A Dose-Finding and Longitudinal Biomarker Study of Rhinovirus Challenge in Healthy
Volunteers and Mild-Moderate Asthmatics to Evaluate the Safety and Use of a Human
Rhinovirus Preparation in Developing High Dimensionality Phenotypes (*Handprints*) for
Asthma

Asthma is associated with chronic airway inflammation and misdirected immunity *
resulting in bronchial smooth muscle hyperreactivity, mucus hypersecretion, and
airway thickening.
This pathologic triad leads to acute and chronic airway obstruction. Asthma
affects 6%-11% of the US population * annually resulting in ~3500 deaths and
>400,000 hospitalizations [1, 2, 3]. Similar epidemiology is observed in Europe
[39, 40], while worldwide, approximately 300 million people are affected [4].
Inhaled corticosteroids (ICS), long acting beta agonists (LABA), and cysteinyl
leukotriene modulators have advanced
asthma care; nevertheless, a great number of people still have severe and/or
poorly controlled asthma. Accordingly, these troublesome asthma subsets are the
subjects of intense investigation * investigation that has been hampered by
disease complexity, interpatient variability, and a poor mechanistic
understanding of disease causality. These hurdles necessitate the study of
large numbers of subjects and large numbers of biologic variables ineach
patient. Accordingly, large consortia have arisen whose purpose it is to join
the capabilities of multiple institutions to achieve the patient numbers and
breadth of study seemingly required to understand severe and poorly controlled
asthma [5,6,7]. The Unbiased Biomarkers for the Prediction of Respiratory
Disease Outcomes (U-BIOPRED) consortium is the broadest such effort. It
attempts to characterize large numbers of asthmatics at high dimensionality and
over time, in order to develop combined clinical and biological biomarkers of
disease subtype, generate testable hypotheses about disease mechanism and
treatment, and develop useful research tools for follow-on investigation.
U-BIOPRED operates under the aegis of the Innovative Medicines Initiative (IMI)
* a pan- European public and private sector collaboration aimed at accelerating
the discovery and development of better medicines for patients. IMI emphasizes
the following steps in pursuing improved prediction of safety and efficacy of
novel medicines: predictive pharmacology and toxicology, discovery of
predictive biomarkers, patient studies, validation of biomarkers, and
benefit/risk assessment. U-BIOPRED is the IMI consortium aimed at severe asthma
[5]. Central to its approach is the development of *handprints* * high
dimensionality descriptions of asthma that encompass demographic, clinical,
imaging-based,
metabolic, transcriptomic, and genetic/genomic metrics. These complex
descriptions will be used to develop multivariate biomarkers that correlate
with asthma subtypes and their respective responses to pharmacologic
intervention. The findings of U-BIOPRED will be
communicated with the world asthma community through conference presentations,
publications, and special announcements
This study (PN218) is a component of the U-BIOPRED effort -- resultant data and
specimens being shared with the members of the consortium to be analyzed in the
larger context. Its purpose is to develop a standard virus challenge-based
model of asthma exacerbation, and to
understand how patient handprints change in that context.

The overarching goal is to qualify a virus challenge model for use in basic
research and clinical development. This model will provide a consistent
approach to generating and testing hypotheses relating to virally induced
asthma exacerbations, and may provide better
positive prediction of efficacy in early development of new molecular entities
(NME).
Furthermore, its adoption by many investigators will allow easier comparison of
results from different laboratories since the same virus preparation and dosing
approach will have been used.
PN218 is designed to achieve this goal in two steps. The first (Part 1) is to
demonstrate tolerability of the RV16UB preparation at different dose levels
with induction of expected cold symptoms at * 1 (one) dose level, and on an
exploratory basis, to assess the reduction in
FEV1 induced by different virus challenge doses in the asthmatic panels.
The lowest tested dose that is both well-tolerated and induces satisfactory
degrees of cold symptoms will be taken forward for the second step -- Part 2
for platform development, biomarker assessment, and handprint discovery.

This is a two-part nonrandomized, multicentre trial of a nasal rhinovirus
challenge in healthy participants (hereafter also called *subjects*) and
subjects with mild-moderate asthma to be conducted in conformance with Good
Clinical Practices.
Part 1 is a dose-finding study of 1) up to 4 panels of up to 6 healthy
volunteers and 2) up to 4 panels of up to 6 mild to moderate asthmatics not
taking long-acting beta agonists (LABA), and 3) up to 4 panels of up to 6 mild
to moderate asthmatics taking LABA -- each undergoing nasal challenge with
U-BIOPRED human rhinovirus 16 (RV16UB) [also referred to in other study
documents as "HRV-16" which all refer to the rhinovirus described in Section
4.1.1 and used in this study] at increasing doses in staggered fashion, as
illustrated in Figure 1. The decision to start a panel of asthmatics at the
next higher virus dose will be made after asthmatic participants in the
previous panel have been safely challenged. The lowest dose asthmatic panel
will begin the study at least one week after the first two panels of healthy
volunteers have safely been challenged. Timing for dose advancement between
panels with healthy volunteers and panels with asthmatics will be based on the
appropriate amount of time needed to review safety data.
Part 2 is a longitudinal biomarker study of up to 25 mild to moderate
asthmatics undergoing RV16UB challenge using the most appropriate dose
identified in Part 1, based on tolerability and viral effects. This biomarker
component is somewhat similar in structure to that used for
each dose level in Part 1, with some changes in timing, procedures and number
of visits. This protocol is written with some flexibility to accommodate the
inherently dynamic nature of Experimental Medicine clinical trials. Please
refer to Section 7.1.5 * Visit Requirements
for modifications permitted within the protocol parameters. Specific procedures
to be performed during the trial, as well as their prescribed times and
associated visit windows, are outlined in the Trial Flow Chart - Section 6.0.
Details of each procedure are provided in Section 7.0 * Trial Procedures.
1. Adaptive viral dose selection will be used in this study. Specifically, the
dose of virus to be used in Part 2 will be determined from results of Part 1 as
described in Section 5.2.1.2.
2. If a dose in the non-LABA taking panel in Part I is determined to be safe,
the same dose does not necessarily need to be repeated in a panel of patients
taking LABA. This is because participants taking LABA should be, in general,
more protected against exacerbation-related AE's.

There are no pharmacologic treatments being studied. This study involves a
nasal rhinovirus challenge in both Parts 1 & 2 of the study.
In Parts 1 and 2, the rhinovirus challenge will occur on Day 0 (up to
approximately 21 days post screening visit). Part 1 will determine the dose of
rhinovirus to be used in Part 2.
Part 1:
Starting Dose: Recent work has focused on low dose inoculations * on the order
of 10 TCID50. In particular, work by S. Johnston at Imperial College, London
[18] and by R.Lutter and K. van der Sluijs at University of Amsterdam
[unpublished] strongly suggests that low dose inoculations are satisfactory for
this approach. (Notably, the latter are investigators in this study.) To date,
the only prominent difference between high -dose and low-dose approaches is a
~1-2 day delay in symptom peak * i.e. ~d6 vs. ~d4 for higher doses (see Figure
5 on page 21 of the protocol). Because the low-dose approach conserves virus
stock, exposes participants to lesser amounts of virus preparation, and perhaps
better reflects *natural* infection; 10 TCID50 will be the starting dose in
Part 1.
The remaining doses span the range (up to 10,000 TCID50) of published
experience with rhinovirus 16 and merit testing to verify similarity of potency
between the RV16UB GMP preparation with other related stocks previously used.
Hence, doses of 10, 100, 1000, and
10000 TCID50 are planned for PN218.
Part 2:
The dose selected for Part 2 will be the lowest dose for which: there are
sufficient data from a
completed panel of asthmatic subjects, there are no concerns arising from key
safety
variables, and the effect criteria of Primary Hypothesis #3 for Part 1 (Section
3.1) have been
met.

No tangible benefits accrue from participation in this clinical study.
Participants will, however, know that they are helping to develop a
standardized tool to enable a better understanding of asthma exacerbation. This
understanding, coupled with the novel biomarkers and mechanistic hypotheses
that may follow, may help advance asthma treatment * especially for patients
with problematic asthma.

Risks to participants fall into two categories: (1) those associated with the
challenge agent, and (2) those associated with the study procedures. Risks
associated with the challenge agent can be subdivided into those associated
with (a) the formulation and (b) the virus
infection itself. These are covered below.
(1a) As with any biologic preparation, the virus stock could induce immediate
reactions resulting from contamination with toll-like receptor (TLR) agonists
or other unintended bioactive materials. Furthermore, the preparations may be
contaminated with infectious organisms other than the intended rhinovirus. To
guard against this, manufacturing is cGMP compliant using well characterized
cell stocks and growth media. Final virus
preparation is tested according to modern biologics manufacturing methods to
rule out lipopolysaccharide contamination and the presence of microorganisms
that could produce TLR agonists or frank infection. Because of these
precautions and the fact that the seed stocks for the RV16UB preparation have
been used in >100 subjects without any immediate reactions or unexpected
infections, the probability of such events is considered to be very small.
(1b) The intended purpose/function of the RV16UB challenge agent is that of a
functioning rhinovirus. Hence, a successful challenge means that participants
will experience symptoms associated with the common cold. The common cold is a
frequent event in human existence and does not confer particular risks except
for those at the extremes of age, the immunosuppressed, and those with
idiosyncratic susceptibilities or
severe underlying conditions. In asthma patients, the common cold may induce
exacerbations characterized by chest symptoms and airflow reduction. Indeed,
mild versions of this are a desired endpoint. To lessen risk of severe
exacerbations necessitating oral steroids or acute medical attention, subjects
will be of moderate age and will be screened for lack of non-asthma
comorbidities, and for having only mildmoderate asthma with no history of
asthma-related ICU admission or intubation during adult life. Furthermore, all
asthmatic subjects will be maintained on their baseline inhaled corticosteroid
regimens. Again, successful performance of dozens of published viral challenges
in asthmatics -- without SAE and with less than a handful of required
treatments with systemic steroids -- suggests that the approach is safe.
(2) Most study procedures such as phlebotomy, spirometry and nasal sampling
entail minimal risk and are not covered here.
Induced sputum carries nominal risk of asthma exacerbation; however, its
performance in many hundreds of published cases without such problems shows the
risk to be low. The sponsor has performed >200 sputum inductions in
allergen-challenged asthmatics over the past three years with no AEs beyond
mild cough, wheeze, and chest discomfort; those AEs were occasional and either
self-limited or controlled with an extra dose of salbutamol. The principal
investigators have had similar experiences over many years of academic
research. Of particular relevance to this study, peer-reviewed work has shown
sputum induction to be safe -- even during exacerbations of asthma and COPD
[41-43].
Risk will be mitigated in this study by pretreatment with inhaled beta agonists
as well as by close monitoring of patient symptoms and airflow before, during,
and after the procedure.