error: 5% (α=0.05), type II error: 20%

(β=0.2), with the 80% power. The efficacy variable used to calculate the sample size was set as

the change in the hemoglobin level throughout the treatment in patients participating in the above-

mentioned Phase II study140.

To calculate the sample size, the investigators estimated the sample mean value and

standard deviation for the efficacy parameter using median values and quartiles given in the above-

mentioned study. The estimate was based on the approach described in the article by X.Wan,

W.Wang141: �̅� ≈ 𝑞1 + 𝑚 + 𝑞33 , 𝑠 ≈ 𝑞3 − 𝑞12 ∗ Φ−1 (0.75 ∗ 𝑛 − 0.125𝑛 + 0.25 ), where:



research and opinion, 2007, Vol. 23, No., 2007, 969–979 140 F.Locatelli, G.Villa, A.L.M. de Francisco, et al. Effect of a continuous erythropoietin receptor activator


research and opinion, 2007, Vol. 23, No., 2007, 969–979. 141 X.Wan, W.Wang, J. Liu, T.Tong. Estimating the sample mean and standard deviation from the sample size,

median, range and/or interquartile range. BMC Medical Research Methodology, 2014.




m - median, 𝑞1, 𝑞3- lower and upper quartiles,

N - sample size, Φ−1 (0.75∗𝑛−0.125𝑛+0.25 ) - quantile of standard normal distribution.

As specified before, in the above-mentioned study of the efficacy of Mircera® for the

treatment of anemia in dialysis patients with CKD previously treated with erythropoietins alfa or

beta, the efficacy evaluation was mainly based on changes in the Hb levels over the treatment

period. Patients included in the study were distributed to three groups depending on the conversion

ratio applied for the calculation of the initial dose of Mircera® based on a weekly dose of

erythropoietin received by each patient. The conversion ratios (CR) used in the study were as

follows: 0.4/150 (Group A), 0.8/150 (Group B) and 1.2/150 (Group C). Also, each of the three

groups was divided into additional dosing regimens: once a week, three times a week and once a

month. The findings obtained from this study showed that the median change in Hb levels was the

lowest in the group in which the CR used was 0.8/150 as compared to the CR of 0.4/150 with

which decreased Hb levels were observed, or as compared to the CR of 1.2/150 with which

increased Hb levels were observed(“Hb levels decreased in group A (–0.62 g/dL), remained stable

in group B (–0.11 g/dL) and increased in group C (0.31 g/dL”) 142. Thus, the median change in the

Hb levels in Group B (CR of 0.8/150) was: – 0.11 [-0.60; 0.36]. At the same time, the effect did

not depend on a dosing regimen (i.e. on the frequency of injections, including the once a month

dosing regimen).

Therefore, based on the results obtained in the group of patients with the CR of 0.8/150

used (Group В) to calculate the initial dose of Mircera® depending on the previous treatment, the

sample mean and standard deviation were calculated: �̅� ≈ 𝑞1 + 𝑚 + 𝑞33 = −0.6 − 0.11 + 0,363 = (−0.1167)𝑔/𝑑𝐿

𝑠 ≈ 𝑞3 − 𝑞12 ∗ Φ−1 (0.75 ∗ 𝑛 − 0.125𝑛 + 0.25 ) = 0,36 + 0,62 ∗ Φ−1 (0.75 ∗ 44 − 0.12544 + 0.25 ) = 0.7357119 𝑔/𝑑𝐿

Since the evaluation of the primary efficacy endpoint is investigated, the above-calculated

parameters were accepted both for the test drug group and for the reference group (the units of Hb

measurement were converted from g/dL to g/L).







1. The true difference in the mean efficacy between the test and control groups:

ε = µТ - µC = (-1.167) – (-1.167) = 0 g/L

2. Standard deviation for the efficacy parameter σ = 7.357119 g/L

3. zα and zβ/2 – quantiles of normal distribution N (0.1) (mean: 0, standard deviation: 1).

4. k - ratio between the group sizes (test and control):

nC/nT = 1.

5. The equivalence margin of the efficacy of the test and reference drugs was δ=10 g/L, as

half of the range of normal target Hb values (100-120 g/L).

Then, using the method described by [Chow Sh.-Ch., Shao J., Wang H., 2008]143, the sample size

was calculated based on the assumption that the sizes of the test (nт) and control groups (nс)

coincide, i.e. k = 1.

𝑛T = 𝑛C = (1 + 1k) ∗ (𝑧𝛼 + 𝑧𝛽/2)2 ∗ 𝜎2(𝛿 − |𝜀|)2 = 2 ∗ (1.64 + 1.28)2 ∗ 7.3571192(10 − 0)2 ≈ 10 𝑝𝑎𝑡./𝑔𝑟. Taking into account the evaluation of the primary efficacy endpoint of the test drug with the

dose selection for subsequent phases and high probability of patient’s early withdrawal (due to the

main disease), 25 patients will be included in each group to get more accurate and relevant efficacy

data. Thus, the study will include up to 100 patients (25 patients in each group of BCD-131, if all

the three groups are formed, and 25 patients in the reference group).

9.4. Suitable level of significance

The level of significance was set as 0.05 (5%), type II error: 20% (β=0.2) with the statistical

power of 0.8 (80%).

9.5. Statistical criteria for stopping and terminating the study

Not specified by the Protocol.

9.6. Handling missing, not evaluable or uncertain data

All information entered in the eCRF must be supported by the data in the source documents.

After entering all data in the electronic database, an employee keeping the database checks

it for inconsistencies, errors, and missing data points. To collect missing data or to correct wrong

data, the Study Manager/Monitor and the Medical Monitor of JSC BIOCAD will prepare queries,

143 S.-C. Chow, J. Shao, H. Wang. Sample Size Calculations in Clinical Research, 2nd Edition,

Chapman&Hall/CRC, 2008




which are study site-specific and study subject-specific. In other words, individual queries are

formed for each subject. The Clinical Study Monitor sends queries to the study site by fax or e-

mail. The investigator must respond within 5 working days from the date when the query was

received. Copies of responses to queries must be stored at the study site; the original responses

must be stored at JSC BIOCAD.

When responses to queries are received from investigators, the employee keeping the

database checks it for inconsistencies, errors, and missing data points. When all the data from all

the study sites are collected and entered, the database is locked, and the statistical processing can

be performed.

Missing, not evaluable or uncertain data will not be substituted.

Missing data and data that cannot be analyzed will be detected during analysis of outliers

by the examination of the Mahalanobis or Cook distance, visual analysis of scattering diagrams

and box-plots. Data suspected to be outliers will be processed by the biomedical statistician

together with the medical expert and, if necessary, the principal investigator.

9.7. Reporting any deviations from the statistical plan

If the initial study plan requires modifications, all changes will be described and explained

in a protocol amendment or interim/final/additional clinical study report.

If initially defined statistical methods cannot be used, the changes should be presented in

the final statistical report and the clinical study report. Justification of these changes should be

given with the references to calculations, statistical parameters, and analysis of a situation that led

to these changes. Decisions regarding emergency deviations (data-modifying allowances) can be

made only by the Sponsor. These decisions must be explained and justified, including in the final

study report.

9.8. Selection of subjects for analysis

Efficacy analysis

The per-protocol analysis will be used to assess the efficacy of treatment using the primary

endpoint. This analysis will include all the patients who completed the treatment according to the

Protocol.

The mITT-analysis will be used to evaluate the efficacy of treatment using secondary

endpoints. The mITT-analysis will include all the patients who were randomized to receive at least




one dose of the study drugs and were not withdrawn at the beginning of the study due to serious

violations of the Protocol rules and inclusion/exclusion criteria.

Safety analysis

The safety population will include all the patients who received at least one dose of the


Immunogenicity analysis

The immunogenicity analysis will include all the patients who received at least one dose

of the test/reference drugs and who have samples (suitable for analysis) taken before the first

injection and at least at one of the subsequent visits.

PK/PD Analysis

The PK/PD analysis will include patients with no missed / lost / damaged blood samples as

follows:

• Samples taken before injection 1 (at least 1 blood sample);

• Not more than 2 blood samples taken after injection 1 to 672 h, inclusive;

• Not more than 2 blood samples taken at visits of Week 9, Week 13, Week 17, Week

21 (for PK analysis).

Reporting:

Upon the completion of all the study periods, the final report will be prepared. It will

contain the data on the efficacy and safety of BCD-131 obtained in this study.

10. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS

The investigator/institution involved in the study must ensure direct access to source

data/documents for the monitor, the auditor, the LEC/IRB or regulatory authorities.

11. QUALITY CONTROL AND ASSURANCE

11.1. Data quality assurance

According to ICH GCP and regulatory requirements, the Sponsor, a third party on its

behalf, regulatory authorities, or local ethics committees can perform audits (inspections) to assure

quality at any time during the study or after its completion. The investigator is responsible for

providing medical auditors with access to all study documentation including the source

documentation, and for allowing his/her time and time of the study team to discuss the

audit/inspection results and other matters with medical auditors.




11.2. Investigator’s adherence to the Protocol

Before beginning the study, the investigator must read and accept all provisions of this

Protocol. The investigator must conduct the study in accordance with this Protocol, the ICH GCP,

and other regulatory requirements of participating countries.

No protocol deviations are allowed during the study without prior written permission from

JSC BIOCAD, the Ministry of Health of the Russian Federation, and the Local Ethics Committee,

except when necessary to protect patients from an immediate hazard.

The Investigator should have enough time to properly perform and close down the study

within the timelines specified by JSC BIOCAD and have a sufficient number of qualified

employees and adequate equipment required to conduct the study in accordance with the Protocol.

Each sub-investigator participating in the study must read the Protocol requirements and

be aware of his/her responsibilities/functions in the study. If the principal investigator delegates

some of his/her functions to sub-investigators, this must be documented in a relevant section of

the Investigator’s File.

11.3. Investigator’s responsibility for protocol compliance

At each study site, the decision regarding patient’s early withdrawal from the study must

be approved by JSC BIOCAD.

If the investigator decides to withdraw a patient from the study, he/she must send a request

(specifying a reason for withdrawal) to BIOCAD’s Medical Advisory Division by fax: +7 (495)

992-82-98.

Within 48 hours (except for weekends and public holidays) after information was received by the

Medical Advisory Division, JSC BIOCAD must inform the investigator regarding its consent for

patient’s withdrawal from the study. If a patient has to be immediately withdrawn from the study

due to a SAE, the investigator must inform JSC BIOCAD about the SAE within 24 hours but does

not have to wait for approval from JSC BIOCAD.

If a patient does not attend a scheduled visit or makes unauthorized changes in the dose of

the investigational product, the investigator must report the violation to the Medical Advisory

Division of JSC BIOCAD within 24 hours from the time of awareness (by fax: + 7 (495) 992-82-

98). Medical advisors will instruct the investigator on further case management and on how to

document the causes of the violations in the CRF/source documents.

If the investigator fails to follow these procedures or if multiple Protocol violations occur,

JSC BIOCAD may suspend or terminate the study at this particular study site.




11.4. Study monitoring

Before the study beginning, at the Initiation Visit or Investigators’ Meeting, an employee

of BIOCAD (Clinical Study Monitor) (or the authorized CRO) will explain the Protocol and eCRF

to the investigators and members of the study team. During the study, the Study Monitor will

regularly visit the study site to check the completeness of subjects’ documentation, accuracy of

information in the eCRF, the compliance with the Protocol and GCP, patients’ recruitment, as well

as storage, dispensing, and accounting of the investigational products according to the

requirements. During these visits, key members of the study site staff should be available to assist

the Monitor and solve issues (if any).

Study monitoring is performed according to appropriate SOPs of JSC BIOCAD.

For each study subject, the investigator should keep source documents containing data

about the subject and records made during visits (medical records of the study center), including

demographics, medical information, laboratory findings, ECG, and all other tests or examinations.

Any information in the CRF should be also recorded in the patient’s source documents. The

Investigator should keep the original ICF. A copy of the signed ICF is given to the patient.

The Investigator should provide the Monitor with all relevant source documents of the

patient to confirm that the data they contain correspond to those in the eCRF. The investigator

must ensure that data are entered in the eCRFs in a timely manner before a visit of the Clinical

Study Monitor.

The Study Monitor will check the eCRFs and other study materials comparing them against

the source data to confirm that the study complies with the Declaration of Helsinki, the ICH GCP,

regulatory requirements of participating countries, and the Study Protocol, and to confirm the

authenticity, accuracy, and completeness of data.

Upon the completion of the study, a representative of JSC BIOCAD (Clinical Study

Monitor) should visit the study site for a closeout visit. During this visit, the Sponsor’s

representative will collect all necessary documentation in accordance with the SOP of JSC

BIOCAD.

11.5. Data management and quality control

At the study sites using eCRFs, JSC BIOCAD employees (or employees of an authorized

CRO) will check the data entered by the study team members for accuracy and completeness. If

there are any inconsistent or missing data points, queries will be generated with a request for




clarification. These queries will be sent to the study site. A designated member of the study team

must immediately answer the request and make all required changes to the database.

At the end of the study, any protocol deviations will be determined. After clarifying

protocol deviations and confirming the completeness and accuracy of the data, the database will

be locked, the blind codes will be opened, and the data will be ready for analysis.

11.6. Study termination

JSC BIOCAD may suspend or terminate the study due to safety or ethical issues, Protocol

compliance issues, or other reasons. If JSC BIOCAD suspends or terminates the study, the study

site will be notified in advance. In case of suspension or termination, JSC BIOCAD and the

investigator have to inform Ethics Committee and regulatory authorities in due time. If the study

is suspended or terminated, all study information must be transferred to and all unused

investigational product must be returned to JSC BIOCAD.

12. ETHICS

12.1. Ethics aspects of the study

This clinical study will be conducted in accordance with ethics principles provided in

Federal Law No. 61-FZ of April 12, 2012: On the Circulation of Medicines; National Standard of

the Russian Federation GOST R 52379-2005 Good Clinical Practice; Constitution of the Russian

Federation; and Federal Law No. 323-FZ of November 21, 2011: On Public Health Protection in

the Russian Federation, the WMA Declaration of Helsinki (Fortaleza 2013), the GCP principles,

and the current law and regulations of the participating countries.

Before the initiation of the study, the final version of the Protocol (including Patient

Information Sheet and Informed Consent Form) will be submitted for approval to the regulatory

authorities and the Local Ethics Committee of the study site.

All subsequent protocol amendments (other than administrative amendments) must be

approved before implementation.

Informed consent must be obtained from patients before starting any study procedures. The

Patient Information Sheet contains all the information that a patient may need to make a conscious

and independent decision about whether to participate.

During the study, all cases of SAEs will be reported to JSC BIOCAD within 24 hours. JSC

BIOCAD will analyze the reports and may suspend the study if considered necessary. Local ethics




committees will also be notified of all SAEs that are related, in the investigator’s opinion, to the

investigational product.

All patient personal information is confidential and can be disclosed only if required by

law (including court decisions).

All study subjects will be insured. If a patient is injured directly due to the investigational

product, the Sponsor will cover all reasonably justified treatment expenses.

12.2. Confidentiality of study subjects

The investigator shall protect confidentiality of the study subjects, the text of this Protocol,

and all other study materials and results.

The investigator must ensure patient anonymity. In the eCRFs and other documents

provided by JSC BIOCAD, patients should be identified by ID codes and/or initials, but never by

their names.

The investigator should keep a separate log with patients' IDs, last names, addresses, phone

numbers, and medical record numbers (if applicable). The investigator must keep data not intended

for submission to JSC BIOCAD strictly confidential.

All study materials proprietary to JSC BIOCAD cannot be transferred to a third party unless

required by the law of the Russian Federation.

13. DATA HANDLING AND RECORD KEEPING

13.1. Record keeping at the study site

All study documents should be archived at the study site or the central archive of the

institution. A list of all identification data of study subjects should be made.

According to the ICH GCP, essential documents include signed protocol and amendments;

copies of completed CRFs; signed ICFs for all patients; medical records; diaries and other source

documents; approvals from IECs/regulatory authorities and all correspondence including approved

documents; drug accountability records; study correspondence; and the list of patient names and

addresses. These are the key documents that must be kept in the Investigator’s File.

The investigator must retain copies of all essential documents for 5 years.

By the end of this period, the Sponsor will inform the investigator(s) about the date when

the documents may be destroyed.

Study subject documentation will be archived in accordance with the site in-house SOPs.




The investigator must inform the Sponsor about the place where essential documents are

stored and request an approval from JSC BIOCAD before destroying any of essential documents.

Appropriate measures must be taken to prevent accidental or premature destruction of these

documents.

13.2. Confidentiality of data

All information about study subjects will be kept confidential. The information will be

processed in compliance with all applicable laws and regulations. These regulations require that

the patients must be informed and give their written consent about the following questions:

• What protected health information will be collected in this study?

• Who will have access to this information and on what grounds?

• Who will use or disclose this information?

• Can study subjects withdraw their consent for the use of confidential health

information?

According to the current regulations, in case the patient recalls his/her authorization to

collect or use his/her protected health information, the investigator still can use all information

obtained before the authorization was withdrawn. If the patient recalls authorization to collect or

use his/her protected health information, the investigator should do as much as possible to get

patient’s permission for collecting at least the safety information (i.e. onset of new or aggravation

of existing adverse events) until the scheduled end of the study period.

To prevent the confidential subjects’ information from unauthorized access, the study data

collection system has safety elements for encryption of all data to be sent in both directions. The

access to the system will be controlled via individually assigned ID codes and user passwords

issued only to authorized and adequately trained personnel.

13.3. Collection of data

This trial uses an electronic data capture (EDC) system. Designated study team members

will enter the data required by the Protocol to eCRFs. The eCRFs have been developed with a

validated and safe web-based software. The study team members will get access to the EDC system

only after being appropriately trained. A computerized validation program inspects eCRFs for

inconsistencies and allows the study team members to change or verify the entered data.

The principal investigator is responsible for completeness and accuracy of all the data

entered to the eCRFs and for entering and updating the information in a timely manner.




Members of the study team will collect blood samples for the assessments of PK and PD

of the investigational products. The samples will be then sent to the Central Lab for processing.

14. FINANCE AND INSURANCE

In this study, the patients included in the PK/PD subset will have to make multiple visits

to the study site for blood sampling, which may be somewhat inconvenient (the patient may have

to miss a day at work, etc.). Therefore, the patients included in the subset for the PK analysis will

be paid a compensation if they have not missed scheduled visits for blood sampling without a

reasonable excuse (except for the cases when the schedule violation was due to developed adverse

events) starting from the moment of blood sampling through dosing.

The overall compensation will be 32 500 Russian Rubles. The compensation will be given

as a one-time payment after the patient completes the final blood sampling for the PK/PD

evaluation. If the patient has missed visits for blood sampling, s/he will be given a compensation

for the actual number of visits for blood sampling s/he has made. If the patient discontinues the

study due to a reason not related to treatment non-compliance or protocol violations, payments

will be performed according to the number of his/her actual visits for blood sampling for the

PK/PD evaluation. Considering that the blood sampling for the PK/PD evaluation will be

performed at 13 visits during the study, the compensation for each visit during which the patient’s

blood will be sampled is 2500 (two thousand five hundred) rubles.

The subject’s expenses for getting to the study site or other additional charges will not be

reimbursed.

Patients not included in the PK/PD subset will not be paid for participation in this study.

During the study, each study subject will be insured as a study participant according to the

applicable law of the participating country. In the Russian Federation, patients will be insured by

the Russian company SPAO Ingosstrakh. The investigator will also give the patient an Individual

Compulsory Life and Health Insurance Policy (required for a patient taking part in a clinical study)

and explain its terms and conditions. If the patient needs to make changes to the Individual

Compulsory Life and Health Insurance Policy, the patient will have to return the previously issued

policy and receive a new one (issued within 2 working days).

The insurance policy covers claims from study participants to the Insurer exclusively

concerning reimbursement of inflicted damage to the life and health that occurred while the subject

was participating in the clinical study. This inflicted damage is to be due to disadvantages of

investigational products or insufficient information on them, unintended errors or neglect. Only




claims first asserted to the Insurer within the insurance period concerning events that took place

in the insurance territory from the beginning of the study and associated with the insured activity

(the study) are covered.

If the patient gets injured due to the study drug or a medical procedure as per the Study

Protocol, the patient will receive sufficient qualified medical care for free (paid by the Insurance

company). The Insurance company will pay for the research-related injury provided the patient

adheres to all instructions of the investigator.

The Insurer shall pay the following compensations according to the Insurance Agreement

(insurance payment):

a) If the insured person dies: 2 million Russian Rubles. The insurance payment in the

specified size is distributed among beneficiary parties in equal parts;

b) If the insured person gets injured, and the injury results in:

Group I disability: 1.5 million Russian Rubles;

Group II disability: 1 million Russian Rubles;

Group III disability: 500 thousand Russian Rubles.

c) If the insured person gets injured, and the injury does not result in disability: not more

than 300 000 Russian Rubles.

Patients in other participating countries will be insured throughout the entire study

according to the law of the participating country.

15. PUBLICATIONS

After completion of the study, its results will be summarized and prepared for publication.

The investigator must not publish any study results, including those obtained at his/her study site,

without a permission from JSC BIOCAD. Results from individual study sites must not be

published before the publication of the overall study results.

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