NRX-101 for Maintenance of Remission From Severe Bipolar Depression in Patients With Suicidal Ideation

NeuroRx is developing NRX-101, a fixed-dose combination oral capsule composed of
D-cycloserine (DCS) and lurasidone for the maintenance of remission from Severe Bipolar
Depression with Acute Suicidal Ideation or Behavior (ASIB) in adults with Bipolar Depression
following initial stabilization with ketamine. NRX-101 has been awarded Fast Track and
Breakthrough Therapy Designation by the US Food and Drug Administration.

In recent years, intravenous and intranasal ketamine have demonstrated rapid and potent
effects in achieving remission from both depression and suicidal ideation in both bipolar
depression and major depressive disorder. However ketamine is will understood to induce
hallucination and other dissociative side effects, to be addictive and have high abuse
potential, and to have potential neurotoxic effects. Moreover, ketamine can only be
administered in a monitored hospital or clinic setting. NRX-101 was developed with the
objective of seeking a safe, non-hallucinogenic, non-addictive, oral medication that might
maintain the effects of ketamine in patients with severe depression and acute suicidal
ideation and which might be considered as initial therapy for patients with depression and
non-acute suicidal ideation. The D-cycloserine component of NRX-101 is believed to act by
inhibiting the brain's NMDA receptor and raising levels of glutamate/glutamine (Glx) in the
anterior cingulate cortex. Increased Glx, as measured by magnetic resonance spectroscopy, has
been associated with clinical improvement following electroconvulsive therapy (ECT) and
following administration of IV ketamine.

Primary Objective:

To test the hypothesis that following successful response to a single infusion of ketamine
(NRX-100), treatment with NRX-101 is superior to lurasidone in maintaining improvement in
symptoms of depression as measured by the MADRS-10 total score.

Secondary Objectives:

Key secondary: To test the hypothesis that following response to a single infusion of
NRX-100, daily oral NRX-101 is superior to lurasidone in delaying time to relapse of
suicidality or depression in patients with Severe Bipolar Depression and Acute Suicidal
Ideation and Behavior (ASIB). Avoiding relapse will be defined as being relapse-free, without
experiencing a 50% or greater return to pre-infusion baseline levels of depression, or
suicidality, or the need to implement a new treatment plan.

- To demonstrate that following NRX-100 response, treatment with NRX-101 are less likely
to suffer from akathisia than those treated with lurasidone.

- To demonstrate that following NRX-100 response, other efficacy advantages observed in
NRX-100 responders are more favorable for NRX-101 vs. lurasidone

- To demonstrate safety and tolerability of NRX-101 vs. lurasidone.

- To demonstrate that following successful NRX-100 response, NRX-101 diminishes the length
of stay for index hospitalization vs. lurasidone.

Methodology: A multi-center, randomized, stratified, double-blind, adaptive trial conducted
under a Special Protocol Agreement with the FDA that enrolls patients demonstrating
successful response in NCT03396601. Randomization will be 2:1 favoring NRX-101 (n=48) vs.
lurasidone alone (n=24).

Inclusion Criteria:

- A subject will be eligible for inclusion in this study based on successful response to
infusion under NCT03396601 and the following criteria:

1. 18 to 65 years of age, inclusive, at screening.

2. Able to understand and provide written and dated informed consent prior to
screening. Deemed likely to comply with study protocol and communicate AEs and
other clinically important information, and agree to be hospitalized to complete
screening and initiate experimental treatment.

3. Resides in a stable living situation, in the opinion of the investigator

4. Has an identified reliable informant, in the opinion of the investigator

5. Diagnosed with bipolar disorder (BD) according to the criteria defined in the
DSM-5. The diagnosis of BD will be made by a psychiatrist and supported by the
MINI 7.0.2.

6. In good general health, as ascertained by medical history, physical examination
(including measurement of seated vital signs), clinical laboratory evaluations,
and electrocardiogram

7. If female, a status of non-childbearing potential or use of an acceptable form of
birth control per the following specific criteria:

a. Non-childbearing potential (e.g., physiologically incapable of becoming
pregnant, i.e., permanently sterilized [status post hysterectomy, bilateral tubal
ligation], or post-menopausal with last menses at least one year prior to
screening); or b. Childbearing potential, and meets the following criteria: i.
Using any form of hormonal birth control, on hormone replacement therapy started
prior to 12 months of amenorrhea, using an intrauterine device (IUD), having a
monogamous relationship with a partner who has had a vasectomy, or sexually
abstinent.

ii. Negative urinary pregnancy test at screening, confirmed by a second negative
urinary pregnancy test at randomization prior to receiving study treatment.

iii. Willing and able to continuously use one of the following methods of birth
control during the course of the study, defined as those which result in a low
failure rate (i.e., less than 1% per year) when used consistently and correctly:
implants, injectable or patch hormonal contraception, oral contraceptives, IUD,
double-barrier contraception, sexual abstinence. The form of birth control will
be documented at screening and pre-ketamine baseline.

8. Body mass index between 18-35kg/m2.

9. Concurrent psychotherapy will be allowed if the type and frequency of the therapy
(e.g., weekly or monthly) has been stable for at least three months prior to
screening and is expected to remain stable for the duration of the study.

10. Concurrent hypnotic therapy (e.g., with zolpidem, zaleplon, melatonin,
benzodiazepines, or trazodone) will be allowed if the therapy has been stable for
at least four weeks prior to screening and if it is expected to remain stable
during the course of the subject's participation in the study. Subjects can also
continue treatment with benzodiazepines used for anxiety if therapy has been
stable for at least four weeks prior to screening and if it is expected to remain
stable during the course of the subject's participation in the study.

Exclusion Criteria:

A subject will not be eligible for inclusion in this study if any of the
following criteria apply:

1. Female of childbearing potential who is not willing to use one of the specified
forms of birth control during the study.

2. Female who is pregnant or breastfeeding.

3. Female with a positive pregnancy test at screening or before oral dosing of
investigational product.

4. Current DSM-5 diagnosis of moderate or severe substance use disorder (except
marijuana or tobacco use disorder) within the 12 months prior to screening.
Substance abuse cannot be the precipitant of entry to treatment.

5. Subjects with a lifetime history of PCP/ketamine drug use, or failed use of
ketamine for depression.

6. History of schizophrenia or schizoaffective disorder, or any history of psychotic
symptoms when not in an acute bipolar mood episode.

7. History of anorexia nervosa, bulimia nervosa, or eating disorder NOS (OSFED)
within five years of screening.

8. Has dementia, delirium, amnestic, or any other cognitive disorder.

9. Any major psychiatric disorder, including a personality disorder, which is
clinically predominant to BD at screening, or has been the primary focus of
treatment predominant to BD at any time within six months prior to screening.

10. Current major psychiatric disorder, diagnosed at screening with the MINI 7.0.2,
that is the primary focus of treatment, with BD as the secondary focus of
treatment, within the past six months.

11. A clinically significant abnormality on the screening physical examination that
might affect safety or study participation, or that might confound interpretation
of study results according to the study clinician.

12. Current episode of:

1. Untreated hypertension, (Stage 1 or greater) as defined by a systolic blood
pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg at screening on two
of three measurements at least 15 minutes apart. If untreated due to missing
medication dose/s this is not exclusionary.

2. Hypertension, Stage 2, as defined by a systolic blood pressure ≥155 mmHg or
diastolic blood pressure ≥99 mmHg within 1.5 hours prior to ketamine
infusion on two of three measurements at least 15 minutes apart at the
pre-ketamine assessment (on Day 0 at Visit 1).

3. Recent myocardial infarction (within one year).

4. Syncopal event within the past year.

5. Congestive heart failure (CHF) New York Heart Association Criteria >Stage 2.

6. Angina pectoris.

7. Heart rate <50 or >105 beats per minute at screening, pre-ketamine infusion
(Day 0) or at randomization (Day 1).

8. QTcF ≥450 msec at screening for men, ≥ 470 msec for women, pre-ketamine
infusion (Day 0), or at randomization (Day 1), on two of three measurements
at least 15 minutes apart.

13. History of hypertension, or on antihypertensives for the purpose of lowering
blood pressure, with either an increase in antihypertensive dose or increase in
the number of antihypertensive drugs used to treat hypertension over the last two
months.

14. Chronic lung disease, excluding asthma.

15. Lifetime history of surgical procedures involving the brain or meninges,
encephalitis, meningitis, degenerative central nervous system (CNS) disorder
(e.g., Alzheimer's or Parkinson's Disease), epilepsy, mental retardation, or any
other disease/procedure/accident/intervention that, according to the screening
clinician, is deemed associated with significant injury to or malfunction of the
CNS; or history of significant head trauma within the past two years.

16. Presents with any of the following lab abnormalities:

a. Subjects with diabetes mellitus fulfilling any of the following criteria: i.
Unstable diabetes mellitus defined as glycosylated hemoglobin (HbA1c) >8.0 % at
screening.

ii. Admitted to hospital for treatment of diabetes mellitus or diabetes
mellitus-related illness in the past 12 weeks.

iii. Not under physician care for diabetes mellitus. iv. Has not been on the same
dose of oral hypoglycemic drug(s) and/or diet for the four weeks prior to
screening. For thiazolidinediones (glitazones) this period should not be less
than eight weeks.

b. Any other clinically significant abnormal laboratory result (as determined by
the investigator and medical monitor) at the time of the screening.

17. Any current or past history of any physical condition which, in the
investigator's opinion, might put the subject at risk or interfere with study
results interpretation.

18. Subjects on exclusionary concomitant psychotropic medications (see Appendix 1) as
defined in the study manual.

19. At randomization, subjects prescribed more than one agent in each category;

1. Approved antidepressants (e.g., SSRIs, SNRIs, TeCAs, fluoxetine), but not
5-HT-2a antagonists (lurasidone, aripiprazole, olanzapine, quetiapine)

2. Mood stabilizers (e.g., lithium, carbamazepine, valproic acid)

20. Subjects with exclusionary laboratory values (see Table 2).

21. Known allergies to lurasidone or Latuda, cycloserine or Seromycin, or the
excipients mannitol, croscarmellose sodium, magnesium stearate, silicon dioxide,
and/or HPMC (hydroxypropylmethylcellulose).

22. Participation in any clinical trial with an investigational drug or device within
the past month or concurrent to study participation.

23. Study site personnel and/or persons employed by NeuroRx, Inc. or Target Health or
by the investigator or study site (i.e., permanent, temporary contract worker, or
designee responsible for the conduct of the study), or an immediate family member
(i.e., spouse or parent, child, or sibling [biological or legally adopted]) of
such persons.