A Trial of Tocilizumab in ALS Subjects

This is a multicenter, randomized, double-blind, placebo-controlled 16-week study evaluating
the safety and tolerability of tocilizumab in subjects with ALS.

The primary objective of the study is to determine the safety and tolerability of intravenous
administration of 8 mg/kg of tocilizumab every 4 weeks vs. matched intravenous placebo
administered every 4 weeks over an 8 week period.

The secondary objectives of the study are to describe the expression of pro-inflammatory
genes in Peripheral Blood Mononuclear Cells (PBMCs) of sporadic ALS patients, to assess the
ability of tocilizumab to reduce the expression of pro-inflammatory genes in PBMCs and
pro-inflammatory cytokines in the cerebrospinal fluid (CSF) of patients with sporadic ALS and
to assess the CSF penetration of tocilizumab. Mean PBR28 uptake will be measured in the motor
cortices as regions of interest (ROIs), and will be compared between pre- and post-dose, for
MGH subjects.

Approximately 5 Northeast ALS Consortium (NEALS) Centers in the US will participate in the
study. Twenty-four subjects will be randomized in the study.

This study will be conducted in subjects who meet the El Escorial criteria of possible,
laboratory-supported probable, probable, or definite criteria for a diagnosis of ALS. At
screening, eligible subjects must be at least 18 years old, must have a slow vital capacity
(SVC) ≥ 40% of predicted capacity for age, height and gender (and in the opinion of the
investigator is able to comply with and complete the trial), and must provide written
informed consent prior to screening. Subjects on a stable dose of riluzole and those not
taking riluzole, and women of child-bearing age at screening are eligible for inclusion as
long as they meet specific protocol requirements. Detailed criteria are described in the body
of the protocol.

Subjects participating in the MR-PET portion of the study (MGH only) must meet the following
additional criteria.High or mixed affinity to bind TSPO protein (Ala/Ala or Ala/Thr,) Upper
Motor Neuron Burden (UMNB) Scale Score ≥25 (out of 45) at the Screening Visit.

and have the ability to safely undergo PET/MRI scans based on the opinion of the site
investigator.

Subjects will be randomly assigned in a 2:1 ratio to intravenous tocilizumab 8 mg/kg or
matching placebo every 4 weeks over an 8 week period.

This research study protocol allows the subject to receive up to 3 infusions of Tocilizumab.
Even if the treatment is shown to be of benefit, additional infusions of Tocilizumab beyond
that allowed in the protocol cannot be given to the subject while she/he is participating in
this study.

Subjects will remain on randomized, placebo-controlled, double-blind treatment until the Week
8 visit. Each randomized subject will also have a Week 12 Follow-up visit and Week 16
End-of-Study visit to assess for adverse events (AEs), changes in concomitant medications, to
administer the ALSFRS-R and selected study procedures.

Inclusion Criteria:

- Participants with ALS (El Escorial criteria: possible, laboratory-supported probable,
probable or definite)

- Capable of providing informed consent and complying with trial procedures.

- High inflammatory profile of PBMC gene expression

- Upright SVC ≥40% of predicted value for gender, height and age at Screening and in the
opinion of the investigator is able to comply with and complete the trial.

- Women must not be able to become pregnant for the duration of the study.

- Negative tuberculosis blood or skin test at Screening

- Not taking riluzole, or on a stable dosage for at least 30 days prior to Screening.

- Subjects medically able to undergo lumbar puncture (LP)

- Subjects must agree not to take live attenuated vaccines 30 days before Screening,
throughout the duration of the trial and for 60 days following the subject's last dose
of study drug

- Geographic accessibility to the study site

Additional MR-PET Inclusion Criteria (MGH only):

- High or mixed affinity to bind TSPO protein (Ala/Ala or Ala/Thr) (see section 7.1)

- Upper Motor Neuron Burden (UMNB) Scale Score ≥25 (out of 45) at the Screening Visit.

- Able to safely undergo PET/MRI scans based on the opinion of the site investigator.

Exclusion Criteria:

- Prior use of Tocilizumab,cell-depleting therapies, alkylating agents, total lymphoid
irradiation

- Stem cell therapies

- Dependence on mechanical ventilation as defined as being unable to lay supine without
it, unable to sleep without it, or continuous daytime use

- Presence of tracheostomy at Screening

- Exposure to any anti-inflammatory agent currently under investigation for the
treatment of patients with ALS (off label use or investigational) within 30 days prior
to the Screening Visit (examples include NP001 and Lunasin). Medications that do not
have an anti-inflammatory mechanism, such as mexiletine or retigabine are allowed if
on stable dose for 30 days prior to Screening visit

- Treatment with a prohibited medication within 30 days of the Screening Visit

- Treatment with intravenous gamma globulin, plasmapheresis or Prosorba column within 6
months of Screening

- Presence of diaphragm pacing system at Screening.

- Primary or secondary immunodeficiency (history of or currently active) unless related
to primary disease under investigation

- History of or active diverticulitis, diverticulosis requiring antibiotic treatment,
peptic ulcer disease, or GI tract perforation, or chronic ulcerative lower GI disease
such as Crohn's disease, ulcerative colitis or other symptomatic lower GI conditions
that might predispose to perforations

- Known active current or history of recurrent bacterial, viral, fungal, mycobacterial
or other opportunistic infections.

- History of severe allergic or anaphylactic reactions to human, humanized or murine
monoclonal antibodies

- Presence of any of the following clinical conditions: bleeding diathesis, or any other
clinical condition that would, in the opinion of the investigator, place the patient
at increased risk during LP. Drug abuse or alcoholism within the past 12 months.
Unstable cardiac, pulmonary, renal, hepatic, endocrine, hematologic, or active
infectious disease, including current or prior malignancy. Rheumatic autoimmune
disease, mixed connective tissue disease, scleroderma, polymyositis, or significant
systemic involvement secondary to rheumatoid arthritis. Evidence of active malignant
disease, malignancies diagnosed within the previous 5 years, or breast cancer
diagnosed within the previous 5 years. Human immunodeficiency virus infection or other
immunodeficient state.Uncontrolled hypertension defined as systolic blood pressure >
170 or diastolic blood pressure > 110. Unstable psychiatric illness defined as
psychosis or untreated major depression within 90 days of the Screening Visit

- Any major episode of infection requiring hospitalization or treatment with IV
antibiotics within 4 weeks of screening

- Screening ALT, AST, or total bilirubin > than 1.5 times the ULN, serum creatinine >
1.6 mg/dL in female patients and > 1.9 mg/dL in male patients (patients with serum
creatinine values exceeding limits may be eligible for the study if their estimated
GFR are >30), hemoglobin < 85 g/L, white blood cells < 3.0 x 109/L, absolute
neutrophil count of <2000/mm3, absolute lymphocyte count < 0.5 x 109/L, platelet
concentration of <100,000/mm3, positive Hepatitis B surface antigen (HBsAg)

- Pregnant women or women currently breastfeeding

- No history of chicken pox infection or no history of varicella zoster vaccination

- Any reason in the opinion of the investigator that the patient may not be able to
comply with study procedures, complete the study or is unsuitable for
immunosuppressive therapy.

Additional MR-PET Exclusion Criteria (MGH only):

- Any contraindication to undergo MRI studies such as

- History of a cardiac pacemaker or pacemaker wires

- Metallic particles in the body

- Vascular clips in the head

- Prosthetic heart valves

- Claustrophobia

- Radiation exposure that exceeds the site's current guidelines

- Current use of tobacco products including cigarettes, e-cigarettes, cigars, snuff and
chewing tobacco, or nicotine replacement products such as gum, or patch

- Taking any other anti-inflammatory or immune modulating medications except for over
the counter NSAIDs

- Unwilling or unable to discontinue benzodiazepine usage (other than Lorazepam,
Clonazepam, or Zolpidem) for one day prior to scanning