methods (additional details available in supplementary … · web viewa total of 400 aes in 85·5%...

Suitability of Nitisinone in Alkaptonuria 2 (SONIA 2) - An international, multicentre,

randomised, evaluator-blinded, no-treatment controlled, parallel-group study to assess the

efficacy and safety of once daily nitisinone in patients with alkaptonuria after 12 months of

treatment, followed by an additional 36-month treatment period

Ranganath LR1,8, Psarelli EE2, Arnoux JB3, Braconi D4, Briggs M5, Bröijersen A6, Loftus N7, Bygott H1, Cox TF2, Davison AS1, Dillon JP8, Fisher M9, Fitzgerald R10, Genovese F11, Glasova H12,13, Hall AK14, Hughes AT1, Hughes JH8, Imrich R12,15, Jarvis JC16, Khedr M1, Laan D17, Le Quan-Sang KH3, Luangrath E1, Lukáčová O15, Milan AM1, Mistry A18, Mlynáriková V15, Norman BP8, Olsson B6, Rhodes NP8, Rovensky J15, Rudebeck M6, Santucci A4, Shweihdi E1, Scott C19, Sedláková J15, Sireau N19, Stančík R15, Szamosi J6, Taylor S7, van Kan C17, Vinjamuri S20, Vrtíková E15, Webb C21, West E22, Záňová E15, Zaťková A12, Gallagher JA8 1Departments of Clinical Biochemistry and Metabolic Medicine, Liverpool University

Hospitals NHS Foundation Trust (LUH), Prescot Street, Liverpool, L7 8XP, UK; 2 Liverpool

Clinical Trials Centre, University of Liverpool, Block C, Waterhouse Building, Liverpool

L69 3GL, UK; 3Hôpital Necker-Enfants Malades, Paris Cedex 15, France; 4Department of

Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy; 5Department of

Ophthalmology, LUH; 6Swedish Orphan Biovitrum AB (publ), Stockholm, Sweden; 7Department of Physiotherapy, LUH; 8William Henry Duncan Building, West Derby Street,

Liverpool, L7 8TX; 9Department of Cardiology, LUH; 10Department of Clinical

Pharmacology, LUH; 11Nordic Bioscience, Herlev, Denmark; 12Institute of Clinical and

Translational Research, Biomedical Research Center, Slovak Academy of Sciences,

Bratislava, Slovakia; 13Institute of Pharmacology and Clinical Pharmacology, Slovak Medical

University, Bratislava, Slovakia; 14Cudos BV, Hoofddorp, Netherlands; 15National Institute of

Rheumatic Diseases, Piešťany, Slovakia; 16School of Sport and Exercise Science, Liverpool

John Moores University, Liverpool, UK; 17PSR group B.V., Hoofddorp, Netherlands; 18Department of Radiology, LUH; 19AKU Society, Cambridge, UK; 20Department of Nuclear

Medicine, LUH; 21Department of ENT, LUH; 22Department of Dermatology, LUH.

Corresponding author: LR Ranganath, Department of Clinical Biochemistry and Metabolic

Medicine, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP; e-mail:

[email protected]

Abstract (word count) – 296

Manuscript (word count) - 4749

Tables - 3

1SONIA 2 manuscript supplementary material

mailto:[email protected]

Figures – 3

References – 26

Supplementary manuscript - 2736

Supplementary figure - 8

Supplementary Tables - 12

Supplementary references - 6

Keywords: alkaptonuria, nitisinone, homogentisic acid, randomised clinical trial, outcome,

safety, ochronosis, AKUSSI


Abstract

Alkaptonuria (AKU) is a genetic, rare, multisystem disease, characterised by accumulation of

homogentisic acid (HGA). There is no approved HGA-lowering therapy. Nitisinone

decreases HGA generation. SONIA 2 investigated the effect of nitisinone on the disease

process, and on progression of AKU.

Methods: This was a 48-month randomised, open-label, evaluator-blinded, parallel-group

study performed in the UK, France and Slovakia. Patients ≥25 years of age with confirmed

AKU and any clinical disease manifestations were randomised to receive either 10 mg

nitisinone or no treatment. Site visits were performed at 3 months and yearly thereafter.

Results from history, photographs of eyes/ears, whole body scintigraphy, echocardiography,

and abdomen/pelvis ultrasonography, were combined to derive the Alkaptonuria Severity

Score Index (cAKUSSI). The primary objective was to show decrease in daily urinary HGA

(u-HGA24) excretion at month 12. Secondary objectives included comparing clinical

outcomes after 48 months.

Findings: 69 patients were randomised to nitisinone and 69 to the control group. 55 patients

in the nitisinone group and 53 in the control group completed the study. u-HGA24 at 12

months was statistically significantly decreased by 99.7% in the nitisinone group compared

with control. The adjusted geometric mean (ratio nitisinone/control) was 0·003 (0·003 –

0·004), p<0·0001. cAKUSSI scores decreased statistically significantly at 48 months in

nitisinone group compared with control [adjusted mean difference -8·6 (-16·0 – 1·2), p=0·02].

The incidence of adverse events (AEs) was similar for the groups, but numerically more AEs

were reported in the nitisinone group (400 AEs in 85·5% of patients) versus control (284 AEs

in 82·6% of patients).


Interpretation: Nitisinone 10 mg daily was well tolerated and effective to reduce urinary

excretion of HGA. Nitisinone decreased ochronosis and improved clinical signs, indicating a

slower disease progression.

Funding

European Commission Seventh Framework Programme funding was granted in 2012

(DevelopAKUre, project number: 304985).


Research in context

Evidence before this study

There has been only one previous long-term clinical study using the potentially disease-modifying agent, nitisinone, to evaluate the effect of the drug on AKU disease progression (Medline search up to and including February 2020). The terms used in the Medline search were nitisinone, alkaptonuria, and outcomes. In addition, because AKU is a rare disease, personal contacts with researchers and clinicians in the field enable us to confidently state that there has been only one previous outcomes trial using nitisinone in AKU. The National Institutes of Health (NIH, USA) nitisinone outcomes study on 20 nitisinone-treated and 20 control AKU patients, employed an improvement in the lateral rotation of the hip as the endpoint to decide on efficacy of 2 mg nitisinone daily over 3 years, the effect on this endpoint deemed inconclusive. There have been three short-term studies, two in the NIH, USA, and one in Liverpool, UK, that reported the metabolic efficacy of nitisinone in terms of lowering HGA. An audit of the use of nitisinone 2mg daily off-label in the National AKU Centre in Liverpool, funded by NHS England Highly Specialized Services, showed metabolic benefit, arrest of ochronosis, and slower progression of AKU disease, but this was an audit of a service rather than a research study.

Added value of this study

The present international, multicentre, randomised, controlled, evaluator-blinded, parallel-group study is an analysis of the efficacy of using 10 mg nitisinone daily in AKU. Both the nitisinone-treated and control groups had similar numbers of patients. The outcome was based on the effect of nitisinone on the change in AKU severity score index, a composite disease score, over four years. The power of the study was much increased by the use of the composite score, AKU severity score index. The composite disease score outcome was also clear cut in showing that nitisinone decreased the progression of AKU for the very first time in a randomised study. The study of the control group over four years has improved our understanding of the natural history further.

Implications of all the available evidence

We believe that the publishing of our manuscript will provide a major boost to the study of, and progress in, rare diseases. Our manuscript will be of interest to the general readership of the journal because AKU is an iconic disease whose study foreshadowed genomic medicine. AE Garrod applied Mendel’s Laws of inheritance to human disease as early as 1902 in his studies of AKU. AKU has the added attribute of being a rare disease, in which the natural history is incompletely understood (an attribute it shares with most rare diseases); rare disease is ‘common’ in the sense that virtually all readers will need to manage rare diseases, with lessons to learn from our experience. The lack of patient numbers in which to study and carry out fully powered clinical trials, as in major frontline diseases like cardiovascular disease and diabetes, challenges the rare disease community to develop innovative ways to develop much needed therapies. We have employed a weighted composite score, which enabled us to overcome the low patient numbers by increasing power, and showing for the first time that nitisinone has disease-modifying attributes as well as metabolic efficacy. Our


experience also provides a powerful example of the effective re-purposing of an existing drug for a novel indication, which may be a more practical strategy than developing entirely new drugs for rare diseases. Our experience may empower researchers into the other 7000 rare diseases in their approach to achieve solutions in their diseases of interest. Finally, our findings demonstrate for the first time the efficacy of a disease modifying drug in the iconic disease AKU, and therefore bring hope to patients with this condition.


Background

Alkaptonuria (AKU) (OMIM 203500) is a rare, serious, autosomal recessive multisystem

disorder1 affecting approximately one in every 250 000 to 1 million people. 2 The disease was

the first ever described in a paper by AE Garrod in 19023, in which Mendel’s laws of

inheritance were applied in human disease. Still, AKU lacks a pharmacological treatment.

Genetic deficiency of homogentisate dioxygenase activity (HGD) results in accumulation of

homogentisic acid (HGA) (Figure S1). HGA is then progressively deposited as yellow/dark

pigment in connective tissue, rendering these more rigid and eventually brittle, and prone to

degradation, a process termed ochronosis.4,5 As the causal agent, HGA may therefore

represent a suitable surrogate for a clinically meaningful endpoint in clinical trials. This was

also suggested by the European Medicines Agency (EMA), during scientific advice before

starting our clinical program. Degradation of ochronotic tissue is mainly responsible for the

multisystem involvement, with varying phenotype, characterised by severe premature

spondyloarthritis, lithiasis, cardiac valve disease, fractures, muscle and tendon ruptures, and

osteopenia.6,7 Palliative analgesia and arthroplasty is the mainstay of AKU therapy.

AKU is a disorder of tyrosine metabolism like another inherited condition known as

hereditary tyrosinaemia type 1 (HT-1) (OMIM 276700). In HT-1, there is a deficiency of

fumarylacetoacetate hydrolase, resulting in early liver and kidney disease and death in

childhood if untreated.8,9 Nitisinone (2-[2-nitro-4-(trifluoromethyl) benzoyl] cyclohexane-1,3-

dione) is an inhibitor of the hydroxyphenylpyruvate dioxygenase (HPPD) (EC 1.13.11.27)

and has been used in HT-1 since 1991. As activity of HPPD leads to formation of HGA

(Figure S1) nitisinone was hypothesised in the late 1990s to be a potential treatment for

AKU.10 Following initial research of nitisinone for treatment of AKU1,11, a three-year clinical

trial comparing a nitisinone-treated patient group, receiving a 2 mg daily dose, with an

untreated group, with 20 AKU patients in each group, was reported as inconclusive, despite

showing excellent biochemical efficacy.12

Despite this setback, research into the use of nitisinone in AKU has continued. In addition,

nitisinone 2 mg daily has been reimbursed for use in the United Kingdom’s National

Alkaptonuria Centre (NAC) since 2012, and a recent publication described positive outcomes

for nitisinone in its metabolic and non-metabolic effects.13,14 However, the off-label use in the

NAC is, despite collecting high-quality data in a protocolised manner, in a service capacity

and not a controlled clinical trial.


In designing the SONIA 2 study, it was assumed that the NIH trial did not succeed because of

the small number of patients recruited, insufficient duration in such a very slowly progressive

condition as AKU, the incomplete understanding of the natural history, and use of a single

and possibly unreliable outcome measure in this multifaceted disease. An identification

campaign to maximise patient recruitment for a new trial was subsequently carried out both

in the UK and the rest of Europe.15 A better understanding of the natural history and it’s

modification by nitisinone was shown in a mouse AKU model.16-18 Careful phenotyping of

the disease in a cohort of untreated AKU patients resulted in a composite score, termed AKU

Severity Score Index (AKUSSI), a key factor when researching a multifaceted condition with

variable phenotype.19,20 In addition, a new clinical trial of nitisinone, with a considerably

higher number of patients and a longer duration, was considered because of the naturally

slow progression. The dose used in the inconclusive NIH trial was based on the experience of

administering nitisinone to two AKU patients10; further, the EMA suggested finding a dose

that normalises HGA, and therefore the issue of optimal dose was revisited in a dose-

response study, the ‘Suitability Of Nitisinone In Alkaptonuria 1’ (SONIA 1).21 In that study,

the 8mg daily dose of nitisinone resulted in a mean reduction of u-HGA24 of 98.8 %, with a

clear dose-response and much less variability compared with the other doses studied (1, 2 and

4 mg). An increase in tyrosine levels was seen at all doses but the dose-response relationship

was less clear, with no tyrosine-related adverse events seen at any dose. Since the 8mg dose

resulted in u-HGA24 close to normal values, a dose of 10 mg daily, which was achieved with

an available capsule strength, was selected for the new trial, SONIA 2. All of these factors

influenced the design of SONIA 2 in which the safety and efficacy of nitisinone 10 mg daily

in AKU was investigated.

METHODS (additional details available in supplementary material)

Objectives

The primary objective in SONIA 2 was to demonstrate that nitisinone was superior compared

to control in reducing u-HGA24 in patients with AKU after 12 months. Secondary objectives

were defined to demonstrate the sustained control of urinary and serum HGA up to 48

months and to demonstrate the effect on clinical parameters and to assesses the safety of

nitisinone in AKU.


Study design

SONIA 2 was a four-year, open-label, evaluator-blinded, multicentre, randomised, no-

treatment controlled, parallel-group study. A formal interim analysis was planned when all

patients completed 12 months of treatment. This analysis included the complete set of

efficacy and safety data up to 12 months, thus including the final analysis of the primary

endpoint. The purpose was to evaluate if data demonstrated results suitable for a regulatory

application already at that stage, even though the study was to continue for another 3 years to

collect more complete efficacy and safety data. The study design is summarised in Figure S2.

The study was performed at three investigational sites: Liverpool (UK), Paris (France) and

Piešťany (Slovakia). Independent Ethics Committee at each centre approved the study.

Patients

The aim was to recruit 140 patients aged 25 years or older, with a confirmed diagnosis of

AKU and any clinical manifestation in addition to increased HGA; 70 randomised to

nitisinone 10 mg and 70 to a control (no-nitisinone) group. All patients provided written

informed consent prior to inclusion.

Treatment

Oral nitisinone (Orfadin®) 10 mg daily was administered in the treated group. The control

group did not receive the study drug.

Nitisinone was withdrawn in patients who developed signs of ocular tyrosine-related adverse

events (AEs). If feasible, once the symptoms had resolved (minimum 2 months after

temporary withdrawal), nitisinone was reintroduced at a lower dose (2 mg daily).

Alternatively, the patient was withdrawn from the study. If ocular tyrosine-related symptoms

reappeared on the lower dose, nitisinone was permanently withdrawn and the patient was

monitored until the symptoms resolved.

There were no restrictions regarding concomitant medications. Patients in both groups could

freely use e.g. analgesics, anti-inflammatory drugs and others as needed to treat symptoms of

AKU.

Randomisation and masking

Patients were randomly assigned to one of the two groups in a 1:1 ratio. The randomisation

was stratified by study centre and age (≤ 55 years and > 55 years) and was carried out by


using randomly permuted blocks (4 patients/block) within each study centre and age stratum.

The study statistician created a program to randomly assign the patients to the two treatment

groups using the SAS System. The randomisation was centrally implemented in the

electronic CRF system (Viedoc®).

It is not possible to blind a study with nitisinone in AKU because one of the signs of the

disease is that the urine darkens due to oxidation of excreted HGA. Patients can therefore

easily notice if they are receiving active drug or not. Therefore, the control group received no

placebo treatment. Instead, the study was evaluator-blinded as far as possible. Assessments

which did not require direct contact between the evaluator and the patient (such as evaluation

of images) were blinded during the entire study. The blinded evaluators were experts in their

respective field, and never met the patients. Other assessments were made by objective

measurements (Table S1), such as that of bone density. It is, however, recognised, that

reporting of subjective assessments may have introduced bias for some of the secondary

endpoints, such as pain and quality-of-life assessments, and reporting of adverse events.

Procedures

In addition to a 24-h urine (u-HGA24) collected into acid for HGA and creatinine

determination, fasting acidified serum for HGA, tyrosine and creatinine, a number of

assessments and investigations were carried out (supplementary material). These included

collection of medical history and physical examination, including those specific for AKU, a

wide range of clinical outcome measures, including range of motion tests and quality of life

assessments, safety assessment and other procedures shown in Table S1 and elsewhere.13,14

AKU Severity Score Index (AKUSSI) assessments (Table S1)

The AKUSSI incorporates multiple, clinically meaningful AKU outcomes that can be

described in a single score.13,19,20 All items included in the AKUSSI were assessed at baseline

and yearly thereafter. Two types of AKUSSI were included as secondary outcomes in SONIA

2. These are the clinical evaluation AKUSSI (cAKUSSI) and a modified AKUSSI

(mAKUSSI = cAKUSSI without pigmentation features).

Patients visited study sites at 3 months, and then annually up to month 48; a close-out phone

call took place at month 49. A questionnaire, completed by patients, collected safety

information at 6, 18, 30 and 42 months.


At each visit, AEs and laboratory values were recorded. AEs included clinically significant signs and symptoms and abnormal test findings (e.g. laboratory analysis

results, vital signs or ECG) that the investigator considered clinically significant and/or that

led to a medical/surgical intervention including withdrawal of nitisinone or discontinuation

from the study.

Statistical analysis

Only a few subjects would be needed to detect a statistically significant effect on the primary

endpoint, u-HGA24. Therefore, the sample size was based on the AKUSSI score, to allow the

possibility to establish an effect on a clinical endpoint. Using data from a cross-sectional

study of AKU using AKUSSI13,14,20 and follow-up data, it was assumed that if nitisinone

reduced the mean increase in AKUSSI over the 4-year period to 4 points, compared to 8

points in the control group, and taking the standard deviation of the increase to be 8, then a

sample size of 64 per group was required for a two-sided t-test with 80% power for a

significance level 0·05. With an estimated 10% drop-out rate, a sample size of 70 per group

was required (140 patients in all).

The Full Analysis Set (FAS) including all randomised patients was used for the analysis of

efficacy variables, containing all randomised patients who had a valid u-HGA24 at baseline.

The Safety Analysis Set was used for the analysis of safety variables. All randomised

patients were included in both sets.

All statistical analyses were performed with the SAS System (version 9.3, SAS Institute,

Cary, NC). Two-sided 95% confidence intervals corresponding to a two-sided 5% level of

significance were used throughout the analyses. All relevant study data were tabulated with

descriptive statistics, including mean, standard deviation, standard error of the mean, median,

minimum and maximum for the continuous variables, and frequencies and proportions for the

categorical variables. Both absolute values and changes from baseline were tabulated, if

feasible. No allowance for multiplicity was made.

Analysis of primary endpoint

The primary endpoint was the u-HGA24 in patients with AKU after 12 months.

A longitudinal model (mixed model for repeated measures (MMRM) with an underlying

normal distribution was fitted for the analysis of the primary endpoint. An unstructured


covariance matrix was used along with a restricted maximum likelihood method (REML),

while the degrees of freedom were estimated using Kenwood-Rogers method. Treatment,

site, age category, visit and treatment by visit interaction were added as fixed factors in the

model together with the baseline log(u-HGA24) value as a covariate and with subject-within-

site included as a random factor. The analysis was performed using the log(u-HGA24) as

dependent variable. Model based point estimates and associated two-sided 95% confidence

intervals were calculated.

Analysis of secondary endpoints supporting primary endpoint

u-HGA24 at month 3, 24, 36 and 48 was analysed using the same MMRM model as in the

primary endpoint analysis.

Analyses of other endpoints

Changes from baseline in cAKUSSI, mAKUSSI, individual AKUSSI items, and pre-dose

s-HGA, were also analysed. For continuous secondary endpoints, the same statistical model

as in the primary endpoint analysis was used, with the exception that these analyses were

conducted on the original scale without transformation. However, this was not the case for

s-HGA and s-Tyr where log transformation was used. Ordinal secondary endpoints were

modelled using a generalised estimating equations (GEE) approach, whereas count data was

modelled using an MMRM with an underlying Poisson distribution.

Analysis of safety data

All adverse events (AEs) during the study were coded using the Medical Dictionary for

Regulatory Activities (MedDRAv.16.0). The incidence of AEs was summarised in frequency

tables. The changes in safety laboratory parameters from baseline to all post-baseline visits

were summarised by treatment group and visit using descriptive statistics. These included

serum concentration of clinical chemistry, haematology, vital signs, electrocardiogram (ECG)

and corneal eye assessments.

A Data Monitoring Committee was assigned to safeguard the interests of study participants

and to continuously monitor the safety of the patients in the study.


The study was registered at clinicaltrials.gov (NCT01916382).

Role of the Funding Source

This study was funded by a grant from the European Union Framework Programme 7

(DevelopAKUre, project number: 304985). The funder of the study had no role in study

design, data collection, data analysis, data interpretation, or writing of the report. The

corresponding author had full access to all the data in the study and had final responsibility

for the decision to submit for publication.

RESULTS

Disposition of patients: 139 patients were screened and 138 included the study between 7th

May 2014 and 16th February 2015, with 69 patients randomised to each of the two study

groups. First patient was randomized on May 7, 2014 and the last patient’s last visit was

February 15, 2019. SONIA 2 was funded by the European Commission under their FP 7

programme, with a strict time limit for its completion. Therefore, as the number of recruited

patients was deemed sufficient at the end of the recruitment period, recruitment was ended

after 138 patients were included (139 screened), to meet these timelines. Of these, 108

patients completed the study. All 138 patients (69 per group) were included in the analysis

and this was by originally assigned groups. The main reason for discontinuation in the control

group was withdrawn consent (10 patients), while AEs were the most common reason for

withdrawal (nine patients) in the nitisinone group (Figure 1).


Demographic data and other baseline characteristics: The two groups were well balanced.

The majority of the patients (134 patients, 97·1%) were Caucasian. There were more males in

the nitisinone-treated group (45 patients, 65·2%) compared to the control group (40 patients,

58·0%). The mean age was slightly lower in the control group compared to the nitisinone

group (Table 1).

Efficacy and safety assessments

Primary outcome - Urinary HGA: The u-HGA24 was statistically significantly decreased in

the nitisinone-treated group compared to the control at all visits after baseline. These findings

were consistent irrespective of age, sex, or study site. At month 12, the time of evaluation of

the primary endpoint, the adjusted mean u-HGA24 had statistically significantly decreased by

99·7% in the nitisinone group compared to the control group [adjusted geometric mean (ratio

nitisinone/control) 0·003 (0·003 – 0·004), p<0·0001] (Table 2, Figure 2A).

Serum HGA: At baseline, the geometric mean s-HGA was comparable for the two study

arms. At month 12, the adjusted geometric mean s-HGA in the nitisinone group had

statistically significantly decreased by 98·8% compared to the control group [adjusted

geometric mean (ratio nitisinone/control) 0·01 (0·01 – 0·02)]. At each visit after baseline, the

difference in change from baseline in s-HGA between the study arms was statistically

significant (p<0·0001) (Table 2, Figure 2B).

Interim analysis of secondary efficacy outcomes: The 12-month analysis of the secondary

efficacy endpoints did not support a regulatory authority application for the new indication.


AKUSSI (cAKUSSI and mAKUSSI) assessments: At baseline, cAKUSSI was slightly higher

in the nitisinone group than in the control group. Over time there was an increase in

cAKUSSI in the control group from baseline to month 48, while there was less of an increase

in the nitisinone group. The difference between the two groups in the change from baseline to

month 48 was statistically significant [adjusted mean difference -8·6 (-16·0 – 1·2), p=0·02].

The adjusted mean increase was 15·1 and 6·7 points in the control and nitisinone groups

respectively, over the duration of the study (Tables 2, S1; Figure 3A).

mAKUSSI: At month 48 there was no statistically significant difference between the two

groups in change from baseline [adjusted mean difference -3·6 (-9·6 – 2·4), p=0·23] (Table

2). There was, however, a continuous increase in mAKUSSI in the control group from

baseline to Month 48, while a slower increase was observed for the nitisinone group (Tables

2, & S1, Figure 3B).

Selected individual AKUSSI items

Statistically significant differences between the two treatment groups were observed at

Month 48, and for some variables also from earlier time points, for the following variables.

Eye pigmentation (Table 2, Figure S3A)

Ear pigmentation (Table 2, Figure S3B)

Osteopenia of the hip (T-scores for bone density) (Table 2, Figure S4A)

Number of spinal regions with pain (Table 2, Figure S5B)

For the number of joints with pain, a statistically significant difference in favour of nitisinone

was observed at Month 12 [adjusted mean difference -0·9 (-1·6 – -0·1), p=0·02].

Numerically, the difference between the groups was relatively constant at subsequent visits,

and at Month 48 [adjusted mean difference -0·7 (-1·6 – 0·1), p=0·10].

An increasing gap, between the two treatment groups from baseline to Month 48, supporting

a lower rate of disease progression in the nitisinone group, was observed for the following

variables, however the result failed to reach statistical significance (p-values>0·05):

mAKUSSI (Table 2, Figure 3B).

Number of fractures (Table 2, Figure S4B).

Number of tendon, ligament and muscle ruptures (Table 2, Figure S4C).


Other key secondary outcomes

Consistent trends towards better outcome in the nitisinone group compared to controls were

also observed for:

Quality of life (SF-36) (Figure S6).

Self-evaluated transition (in SF-36) (Table S8).

Range of motion of the joints (Figure S7).

No notable difference between the treatment groups was observed for any of the other

variables.

Safety:

A total of 400 AEs in 85·5% of patients in the nitisinone group and 284 AEs in 82·6% of

patients in the control group were reported. Most AEs reported were within the system organ

class (SOC) “Musculoskeletal and connective tissue disorder” (mostly manifestations of

AKU); 53 and 54 events were reported for 24 patients in the control group and 31 patients in

the nitisinone group, respectively. “Infections and infestations” was the second most common

SOC. There was a higher incidence of AEs in this SOC in the nitisinone group; 56 AEs were

reported for 27 patients while in the control group there were 24 AEs reported for 11 patients.

Pneumonia and bronchitis were more commonly reported in the nitisinone group than in the

control group. Other than that, there was no clear pattern. “Eye disorders”, the third most

common SOC, were reported for 8 (11·6%) patients in the control group and 25 (36·2%)

patients in the nitisinone group (Tables 3, S9, S10, S11, S12).

The incidence of AEs was 2·13 per 10 patient years in the control group and 2·27 in the

nitisinone group. The incidence of eye-related AEs was 0·3 and 0·96 per 10 patient years

respectively.


There were two deaths in the study, one due to heart failure and the other to myocardial

infarction; both occurred in nitisinone-treated patients. None of the events was considered to

be related to nitisinone treatment (Table 3).

A total of 53 patients, 26 in the control group and 27 in the nitisinone group, experienced at

least one SAE during the study. None of these events was considered by the investigator to be

related to nitisinone (Table S10). The SOC “Musculoskeletal and connective tissue disorders”

had the highest number of SAEs, most of them related to joint replacements, fractures and

other manifestations of AKU.

Ocular adverse events: A total of 77 AEs in the SOC “Eye disorders” were reported. In the

control group, 8 (11·6%) patients reported 12 events. In the nitisinone group, 25 patients

(36·2%) reported 65 events. A majority of these, such as keratopathy (10 patients), eye pain

(8 patients), dry eye (6 patients), increased lacrimation (4 patients), ocular hyperaemia (4

patients), eye irritation (3 patients), are considered related to the increased levels of tyrosine

caused by nitisinone treatment (Tables S9, S10).

Nine of the patients in the nitisinone group developed tyrosine-related keratopathy in one or

both eyes confirmed by slit-lamp examination. One further patient, who could not come for a

follow-up visit, was withdrawn due to suspected keratopathy based on convincing ocular

symptoms. Of the nine keratopathy patients confirmed by slit-lamp examination, eight had

other eye symptoms, such as pain, blurred vision or other signs. One patient reported no

symptoms before keratopathy was seen by slit-lamp at a pre-planned visit. In these nine

patients with keratopathy, complete resolution was shown at a follow-up visit at least 2

months after nitisinone withdrawal. Eight patients restarted nitisinone at a dose of 2 mg/day

after the recovery; five of those had recurrent symptoms while three were still asymptomatic

at the end of the study (Tables 3, S9).

As expected, serum tyrosine (s-Tyr) concentrations were above 500 µmol/L in all nitisinone-

treated patients. At Month 12, the median value was 925 µmol/L, with a range from 563 to

1530 µmol/L. Decreasing the dose in those who switched from 10 to 2 mg following

keratopathy had a limited effect on s-Tyr, with all patients still having levels above 500

µmol/L (Table S9, Figure S8).

DISCUSSION

The direct cause of morbidity in AKU is HGA accumulation, resulting from genetic HGD

deficiency.22 HGA is therefore a surrogate for a clinically meaningful endpoint in clinical 17

SONIA 2 manuscript supplementary material

trials. In SONIA 2, u-HGA24 decreased markedly in the nitisinone-treated group compared to

controls at all visits after baseline, and the primary objective of the study was thus met.

Nitisinone efficiently decreased both u-HGA24 and s-HGA in nitisinone-treated patients, with

mean values at month 12 decreasing by greater than 98% compared to control for both

variables.

The difference between the groups in change in pigmentation, i.e. the ochronosis, which is

the fundamental patho-physiological process in AKU, was statistically significant. This

indicates that treatment with nitisinone arrested the ochronosis process in the eye and

reversed it in the ear, by decreasing the accumulation of HGA. The crucial importance of

ochronosis in AKU has recently been highlighted.22 Reversal of the disease process in the ear

was seen soon after starting nitisinone, and continued throughout the study duration.

Although reversal of ochronosis in the ear was observed, the decrease in pigmentation was

not total, and it is not clear whether a longer follow-up period would have shown more de-

pigmentation.

A weighted composite score, the cAKUSSI, was used in SONIA 2, as for previously

published data in AKU13,13 This score was employed as it would have been difficult to have a

sufficiently large number of patients to demonstrate a difference in a single end point, such as

lateral rotation of the hip as employed in the NIH trial12, given the ultra-rare nature of AKU,

and the heterogeneous phenotypic severity. In SONIA 2, the baseline cAKUSSI scores were

higher in the nitisinone group than in the controls. This may be because the nitisinone group

was older, with an age difference in medians of three years, and containing more male

patients, who have been shown to experience a more severe disease.19,20

In SONIA 2 a statistically significant effect (difference between the treatment groups in

change from baseline) on cAKUSSI was seen. The cAKUSSI consists of clinically

meaningful outcomes such as fractures, ruptures and joint replacements among others. The

adjusted mean increase in scores was 15·1 in control patients, and 6·7 in the nitisinone group

over the duration of the study, a reduction of nearly 56%, equivalent to a difference of two

joint replacements or one fracture or rupture, if the difference occurred only in a single

feature rather than all the features as seen in the cAKUSSI in SONIA 2. There was a strong

trend toward fewer ruptures in the nitisinone group than in the control, consistent with the

decrease in observed ochronosis scores. Also, there was a trend towards fewer fractures in the

nitisinone group than in the control, in keeping with the statistically significant difference in


change from baseline, in BMD, between the treatment groups, in favour of nitisinone. In

bisphosphonate fracture prevention studies, the increase in BMD is around 5% 23; in SONIA

2, at 48 months the T-scores descreased by 11.9% in the control group, and apparently

increased by 6.1% in the nitisinone group. Previous investigations have shown that stable or

increased bone mineral density after bone-strengthening therapy is associated with fracture-

protection.24,25

Amelioration of pain is a crucial and constant requirement in patients with AKU. In this

regard, the significant decrease in pain from baseline, both in joints and spine, in nitisinone-

treated patients is important. The difference in change from baseline at Month 48 between

treatment groups was, however, only statistically significant for the spine but showed a

positive trend also for joint pain. The difference in pain between the control and treatment

groups could explain the beneficial difference in SF36 and active range of motion between

the two groups.

There were more AEs reported in the nitisinone group than in the control group partly due to

more reports of infections and infestations, eye disorders, and weight gain. There is no

obvious explanation for the higher number of infections and infestations and no known

mechanism by which nitisinone could increase infections. This has not been observed in the

previous experience with nitisinone in HT-1. Tyrosine-related eye disorders were not

unexpected, considering that the patients were not actively managed on a truly low-protein

diet, and that nitisinone-treated patients had s-Tyr concentrations well above 500 µmol/L.

Due to study logistics serum tyrosine was not measured at the time of keratopathy. Serum

tyrosine was only measured during study site visits. In fact, the majority of the nitisinone-

treated patients (86%) did not develop tyrosine-related symptoms despite very high serum

tyrosine. Also, all patients who developed keratopathies did so during the first three years of

the study. During year four there were no new cases.

In patients with keratopathies, lowering the nitisinone dose to 2 mg/day resulted in only

minor decreases in s-Tyr, in agreement with results from previously reported dose-response

study, and recurrent keratopathies were seen in several of those patients.26 No direct

relationship between tyrosine levels and occurrence of these events could be seen. It is likely

that it is the ocular tyrosine concentrations that are key to causing keratopathy rather than

those in the serum.


All patients were asked to reduce their protein intake. Decreasing dietary protein could have

led to consumption of a diet containing more carbohydrates and fat, and this may be the

explanation for the weight gain seen in the nitisinone group, who were probably more likely

to make the dietary change, as they were made aware of the risk of developing tyrosine-

related ocular symptoms. In patients who develop keratopathies, plasma tyrosine levels

should be monitored. A diet restricted in tyrosine and phenylalanine should be implemented

to keep the plasma tyrosine level below 500 µmol/L. In addition, nitisinone should be

temporarily discontinued and reintroduced only when the keratopathy has resolved.

There were some limitations in SONIA 2. The inability to blind patients to nitisinone led to a

trial design that may have affected the results of some subjective variables, including possibly

leading to an under-reporting of AEs in the control group. Morbid events such as fractures

and ruptures were studied in an unselected population. For example, fracture intervention

trials traditionally have been carried out in homogenous populations all having osteoporosis

at recruitment; in SONIA 2 only a proportion had osteopenia at recruitment, affecting the

statistical significance of outcomes such as fractures and others such as ruptures 27. The age

of patients varied from around 25 to over 70 years, with a large variation in disease severity.

There were more dropouts than anticipated and this was due to disabled and immobile

patients having to travel long distances to attend the study. It was especially hard to motivate

the control patients to attend the final visit at Month 48. Further, it was not possible to put in

place dietetic management of the expected tyrosinaemia due to patients being dispersed all

over Europe and Jordan; such a measure could have possibly reduced drop-outs due to

keratopathies in the nitisinone group. In addition, a longer trial could have provided further

insights for this slowly progressive disease, however this was logistically not feasible.

In conclusion, we have shown that nitisinone 10 mg daily offers a ‘biochemical cure’ of

AKU, demonstrated by the marked decreases in urine and serum HGA. For the first time a

randomised research study has shown that nitisinone also reverses the ochronotic process

shown by reduction in ear pigment, and reduces the rate of disease progression revealed by a

lower cAKUSSI score in the nitisinone group.

References

1. O’Brien WM, La Du BN, Bunim JJ. Biochemical, pathologic and clinical aspects of alcaptonuria, ochronosis and ochronotic arthropathy: review of world literature (1584-1962). Am J Med. 1963;34:813-38.


2. Phornphutkul C, Introne WJ, Perry MB, et al. Natural history of alkaptonuria. N Engl J Med. 2002;347:2111-21.

3. Garrod, AE. The incidence of alkaptonuria: A study in chemical individuality. Lancet. 1902;ii:1616-1620.

4. Zannoni VG, Lomtevas N, Goldfinger S. Oxidation of homogentisic acid to ochronotic pigment in connective tissue. Biochim Biophys Acta. 1969;177:94-105.

5. Taylor AM, Boyde A, Wilson PJ, et al. The role of calcified cartilage and subchondral bone in the initiation and progression of ochronotic arthropathy in alkaptonuria. Arthritis Rheum. 2011;63:3887-96.

6. La Du BN, Zannoni VG, Laster L, et al. The nature of the defect in tyrosine metabolism in alcaptonuria. J Biol Chem. 1958;230:251-60.

7. Helliwell TR, Gallagher JA, Ranganath L. Alkaptonuria—a review of surgical and autopsy pathology. Histopath. 2008;53:503-12.

8. Lindstedt S, Holme E, Lock EA, et al. Treatment of hereditary tyrosinaemia type 1 by inhibition of 4-hydroxyphenylpyruvate dioxygenase. Lancet. 1992;340;813-17.

9. McKiernan PJ. Nitisinone for the treatment of hereditary tyrosinemia type I. Expert Opinion on Orphan Drugs. 2013;1:491-497.

10. Anikster Y, Nyhan WL, Gahl WA. NTBC and alkaptonuria. Am J Hum Genet. 1998;63:920-921.

11. Suwannarat P, O’Brien K, Perry MB, et al. Use of nitisinone in patients with Alkaptonuria. Metab. 2005;54:719-28.

12. Introne WJ, Perry MB, Troendle J, et al. A 3-year randomized therapeutic trial of nitisinone in Alkaptonuria. Mol Genet Metab. 2011;103:307-14

13. Ranganath LR, Khedr M, Milan AM, et al. Nitisinone arrests ochronosis and decreases rate of progression of Alkaptonuria: evaluation of the effect of nitisinone in the United Kingdom National Alkaptonuria Centre. Mol Genet Metab. 2018;125:127-134

14. Griffin R, Psarelli EE, Cox TF, et al. Data on items of AKUSSI in Alkaptonuria collected over three years from the United Kingdom National Alkaptonuria Centre and the impact of nitisinone. Mol Genet Metab. 2018;20:1620-1628

15. Ranganath LR, Taylor AM, Gallagher JA, et al. Identification of alkaptonuria in the general population: A United Kingdom experience describing the challenges, possible solutions and persistent barriers. J Inherit Metab Dis. 2011;34:723-30.

16. Taylor AM, Preston AJ, Paulk NK, et al. Ochronosis in a murine model of alkaptonuria is synonymous to that in the human condition. Osteoarthritis Cartilage. 2012;20:880-6.

17. Preston AJ, Keenan CM, Sutherland H, et al. Ochronotic osteoarthropathy in a mouse model of alkaptonuria, and its inhibition by nitisinone. Ann Rheum Dis. 2014;73:284-9.

18. Keenan CM, Preston A, Sutherland H, et al. Nitisinone arrests but does not reverse ochronosis in alkaptonuric mice. JIMD Rep. 2015;24:45-50.


19. Ranganath, LR, Cox, TF. Natural history of alkaptonuria revisited: analyses based on scoring systems. J Inherit Metab Dis. 2011;34:1141-51.

20. Cox T, Ranganath L. A quantitative assessment of alkaptonuria: testing the reliability of two disease severity scoring systems. J Inherit Metab Dis. 2011;34:1153-62.

21. Ranganath LR, Milan AM, Hughes AT, et al. Suitability of nitisinone in alkaptonuria 1 (SONIA 1): an international, multicentre, randomised, open-label, control controlled, parallel-group, dose–response study to investigate the effect of once daily nitisinone on 24-h urinary homogentisic acid excretion in patients with alkaptonuria after 4 weeks of treatment. Ann Rheum Dis. 2016;75:362-367.

22. Ranganath LR, Norman BP, Gallagher JA. Ochronotic pigmentation is caused by homogentisic acid and is the key event in Alkaptonuria leading to the destructive consequences of the disease – a review. J Inherit Metab Dis. 2019;42:776-792.

23.Burnett-Bowie SAM, Saag K, Sebba A, et al. Prediction of Changes in Bone Mineral Density in Postmenopausal Women Treated with Once-Weekly Bisphosphonates. J Clin Endocrinol Metab. 2009;94:1097-1103.

24. Drake MT, Clarke BL, Khosla S. Bisphosphonates: mechanism of action and role in Clinical Practice. Mayo Clin Proc. 2008;83:1032-1045.

25. Riggs BL, Melton LJ. Bone turnover matters: the raloxifene treatment paradox of dramatic decreases in vertebral fractures without commensurate increases in bone density [editorial] J Bone Miner Res. 2002;17:11-14.

26. Olsson B, Cox TF, Psarelli EE, et al. Relationship Between Serum Concentrations of Nitisinone and Its Effect on Homogentisic Acid and Tyrosine in Patients with Alkaptonuria. JIMD Rep. 2015;24:21-7.

27.Black DM, Thompson DE, Bauer DC, et al. Fracture Risk Reduction with Alendronate in Women with Osteoporosis: The Fracture Intervention Trial. J Clin Endocrinol Metab. 2000;85:4118–4124.


https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18775204

https://www.ncbi.nlm.nih.gov/pubmed/31282009

Author contributions

LRR, JAG, NS – pioneered the idea for SONIA 2, secured funding, and managed the study, drafting manuscript and final approval of the manuscript

AKH – finalising SONIA 2 logistics, writing protocol, serving as a medical monitor, drafting manuscript and final approval of the manuscript

AMM, ATH, ASD, ES, BPN, JHH – carried out the metabolic analyses, drafting manuscript and final approval of the manuscript

FG, DB, AS, AZ – carried out the biomarkers and genetic analyses, drafting manuscript and final approval of the manuscript

MK, HB, EL, RF, MF, MB, EW, CW, SV, AM, ST, NB – At RLUH in Liverpool assisted in conduct of study, as well as in advising on the various investigations, assessments and processes used in SONIA 2, drafting manuscript and final approval of the manuscript

JBA, KHLQS – Assisted with conduct of study in Paris, drafting manuscript and final approval of the manuscript

HG, RS, RI, VM, OL, EZ, EV, JS, JR - Assisted with conduct of study in Piešťany, drafting manuscript and final approval of the manuscript

JPD – At University of Liverpool assisted in conduct of study, drafting manuscript and final approval of the manuscript

EEP, TFC – planning and carrying out all statistic aspects of the study, drafting manuscript and final approval of the manuscript; TFC contributed to study design; EEP took over as the Main Trial Statistician after TFC retired

CvK, DL – management and coordination of clinical trial, drafting manuscript and final approval of the manuscript

BO, MR, JSM - contributed to study design and interpretation of the results, drafting the manuscript and final approval of the version to be published

AB - contributed to interpretation of the results, drafting the manuscript and final approval of the version to be published

JCJ, NPR – editing manuscript, as well as planning and securing funding for the study, drafting manuscript and final approval of the manuscript

CS – study conduct and drafting manuscript and final approval of the manuscript


Declaration of interests

BO/JSM/AB/MR reports personal fees and other from Swedish Orphan Biovitrum during the conduct of the study.

CS/NS disclosed that the AKU Society received £10,000 grant towards organising an AKU Patient Workshop

LR reports grants from the European Commission during the conduct of the study

FG reports grant from the EU during the conduct of the study, other from Nordic Bioscience, outside the submitted work.

AKH reports grants from the EU (the FP7 grant), other from Cudos B.V., other from PSR Group B.V., during the conduct of the study.


Acknowledgements

We would like to thank the European Commission for the Framework 7 grant award (DevelopAKUre, project number: 304985) that was crucial to allow SONIA 2 to be carried out.

We would like to thank all patients in SONIA 2, a very demanding four-year participation, as well as the patient societies supporting the patients in the study and for their immense efforts in successfully recruiting these many patients.

We wish to thank the following people (with their affiliation in brackets) for their invaluable support during SONIA 2: Pam Neagle, Heather Rogers, Julia West, Hollie Washington, Leanne A Evans, Shirley Judd (staff members at RLUH); Matthew Gornall, Rebecca Griffin (Statisticians at Liverpool Clinical Trials Centre); Serge Sireau, Simone Sireau (Staff at ALCAP); Na An, Julien Tavet, Christine Broissand, Chantal Deslandre, Laurent Sabbah, Charlotte Celerier, Matthieu Robert (Hôpital Necker-Enfants Malades, Paris Cedex 15, France); Florence Tenenbaum, Catherine Cormier (Hôpital Cochin, Paris Cedex 14, France); Lucia Chalasová, Miroslav Borovský, Miroslav Konečný (National Institute of Rheumatic Diseases, Piešťany, Slovakia); Oliver Timmis, Sorsha Roberts, Hana Ayoob, Eve Whitley, Lesley Harrison (AKU Society, Cambridge, UK); Kristin Önnestam, Carin Junestrand, Karin Grünbaum, Sirkka Thome, Ingrid Palmgren, Erik Sparve, Kristina Lindsten (Sobi); Mohammed Alsbou (Jordan AKU Society); Enrico Selvi (Italy); and Dennis Omtzigt, Jolanda Overwheel (PSR). We wish to thank the independent DMC chaired by Robert Moots, Theresa Barnes, Andy Vail, Patrick McKiernan for their assistance. Finally, we wish to thank the Trial Steering Committee chaired by Alan Shenkin, Wendy Introne, Virginia Kraus, and Duncan Batty for their advice and guidance.


Data-sharing statement for SONIA 2

Data access will be granted in response to qualified research requests. All de-identified individual participant data, for patients with separate consent signed for this purpose, can be made available to researchers. Data will be shared based on: the scientific merit of the proposal – i.e. the proposal should be scientifically sound, ethical, and have the potential to contribute to the advancement of public health as well as the feasibility of the research proposal – i.e. the requesting research team must be scientifically qualified and have the resources to conduct the proposed project. The data files would exclude data dictionaries that require user licenses. Data could be made available following finalized regulatory authority review and end of any data exclusivity periods and ending after 36 months or until corresponding author is able to fulfil this obligation whichever is earlier. Further, the study protocol and statistical analysis plan can be made available. Proposals should be directed to [email protected] to gain access. Data requestors will need to sign a data access agreement.


mailto:[email protected]

Legend to Tables

Table 1. Demographic data and baseline characteristics (FAS)

Table 2. HGA and other continuous efficacy variables in AKUSSI (FAS)

Table 3. Overall summary of adverse events (Safety analysis set)

Legend to figures

Figure 1. SONIA 2 (CONSORT) Flow Diagram

Figure 2. (a) u-HGA 24 (µmol)and (b) s-HGA over time (FAS)

Figure 3. (a) cAKUSSI and (b) mAKUSSI scores over time (FAS)


Tables

Table 1. Demographic data and baseline characteristics (FAS)

Variable StatisticControl(n=69)

Nitisinone(n=69)

Total(n=138)

Age (years) Mean (SD) 47·6 (10·1) 49·0 (11·3) 48·3 (10·7)Body weight (kg) Mean (SD) 74·1 (15·6) 74·8 (14·8) 74·4 (15·1)Height (cm) Mean (SD) 167 (9·5) 166 (9·2) 167 (9·4)Sex n (%) Male 40 (58·0) 45 (65·2) 85 (61·6)Race n (%) White 67 (97·1) 67 (97·1) 134 (97·1)

Black 0 (0·0) 1 (1·4) 1 (0·7)Asian 2 (2·9) 1 (1·4) 3 (2·2)

Centre n (%) Liverpool 21 (30·4) 20 (29·0) 41 (29·7)Piešt'any 32 (42·6) 33 (47·8) 65 (47·1)Paris 16 (23·2) 16 (23·2) 32 (23·2)


Table 2. HGA and other continuous efficacy variables in AKUSSI (FAS)

Baseline Month 12 Month 48HGA

HGA Control Nitisinone Control Nitisinone Control Nitisinoneu-HGA24µmol

Mean(SD)

35394(13869)

35019(13124)

26444(10397)

179(398)

33207(10160)

1569(6220)

Adjusted geometric mean (quotient nitisinone/control)with 95% CI

NA0·003

(0·003 - 0·004)0·005

(0·003 - 0·008)

s-HGAmmol/L

Mean(SD)

28·26(8·66)

30·35(10·98)

28·93(13·04)

0·71(1·63)

37·08(21·03)

2·80(7·33)

Adjusted geometric mean (quotient nitisinone/control)with 95% CI

NA0·01

(0·01 - 0·02)0·02

(0·02 - 0·03)

AKUSSIcAKUSSI(points)

Mean (SD)

80·5(33·4)

87·0(34·2)

80·1 (34·7)

84·5 (33·7)

95·6 (36·0)

93·7 (37·8)

Adjusted mean (difference nitisinone-control) with 95% CI

NA -2·5 (-5·7; 0·7) -8·6 (-16·0; -1·2)

mAKUSSI(points)

Mean (SD)

54·1(24·9)

56·7(26·7)

54·8(25·7)

57·5(26·8)

66·7(29·7)

66·1(31·1)


NA -0·5 (-2·5; 1·6) -3·6 (-9·6; 2·4)

Individual AKUSS itemsEye ochronosis Mean

(SD)14·1 (9·6)

17·3 (9·2)

14·7 (9·0)

16·8 (9·5)

16·4 (9·5)

16·5 (9·3)


NA -0·8 (-1·9; 0·3) -2·5 (-3·9; -1·0)

Ear ochronosis Mean(SD)

3·9 (2·9)

4·1 (2·9)

4·0 (2·8)

4·1 (2·9)

4·0 (2·8)

4·0 (2·9)


NA -0·2 (-0·4; 0·0) -0·5 (-0·9; -0·1)

BMD (T-score)

Mean(SD)

-1·26 (0·98)

-1·3(1·2)

-1·28 (0·98)

-1·39 (1·14)

-1·41 (0·81)

-1·22 (1·17)


NA -0·09 (-0·18; -0·01) 0·14 (0·00; 0·28)

Aortic velocity (m/s)

Mean(SD)

1·6 (0·6)

1·8 (0·8)

1·6 (0·6)

1·8 (0·8)

1·7(0·6)

1·8 (0·8)



NA -0·009 (-0·092; 0·075)

-0·030 (-0·149; 0·089)

Joint pain Mean(SD)

4·6 (3·3)

4·8 (3·0)

4·0 (3·1)

3·5 (2·7)

4·2 (3·3)

3·8 (2·7)


NA -0·9 (-1·6·; -0·1) -0·7 (-1·6; 0·1)

Number of joints with osteoarticular disease

Mean(SD)

6·7(3·2)

6·1(3·1)

6·7 (3·2)

6·4 (3·2)

9·1(3·3)

8·5(3·6)


NA 0·0 (-0·1·; 0·2) -0·1 (-1·3; 1·1)

Spinal pain Mean(SD)

2·3(1·2)

2·3(1·3)

2·0 (1·2)

1·9 (1·3)

2·2(1·4)

1·7(1·3)


NA -0·2 (-0·5·; 0·2) -0·5 (-0·9; 0·0)

Number of spinal regions with osteoarticular disease

Mean(SD)

3·0(2·1)

3·4(2·1)

3·0 (2·1)

3·4 (2·2)

3·5(2·1)

3·7(2·0)

NA 0·0 (-0·3·; 0·4) -0·1 (-0·4; 0·3)

Kyphosis(Cobb angles)

Mean(SD)

35·2(10·2)

36·4(10·6)

35·2 (9·2)

37·1 (10·7)

37·2(7·8)

39·5(9·7)


NA 0·9 (-0·3·; 2·1) 1·0 (-0·8; 2·7)

Scoliosis (Cobb angles)

Mean(SD)

10·5(5·4)

10·8(5·2)

10·5 (4·9)

10·7 (4·5)

11·8(6·6)

12·1 (5·2)


NA 0·0 (-0·6·; 0·6) -0·1 (-1·6; 1·4)

NA: Not applicable


Table 3. Overall summary of adverse events (Safety analysis set)

Control (n=69) Nitisinone (n=69)

n (%) Incidence rate per patient years

n (%) Incidence rate per patient years

No· of patients with at least one AE 57 (82·6) 2·1 59 (85·5) 2·3

No· of AEs 284 400

No· of patients with at least one SAE 26 (37·7) 1·0 27 (39·1) 1·0

No· of SAEs 52 57

No· of patients with at least one related AE a

NA NA 18 (26·1) 0·7

No· of related AEs NA 48

No· of patients who died 0 (0·0) 0·0 2 (2·9) 0·1

No· of patients with AEs leading to study discontinuation

1 (1·4) 0·0 9 (13·0) 0·3

No· of patients with AEs leading to dose reduction

NA NA 8 (11·6) 0·3

a Related to study drug, as judged by the investigator·AE: Adverse Event n: Number of patients observed NA: Not applicable SAE: Serious Adverse EventPercentage calculated on n (patients in treatment groups)


Figure 1. SONIA 2 (CONSORT) Flow Diagram


Assessed for eligibility (n= 139)

Excluded (n= 1) Not meeting inclusion criteria (n= 1) Declined to participate (n= 0) Other reasons (n= 0)

Analysed (n= 69) Excluded from analysis (n= 0)

Lost to follow-up (n= 1)

Discontinued intervention (n= 15)

- 1 adverse event

- 10 consent withdrawn

- 4 other (patients too unwell to travel)

Allocated to control group (n= 69) Received allocated intervention (n= 69) Did not receive allocated intervention (n= 0)

Lost to follow-up (n= 1)

Discontinued intervention (n= 13)

- 9 adverse event

- 4 consent withdrawn

Allocated to nitisinone (n= 69) Received allocated intervention (n= 69) Did not receive allocated intervention (n= 0)

Analysed (n= 69) Excluded from analysis (n= 0)

Allocation

Analysis

Follow-Up

Randomised (n= 138)

Enrollment

Figure 2A. u-HGA 24 (µmol) over time (FAS)

Graph shows geometric mean (95% CI) for baseline and adjusted geometric mean (95% CI) for later time points;Y-axis on log scale.


Figure 2B. s-HGA (µmol/L) over time (FAS)

Graph shows geometric mean (95% CI) for baseline and adjusted geometric mean (95% CI) for later time points;Y-axis on log scale.


Figure 3A. cAKUSSI scores over time (FAS)

Graph shows mean (95% CI) for baseline and adjusted mean (95% CI) for later time points.


Figure 3B. mAKUSSI scores over time (FAS)

Graph shows mean (95% CI) for baseline and adjusted mean (95% CI) for later time points.


Table of Contents. Supplementary material.

SONIA 2 Supplementary material Page No.Table of contents 11.0 Methods 31.1 Patients 31.2 Selection of study population 31.3 Treatment 41.4 Prior and concomitant therapy 41.5. Treatment compliance 42.0 Efficacy and safety assessments 43.0. Safety Assessment 54.0 Protocol amendments 65.0 Ethics committees approvals 66.0 Data handling procedures 67.0 Study oversight 68.0 DMC Oversight 69.0 Statistical analysis 610.0 Addressing bias in SONIA 2 711.0 Results: Selected individual AKUSSI items 711.1 Eye pigmentation 711.2 Ear pigmentation 711.3 Bone mineral density (BMD) of the hip 711.4 Fractures 711.5 Tendon, ligament and muscle ruptures 711.6 Joint pain 711.7 Spine pain 711.8 Range of Motion (Forest Plot) 711.9 SF-36 (Forest Plot) 812.0 References 913.0 Supplementary figures 1013.1 Figure S1. Tyrosine metabolic pathway 1013.2 Figure S2. Suitability Of Nitisinone In Alkaptonuria 2 (SONIA 2) study design 1113.3 Figure S3. Comparison of mean total eye (A) and ear (B) ochronosis scores estimates at baseline and adjusted

means at months 12, 24, 36 and 48 (Error bars represent ±95%CI).12, 13

13.4 Figure S4. Comparison of mean BMD estimates (T-scores) (A), fractures (cumulative numbers) (B) and ruptures (cumulative numbers) (C) at baseline and adjusted means at months 12, 24, 36 and 48 (error bars represent ±95%CI)

14, 15, 16

13.5 Figure S5. Comparison of mean number of joints (A) and spinal regions (B) with pain at baseline and adjusted means at months 12, 24, 36 and 48 (error bars represent ±95%CI)

17, 18

13.6 Figure S6. Forest plots of the change from baseline in SF-36 results yearly from month 12 to month 48 (Full analysis set)

19

13.7 Figure S7. Forest plots of the change from baseline in active range of motion results yearly from month 12 to month 47 (% of maximum normal value) (Full analysis set)

20

13.8 Figure S8. S-TYR (µmol/L) over time (Full analysis set) 2113.9 Figure S9 p-values for treatment differences at 12 months in U-HGA 24 (µmol) (log.) for increasing shift in

nitisinone group (FAS)22

13.10

Figure S10 p-values for treatment differences at 24, 36 and 48 months in change from baseline in total ear pigmentation for increasing shift in nitisinone group

23

13.11

Figure S11 p-values for treatment differences at 36 and 48 months in change from baseline in total eye pigmentation for increasing shift in nitisinone group

24

13.12

Figure S12 p-values for treatment differences at 48 months in change from baseline in osteopenia of the hip (T score) for increasing shift in nitisinone group

25

13.13

Figure S13 p-values for treatment differences at 48 months in change from baseline in number of spinal regions with pain for increasing shift in nitisinone group

26

13.14

Figure S14 p-values for treatment differences at 48 months in change from baseline in cAKUSSI scores for increasing shift in nitisinone group

27

14.0 Supplementary tables 28


14.1 Table S1. Clinical AKU Severity Score Index (cAKUSSI) (procedure shown in italics) 2814.2 Table S2. Patient disposition (All randomised patients) 2914.3 Table S3. Treatments administered 3014.4 Table S4. Schedule of events 3014.5 Table S5. Treatment compliance (FAS, nitisinone-treated only) 3114.6 Table S6. u-HGA24 (µmol), by age category, MMRM (FAS) 3214.7 Table S7. u-HGA24 (µmol), by centre, MMRM (FAS) 3414.8 Table S8. Change from baseline in SF-36, self-evaluated transition (SET) item (FAS) 3614.9 Table S9. Tyrosine corneal keratopathy in SONIA 2 3714.10

Table S10. Adverse Events by System Organ Class and Preferred Term (Safety Analysis Set) 38

14.11

Table S11. Anticipated and Study emergent Adverse Events by System Organ Class and Preferred Term (Safety Analysis Set)

49

14.12

Table S12. Adverse Events by Preferred Term classified by maximum severity in descending order of incidence in the nitisinone group (Safety Analysis Set)

60

14.13

Table S13. Tipping point for u-HGA24 (µmol), MMRM Least Square mean estimates for treatment difference at 12 months (FAS)

83

14.14

Table S14. Tipping point analysis for change from baseline in total ear pigmentation, MMRM Least Square mean estimates for treatment difference at 24, 36 and 48 months (FAS)

85

14.15

Table S15. Tipping point analysis for change from baseline in total eye pigmentation, MMRM Least Square mean estimates for treatment difference at 36 and 48 months (FAS)

87

14.16

Table S16. Tipping point analysis for change from baseline in osteopenia of the hip (T score), MMRM Least Square mean estimates for treatment difference at 48 months (FAS)

89

14.17

Table S17. Tipping point analysis for change from baseline in number of spinal regions with pain, MMRM Least Square mean estimates for treatment difference at 48 months (FAS)

90

14.18

Table S18. Tipping point analysis for change from baseline in cAKUSSI scores, MMRM Least Square mean estimates for treatment difference at 48 months (FAS)

91

15.0 SONIA 2 protocol 92


1.0. METHODS1.1. Patients

Patients with a well-documented AKU verified by increased urine HGA excretion and who were at least 25 years old were eligible for inclusion in the study. Details of inclusion and exclusion criteria are described in this supplementary appendix. In all patients, diagnosis of AKU was also confirmed by HGD gene mutation identification performed during the study (data not shown). 140 AKU patients were to be randomised, equally distributed to two groups, to receive either nitisinone or no treatment (control).

1.2. Selection of study populationInclusion criteriaA patient needed to fulfil the following criteria in order to be included in the study:

1. Diagnosis of AKU.

2. Any clinical manifestations of AKU, such as clinical ochronosis or chronic back/joint pain.

3. Age ≥ 25 years.

4. Willing and able to visit the investigational site for study visits.

5. Signed written informed consent given.

Exclusion criteriaThe presence of any of the following excluded a patient from inclusion in the study:

1. Treatment with nitisinone within 3 months of randomisation.

2. Participation in another clinical study within 3 months of randomisation.

3. Known allergy to nitisinone or any of the constituents of the investigational product.

4. Female patient of child-bearing potential not using a reliable method of contraception.

5. Currently pregnant or lactating.

6. Current malignancy.

7. Uncontrolled hypertension (blood pressure greater than 180 mmHg systolic or greater than 95 mmHg diastolic).

8. Unstable cardiovascular disease.

9. Serum potassium < 3·0 mmol/L.

10. eGFR < 60 mL/min/1·73 m2.

11. ALT > 3 x upper limit of normal.

12. Haemoglobin < 10·0 g/dL.

13. Platelets < 100 x 109/L.

14. Total white blood count < 3·0 x 109/L or neutrophil count < 1·5 x 109/L.

15. History of alcohol or drug abuse.

16. Psychiatric or somatic illness that interferes with compliance or communication with health care personnel.

17. Foreseeable inability to cooperate with given instructions or study procedures.

18. Any other medical condition which in the opinion of the investigator makes the patient unsuitable for inclusion.

Withdrawal of subjects from treatment or studyA patient was withdrawn from treatment if the patient developed the following signs or symptoms which were judged by the investigator to be related to elevated tyrosine:

Developed ocular signs or symptoms, or

Developed a skin rash (including hyperkeratotic lesions)


Patients withdrawn due to an adverse event could not re-enter the study. Patients temporarily withdrawn from treatment due to suspected tyrosine toxicity could, however, continue in the study on a lower dose of nitisinone (2 mg) at the discretion of the investigator and only once all signs and symptoms of tyrosine toxicity had resolved. Patients who were temporarily withdrawn due to a suspected tyrosine toxicity, but not later confirmed, could continue in the study on the 10 mg dose. In both cases, dates for temporary withdrawal of nitisinone, the date when treatment is reinitiated, and the dose used after the pause, were recorded in the eCRF.

A patient was also to be withdrawn from the study if the he/she:

Became pregnant.

Developed allergy to nitisinone or any of the constituents of the investigational product.

ALT increased to > 3 x upper limit of normal.

Platelets decreased to < 100 x 109/L.

Total white blood count decreased to < 2·5 x 109/L or neutrophils < 1·0 x 109/L.

Furthermore, a patient was to be withdrawn from the study treatment if, in the opinion of the investigator, it was medically necessary, or if it was the wish of the patient.

1.3. Treatment (Table S1)

The dose used in SONIA 2 was 10 mg oral daily, based on the results of the SONIA 1 study, where daily urine HGA was decreased by 99·4 % at nitisinone 8 mg.1 In the short study of SONIA 1, a liquid nitisinone suspension was employed. For the much longer SONIA 2 study, 10 mg nitisinone (Orfadin®) capsules, closest to the 8 mg liquid suspension used in SONIA 1, were taken by patients first thing in the morning. A dose of 2 mg was used when a patient developed tyrosine-related adverse events, such as corneal keratopathy.

1.4. Prior and concomitant therapy

Patients were allowed to continue on any chronic medication and any changes during the study were recorded, from the time of the screening and randomisation visit until the follow-up telephone call. Patients were not allowed to have used nitisinone within the 60 days prior to randomisation.

1.5. Treatment compliance

Product accountability records were kept by the pharmacy and investigator. All unused IMP was returned to the clinical study sites and measured. The amount consumed was compared to the expected consumption for the randomised dose.

2.0. Efficacy and safety assessments

Detailed description of all efficacy and safety assessments is provided in the supplied protocol. The Schedule of Events for the study is provided in Table S2.

Patients in the control arm underwent all the study procedures and investigations except they did not take nitisinone. All procedures were harmonised across all three study sites right at the beginning. All patients were to be evaluated with standard history taking and physical examination including those specific for AKU. For those assessments which were operator-dependent, the same persons were to conduct the test throughout the study, where possible. The persons performing these assessments were kept blinded as far as possible. Also, whenever possible, a central blinded assessor evaluated the results. Echocardiography, scintigraphic scans, X-rays, and photographs of eyes and ears were evaluated by completely blinded assessors.

A timed 24-h urine ((u-HGA24) was collected in bottles containing 30 mL of 5N H2SO4. Fasting blood samples were collected at each visit and an aliquot also acidified as previously described to stabilise the serum HGA. 1

Urine was analysed for HGA, creatinine and urea. Creatinine was analysed by the Jaffe reaction (Roche Doagnostics, Germany). Serum analyses included HGA, tyrosine and nitisinone. The concentrations of tyrosine and HGA in serum and urine were measured by liquid chromatography tandem mass spectrometry. All analyses were performed on an Agilent 6490 Triple Quadrupole mass spectrometer with Jet-Stream electrospray ionisation coupled with an Agilent 1290 infinity II Ultra High-Performance Liquid Chromatography (UHPLC) pump and HTC autosampler. All serum and urine quantitation analyses were performed by the Department of Clinical Biochemistry and Metabolic Medicine at the Royal Liverpool University Hospital as described previously.2,3


Photographs of the eyes and ears were carried out at each visit. Pigmentation of eyes and ears was assessed using clinical photographs. Photographs were taken using standardised conditions as far as possible. The photographs included pictures of each eye (temporal and nasal aspects) separately, and of each ear. Plain radiographs, anteroposterior and lateral views X-rays, including the whole spine and pelvis (from Cobb angle measurements for kyphosis and scoliosis), were performed. Standard abdominal ultrasonography was used to assess renal and prostate stones; in addition, patients were asked to record details about possible episodes of renal or prostate stones between visits in a diary. Bone densitometry using Dual Energy X-Ray Absorptiometry was measured at one hip, usually the non-dominant one (Table 1). A transthoracic echocardiogram assessed cardiac function and extent of valvular disease annually. Transthoracic echocardiography was used to assess aortic stenosis and sclerosis. The echocardiograms were performed according to British Society of Echocardiography Guidelines for Valve Quantification.4,5 The echocardiograms were evaluated by a central blinded assessor. In addition to the categorical stratifications of aortic valve involvement, both the peak aortic velocity and the aortic valve area, calculated by the continuity equation method were employed for assessment. Audiometry was used to assess hearing loss (Table 1); both ears were tested through a range of frequencies (0.5, 1, 2, 3, 4, 6 and 8 kHz) and hearing loss (dB) recorded for each frequency, via a series of sound exposures. All fractures and ruptures were to be reported by the patient. At the baseline visit, the patient was asked about any previous adult fractures and ruptures. New fractures and ruptures occurring after study start were reported by the patient in a diary.

Musculoskeletal system was evaluated for symptoms (pain) in 14 joint areas (hips, knees, ankles, feet, shoulders, elbows and hands) and 4 spine areas (cervical, thoracic, lumber and sacroiliac); a score of 1 was given for presence of pain in the joint areas within the previous week and a score of 2 was given for pain in spine areas similarly. A scintigraphic scan was performed at the initial visit and each subsequent visit; this was a 18FPETCT at the Liverpool site and Technetium 99m-methyl diphosphonate at the Piešťany and Paris sites; joint and spine areas were scored for involvement. A score of 2 each was given for presence of tracer uptake in the joint areas already described and a score of 4 each was given for pain in spine within the previous week (cervical, thoracic, lumber and sacroiliac), and associated areas (costochondral and pubic symphysis) similarly.

Full ocular examinations including slit lamp examination and corneal photographs were completed at each visit. Otoscopic examination was carried out with photographs of tympanic membrane performed. Advice on limiting protein intake was provided and reinforced by a diet sheet; a dietician was not involved since the previous randomised study did not reveal significant corneal toxicity.6

3.0. Safety Assessment

At each visit, adverse events (AEs) and laboratory values were recorded. Routine laboratory processes at each clinical study site were employed to measure biochemistry and haematology profiles. AEs included abnormal test findings (e.g. laboratory analysis results, vital signs or ECG) that the investigator considered clinically significant and/or that led to a medical/surgical intervention including withdrawal of IMPs or discontinuation from the study. If the test was associated with accompanying symptoms, the symptom, not the test result, was recorded as an AE. All directly observed AEs, and all AEs spontaneously reported by the patient, were recorded in the eCRF. The question asked was “Have you had any health problems since your last clinic visit?”.

Tyrosine can occasionally cause idiosyncratic reversible corneal dendritiform keratopathy and skin rash. Elevated tyrosine may lead to ocular signs and symptoms, including corneal ulcers, corneal opacities, keratitis, conjunctivitis, eye pain, and photophobia.

At the start of the study, all patients were provided with instructions to contact the investigator and visit the investigational site as soon as possible if they developed a skin rash or photophobia, eye pain, or signs of inflammation such as redness, swelling, or burning of the eyes during the study. In case a patient developed such signs or symptoms, this was reported and followed up as an AE.

Nitisinone was withdrawn in patients who developed signs of tyrosine-related AEs. If feasible, once the symptoms had resolved (minimum 2 months after temporary withdrawal), nitisinone was reintroduced at a lower dose (2 mg/day). Alternatively, the patient was withdrawn from the study. If ocular tyrosine-related symptoms reappeared on the lower dose, nitisinone was permanently withdrawn and the patient was to be monitored until the symptoms resolved. Nitisinone was not reintroduced again. Patients who were temporarily withdrawn due to a suspected, but not later confirmed, tyrosine-related AE, continued in the study on the 10 mg dose.

Other safety monitoring included laboratory tests (clinical chemistry and haematology), electrocardiogram, and vital signs (blood pressure, pulse, temperature). Patients completed a safety monitoring questionnaire between the scheduled site visits, at months 6, 18, 30 and 42 in order to collect safety information specifically concerning


possible tyrosine-related AEs. The patients were asked if they had had any problems with their eyes or skin since their last visit to the study site.

Patients were asked to record information about any emerging AKU-related events in a diary (event and date, treating physician’s name and institution) on the following items as they occurred, namely fractures, muscle/tendon/ligament ruptures, renal stones, prostate stones, arthroscopies, and joint replacements.

A corneal eye examination was performed at all scheduled visits to the clinic. This consisted of corneal photographs with or without slit-lamp examination.

4.0. Protocol amendments: The amendments mostly contained corrections and clarifications. There were no major changes that affected the performance of the study in any important way. Amendment 1 added results from SONIA 1 in the background and defined the dose. This information was missing when Version 1 was written. Amendment 2 only contained corrections and clarifications. In amendment 3, MRI was reclassified from a secondary to an exploratory assessment and changes to the study staff were presented, along with further clarifications.

5.0. Ethics committees approvals: The reference numbers for the ethics approvals are as follows:

EC Liverpool (NRES Committee North-West – Liverpool Central) Reference number: 13/NW/0567.

EC Piešťany (NURCH Ethica Committee, National Institute of Rheumatic Diseases, Ivana Krasku 4,92101 Piešťany, Slovak Republic) Reference number: 04196/0029/001/001.

EC Paris (EC Ile De France II, hospital Necker 149 Rue de Sevres 75 743 Paris Cedex 15, Porte N2, 1er etage, France). Reference number: 2013-08-08.

6.0. Data handling procedures: The data for the SONIA 2 trial has been collected using an electronic Case Report Form (eCRF). The eCRF is developed in Viedoc 3, a 21 CFR Part 11 compliant web-based software, based on the study protocol. The set-up was approved after User Acceptance Testing by Sponsor and CRO. Data was entered by the Principal investigators or designees. The completed data was checked on site with the source for completeness and accuracy. Central assessors, experts on specific examinations, reviewed specific tests and provided the results. These results were also captured in the eCRF. Principal investigators confirmed all data to be complete and correct by signing off all completed data.

Medical History terms and Adverse Events were reported in the eCRF and coded with the MSSO MedDRA dictionary version 21.1. Concomitant medication was coded with the ATC codes from the WHO drug dictionary ATC/DDD Index 2019. All coding was approved by a Medical Doctor and Pharmacist.

Data exports were provided to the Trial Statistician from the University of Liverpool (UoL) in SAS format. Once the data extract was received by the Trial statistician, then any data handling and analysis was performed in SAS and datasets were stored in a secure UoL server.

7.0. Study oversight

The study was conducted at three sites, Liverpool (United Kingdom), Paris (France) and Piešťany (Slovakia) from May 2014 to February 2019. Data were recorded by investigators at each site, collected, and monitored by the Contract Research Organisation PSR Group (Amsterdam, Netherlands). The protocol and amendments were approved by the relevant ethics review boards and national regulatory authorities. Written informed consent was obtained from all patients before any study procedures. An independent Data and Safety Monitoring Board was assigned to evaluate the safety data.

8.0. DMC Oversight: DMC meetings were held once yearly. The members of the DMC were Professor RJ Moots (Chair), Dr Andy Vail (Independent Statistician), Dr Theresa Barnes (Rheumatologist) and Dr Patrick McKiernan (Metabolic Physician). No DMC review resulted in a protocol amendment. The remit of the DMC was to consider only safety as the intention was always to complete the 4-year duration if safety was acceptable regardless of efficacy data at 12 months. The DMC charter reflected this decision.

9,0. Statistical analysis In addition to the Full Analysis Set (FAS), a Per-protocol analysis set (PP), including all randomised patients who had no important protocol violations or deviations that could affect the primary end point, was a subset of FAS. However, no analyses were conducted on the PP set as the proportion of patients included within the data set was more than 85 % of FAS. The Safety Analysis Set was used for the analysis of safety variables. All


randomised patients were included with the exception of patients randomized to nitisinone who never received any study medication.

An interim analysis occurred after all patients completed the first 12 months in the study. This included a complete set of analyses of all variables up to 12 months.

10.0. Addressing bias in SONIA 2: Randomisation bias excluded as far as possible by rigorous attention to masking and concealment. We could not blind patients as already explained and therefore there is the possibility of bias due to patient expectations especially in relation to pain scores, quality of life questionnaires and possible active range of motion. Drop-outs were not followed up and it is unknown if any bias was introduced. Intention-to-treat analysis was followed as described a priori in statistical analysis plan. All data collected in drop-outs were analysed. Despite involvement of industry partners, every care was taken to minimise the effect of competing interests. All data including positive and negative results has been declared to minimise publication bias.

11.0. Results: Selected individual AKUSSI items

11.1. Eye pigmentation: At baseline, the mean pigmentation score was higher in the nitisinone group than in the control group. From month 12 to month 48 there was a steady increase in eye pigmentation scores in the control group while the scores remained at a fairly constant level in the nitisinone group. The difference between the two groups was significant at month 48 (p=0·0011) (Tables 1 & S1, Figure 5A).

11.2. Ear pigmentation: At baseline, the mean ear pigmentation score was comparable for the two treatment groups. There was a steady increase in ear pigmentation in the control group, while there was a decrease in the nitisinone group. The adjusted mean difference in the change from baseline was significant at all visits (Tables 1 & S1, Figure 5B).

11.3. Bone mineral density (BMD) of the hip: At baseline, there was a slightly higher number of patients with lower than normal BMD (T-scores < -1·0) in the nitisinone group compared to the control group. At month 48, there was a significant difference in favor of nitisinone between the treatment groups, in changes in T-scores from baseline (p=0·05) (Tables 1 & S1, Figure 6A).

11.4. Fractures: At baseline, the same number of adult fractures were reported for both treatment groups. At month 48, the number of patients who experienced fractures after baseline was numerically higher in the control group than in the nitisinone group. This difference was not statistically significant (p=0·16). There was, however, a trend towards an increase over time in the number of fractures in the control group compared to nitisinone-treated patients (Tables 1 & S1, Figure 6B).

11.5. Tendon, ligament and muscle ruptures: At baseline, more patients in the control group had experienced at least one rupture compared to patients in the nitisinone group. Over time, there was a steady increase in the control group in cumulative number of new ruptures since baseline, while from month 12 there was only one new rupture in the nitisinone group, but the difference was not significant (Tables 1 & S1, Figure 6C).

11.6. Joint pain: At baseline, the mean (SD) number of joints with pain was comparable in the two treatment groups, namely 4·6 (3·3) and 4·8 (3·0) joints, in the control and nitisinone groups respectively. At month 48, there was a decrease in the number of joints with pain in the nitisinone group; the adjusted mean [95% CI] change from baseline was -1·0 [-1·6; -0·3] joints. In the control group, the corresponding value was -0·2 [-0·9; 0·4]. The difference between the two groups did not, however, reach significance although it should be noted that the observed difference was seen at all post-baseline visits (Tables 1 & S1, Figure 7A).

11.7. Spine pain: At baseline, the mean (SD) number of spinal regions with pain was comparable in the two treatment groups; 2·3 (1·2) and 2·3 (1·3) in the control and nitisinone groups respectively. There was a significant decrease in the number of spinal regions with pain in the nitisinone group at month 48 compared to baseline (p=0·05); the adjusted mean [95% CI] change from baseline was -0·6 [-0·9; -0·3] regions. In the control group, the corresponding value was -0·2 [-0·5; 0·2]. The difference between the two groups did not reach statistical significance (Tables 1 & S1, Figure 7B).

11.8. Range of Motion (Forest Plot): Overall, there was a trend in favour of nitisinone in both the passive and the active range of motion of the joints at Months 12, 24, and 36 but this positive trend was no longer seen at Month 48. There was a statistically significant difference in favour of nitisinone between the treatment groups in the change from baseline in the passive range of motion in the worst ankle at baseline at Month 12 and Month 36, in the active range of motion for both ankles at Month 12, and in the worst ankle at Month 36.


11.9. SF-36 Forest plot: The results are summarized in Forest plots showing the results year by year. Overall, the results favour nitisinone. For the different components and domains there were statistically significant differences in change from baseline in favour of nitisinone for the change from baseline in:

Mental health at Months 12, 24 and 36.

General health perception domain at Months 24 and 36 (and with a p-value of 0.065 at Month 48).

Mental role functioning domain at Months 12 and 36 (and with a p-value of 0.057 at Month 24).

Social role functioning domain and Months 12 and 24 (and with a p-value of 0.081 at Month 36).


12. References

1. Ranganath LR, Milan AM, Hughes AT, et al. Suitability of nitisinone in alkaptonuria 1 (SONIA 1): an international, multicentre, randomised, open-label, no-treatment controlled, parallel-group, dose–response study to investigate the effect of once daily nitisinone on 24-h urinary homogentisic acid excretion in patients with alkaptonuria after 4 weeks of treatment. Ann Rheum Dis 2016; 75: 362-367.

2. Hughes AT, Milan AM, Christensen P, et al. Urine homogentisic acid and tyrosine: simultaneous analysis by liquid chromatography tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2014; 963: 106-112.

3. Hughes A.T, Milan AM, Davison AS, et al. Serum markers in alkaptonuria: simultaneous analysis of homogentisic acid, tyrosine and nitisinone by liquid chromatography tandem mass spectrometry. Ann Clin Biochem 2015; 52(Pt 5): 597-605.

4. Masani, N. Echocardiography: Guidelines for valve quantification. 2008; Available from:http://www.bhf.org.uk/plugins/PublicationsSearchResults/DownloadFile.aspx?docid=9b5b813e-5c63-45ef-84d4-23fab72ac5a0&version= 1&title=Echocardiographyguidelinesforvalvequantification&resource=G408

5. Bonow RO, Carabello BA, Chatterjee K, et al. Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118: 523-661.

6. Introne WJ, Perry MB, Troendle J, et al. A 3-year randomized therapeutic trial of nitisinone in Alkaptonuria. Mol Genet Metab 2011; 103: 307–14.


http://www.bhf.org.uk/plugins/PublicationsSearchResults/DownloadFile.aspx?docid=9b5b813e-5c63-45ef-84d4-23fab72ac5a0&version=%201&title=Echocardiographyguidelinesforvalvequantification&resource=G408



13.0. Figures

13.1.Figure S1. Tyrosine metabolic pathway – highlighting (1) the metabolic fate of tyrosine in health, (2) site of the enzyme defect observed in Alkaptonuria, homogentisate 1,2-dioxygenase (HGD EC 1.13.11.5) and Hereditary Tyrosinaemia type 1, fumarylacetoacetate hydrolase (FAH EC 3.7.1.2) , and (3) the site where nitisinone inhibits 4-hydroxyphenylpyruvate dioxygenase (HPPD EC 1.13.11.27) activity.


13.2. Figure S2. Suitability Of Nitisinone In Alkaptonuria 2 (SONIA 2) study design. The study consisted of two main periods: treatment and follow-up. After screening, patients were randomised at baseline (1:1) to control, and oral daily doses of nitisinone of 10 mg. The treatment period consisted of 48 months, during which study drug was administered. At 49 months a follow-up telephone call concluded the study (Abbreviations: S+R=screening, baseline and randomisation visit; F=final treatment visit; T=telephone follow-up visit). Various assessments were carried out at visits to study sites. In between study site visits, patients completed safety questionnaires at 6, 18, 30 and 42 months and returned by post.


13.3.Figure S3A. Comparison of mean total eye (A) and ear (B) ochronosis scores estimates at baseline and adjusted means at months 12, 24, 36 and 48 (Error bars represent ±95%CI).


13.3. Figure S3B. Comparison of mean eye (A) and ear (B) ochronosis scores estimates at baseline and adjusted means at months 12, 24, 36 and 48 (Error bars represent ±95%CI).


13.4. Figure S4A. Comparison of mean BMD estimates (T-scores) (A), fractures (cumulative numbers) (B) and ruptures (cumulative numbers) (C) at baseline and adjusted means at months 12, 24, 36, and 48 (Error bars represent ±95%CI).


13.4. Figure S4B. Comparison of mean BMD estimates (T-scores) (A), fractures (cumulative numbers) (B) and ruptures (cumulative numbers) (C) at baseline and adjusted means at months 12, 24, 36, and 48 (Error bars represent ±95%CI).


13.4. Figure S4C. Comparison of mean BMD estimates (T-scores) (A), fractures (cumulative numbers) (B) and ruptures (cumulative numbers) (C) at baseline and adjusted means at months 12, 24, 36, and 48 (Error bars represent ±95%CI).


13.5. Figure S5A. Comparison of mean number of joints (A) and spinal (B) regions with pain at baseline and adjusted means at

months 12, 24, 36 and 48 (Error bars represent ±95%CI).


13.5. Figure S5B. Comparison of mean number of joints (A) and spinal (B) regions with pain at baseline and adjusted means at months 12, 24, 36 and 48 (Error bars represent ±95%CI).


13.6. Figure S6. Forest plots of the change from baseline in SF-36 results yearly from Month 12 to Month 48 (Full analysis set)

Graphs show adjusted mean (95% CI) change from baseline between nitisinone treated and untreated patients


13.7. Figure S7. Forest plots of the change from baseline in active range-of-motion results yearly from Month 12 to Month 48 (% of maximum normal value) (Full analysis set)

Graphs show adjusted mean (95% CI) change from baseline between nitisinone treated and untreated patients


13.8. Figure S8. s-TYR (µmol/L) over time (FAS)


13.9. Figure S9.1. p-values for treatment differences at 12 months in U-HGA 24 (µmol) (log.) for increasing shift in nitisinone group (FAS)

1700 1750 1800 1850 1900

Percentual shift in U-HGA (log.)

0.03

0.04

0.05

0.06

p-va

lue

Created using lab_urine.sas and rand.sas version 1 in S:\Statistical Documents\AKU\Trials\SONIA 2\Final analysis\Final programming\Data by MG on 13JAN20:11:06:32.


13.10. Figure S10. p-values for treatment differences at 24, 36 and 48 months in change from baseline in total ear pigmentation for increasing shift in nitisinone group

Percentual shift in total ear pigmentation

P-va

lue

Month 48

Month 36Month 24

0 10 20 300 10 20 30

0.0

0.2

0.4

0.6

0.8

0.0

0.2

0.4

0.6

0.8

Created using akussi1.sas, akussi2.sas, akussi3.sas and rand_fas.sas version 1 in S:\Statistical Documents\AKU\Trials\SONIA 2\Final analysis\Final programming\Data by EP on 08JAN20:16:15:13.


13.11. Figure S11. p-values for treatment differences at 36 and 48 months in change from baseline in total eye pigmentation for increasing shift in nitisinone group

Percentual shift in total eye pigmentation

Month 48Month 36

0 5 10 15 200 5 10 15 20

0.000

0.025

0.050

0.075

0.100

0.125

P-va

lue



13.12. Figure S12. p-values for treatment differences at 48 months in change from baseline in osteopenia of the hip (T score) for increasing shift in nitisinone group

-10.0 -7.5 -5.0 -2.5 0.0 2.5 5.0

Percentual shift in osteopenia of the hip (T score)

0.02

0.04

0.06

0.08

0.10

0.12

P-va

lue



13.13. Figure S13. p-values for treatment differences at 48 months in change from baseline in number of spinal regions with pain for increasing shift in nitisinone group

0 5 10 15 20

Percentual shift in number of spinal regions with pain

0.03

0.04

0.05

0.06

P-va

lue



13.14. Figure S14. p-values for treatment differences at 48 months in change from baseline in cAKUSSI scores for increasing shift in nitisinone group

0 2 4 6 8 10

Percentual shift in cAKUSSI scores

0.02

0.04

0.06

0.08

P-va

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14.0. Supplementary tables

14.1. Table S1. Clinical AKU Severity Score Index (cAKUSSI)

Table S1. Clinical AKU Severity Score Index (cAKUSSI) (procedure shown in italics)

Feature Score Feature Score

CLINICAL FEATURES (excluding spine and joint)

Eye pigment (Standardised Medical Photography)

Right eye (Nasal) Slight 4 Left eye (Nasal) Slight 4

Marked 8 Marked 8

Right eye (Temporal)

Slight 4 Left eye (Temporal)

Slight 4

Marked 8 Marked 8

Ear pigment (Standardised Medical Photography)

Right ear Slight 2 Left ear Slight 2

Marked 4 Marked 4

Stones (Ultrasonography of abdomen and pelvis)

Prostate Stones Per episode 4 Renal Stones Per episode 4

Musculoskeletal

Bone mineral density of hipDual Energy X-Ray Absorbtiometry (DEXA)

Grade (T-scores)≥ -1·0-1·0 to -1·7-1·8 to -2·4< -2·5

0246

Adult fracture (Questionnaire)

Per fracture 8 Ligament rupture Per rupture 8

Tendon rupture(Questionnaire)

Per rupture 8 Muscle rupture Per rupture 8

Heart (Transthoracic echocardiography)

NormalAortic sclerosis

04

Aortic valve stenosis MildModerateSevere

81012

ENT (Audiometry)

Hearing impairment Grade on audiometry (dB loss), per ear≤ 2021-35 (mild)36-60 (moderate)>60 (severe)

01 2 4

Dark tympanic membrane(Otoscopic examination)

Per ear 6

JOINT FEATURES

Clinical joint pain (1 for each large joint area; hips, knees, ankles, feet, shoulders, elbows, wrists & hands - right and left sides = 14 joint areas) (Questionnaire)

Max 14

Non-spine joint disease (2 for each large joint area; hips, knees, ankles, feet, shoulders, elbows, wrists & hands - right and left sides = 14 joint areas) (either Technetium 99m-methyl diphosphonate or 18FPETCT)

Max 28

Arthroscopies (Questionnaire) 2 each

Joint replacements (Questionnaire) 4 each

SPINE FEATURES

Clinical spinal pain (2 each for cervical, thoracic, lumbar, sacroiliac) (Questionnaire) Max 8


Table S1. Clinical AKU Severity Score Index (cAKUSSI) (procedure shown in italics)

Feature Score Feature Score

Spine disease (4 each for pubic symphysis, ribs, sacroiliac, lumbar, thoracic, cervical)

(either Technetium 99m-methyl diphosphonate or 18FPETCT)

Max 24

Kyphosis(X-Ray Lateral Spine and pelvis)

(Cobb angles)<4545.-60>60

036

ScoliosisX-Ray antero-posterior Spine and pelvis

(Cobb angles)<55-2021-30>30

0246

14.2. Table S2. Patient disposition (All randomised patients)

Number of patients (%)Control(n=69)

Nitisinone(n=69)

Total(n=138)

Randomised 69 (100·0) 69 (100·0) 138 (100·0)

Completed 53 (76·8) 55 (79·7) 108 (78·3)Discontinued before 48-month visit 16 (23·2) 14 (20·3) 30 (21·7)

Primary reason for discontinuation Adverse Event 1 (1·4) 9 (13·0) 10 (7·2)

Consent withdrawn 10 (14·5) 4 (5·8) 14 (10·1) Lost to follow-up 1 (1·4) 1 (1·4) 2 (1·4)

Other 4 (5·8) 0 (0·0) 4 (2·9)


14.3. Table S3. Treatments administered

Patients Investigational product

Dosage form Route Daily dose Dosage

regimenControls None Not

applicableNot applicable

Not applicable

Not applicable

Treated Nitisinone (Orfadin®)

Capsules Oral 10 mg Once daily

Treated, after recovery from tyrosine-related ocular AEs

Nitisinone (Orfadin®)

Capsules Oral 2 mg Once daily

14.4. Table S4. Schedule of events

Visit 1Month 0

Visit 2Month 3

Visit 3Month 12

Visit 4Month 24

Visit 5Month 36

Visit 6Month 48

Visit 7Month 491

Informed consent XDemographics XMedical history XPhysical examination2 X X X X X XInclusion/exclusion criteria XRandomisation XVital signs X X X X X X12-lead ECG X X X X X XHematology X X X X X XClinical chemistry X X X X X XPregnancy test3 X X X X XCorneal eye assessment X X X X X XTreatment with nitisinone (treated group only)24 h urine for HGA X X X X X XsHGA, s-Tyr X X X X X XAKUSSI assessments X X X X X

Photographs for eye and ear pigmentation X X X X X

Ultrasound abdomen and pelvis for prostate and renal stones

X X X X X

Bone mineral density of the hip X X X X X

Adult fractures X X X X XTendon, ligament and muscle ruptures X X X X X

Echocardiogram for aortic stenosis and sclerosis X X X X X

Audiometry for hearing impairment X X X X X

Otoscopy with photography of eardrum X X X X X

Joint and spine pain X X X X XScintigraphic scan of joints and spine X X X X X


Visit 1Month 0

Visit 2Month 3

Visit 3Month 12

Visit 4Month 24

Visit 5Month 36

Visit 6Month 48

Visit 7Month 491

X-Ray full spine for kyphosis and scoliosis X X X X X

Arthroscopies and joint replacements X X X X X

Dispense nitisinone (treatment group only) X X X X X

Drug accountability (treatment group only) X X X X X

Prior and concomitant medication X X X X X X X

Adverse Events5 X X X X X X X1) Telephone contact only.2) Including weight and height.3) Women of childbearing potential.4) All SAEs reported to the follow-up visit (Visit 7), or at least 28 days after Visit 6, and thereafter only

SAEs judged to be related to the IMP.

14.5. Table S5. Treatment compliance (FAS, nitisinone-treated only)

Visit % of planned consumptionNitisinone(n=69)

Month 12 n 69≥ 80%, n (%) 69 (100·0)< 80%, n (%) 0 (0·0)

Month 24 n 66≥ 80%, n (%) 66 (95·7)< 80%, n (%) 0 (0·0)

Month 36 n 62≥ 80%, n (%) 62 (89·9)< 80%, n (%) 0 (0·0)

Month 48 n 59≥ 80%, n (%) 59 (85·5)< 80%, n (%) 0 (0·0)

n: Number of patients observedPercentage of patients calculated on n (patients in treatment groups)


14.6. Table S6. u-HGA24 (µmol), by age category, MMRM (FAS)

≤ 55 years >55 years

Visit StatisticControl(N=50)

Nitisinone(N=46)

Control(N=19)

Nitisinone(N=23)

Baseline Mean 36295·0 36595·0 33021·4 31865·9

SD 14510·4 13967·3 12051·3 10852·3

Geometric mean 33625·0 34172·1 30541·6 29594·2

Month 3 Adjusted geometric meana

27338·7 119·6 25176·1 71·5

95% CI 21967·7; 34022·9 95·5; 149·6 16727; 37894 49·5; 103·4

Adjusted geometric mean (quotient nitisinone/untreated)

0·004 0·003

95% CI 0·003; 0·006 0·002; 0·005

p-value* <0·001 <0·001


27854·4 109·9 27406·4 58·4

95% CI 22921·4; 33849·0 90·0; 134·1 18964; 39607 42·1; 81·0


0·004 0·002

95% CI 0·003; 0·005 0·001; 0·003

p-value* <0·001 <0·001


26744·8 199·7 27445·4 84·9

95% CI 19332·2; 36999·8 142·9; 279·0 16885; 44611 55·8; 129·3


0·007 0·003

95% CI 0·005; 0·012 0·002; 0·006

p-value* <0·001 <0·001


31085·6 237·8 24886·5 82·4

95% CI 22021·9; 43879·7 165·7; 341·3 15405; 40205 53·7; 126·6


0·008 0·003

95% CI 0·005; 0·013 0·002; 0·006

p-value* <0·001 <0·001


≤ 55 years >55 years


Nitisinone(N=46)

Control(N=19)

Nitisinone(N=23)


33032·6 236·4 29042·0 71·9

95% CI 22793·2; 47871·8 160·6; 348·1 19358; 43571 50·1; 103·2


0·007 0·002

95% CI 0·004; 0·012 0·001; 0·004

p-value* <0·001 <0·001a Based on entire FAS.*Difference between treatments in each age category is analysed using a mixed model with repeated measurements (MMRM).


14.7. Table S7. u-HGA24 (µmol), by centre, MMRM (FAS)

Liverpool Piešťany Paris


Nitisinone(N=20)

Control(N=32)

Nitisinone(N=33)

Control(N=16)

Nitisinone(N=16)

Baseline Mean 35245·0 33444·7 39705·9 38535·4 26963·8 29732·8

SD 10203·2 11487·4 16122·7 14920·7 8966·4 8857·0

Geometric mean 33715·2 31628·4 36378·5 35429·9 25536·8 28411·5


32113·2 120·2 23887·6 124·5 22652·7 53·5

95% CI 24834·8; 41524·6 93·4; 154·6 16999·4; 33566·9 89·8; 172·8 15870·0; 32334·2 38·3; 74·7


0·004 0·005 0·002

95% CI 0·003; 0·005 0·003; 0·008 0·001; 0·004

p-value* <0·001 <0·001 <0·001


31537·4 107·7 26520·8 110·2 22115·1 44·7

95% CI 23466·0; 42385·0 81·0; 143·4 20549·2; 34227·8 85·4; 142·2 14541·3; 33633·5 30·3; 65·9


0·003 0·004 0·002

95% CI 0·002; 0·005 0·003; 0·006 0·001; 0·004

p-value* <0·001 <0·001 <0·001


32766·8 247·8 23221·3 161·0 26658·2 77·4

95% CI 19080·1; 56271·5 145·0; 423·4 15790·0; 34150·1 109·2; 237·5 15922·6; 44632·0 48·5; 123·6


Liverpool Piešťany Paris


Nitisinone(N=20)

Control(N=32)

Nitisinone(N=33)

Control(N=16)

Nitisinone(N=16)


0·008 0·007 0·003

95% CI 0·004; 0·016 0·004; 0·012 0·001; 0·006

p-value* <0·001 <0·001 <0·001


30915·2 247·1 25245·0 196·5 33920·6 78·7

95% CI 19277·6; 49578·2 151·8; 402·2 15989·3; 39858·7 123·6; 312·6 20370·1; 56485·1 49·4; 125·5


0·008 0·008 0·002

95% CI 0·004; 0·016 0·004; 0·015 0·001; 0·005

p-value* <0·001 <0·001 <0·001


32068·6 210·0 32182·1 234·8 28793·8 59·3

95% CI 19339·9; 53174·5 125·1; 352·5 19915·2; 52005·0 145·0; 380·3 17700·3; 46839·9 38·0; 92·5


0·007 0·007 0·002

95% CI 0·003; 0·013 0·004; 0·014 0·001; 0·004

p-value* <0·001 <0·001 <0·001a Based on entire FAS.*Difference between treatments in each site is analysed using a mixed model with repeated measurements (MMRM).


14.8. Table S8. Change from baseline in SF-36, self-evaluated transition (SET) item (FAS)


Nitisinone(N=69)

Month 12 Adjusted mean -0·2 -0·6

95% CI -0·4; 0·0 -0·8; -0·4

Adjusted mean (difference nitisinone-untreated)

-0·4

95% CI -0·7; -0·1

p-value* 0·014

Month 24 Adjusted mean 0·2 -0·2

95% CI 0·0; 0·4 -0·4; -0·1


-0·4

95% CI -0·7; -0·2

p-value* 0·002


95% CI -0·2; 0·3 -0·5; -0·1


-0·3

95% CI -0·6; -0·1

p-value* 0·021


95% CI -0·1; 0·4 -0·6; -0·2


-0·6

95% CI -0·9; -0·2

p-value* 0·001

*Change from baseline is analysed using a mixed model with repeated measurements (MMRM).Higher score indicates worse quality of life.

72

14.9. Table S9. Tyrosine corneal keratopathy in SONIA 2*

Patient No

Age (years)

Sex Time to diagnosis

(months from baseline)

Last tyrosine value (µmol/L) before

nitisinone withdrawal*

Slit-lamp confirmatio

n

Fully resolved after nitisinone withdrawal?

1 50 M 12 1236 Yes Yes

2 39 M 6 1118 Yes Yes

3 56 F 3 1022 Yes Yes

4 69 F 14 1191 No** NA***

5 35 M 1 816 Yes Yes

6 44 M 13 1036 Yes Yes

7 29 M 36 1149 Yes Yes

8 41 M 30 976 Yes Yes

9 51 M 24 934 Yes Yes

10 43 M 6 609 Yes Yes

*Serum tyrosine not always measured at diagnosis of keratopathy **Patient 4 could not travel to study site; ***Assumed full reversal due to no further contact

73

14.10. Table S10. Adverse Events by System Organ Class and Preferred Term (Safety Analysis Set)

Control(N=69; PYRs=268)

Nitisinone(N=69; PYRs=260)

SOC PT

n (%) [Events] Incidence rateper 10 patientyears


Patients with at least one AE 57 (82·6) [284] 2·13 59 (85·5) [400] 2·27

Musculoskeletal and connective tissue disorders 24 (34·8) [53] 0·90 31 (44·9) [54] 1·19

Arthritis 6 (8·7) [6] 0·22 6 (8·7) [7] 0·23

Arthralgia 4 (5·8) [5] 0·15 6 (8·7) [11] 0·23

Osteoarthritis 5 (7·2) [7] 0·19 4 (5·8) [5] 0·15

Back pain 2 (2·9) [3] 0·07 3 (4·3) [3] 0·12

Tendon discomfort 1 (1·4) [1] 0·04 3 (4·3) [4] 0·12

Tendon disorder 4 (5·8) [4] 0·15 2 (2·9) [3] 0·08

Tendonitis 2 (2·9) [4] 0·07 2 (2·9) [2] 0·08

Musculoskeletal stiffness 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Myalgia 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Rotator cuff syndrome 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Musculoskeletal pain 4 (5·8) [5] 0·15 1 (1·4) [1] 0·04

Foot deformity 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mobility decreased 1 (1·4) [3] 0·04 1 (1·4) [1] 0·04

Muscular weakness 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Exostosis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Intervertebral disc protrusion 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Musculoskeletal discomfort 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Neck pain 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Pain in extremity 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Pathological fracture 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Spinal pain 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Tendon pain 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Chondrocalcinosis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Intervertebral disc disorder 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Joint stiffness 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Muscle spasms 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

74



SOC PT



Muscle swelling 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Osteonecrosis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pain in jaw 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Plantar fasciitis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pseudarthrosis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Synovial cyst 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Infections and infestations 11 (15·9) [24] 0·41 27 (39·1) [56] 1·04

Bronchitis 1 (1·4) [1] 0·04 5 (7·2) [7] 0·19

Urinary tract infection 2 (2·9) [3] 0·07 4 (5·8) [12] 0·15

Pneumonia 0 (0·0) [0] 0·00 4 (5·8) [4] 0·15

Nasopharyngitis 2 (2·9) [2] 0·07 3 (4·3) [3] 0·12

Influenza 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Tooth abscess 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Conjunctivitis 1 (1·4) [1] 0·04 1 (1·4) [2] 0·04

Erysipelas 1 (1·4) [1] 0·04 1 (1·4) [2] 0·04

Viral upper respiratory tract infection 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Breast abscess 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Candida infection 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cellulitis 0 (0·0) [0] 0·00 1 (1·4) [3] 0·04

Cystitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Ear infection 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Folliculitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Fungal infection 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Herpes zoster 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Kidney infection 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Onychomycosis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Ophthalmic herpes simplex 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Pharyngitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Pulpitis dental 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Rhinitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Tonsillitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

75



SOC PT



Vulvovaginal candidiasis 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Vulvovaginal mycotic infection 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hordeolum 1 (1·4) [6] 0·04 0 (0·0) [0] 0·00

Lower respiratory tract infection 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Oral herpes 1 (1·4) [2] 0·04 0 (0·0) [0] 0·00

Respiratory tract infection 1 (1·4) [2] 0·04 0 (0·0) [0] 0·00

Tinea versicolour 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Varicella 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Wound infection 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Eye disorders 8 (11·6) [12] 0·30 25 (36·2) [65] 0·96

Keratopathy 0 (0·0) [0] 0·00 9 (13·0) [12] 0·35

Eye pain 0 (0·0) [0] 0·00 8 (11·6) [9] 0·31

Dry eye 1 (1·4) [1] 0·04 6 (8·7) [7] 0·23

Lacrimation increased 1 (1·4) [1] 0·04 4 (5·8) [6] 0·15

Ocular hyperaemia 0 (0·0) [0] 0·00 4 (5·8) [5] 0·15

Eye irritation 2 (2·9) [2] 0·07 3 (4·3) [4] 0·12

Corneal opacity 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Eye pruritus 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Vision blurred 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Cataract 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Glaucoma 1 (1·4) [2] 0·04 1 (1·4) [1] 0·04

Cataract cortical 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Conjunctival haemorrhage 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Corneal scar 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eye discharge 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eye disorder 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eye inflammation 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eye swelling 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eyelid cyst 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eyelid oedema 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Keratitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

76



SOC PT



Photophobia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Swollen tear duct 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Visual impairment 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Vitreous disorder 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Asthenopia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Eye haemorrhage 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Ulcerative keratitis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Visual acuity reduced 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Investigations 10 (14·5) [12] 0·37 24 (34·8) [35] 0·92

Weight increased 4 (5·8) [4] 0·15 14 (20·3) [14] 0·54

Blood alkaline phosphatase increased 0 (0·0) [0] 0·00 3 (4·3) [3] 0·12

Weight decreased 4 (5·8) [4] 0·15 2 (2·9) [2] 0·08

Blood glucose increased 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Blood calcium decreased 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Blood phosphorus decreased 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Aortic bruit 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Blood creatinine increased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Blood pressure increased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cardiac murmur 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Gamma-glutamyltransferase increased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Glomerular filtration rate decreased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Heart rate irregular 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hepatic enzyme increased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Red blood cell sedimentation rate increased 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Serum ferritin increased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Vitamin D decreased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Arthroscopy 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Injury, poisoning and procedural complications 16 (23·2) [29] 0·60 19 (27·5) [28] 0·73

Fall 6 (8·7) [6] 0·22 8 (11·6) [9] 0·31

Ligament sprain 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Road traffic accident 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

77



SOC PT



Skin abrasion 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Foot fracture 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Hand fracture 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Muscle strain 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Ankle fracture 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Contusion 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Femur fracture 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Joint injury 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Tooth fracture 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Upper limb fracture 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Asbestosis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Fibula fracture 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Muscle rupture 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Soft tissue injury 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Tendon rupture 3 (4·3) [3] 0·11 0 (0·0) [0] 0·00

Animal bite 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Axillary nerve injury 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Cartilage injury 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Epicondylitis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Humerus fracture 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Ligament rupture 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Meniscus injury 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Overdose 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Skin and subcutaneous tissue disorders 9 (13·0) [10] 0·34 15 (21·7) [24] 0·58

Pruritus 0 (0·0) [0] 0·00 3 (4·3) [3] 0·12

Rash 0 (0·0) [0] 0·00 2 (2·9) [3] 0·08

Skin lesion 1 (1·4) [1] 0·04 1 (1·4) [6] 0·04

Acne 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Angioedema 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Ecchymosis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Miliaria 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

78



SOC PT



Plantar erythema 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Seborrhoeic dermatitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Skin disorder 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Skin fissures 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Skin hypertrophy 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Skin odour abnormal 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Vitiligo 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eczema 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Dermal cyst 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Dermatitis contact 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Erythema 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Night sweats 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pigmentation disorder 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Rash macular 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Urticaria 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Gastrointestinal disorders 13 (18·8) [17] 0·49 14 (20·3) [27] 0·54

Abdominal pain upper 3 (4·3) [3] 0·11 3 (4·3) [3] 0·12

Toothache 1 (1·4) [1] 0·04 3 (4·3) [4] 0·12

Dyspepsia 2 (2·9) [2] 0·07 2 (2·9) [2] 0·08

Abdominal distension 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Constipation 1 (1·4) [1] 0·04 2 (2·9) [3] 0·08

Vomiting 1 (1·4) [1] 0·04 2 (2·9) [4] 0·08

Abdominal pain 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Gastrooesophageal reflux disease 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Umbilical hernia 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Abdominal hernia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Dysphagia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Gastritis 0 (0·0) [0] 0·00 1 (1·4) [3] 0·04

Mouth swelling 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Colitis ulcerative 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Duodenogastric reflux 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

79



SOC PT



Nausea 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pancreatitis chronic 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Nervous system disorders 12 (17·4) [16] 0·45 14 (20·3) [26] 0·54

Headache 2 (2·9) [2] 0·07 6 (8·7) [11] 0·23

Cranial nerve disorder 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Sensory disturbance 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Migraine 1 (1·4) [1] 0·04 1 (1·4) [3] 0·04

Neuralgia 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Amnesia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Areflexia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hyperreflexia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Muscle contractions involuntary 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Paraesthesia 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Polyneuropathy 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hypoaesthesia 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Hyporeflexia 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Aphasia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Facial paresis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Lethargy 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Migraine with aura 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Monoparesis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Radicular syndrome 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Sciatica 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Transient ischaemic attack 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

General disorders and administration site conditions

4 (5·8) [6] 0·15 10 (14·5) [10] 0·38

Peripheral swelling 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Oedema peripheral 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Chest pain 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Hernia 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Asthenia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

80



SOC PT



Complication associated with device 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Crepitations 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Fatigue 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Nodule 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Influenza like illness 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Swelling 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Cardiac disorders 10 (14·5) [11] 0·37 9 (13·0) [9] 0·35

Bundle branch block right 6 (8·7) [6] 0·22 4 (5·8) [4] 0·15

Myocardial infarction 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Bundle branch block left 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Cardiac arrest 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cardiac failure 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Palpitations 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Sinus bradycardia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Tachycardia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Vascular disorders 12 (17·4) [14] 0·45 8 (11·6) [10] 0·31

Hypertension 9 (13·0) [9] 0·34 3 (4·3) [3] 0·12

Deep vein thrombosis 1 (1·4) [1] 0·04 3 (4·3) [4] 0·12

Arteriosclerosis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hypertensive crisis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Peripheral coldness 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Aortic stenosis 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Haematoma 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Peripheral artery occlusion 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Metabolism and nutrition disorders 13 (18·8) [19] 0·49 6 (8·7) [7] 0·23

Vitamin D deficiency 5 (7·2) [5] 0·19 3 (4·3) [3] 0·12

Hypokalaemia 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Hypoglycaemia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Iron deficiency 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Weight fluctuation 4 (5·8) [4] 0·15 0 (0·0) [0] 0·00

Type 2 diabetes mellitus 3 (4·3) [3] 0·11 0 (0·0) [0] 0·00

81



SOC PT



Hypercholesterolaemia 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Hyperuricaemia 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Folate deficiency 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Hypocalcaemia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Overweight 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Psychiatric disorders 4 (5·8) [5] 0·15 6 (8·7) [7] 0·23

Depression 1 (1·4) [1] 0·04 3 (4·3) [4] 0·12

Depressed mood 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Libido decreased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Anxiety 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Sleep disorder 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Respiratory, thoracic and mediastinal disorders 7 (10·1) [10] 0·26 5 (7·2) [6] 0·19

Sleep apnoea syndrome 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Pulmonary embolism 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Asthma 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Cough 3 (4·3) [4] 0·11 0 (0·0) [0] 0·00

Epistaxis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Nasal discomfort 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Nasal obstruction 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Oropharyngeal pain 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Rales 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Ear and labyrinth disorders 4 (5·8) [5] 0·15 5 (7·2) [5] 0·19

Vertigo 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Excessive cerumen production 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Hypoacusis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Inner ear disorder 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

External ear inflammation 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Tinnitus 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Surgical and medical procedures 3 (4·3) [3] 0·11 5 (7·2) [5] 0·19

Carpal tunnel decompression 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Cataract operation 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

82



SOC PT



Curetting of chalazion 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Umbilical hernia repair 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Limb operation 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Varicose vein operation 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Renal and urinary disorders 8 (11·6) [16] 0·30 4 (5·8) [10] 0·15

Renal colic 3 (4·3) [7] 0·11 3 (4·3) [5] 0·12

Nephrolithiasis 1 (1·4) [1] 0·04 1 (1·4) [4] 0·04

Renal impairment 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Micturition urgency 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Pollakiuria 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Nephropathy 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Perinephric collection 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Urethral stenosis 1 (1·4) [2] 0·04 0 (0·0) [0] 0·00

Reproductive system and breast disorders 7 (10·1) [7] 0·26 4 (5·8) [6] 0·15

Prostatitis 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Breast mass 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cervical cyst 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Orchitis noninfective 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Vulvovaginal dryness 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Benign prostatic hyperplasia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Breast enlargement 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Menorrhagia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Metrorrhagia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Prostatomegaly 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Neoplasms benign, malignant and unspecified (incl cysts and polyps)

1 (1·4) [1] 0·04 3 (4·3) [3] 0·12

Benign neoplasm of thyroid gland 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Endometrial cancer 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Uterine leiomyoma 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Thyroid cancer 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Hepatobiliary disorders 3 (4·3) [3] 0·11 2 (2·9) [3] 0·08

83



SOC PT



Biliary cyst 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Liver disorder 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Cholelithiasis 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Hepatic calcification 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Immune system disorders 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Allergy to metals 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hypersensitivity 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Contrast media allergy 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Blood and lymphatic system disorders 3 (4·3) [3] 0·11 1 (1·4) [1] 0·04

Leukopenia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Anaemia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Iron deficiency anaemia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Splenomegaly 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Product issues 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Device dislocation 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Endocrine disorders 4 (5·8) [5] 0·15 0 (0·0) [0] 0·00

Goitre 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Hyperthyroidism 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Thyroid mass 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Toxic nodular goitre 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Congenital, familial and genetic disorders 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Phimosis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pregnancy, puerperium and perinatal conditions 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pregnancy 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

PT: Preferred term; PYRs: Patient years; SOC: System Organ Class.n: Number of patients observed.Percentage calculated on N (patients in treatment groups).

84

14.11.Table S11. Anticipated and Study emergent Adverse Events by System Organ Class and Preferred Term (Safety Analysis Set)

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT

n (%) [Events] n (%) [Events]

Anticipated AEs

Eye disorders 1 (1·4) [1] 12 (17·4) [25] 0·002

Keratopathy 0 (0·0) [0] 9 (13·0) [12] 0·003

Eye pain 0 (0·0) [0] 8 (11·6) [9] 0·006

Corneal opacity 0 (0·0) [0] 2 (2·9) [2] 0·50

Keratitis 0 (0·0) [0] 1 (1·4) [1] 1·00

Photophobia 0 (0·0) [0] 1 (1·4) [1] 1·00

Ulcerative keratitis 1 (1·4) [1] 0 (0·0) [0] 1·00

Blepharitis 0 (0·0) [0] 0 (0·0) [0] NA

Skin and subcutaneous tissue disorders 2 (2·9) [2] 6 (8·7) [7] 0·27

Pruritus 0 (0·0) [0] 3 (4·3) [3] 0·24

Rash 0 (0·0) [0] 2 (2·9) [3] 0·50

Plantar erythema 0 (0·0) [0] 1 (1·4) [1] 1·00

Erythema 1 (1·4) [1] 0 (0·0) [0] 1·00

Rash macular 1 (1·4) [1] 0 (0·0) [0] 1·00

Blood and lymphatic system disorders 0 (0·0) [0] 1 (1·4) [1] 1·00

Leukopenia 0 (0·0) [0] 1 (1·4) [1] 1·00

Granulocytopenia 0 (0·0) [0] 0 (0·0) [0] NA

Leukocytosis 0 (0·0) [0] 0 (0·0) [0] NA

Thrombocytopenia 0 (0·0) [0] 0 (0·0) [0] NA

Study emergent AEs

Musculoskeletal and connective tissue disorders 24 (34·8) [53] 31 (44·9) [54]

Arthritis 6 (8·7) [6] 6 (8·7) [7]

Arthralgia 4 (5·8) [5] 6 (8·7) [11]

Osteoarthritis 5 (7·2) [7] 4 (5·8) [5]

Back pain 2 (2·9) [3] 3 (4·3) [3]

Tendon discomfort 1 (1·4) [1] 3 (4·3) [4]

Tendon disorder 4 (5·8) [4] 2 (2·9) [3]

Tendonitis 2 (2·9) [4] 2 (2·9) [2]

Musculoskeletal stiffness 1 (1·4) [1] 2 (2·9) [2]

85

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT


Myalgia 1 (1·4) [1] 2 (2·9) [2]

Rotator cuff syndrome 1 (1·4) [1] 2 (2·9) [2]

Musculoskeletal pain 4 (5·8) [5] 1 (1·4) [1]

Foot deformity 1 (1·4) [1] 1 (1·4) [1]

Mobility decreased 1 (1·4) [3] 1 (1·4) [1]

Muscular weakness 1 (1·4) [1] 1 (1·4) [1]

Exostosis 0 (0·0) [0] 1 (1·4) [1]

Intervertebral disc protrusion 0 (0·0) [0] 1 (1·4) [1]

Musculoskeletal discomfort 0 (0·0) [0] 1 (1·4) [1]

Neck pain 0 (0·0) [0] 1 (1·4) [1]

Pain in extremity 0 (0·0) [0] 1 (1·4) [1]

Pathological fracture 0 (0·0) [0] 1 (1·4) [2]

Spinal pain 0 (0·0) [0] 1 (1·4) [1]

Tendon pain 0 (0·0) [0] 1 (1·4) [1]

Chondrocalcinosis 1 (1·4) [1] 0 (0·0) [0]

Intervertebral disc disorder 1 (1·4) [1] 0 (0·0) [0]

Joint stiffness 1 (1·4) [1] 0 (0·0) [0]

Muscle spasms 1 (1·4) [1] 0 (0·0) [0]

Muscle swelling 1 (1·4) [1] 0 (0·0) [0]

Osteonecrosis 1 (1·4) [1] 0 (0·0) [0]

Pain in jaw 1 (1·4) [1] 0 (0·0) [0]

Plantar fasciitis 1 (1·4) [1] 0 (0·0) [0]

Pseudarthrosis 1 (1·4) [1] 0 (0·0) [0]

Synovial cyst 1 (1·4) [1] 0 (0·0) [0]

Infections and infestations 11 (15·9) [24] 27 (39·1) [56]

Bronchitis 1 (1·4) [1] 5 (7·2) [7]

Urinary tract infection 2 (2·9) [3] 4 (5·8) [12]

Pneumonia 0 (0·0) [0] 4 (5·8) [4]

Nasopharyngitis 2 (2·9) [2] 3 (4·3) [3]

Influenza 1 (1·4) [1] 2 (2·9) [2]

Tooth abscess 0 (0·0) [0] 2 (2·9) [2]

Conjunctivitis 1 (1·4) [1] 1 (1·4) [2]

Erysipelas 1 (1·4) [1] 1 (1·4) [2]

86

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT


Viral upper respiratory tract infection 1 (1·4) [1] 1 (1·4) [1]

Breast abscess 0 (0·0) [0] 1 (1·4) [1]

Candida infection 0 (0·0) [0] 1 (1·4) [1]

Cellulitis 0 (0·0) [0] 1 (1·4) [3]

Cystitis 0 (0·0) [0] 1 (1·4) [1]

Ear infection 0 (0·0) [0] 1 (1·4) [1]

Folliculitis 0 (0·0) [0] 1 (1·4) [1]

Fungal infection 0 (0·0) [0] 1 (1·4) [1]

Herpes zoster 0 (0·0) [0] 1 (1·4) [1]

Kidney infection 0 (0·0) [0] 1 (1·4) [1]

Onychomycosis 0 (0·0) [0] 1 (1·4) [1]

Ophthalmic herpes simplex 0 (0·0) [0] 1 (1·4) [1]

Pharyngitis 0 (0·0) [0] 1 (1·4) [1]

Pulpitis dental 0 (0·0) [0] 1 (1·4) [2]

Rhinitis 0 (0·0) [0] 1 (1·4) [1]

Tonsillitis 0 (0·0) [0] 1 (1·4) [1]

Vulvovaginal candidiasis 0 (0·0) [0] 1 (1·4) [2]

Vulvovaginal mycotic infection 0 (0·0) [0] 1 (1·4) [1]

Hordeolum 1 (1·4) [6] 0 (0·0) [0]

Lower respiratory tract infection 1 (1·4) [1] 0 (0·0) [0]

Oral herpes 1 (1·4) [2] 0 (0·0) [0]

Respiratory tract infection 1 (1·4) [2] 0 (0·0) [0]

Tinea versicolour 1 (1·4) [1] 0 (0·0) [0]

Varicella 1 (1·4) [1] 0 (0·0) [0]

Wound infection 1 (1·4) [1] 0 (0·0) [0]

Eye disorders 8 (11·6) [12] 22 (31·9) [42]

Dry eye 1 (1·4) [1] 6 (8·7) [7]

Lacrimation increased 1 (1·4) [1] 4 (5·8) [6]

Ocular hyperaemia 0 (0·0) [0] 4 (5·8) [5]

Eye irritation 2 (2·9) [2] 3 (4·3) [4]

Corneal opacity 0 (0·0) [0] 2 (2·9) [2]

Eye pruritus 0 (0·0) [0] 2 (2·9) [2]

Vision blurred 0 (0·0) [0] 2 (2·9) [2]

87

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT


Cataract 2 (2·9) [2] 1 (1·4) [1]

Glaucoma 1 (1·4) [2] 1 (1·4) [1]

Cataract cortical 0 (0·0) [0] 1 (1·4) [1]

Conjunctival haemorrhage 0 (0·0) [0] 1 (1·4) [1]

Corneal scar 0 (0·0) [0] 1 (1·4) [1]

Eye discharge 0 (0·0) [0] 1 (1·4) [1]

Eye disorder 0 (0·0) [0] 1 (1·4) [1]

Eye inflammation 0 (0·0) [0] 1 (1·4) [1]

Eye swelling 0 (0·0) [0] 1 (1·4) [1]

Eyelid cyst 0 (0·0) [0] 1 (1·4) [1]

Eyelid oedema 0 (0·0) [0] 1 (1·4) [1]

Swollen tear duct 0 (0·0) [0] 1 (1·4) [1]

Visual impairment 0 (0·0) [0] 1 (1·4) [1]

Vitreous disorder 0 (0·0) [0] 1 (1·4) [1]

Asthenopia 1 (1·4) [1] 0 (0·0) [0]

Eye haemorrhage 1 (1·4) [1] 0 (0·0) [0]

Visual acuity reduced 1 (1·4) [1] 0 (0·0) [0]

Investigations 10 (14·5) [12] 24 (34·8) [35]

Weight increased 4 (5·8) [4] 14 (20·3) [14]

Blood alkaline phosphatase increased 0 (0·0) [0] 3 (4·3) [3]

Weight decreased 4 (5·8) [4] 2 (2·9) [2]

Blood glucose increased 1 (1·4) [1] 2 (2·9) [2]

Blood calcium decreased 1 (1·4) [1] 1 (1·4) [1]

Blood phosphorus decreased 1 (1·4) [1] 1 (1·4) [1]

Aortic bruit 0 (0·0) [0] 1 (1·4) [1]

Blood creatinine increased 0 (0·0) [0] 1 (1·4) [1]

Blood pressure increased 0 (0·0) [0] 1 (1·4) [1]

Cardiac murmur 0 (0·0) [0] 1 (1·4) [1]

Gamma-glutamyltransferase increased 0 (0·0) [0] 1 (1·4) [1]

Glomerular filtration rate decreased 0 (0·0) [0] 1 (1·4) [1]

Heart rate irregular 0 (0·0) [0] 1 (1·4) [1]

Hepatic enzyme increased 0 (0·0) [0] 1 (1·4) [1]

Red blood cell sedimentation rate increased 0 (0·0) [0] 1 (1·4) [2]

88

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT


Serum ferritin increased 0 (0·0) [0] 1 (1·4) [1]

Vitamin D decreased 0 (0·0) [0] 1 (1·4) [1]

Arthroscopy 1 (1·4) [1] 0 (0·0) [0]

Injury, poisoning and procedural complications 16 (23·2) [29] 19 (27·5) [28]

Fall 6 (8·7) [6] 8 (11·6) [9]

Ligament sprain 0 (0·0) [0] 2 (2·9) [2]

Road traffic accident 0 (0·0) [0] 2 (2·9) [2]

Skin abrasion 0 (0·0) [0] 2 (2·9) [2]

Foot fracture 2 (2·9) [2] 1 (1·4) [1]

Hand fracture 2 (2·9) [2] 1 (1·4) [1]

Muscle strain 2 (2·9) [2] 1 (1·4) [1]

Ankle fracture 1 (1·4) [1] 1 (1·4) [1]

Contusion 1 (1·4) [1] 1 (1·4) [1]

Femur fracture 1 (1·4) [1] 1 (1·4) [1]

Joint injury 1 (1·4) [1] 1 (1·4) [1]

Tooth fracture 1 (1·4) [1] 1 (1·4) [1]

Upper limb fracture 1 (1·4) [1] 1 (1·4) [1]

Asbestosis 0 (0·0) [0] 1 (1·4) [1]

Fibula fracture 0 (0·0) [0] 1 (1·4) [1]

Muscle rupture 0 (0·0) [0] 1 (1·4) [1]

Soft tissue injury 0 (0·0) [0] 1 (1·4) [1]

Tendon rupture 3 (4·3) [3] 0 (0·0) [0]

Animal bite 1 (1·4) [1] 0 (0·0) [0]

Axillary nerve injury 1 (1·4) [1] 0 (0·0) [0]

Cartilage injury 1 (1·4) [1] 0 (0·0) [0]

Epicondylitis 1 (1·4) [1] 0 (0·0) [0]

Humerus fracture 1 (1·4) [1] 0 (0·0) [0]

Ligament rupture 1 (1·4) [1] 0 (0·0) [0]

Meniscus injury 1 (1·4) [1] 0 (0·0) [0]

Overdose 1 (1·4) [1] 0 (0·0) [0]

Skin and subcutaneous tissue disorders 8 (11·6) [8] 10 (14·5) [17]

Skin lesion 1 (1·4) [1] 1 (1·4) [6]

Acne 0 (0·0) [0] 1 (1·4) [2]

89

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT


Angioedema 0 (0·0) [0] 1 (1·4) [1]

Ecchymosis 0 (0·0) [0] 1 (1·4) [1]

Miliaria 0 (0·0) [0] 1 (1·4) [1]

Seborrhoeic dermatitis 0 (0·0) [0] 1 (1·4) [1]

Skin disorder 0 (0·0) [0] 1 (1·4) [1]

Skin fissures 0 (0·0) [0] 1 (1·4) [1]

Skin hypertrophy 0 (0·0) [0] 1 (1·4) [1]

Skin odour abnormal 0 (0·0) [0] 1 (1·4) [1]

Vitiligo 0 (0·0) [0] 1 (1·4) [1]

Eczema 2 (2·9) [2] 0 (0·0) [0]

Dermal cyst 1 (1·4) [1] 0 (0·0) [0]

Dermatitis contact 1 (1·4) [1] 0 (0·0) [0]

Night sweats 1 (1·4) [1] 0 (0·0) [0]

Pigmentation disorder 1 (1·4) [1] 0 (0·0) [0]

Urticaria 1 (1·4) [1] 0 (0·0) [0]

Gastrointestinal disorders 13 (18·8) [17] 14 (20·3) [27]

Abdominal pain upper 3 (4·3) [3] 3 (4·3) [3]

Toothache 1 (1·4) [1] 3 (4·3) [4]

Dyspepsia 2 (2·9) [2] 2 (2·9) [2]

Abdominal distension 1 (1·4) [1] 2 (2·9) [2]

Constipation 1 (1·4) [1] 2 (2·9) [3]

Vomiting 1 (1·4) [1] 2 (2·9) [4]

Abdominal pain 2 (2·9) [2] 1 (1·4) [1]

Gastrooesophageal reflux disease 1 (1·4) [1] 1 (1·4) [1]

Umbilical hernia 1 (1·4) [1] 1 (1·4) [1]

Abdominal hernia 0 (0·0) [0] 1 (1·4) [1]

Dysphagia 0 (0·0) [0] 1 (1·4) [1]

Gastritis 0 (0·0) [0] 1 (1·4) [3]

Mouth swelling 0 (0·0) [0] 1 (1·4) [1]

Colitis ulcerative 1 (1·4) [1] 0 (0·0) [0]

Duodenogastric reflux 1 (1·4) [1] 0 (0·0) [0]

Nausea 1 (1·4) [1] 0 (0·0) [0]

Pancreatitis chronic 1 (1·4) [1] 0 (0·0) [0]

90

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT


Nervous system disorders 12 (17·4) [16] 14 (20·3) [26]

Headache 2 (2·9) [2] 6 (8·7) [11]

Cranial nerve disorder 0 (0·0) [0] 2 (2·9) [2]

Sensory disturbance 0 (0·0) [0] 2 (2·9) [2]

Migraine 1 (1·4) [1] 1 (1·4) [3]

Neuralgia 1 (1·4) [1] 1 (1·4) [1]

Amnesia 0 (0·0) [0] 1 (1·4) [1]

Areflexia 0 (0·0) [0] 1 (1·4) [1]

Hyperreflexia 0 (0·0) [0] 1 (1·4) [1]

Muscle contractions involuntary 0 (0·0) [0] 1 (1·4) [1]

Paraesthesia 0 (0·0) [0] 1 (1·4) [2]

Polyneuropathy 0 (0·0) [0] 1 (1·4) [1]

Hypoaesthesia 2 (2·9) [2] 0 (0·0) [0]

Hyporeflexia 2 (2·9) [2] 0 (0·0) [0]

Aphasia 1 (1·4) [1] 0 (0·0) [0]

Facial paresis 1 (1·4) [1] 0 (0·0) [0]

Lethargy 1 (1·4) [1] 0 (0·0) [0]

Migraine with aura 1 (1·4) [1] 0 (0·0) [0]

Monoparesis 1 (1·4) [1] 0 (0·0) [0]

Radicular syndrome 1 (1·4) [1] 0 (0·0) [0]

Sciatica 1 (1·4) [1] 0 (0·0) [0]

Transient ischaemic attack 1 (1·4) [1] 0 (0·0) [0]

General disorders and administration site conditions

4 (5·8) [6] 10 (14·5) [10]

Peripheral swelling 0 (0·0) [0] 2 (2·9) [2]

Oedema peripheral 2 (2·9) [2] 1 (1·4) [1]

Chest pain 1 (1·4) [1] 1 (1·4) [1]

Hernia 1 (1·4) [1] 1 (1·4) [1]

Asthenia 0 (0·0) [0] 1 (1·4) [1]

Complication associated with device 0 (0·0) [0] 1 (1·4) [1]

Crepitations 0 (0·0) [0] 1 (1·4) [1]

Fatigue 0 (0·0) [0] 1 (1·4) [1]

Nodule 0 (0·0) [0] 1 (1·4) [1]

91

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT


Influenza like illness 1 (1·4) [1] 0 (0·0) [0]

Swelling 1 (1·4) [1] 0 (0·0) [0]

Cardiac disorders 10 (14·5) [11] 9 (13·0) [9]

Bundle branch block right 6 (8·7) [6] 4 (5·8) [4]

Myocardial infarction 1 (1·4) [1] 2 (2·9) [2]

Bundle branch block left 1 (1·4) [1] 1 (1·4) [1]

Cardiac arrest 0 (0·0) [0] 1 (1·4) [1]

Cardiac failure 0 (0·0) [0] 1 (1·4) [1]

Palpitations 1 (1·4) [1] 0 (0·0) [0]

Sinus bradycardia 1 (1·4) [1] 0 (0·0) [0]

Tachycardia 1 (1·4) [1] 0 (0·0) [0]

Vascular disorders 12 (17·4) [14] 8 (11·6) [10]

Hypertension 9 (13·0) [9] 3 (4·3) [3]

Deep vein thrombosis 1 (1·4) [1] 3 (4·3) [4]

Arteriosclerosis 0 (0·0) [0] 1 (1·4) [1]

Hypertensive crisis 0 (0·0) [0] 1 (1·4) [1]

Peripheral coldness 0 (0·0) [0] 1 (1·4) [1]

Aortic stenosis 2 (2·9) [2] 0 (0·0) [0]

Haematoma 1 (1·4) [1] 0 (0·0) [0]

Peripheral artery occlusion 1 (1·4) [1] 0 (0·0) [0]

Metabolism and nutrition disorders 13 (18·8) [19] 6 (8·7) [7]

Vitamin D deficiency 5 (7·2) [5] 3 (4·3) [3]

Hypokalaemia 0 (0·0) [0] 2 (2·9) [2]

Hypoglycaemia 0 (0·0) [0] 1 (1·4) [1]

Iron deficiency 0 (0·0) [0] 1 (1·4) [1]

Weight fluctuation 4 (5·8) [4] 0 (0·0) [0]

Type 2 diabetes mellitus 3 (4·3) [3] 0 (0·0) [0]

Hypercholesterolaemia 2 (2·9) [2] 0 (0·0) [0]

Hyperuricaemia 2 (2·9) [2] 0 (0·0) [0]

Folate deficiency 1 (1·4) [1] 0 (0·0) [0]

Hypocalcaemia 1 (1·4) [1] 0 (0·0) [0]

Overweight 1 (1·4) [1] 0 (0·0) [0]

Psychiatric disorders 4 (5·8) [5] 6 (8·7) [7]

92

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT


Depression 1 (1·4) [1] 3 (4·3) [4]

Depressed mood 0 (0·0) [0] 2 (2·9) [2]

Libido decreased 0 (0·0) [0] 1 (1·4) [1]

Anxiety 2 (2·9) [2] 0 (0·0) [0]

Sleep disorder 2 (2·9) [2] 0 (0·0) [0]

Respiratory, thoracic and mediastinal disorders 7 (10·1) [10] 5 (7·2) [6]

Sleep apnoea syndrome 1 (1·4) [1] 2 (2·9) [2]

Pulmonary embolism 0 (0·0) [0] 2 (2·9) [2]

Asthma 0 (0·0) [0] 1 (1·4) [2]

Cough 3 (4·3) [4] 0 (0·0) [0]

Epistaxis 1 (1·4) [1] 0 (0·0) [0]

Nasal discomfort 1 (1·4) [1] 0 (0·0) [0]

Nasal obstruction 1 (1·4) [1] 0 (0·0) [0]

Oropharyngeal pain 1 (1·4) [1] 0 (0·0) [0]

Rales 1 (1·4) [1] 0 (0·0) [0]

Ear and labyrinth disorders 4 (5·8) [5] 5 (7·2) [5]

Vertigo 1 (1·4) [1] 2 (2·9) [2]

Excessive cerumen production 2 (2·9) [2] 1 (1·4) [1]

Hypoacusis 0 (0·0) [0] 1 (1·4) [1]

Inner ear disorder 0 (0·0) [0] 1 (1·4) [1]

External ear inflammation 1 (1·4) [1] 0 (0·0) [0]

Tinnitus 1 (1·4) [1] 0 (0·0) [0]

Surgical and medical procedures 3 (4·3) [3] 5 (7·2) [5]

Carpal tunnel decompression 1 (1·4) [1] 2 (2·9) [2]

Cataract operation 0 (0·0) [0] 1 (1·4) [1]

Curetting of chalazion 0 (0·0) [0] 1 (1·4) [1]

Umbilical hernia repair 0 (0·0) [0] 1 (1·4) [1]

Limb operation 1 (1·4) [1] 0 (0·0) [0]

Varicose vein operation 1 (1·4) [1] 0 (0·0) [0]

Renal and urinary disorders 8 (11·6) [16] 4 (5·8) [10]

Renal colic 3 (4·3) [7] 3 (4·3) [5]

Nephrolithiasis 1 (1·4) [1] 1 (1·4) [4]

Renal impairment 0 (0·0) [0] 1 (1·4) [1]

93

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT


Micturition urgency 2 (2·9) [2] 0 (0·0) [0]

Pollakiuria 2 (2·9) [2] 0 (0·0) [0]

Nephropathy 1 (1·4) [1] 0 (0·0) [0]

Perinephric collection 1 (1·4) [1] 0 (0·0) [0]

Urethral stenosis 1 (1·4) [2] 0 (0·0) [0]

Reproductive system and breast disorders 7 (10·1) [7] 4 (5·8) [6]

Prostatitis 2 (2·9) [2] 1 (1·4) [1]

Breast mass 0 (0·0) [0] 1 (1·4) [1]

Cervical cyst 0 (0·0) [0] 1 (1·4) [1]

Orchitis noninfective 0 (0·0) [0] 1 (1·4) [2]

Vulvovaginal dryness 0 (0·0) [0] 1 (1·4) [1]

Benign prostatic hyperplasia 1 (1·4) [1] 0 (0·0) [0]

Breast enlargement 1 (1·4) [1] 0 (0·0) [0]

Menorrhagia 1 (1·4) [1] 0 (0·0) [0]

Metrorrhagia 1 (1·4) [1] 0 (0·0) [0]

Prostatomegaly 1 (1·4) [1] 0 (0·0) [0]

Neoplasms benign, malignant and unspecified (incl cysts and polyps)

1 (1·4) [1] 3 (4·3) [3]

Benign neoplasm of thyroid gland 0 (0·0) [0] 1 (1·4) [1]

Endometrial cancer 0 (0·0) [0] 1 (1·4) [1]

Uterine leiomyoma 0 (0·0) [0] 1 (1·4) [1]

Thyroid cancer 1 (1·4) [1] 0 (0·0) [0]

Hepatobiliary disorders 3 (4·3) [3] 2 (2·9) [3]

Biliary cyst 0 (0·0) [0] 1 (1·4) [1]

Liver disorder 0 (0·0) [0] 1 (1·4) [2]

Cholelithiasis 2 (2·9) [2] 0 (0·0) [0]

Hepatic calcification 1 (1·4) [1] 0 (0·0) [0]

Immune system disorders 1 (1·4) [1] 2 (2·9) [2]

Allergy to metals 0 (0·0) [0] 1 (1·4) [1]

Hypersensitivity 0 (0·0) [0] 1 (1·4) [1]

Contrast media allergy 1 (1·4) [1] 0 (0·0) [0]

Product issues 0 (0·0) [0] 1 (1·4) [1]

Device dislocation 0 (0·0) [0] 1 (1·4) [1]

94

Control(N=69)

Nitisinone (N =69)

p-value*SOC PT


Blood and lymphatic system disorders 3 (4·3) [3] 0 (0·0) [0]

Anaemia 1 (1·4) [1] 0 (0·0) [0]

Iron deficiency anaemia 1 (1·4) [1] 0 (0·0) [0]

Splenomegaly 1 (1·4) [1] 0 (0·0) [0]

Endocrine disorders 4 (5·8) [5] 0 (0·0) [0]

Goitre 2 (2·9) [2] 0 (0·0) [0]

Hyperthyroidism 1 (1·4) [1] 0 (0·0) [0]

Thyroid mass 1 (1·4) [1] 0 (0·0) [0]

Toxic nodular goitre 1 (1·4) [1] 0 (0·0) [0]

Congenital, familial and genetic disorders 1 (1·4) [1] 0 (0·0) [0]

Phimosis 1 (1·4) [1] 0 (0·0) [0]

Pregnancy, puerperium and perinatal conditions 1 (1·4) [1] 0 (0·0) [0]

Pregnancy 1 (1·4) [1] 0 (0·0) [0]

PT: Preferred term; PYRs: Patient years; SOC: System Organ Class.n: Number of patients observed.Percentage calculated on N (patients in treatment groups).* p-value calculated using Fisher’s exact test on number of patients reporting events.NA: Not applicable.

95

14.12. Table S12. Adverse Events by Preferred Term classified by maximum severity in descending order of incidence in the nitisinone group (Safety Analysis Set)



PT



Patients with at least one AE 57 (82·6) [284] 2·13 59 (85·5) [400] 2·27

Mild 24 (34·8) [191] 0·90 15 (21·7) [275] 0·58

Moderate 18 (26·1) [74] 0·67 29 (42·0) [102] 1·11

Severe 15 (21·7) [19] 0·56 15 (21·7) [23] 0·58

Weight increased 4 (5·8) [4] 0·15 14 (20·3) [14] 0·54

Mild 4 (5·8) [4] 0·15 14 (20·3) [14] 0·54

Keratopathy 0 (0·0) [0] 0·00 9 (13·0) [12] 0·35

Mild 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Moderate 0 (0·0) [0] 0·00 7 (10·1) [10] 0·27

Fall 6 (8·7) [6] 0·22 8 (11·6) [9] 0·31

Mild 3 (4·3) [3] 0·11 7 (10·1) [8] 0·27

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Severe 3 (4·3) [3] 0·11 0 (0·0) [0] 0·00

Eye pain 0 (0·0) [0] 0·00 8 (11·6) [9] 0·31

Mild 0 (0·0) [0] 0·00 4 (5·8) [4] 0·15

Moderate 0 (0·0) [0] 0·00 3 (4·3) [4] 0·12

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Arthritis 6 (8·7) [6] 0·22 6 (8·7) [7] 0·23

Mild 3 (4·3) [3] 0·11 1 (1·4) [1] 0·04

Moderate 3 (4·3) [3] 0·11 4 (5·8) [5] 0·15

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Arthralgia 4 (5·8) [5] 0·15 6 (8·7) [11] 0·23

Moderate 2 (2·9) [2] 0·07 4 (5·8) [8] 0·15

Severe 2 (2·9) [3] 0·07 2 (2·9) [3] 0·08

Headache 2 (2·9) [2] 0·07 6 (8·7) [11] 0·23

Mild 0 (0·0) [0] 0·00 3 (4·3) [8] 0·12

Moderate 2 (2·9) [2] 0·07 3 (4·3) [3] 0·12

Dry eye 1 (1·4) [1] 0·04 6 (8·7) [7] 0·23

96



PT



Mild 1 (1·4) [1] 0·04 4 (5·8) [4] 0·15

Moderate 0 (0·0) [0] 0·00 2 (2·9) [3] 0·08

Bronchitis 1 (1·4) [1] 0·04 5 (7·2) [7] 0·19

Mild 1 (1·4) [1] 0·04 3 (4·3) [4] 0·12

Moderate 0 (0·0) [0] 0·00 2 (2·9) [3] 0·08

Bundle branch block right 6 (8·7) [6] 0·22 4 (5·8) [4] 0·15

Mild 6 (8·7) [6] 0·22 4 (5·8) [4] 0·15

Osteoarthritis 5 (7·2) [7] 0·19 4 (5·8) [5] 0·15

Mild 1 (1·4) [1] 0·04 0 (0·0) [1] 0·00

Moderate 1 (1·4) [3] 0·04 3 (4·3) [3] 0·12

Severe 3 (4·3) [3] 0·11 1 (1·4) [1] 0·04

Urinary tract infection 2 (2·9) [3] 0·07 4 (5·8) [12] 0·15

Mild 1 (1·4) [1] 0·04 3 (4·3) [11] 0·12

Moderate 1 (1·4) [2] 0·04 1 (1·4) [1] 0·04

Lacrimation increased 1 (1·4) [1] 0·04 4 (5·8) [6] 0·15

Mild 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Moderate 0 (0·0) [0] 0·00 2 (2·9) [4] 0·08

Ocular hyperaemia 0 (0·0) [0] 0·00 4 (5·8) [5] 0·15

Mild 0 (0·0) [0] 0·00 2 (2·9) [3] 0·08

Moderate 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Pneumonia 0 (0·0) [0] 0·00 4 (5·8) [4] 0·15

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Severe 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Hypertension 9 (13·0) [9] 0·34 3 (4·3) [3] 0·12

Mild 7 (10·1) [7] 0·26 2 (2·9) [2] 0·08

Moderate 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Vitamin D deficiency 5 (7·2) [5] 0·19 3 (4·3) [3] 0·12

Mild 5 (7·2) [5] 0·19 2 (2·9) [2] 0·08

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Abdominal pain upper 3 (4·3) [3] 0·11 3 (4·3) [3] 0·12

97



PT



Mild 3 (4·3) [3] 0·11 3 (4·3) [3] 0·12

Renal colic 3 (4·3) [7] 0·11 3 (4·3) [5] 0·12

Mild 1 (1·4) [4] 0·04 0 (0·0) [2] 0·00

Moderate 2 (2·9) [3] 0·07 2 (2·9) [2] 0·08

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Back pain 2 (2·9) [3] 0·07 3 (4·3) [3] 0·12

Mild 0 (0·0) [1] 0·00 2 (2·9) [2] 0·08

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Eye irritation 2 (2·9) [2] 0·07 3 (4·3) [4] 0·12

Mild 2 (2·9) [2] 0·07 1 (1·4) [2] 0·04

Moderate 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Nasopharyngitis 2 (2·9) [2] 0·07 3 (4·3) [3] 0·12

Mild 2 (2·9) [2] 0·07 2 (2·9) [2] 0·08

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Deep vein thrombosis 1 (1·4) [1] 0·04 3 (4·3) [4] 0·12

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 0 (0·0) [0] 0·00 2 (2·9) [3] 0·08

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Depression 1 (1·4) [1] 0·04 3 (4·3) [4] 0·12

Mild 1 (1·4) [1] 0·04 2 (2·9) [3] 0·08

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Tendon discomfort 1 (1·4) [1] 0·04 3 (4·3) [4] 0·12

Mild 1 (1·4) [1] 0·04 3 (4·3) [4] 0·12

Toothache 1 (1·4) [1] 0·04 3 (4·3) [4] 0·12

Mild 1 (1·4) [1] 0·04 2 (2·9) [3] 0·08

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Blood alkaline phosphatase increased 0 (0·0) [0] 0·00 3 (4·3) [3] 0·12

Mild 0 (0·0) [0] 0·00 3 (4·3) [3] 0·12

Pruritus 0 (0·0) [0] 0·00 3 (4·3) [3] 0·12

Mild 0 (0·0) [0] 0·00 3 (4·3) [3] 0·12

98



PT



Tendon disorder 4 (5·8) [4] 0·15 2 (2·9) [3] 0·08

Mild 4 (5·8) [4] 0·15 2 (2·9) [3] 0·08

Weight decreased 4 (5·8) [4] 0·15 2 (2·9) [2] 0·08

Mild 4 (5·8) [4] 0·15 2 (2·9) [2] 0·08

Dyspepsia 2 (2·9) [2] 0·07 2 (2·9) [2] 0·08

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Tendonitis 2 (2·9) [4] 0·07 2 (2·9) [2] 0·08

Mild 0 (0·0) [2] 0·00 2 (2·9) [2] 0·08

Moderate 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Abdominal distension 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Mild 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Blood glucose increased 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Mild 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Carpal tunnel decompression 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Constipation 1 (1·4) [1] 0·04 2 (2·9) [3] 0·08

Mild 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Moderate 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Influenza 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Musculoskeletal stiffness 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Myalgia 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Mild 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Myocardial infarction 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

99



PT



Rotator cuff syndrome 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Sleep apnoea syndrome 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Vertigo 1 (1·4) [1] 0·04 2 (2·9) [2] 0·08

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Vomiting 1 (1·4) [1] 0·04 2 (2·9) [4] 0·08

Mild 0 (0·0) [0] 0·00 2 (2·9) [4] 0·08

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Corneal opacity 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cranial nerve disorder 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Depressed mood 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Eye pruritus 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hypokalaemia 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Ligament sprain 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Peripheral swelling 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Pulmonary embolism 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

100



PT



Severe 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Rash 0 (0·0) [0] 0·00 2 (2·9) [3] 0·08

Mild 0 (0·0) [0] 0·00 2 (2·9) [3] 0·08

Road traffic accident 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Sensory disturbance 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Skin abrasion 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Tooth abscess 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Mild 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Vision blurred 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Moderate 0 (0·0) [0] 0·00 2 (2·9) [2] 0·08

Musculoskeletal pain 4 (5·8) [5] 0·15 1 (1·4) [1] 0·04

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Moderate 2 (2·9) [3] 0·07 0 (0·0) [0] 0·00

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Abdominal pain 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Mild 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Cataract 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Excessive cerumen production 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Mild 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Foot fracture 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Mild 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Hand fracture 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Mild 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Muscle strain 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

101



PT



Oedema peripheral 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Prostatitis 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Mild 2 (2·9) [2] 0·07 1 (1·4) [1] 0·04

Ankle fracture 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Blood calcium decreased 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Blood phosphorus decreased 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Bundle branch block left 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Chest pain 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Conjunctivitis 1 (1·4) [1] 0·04 1 (1·4) [2] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [2] 0·04

Contusion 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Erysipelas 1 (1·4) [1] 0·04 1 (1·4) [2] 0·04

Mild 1 (1·4) [1] 0·04 0 (0·0) [1] 0·00

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Femur fracture 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Foot deformity 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Gastrooesophageal reflux disease 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

102



PT



Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Glaucoma 1 (1·4) [2] 0·04 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 1 (1·4) [2] 0·04 0 (0·0) [0] 0·00

Hernia 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Joint injury 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Migraine 1 (1·4) [1] 0·04 1 (1·4) [3] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [3] 0·04

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mobility decreased 1 (1·4) [3] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [3] 0·04 1 (1·4) [1] 0·04

Muscular weakness 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Nephrolithiasis 1 (1·4) [1] 0·04 1 (1·4) [4] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [4] 0·04

Neuralgia 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Skin lesion 1 (1·4) [1] 0·04 1 (1·4) [6] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [6] 0·04

Tooth fracture 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Umbilical hernia 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Upper limb fracture 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Moderate 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

103



PT



Viral upper respiratory tract infection 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Mild 1 (1·4) [1] 0·04 1 (1·4) [1] 0·04

Abdominal hernia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Acne 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Allergy to metals 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Amnesia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Angioedema 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Aortic bruit 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Areflexia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Arteriosclerosis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Asbestosis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Asthenia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Asthma 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Benign neoplasm of thyroid gland 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Biliary cyst 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Blood creatinine increased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Blood pressure increased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

104



PT



Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Breast abscess 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Breast mass 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Candida infection 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cardiac arrest 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cardiac failure 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cardiac murmur 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cataract cortical 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cataract operation 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Cellulitis 0 (0·0) [0] 0·00 1 (1·4) [3] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [3] 0·04

Cervical cyst 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Complication associated with device 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Conjunctival haemorrhage 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Corneal scar 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Crepitations 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Curetting of chalazion 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

105



PT



Cystitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Device dislocation 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Dysphagia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Ear infection 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Ecchymosis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Endometrial cancer 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Exostosis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eye discharge 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eye disorder 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eye inflammation 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eye swelling 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eyelid cyst 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Eyelid oedema 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Fatigue 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Fibula fracture 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Folliculitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

106



PT



Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Fungal infection 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Gamma-glutamyltransferase increased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Gastritis 0 (0·0) [0] 0·00 1 (1·4) [3] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [3] 0·04

Glomerular filtration rate decreased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Heart rate irregular 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hepatic enzyme increased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Herpes zoster 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hyperreflexia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hypersensitivity 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hypertensive crisis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hypoacusis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Hypoglycaemia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Inner ear disorder 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Intervertebral disc protrusion 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Iron deficiency 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

107



PT



Keratitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Kidney infection 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Leukopenia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Libido decreased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Liver disorder 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Miliaria 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mouth swelling 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Muscle contractions involuntary 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Muscle rupture 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Musculoskeletal discomfort 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Neck pain 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Nodule 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Onychomycosis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Ophthalmic herpes simplex 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Orchitis noninfective 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

108



PT



Pain in extremity 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Paraesthesia 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Pathological fracture 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Severe 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Peripheral coldness 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Pharyngitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Photophobia 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Plantar erythema 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Polyneuropathy 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Pulpitis dental 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Red blood cell sedimentation rate increased 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Renal impairment 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Rhinitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Seborrhoeic dermatitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Serum ferritin increased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Skin disorder 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

109



PT



Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Skin fissures 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Skin hypertrophy 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Skin odour abnormal 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Soft tissue injury 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Spinal pain 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Swollen tear duct 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Moderate 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Tendon pain 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Tonsillitis 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Umbilical hernia repair 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Uterine leiomyoma 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Visual impairment 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Vitamin D decreased 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Vitiligo 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Vitreous disorder 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Vulvovaginal candidiasis 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [2] 0·04

110



PT



Vulvovaginal dryness 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Vulvovaginal mycotic infection 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Mild 0 (0·0) [0] 0·00 1 (1·4) [1] 0·04

Weight fluctuation 4 (5·8) [4] 0·15 0 (0·0) [0] 0·00

Mild 4 (5·8) [4] 0·15 0 (0·0) [0] 0·00

Cough 3 (4·3) [4] 0·11 0 (0·0) [0] 0·00

Mild 3 (4·3) [4] 0·11 0 (0·0) [0] 0·00

Tendon rupture 3 (4·3) [3] 0·11 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Type 2 diabetes mellitus 3 (4·3) [3] 0·11 0 (0·0) [0] 0·00

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Anxiety 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Aortic stenosis 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Cholelithiasis 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Eczema 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Goitre 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Hypercholesterolaemia 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Hyperuricaemia 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

111



PT



Hypoaesthesia 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Hyporeflexia 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Micturition urgency 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Pollakiuria 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Mild 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Sleep disorder 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Moderate 2 (2·9) [2] 0·07 0 (0·0) [0] 0·00

Anaemia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Animal bite 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Aphasia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Arthroscopy 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Asthenopia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Axillary nerve injury 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Benign prostatic hyperplasia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Breast enlargement 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Cartilage injury 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Chondrocalcinosis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Colitis ulcerative 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

112



PT



Severe 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Contrast media allergy 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Dermal cyst 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Dermatitis contact 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Duodenogastric reflux 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Epicondylitis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Epistaxis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Erythema 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

External ear inflammation 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Eye haemorrhage 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Facial paresis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Folate deficiency 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Haematoma 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Hepatic calcification 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Hordeolum 1 (1·4) [6] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [3] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [3] 0·04 0 (0·0) [0] 0·00

Humerus fracture 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

113



PT



Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Hyperthyroidism 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Hypocalcaemia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Influenza like illness 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Intervertebral disc disorder 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Iron deficiency anaemia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Joint stiffness 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Lethargy 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Ligament rupture 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Limb operation 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Lower respiratory tract infection 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Meniscus injury 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Menorrhagia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Metrorrhagia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Migraine with aura 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Monoparesis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

114



PT



Muscle spasms 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Muscle swelling 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Nasal discomfort 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Nasal obstruction 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Nausea 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Nephropathy 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Night sweats 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Oral herpes 1 (1·4) [2] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [2] 0·04 0 (0·0) [0] 0·00

Oropharyngeal pain 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Osteonecrosis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Overdose 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Overweight 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pain in jaw 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Palpitations 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pancreatitis chronic 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Perinephric collection 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

115



PT



Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Peripheral artery occlusion 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Phimosis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pigmentation disorder 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Plantar fasciitis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pregnancy 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Prostatomegaly 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Pseudarthrosis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Radicular syndrome 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Rales 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Rash macular 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Respiratory tract infection 1 (1·4) [2] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [2] 0·04 0 (0·0) [0] 0·00

Sciatica 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Sinus bradycardia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Splenomegaly 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Swelling 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

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PT



Synovial cyst 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Tachycardia 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Thyroid cancer 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Thyroid mass 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Tinea versicolour 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Tinnitus 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Toxic nodular goitre 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Transient ischaemic attack 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Severe 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Ulcerative keratitis 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Urethral stenosis 1 (1·4) [2] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [2] 0·04 0 (0·0) [0] 0·00

Urticaria 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Varicella 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Varicose vein operation 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Visual acuity reduced 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Mild 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Wound infection 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

Moderate 1 (1·4) [1] 0·04 0 (0·0) [0] 0·00

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PT: Preferred term; PYRs: Patient years.n: Number of patients observed.Percentage calculated on N (patients in treatment groups.

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14.13. Table S13. Tipping point for u-HGA24 (µmol), MMRM Least Square mean estimates for treatment difference at 12 months (FAS)

Percentual shift in u-HGA

Actual shift in u-HGA (log.)

Treatment difference estimate (log.)

Standard error

Adjusted geometric mean (quotient nitisinone/ untreated) 95% CI p-value

1800 81·0 -3·38 1·636 0·0340 0·0014; 0·8384 0·0387

1850 83·3 -3·32 1·680 0·0362 0·0013; 0·9727 0·0481

1851 83·3 -3·32 1·680 0·0362 0·0013; 0·9727 0·0481

1852 83·4 -3·30 1·691 0·0367 0·0013; 1·0095 0·0507

1853 83·4 -3·30 1·691 0·0367 0·0013; 1·0095 0·0507

1854 83·5 -3·30 1·691 0·0367 0·0013; 1·0095 0·0507

1855 83·5 -3·30 1·691 0·0367 0·0013; 1·0095 0·0507

1856 83·6 -3·30 1·691 0·0367 0·0013; 1·0095 0·0507

1857 83·6 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1858 83·7 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1859 83·7 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1860 83·7 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1861 83·8 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1862 83·8 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1863 83·9 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1864 83·9 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1865 84·0 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1866 84·0 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1867 84·1 -3·30 1·695 0·0370 0·0013; 1·0253 0·0517

1868 84·1 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1869 84·2 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1870 84·2 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1871 84·2 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1872 84·3 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1873 84·3 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1874 84·4 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1875 84·4 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1876 84·5 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1877 84·5 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1878 84·6 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1879 84·6 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1880 84·6 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

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Percentual shift in u-HGA

Actual shift in u-HGA (log.)

Treatment difference estimate (log.)

Standard error

Adjusted geometric mean (quotient nitisinone/ untreated) 95% CI p-value

1881 84·7 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1882 84·7 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1883 84·8 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1884 84·8 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1885 84·9 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1886 84·9 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1887 85·0 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1888 85·0 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1889 85·1 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1890 85·1 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1891 85·1 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1892 85·2 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1893 85·2 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1894 85·3 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1895 85·3 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1896 85·4 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1897 85·4 -3·28 1·705 0·0375 0·0013; 1·0608 0·0542

1898 85·5 -3·24 1·733 0·0390 0·0013; 1·1640 0·0612

1899 85·5 -3·24 1·733 0·0390 0·0013; 1·1640 0·0612

1900 85·5 -3·24 1·733 0·0390 0·0013; 1·1640 0·0612

a Based on entire FAS.Difference between treatments is analysed using a mixed model with repeated measurements (MMRM).Percentual shift calculated as percentage of the mean u-HGA (log.) value in Nitisinone group at each visit.Shift added to monotonously missing observations in Nitisinone group, when imputed using multiple imputation.Created using lab_urine.sas and rand.sas version 1 in S:\Statistical Documents\AKU\Trials\SONIA 2\Final analysis\Final programming\Data by MG on 13JAN20:11:06:31.

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14.14. Table S14. Tipping point analysis for change from baseline in total ear pigmentation, MMRM Least Square mean estimates for treatment difference at 24, 36 and 48 months (FAS)

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Actual shift in total ear pigmentation


Standard error 95% CI P-value

Month 24 0 0·0 -0·28 0·124 -0·5204; -0·0354 0·0247

5 0·2 -0·27 0·124 -0·5148; -0·0292 0·0281

10 0·4 -0·27 0·124 -0·5096; -0·0228 0·0321

15 0·6 -0·26 0·125 -0·5047; -0·0161 0·0367

20 0·8 -0·25 0·125 -0·5000; -0·0090 0·0421

25 1·0 -0·25 0·126 -0·4956; -0·0017 0·0485

26 1·1 -0·25 0·126 -0·4947; -0·0002 0·0498

27 1·1 -0·25 0·126 -0·4939; 0·0013 0·0513

28 1·1 -0·25 0·127 -0·4930; 0·0029 0·0527

29 1·2 -0·24 0·127 -0·4922; 0·0044 0·0542

30 1·2 -0·24 0·127 -0·4914; 0·0060 0·0558

31 1·3 -0·24 0·127 -0·4906; 0·0075 0·0574

32 1·3 -0·24 0·127 -0·4898; 0·0091 0·0590

33 1·3 -0·24 0·127 -0·4890; 0·0107 0·0607

34 1·4 -0·24 0·128 -0·4882; 0·0123 0·0624

35 1·4 -0·24 0·128 -0·4874; 0·0139 0·0642

Month 36 0 0·0 -0·43 0·158 -0·7438; -0·1246 0·0060

5 0·2 -0·40 0·158 -0·7146; -0·0949 0·0105

10 0·4 -0·38 0·159 -0·6872; -0·0634 0·0184

15 0·6 -0·35 0·161 -0·6617; -0·0300 0·0319

16 0·6 -0·34 0·162 -0·6568; -0·0231 0·0355

17 0·7 -0·33 0·162 -0·6520; -0·0162 0·0394

18 0·7 -0·33 0·163 -0·6472; -0·0092 0·0438

19 0·7 -0·32 0·163 -0·6425; -0·0021 0·0485

20 0·8 -0·32 0·164 -0·6379; 0·0051 0·0537

Month 48 0 0·0 -0·48 0·213 -0·8991; -0·0659 0·0232

1 0·0 -0·47 0·212 -0·8863; -0·0536 0·0270

2 0·1 -0·46 0·212 -0·8737; -0·0411 0·0313

3 0·1 -0·44 0·212 -0·8612; -0·0285 0·0363

4 0·2 -0·43 0·213 -0·8488; -0·0158 0·0419

5 0·2 -0·42 0·213 -0·8365; -0·0029 0·0484

6 0·2 -0·41 0·213 -0·8244; 0·0101 0·0558

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Actual shift in total ear pigmentation



7 0·3 -0·39 0·213 -0·8125; 0·0233 0·0642

8 0·3 -0·38 0·214 -0·8007; 0·0366 0·0737

Sum of pigmentation AKUSSI scores for both ears.*Change from baseline is analysed using a mixed model with repeated measurements (MMRM).Created using akussi1.sas, akussi2.sas, akussi3.sas and rand_fas.sas version 1 in S:\Statistical Documents\AKU\Trials\SONIA 2\Final analysis\Final programming\Data by EP on 08JAN20:16:15:12.Percentual shift calculated as percentage of the mean total ear pigmentation value in Nitisinone group at each visit.Shift added to monotonously missing observations in Nitisinone group, when imputed using multiple imputation.

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14.15. Table S15. Tipping point analysis for change from baseline in total eye pigmentation, MMRM Least Square mean estimates for treatment difference at 36 and 48 months (FAS)

Visit

Percentual shift in total eye pigmentation

Actual shift in total eye pigmentation



Month 36 0 0·0 -1·48 0·609 -2·6714; -0·2832 0·0153

1 0·2 -1·45 0·610 -2·6489; -0·2594 0·0171

2 0·3 -1·43 0·610 -2·6267; -0·2353 0·0190

3 0·5 -1·41 0·611 -2·6047; -0·2109 0·0211

4 0·7 -1·38 0·611 -2·5830; -0·1863 0·0235

5 0·8 -1·36 0·612 -2·5615; -0·1614 0·0262

6 1·0 -1·34 0·613 -2·5403; -0·1361 0·0291

7 1·2 -1·32 0·614 -2·5194; -0·1106 0·0324

8 1·3 -1·29 0·616 -2·4987; -0·0849 0·0359

9 1·5 -1·27 0·617 -2·4783; -0·0588 0·0399

10 1·7 -1·25 0·619 -2·4581; -0·0325 0·0442

11 1·8 -1·22 0·621 -2·4382; -0·0059 0·0489

12 2·0 -1·20 0·622 -2·4186; 0·0210 0·0541

Month 48 0 0·0 -2·51 0·747 -3·9717; -1·0433 0·0008

1 0·2 -2·45 0·748 -3·9166; -0·9847 0·0011

2 0·3 -2·39 0·749 -3·8624; -0·9253 0·0014

3 0·5 -2·34 0·751 -3·8089; -0·8651 0·0019

4 0·7 -2·28 0·753 -3·7561; -0·8041 0·0025

5 0·8 -2·22 0·756 -3·7041; -0·7424 0·0033

6 1·0 -2·17 0·758 -3·6528; -0·6800 0·0043

7 1·2 -2·11 0·762 -3·6023; -0·6167 0·0056

8 1·3 -2·05 0·765 -3·5525; -0·5528 0·0073

9 1·5 -2·00 0·769 -3·5034; -0·4881 0·0095

10 1·7 -1·94 0·774 -3·4549; -0·4227 0·0122

11 1·8 -1·88 0·778 -3·4072; -0·3565 0·0156

12 2·0 -1·82 0·783 -3·3602; -0·2897 0·0198

13 2·1 -1·77 0·789 -3·3138; -0·2222 0·0250

14 2·3 -1·71 0·794 -3·2680; -0·1540 0·0313

15 2·5 -1·65 0·800 -3·2229; -0·0852 0·0388

16 2·6 -1·60 0·807 -3·1784; -0·0158 0·0478

17 2·8 -1·54 0·813 -3·1345; 0·0543 0·0583

18 3·0 -1·48 0·820 -3·0913; 0·1250 0·0707

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Sum of pigmentation AKUSSI scores for all 4 locations.*Change from baseline is analysed using a mixed model with repeated measurements (MMRM).Created using akussi1.sas and rand_fas.sas version 1 in S:\Statistical Documents\AKU\Trials\SONIA 2\Final analysis\Final programming\Data by EP on 08JAN20:16:48:16.Percentual shift calculated as percentage of the mean total eye pigmentation value in Nitisinone group at each visit.Shift added to monotonously missing observations in Nitisinone group, when imputed using multiple imputation.

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14.16. Table S16. Tipping point analysis for change from baseline in osteopenia of the hip (T score), MMRM Least Square mean estimates for treatment difference at 48 months (FAS)

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Percentual shift in osteopenia of the hip (T score)

Actual shift in osteopenia of the hip (T score)



Month 48 -6 0·07 0·16 0·070 0·0188; 0·2916 0·0258

-5 0·06 0·15 0·069 0·0148; 0·2872 0·0298

-4 0·05 0·15 0·069 0·0108; 0·2827 0·0344

-3 0·04 0·14 0·069 0·0067; 0·2784 0·0397

-2 0·02 0·14 0·069 0·0027; 0·2741 0·0457

-1 0·01 0·13 0·069 -0·0015; 0·2698 0·0525

0 0·00 0·13 0·069 -0·0056; 0·2655 0·0603

3 -0·04 0·12 0·069 -0·0184; 0·2530 0·0901

4 -0·05 0·11 0·069 -0·0227; 0·2490 0·1026

5 -0·06 0·11 0·069 -0·0271; 0·2449 0·1164

*Change from baseline is analysed using a mixed model with repeated measurements (MMRM).Created using akussi1.sas, akussi2.sas, akussi3.sas and rand_fas.sas version 1 in S:\Statistical Documents\AKU\Trials\SONIA 2\Final analysis\Final programming\Data by EP on 10JAN20:13:55:53.Percentual shift calculated as percentage of the mean T score value for osteopenia of the hip in Nitisinone group at each visit.Shift added to monotonously missing observations in Nitisinone group, when imputed using multiple imputation.

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14.17. Table S17. Tipping point analysis for change from baseline in number of spinal regions with pain, MMRM Least Square mean estimates for treatment difference at 48 months (FAS)

Visit

Percentual shift in number of spinal regions with pain

Actual shift in number of spinal regions with pain



Month 48 0 0·00 -0·49 0·225 -0·934; -0·052 0·0286

1 0·02 -0·49 0·225 -0·930; -0·048 0·0299

2 0·03 -0·49 0·225 -0·926; -0·044 0·0312

3 0·05 -0·48 0·225 -0·923; -0·040 0·0326

4 0·07 -0·48 0·225 -0·919; -0·036 0·0340

5 0·08 -0·47 0·225 -0·915; -0·032 0·0355

6 0·10 -0·47 0·225 -0·912; -0·028 0·0370

7 0·12 -0·47 0·225 -0·908; -0·024 0·0386

8 0·14 -0·46 0·225 -0·904; -0·020 0·0403

9 0·15 -0·46 0·226 -0·901; -0·017 0·0420

10 0·17 -0·45 0·226 -0·897; -0·013 0·0438

11 0·19 -0·45 0·226 -0·893; -0·009 0·0457

12 0·20 -0·45 0·226 -0·890; -0·005 0·0476

13 0·22 -0·44 0·226 -0·886; -0·001 0·0497

14 0·24 -0·44 0·226 -0·883; 0·003 0·0517

15 0·25 -0·44 0·226 -0·879; 0·007 0·0539

16 0·27 -0·43 0·226 -0·875; 0·011 0·0561

17 0·29 -0·43 0·226 -0·872; 0·015 0·0585

18 0·30 -0·42 0·226 -0·868; 0·019 0·0609

19 0·32 -0·42 0·227 -0·865; 0·023 0·0634

20 0·34 -0·42 0·227 -0·861; 0·027 0·0659

*Change from baseline is analysed using a mixed model with repeated measurements (MMRM).Created using akussi1.sas, akussi2.sas, akussi3.sas and rand_fas.sas version 1 in S:\Statistical Documents\AKU\Trials\SONIA 2\Final analysis\Final programming\Data by EP on 15JAN20:12:34:45.Percentual shift calculated as percentage of the mean number of spinal regions with pain in Nitisinone group at each visit.Shift added to monotonously missing observations in Nitisinone group, when imputed using multiple imputation.

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14.18. Table S18. Tipping point analysis for change from baseline in cAKUSSI scores, MMRM Least Square mean estimates for treatment difference at 48 months (FAS)

Visit

Percentual shift in cAKUSSI scores

Actual shift in cAKUSSI scores

Adjusted mean (difference nitisinone- untreated)


Month 48 0 0·00 -9·02 3·783 -16·432; -1·604 0·0171

1 0·94 -8·78 3·780 -16·189; -1·371 0·0202

2 1·87 -8·54 3·779 -15·949; -1·136 0·0238

3 2·81 -8·30 3·779 -15·711; -0·898 0·0280

4 3·75 -8·07 3·780 -15·477; -0·657 0·0329

5 4·68 -7·83 3·783 -15·245; -0·414 0·0385

6 5·62 -7·59 3·787 -15·015; -0·168 0·0450

7 6·56 -7·35 3·793 -14·788; 0·081 0·0525

8 7·50 -7·12 3·800 -14·564; 0·332 0·0611

9 8·43 -6·88 3·808 -14·343; 0·586 0·0709

10 9·37 -6·64 3·818 -14·124; 0·842 0·0820

*Change from baseline is analysed using a mixed model with repeated measurements (MMRM).Created using akussi1.sas, akussi2.sas, akussi3.sas and _patientinfo.sas version 1 in S:\Statistical Documents\AKU\Trials\SONIA 2\Final analysis\Final programming\Data by EP on 15JAN20:11:51:46.Percentual shift calculated as percentage of the mean cAKUSSI scores in Nitisinone group at each visit.Shift added to monotonously missing observations in Nitisinone group, when imputed using multiple imputation.

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15.0. SONIA 2 protocol

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