A physician-initiated double-blind, randomised, placebo-controlled, Phase 2 study evaluating the efficacy and safety of inhibition of NADPH Oxidase with the first -in-class Nox-1/4 inhibitor, GKT137831, in adults with type 1 diabetes and persistently elevated urinary albumin excretion: Protocol and statistical considerations.

Anne T Reutensa [email protected]; Karin Jandeleit-Dahmb karin.jandeleit- [email protected]; Merlin Thomasb [email protected]; Leon A Bachc,d [email protected]; Peter G Colmane [email protected]; Timothy M E Davisf
[email protected]; Michael D’Emdeng [email protected]; Elif I Ekincih
j,k [email protected]; Greg Fulcheri [email protected]; Peter Shane Hamblin [email protected]; Mark A Kotowiczl [email protected]; Richard J MacIsaacm
[email protected]; Claire Morbeyn [email protected]; David Simmonso [email protected]; Georgia Soldatosp [email protected]; Gary
b Wittertq [email protected]; Ted Wur [email protected]; Mark E Cooper [email protected]; Jonathan E Shawa [email protected]

aBaker Heart and Diabetes Institute, Level 4, Alfred Centre, 99 Commercial Road, Melbourne VIC 3004, Australia
bMonash University, Department of Diabetes, Central Clinical School, Level 5, Alfred Centre, 99 Commercial Road, Melbourne VIC 3004, Australia
cDepartment of Endocrinology and Diabetes, Level 5 Centre Block, The Alfred, PO Box 315, Prahran VIC 3181, Australia
dMonash University, Department of Medicine, Central Clinical School, Level 5, Alfred Centre, 99 Commercial Road, Melbourne VIC 3004, Australia
eDepartment of Diabetes and Endocrinology, The Royal Melbourne Hospital, RMH VIC 3050, Australia
fUniversity of Western Australia, Medical School, Fremantle Hospital, PO Box 480, Fremantle WA 6959, Australia
gEndocrinology Research Unit, Level 1, Dr James Mayne Building, Royal Brisbane & Women’s Hospital, Butterfield Street, Herston QLD 4029, Australia
hDepartment of Medicine, The University of Melbourne and Department of Endocrinology, Austin Health, Heidelberg Repatriation Hospital, Dept. of Medicine, Boronia Building, Level 1, 300 Waterdale Rd, Heidelberg VIC 3081, Australia
iDepartment of Endocrinology, Level 3, Acute Services Building, Royal North Shore Hospital, St Leonards NSW 2065, Australia; The University of Sydney NSW 2006, Australia
jDiabetes & Endocrinology Centre, Sunshine Hospital, 176 Furlong Road, St Albans VIC 3021, Australia
kDepartment of Medicine-Western Precinct, University of Melbourne St Albans VIC 3021, Australia
lDeakin University, Geelong VIC, Australia

mDepartment of Endocrinology & Diabetes, Level 4 Daly Wing, St Vincent’s Hospital, University of
Melbourne, PO Box 2900, Fitzroy VIC 3065, Australia
nHunter Diabetes Centre, Level 1, 41 Llewellyn Street, Merewether NSW 2291.
o School of Medicine, Western Sydney University, Campbelltown Hospital, Therry Rd, Campbelltown NSW 2560, Australia
pDiabetes and Vascular Medicine Unit, Monash Health, 246 Clayton Road, Clayton VIC 3168, Australia
qAdelaide Medical School, Faculty of Health and Medical Sciences; The University of Adelaide, Level 5, Adelaide Health and Medical Sciences Building, Corner of North Terrace and George Street, Adelaide SA 5005, Australia
rDiabetes Centre, Level 6, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050, Australia

Corresponding author: Anne Reutens
ATR and KJD are equal first authors. MEC and JES are equal last authors.

ACEi angiotensin-converting-enzyme inhibitor, AEs adverse events, ARB angiotensin II receptor blocker, BID twice daily, eGFR estimated glomerular filtration rate; FBE full blood examination; FT4 free T4; HbA1c glycated haemoglobin, hsCRP: high sensitivity C reactive protein, IL-6: interleukin-6, KIM1: kidney injury molecule 1; LFTs liver function tests; NADPH nicotinamide adenine dinucleotide phosphate, NGAL: neutrophil gelatinase-associated lipocalin; RAS renin angiotensin system, ROS reactive oxygen species; TSH thyroid stimulating hormone UACR urine albumin to creatinine ratio, UandECreat urea and electrolytes, creatinine; WOCP woman of child-bearing potential.

Abstract Purpose
Kidney disease caused by type 1 diabetes can progress to end stage renal disease and can increase mortality risk. Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (Nox) plays a major role in producing oxidative stress in the kidney in diabetes, and its activity is attenuated by GKT137831, an oral Nox inhibitor with predominant inhibitory action on Nox -1 and Nox-4. Previous studies have demonstrated renoprotective effects with GKT137831 in various experimental models of type 1 diabetes-related kidney disease. This study will evaluate the effect of GKT137831 in treating clinical diabetic kidney disease.

This is a multi-center, randomized, placebo-controlled trial, parallel arm study evaluating the effect on
albuminuria of treatment with GKT137831 200 mg BID for 48 weeks. The study will randomize 142 participants who have persistent albuminuria and estimated glomerular filtration rate (eGFR) at baseline of at least 40 ml/min/1.73m2.

Primary outcome measures
Difference between arms in urine albumin to creatinine ratio. Secondary outcome measures include eGFR.

This study is important because it may identify a new way of halting renal disease progression in people with type 1 diabetes and albuminuria already receiving standard of care treatment.

Diabetic nephropathy; NADPH oxidase, type 1 diabetes, albuminuria Abstract 187 words (limit 250)
Introduction 500 words (limit 500) Discussion 361 words (limit 1500) 1. Introduction
Diabetic kidney disease affects 14-31% of people with type 1 diabetes, causing microalbuminuria, macroalbuminuria, and/or decreased glomerular filtration rate1. Current management focuses on improved glycemic, blood pressure and lipid control, and renin angiotensin system (RAS) blockade. However, the cumulative incidence of end stage renal disease (ESRD) was still 7.8% at 30 years after diagnosis in the Finnish Diabetic Nephropathy [FinnDiane] Study), conducted between 1997 and 2006. Chronic kidney disease is associated with significantly increased all-cause mortality and
incident cardiovascular disease in type 1 diabetes 2. Therefore, novel treatment strategies are needed. Oxidative stress caused by chronic hyperglycemia is a critical factor in the initiation and progression
of diabetic kidney disease 3, 4. Reactive oxygen species (ROS) damage the glomerular epithelium, podocyte, mesangial cell and tubule5. The major source of renal ROS is nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (Nox), activated by hyperglycemia, advanced glycation end products, angiotensin II, cytokines and growth factors. Nox has two membrane-associated components, p22phox, and one of seven Nox isoforms (Nox-1 to Nox-5, Duox-1 and Duox-2), and cytosolic components. Several isoforms, Nox-1, Nox-2, Nox-4 and Nox-5, are found in the kidney and blood vessels. Genetic deletion or pharmacologic inhibition of Nox -4 in diabetic mice attenuated albuminuria, extracellular matrix accumulation, fibrosis and renal inflammation 6, 7. Genetic deletion of Nox-1 reduced atherogenic changes but did not affect diabetic renal damage8. Therefore, homolog- specific inhibition of Nox-4 (for renal protection) and Nox-1 (for vascular protection) but not Nox-2 (required for immune protection) is a promising adjunct therapy for diabetes complications .

GKT-137831 is a small-molecule, dual Nox-4/ Nox-1 inhibitor developed by Genkyotex (Saint-Julien-
en-Genevois, France). Pre-clinical studies in mouse models of diabetes showed renal protection6, 9, 10
even in established kidney and macrovascular disease11. A Phase 2 trial in people with type 2 diabetes and advanced kidney disease with macroalbuminuria [Clinicaltrials.gov reference NCT02010242]12 treated participants for 12 weeks, starting with 100 mg BID, and increasing to 200 mg BID. There was no effect on the primary endpoint of albuminuria, but GKT137831 had statistically significant beneficial effects on secondary efficacy endpoints of inflammation and liver injury with an excellent safety profile. The lack of effect on renal endpoints may have been due to the lower dose used in the first half of the study, short treatment duration, and/or treatment in people with advanced kidney disease. The results of the trial in type 2 diabetes cannot be extrapolated to the setting of type
1diabetes, because other factors in type 2 diabetic kidney disease, such as hypertension and insulin resistance, make it more clinically heterogeneous. Therefore, a trial with longer treatment duration, higher GKT137831 dosage and a population with less advanced disease (microalbuminuria or macroalbuminuria, eGFR at least 40 ml/min/1.73 m2) has been designed.
This paper describes the protocol and proposed statistical analysis for a Phase 2 clinical trial that will be the first to investigate the effect of GKT137831 on urinary albumin excretion in people with type 1 diabetes. This study is registered on the Australian and New Zealand Clinical Trial Registry (ACTRN12617001187336).
2.Methods and design
2.1Study design
This is a Phase 2, double-blind, placebo-controlled, randomized study occurring at multiple sites in Australia, which will be conducted in adults with type 1 diabetes and persistent albuminuria (as detailed in Table 2). The study plans to randomize 142 participants; to achieve this number of randomizations, up to 284 people will be screened. The study will evaluate the efficacy and safety of GKT137831 (400 mg/day) over 48 weeks of treatment, with the primary endpoint at 48 weeks. The study design is shown in Figure 1.
Figure 1. Study design

2.2Study rationale
GKT137831, by acting as a dual inhibitor of Nox-1 and Nox-4, is anticipated to reduce renal oxidative stress in diabetes. As a result of reduced production of reactive oxygen species, GKT137831
treatment is expected to attenuate the glomerular structural damage associated with diabetes, leading to reduction in albuminuria by a decrease in renal inflammation, mitochondrial st ress and fibrosis. The previous Phase 2 study had been conducted in advanced type 2 diabetic kidney disease, and showed lack of efficacy with a short treatment period of 12 weeks 12. Treatment duration of 48 weeks for the current trial has been chosen, to allow sufficient time for the effects on glomerular structure to occur. The study population for this current trial will exclude those with advanced diabetic kidney disease.

2.3Dosing rationale
The dose of GKT137831 200 mg twice daily (BID) was selected for this study to achieve target plasma exposure levels in a majority of study participants. The plasma exposure target was defined according to the exposure achieved in mice by the maximally effective dose. The expected steady state exposure for this trial was then modelled based on the pharmacokinetic data available from the completed Phase 2 study. These exposure estimates indicate that more than 90% of participants receiving the 200 mg BID dose are predicted to have plasma exposure levels at or above the maximally effective dose in preclinical mouse models. GKT137831 200 mg BID was also the dose received for the last 6 weeks of treatment in the completed Phase 2 study, and this was well tolerated and safe.
2.4Study objectives and endpoints

The endpoints of this study are listed in Table 1. The primary objective is to assess the effect of 48 weeks of GKT137831 on urine albumin to creatinine ratio (UACR) in comparison with placebo, in participants with type 1 diabetes and persistent albuminuria, who are receiving optimal standard of care (including an angiotensin II receptor blocker [ARB] or an angiotensin-converting-enzyme inhibitor [ACEi] where appropriate). The primary efficacy endpoint is the difference between the two treatment arms in mean UACR at the end of the treatment period of 48 weeks, adjusted for baseline UACR. Baseline UACR is the geometric mean of 4 UACRs: the 2 consecutive daily first void UACR values at Visit 2 (2 weeks before randomisation) and the 2 consecutive daily first void UACR values at Visit 3 (randomisation). UACR at the end of the treatment period of 48 weeks is defined as the geometric mean of 4 UACRS: the 2 consecutive daily first void UACR values at Visit 8 (46 weeks of treatment) and the 2 consecutive daily first void UACR values at Visit 9 (48 weeks of treatment).

Key secondary efficacy endpoints will evaluate the effect of GKT137831 on UACR at 24 weeks of treatment, and on estimated glomerular filtration rate (eGFR) at 48 weeks and 24 weeks of treatment. eGFR will be calculated using the CKD-EPI formula. Safety assessments and pharmacokinetics will be evaluated as secondary objectives. Planned exploratory endpoints are the difference between the two arms at week 48 of treatment adjusted for baseline, for the following: epigenetic markers, transcriptome, metabolomic and lipidomic profiles, cystatin C, urinary biomarkers; serum inflammatory biomarkers.

Table 1. Study endpoints

Primary efficacy endpoint
(active treatment versus placebo arm) Key secondary efficacy endpoints
(active treatment versus placebo arm)
Mean UACR at 48 weeks adjusted for baseline UACR Mean UACR at 24 weeks adjusted for baseline UACR Mean eGFR at 48 weeks adjusted for baseline eGFR Meant eGFR at 24 weeks adjusted for baseline eGFR
Other secondary safety endpoints (active treatment versus placebo arm)
Treatment emergent adverse events.

Summarystatistics for each treatment arm for markedlyabnormal laboratoryanalytes. Summarystatistics for each treatment arm for vital signs and weight.
Mean systolic and diastolic blood pressure, heart rate and weight, adjusted for baseline values. Summarystatistics for QTc and descriptive ECG abnormalities.
Mean QTc, adjusted for baseline values. Pharmacokinetic endpoint
Pre-dose plasma level of GKT137831
Exploratory endpoints (active treatment versus placebo arm)
Transcriptome (total whole blood mRNA) Metabolomic profile
Lipidomic profile Cystatin C
Urine biomarkers: UrinaryKIM1 and NGAL Inflammatorymarkers: hsCRP, fibrinogen, IL-6


UACR: urine albumin to creatinine ratio; eGFR: estimated glomerular filtration rate; KIM1: kidney injury molecule 1; NGAL: neutrophil gelatinase-associated lipocalin; hsCRP: high sensitivityC reactive protein, fibrinogen, and IL – 6: interleukin-6

2.5Sample size
The planned sample size was determined using the following assumptions: mean UACR of 13.56 mg/mmol for the control arm, difference between UACR means of the treatment arms of 3.56 mg/mmol/L (26%), SD of 7.5 mg/mmol, power of 80% with a 1 sided alpha of 0.05. This was selected because the study in type 2 diabetes confirmed that GKT-137831 was safe, there was no increase in albuminuria with this treatment, and the active treatment arm had fewer side effects than the placebo arm. The estimated dropout rate is 15% and estimated screen fail rate is 50%. 142 people will need to be randomised to achieve 120 participants reaching the end of the treatment period. Therefore, up to 284 people will need to be screened. These calculations were based on results from a previous unpublished study using alagebrium chloride in people with type 1 diabetes on standard therapy including optimal RAS blockade. The treatment effect is an estimate comparable to the known effect
of RAS inhibition on urinary albumin excretion in people with type 1 diabetes and baseline albumin excretion in the microalbuminuric range.
2.6Trial setting
The trial is being conducted at 15 sites, located in public hospitals or research institutes in the Australian states of Victoria, Western Australia, South Australia, New South Wales and Queensland. Additional sites may be added if these are needed to meet the recruitment target. The study received human research ethics approval from the Alfred Hospital Ethics Committee and the South Metropolitan Health Service Human Research Ethics Committee. The conduct of this trial was reviewed and approved by the Regulatory Governance Office at each site. It is conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines . All participants will give voluntary written informed consent prior to commencement of study procedures.

3.Study procedures
To be eligible for the study, participants with type 1 diabetes will need to have persistent albuminuria, with documented abnormal UACRs in the preceding 24 months before enrolment in the trial. Participants will already be receiving standard of care therapy for albuminuria, and have well – controlled blood pressure and HbA1c. The occurrence within 13 weeks before screening of recent changes in medications that may alter albumin excretion or eGFR, or certain procedures that may potentially affect kidney function, or acute kidney injury, will exclude participants. The inclusion and exclusion criteria are shown respectively in Tables 2 and 3.

Table 2. Inclusion criteria

1.Capable of understanding the content of and able voluntarily to provide a personallysigned and dated written informed consent form.
2.Stated willingness to complywith all study procedures and availabilityfor the duration of the study.
3.Male or female, aged 18-70 years inclusive.
4.Clinical diagnosis of type 1 diabetes, defined as at least 2 out of 3 of the following: (i) age of onset < 40 years, (ii) insulin commenced within 1 year of the diagnosis of diabetes, (iii) positive autoantibodies for at least 1 of the antibodies associated with type 1 diabetes (islet cell antibody[ICA], insulin autoantibody[IAA], tyrosine phosphatase–like insulinoma antigen-2 autoantibody[IA-2A], zinc transporter 8 autoantibody(ZnT8 A) and glutamic acid decarboxylase autoantibody[GADA]).
5.Established albuminuria, defined as an urine albumin to creatinine ratio (UACR) ≥2.5 mg/mmol in men or ≥3.5 mg/mmol in women, with
(a)the most recent UACR to have been within the albuminuria range and collected within the 12 months before Visit 1, AND
(b)at least one other UACR within the albuminuria range in the last 24 months before Visit 1, AND
(c)not more than 1 normal UACR (i.e. <2.5 mg/mmol in men or <3.5 mg/mmol in women) in the 24 months before Visit 1, AND
(d)the geometric mean of the 2 UACR tests collected at Visit 1 is in the albuminuria range, ≥2.5 mg/mmol in men or ≥3.5 mg/mmol in women.
6.eGFR ≥ 40 mL/min/1.73 m2, as calculated bythe CKD-EPI creat formula, at Visit 1.
7.Participants must be taking either ACEI or ARB at a constant dose for at least 13 weeks prior to Visit 1, where the dose of the ACEI or the ARB is considered appropriate for that patient (up to maximum daily dose approved by the TGA) and it is anticipated that the same dose can and will be maintained throughout the course of the study. The only exception is if the participant has a documented intolerance to RAS blockade, such that neither an ACEI nor ARB are used or intended to be used for the duration of the study. The nature of the intolerance (e.g. hyperkalaemia, hypotension) must be documented bythe Investigator in the study record at Visit 1. Combination therapyusing an ACEI and an ARB is not permitted.
8.Participants taking any blood pressure-lowering medications in addition to an ACEI or ARB, including diuretics, must be on a stable dose for at least 13 weeks prior to Visit 1.
9.Ability to take oral medication and be willing to adhere to the medication regi men.
10. Willing to practice highlyeffective methods of birth control (both males who have partners of childbearing potential and females of childbearing potential) during the screening period, while taking investigational product and for at least 90 days after the last dose of investigational product is ingested. Women of childbearing potential are female participants who are not surgicallysterile (no history of bilateral tubal ligation, hysterectomy, or bilateral salpingo-oophorectomy), and are not postmenopausal for at least 1 year. Furthermore, male studyparticipants must also not donate sperm from dayof randomisation until 90 days after the last dose of investigational product.
eGFR: estimated glomerular filtration rate; ACEi: Angiotensin converting enzyme inhibitor; ARB:
Angiotensin II receptor blocker; TGA: Therapeutic Goods Administration Table 3. Exclusion criteria
1.History of type 2 diabetes.
2.HbA1c at Visit 1 ≥ 10.0% (≥ 86 mmol/mol).
3.Chronic kidney disease due to a documented historyof non-diabetic kidneydisease(s), except for hypertensive nephropathy, which is acceptable. Therefore, the chronic kidney disease must be due to diabetic kidney disease, with or without hypertensive kidney disease.
a.Diagnostic or interventional procedure requiring a contrast agent within 4 weeks of the first screening visit.
b.Untreated urinary tract infection at Visit 1 that would impact urinaryprotein levels.
c.History of renal transplant or other solid organ transplant, or planned renal transplant or other solid

organ transplant during the study.
d.A history of acute renal dialysis or acute kidney injury (defined according to the Kidney Disease: Improving Global Outcomes [KDIGO] definition) within 13 weeks of Visit 1.
4.Body mass index(BMI) <18.5 kg/m 2 or >40 kg/m 2.
5.eGFR <40 ml/min/1.73m2, as calculated by the CKD-EPI creat formula.
6.Alteration in anti-hypertensive therapy within 13 weeks prior to Visit 1, including change in dosing with ACEI or ARB.
7.Women who are lactating, pregnant, or intend to become pregnant during the course of the study.
8.Participants with clinicallysignificant liver disease or elevated liver enzymes, defined as alkaline phosphatase or transaminase (alanine aminotransferase [ALT] or aspartate aminotransferase [AST]) levels
>3 × the upper limit of normal (ULN) measured at Visit 1 or bilirubin >1.5 x the ULN measured at Visit 1.
9.Inadequatelycontrolled arterial blood pressure, defined as SBP >160 mmHg at Visit 1 or DBP > 95 mm Hg at Visit 1.
10.Current history of thyroid disorder requiring thyroid hormone replacement therapy, unless the dose of thyroid hormone replacement has been stable for at least 4 weeks prior to Visit 1 and the thyroid stimulating hormone (TSH) value is not greater than the ULN at Visit 2.
11.History of active cardiovascular disease defined as the occurrence of the following events or conditions within the 13 weeks preceding Visit 1: acute myocardial infarction; unstable angina pectoris; stroke, including a transient ischemic attack; a coronary revascularisation procedure ; congestive heart failure New York
Health Association (NYHA) Class III or IV.
12.A personal or familyhistory of long QT syndrome.
13.Evidence of any of the following cardiac conduction abnormalities during the screening period: A QTc Fridericia interval >450 m illiseconds for males and >470 milliseconds for females; second or third degree AV block not successfullytreated with a pacemaker.
14.A history of bone marrow disorder, including aplastic anaemia, or marked anaemia at Visit 1 defined as haemoglobin < 100 g/L.
15.Participants with a historyof treatment for neoplastic disease within 5 years prior to Visit 1. The exceptions allowed are adequatelytreated basal or squamous cell carcinoma of the skin, adequatelytreated in situ carcinomas of the cervix, prostate, ductal breast, or superficial bladder cancer stage 0.
16.Current history of drug or alcohol abuse, as assessed bythe site Investigator.
17.The occurrence of any acute infection requiring systemic antibiotic therapywithin the 2 weeks prior to Visit 1, or known infection with hepatitis B, hepatitis C, or human immunodeficiencyvirus (HIV) infection.
18.Use of the following medications within 4 weeks of Visit 1: direct renin inhibitors, endothelin receptor antagonists.
19.Participants anticipated to require systemic immunosuppression therapyfor >2 weeks during the study or a past history of systemic immunosuppression for more than 2 weeks, cumulatively, within the 13 weeks prior to Visit 1. Inhaled steroids are not considered to be systemic immunosuppression.
20.Administration of any investigational product within 30 days or within 5 half-lives of the investigational agent (whichever is longer) of Visit 1.
21.Any condition which, in the opinion of the Investigator, constitutes a risk or contraindication for the participation of the participant in the study, or that could interfere with the study objectives, conduct, or evaluation. This includes participants unlikelyto comply with the study protocol (e.g. an inability and unwillingness to participate in adequate training, an uncooperative attitude, inability to return for follow-up visits, or unlikelihood of completing the study).
22.Persons employed by the Sponsor, contract research organisation or Genkyotex.
23.Persons who are Investigator site personnel directlyaffiliated with this study and/or their immediate families.
24.Use of SGLT2 inhibitors in the 13 weeks before Visit 1 or proposed use during the study.

3.2Prior and concomitant therapy

GKT137831 is a weak inhibitor of CYP3A4. Therefore, the concomitant use of potent CYP3A 4 inhibitors is not permitted. Prohibited medications are: itraconazole, lopinavir/itonavir, telaprevir, clarithromycin, ritonavir, ketoconazole, indinavir/ritonavir, conivaptan, and voriconazole. Concomitant use of other drugs which are CYP3A4 substrates with narrow therapeutic range should be avoided. These drugs include alfentanyl, astemizole, cisapride, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, systemic sirolimus, systemic tacrolimus, terfenadine. Should fentanyl or alfentanyl use be required during the study, either the anesthesiologist should be informed ahead of

the procedure so that the dose can be carefully titrated down, or there should be a washout of 5 days from GKT137831 before the use of fentanyl.

Participants who are eligible will be assigned to GKT137831 or placebo treatment at Visit 3. Randomisation will be stratified by geometric mean UACR at Visit 1 (females UACR ≤ 35, > 35 mg/mmol; males UACR ≤ 25, > 25 mg/mmol) and by study centre. Randomization will be 1: 1 between active drug and placebo control arms. The method of randomization will use a minimization program integrated into the Interactive Web Response System, accessed live by sites through the website Randomize.net.
3.4Study drug administration and blinding
Participants will take 2 capsules of 100 mg GKT137831 or placebo in the morning, and 2 capsules of 100 mg GKT137831 or placebo in the evening, with meals or up to 30 minutes after eating a meal. The capsules are swallowed whole without chewing or crushing. The Sponsor, investigators and participants will be blinded to the treatment allocation. The GKT137831 and placebo are indistinguishable in bottle, label and capsule appearance.
4.0Study assessments
The schedule of events for study assessments is shown in Table 4.


Table 4. Schedule of events

Study period Consent & Screening Double blind treatment Follow-
Visit 1 1b 2 3 4 5 6 7 8 9 10
Study weeks -4 -3 -2 0 4 12 24 36 46 48 52
Informed consent X
Determination of eligibility X X
Demographics and medical history X
Prior/concomitant medication recording X X X X X X X X X X
Body weight X X X X X X X
Body height X
Vital signs X X X X X X X X X X
Physical examination (complete) X X
Physical examination (brief, symptom -directed) X X X X X X X X
Randomization X
Dispense investigational product X X X X X
Compliance check X X X X X
Recording of AEs X X X X X X X X X
12-lead ECG X X X
HbA1c X X X X X
UandECreat, eGFR X X X X X X X X X X
TSH (+FT4 if TSH is abnormal) X X
Fasting glucose and lipids X X X
Collection of serum for further biomarker analysis,
including inflammatorymarkers X X X
Collection of plasma for PK assessment X X X
Optional collection of DNA and RNA sample X X
Pregnancy test (if WOCP) X
Urinalysis X X
Pregnancy test (if WOCP) X X X X X X X X
2 early morning UACR determinations X X X X X X X X X X
Collection of urine for further biomarker analysis X X X

AEs adverse events, UACR: urine albumin to creatinine ratio; eGFR estimated glomerular filtration rate; HbA1c glycated hemoglobin; UandECreat urea and electrolytes, creatinine; LFTs liver function tests; FBE full blood examination; TSH thyroid stimulating hormone; FT4 free T4; WOCP woman of child -bearing potential.


4.1Screening procedures

After informed consent is provided, eligibility will be determined at Visit 1 by reviewing the participant’s demographic information, medical history and medication history. Blood will be collected for tests of HbA1c, urea, electrolytes and creatinine, eGFR, liver function and full blood examination. Two consecutive daily first morning void spot urine specimens will be collected for analysis of urine
albumin to creatinine ratio. Urinalysis will be performed and a serum beta HCG pregnancy test obtained if applicable. If the test results at Visit 1 fall within eligible levels, the following two further tests will be done at Visit 2 to confirm eligibility; electrocardiogram will be done after resting, and before the blood draw done to check thyroid function tes ts. Rescreening of participants is allowed one more time, after at least a one month interval between visits .
4.2Safety assessments
Participant safety will be assessed by physical examination, assessment of concomitant medications and adverse events, obtaining vital signs, ECG and laboratory tests for renal, liver, metabolic and hematology tests (see Table 4).
4.3Physical examination, measurements and laboratory tests
The participants will receive a complete physical examination at Visit 1 and at the end of the treatment phase (Visit 9). Symptom-directed physical examinations will be conducted at every other study visit, including the follow-up visit occurring 4 weeks after end of treatment. Height and weight will be measured at Visit 1, and weight will be measured on 6 other visits, as shown in Table 4. At every visit, vital sign evaluation will be conducted after the participant has been seated at rest for 5 minutes, and before any blood draw or ECG. Urine pregnancy point of care tests will be performed if applicable. At each study visit, the participant will bring in two spot urine specimens taken on the day before and the morning of the study visit, for determination of urine albumin to creatinine ratio. If the participant has symptoms of an untreated urinary tract infection at the study visit, or has been on treatment for urinary tract infection with antibiotics for less than a week, at Visit 1 the participant is ineligible as there
should not be any urinary tract infection within 1 week of Visit 1; for Visits 2-9 – as well as the 2 consecutive first morning void urine specimens brought in by the participant which should be sent for central lab analysis, 2 consecutive first morning void specimens will be collected once the course of antibiotics has finished. If the participant has been on antibiotic treatment for more than one week to treat the urinary tract infection, repeat UACR samples are not required. Urine should not be collected during a participant’s menstrual period to avoid contamination, as this will affect the UACR level. Blood will be taken for serum chemistry tests of urea, electrolytes and creatinine at every study visit. At selected study visits indicated in Table 4, blood tests will evaluate liver function, hematology, fasting glucose and lipid levels, and HbA1c. Blood and urine will be collected at Visits 3, 6 and 9 (pre dose samples) for biomarkers including cystatin C, metabolomics, lipidomics, KIM1 and NGAL tests, hsCRP, IL-6, fibrinogen.
4.4Adverse events
These will be recorded at each study visit and evaluated for start and end dates, severity, seriousness, relationship to study drug, action taken and final outcome. Grading of intensity will follow the Common Terminology Criteria for Adverse Events (CTCAE) grading system from the US National Institute of Health and National Cancer Institute, as shown in Table 5.
Table 5. Grades of intensity of adverse events.

Grade Symptoms
1 Mild; asymptomatic or mild symptoms; clinical or diagnostic observations onlyin tervention not indicated.
2 Moderate; minimal, local or non-invasive intervention indicated; limiting age-appropriate instrumental activities of dailyliving (ADL). Instrumental ADL refers to preparing meals, shopping for groceries or clothes, using the telephone, managing money.
3 Severe or medicallysignificant but not immediatelylife-threatening; hospitalisation or

prolongation of hospitalisation indicated; disabling; limiting self-care activities of daily living (ADL). Self-care ADL refers to bathing, dressing and undressing, feeding self, using the toilet, taking medications, and not bedridden.
4 Life-threatening consequences; urgent intervention indicated.
5 Death related to AE.

4.5Pharmacokinetic analyses
At study visits 4, 5 and 7 occurring during the treatment phase, a pre-dose plasma sample will be collected.
4.6Other study procedures
At Visits 3, 6 and 9, participants will fast for at least 8 hours before blood is collected for metabolic tests. Optional DNA and RNA tests will be collected at the randomization and end of treatment visits.
4.7Criteria for withdrawal of study drug
The study treatment will be discontinued in cases of a Grade 4 severity AE, or if, in the opinion of the investigator, the AE is possibly or probably related to the study agent for cases of Grade 3 severity AE which do not resolve to ≤ Grade 2 within 24 hours of study drug being withheld, or if the Grade 3 severity AE recurs after resumption. Treatment will also be withdrawn if the participant withdraws
totally from the trial, or partially withdraws from the trial by requesting to discontinue study drug treatment but continue on study visits, or if the blind is broken for that partici pant. Treatment will stop if the trial is terminated.
5.Outcome measures
5.1Efficacy evaluations These are shown in Table 1.
5.2Safety evaluations
The safety analyses will include the measurement of AEs, clinical laboratory tests, vital signs, physical examination findings and ECG. The clinical laboratory tests will include kidney and liver function tests, hematology, thyroid function tests; fasting plasma glucose (FPG), lipid profile, pregnancy tests and urine albumin to creatinine ratio.
5.3Statistical evaluation
The primary efficacy endpoint is the difference between the mean UACR of each arm at the end of the treatment period of 48 weeks, adjusted for baseline. The primary analysis will be an analysis of covariance (ANCOVA) comparing the primary endpoint for GKT137831 versus placebo after controlling for the baseline UACR level, and for study centre. The UACR measurements will be log- transformed (natural log) prior to analysis. If there are clinically relevant differences between the treatment arms, for baseline variables known to affect outcomes, then these will be adjusted for accordingly. These pre-specified variables are: age, gender, blood pressure, HbA1c, diabetes duration, lipid levels. There will not be an adjustment for multiplicity in the pri mary analysis. This primary analysis will use the intention to treat (ITT) population.

The analysis of secondary efficacy endpoints will use ANCOVA and adjust for baseline values. These analyses will be conducted in the full analysis set, the modified ITT population and the per protocol population. The secondary endpoints will be UACR at 24 weeks of treatment; eGFR at 48 weeks of treatment; eGFR at 24 weeks of treatment.

Treatment emergent adverse events (TEAEs) will be coded using the Medical Dictionary for Regulatory Activities (MedDRA) and reported in preferred term and system organ class (SOC). Summary statistics will be provided for TEAEs, drug-related TEAEs, grade 3 or higher TEAEs, grade 3 or higher drug-related TEAEs, SAEs, study discontinuation due to AEs or death. Counts and

proportion of participants experiencing the event of interest will be reported for each treatment group. Where relevant, treatment comparison for frequency of adverse events will be implemented using the Chi-square test, or if there are less than 5 counts in any category, with Fisher’s exact test.

Frequencies of laboratory results falling into “notably abnormal” ranges will be tabulated by treatment group. A summary of abnormal physical examination findings by treatment group and scheduled visit will be presented. Summary statistics will be presented for blood pressure and heart rate. For QTc,
the primary analysis method will use the ANCOVA approach. For treatment emergent qualitative ECG changes, these will be listed by treatment group and patient.

Prior and concomitant medications will be coded. Concomitant medications will be summarized according to classification and treatment group. Frequencies will be analysed by Chi -square test.

Sensitivity analysis will be performed using the same ANCOVA for the primary outcome, removing those who changed ACEi or ARB dose. Study drug treatment adherence for each visit interval is defined as taking at least 80% of required study drug. Adherence will be summarized by treatment arms and visits. Frequency counts and percentages of all participants entered, randomised, completing, and/or discontinuing from the study will be presented for each of the treatment groups. The reasons for discontinuation from the study will be summarized by treatment group. A summary of discontinuations will also be presented by visit. The overall percent discontinued comparisons among the treatments will be performed using a Chi-square test. Demographics and other baseline characteristics will be summarized.

Population subgroups of interest will be displayed using descriptive summaries and figures for the primary treatment arms for the variables of UACR and eGFR. Other variables may also be evaluated. The following are candidate subgroups that might be analysed: gender; 6.Discussion
This multi-center, randomised, placebo-controlled, parallel arm clinical trial will add valuable information on the efficacy of Nox-1 and Nox-4 inhibition by GKT137831, in treating albuminuric kidney disease in type 1 diabetes. It builds on considerable pre-clinical data showing the fundamental importance of Nox-1 and Nox-4 in development of kidney disease, pre-clinical proof of principle data showing functional and morphologic benefit of treatment with GKT137831 and safety data from a previous Phase 2 trial.
Strengths of the protocol design are (a) long duration of treatment, (b) a participant population with baseline treatment reflecting current standards of care, (c) targeting a participant population that is early enough in the course of diabetic kidney disease to be likely to respond to therapy. While not directly tested in this clinical trial, GKT137831 may also have vasculoprotective effects. A possible criticism of the trial design is the use of albuminuria as the primary endpoint instead of eGFR, which is a secondary endpoint. Surrogate endpoints proposed for chronic kidney disease trials have included 30% or 40% decline in eGFR from baseline13. However, this would require more years of follow-up
and a very much larger sample size, given the relatively well-preserved eGFR of participants at entry to this study, which would be expensive and difficult to conduct. Drug-induced reductions in albuminuria have in general correlated with longer term renal protection14. To counter the effect of variation in spot urine albuminuria results, the current protocol design employs multiple evaluations of UACR, with baseline and endpoint values calculated from 4 samples.
In summary, diabetic kidney disease is a serious complication for which current treatments frequently do not stop progression to end stage renal failure or cardiovascular death. This trial will be the first to study Nox-1 and Nox-4 inhibition to treat kidney disease in people with type 1 diabetes. If the results are positive, the study will identify a potentially safe, simple and effective way to treat the disease. If negative, it will still contribute further to safety data and the biomarker analysis will shed light on anti -

inflammatory and other pathogenic pathways involved in the development of diabetes -related complications that may not be reflected by changes in albuminuria.
This study is an investigator-initiated trial funded by the Juvenile Diabetes Research Fund (JDRF) Australia, the recipient of the Australian Research Council Special Research Initiative in Type 1 Juvenile Diabetes, and by the Baker Heart and Diabetes Institute. Study drug is provided by Genkyotex S.A. (France). The Sponsor is Baker Heart and Diabetes Institute and the study was designed by the members of the steering committee at the Institute and Monash University.
Disclosures/Conflicts of Interest
KJD received previous small research grants from Genkyotex. MD has served on advisory boards and received honoraria from Eli Lilly and Company, Boehringer Ingelheim, Novo Nordisk, AstraZeneca, Sanofi, Bristol-Myers, Novartis, Otsuka and Abbot. GW is Editor in Chief of Obesity Research and Clinical Practice; he has served as International Advisor for Clinical Key (Elsevier) and is the Independent Chair of the Weight Management Council of Australia. He has had research support from Weight Watchers, Bayer, Eli Lilly, Lawleys, and he has received honoraria from Novo Nordisk, I-Nova, Merck-Serono, Abbvie, Astra Zeneca, Roche, Bayer and Besins. TW has received research support from Novo Nordisk and Merck (MSD). He has served on advisory boards and received honoraria from Eli Lilly and Company, Boehringer Ingelheim, Novo Nordisk, Merck (MSD), AstraZeneca, Sanofi, Bristol-Myers Squibb, Novartis, Janssen Cilag, Roche and Abbot. MC received honoraria from Servier, Sanofi, AstraZeneca, Boehringer Ingelheim, Lilly, Bayer and Novartis. He
received a research grant from Novo Nordisk. JES has received honoraria from Astra Zeneca; Sanofi; Novo Nordisk; MSD; Eli Lilly; Abbott; Mylan, and Boehringer Ingelheim.MAK has received honoraria from AstraZeneca and NovoNordisk.

The authors thank the participants, the study coordinators, clinical research associates from Mobius Medical Pty Ltd for clinical trial monitoring, and the staff at Pharmaceutical Packaging Professionals Pty Ltd.


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