Phase2, double-blind, randomized, placebo-controlled, multicentre study to evaluation the safety, efficacy, and pharmacokinetics of TAK-242 and Granulocyte Colony-Stimulating Factor (G-CSF) (G-TAK) in subjects with severe alcoholic hepatitis (sAH) and acute-on-chronic liver failure (ACLF).

The primary objective of this Phase 2 clinical trial is to investigate the **safety** of TAK-242 in combination with Granulocyte Colony-Stimulating Factor (G-CSF), referred to as G-TAK, in patients with severe alcoholic hepatitis (sAH) and acute-on-chronic liver failure (ACLF). This is clinically relevant as it aims to ensure that the combination therapy does not pose undue risk to patients, which is crucial for the potential therapeutic application in managing these severe liver conditions.

Secondary objectives include evaluating the effect of G-TAK on the disease severity of ACLF and exploring the disease mechanisms modulated by G-TAK. These objectives are important for understanding the therapeutic potential and mechanistic action of the treatment, which could inform future clinical strategies and improve patient outcomes in these complex liver diseases.

The clinical trial involves a total of **28 participants** diagnosed with **acute-on-chronic liver failure (ACLF)**, specifically targeting those with Grade 1 to 3 ACLF, limited to three organ failures, and a baseline CLIF-C ACLF-CRP score between 35 and 60. The study population includes both male and female subjects aged between 18 and 75 years. Participants are required to comply with acceptable contraceptive methods. The trial focuses on individuals with severe alcoholic hepatitis resistant to steroid therapy, as indicated by a Lille score greater than 0.45, or in cases where steroids are contraindicated. The selection process ensures the inclusion of a vulnerable population, with no specific lifestyle considerations such as diet or physical activity mentioned. The trial aims to assess the safety of the combination therapy of TAK-242 and G-CSF in this patient group.

The clinical trial is a **Phase 2**, double-blind, randomized, placebo-controlled, multicenter study designed to evaluate the safety, efficacy, and pharmacokinetics of **TAK-242** and **Granulocyte Colony-Stimulating Factor (G-CSF)** in subjects with severe alcoholic hepatitis (sAH) and acute-on-chronic liver failure (ACLF). The trial aims to enroll up to 78 participants with Grade 1-3 ACLF, characterized by a maximum of three organ failures and a baseline CLIF-C ACLF-CRP score between 35 and 60. The study will assess the primary endpoint of the percentage of subjects experiencing at least one treatment-emergent adverse event (TEAE) or serious adverse event (SAE), as well as the percentage of subjects discontinuing the study drug due to an adverse event.

The trial will be conducted over an estimated duration from April 17, 2023, to January 31, 2025. Participants will be randomly assigned to receive either the investigational product, TAK-242, in combination with G-CSF, or a placebo. The investigational product will be administered as a concentrate for solution for infusion, while the placebo will be provided as a solution for injection. The maximum treatment period for TAK-242 is 10 days, with a daily dose not exceeding 1.8 mg/kg/h and a total dose not exceeding 18 mg/kg/h. For G-CSF, the maximum treatment period is 6 days, with a daily dose not exceeding 5 µg/kg and a total dose not exceeding 30 µg/kg.

Study visits will include an initial screening visit to confirm eligibility based on inclusion criteria such as age, diagnosis of severe alcoholic hepatitis, and compliance with contraceptive methods. Follow-up visits will be scheduled to monitor safety, efficacy, and pharmacokinetics, with assessments of organ function, systemic inflammation, and quality of life. The end-of-study visit will evaluate the overall survival and transplant-free survival at Day 28 and Day 84. Participants are expected to be involved in the study for the duration of the treatment period and follow-up assessments, with conditions for early termination including the occurrence of significant adverse events or withdrawal of consent.

The clinical trial involves the administration of **Resatorvid (TAK-242)**, a **concentrate for solution for infusion**. This experimental medication is a selective inhibitor of TLR4-mediated signaling, provided by YAQRIT LTD. The pharmaceutical form is a concentrate for solution for infusion, and it is administered intravenously. The dosage is calculated based on body weight, with a maximum daily dose of 1.8 mg/kg/h and a total maximum dose of 18 mg/kg over a treatment period of up to 10 days. Participant compliance is monitored through regular assessments of infusion rates and adherence to the dosing schedule.

A **placebo** is used as a comparator in this study. The placebo is formulated as a solution for injection and is chemically inert, serving as a control to evaluate the efficacy and safety of Resatorvid. The placebo is administered in the same manner as the experimental drug, with a maximum daily dose of 1.8 mg/kg/h and a total maximum dose of 18 mg/kg over a 10-day period. This ensures blinding and maintains the integrity of the study design.

Additionally, the trial includes the administration of **Neupogen 30 MU (0.3 mg/ml) solution for injection**, which contains the active substance **filgrastim**. This medication is provided by AMGEN EUROPE B.V. and is used as a leukocyte growth factor. It is administered subcutaneously, with a maximum daily dose of 5 µg/kg and a total maximum dose of 30 µg/kg over a treatment period of up to 6 days. The dosing schedule involves subcutaneous injections, and participant compliance is monitored through regular follow-ups and assessments of injection adherence.

The study also involves the use of a **placebo for filgrastim**, which is administered subcutaneously on days 1-5 and additionally on day 8, totaling six doses. This placebo consists of the vehicle used in commercial filgrastim vials and is supplied by the sponsor. The placebo is used to maintain blinding and ensure the validity of the trial results by providing a control for the filgrastim treatment group.

The efficacy of the investigational treatment in this clinical trial will be assessed using several secondary endpoints. These include the change in the CLIF-C OF score from baseline to Day 14 in subjects treated with the combination of TAK-242 and Granulocyte Colony-Stimulating Factor (G-CSF), referred to as G-TAK, compared to placebo. Additionally, the change in the CLIF-C OF score in subjects treated with TAK-242 alone will be compared with those receiving G-TAK, as well as the CLIF-C ACLF-CRP score across all treatment arms. The pharmacokinetics of TAK-242 alone or in combination with G-CSF will be defined by measuring plasma Cmax and Cav of TAK-242, G-CSF, and their metabolites.

Further efficacy assessments will investigate the effects of TAK-242 alone or in combination with G-TAK on key biomarkers related to inflammation, cell death, liver function, regeneration, and senescence. These biomarkers include total bilirubin (TB), cleaved Cytokeratin-18 (M30)/Cytokeratin-18 (M65), transforming growth factor beta 1 (TGFb1), interleukin 22 (IL-22), interleukin 22 binding protein (IL-22BP), CRP, hepatic growth factor (HGF), and SDF. The trial will also evaluate the effect of TAK-242 alone or in combination with G-TAK on transplant-free and overall survival on Day 28 and Day 84 compared to placebo.

Organ function will be regularly assessed, focusing on hepatic, renal, brain, coagulation, respiratory, and cardiovascular functions. This will include evaluations using the CLIF-C organ failure score (CLIF-C OF), CLIF-C acute decompensation score (CLIF-C AD), CLIF-C ACLF-CRP score, and Systemic Inflammatory Response Score (SIRS). Changes in inflammatory markers and an ACLF-related panel, including IL-6, TNF-α, IL-10, M30/M65, sCD163, and sCD206, will be measured from baseline to Day 4, 7, and 14. The effect on the Quality of Life in subjects with severe alcoholic hepatitis (sAH) and acute-on-chronic liver failure (ACLF) will be assessed using the EQ5D5L scoring system. Additional parameters include the number of days in intensive care and the total costs of hospital treatment over a 90-day period across treatment arms.