RFP 75N95022R00041- Attachments.pdf

PACKAGING AND DELIVERY OF PROPOSAL Attachment 1

Packaging and Delivery of Proposals for Use with the NIH electronic Contract Proposal Submission (eCPS) Website

I. PROPOSAL SUBMISSION

A. eCPS

1. Proposals must be submitted via the electronic Contract Proposal Submission (eCPS) website at https://ecps.nih.gov.

2. Proposals submitted by facsimile or e-mail will not be accepted.

3. Follow the “How to Submit an Electronic Proposal” instructions provided on the eCPS website at: https://ecps.nih.gov/home/howto. Please note that creating an account to submit may take up to three (3) business days. Please apply for a new account early to allow enough time for the registration process.

4. Offerors are solely responsible for submitting proposals and any modifications or revisions so as to reach the Government office designated above by the date and time specified in the solicitation. If your proposal is not received by the date and time specified in the solicitation, it will be considered a “late proposal,” in accordance with FAR Clause 52.215-1 Instructions to Offerors – Competitive Acquisition.

B. Creating and Naming Files:

1. Create one PDF file of your Technical Proposal, including all attachments. The Technical Proposal should be created in a PDF format that enables word searches to the maximum extent practicable. Forms and/or documents requiring signature(s) may be scanned, but must be merged into the Technical Proposal PDF file.

2. Create one PDF file of your Business Proposal, including all attachments:

The Business Proposal should be created in a PDF format that enables word searches to the maximum extent practicable. Forms and/or documents requiring signature(s) may be scanned, but must be merged into the Business Proposal PDF file.

Additionally, the “Breakdown of Proposed Estimated Costs (plus Fee) with Excel Spreadsheet” (http://oamp.od.nih.gov/sites/default/files/DGS/contracting-forms/spshexcl_dec2012.xlsx) must be included in the Business Proposal.

3. Create your Business Document Excel. The Excel file should be the “Breakdown of Proposed Estimated Costs (plus Fee) with Excel Spreadsheet” (http://oamp.od.nih.gov/sites/default/files/DGS/contracting-forms/spshexcl_dec2012.xlsx) included in the Business Proposal in its original Excel format, not PDF. Multiple Excel files may be included, as necessary.

4. Each of the proposals, Technical and Business, must be separate and complete in itself.

Do not reference one proposal in another.

https://ecps.nih.gov/ https://ecps.nih.gov/home/howto http://oamp.od.nih.gov/sites/default/files/DGS/contracting-forms/spshexcl_dec2012.xlsx http://oamp.od.nih.gov/sites/default/files/DGS/contracting-forms/spshexcl_dec2012.xlsx http://oamp.od.nih.gov/sites/default/files/DGS/contracting-forms/spshexcl_dec2012.xlsx http://oamp.od.nih.gov/sites/default/files/DGS/contracting-forms/spshexcl_dec2012.xlsx

PACKAGING AND DELIVERY OF PROPOSAL Attachment 1

5. File naming convention: It is requested that the filenames for your Technical Proposal, Business Proposal, and Excel Workbook include the name of the offeror, the solicitation number and the type of proposal (i.e., Technical, Business, or Excel Workbook).

Examples:

Technical Proposal: XYZ Company_NIHAI2012001_Technical.pdf Business Proposal: XYZ Company_NIHAI2012001_Business.pdf Excel Workbook: XYZ Company_NIHAI2012001_Business.xlsx

PROPOSAL INTENT RESPONSE FORM

RFP No:

RFP Title:

Please review the Request for Proposal (RFP). Furnish the information requested below and return this page to the Contracting Officer/Contract Specialist identified on Section A-Solicitation/Contract Form by

Your expression of intent is not binding but will greatly assist us in planning for proposal evaluation.

Choose one of the following Options:

Do intend to submit a proposal Do Not intend to submit a proposal

If you are not responding to this RFP, please provide your reason(s):

Please provide the following contact information:

Name (First, Middle Initial, Last):

Title:

Organization:

E-mail:

Attachment 2

April 2023 IDIQ - Attachment 3

STATEMENT OF WORK (IDIQ)

Title: Clinical evaluation of Phenserine tartrate Extended Controlled Release Tablet (ECRT) formulation in early mild Alzheimer’s disease and mild to moderate traumatic brain injury

I. BACKGROUND AND INTRODUCTION

There is a significant unmet need for Alzheimer’s disease therapeutics as well as drugs that favorably impact the consequences of brain injury as it can initiate cascades of biological events that may lead to long-term neurodegenerative disorders such as Alzheimer’s disease (AD).

One of the goals of the National Institute on Aging (NIA) is to conduct research to better understand the effects and effectiveness of pharmaceuticals on neurodegenerative disorders and, in particular, AD and traumatic brain injury (TBI). This Contract shall ensure that NIA is able to evaluate the potential of the candidate AD drug (-)-Phenserine tartrate ECRT formulation in relation to pharmacokinetic and pharmacodynamic measures with regard to achieving steady-state drug concentrations of the agent, and measures of drug/target engagement and efficacy when optimally dosed. Plasma samples obtained from the contract shall be evaluated both at NIA and by other organizations to quantify drug concentrations as well as markers of drug action (such assays will be outside this contract) – but shall be undertaken on samples obtained from this contract. Results from these assays will be related to tolerability and/or cognitive/imaging measures obtained within the present contract.

Specifically, this contract is to evaluate pharmacokinetic and pharmacodynamic measures of (-)-Phenserine tartrate ECRT formulation in subjects with early mild Alzheimer’s disease (AD) in a phase 1/2 clinical trial and in mild to moderate traumatic brain injury (TBI) subjects in a phase 1/2 clinical study. Specifically, the contract is to provide clinical services for the approved administration of the drug to two well-characterized patient populations, and to obtain blood and other sample/measures from them under rigorously safe conditions for later evaluation of pharmacokinetic and pharmacodynamic measures associated with drug plasma concentrations, blood markers of drug action, tolerability and brain/blood markers of efficacy.

A. Objectives:

The aim of this contract is to first obtain regulatory and Institutional Review Board (IRB) approvals for, and then to undertake a multiple ascending dose (MAD) clinical study to evaluate the safety, tolerability, and time-dependent pharmacokinetics/pharmacodynamics (particularly acetylcholinesterase (AChE) inhibition) of phenserine tartrate ECRT (Task Order 1). This will involve a classical Multiple Ascending Dose (MAD) study over a duration of approx. 30 days.

Thereafter, with an understanding of the optimal dose achieved in the MAD study, to then safely and rapidly titrate up to this optimal dose and evaluate this optimal dose of phenserine tartrate ECRT over an extended time in two patient populations: in AD (Task Order 2) and in TBI subjects (Task Order 3). Dosing for TBI subjects will be for up to 30 days and, thereafter, the subjects will be followed – alongside a matching group of ‘placebo’ subjects that will be provided best non-pharmacological care (i.e., without phenserine tartrate ECRT). Dosing of AD

April 2023 IDIQ - Attachment 3 subjects will be for up to 52 weeks (depending on the availability of phenserine tartrate ECRT) – alongside a matching group of placebo subjects that can be administered a standard dose of the drug donepezil (instead of Phenserine tartrate ECRT).

The study will be focused on monitoring safety to achieve an optimal/maximally tolerated Phenserine tartrate ECRT dose (that does not cause unacceptable side effects or overt toxicity) and obtaining blood samples to support pharmacokinetic (e.g., drug levels of primary drug and select major metabolites) and biomarker analyses (e.g., exosome biomarkers of (i) cell death pathways, (ii) Alzheimer’s disease markers, (iii) synaptic markers and (iv) neuroinflammation markers) – involving assays that will be conducted in other labs (not within this contract or SOW). However, clinical (computerized neuropsychology) and imaging outcomes on enrolled participants in the AD and TBI trials will be undertaken within this contract. Additionally, rapid assay of red blood cell acetylcholinesterase inhibition is an essential requirement of the contract, particularly within the MAD portion of the study, to ensure that phenserine tartrate ECRT dosing maximally achieves approx. 45% to 50% inhibition but, importantly, does not exceed 55% inhibition.

Alzheimer’s disease and Traumatic brain injury Alzheimer’s disease (AD) is the most common neurodegenerative disorder worldwide. In the US alone, an estimated 5.8 million people aged 65 and older were affected in 2020, which is projected to increase to 13.8 million by 2050 [Liesi et al., 2013]. Because of the significant health, social and economic burden associated with the disease, there have been numerous attempts to find a pharmacologic treatment able to effectively delay or prevent the onset and development of pathology. Despite these efforts, the clinical trial failure rate remains extremely high. The few currently approved AD drugs address symptomatic issues. Being able to mitigate the cognitive impairment characteristic of the disorder only temporarily; they are not effective in stopping or reversing disease progression (Pangalos et al., 2007; Mehta et al., 2017; Lao et al., 2019).

Traumatic brain injury (TBI) is a major cause of death and long-term disability, with in excess of 10 million people suffering a TBI annually worldwide – with some 1.6 to 3.8 million cases occurring in the US, alone [Mckee et al., 2015] . The preponderance of TBIs are mild to moderate in nature, representing 80–95% of cases, with severe TBI compromising the rest. With increased survival following original injury, TBI may elicit significant and lifelong cognitive, physical, and behavioral deficiencies that necessitate long-term care [LoBue et al., 2019;

Pavlovic et al., 2019]. Indeed, TBI represents a progressive process rather than a single event and is one of the most important risk factors for later development of dementia, particularly AD and Parkinson’s disease [Gardner and Yaffe 2015], associated with changes in gene expressions in pathways that lead to these disorders [Tweedie et al., 2016; Tweedie et al., 2013]. The reported increased incidence of TBI [Coronado et al., 2015] has led to estimates that by 2020, TBI will comprise the third largest global disease burden [Dewan et al., 2018].

Phenserine and required clinical services Phenserine: The focus of this contract is to evaluate select pharmacodynamic and pharmacokinetic measures of an Alzheimer drug, (-)-Phenserine tartrate ECRT, in (i) the early mild AD state and (ii) in mild to moderate TBI. The study in the TBI population is to aid in the interpretation of the drug evaluation in AD subjects, as the neuronal cell dysfunction and death https://pubmed.ncbi.nlm.nih.gov/23390181/ https://pubmed.ncbi.nlm.nih.gov/17599084/ https://pubmed.ncbi.nlm.nih.gov/28460541/ https://pubmed.ncbi.nlm.nih.gov/29732929/ https://pubmed.ncbi.nlm.nih.gov/29732929/ https://pubmed.ncbi.nlm.nih.gov/25702209/ https://pubmed.ncbi.nlm.nih.gov/31282414/ https://pubmed.ncbi.nlm.nih.gov/30929221/ https://pubmed.ncbi.nlm.nih.gov/25748121/ https://pubmed.ncbi.nlm.nih.gov/27254111/ https://pubmed.ncbi.nlm.nih.gov/23454194/ https://pubmed.ncbi.nlm.nih.gov/23454194/ https://pubmed.ncbi.nlm.nih.gov/25955705/ https://pubmed.ncbi.nlm.nih.gov/29701556/

April 2023 IDIQ - Attachment 3 that accompanies TBI (and associated neuroinflammation and other related processes) are initiated by the injury – and, hence, are “synchronized” time-dependently. This contrasts with the same processes in AD – which represents a chronic disorder in which these processes do not occur in synchrony.

Clinical services are required by a team with specific knowledge and background in (i) the patient populations (AD and TBI), (ii) the drug class being evaluated (agents that mitigate neuronal cell dysfunction/death together with anticholinesterases), as well as (iii) on the specific drug of interest (Phenserine tartrate), to ensure rigorous safety in its administration and dose escalation, and optimization in patients to provide required blood samples and related materials that will be provided by the Contractor to the National Institute on Aging (NIA).

Prior preclinical Phenserine studies: Phenserine tartrate was initially developed and evaluated as a cholinesterase inhibitor (Greig et al., 2005) but there are several mechanisms by which the drug phenserine may act on neuronal and synaptic loss, key common pathways evident in Alzheimer’s disease, traumatic brain injury and other neurodegenerative diseases. A range of pre-clinical studies indicate that phenserine suppresses interleukin-1b, reduces glutamate-induced excitotoxicity, protects against H2O2-induced oxidative toxicity, reduces A-beta levels, improves neural precursor cell viability, elevates neurotrophic brain-derived neurotrophic factor, and inhibits APP and α-synuclein synthesis (Ballard et al., 2020). Whilst these potential actions are of interest, more significantly recent work has suggested that phenserine may confer significant neuroprotection by inhibiting apoptosis through actions on a Pre-Programmed Cell Death Pathway (Lecca et al., 2019). This has been evaluated in several rodent models of neuronal loss, including APP/PSEN1 transgenic AD mice, re-perfusion injury and a weight drop mouse model of traumatic brain injury. In all of these animal studies, treatment with phenserine significantly reduced neurodegenerative lesions, and decreased the neuro-inflammatory response through IBA1 and TNF-α pathways in both wild type and Alzheimer transgenic mice (Greig et al., 2020).

Synaptic density and synaptophysin levels were also significantly protected in phenserine treated Alzheimer transgenic and traumatic brain injury (TBI) animals.

Prior clinical Phenserine studies: (-)-Phenserine tartrate has been evaluated as an “immediate release” formulation in several trials in people with mild to moderate AD. A phase 2, twelve-week RCT indicated that (-)-phenserine (5-10 mg b.i.d.) had a favourable safety profile and conferred significant improvements in cognitive function with related improvements in cerebral glucose metabolism. However, in these studies as well as in a phase III trial, Phenserine was not administered in a manner to maintain steady-state therapeutic levels – even though some benefits were evident at a dose of 15mg BID. The results are hence difficult to interpret on the basis of preliminary reports, especially as several studies were significantly under-powered for cognitive and functional outcomes.

Overall, there is strong nonclinical evidence of biological effects that are relevant to the treatment of Alzheimer’s disease and other neurodegenerative conditions, with a novel effect on apoptosis and a good clinical safety profile, but the potential for clinical benefit has not been evaluated in an adequately powered trial and the potential for disease modifying actions need to be confirmed in human studies.

https://pubmed.ncbi.nlm.nih.gov/15974893/ https://pubmed.ncbi.nlm.nih.gov/32939050/ https://pubmed.ncbi.nlm.nih.gov/31295555/ https://pubmed.ncbi.nlm.nih.gov/31828969/

April 2023 IDIQ - Attachment 3

II. SCOPE AND OBJECTIVES

The main objective of this Contract is to provide a service to perform a phase 1/2 clinical trial evaluation of Phenserine tartrate ECRT in subjects with early mild Alzheimer’s disease (AD) and in mild to moderate traumatic brain injury (TBI). Specifically, the Contract shall perform clinical services to provide brain imaging, cognitive assessment as well as blood and other samples to support evaluation of pharmacokinetic and pharmacodynamic measures. This will involve a multiple ascending dose (MAD) study of Phenserine ECRT (Task Order 1), and then the selection of the optimal dose of drug to carry forward into a longer-term analysis of early efficacy in AD (Task Order 2) and TBI subjects (Task Order 3).

III. TECHNICAL REQUIREMENTS

Independently and not as an agent of the Government, the Contractor shall furnish all the necessary resources, qualified personnel, material, equipment, and facilities, not otherwise provided by the Government under the terms of this Contract, as needed to perform the technical requirements outlined below through the individual Task Orders (TOs). (-)-Phenserine tartrate ECRT will be provided to the Contractor – as will Phenserine immediate dose formulation (if required within the TBI portion of the study – to achieve a more immediate steady-state blood level).

Should the MAD (Task Order 1) phase of the project demonstrate that (-)-Phenserine tartrate ECRT does not adequately release (-)-phenserine/and metabolites to achieve a steady-state. (-)- Phenserine immediate release capsules can be provided to the Contractor by the Government (for administration up to 4 times daily to achieve an approx. steady-state) to allow Task Orders 2 and 3 to move ahead.

IV. Specific Task Areas

Task Area 1. Clinical Trial Services: Following regulatory and other required approvals (such as IRB approval), subjects, qualifying and giving informed consent, shall be randomly assigned to treatment conditions: a minimum of 30 subjects and up to 40 clinical trial subjects. Additional subjects may then be assessed, as needed, to estimate power for future clinical studies.

The shorter-term (approx. 30 day) MAD study (Task Order 1) can be undertaken in either AD subjects – that could then progress directly into Task Order 2 (i.e., the more chronic evaluation of the optimal (-)-phenserine ECRT schedule/dose portion of the study). Or, alternatively, Task Order 1 may be undertaken in healthy elderly volunteers – and then knowledge of the optimal (- )-phenserine tartrate dose can be applied to AD subjects in Task Order 2 (in which the AD subjects would be safely and rapidly dose-escalated on the optimal (-)-phenserine tartrate ECRT dose and then followed for as long as possible.

In the below scenario, Task Orders 1 and 2 have been combined in a manner in which AD subjects are used in Task Order 1 and then continued forward into Task Order 2. However, as

April 2023 IDIQ - Attachment 3 noted above, Task Order 1 alternatively could be undertaken in healthy human volunteers and then the optimal dose applied to AD subjects in Task Order 2.

(i) Alzheimer’s disease clinical study All AD patients shall discontinue their AChE inhibitor, donepezil or other, for one week. Subjects shall then receive their randomly assigned treatment of the previous dose of donepezil or donepezil 10 mg. q. d. or ECRT (-)-Phenserine tartrate (PhenT) according to treatment assignments. Since biomarkers are the outcome, double-blinding is not required. PhenT shall be dosed with a stepwise increase weekly* - until approx. steady-state 45 to 50% AChE inhibition is achieved (red blood cell assay); thereafter, this dose will be carried forward for a minimum of 26 weeks or as long as drug supplies last (except in the case of toxicity – where a dose reduction shall occur).

The ideal total time of dosing is 52 weeks – but this time is dependent on the availability of (-)- Phenserine ECRT to provide 52 weeks of dosing at the optimal dose.

AD subjects: Dosing = 26 weeks (assessments: weekly to 30 days, and then 90 days, 26 weeks and potentially longer (specifically 52 weeks - depending on available drug)). If sufficient (-)- Phenserine ECRT is available at the optimal dose, then dosing shall be continued to 52 weeks and assessments shall be made at 30 days, 26 weeks and 52 weeks (instead of 30 days, 90 and 26 weeks).

Clinical services shall provide time-dependent blood samples to support measurements for Primary biomarker assays that will be indicators of reduced Pre-programmed Neuronal Cell Death (PNCD) activities (a MINIMUM of 1 ml plasma sample (2x 0.5 ml) shall be provided by Contractor: Plasma neural- and astrocytic-derived extracellular vesicle (NEV and AEV) preparations shall be isolated from plasma samples to allow the following assays – which shall be sent to NIA/NIH.

Five panels of markers will be evaluated in samples at labs within NIA*

• PNCD: such as BAX, Bcl-2 and related family proteins, pro-caspase-3, AIF

(ELISA)

• Synaptic: such as synaptotagmin, synaptophysin, synaptopodin, PSD-95, neuronal pentraxin 2 (ELISA)

• Inflammatory: such as TNF-α, IFN-γ, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL- 12p70, IL-13 (Meso Scale Discovery multiplex assay)

• AD: such as APP, Aβ1-42, Tau, P-T181-tau and P-S396-tau (ELISA)

• Cell survival factors: such as LDLRP-6, heat-shock factor-1, and repressor element 1-/STF (ELISA).

To be undertaken by Contractor: Brain imaging (FDG PET brain imaging x2 or alike brain imaging - to be approved by NIA.

ESSENTIAL Clinical Services to be undertaken by Contractor:

Rapid AChE assay (Ellman) – to define levels of red blood cell AChE inhibition to ensure the safety of the drug study with (-)-Phenserine tartrate ECRT – this is required to be a RAPID “IN HOUSE” ASSAY and must be performed within a week of each dose escalation to define the steady-state level of erythrocyte AChE inhibition (to monitor and keep it below 55% inhibition – optimally at 45%-50% inhibition).

April 2023 IDIQ - Attachment 3

Pharmacokinetic samples must be collected by the Contractor to allow assay for:

Phenserine (P), N1 Nor P, N8 Nor P, N1,N8 Bisnor P. These samples (plasma) shall be collected under steady-state conditions by the Contractor, and plasma will be frozen to - 80o C for pharmacokinetic assays that shall be performed elsewhere under a separate contract. A plasma sample (0.5 ml) shall be collected for each PhenT dose – and will be kept frozen (-80 C) and provided to NIA by the contractor for LC/MS analysis (assay of drug concentrations does NOT fall under this current contract).

(ii) TBI clinical study Mild to moderate TBI subjects within 24 hr of injury, qualifying and giving informed consent (30 TBI subjects minimum), shall be randomly assigned to treatment conditions. Additional subjects may then be assessed, as needed, to estimate power for future clinical studies.

Subjects shall receive their randomly assigned treatment of the best available non-pharmacological care (i.e., placebo) or ECRT Phenserine (PhenT) according to treatment assignments. Since biomarkers are a key outcome, double-blinding is not required. PhenT shall be dosed with a stepwise increase weekly* - until 45 to 50% AChE inhibition is achieved;

thereafter, this dose shall be carried forward to 30 days. Thereafter pharmacological treatment will cease; however, both groups of subjects shall be followed for 1 year.

In synopsis, as shown in the Table below, TBI subjects: 30 days treatment with placebo or ECRT PhenT in increasing doses (assessments shall be made: weekly to 30 days; with follow up: 90 days, 1 year).

Study Days Dosing Schedule* PhenT Daily Dose

(Release: mg/hr) AChE Activity+

0. Patient recruitment

Rater-blinded randomization to either PhenT or placebo x**

1. PhenT ECRT Placebo

One 20 mg ECRT q.d.

Current treatment practice

1/3 Predicted Daily Dose x*

2. PhenT ECRT Placebo

One 20 mg ECRT bid Current treatment practice

2/3 Predicted Daily Dose x*

3. PhenT ECRT Placebo

One 20 mg ECRT tid Current treatment practice

3/3 Predicted Daily Dose x*

4. PhenT ECRT Placebo

Two 20 mg ECRT bid Current treatment practice

4/3 Predicted Daily Dose x*

5. PhenT ECRT Placebo

Two 20 mg ECRT bid At clinically indicated doses

4/3 Predicted Daily Dose x*

*Weekly Dose Escalation (1 thru 5) + At baseline prior to initial dosing, a blood sample for AChE activity shall be withdrawn coordinated with a blood draw for exosome and blood-based research and safety studies.

Thereafter, alike samples shall be taken for each dose-escalation and an AChE inhibition assay shall be performed by the Contractor in “real time” to allow safe and ‘informed’ dose escalation

April 2023 IDIQ - Attachment 3 up to 45%-50% erythrocyte AChE inhibition under steady-state conditions (importantly, AChE erythrocyte inhibition should not exceed 55%) – The optimal dose shall be taken forward to 30 days total treatment (at this point drug treatment will end and ‘follow up’ shall be initiated).

Follow up at 90 days and 26 weeks will be undertaken by the Contractor in the event that the AD portion of the study last for 26 weeks total. However, follow for the TBI study shall be at 26 and 52 weeks in the event that the AD portion of the study last for 52 weeks total.

Patient number:

Patient Number: in the event that Task Order 1 MAD study is undertaken in healthy human volunteers, a minimum of 6 subjects is required.

In the event that Task Orders 1 and 2 are combined and undertaken in AD subjects – whereby AD subjects are recruited into Task Order 1 – an optimal Phenserine ECRT dose is found to achieve approx. steady-state 45% to 50% (but less than 55%) AChE inhibition – and then this dose is advanced into Task Order 2 for longer-term evaluation – a minimum of 15 AD patients taking (-)-phenserine ECRT is required. An equal group of 15 AD subjects will be followed that receive a routine dose of donepezil (routine 5 mg dose). This study is not double blind (but is blinded to the patients and neuropsychologist administering and computerized evaluation)

In the event that Task Order 2 is separate from Task Order 1 - a minimum of 15 AD patients taking (-)-phenserine ECRT is required. An equal group of 15 AD subjects will be followed that receive a routine dose of donepezil (routine 5 mg dose). This study is not double blind (but is blinded to the patients and neuropsychologist administering and computerized evaluation

For Task Order 3 (TBI) - a minimum of 15 TBI patients taking (-)-phenserine ECRT is required.

An equal group of 15 TBI subjects will be followed that receive a routine non-pharmacological care. This study is not double-blind.

Deliverables:

(i) Time-dependent plasma samples (frozen and stored at approx. -80oC) from pharmacokinetic (MAD) studies to allow quantification of primary drug + metabolites elsewhere. (ii) Data relating to percent inhibition of erythrocyte AChE activity of each subject from MAD study. (iii) Data related to drug tolerability and routine physiological function(s) related to MAD study as well as to subjects moved into Task Order 2 and 3. (iv) Data related to efficacy outcomes defined for AD in Task Order 2 and for TBI in Task Order 3. (v) Statistical evaluation of the provided data

April 2023 Task Order 1 - Attachment 3

STATEMENT OF WORK

Task Order 1: Multiple ascending dose (MAD) study

Title: Clinical evaluation of Phenserine tartrate Extended Controlled Release Tablet brain injury

I. BACKGROUND AND INTRODUCTION

There is a significant unmet need for Alzheimer’s disease therapeutics as well as drugs that favorably impact the consequences of brain injury as it can initiate cascades of biological events that may lead to long-term neurodegenerative disorders such as Alzheimer’s disease. The focus of this contract is to evaluate a promising candidate that may provide beneficial actions to both disorders.

Task Order 1 is to undertake a multiple ascending dose (MAD) evaluation of a (-)-Phenserine tartrate Extended Controlled Release Tablet (ECRT) formulation in either healthy elderly volunteers or subjects with early mild Alzheimer’s disease (AD) within a broader project to evaluate pharmacokinetic and pharmacodynamic measures of (-)-Phenserine tartrate ECRT in a phase ½ clinical trial of subjects with (i) early mild AD and (ii) moderate traumatic brain injury (TBI). Specifically, the contract (Task Order 1) is to provide clinical services for the approved administration of drug to a well-characterized patient population (either mild AD or healthy elderly volunteers (>65 years age)), and to obtain blood and other sample/measures from them under rigorously safe conditions for later evaluation of pharmacokinetic and pharmacodynamic measures associated with drug plasma concentrations, blood markers of drug action, and tolerability.

A. Objectives:

The aim of this task order is to first obtain regulatory and Institutional Review Board (IRB) approvals for, and then to undertake a multiple ascending dose (MAD) clinical study to evaluate the safety, tolerability, and time-dependent pharmacokinetics/pharmacodynamics (particularly acetylcholinesterase (AChE) inhibition) of (-)-phenserine tartrate ECRT (Task Order 1). This will involve a classical Multiple Ascending Dose (MAD) study over a duration of approx. 30 days.

Of note, information gained from Task Order 1 will feed into Task Order 2 (see separate SOW). Specifically, with an understanding of the optimal dose achieved in the MAD study undertaken in Task Order 1, this will allow the safe and rapid titration up to this optimal dose to then allow evaluation of this optimal dose of (-)-phenserine tartrate ECRT over an extended time in mild AD (Task Order 2).

Notably, in the event that the patient population is mild AD subjects in Task Order 1, these same subjects could then be extended into Task Order 2, and evaluated at their optimal drug dose obtained from Task Order 1. For Task Order 2 (see separate SOW), the evaluation time would be over a minimum of 26 weeks (and, depending on drug availability, may be further extended). A single-blinded group of matched early AD subjects taking a routine dose of donepezil will act as the placebo arm.

Task Order 1 - Attachment 3

April 2023

The Task Order 1 study shall be focused on monitoring (i) safety and (ii) erythrocyte acetylcholinesterase (AChE) inhibition (that can be up to but no more that 50%) to achieve an optimal/maximally tolerated (-)-Phenserine tartrate ECRT dose (that does not cause unacceptable side effects or overt toxicity). Blood samples shall obtain from the MAD study to support pharmacokinetic (e.g., quantification of drug levels of primary drug and select major metabolites) and biomarker analyses (e.g., exosome biomarkers of (i) cell death pathways, (ii) Alzheimer’s disease markers, (iii) synaptic markers and (iv) neuroinflammation markers) – involving assays that shall be conducted in other labs (not within this contract or SOW).

Of note, a rapid assay of red blood cell acetylcholinesterase inhibition is an essential requirement of Task Order 1 in the MAD portion of the study, to ensure that (-)-phenserine tartrate ECRT dosing maximally achieves approx. 45% to 50% inhibition but, importantly, does not exceed 50% inhibition. Drug dosing shall be increased (and blood samples, toxicity evaluation performed) upto 45% to 50% erythrocyte inhibition or dose-limiting toxicity is achieved – and then will be stopped.

B. Background Alzheimer’s disease (AD) is the most common neurodegenerative disorder worldwide, and afflicted in excess of 5.8 million people aged 65 and older in the US in 2020. New pharmacologic treatments able to effectively delay or prevent AD onset and development are required. The focus of this contract is to evaluate a new treatment under optimal dosing conditions – whereby the drug achieves steady-state levels in plasma consequent to its administration as an oral extended release tablet formulation.

Phenserine: The focus of this task order is to evaluate select pharmacodynamic and pharmacokinetic measures of an Alzheimer drug, (-)-Phenserine tartrate ECRT to specifically define what drug dose can be safely titrated up to to achieve approx. 45% to 50% erythrocyte AChE inhibition without toxicity. This dose shall then be utilized in other clinical studies (Task Orders 2 and 3). (-)-Phenserine tartrate has been previously administered to human subjects – but primarily in the form of an oral immediate release formulation (Greig et al., 2005; Kadir et al., 2008; Winblad et al., 2010).

References Greig NH, Ruckle J, Comer P, Brownell L, Holloway HW, Flanagan DR Jr, Canfield CJ, Burford RG. Anticholinesterase and pharmacokinetic profile of phenserine in healthy elderly human subjects. Curr Alzheimer Res. 2(4):483-92, 2005.

Kadir A, Andreasen N, Almkvist O, Wall A, Forsberg A, Engler H, Hagman G, Lärksäter M, Winblad B, Zetterberg H, Blennow K, Långström B, Nordberg A. Effect of phenserine treatment on brain functional activity and amyloid in Alzheimer's disease. Ann Neurol. 63(5):621-31, 2008.

Winblad B, Giacobini E, Frölich L, Friedhoff LT, Bruinsma G, Becker RE, Greig NH.

Phenserine efficacy in Alzheimer's disease. J Alzheimers Dis. 22(4):1201-8, 2010.

The contractor shall provide a team with specific knowledge and background in (i) the patient populations (AD and/or health elderly volunteers), (ii) the drug class being evaluated (agents that mitigate neuronal cell dysfunction/death together with anticholinesterases action), as well as (iii) on the specific drug of interest ((-)-Phenserine tartrate), to ensure rigorous safety in its https://pubmed.ncbi.nlm.nih.gov/16248851/ https://pubmed.ncbi.nlm.nih.gov/18300284/ https://pubmed.ncbi.nlm.nih.gov/18300284/ https://pubmed.ncbi.nlm.nih.gov/20930279/ https://pubmed.ncbi.nlm.nih.gov/16248851/ https://pubmed.ncbi.nlm.nih.gov/16248851/ https://pubmed.ncbi.nlm.nih.gov/18300284/ https://pubmed.ncbi.nlm.nih.gov/18300284/ https://pubmed.ncbi.nlm.nih.gov/20930279/

April 2023 administration and dose escalation, and optimization in patients to obtain and provide required blood samples and related materials to NIA by the contractor.

Task Order 1 will evaluate a new Extended Controlled Release Tablet (ECRT) formulation of (- )-Phenserine tartrate – and shall evaluate (i) its ability to safely maintain steady-state therapeutic levels drug + metabolite concentrations in either healthy elderly volunteers (>65 years age) or early mild AD subjects following different doses, (ii) its short-term ability to impact select markers: specifically, red blood cell (RBC) acetylcholinesterase inhibition levels (AChEI) – as a rapid marker of safe drug levels (levels of RBC AChEI – together with lack of adverse events (AEs) will define safe dose escalation to an optimal level of approx. 45 to 50% AChEI), (iii) exosome markers of (a) apoptotic/pro-survival proteins, (b) AD markers, (c) synaptic and (d) neuroinflammatory processes.

Task Order 1 shall hence be an evaluation of the tolerability and pharmacokinetics/pharmacodynamics of ECRT (-)-Phenserine tartrate in a classical MAD study that can be undertaken either in healthy elderly volunteers or in AD subjects. The focus of this study would be to evaluate the duration of action (i.e., pharmacokinetics of (-)-phenserine and select primary metabolites, and AChE red blood cell inhibition) in order to achieve an approx.

steady-state 45% to 50% inhibition of red blood cell AChE. This would involve a rational evaluation of drug scheduling and dose escalation to achieve such a steady-state in a MAD study that would take place over approx. 30 days.

Thereafter, such knowledge – will be applied to Task Order 2 and Task Order 3.

I. SCOPE AND OBJECTIVES

The main objective of Task Order 1 is to provide a service to perform an evaluation of (-)- Phenserine tartrate ECRT in subjects with early mild Alzheimer’s disease (AD) or that are healthy elderly volunteers to support assessment of blood and other samples to evaluate pharmacokinetic and pharmacodynamic measures. This will involve a multiple ascending dose (MAD) study of (-)-Phenserine ECRT (Task Order 1).

II. III. TECHNICAL REQUIREMENTS

Independently and not as an agent of the Government, the Contractor shall furnish all the necessary resources, qualified personnel, material, equipment, and facilities, not otherwise provided by the Government under the terms of this Contract, as needed to perform the technical requirements outlined below. (-)-Phenserine tartrate ECRT will be provided to the Contractor – as will Phenserine immediate dose formulation (if required within the TBI portion of the study – to achieve a more immediate steady-state blood level).

Should the MAD (Task Order 1) phase of the project demonstrate that (-)-Phenserine tartrate ECRT does not adequately release (-)-phenserine/and metabolites to achieve a steady-state. (-)- Phenserine immediate release capsules can be provided to the Contractor by the Government (for administration up to 4 times daily to achieve an approx. steady-state) to allow Task Orders 2 and 3 to move ahead.

April 2023

III. A. Specific Task Areas

Proposed Clinical Trial Services: Following regulatory and other required approvals (such as IRP approval), subjects, qualifying and giving informed consent, will be randomly assigned to treatment conditions: up to 10 clinical trial subjects. Additional subjects may then be assessed, as needed.

The proposed shorter-term (approx. 30 day) MAD study (Task Order 1) can be undertaken in either AD subjects – that could then progress directly into Task Order 2 (i.e., the more chronic evaluation of the optimal (-)-phenserine ECRT schedule/dose portion of the study). Or, alternatively, Task Order 1 may be undertaken in healthy elderly volunteers – and then knowledge of the optimal (-)-phenserine tartrate dose can be applied to AD subjects in Task Order 2 (in which the AD subjects would be safely and rapidly dose-escalated on the optimal (- )-phenserine tartrate ECRT dose and then followed for as long as possible.

In the below scenario, Task Orders 1 and 2 could then be combined in a manner in which AD subjects are used in Task Order 1 and then continued forward into Task Order 2. However, as noted above, Task Order 1 alternatively could be undertaken in healthy human volunteers and then the optimal dose applied to AD subjects in Task Order 2.

(i) MAD clinical study Should AD patients be used, they must discontinue their AChE inhibitor (donepezil or other) for one week. Subjects shall then receive their randomly assigned treatment of either a placebo (2 subjects) or (-)-Phenserine tartrate ECRT (PhenT) (6 to 8 subjects). As biomarkers are the outcome, double-blinding is not required (single-blinding of the patient is encouraged). PhenT shall be dosed with a stepwise increase weekly* - until approx. steady-state 45 to 50% AChE inhibition is achieved (red blood cell assay); thereafter, this dose shall be carried forward into Task Order 2.

Over a 30 day period the following MAD study will be undertaken as Task Order 1 in either mild AD subjects or health elderly volunteers (but not both)

Study Days Dosing Schedule* PhenT Daily Dose

(Release: mg/hr) AChE Activity+

0. Holiday Week

No AChE drug dosing for one week prior to drug. Baseline measures will be taken for erythrocyte AChE x*+

1. PhenT

ECRT

or placebo

One x 20 mg ECRT q.d.

Dosed similar to PhenT

1/3 Predicted Required Daily Dose x*

2. PhenT

ECRT

or placebo

One x 20 mg ECRT bid

Dosed similar to PhenT

2/3 Predicted Daily Dose x*

3. PhenT

ECRT

or placebo

One x 20 mg ECRT tid

Doses similar to PhenT

3/3 Predicted Daily Dose x*

April 2023

4. PhenT

ECRT

or placebo

Two x 20 mg ECRT bid

Dosed similar to PhenT

4/3 Predicted Daily Dose x*

5. PhenT

ECRT

or placebo

Two x 20 mg ECRT bid

Dosed similar to PhenT

4/3 Predicted Daily Dose x*

*5 day to weekly Dose Escalation + At baseline prior to dosing, a blood sample for AChE activity shall be withdrawn coordinated with blood draw for exosome and blood-based research and safety studies.

Outcome Measures that Services shall be focused towards:

Study

Days 0-30 (dose escalation every 5 days to weekly until optimal dose identified (maximal 45~50% erythrocyte AChE inhibition) – as evaluated by REQUIRED in house AChEI assay (Ellman or other assay - to be approved by NIA, NIH).

Assessments Qualification Prior to Week 1, Baseline and under each steady-state to End

The contractor shall provide time-dependent blood samples to support measurements for primary assays: (i) red blood cell AChE inhibition assay shall be rapidly performed by the contractor to ensure that AChE inhibition remains lower than 50% prior to the next dose escalation (it is hence essential that the contractor has access to a AChE assay that can be quickly performed). This assay requires a ‘whole blood sample’. (ii) Plasma samples shall be obtained that will allow evaluation of drug + primary metabolite concentrations. These plasma samples shall be immediately frozen and stored for later shipping to NIA, NIH. A MINIMUM of 2 ml plasma sample (4 x 0.5 ml) shall be provided by Contractor.

For the maximally tolerated dose of PhenT, additional blood samples shall be taken for evaluation of safety measures by the contractor (such as liver enzyme levels, electrolytes, blood differential test, etc.). AEVs shall be evaluated and ECG, etc., monitored.

Patient number:

Patient Number: in the event that Task Order 1 MAD study is undertaken in healthy human volunteers is a minimum of 6 subjects on PhenT and 2 placebo subjects.

In the event that Task Orders 1 and 2 are combined and undertaken in AD subjects – whereby AD subjects are recruited into Task 1 – an optimal (-)-Phenserine ECRT dose is found to achieve approx. steady-state 45% to 50% AChE inhibition – and then this dose is advanced into Task Order 2 for longer-term evaluation – a minimum of 15 AD patients taking (-)-phenserine ECRT is required in Task Order 2. An equal group of 15 AD subjects shall be followed that receive a routine dose of donepezil (routine 5 mg dose). This study is not double blind (but is blinded to the patients and neuropsychologist administering and computerized evaluation).

April 2023

Deliverables and Schedules:

(i) Time-dependent plasma samples (frozen and stored at approx. -80oC) from pharmacokinetic (MAD) studies to allow quantification of primary drug + metabolites elsewhere.

(ii) Data relating to percent inhibition of erythrocyte AChE activity of each subject from MAD study. (iii) Data related to drug tolerability and routine physiological function(s) related to MAD study.

These deliverables are due at the end of the task order period of performance.

Period of Performance: 9 months.

April 2023 Task Order 2 - Attachment 3

Task Order 2: Alzheimer efficacy study

Title: Clinical evaluation of (-)-Phenserine tartrate Extended Controlled Release Tablet brain injury

I. BACKGROUND AND INTRODUCTION

There is a significant unmet need for Alzheimer’s disease therapeutics as well as drugs that favorably impact the consequences of brain injury as it can initiate cascades of biological events that may lead to long-term neurodegenerative disorders such as Alzheimer’s disease. The focus of this task order is to evaluate a promising candidate that may provide beneficial actions to both disorders.

The purpose of this task order is to select and evaluate the optimal dose that induces approx.

steady-state levels of acetylcholinesterase erythrocyte inhibition of 45-55% (but no greater than approx. 50%) in subjects with early mild Alzheimer’s disease (AD). This Phenserine tartrate ECRT group of 15 AD patients shall be compared to a matched group of 15 AD patients taking a routine dose of the drug Donepezil (single-blinded)

Specifically, the contract is to provide clinical services for the approved administration of the drug Phenserine tartrate ECRT at an optimized dose (determined in Task Order 1 – separate SOW) in a well-characterized mild AD patient populations, and to obtain blood and other sample/measures from them under rigorously safe conditions for later evaluation of pharmacokinetic and pharmacodynamic measures associated with drug plasma concentrations, blood markers of drug action, tolerability and brain/blood markers of efficacy.

A. Objectives:

The aim of this task order (Task Order 2), is to then safely and rapidly titrate up to this optimal dose and evaluate this optimal dose of phenserine tartrate ECRT over an extended time in mild AD patients. Dosing of AD subjects shall be for up to 26 weeks and may potentially extend to 52 weeks (depending on the availability of (-)-phenserine tartrate ECRT) – alongside a matching group of AD subjects administered a routine dose of donepezil (5 mg) (instead of (-)-Phenserine tartrate ECRT), which shall act as the ‘control arm’ of the study.

The study shall be focused on monitoring safety to achieve an optimal/maximally tolerated Phenserine tartrate ECRT dose (that does not cause unacceptable adverse effects or overt toxicity) and obtaining blood samples to support pharmacokinetic (e.g., drug levels of primary drug and select major metabolites) and biomarker analyses (e.g., exosome biomarkers of (i) cell death pathways, (ii) Alzheimer’s disease markers, (iii) synaptic markers and (iv) neuroinflammation markers) – involving assays that will be conducted in other labs (not within this contract or SOW). However, clinical (computerized neuropsychology) and imaging outcomes on enrolled participants in the this AD Task Order 2 study shall be undertaken within this contract. Additionally, rapid assay of red blood cell acetylcholinesterase inhibition is an essential requirement of the contract, to ensure that (-)-phenserine tartrate ECRT dosing

April 2023 Task Order 2 - Attachment 3 maximally achieves approx. 45% to 50% inhibition but, importantly, does not exceed approximately 50% inhibition.

B. Background Alzheimer’s disease: Alzheimer’s disease (AD) is the most common neurodegenerative disorder worldwide. In the US alone, an estimated 5.8 million people aged 65 and older were affected in 2020, which is projected to increase to 13.8 million by 2050 [Herbert et al., 2013]. Because of the significant health, social and economic burden associated with the disease, there have been numerous attempts to find a pharmacologic treatment able to effectively delay or prevent the onset and development of pathology. Despite these efforts, the clinical trial failure rate remains extremely high. The few currently approved AD drugs address symptomatic issues. Being able to mitigate the cognitive impairment characteristic of the disorder only temporarily; they are not effective in stopping or reversing disease progression (Pangalos et al., 2007; Mehta et al., 2017;

Lao et al., 2019).

Hebert LE, Weuve J, Scherr PA, Evans DA Alzheimer disease in the United States (2010-2050) estimated using the 2010 census. Neurology. 80(19):1778-83, 2013.

Lao K, Ji N, Zhang X, Qiao W, Tang Z, Gou X. Drug development for Alzheimer's disease:

review. J Drug Target. 27(2):164-173, 2019.

Mehta D, Jackson R, Paul G, Shi J, Sabbagh M.Why do trials for Alzheimer's disease drugs keep failing? A discontinued drug perspective for 2010-2015. Expert Opin Investig Drugs. 26(6):735- 739, 2017.

Pangalos MN, Schechter LE, Hurko O. Drug development for CNS disorders: strategies for balancing risk and reducing attrition. Nat Rev Drug Discov. 6(7):521-32, 2007.

Task Order 2 shall evaluate a new Extended Controlled Release Tablet (ECRT) formulation of (-)-Phenserine tartrate – and shall evaluate (i) it’s ability to maintain steady-state therapeutic levels in early mild AD subjects following an optimized dose (obtained from Task Order 1), (ii) Its ability maintain red blood cell (RBC) acetylcholinesterase inhibition levels (AChEI) – as a rapid marker of safe drug levels (levels of RBC AChEI are optimal at approx. 45 to 50% AChEI, and importantly should not exceed approx. 50% AChEI), (iii) exosome markers of (a) apoptotic/pro-survival proteins, (b) AD markers, (c) synaptic and (d) neuroinflammatory processes. (iv) Longer term markers of the same, as well as of safety, cognitive and imaging outcomes.

Task Order 2 shall be the rapid and safe titration to the optimal dose (i.e., the schedule and dose that best achieves approx. steady-state 50% inhibition of red blood cell AChE deriving from Task Order 1) in AD subjects and then to maintain this dose chronically (for 26 weeks or – if possible – for up to 12 months depending on the exhaustion of the available supply of ECRT (-)-phenserine tartrate).

https://pubmed.ncbi.nlm.nih.gov/23390181/ https://pubmed.ncbi.nlm.nih.gov/17599084/ https://pubmed.ncbi.nlm.nih.gov/28460541/ https://pubmed.ncbi.nlm.nih.gov/29732929/ https://pubmed.ncbi.nlm.nih.gov/29732929/ https://pubmed.ncbi.nlm.nih.gov/29732929/ https://pubmed.ncbi.nlm.nih.gov/28460541/ https://pubmed.ncbi.nlm.nih.gov/28460541/

April 2023 Task Order 2 - Attachment 3

I. SCOPE AND OBJECTIVES

The main objective of this task order is to provide a service to perform a phase 1/2 clinical trial evaluation of Phenserine tartrate ECRT in subjects with early mild Alzheimer’s disease (AD) (Task Order 2). Specifically, Task Order 2 shall perform clinical services to provide safety/tolerability assessment, brain imaging, cognitive assessment as well as blood and other samples to support evaluation of pharmacokinetic and pharmacodynamic measures of (-)- Phenserine tartrate ECRT chronically when administered as an approximate steady-state dose that achieves an approx. 45-50% inhibition of erythrocyte AChE . In initial Task Order 1, a multiple ascending dose (MAD) study of (-)-Phenserine ECRT will be undertaken to target the dose for current Task Order 2 – to support a longer-term study in mild AD subjects.

II. III. TECHNICAL REQUIREMENTS

Independently and not as an agent of the Government, the Contractor shall furnish all the necessary resources, qualified personnel, material, equipment, and facilities, not otherwise provided by the Government under the terms of this Contract, as needed to perform the technical requirements outlined below. (-)-Phenserine tartrate ECRT will be provided to the Contractor by

NIA.

Should the MAD (Task Order 1) phase of the project demonstrate that (-)-Phenserine tartrate ECRT does not adequately release (-)-phenserine/and metabolites to achieve a steady-state. (-)- Phenserine immediate release capsules can be provided to the Contractor by the Government (for administration up to 4 times daily to achieve an approx. steady-state) to allow Task Orders 2 to move ahead.

III. A. Specific Task Areas

Proposed…