Protocol. This trial protocol has been provided by the authors to give readers additional information about their work.

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1 Protocol This trial protocol has been provided by the authors to give readers additional information about their work. Protocol for: Lembo AJ, Schneier HA, Shiff SJ, et al. Two randomized trials of linaclotide for chronic constipation. N Engl J Med 2011;365:

2 1.0 TITLE PAGE Forest Research Institute Harborside Financial Center, Plaza V Jersey City, NJ A Phase III, Randomized, Double-Blind, Placebo-Controlled, Parallel-Group Trial of Linaclotide Administered Orally for 12 Weeks in Patients With Chronic Constipation LIN-MD-01 IND #63,290 Original Protocol Date: August 19, 2008 Amendment #1: December 18, 2008 Amendment #2: October 7, 2009 Confidentiality Statement This document is the property of Forest Research Institute, Inc., (a wholly owned subsidiary of Forest Laboratories, Inc.) and may not in full or part be passed on, reproduced, published, distributed to any person, or submitted to any regulatory authority without the express written permission of Forest Laboratories, Inc.

3 Forest Research Institute Page SYNOPSIS AND SCHEDULE OF EVALUATIONS Trial Number Title of Trial Trial Centers (Country) Development Phase Objective Methodology Number of Patients Diagnosis and Main Criteria for Inclusion Test Product, Dosage, and Mode of Administration CLINICAL TRIAL SYNOPSIS: Study LIN-MD-01 LIN-MD-01 A Phase III, Randomized, Double-Blind, Placebo-Controlled, Parallel-Group Trial of Linaclotide Administered Orally for 12 Weeks in Patients With Chronic Constipation Up to 150 trial centers (United States and Canada) III To determine the efficacy and safety of linaclotide administered to patients with chronic constipation (CC) Multicenter, randomized, double-blind, placebo-controlled, parallel-group, multipledose, 12-week trial Approximately 600 patients (200 patients in the 150-μg treatment group, 200 in the 300 μg treatment group, and 200 patients in the placebo group) Male and female outpatients who are 18 years or older, meet Rome II criteria for CC, and meet required bowel movement (BM) criteria during the pretreatment period Linaclotide 150 μg/d, oral administration Linaclotide 300 μg/d, oral administration Screening period of up to 21 days, followed by a pretreatment period of 14 to 21 Duration of Treatment days, followed by a 12-week double-blind treatment phase Reference Therapy, Dosage, Placebo, oral administration and Mode of Administration Criteria for Evaluation Interactive voice response system (IVRS) information that determines Primary Efficacy Assessment whether a BM is a complete spontaneous bowel movement (CSBM) (the primary efficacy parameter is 12-week CSBM overall responder). Secondary Efficacy Assessments Safety Measures IVRS questions that determine the following: Whether a BM is a spontaneous bowel movement (SBM) Stool consistency (Bristol Stool Form Scale [BSFS]) Severity of straining Weekly patient assessment of constipation severity Daily patient assessment of abdominal discomfort Daily patient assessment of bloating Adverse event (AE) recording, clinical laboratory measures, vital sign parameters, pharmacokinetic (PK) samples, and electrocardiograms (ECGs) Amended Protocol LIN-MD-01Amendment #2

4 Forest Research Institute Page 3 Statistical Methods Statistical Methods (cont d) The primary efficacy parameter is 12-week CSBM overall responder. A 12-week CSBM overall responder is a patient who is a CSBM weekly responder for at least 9 out of the 12 weeks of the treatment period. A CSBM weekly responder is a patient who had a CSBM weekly frequency rate that was 3 or greater and increased by 1 or more from baseline. If a patient does not have CSBM frequency data for a particular treatment period week, the patient will not be considered a CSBM weekly responder for that week. The primary efficacy analysis is the Cochran-Mantel-Haenszel (CMH) test controlling for geographic region. For each of the two linaclotide dose groups, the proportion of 12-week CSBM overall responders will be compared with the proportion in the placebo group using the CMH test controlling for geographic region. The secondary efficacy parameters are Change from baseline in 12-week CSBM frequency Change from baseline in 12-week SBM frequency Change from baseline in 12-week stool consistency Change from baseline in 12-week severity of straining Change from baseline in 12-week constipation severity Change from baseline in 12-week abdominal discomfort Change from baseline in 12-week bloating For each of the above secondary efficacy parameters, each of the two linaclotide dose groups will be compared to the placebo group using an analysis of covariance (ANCOVA) model with fixed effect terms for treatment group and geographic region, and the patient s corresponding baseline value of the parameter as a covariate. The overall type I family-wise error rate for testing the primary and secondary efficacy parameters will be controlled at the 0.05 significance level using the following five-step serial gatekeeping multiple comparisons procedure (MCP). Following this MCP, progression to the next step will only occur if all individual hypotheses within a step are rejected and the previous step(s) are all rejected at the step-specific overall significance level. If all hypotheses within a step are not rejected, the hypothesis tests corresponding to all subsequent steps will be considered not statistically significant. All hypothesis tests will be two-sided. 1. The first step will test the primary efficacy parameter for the 300-μg dose group at the 0.05 significance level 2. The second step will test the primary efficacy parameter for the 150-μg dose group and the first five secondary parameters (ie, CSBM, SBM, BSFS stool consistency, straining severity, constipation severity) for the 300-μg dose group. The six individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure to control for multiple parameters within this step 3. The third step will test the last two secondary parameters (ie, bloating, discomfort) for the 300-μg dose group. The two individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure to control for multiple parameters Amended Protocol LIN-MD-01Amendment #2

5 Forest Research Institute Page 4 Statistical Methods (cont d) 4. The fourth step will test the first five secondary parameters for the 150-μg dose group. The five individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure to control for multiple parameters 5. The fifth step will test the last two secondary efficacy parameters for the 150-μg dose group. The two individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure to control for multiple parameters within this step All safety parameters will be analyzed descriptively. Safety analyses will be based on the Safety Population, defined as all randomized patients who receive at least one dose of double-blind study drug. Efficacy analyses will be based on the Intent-to-Treat (ITT) Population, defined as all patients in the Safety Population who have at least one postrandomization entry of the primary efficacy assessment. Amended Protocol LIN-MD-01Amendment #2

6 Forest Research Institute Page 5 SCHEDULE OF EVALUATIONS: TRIAL LIN-MD-01 Visit Trial Day Informed consent Inclusion and exclusion criteria verification IVRS registration Medical and surgical history Physical examination Body weight and height Seated vital signs Single 12-Lead ECG (for patients entering study pre- and postcompletion of triplicate ECG f program) b e c d Screening Period (Up to 21 days) Screening Visit Visit 1 Day 42 through Day 15 X Pretreatment Period (14-21 days) Pretreatment Visit Randomization Visit Treatment Period (12 weeks) Week 2 Week 4 Week 8 EOT Visit a Week 12 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Day 21 through Day 14 X X X X X X X X X Day 1 Day 15 ± 3 Day 29 ± 3 Day 57 ± 3 Day 85 ± 3 X X X X X X X X X X X X X X X Triplicate ECG g X X X X X X Prior and concomitant medicines X X X X X X X Clinical laboratory h X X X X determinations X X Amended Protocol LIN-MD-01Amendment #2

7 Forest Research Institute Page 6 SCHEDULE OF EVALUATIONS: TRIAL LIN-MD-01 Visit Trial Day i PK Sample Pregnancy test j Laxative, suppository, and enema k washout instructions l AE evaluations Screening Period (Up to 21 days) Screening Visit Visit 1 Day 42 through Day 15 X X Pretreatment Period (14-21 days) Pretreatment Visit Randomization Visit Treatment Period (12 weeks) Week 2 Week 4 Week 8 EOT Visit a Week 12 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Day 21 through Day 14 Day 1 Day 15 ± 3 Day 29 ± 3 Day 57 ± 3 Day 85 ± 3 X X X X X X X X IVRS training or IVRS compliance verification and X X X X X reminder m n Rescue medicine dispensed X X X X X Randomization Patient IVRS call, in clinic PAC-QOL questionnaire X X EQ-5D questionnaire X X X X X HRUQ X X X X SF-12 X X X X X WPAI:C X X X X X X X X X Amended Protocol LIN-MD-01Amendment #2

8 Forest Research Institute Page 7 SCHEDULE OF EVALUATIONS: TRIAL LIN-MD-01 Visit Trial Day Treatment-satisfaction assessment Rome III status Screening Period (Up to 21 days) Screening Visit Visit 1 Day 42 through Day 15 Pretreatment Period (14-21 days) Pretreatment Visit Randomization Visit Treatment Period (12 weeks) Week 2 Week 4 Week 8 EOT Visit a Week 12 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Day 21 through Day 14 Day 1 Day 15 ± 3 Day 29 ± 3 Day 57 ± 3 Day 85 ± 3 X X X X X Study drug dispensed X X X o Study drug administration Study drug accountability X X X Treatment-continuation assessment a b c d e f Patients who are randomized but do not complete the treatment period (withdraw consent or are discontinued before they have completed 12 weeks of treatment) shall be considered treatment-period withdrawals and should complete the procedures required at the EOT Visit (even out of window). Trial Coordinator should call IVRS to transition the patient to the next appropriate trial period. Refer to the IVRS Center User Manual. A physical examination should include the following: general appearance, HEENT (head, ears, eyes, nose, and throat), neck, cardiovascular, thorax/lungs, abdomen, rectal, musculoskeletal, lymph nodes, skin, and neurologic and mental status. A rectal examination should be performed during the screening period on all patients who do not require a colonoscopy. After the screening period, the rectal examination is optional and may be performed at the discretion of the Investigator. Breast and genitourinary examinations are optional at the discretion of the Investigator. Height will only be measured at Visit 1 (Screening). Vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) must be obtained from patients who are in the seated position. Single 12-lead ECGs (Single tracing to be performed on trial patients consented prior to and after completion of the triplicate ECG program.) will be performed at the Screening (Visit 1) and EOT Visits (Visit 7) X X Amended Protocol LIN-MD-01Amendment #2

9 Forest Research Institute Page 8 SCHEDULE OF EVALUATIONS: TRIAL LIN-MD-01 Visit Trial Day Screening Period (Up to 21 days) Screening Visit Visit 1 Day 42 through Day 15 Pretreatment Period (14-21 days) Pretreatment Visit Randomization Visit Treatment Period (12 weeks) Week 2 Week 4 Week 8 EOT Visit a Week 12 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Day 21 through Day 14 Day 1 Day 15 ± 3 Day 29 ± 3 Day 57 ± 3 Day 85 ± 3 g Triplicate 12-lead ECGs will be performed at the Screening (Visit 1), Pretreatment (Visit 2), Randomization (Visit 3), Week 4 (Visit 5), Week 8 (Visit 6), and EOT Visits (Visit 7), on the trial patients consented during the triplicate ECG program (see Appendix X) h Complete blood count, chemistry, urinalysis, and urine drug screen. The drug screen will be performed only at the Screening Visit (Visit 1). i PK samples will be taken for the trial patients consented during the PK sample program (see Appendix X) j To be eligible to continue in the trial, a negative serum pregnancy test must be documented at the Screening Visit (Visit 1) and at Week 4 (Visit 5). A negative urine pregnancy test must be documented at the Randomization Visit (Visit 3) before dosing and at the EOT Visit (Visit 7). k Trial Coordinator will instruct patients about the use of laxatives, suppositories, and enemas (refer to Appendix II, Concomitant Medicines). l All AEs occurring after the patient signs the informed consent form will be documented. m At Visit 2 (pretreatment), the Trial Coordinator will instruct the patients about the use of the IVRS. At subsequent visits, the Trial Coordinator will access the IVRS to verify patient compliance with the daily IVRS call requirement. After determining the patient s compliance, the Trial Coordinator will remind patients to call the IVRS daily. (IVRS questions may be found in the IVRS Center User Manual [refer to Efficacy Measurements, Section 9.5.2]). n Rescue medicine (bisacodyl tablets or bisacodyl suppositories) will be supplied to patients at Visit 2 (pretreatment) and, if needed, at subsequent visits. o Study drug will be administered in the clinic at the Randomization Visit (Visit 3) (study drug does not need to be taken in the morning before breakfast). On all other days, study drug will be taken once daily in the morning at least 30 minutes before breakfast. Patients will not take study drug on the morning of the EOT Visit (Visit 7). Patients are instructed to fast 2 hours before the Randomization Visit (Visit 3) and EOT Visit (Visit 7). AE = adverse event; ECG = electrocardiogram; EOT = end of trial; EQ-5D = EuroQoL-5D; HRUQ = Health Resource Use Questionnaire; IVRS = interactive voice response system; PAC-QOL = Patient Assessment of Constipation Quality of Life questionnaire; SF-12 = Short Form-12 Health Survey; WPAI:C = Work Productivity and Activity Impairment Questionnaire for Constipation. Amended Protocol LIN-MD-01Amendment #2

10 Forest Research Institute Page TABLE OF CONTENTS 1.0 TITLE PAGE SYNOPSIS AND SCHEDULE OF EVALUATIONS TABLE OF CONTENTS LIST OF ABBREVIATIONS ETHICAL CONSIDERATIONS Institutional Review Board Ethical Conduct of the Trial Patient Information and Consent INVESTIGATORS AND TRIAL ADMINISTRATIVE STRUCTURE INTRODUCTION TRIAL OBJECTIVES INVESTIGATIONAL PLAN Overall Trial Design and Plan: Description Trial Periods Screening Period Pretreatment Period Treatment Period Discussion of Trial Design, Including the Choice of Control Groups Selection of Trial Population Inclusion Criteria Exclusion Criteria Removal of Patients From Therapy or Assessment Replacement Procedures Treatments Treatments Administered Identity of Investigational Products Method of Assigning Patients to Treatment Groups Selection of Dosages in the Trial Selection and Timing of Dose for Each Patient Blinding Prior and Concomitant Medicines Treatment Compliance Efficacy and Safety Variables Schedule of Evaluations Screening Visit (Visit 1) Pretreatment Visit (Visit 2) Randomization Visit (Visit 3) Week 2 (Visit 4) Week 4 (Visit 5) Week 8 (Visit 6) End-of-Trial Visit (Final Visit) (Visit 7) Amended Protocol LIN-MD-01 Amendment #2

11 Forest Research Institute Page Efficacy Measurements Primary Efficacy Assessment Secondary Efficacy Assessments Additional Efficacy Assessments Health Outcome Assessments Safety Assessments Adverse Events Serious Adverse Events Clinical Laboratory Determinations Vital Signs Electrocardiograms Other Safety Assessments Drug Concentration Measurements Laxative, Suppository, Enema, and Prohibited Medicines Washout Data Quality Assurance Data Monitoring Data Recording and Documentation Statistical Methods and Determination of Sample Size Patient Populations Screened Population Randomized Population Safety Population Intent-to-Treat Population Patient Disposition Demographics and Other Baseline Characteristics Extent of Exposure and Treatment Compliance Study Drug Prior and Concomitant Medicines Measurement of Treatment Compliance Efficacy Analyses Primary Efficacy Parameter Secondary Efficacy Parameters Controlling for Multiplicity Additional Efficacy Parameters Health Outcomes Parameters Safety Analyses Adverse Events Clinical Laboratory Parameters Vital Signs Electrocardiograms Other Safety Parameters Interim Analysis Determination of Sample Size Computer Methods Changes in the Conduct of the Trial or Planned Analyses TRIAL SPONSORSHIP Trial Termination Reporting and Publication INVESTIGATOR OBLIGATIONS Documentation Performance Amended Protocol LIN-MD-01 Amendment #2

12 Forest Research Institute Page Use of Investigational Materials Case Report Forms Retention and Review of Records Patient Confidentiality INVESTIGATOR S STATEMENT APPENDICES Appendix I. Elements of Informed Consent Appendix II. Concomitant Medicines Appendix III. Summary of American Gastroenterological Association Guidelines Appendix IV. EQ-5D Questionnaire Appendix V. Bristol Stool Form Scale Appendix VI. Disease-Specific Quality of Life Appendix VII. Health Resource Use Questionnaire Appendix VIII. Short Form-12 Health Survey Appendix IX. Work Productivity and Activity Impairment Questionnaire for Constipation Appendix X Additional ECG and Pharmacokinetic (PK) Measurements LITERATURE CITED Amended Protocol LIN-MD-01 Amendment #2

13 Forest Research Institute Page AE ANOVA BM BSFS CBC CC CFR CMH CSBM EC ECG ecrf EDC EOT EQ-5D FDA FM GC-C GI LIST OF ABBREVIATIONS adverse event or adverse experience analysis of variance bowel movement Bristol Stool Form Scale complete blood count chronic constipation Code of Federal Regulations Cochran-Mantel-Haenszel (test) complete spontaneous bowel movement Ethics Committee electrocardiogram; electrocardiographic electronic case report form electronic data capture end of trial EuroQoL-5D US Food and Drug Administration Field Monitor guanylate cyclase subtype C gastrointestinal HIPAA Health Insurance Portability and Accountability Act of 1996 HRUQ IBS-C ICF ICH Health Resource Use Questionnaire irritable bowel syndrome with constipation informed consent form International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use Amended Protocol LIN-MD-01 Amendment #2

14 Forest Research Institute Page 13 IRB ITT IVRS LOCF MCP NOAEL PAC-QOL PCS PID PK QTc SAE SBM SF-12 TEAE UA WPAI:C Institutional Review Board intent to treat interactive voice response system Last observation carried forward multiple comparisons procedure no observable adverse-effect level Patient Assessment of Constipation Quality of Life (questionnaire) potentially clinically significant patient identification pharmacokinetic corrected QT (interval) serious adverse event spontaneous bowel movement Short Form-12 Health Survey treatment-emergent adverse event urinalysis Work Productivity and Activity Impairment Questionnaire for Constipation Amended Protocol LIN-MD-01 Amendment #2

15 Forest Research Institute Page ETHICAL CONSIDERATIONS This clinical trial is designed to comply with the International Conference on Harmonisation (ICH) Guidance on General Considerations for Clinical Trials (62 CFR [Code of Federal Regulations] 66113, December 17, 1997), Nonclinical Safety Studies for the Conduct of Human Clinical Trials for Pharmaceuticals (62 CFR 62922, November 25, 1997), and Good Clinical Practice: Consolidated Guidance (62 CFR 25692, May 9, 1997). This trial will be conducted in accordance with the recommendations guiding physicians in biomedical research involving human patients adopted by the 18th World Medical Assembly of Helsinki (1964), which were revised in Tokyo (1975), Venice (1983), Hong Kong (1989), Somerset West (1996), and Edinburgh (2000), and will include the notes of clarification of paragraph 29 made by the World Medical Assembly of Washington (2002) and Tokyo (2004). The trial will also be done in compliance with ICH good clinical practice guidelines. 5.1 INSTITUTIONAL REVIEW BOARD Approval by the Institutional Review Board (IRB)/Ethics Committee (EC) before the start of the trial will be the responsibility of the Investigator. A copy of the approval letter will be supplied to the Sponsor, along with a roster of IRB/EC members or the US Department of Health and Human Services general assurance number. During the course of the trial, the Investigator will provide timely and accurate reports to the IRB/EC on the progress of the trial at intervals not exceeding 1 year (or as appropriate) and will notify the IRB/EC of serious adverse events (SAEs) or other significant safety findings. The trial protocol, informed consent form (ICF), advertisements, and amendments (if any) will be approved by the IRBs at the trial centers in compliance with CFR, Title 21, Part ETHICAL CONDUCT OF THE TRIAL The trial will be conducted in full compliance with US Food and Drug Administration (FDA) guidelines for good clinical practice and in accordance with the ethical principles that have their origins in the Declaration of Helsinki and 21 CFR PATIENT INFORMATION AND CONSENT Patients, after being given an explanation of the trial, will give voluntary and written informed consent and HIPAA (Health Insurance Portability and Accountability Act of 1996) authorization (in compliance with 21 CFR, Parts 50 and 312) at the Screening Visit (Visit 1) before participating in any trial-related procedures. Amended Protocol LIN-MD-01 Amendment #2

16 Forest Research Institute Page 15 Patients unable to give written informed consent must orally assent to the procedures, and written informed consent must be obtained from their legally authorized representative in accordance with the appropriate state laws, where applicable. Each patient will read, assent understanding of, and sign an instrument of informed consent and the HIPAA authorization form after having had an opportunity to discuss them with the Investigator or an appropriately trained health professional listed on Form FDA Each patient will be made aware that he/she may withdraw from the trial at any time. The informed consent statement will contain all the elements of informed consent listed in Appendix I of the protocol; the HIPAA authorization will contain all the core elements and mandatory statements as defined in the CFR. Signed copies of the ICF and the HIPAA authorization form will be given to the patient and will be placed in the Investigator s trial files. A unique patient identification (PID) number will be assigned according to Section at the time the patient signs the ICF. Amended Protocol LIN-MD-01 Amendment #2

17 Forest Research Institute Page INVESTIGATORS AND TRIAL ADMINISTRATIVE STRUCTURE This trial will be performed at up to 150 trial centers located in the United States and Canada. At each trial center, the Investigator will be responsible for ensuring that the investigation is conducted according to the signed Investigator Agreement, protocol, IRB/EC requirements, and good clinical practice guidelines. The Principal Investigator (PI) at each trial center will be responsible for the management of the trial, which will consist of maintaining the trial file and patient records; corresponding with the IRB; and completing the case report forms (CRFs) and electronic case report forms (ecrfs). Amended Protocol LIN-MD-01 Amendment #2

18 Forest Research Institute Page INTRODUCTION Chronic Constipation (CC) is a common problem, affecting 2% to 27% of North Americans (Stewart, et al, 1999; Pare, et al, 2001; Sonnenberg, 1989). In addition to reduced Bowel Movement (BM) frequency, symptoms include hard stools, sense of incomplete evacuation, straining during defecation, and, at times, abdominal discomfort (Sandler et al, 1987; Koch, 1997; Johanson, 2007). While these symptoms are typically mild and intermittent, CC can be debilitating and difficult to treat. Current therapy with lubiprostone (Amitiza, 2006), a chloride channel activator and the only approved prescription medicine for CC, is associated with troublesome adverse effects. Therefore, there remains an unmet medical demand for a well-tolerated and effective therapy for all patients with CC that not only increases bowel frequency but also relieves the various associated symptoms. Linaclotide, a chemically synthesized 14 amino acid peptide composed of naturally occurring L-amino acids, is a novel orally administered therapeutic agent that is being developed for the treatment of irritable bowel syndrome with constipation (IBS-C) and chronic constipation (CC). Linaclotide mimics the endogenous peptide hormones guanylin and uroguanylin. The molecular target for these peptides is the guanylate cyclase subtype C (GC-C) receptor, a key regulator of intestinal function in mammals. GC-C receptors, expressed on the luminal surface of intestinal epithelial cells, respond to guanylin and uroguanylin (and linaclotide), resulting in the elevation of intracellular cyclic guanosine monophosphate concentration and an increase in chloride and bicarbonate secretion into the intestinal lumen (Forte, 1999). This anion secretion results in an increase in intestinal fluid secretion and a reflex acceleration of gastrointestinal (GI) transit. GC-C receptor agonists also inhibit colonic fluid absorption (Grøndahl et al, 1998; Ieda et al, 1999). In addition to its effect on luminal fluid secretion, linaclotide has been shown to reduce visceral hypersensitivity in several rodent models. This antinociceptive effect requires expression of GC-C receptors, as evidenced by the loss of responsiveness in GC-C receptor knockout animals. The mechanism by which linaclotide reduces sensitivity to nociceptive visceral stimuli is postulated to be by increasing extracellular cyclic guanosine monophosphate, which acts on afferent nerves to decrease sensitivity to noxious stimuli. Linaclotide is stable to acid and intestinal proteases including pepsin, trypsin, chymotrypsin, and aminopeptidase under nonreducing conditions. Linaclotide is hydrolytically cleaved by intestinal carboxypeptidase A to produce a 13 amino acid peptide (MM ), which retains the full biological activity of linaclotide. In the presence of intestinal proteases under reducing conditions in vitro and in rat intestinal loops in vivo, linaclotide is rapidly degraded to short peptides and, subsequently, to naturally occurring L-amino acids. Amended Protocol LIN-MD-01 Amendment #2

19 Forest Research Institute Page 18 Pharmacokinetic studies in animals have indicated very limited oral bioavailability of linaclotide and MM ( 0.20%) across all species. The safety of linaclotide has been evaluated in both safety pharmacology and general toxicology studies following both single intravenous and oral doses and repeat oral doses. In phase I studies of single doses up to 3000 μg and 7-day repeat doses up to 1000 μg, linaclotide as an oral solution was shown to be well tolerated in healthy male and female subjects. No detectable systemic exposure (lower limit of quantification = 3 ng/ml) to linaclotide or MM was observed in any subject on any dose at any time point. In a recently conducted study (study MCP ), healthy volunteers received a supratherapeutic dose of 3000 μg of linaclotide. Using an improved and more sensitive bioanalytical method (lower limit of quantification = 0.2 ng/ml), linaclotide was detectable in the plasma of 2 of 18 subjects receiving the 3000-μg dose. However, exposure levels were not high enough or sustained long enough to allow calculation of pharmacokinetic parameters in these subjects. In a phase IIa study (MCP ) that enrolled 36 female patients with IBS-C, linaclotide was found to be well tolerated at oral doses of 100 μg and 1000 μg. In this study, the 1000-μg dose of linaclotide significantly accelerated ascending colon emptying, as well as overall colonic transit at 48 hours. There was also a dose-dependent improvement in bowel function. In this study, there was no apparent relationship between the dose of linaclotide and the nature, incidence, frequency, severity, relationship to study drug, or duration of the treatment-emergent adverse events (TEAEs). Amended Protocol LIN-MD-01 Amendment #2

20 Forest Research Institute Page 19 In another phase IIa study (MCP ) in 42 patients with CC, all three oral solution doses of linaclotide (100 μg, 300 μg, and 1000 μg) provided improvements versus placebo in spontaneous bowel movement (SBM) frequency, complete spontaneous bowel movement (CSBM) frequency, Bristol Stool Form Scale (BSFS) score for stool consistency, ease of passage (straining), and abdominal discomfort. In this same study, there was no apparent relationship between the dose of linaclotide and the nature, incidence, frequency, severity, relationship to study drug, or duration of the TEAEs. A phase IIb dose-range-finding study (MCP ) evaluated the safety and efficacy of linaclotide (administered as an oral capsule) in patients with CC. A total of 310 patients were randomized to either linaclotide (75, 150, 300, or 600 μg) or placebo once daily for 4 weeks. Statistically significant differences were observed in the Evaluable Population (the primary efficacy population) between each dose of linaclotide and placebo for SBM frequency, the primary end point of the study, except the 75-μg dose. For all the doses, SBM frequency was statistically significant compared with that of placebo in the Intent-To-Treat (ITT) Population. Statistically significant) differences were observed between linaclotide and placebo for all secondary end points bowel habits (CSBM frequency, stool consistency, and severity of straining), daily patient severity assessments (abdominal pain, abdominal discomfort, and bloating), and overall assessment of constipation severity. In this study, linaclotide was well tolerated. There were no deaths. The three SAEs reported during the study occurred in two patients receiving placebo, and all three were considered to be unrelated to study drug. Except for diarrhea, the proportion of patients reporting adverse events (AEs) was similar between placebo and each linaclotide dose group. Diarrhea was reported as an AE by 2.9% of patients treated with placebo and 5.1%, 8.9%, 4.8%, and 14.3% of patients treated with 75 μg, 150 μg, 300 μg, and 600 μg linaclotide, respectively. Diarrhea resulted in the discontinuation of approximately 2.5% of patients treated with linaclotide (from 0% with 75 μg to 4.8% with 600 μg) and no patients treated with placebo. No patient who reported diarrhea as a TEAE experienced dehydration, electrolyte abnormalities, or any other potential adverse clinical sequelae of diarrhea. Amended Protocol LIN-MD-01 Amendment #2

21 Forest Research Institute Page 20 A phase IIb dose-range-finding study (MCP ) evaluated the safety and efficacy of linaclotide (administered as an oral capsule) in patients with IBS-C. A total of 420 patients were randomized to either linaclotide (75 μg, 150 μg, 300 μg, or 600 μg) or placebo once daily for 12 weeks. For the primary efficacy end point, CSBM frequency, statistically significant differences were observed in the Evaluable Population (the primary efficacy population) between placebo and each dose of linaclotide, except the 150-μg dose. For all the doses, SBM frequency was statistically significantly increased compared with that of placebo in the ITT Population. For all other end points (bowel habits [SBM frequency, stool consistency, and severity of straining], daily patient severity assessments [abdominal pain, abdominal discomfort, and bloating], and patient global assessments [overall assessment of constipation severity, overall assessment of irritable bowel syndrome symptom severity, degree of relief of irritable bowel syndrome symptoms, and adequate relief]), the 300-μg and 600-μg doses of linaclotide demonstrated statistically significant differences from placebo that, in general, were notably larger than the differences observed between placebo and the two lower doses of linaclotide. An analysis of the results at each week during the study indicates that the therapeutic effect had an onset during the first week of dosing, persisted throughout the 12 weeks of the treatment period, and was not followed by a rebound worsening of symptoms when treatment was withdrawn during the 2-week posttreatment period. Overall, linaclotide was well tolerated. There were no deaths. One patient (linaclotide 300 μg) had an SAE, fecal impaction, that was considered by the Investigator to be unrelated to study drug. Except for diarrhea, the proportion of patients reporting a TEAE was similar between placebo and each linaclotide dose group. Diarrhea was reported as an AE by 1.2% of patients treated with placebo and 11.4%, 12.2%, 16.5%, and 18.0% of patients treated with 75, 150, 300, and 600 μg linaclotide, respectively. Diarrhea resulted in the discontinuation of no patients treated with placebo and 2.5%, 4.9%, 1.2%, and 6.7% of patients treated with 75, 150, 300, and 600 μg of linaclotide, respectively. No patient who reported diarrhea as a TEAE experienced dehydration, electrolyte abnormalities, or any other potential adverse clinical sequelae of diarrhea. Refer to the Investigator s Brochure for a more detailed description of the chemistry, pharmacology, efficacy, and safety of linaclotide, based on studies conducted in animals and in patients with CC and IBS-C (Linaclotide, 2008). A phase III trial (LIN-MD-31) is currently being conducted in patients with IBS-C. A phase III long-term safety study (LIN-MD-02) is currently being conducted in patients with IBS-C and CC. The results of phase I and II studies completed to date provide continued support for the therapeutic potential of linaclotide in IBS-C and CC. The aim of the present trial is to provide confirmatory evidence of the safety and efficacy of linaclotide relative to placebo in patients with CC. Amended Protocol LIN-MD-01 Amendment #2

22 Forest Research Institute Page TRIAL OBJECTIVES The objective of this trial is to determine the efficacy and safety of linaclotide administered to patients with CC. Amended Protocol LIN-MD-01 Amendment #2

23 Forest Research Institute Page INVESTIGATIONAL PLAN 9.1 OVERALL TRIAL DESIGN AND PLAN: DESCRIPTION This clinical trial will be a multicenter, randomized, double-blind, placebo-controlled, parallel-group, multiple-dose, 12-week trial comparing two doses of linaclotide with placebo. Up to 150 trial centers will participate, and approximately 600 patients with a diagnosis of CC (modified Rome II criteria) will be randomized. The trial will consist of up to 21 days of screening, 14 to 21 days of pretreatment, and 12 weeks of double-blind treatment. At the end of the pretreatment period, during which patients will provide qualifying bowel habit, symptom severity, and rescue medicine information, patients meeting the entry criteria for this trial will be randomized to one of three double-blind treatment groups: 150 μg linaclotide, 300 μg linaclotide, or placebo (1:1:1). Detailed descriptions of each trial visit can be found in Section The Schedule of Evaluations is provided in Section 2.0. Figure is a schematic description of the trial design Trial Periods Screening Period The screening period starts with signature of the ICF and lasts for up to 21 calendar days. During this period, patient eligibility for entry into the pretreatment period will be determined. The end of the screening period coincides with the start of the pretreatment period. Any over-the-counter or prescription laxatives, suppositories, or enemas used to treat CC must not be taken during the calendar day before the Pretreatment Visit (Visit 2); whereas other prohibited medicines must not be taken during the 14 calendar days before the Pretreatment Visit (refer to Appendix II). Amended Protocol LIN-MD-01 Amendment #2

24 Forest Research Institute Page Pretreatment Period The pretreatment period is defined as the 14 calendar days (minimum) to 21 calendar days (maximum) immediately before randomization. During this period, patients will provide the following information through daily interactive voice response system (IVRS) calls: Daily bowel habits and daily patient symptom severity assessments Weekly patient assessment of constipation severity Weekly patient assessment of degree of relief of constipation symptoms Use of per-protocol rescue medicine or any other laxatives, suppositories, or enemas Treatment Period The treatment period begins with randomization and lasts for 12 weeks. Patients who meet all entry criteria will be randomized to treatment with 150 μg linaclotide, 300 μg linaclotide, or placebo (1:1:1). Except for the first dose, study drug will be taken once daily in the morning at least 30 minutes before breakfast. (Note: Patients will take their initial dose of study drug at the trial center during the Randomization Visit on Day 1 [Visit 3]. Patients must have fasted for at least 2 hours before arriving at the clinic for the Randomization Visit [Visit 3] and End-of-Trial Visit (EOT) [Visit 7]. Patients will not take any study drug on the day of the EOT Visit [Visit 7].) Patients will continue to call the IVRS to provide their daily assessments (daily bowel habit assessments and daily patient symptom-severity assessments), their weekly assessments (patient assessment of constipation severity and patient assessment of degree of relief of constipation symptoms), and their use of rescue medicine and any other laxatives, suppositories, or enemas. A Treatment Satisfaction Assessment will be performed at the Week 2 Visit (Visit 4) and all subsequent visits. A Treatment Continuation Assessment will be performed at the EOT Visit (Visit 7). A number of quality-of-life and patient-outcome assessments are performed at trial visits throughout the treatment period. A list of these assessments and the visits when they are performed is provided in the Schedule of Evaluations (Section 2.0). Amended Protocol LIN-MD-01 Amendment #2

25 Forest Research Institute Page 24 Figure Overview of Trial Design Screening Period Pretreatment Period Treatment Period Up to 21 days 14 to 21 days Day 1 to Day 84 Week 2 Visit (Day 15 ± 3) Week 4 Visit (Day 29 ± 3) Week 8 Visit (Day 57 ± 3) Screening Visit (Day 42 through Day 15) Pretreatment Visit (Day 21 through Day 14) Randomization Visit (Day 1) End-of-Trial Visit (Day 85 ± 3) Note: There is no Day DISCUSSION OF TRIAL DESIGN, INCLUDING THE CHOICE OF CONTROL GROUPS A double-blind, placebo-controlled, parallel-group trial design was chosen in accordance with the concepts in ICH E10, Choice of Control Groups and Related Issues in Clinical Trials (International Conference on Harmonisation, 2000) to provide comparable treatment groups and minimal chance of selection or Investigator bias. Furthermore, its design is consistent with the pivotal studies that led to the FDA approval of lubiprostone and tegaserod for CC. To that end, this trial has a 14- to 21-day pretreatment period to establish a baseline without therapy and to familiarize patients with data collection methodology (ie, IVRS) and a 12-week treatment period to compare the test treatment with a placebo control. Amended Protocol LIN-MD-01 Amendment #2

26 Forest Research Institute Page SELECTION OF TRIAL POPULATION Inclusion Criteria To be eligible to participate in the trial, patients must meet the following criteria: 1. Sign an ICF 2. Be an ambulatory, community-dwelling male or nonpregnant female aged 18 years or older at the Screening Visit (Visit 1). Lactating females must agree not to breastfeed 3. If a sexually active woman of childbearing potential, agree to use one of the following methods of birth control from the date she signs the ICF until 24 hours after the final dose of study drug: a. Hormonal contraception (ie, oral contraceptive, contraceptive implant, injectable hormonal contraceptive) b. Double-barrier birth control (eg, condom plus intrauterine device, diaphragm plus spermicide) c. Surgical sterilization (ie, bilateral oophorectomy, hysterectomy, tubal ligation) d. Maintenance of a monogamous relationship with a male partner who has been surgically sterilized by vasectomy 4. If a woman of childbearing potential, have a negative serum pregnancy test at the Screening Visit (Visit 1) and a negative urine pregnancy test at the Randomization Visit (Visit 3) before dosing 5. Meet the colonoscopy requirements defined by the American Gastroenterological Association guidelines and described in Appendix III. (Note: Patients are eligible to enter the pretreatment period on the fifth calendar day after a colonoscopy) 6. Have no clinically significant findings on a physical examination, 12-lead electrocardiogram (ECG), or clinical laboratory tests (complete blood count [CBC], chemistry panel, urinalysis [UA], urine drug screen) after signing the ICF but before receiving the first dose of study drug. (Note: The Investigator will determine if a particular finding is clinically significant. In making this determination, the Investigator will consider whether the particular finding could prevent the patient from performing any of the protocol-specified assessments, could represent a condition that would exclude the patient from the trial, could represent a safety concern if the patient participates in the trial, or could confound the trial-specified assessments of safety or efficacy) Amended Protocol LIN-MD-01 Amendment #2

27 Forest Research Institute Page Meet Rome II criteria (Drossman, 2000) for CC, which have been slightly modified from the original: patient reports fewer than three bowel movements (BMs) per week (with each BM occurring in the absence of any laxative, suppository, or enema use during the preceding 24 hours) and reports one or more of the following symptoms for at least 12 weeks, which need not be consecutive, in the 12 months before the Screening Visit (Visit 1) or before starting chronic treatment with tegaserod, lubiprostone, polyethylene glycol 3350, or any laxative: a. Straining during more than 25% of BMs b. Lumpy or hard stools during more than 25% of BMs c. Sensation of incomplete evacuation during more than 25% of BMs 8. Report an average of fewer than three CSBMs per week and 6 or fewer SBMs per week by the IVRS during the 14 days before the start of the treatment period. (Note: A CSBM is an SBM that is associated with a sense of complete evacuation. An SBM is a BM that occurs in the absence of laxative, suppository, or enema use on the calendar day of the BM or the calendar day before the BM) 9. Be compliant with IVRS completion by adequately responding to IVRS questions on 10 or more of the 14 days before the start of the treatment period 10. Be willing to discontinue any laxative use before the Pretreatment Visit (Visit 2) in favor of the protocol-defined rescue medicine (bisacodyl tablets or bisacodyl suppositories) 11. Be fluent in English, Spanish, or French 12. Have unrestricted access to a working touch-tone telephone for the entire trial 13. Agree to refrain from making any new, major life-style changes that may affect CC symptoms (eg, starting a new diet or changing his or her exercise pattern) from the time of signing the ICF to the last trial visit Exclusion Criteria Patients who meet any of the following criteria will not be eligible to participate in the trial: 1. Report loose (mushy) or watery stools (BSFS score of 6 or 7) in the absence of any laxative, suppository, enema, or prohibited medicine (as described in Appendix II) for more than 25% of BMs during the 12 weeks before the Screening Visit (Visit 1) Amended Protocol LIN-MD-01 Amendment #2

28 Forest Research Institute Page Meet the Rome II criteria for irritable bowel syndrome (Drossman, 2000): reports abdominal discomfort or pain that has two or more of the following three features for at least 12 weeks, which need not be consecutive, in the 12 months before the Screening Visit (Visit 1): a. Relieved with defecation b. Onset associated with a change in frequency of stool c. Onset associated with a change in form (appearance) of stool 3. Have a structural abnormality of the GI tract or a disease or condition that can affect GI motility 4. Have ever had a diagnosis of familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, or any other form of familial colorectal cancer or inflammatory bowel disease. Patient has a family history of familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer or other familial form of colorectal cancer 5. Have currently unexplained and clinically significant alarm symptoms (lower GI bleeding [rectal bleeding or heme-positive stool], iron-deficiency anemia, weight loss), or systemic signs of infection or colitis 6. Have currently active peptic ulcer disease (ie, disease that is not adequately treated or stable with therapy) 7. Have a history of diverticulitis or any chronic condition (eg, chronic pancreatitis, polycystic kidney disease, ovarian cysts, endometriosis) that can be associated with abdominal pain or discomfort and could confound the assessments in this trial 8. Have a potential central nervous system cause of constipation (eg, Parkinson s disease, spinal cord injury, multiple sclerosis) 9. Have ever had any of the following diseases or conditions that could be associated with constipation: pseudo-obstruction, megacolon, megarectum, bowel obstruction, descending perineum syndrome, solitary rectal ulcer syndrome, systemic sclerosis 10. Have ever had a fecal impaction that required hospitalization or emergency room treatment or have a history of cathartic colon, laxative or enema abuse, ischemic colitis, or pelvic floor dysfunction (unless successful treatment has been documented by a normal balloon expulsion test) 11. Have had surgery that meets any of the following criteria: Amended Protocol LIN-MD-01 Amendment #2

29 Forest Research Institute Page 28 a. Bariatric surgery for treatment of obesity or surgery to remove a segment of the GI tract at any time before the Screening Visit (Visit 1) b. Surgery of the abdomen, pelvis, or retroperitoneal structures during the 6 months before the Screening Visit (Visit 1) c. Appendectomy or cholecystectomy during the 60 days before the Screening Visit (Visit 1) d. Other major surgery during the 30 days before the Screening Visit (Visit 1) 12. Have a history of cancer other than treated basal cell or squamous cell carcinoma of the skin. (Note: Patients with a history of cancer are allowed provided that the malignancy has been in a complete remission for at least 5 years before the Randomization Visit (Visit 3). A complete remission is defined as the disappearance of all signs of cancer in response to treatment) 13. Have a history of diabetic neuropathy 14. Have hypothyroidism that is being treated and for which the dose of thyroid hormone has not been stable for at least 6 weeks at the time of the Screening Visit (Visit 1) 15. Have a recent history (during the 12 months before the Randomization Visit [Visit 3]) of drug or alcohol abuse. (Note: Patients with a history of drug or alcohol abuse that was diagnosed greater than 12 months before the Randomization Visit may be enrolled as long as they have exhibited no actual abuse during the 12 months before the Randomization Visit) 16. Report a BSFS score of 6 (loose, mushy stools) for more than one SBM or a BSFS score of 7 (watery stools) with any SBM during the 14 days before the start of the treatment period 17. Have used rescue medicine (bisacodyl tablet or suppository) or any other laxative, suppository, or enema on the calendar day before or the calendar day of the start of the treatment period (ie, before the Randomization Visit [Visit 3]) 18. Report of using a prohibited medicine (excluding laxatives, suppositories, and enemas) during the pretreatment period or is not willing or able to abide by the restrictions regarding use of prohibited medicines defined in Appendix II. (Note: The use of fiber, bulk laxatives, or stool softeners [such as docusate] is acceptable, provided the patient has been on a stable dose during the 30 days before the Screening Visit [Visit 1] and plans to continue on a stable dose throughout the trial) Amended Protocol LIN-MD-01 Amendment #2

30 Forest Research Institute Page Have been hospitalized for a psychiatric condition or have made a suicide attempt during the 2 years before the Randomization Visit (Visit 3) 20. Have received an investigational drug during the 30 days before the Screening Visit (Visit 1) or are planning to receive an investigational drug (other than the study drug administered during this trial) or use an investigational device at any time during the trial 21. Have an acute or chronic condition that, in the Investigator s opinion, would limit the patient s ability to complete or participate in this clinical trial 22. Have been randomized into any phase I or phase II study in which linaclotide was a treatment (patients who enrolled into these studies but failed to be randomized are eligible for the current trial) or have previously entered the pretreatment period of this trial or any other phase III trial in which linaclotide was a treatment 23. Have directly or indirectly been involved in the conduct and administration of this trial as an Investigator, Sub-Investigator, Trial Coordinator, or other trial staff member or have a first-degree family member, significant other, or relative residing with one of the above persons involved directly or indirectly in the trial Removal of Patients From Therapy or Assessment A premature discontinuation will occur when a patient who signed the ICF ceases participation in the trial, regardless of circumstances, before the completion of the protocol. Patients can prematurely discontinue or be prematurely discontinued from the trial by the Investigator or Sponsor at any time for any reason including the following: Failure to meet inclusion or exclusion criteria AE Insufficient therapeutic response (lack of efficacy) Protocol violation, including lack of compliance Withdrawal of consent Lost to follow-up (every effort must be made to contact the patient; a certified letter must be sent) Trial termination by the Sponsor Other reasons, such as administrative reasons or pregnancy Amended Protocol LIN-MD-01 Amendment #2

31 Forest Research Institute Page 30 Patients who are randomized but do not complete the treatment period (withdraw consent before they have completed visits up to and including the EOT Visit [Visit 7]) will be considered treatment-period withdrawals and should complete the procedures required at the EOT Visit (Visit 7) (even if out of window) at the time of their discontinuation. The reasons for premature discontinuation from the trial will be reflected on the trial termination form of the ecrf. All data on the patient before discontinuation will be made available to Forest Research Institute. Any patient who withdraws because of an AE will be followed until the AE resolves, stabilizes, or can be explained as being unrelated to study drug. The trial centers should make a reasonable effort to follow pregnant patients until delivery or end of the pregnancy. If a patient does not return for a scheduled visit, the trial center should contact the patient. Every effort is to be made to contact the patient, including sending a certified letter. In every case, the patient outcome, including information on loss to follow-up will be documented. The Investigator may allow a patient to stop taking study drug for up to 3 days should an intolerable AE occur. If the Investigator believes that the patient is unable to resume dosing or requires a suspension of dosing on more than one occasion, the Investigator should contact the Medical Monitor to discuss the patient s continued participation in the trial Replacement Procedures Patients in this trial who prematurely discontinue treatment will not be replaced. 9.4 TREATMENTS Treatments Administered Study drug in the form of capsules will be provided by Forest Research Institute. For the double-blind treatment period, patients will be supplied with identically appearing capsules containing 150 μg linaclotide, 300 μg linaclotide, or placebo Identity of Investigational Products All study drug will be supplied in bottles containing 35 capsules and will be labeled with the following content: protocol number, storage information, investigational use language (viz., Caution: New Drug Limited by Federal Law to Investigational Use ), and instructions to take the capsules once daily in the morning at least 30 minutes before breakfast. The label will also include the bottle number. Immediately before dispensing study drug, the Trial Coordinator will write the patient s initials, PID number, and dispensing date on the label. Amended Protocol LIN-MD-01 Amendment #2

32 Forest Research Institute Page 31 All study drugs will be provided by Forest Research Institute. Study drug must be shipped at a temperature of 2 C to 8 C, with short excursions permitted. Excursions reported by the site will be reviewed by Clinical Packaging to determine if excursion is allowable. Study drug must be stored at the trial center in an appropriately secured area in a refrigerator at 2 C to 8 C (36 F to 46 F) and protected from light. The Investigator must ensure that the receipt and use of all study drugs supplied is recorded and must supervise the storage and allocation of these supplies. All unused study drug must be returned to Forest Research Institute. Whenever study drug is returned (excluding Sponsor-supplied protocol-defined rescue medicine), unit counts must be performed by trial center staff and verified by a site monitor to ensure reliable drug accountability. Drug unit counts are documented on the appropriate ecrf form. Before the end of the trial, detailed instructions for the return of all unused capsules and study drug bottles will be provided. Those unused capsules and study drug bottles should be returned to Forest at the following address: Forest Laboratories, Inc. 155 Commerce Drive Hauppauge, NY ATTN: Clinical Packaging, PR&D Method of Assigning Patients to Treatment Groups The PID number will consist of seven digits; the first three digits will represent the trial center number, followed by a two-digit study indicator ( 01 ) and a two-digit patient number assigned in an ascending sequential order, beginning with 01, 02, and so on. The patient will retain the same PID number (which is also the screening number) throughout the treatment period Selection of Dosages in the Trial The linaclotide doses (150 and 300 μg) were chosen based on the safety and efficacy results from Study MCP , the phase IIb 4-week dose-ranging trial in patients with CC. The 300-μg dose was chosen as one of the doses for the phase III trials because it demonstrated efficacy similar to that of the 600-μg dose with a lower incidence of diarrhea. The 150-μg dose was chosen as an additional dose for the phase III trials because it also demonstrated efficacy and had a diarrhea rate that was similar to the rates observed with the 75- and 300-μg doses. Given the longer treatment duration of this Phase III trial (12 weeks), it was thought reasonable to test the 150-μg dose in addition to the 300-μg dose because the 150-μg dose is likely to provide reasonable efficacy and possibly better tolerance compared with the higher dose. Amended Protocol LIN-MD-01 Amendment #2

33 Forest Research Institute Page Selection and Timing of Dose for Each Patient All study drugs will be administered orally as a single daily dose. Patients who meet all eligibility criteria at screening and pretreatment will be randomized to treatment at the Randomization Visit (Visit 3) (randomization number assigned by the IVRS) and dispensed one bottle containing 35 capsules. Additional bottles will be dispensed at subsequent visits per the Schedule of Evaluations (Section 2.0). Patients will take their initial dose of study drug (either one capsule of 150 μg linaclotide, 300 μg linaclotide, or matching placebo) at the trial center during the Randomization Visit (Visit 3). Patients must have fasted for at least 2 hours before arriving at the clinic for the Randomization Visit (Visit 3) and EOT Visit (Visit 7). Study drug should be refrigerated at the patient s home during the treatment period. Patients will be instructed to take one capsule of study drug in the morning at least 30 minutes before breakfast. Patients will not take any study drug on the day of the EOT Visit (Visit 7). Patients will be instructed to return all unused study drug and bottles to the trial center at the visits defined in the Schedule of Evaluations (Section 2.0) Blinding The randomization codes will be generated by the Randomization Code Administrator, an individual within Statistical Programming at Forest Research Institute who will generate the randomization codes and will not be assigned the role of Statistical Programmer for this study. The randomization codes will be provided in a secure manner to the IVRS contract research organization by the Forest Research Institute Randomization Code Administrator. The kit randomization schedule will be created by the IVRS contract research organization. In case of an emergency, there will be two methods for obtaining the study drug assignment of a patient: the Medical Monitor or designee may be called or the IVRS may be accessed. Accessing the IVRS for emergency unblinding should be done only in an emergency that necessitates identifying the study drug for the welfare of the patient and only after unsuccessfully attempting to contact the Medical Monitor or designee. If the blind is broken, the trial center will notify the Forest Research Institute in-house clinical team representative or Medical Monitor immediately. An explanation for breaking the blind will be recorded on the relevant ecrf. Breaking the blind at the trial center will disqualify the patient from further participation in the trial. Amended Protocol LIN-MD-01 Amendment #2

34 Forest Research Institute Page Prior and Concomitant Medicines A complete list of drugs that are conditionally allowed and drugs that are not allowed as concomitant medicines for either episodic or chronic use or as rescue medicine is provided in Appendix II. During the pretreatment and treatment periods, a patient may use dispensed, protocol-defined laxatives (bisacodyl tablets or bisacodyl suppositories) as rescue medicine when at least 72 hours have passed since the patient s previous BM or when symptoms become intolerable. At the Screening Visit (Visit 1), all ongoing medicines taken by the patient and any past use of tegaserod (Zelnorm) and lubiprostone (Amitiza) will be recorded. Any over-thecounter or prescription laxatives, suppositories, or enemas used to treat CC or diarrhea may not be used on the calendar day before the Pretreatment Visit (Visit 2); whereas other prohibited medicines may not be used during the 14 calendar days before the Pretreatment Visit (refer to Appendix II). To qualify for randomization into the treatment period, patients must not have used rescue medicine on the calendar day before the Randomization Visit (Visit 3) and on the day of the Randomization Visit up until the time of the clinic visit. Patients must also agree to refrain from using rescue medicine from the time of the clinic visit through the calendar day after randomization. Thereafter, any changes in concomitant medicines or new medicines added will be recorded on the ecrf. Concomitant medicines will be recorded at trial visits throughout the entire trial. Rescue medicine will be documented by the patient via IVRS Treatment Compliance Study drug will be administered to the patient by trial center staff at the Randomization Visit (Visit 3). For all other days in the treatment period, study drug will be taken once daily by the patient in the morning at least 30 minutes before breakfast (from the bottle of study drug previously provided). Patients will not take study drug on the day of the EOT Visit. Study drug compliance by the patient will be closely monitored during the treatment period by counting the number of capsules returned and recording that information on the ecrf. Every effort will be made to collect all unused study drug. 9.5 EFFICACY AND SAFETY VARIABLES Schedule of Evaluations The schedule of trial procedures and assessments is tabulated by visit in the Schedule of Evaluations in Section 2.0. The descriptions of the procedures to be performed at each visit are provided below. All visits should adhere to a window of ± 3 days during the treatment period, except for the Randomization Visit (Visit 3). A pre-defined subset of patients will complete triplicate ECG and pharmacokinetic (PK) assessments (refer to Appendix X). Amended Protocol LIN-MD-01 Amendment #2

35 Forest Research Institute Page Screening Visit (Visit 1) At the Screening Visit, a review of inclusion and exclusion criteria will be conducted to determine the patient s eligibility for progression to the pretreatment period. Overall eligibility should be determined by the Investigator or an appropriately trained health professional listed on Form FDA Trial procedures will be reviewed with the patient, the caregiver, and the legally authorized representative (if different from the caregiver); and documentation of informed consent will be obtained. After the patient signs the ICF, the Trial Coordinator will call IVRS to register the patient for the screening period, and the patient will then be assigned a unique PID number in sequential order. The following procedures will be performed thereafter: Recording of medical history Performance of physical examination Physical examination should include all assessments (general appearance, HEENT [head, ears, eyes, nose and throat], neck, cardiovascular, thorax/lungs, abdomen, rectal, genitourinary, breasts, musculoskeletal, lymph nodes, skin, and neurologic and mental status) Rectal examination should be performed during the screening period on all patients who do not require a colonoscopy. After the screening period, the rectal examination is optional and may be performed at the discretion of the Investigator Breast and genitourinary examinations are optional at the discretion of the Investigator Measurement of body weight and height Recording of seated vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) Performance of 12-lead ECG OR o Single 12-lead ECG (Single tracing to be performed on trial patients consented prior to and after the completion of the triplicate ECG program) o Triplicate 12-lead ECG (see Appendix X) Documentation of prior and concomitant medicines, including past use of tegaserod (Zelnorm), lubiprostone (Amitiza), and previous CC prescription medicines Collection of blood and urine samples for clinical laboratory determinations Amended Protocol LIN-MD-01 Amendment #2

36 Forest Research Institute Page 35 CBC Chemistry UA Urine drug screen Serum pregnancy test result must be confirmed as negative to qualify patient for study participation Providing of patient instructions for laxative, suppository, and enema washout (Appendix II) Scheduling of patient s next visit and reminding the patient to refrain from using prohibited medicines as described in Appendix II) Pretreatment Visit (Visit 2) The pretreatment period will occur between 14 and 21 days immediately before the Randomization Visit (Visit 3). The purposes of this period are to collect pretreatment period data to determine whether the patient is eligible to continue into the Treatment Period of the trial, to provide the patient with experience using the data collection methods employed during the trial (ie, IVRS), and for comparison with data collected during and after treatment. The Trial Coordinator will call IVRS to register the patient into the pretreatment period. At the Pretreatment Visit, which will occur between Day 21 and Day 14 (inclusive), the inclusion and exclusion criteria will again be reviewed, trial procedures will be explained to the patient, and the following will be performed: Verification that inclusion and exclusion criteria continue to be met Measurement of body weight Recording of seated vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) Triplicate 12-lead ECG, if applicable (see Appendix X) Documentation of concomitant medicines Review of any AEs occurring from the signing of the ICF to this visit Amended Protocol LIN-MD-01 Amendment #2

37 Forest Research Institute Page 36 Dispensing of rescue medicine; review with patient how rescue medicine should be used Training on IVRS (patients will be instructed on the use of IVRS) and the assessments that will be collected as listed below: Assessment of daily bowel habits (frequency, consistency, straining, and completeness) Daily patient symptom severity assessments (abdominal pain, abdominal discomfort, and bloating) Use of per-protocol rescue medicine or any other laxative, suppository, or enema Weekly patient assessment of constipation severity Weekly patient assessment of degree of relief of constipation symptoms Reminder for patients to fast for at least 2 hours before arriving at the clinic for the Randomization Visit (Visit 3) Scheduling of patient s next visit and reminding the patient to refrain from using prohibited medicines and refrain from using rescue medicine the calendar day before the Randomization Visit [Visit 3] and the day of randomization) Randomization Visit (Visit 3) At the Randomization Visit the inclusion and exclusion criteria will again be reviewed to confirm the patient s eligibility, including the patient s abstinence from rescue medicine on the calendar day before and day of randomization. At Visit 3, the Trial Coordinator will call IVRS (refer to IVRS User Manual) to transition the into the Prerandomization phase of the visit. Following this call and during the clinic visit, the patient will complete an IVRS call to provide the required assessments. After the patient completes this IVRS call in the clinic, the Trial Coordinator will again call IVRS to confirm the patient s eligibility. If the patient s eligibility is confirmed, the IVRS will randomize the patient. Each eligible patient will be dispensed one bottle containing double-blind study drug for the first 4 weeks of the treatment period. Trial personnel will review the trial procedures with the patient and instruct the patient that his or her routine IVRS call must still be placed later in the day (ie, the day of randomization). Amended Protocol LIN-MD-01 Amendment #2

38 Forest Research Institute Page 37 Patients Ineligible for Randomization at Visit 3 Patients who are ineligible for randomization should have all Visit 3 procedures completed with the exception of assessments of patient outcomes (i.e., paper questionnaires) and procedures that would be performed after randomization. Specifically, the patient should complete the following procedures: vital signs, weight, collection of blood and urine samples, urine pregnancy test (for women of childbearing potential), assessment of ROME III criteria, and reporting of AEs and concomitant medicines. These data should be recorded on the designated ecrf panel for screen failures. Patients who screen-fail at Visit 3 may be eligible for entry into a long-term safety study (LIN-MD-02) and can be evaluated at this visit for potential participation. The following procedures will be performed before randomization and administration of the first dose of study drug at the trial center: Verification that inclusion and exclusion criteria continue to be met, including verification of the patient s compliance with the daily call requirement during the Pretreatment Period Measurement of body weight Recording of seated vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) Triplicate 12-lead ECG, if applicable (pre-dose [see Appendix X]) Documentation of concomitant medicines Collection of blood and urine samples for clinical laboratory determinations CBC Chemistry UA Confirmation of negative result on the urine pregnancy test before randomization and the administration of the first dose of study drug Review of AEs Trial Coordinator call to IVRS (refer to IVRS Center User Manual) to transition the patient into the Prerandomization Phase of the visit IVRS assessments (a call will be made in the clinic to the IVRS so that the patient can provide the following information): Amended Protocol LIN-MD-01 Amendment #2

39 Forest Research Institute Page 38 Assessment of daily bowel habits Daily patient symptom severity assessments Use of per-protocol rescue medicine or any other laxative, suppository, or enema Weekly patient assessment of constipation severity Weekly patient assessment of degree of relief of constipation symptoms Trial Coordinator call to IVRS to confirm patient eligibility and randomize patient The following procedures will be performed after randomization (prior to first dose): Assessment of whether patient meets Rome III criteria for CC (completed by the Trial Coordinator) Health Resource Use Questionnaire (HRUQ) administered by the Trial Coordinator (Appendix VII) Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire (selfadministered by the patient) (Appendix VI) EuroQoL-5D (EQ-5D) for quality-of-life assessment (self-administered by the patient) (Appendix IV) Short Form-12 Health Survey (SF-12) self-administered by the patient (Appendix VIII) Work Productivity and Activity Impairment Questionnaire for Constipation (WPAI:C) self-administered by the patient (Appendix IX) Administration of study drug (initial dose) in the clinic from the patient s bottle containing 35 capsules. The following procedures will be performed after study drug administration: Dispensing of study drug (bottle provided to the patient) Dispensing of rescue medicine as needed; review with patient how rescue medicine should be used Triplicate 12-lead ECG, if applicable (post-dose [see Appendix X]) PK blood draw, if applicable (see Appendix X) Amended Protocol LIN-MD-01 Amendment #2

40 Forest Research Institute Page 39 Reminding patient to call IVRS (patients will be instructed to call the IVRS during the evening of the Randomization Visit and reminded to call the IVRS at the same time each day thereafter) Scheduling of patient s next visit and reminding the patient to refrain from using prohibited medicines and to refrain from using rescue medicine for the remainder of the day of randomization and for the calendar day after randomization Week 2 (Visit 4) The following procedures will be performed: Measurement of body weight Recording of seated vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) Documentation of concomitant medicines Review of AEs Dispensing of rescue medication as needed; review with patient how rescue medicine should be used Verification of IVRS compliance and providing of IVRS reminder (Trial Coordinator will access the IVRS to verify the patient s compliance with the daily call requirement. After determining the patient s compliance, the Trial Coordinator will remind the patient to call the IVRS at the same time each day to provide the following information): Assessment of daily bowel habits Daily patient symptom severity assessments Use of per-protocol rescue medicine or any other laxative, suppository, or enema Weekly patient assessment of constipation severity Weekly patient assessment of degree of relief of constipation symptoms Patient self-administration of the EQ-5D Patient self-administration of the SF-12 Patient self-administration of the treatment-satisfaction assessment Amended Protocol LIN-MD-01 Amendment #2

41 Forest Research Institute Page 40 Scheduling of patient s next visit and reminding the patient to return any unused study drug at the next visit and to refrain from using prohibited medicines Week 4 (Visit 5) The following procedures will be performed: Measurement of body weight Recording of seated vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) Triplicate 12-lead ECG, if applicable (see Appendix X) Documentation of concomitant medicines Collection of blood and urine samples for clinical laboratory determinations CBC Chemistry UA Serum pregnancy test result must be confirmed as negative to continue patient in the trial PK blood sample, if applicable (see Appendix X) Review of AEs Determination of study drug accountability Dispensing of study drug (one bottle containing 35 capsules) Dispensing of rescue medication as needed; review with patient how rescue medicine should be used Verification of IVRS compliance and providing of IVRS reminder (Trial Coordinator will access the IVRS to verify the patient s compliance with the daily call requirement. After determining the patient s compliance, the Trial Coordinator will remind the patient to call the IVRS at the same time each day to provide the following information): Assessment of daily bowel habits Amended Protocol LIN-MD-01 Amendment #2

42 Forest Research Institute Page 41 Daily patient symptom severity assessments Use of per-protocol rescue medicine or any other laxative, suppository, or enema Weekly patient assessment of constipation severity Weekly patient assessment of degree of relief of constipation symptoms EQ-5D (self-administered by the patient) HRUQ (administered by the Trial Coordinator) SF-12 (self-administered by the patient) WPAI:C (self-administered by the patient) Treatment-satisfaction assessment (self-administered by the patient) Scheduling of patient s next visit and reminding the patient to return any unused study drug at the next visit and to refrain from using prohibited medicines Week 8 (Visit 6) The following procedures will be performed: Measurement of body weight Recording of seated vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) Triplicate 12-lead ECG, if applicable (see Appendix X) Documentation of concomitant medicines Review of AEs Dispensing of study drug (one bottle containing 35 capsules) Determination of study drug accountability Dispensing of rescue medication as needed; review with patient how rescue medicine should be used Verification of IVRS compliance and providing of IVRS reminder (Trial Coordinator will access the IVRS to verify the patient s compliance with the daily call Amended Protocol LIN-MD-01 Amendment #2

43 Forest Research Institute Page 42 requirement. After determining the patient s compliance, the Trial Coordinator will remind the patient to call the IVRS at the same time each day to provide the following information): Assessment of daily bowel habits Daily patient symptom severity assessments Use of per-protocol rescue medicine or any other laxative, suppository, or enema Weekly patient assessment of constipation severity Weekly patient assessment of degree of relief of constipation symptoms EQ-5D (self-administered by the patient) HRUQ (administered by the Trial Coordinator) SF-12 (self-administered by the patient) WPAI:C (self-administered by the patient) Treatment-satisfaction assessment (self-administered by the patient) Reminder for patients to not take study drug on the morning of the EOT Visit (Visit 7) Reminder for patients to fast for at least 2 hours before arriving at the clinic for the EOT Visit (Visit 7) Scheduling of patient s next visit and reminding the patient to return any unused study drug at the next visit and to refrain from using prohibited medicines End-of-Trial Visit (Final Visit) (Visit 7) Patients who are randomized but do not complete the treatment period (withdraw consent or are discontinued before they have completed all 12 weeks of treatment), shall be considered to be withdrawals and should complete the EOT Visit (even if out of window). The Trial Coordinator will call IVRS to discontinue patients who are treatment-period withdrawals. Any clinical findings obtained during the final examination or at premature discontinuation for any reason, including clinically significant laboratory abnormalities, will be followed until the condition returns to screening status, has resolved or stabilized, or can be explained as being unrelated to study drug. Amended Protocol LIN-MD-01 Amendment #2

44 Forest Research Institute Page 43 Patients who complete the treatment period will undergo the following procedures at the EOT Visit, and then will be registered as completing the trial in IVRS by the Trial Coordinator: Physical examination (rectal, breast, and genitourinary examinations are optional at the discretion of the Investigator) Measurement of body weight Recording of seated vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) Performance of 12-lead ECG OR o Single 12-lead ECG (Single tracing to be performed on trial patients consented prior to and after the completion of the triplicate ECG program) o Triplicate 12-lead ECG (see Appendix X) Documentation of concomitant medicines Collection of blood and urine samples for clinical laboratory determinations CBC Chemistry UA Urine pregnancy test Review of AEs Determination of study drug accountability PAC-QOL questionnaire (self-administered by patient) Treatment-satisfaction assessment (self-administered by patient) Treatment-continuation assessment (self-administered by patient) EQ-5D (self-administered by patient) HRUQ (administered by the Trial Coordinator) Amended Protocol LIN-MD-01 Amendment #2

45 Forest Research Institute Page 44 SF-12 (self-administered by the patient) WPAI:C (self-administered by the patient) Registration in IVRS (Trial Coordinator will inform IVRS that the patient has ended participation in the trial) Efficacy Measurements Primary Efficacy Assessment The primary efficacy assessment, which will be used to determine the primary efficacy parameter (12-week CSBM overall responder [Section ] during the 12 weeks of treatment in the treatment period), is the IVRS information that determines whether a BM is a CSBM: The day of the BM How many bowel movements did you have since yesterday s call at < IVRS inserts time when this question was answered yesterday>? Was this bowel movement today or yesterday? 1 = today 2 = yesterday Whether the BM is associated with a sense of complete evacuation. This is assessed by the patient answering the following IVRS question for each BM: Did you feel like you completely emptied your bowels? 1 = yes 2 = no Day of any rescue medicine use Have you taken any laxatives, suppositories, or enemas since yesterday s call at <IVRS inserts time when yesterday s call was completed>? 1 = yes 2 = no Amended Protocol LIN-MD-01 Amendment #2

46 Forest Research Institute Page 45 If yes, Please enter 1 = oral bisacodyl, 2 = bisacodyl suppository, or 3 = other laxatives, suppositories, or enemas. Was this rescue medication use today or yesterday? 1 = today 2 = yesterday Each day of the pretreatment and treatment periods, the patient will call into the IVRS and provide the number of BMs he or she had since the previous day s call. For each BM, the patient will also provide the day the BM occurred and if the BM was associated with a sense of complete evacuation (the patient is also asked to provide assessments of consistency and straining, which are secondary efficacy assessments). The patient will also be asked if he or she took any medicines to treat their constipation since the previous day s call. For each type of rescue medicine taken (eg, bisacodyl tablet, bisacodyl suppository) or other laxatives, suppositories, or enemas, the patient will be asked to provide the day it was taken Secondary Efficacy Assessments In addition to the primary efficacy assessment, the following efficacy assessments will be used in determining the secondary efficacy parameters: Spontaneous Bowel Movement The SBM assessment comprises the IVRS information that determines whether a BM is an SBM as follows: Day of the BM Day of any rescue medicine use Refer to Section for the questions. Amended Protocol LIN-MD-01 Amendment #2

47 Forest Research Institute Page 46 Stool Consistency (Bristol Stool Form Scale) Patient assessment of stool consistency will be collected by daily IVRS calls. For each BM, stool consistency is assessed by the patient using the BSFS. Appendix V depicts the stool consistency characteristics upon which each patient will assign a corresponding score for each BM. The BSFS is a well-accepted and widely-used measurement of stool consistency (Lewis and Heaton, 1997). The seven-point ordinal BSFS is provided below: Please describe the consistency of the BM using the following scale where: 1 = separate hard lumps like nuts (difficult to pass) 2 = sausage shaped but lumpy 3 = like a sausage but with cracks on surface 4 = like a sausage or snake, smooth and soft 5 = soft blobs with clear-cut edges (passed easily) 6 = fluffy pieces with ragged edges, a mushy stool 7 = watery, no solid pieces (entirely liquid) Severity of Straining Patient assessment of straining will be collected daily by IVRS calls. For each BM, degree of severity of straining will be assessed by the patient using the following five-point ordinal scale: How much did you strain during the bowel movement? 1 = not at all 2 = a little bit 3 = a moderate amount 4 = a great deal 5 = an extreme amount Amended Protocol LIN-MD-01 Amendment #2

48 Forest Research Institute Page 47 Weekly Patient Assessment of Constipation Severity Patient assessment of constipation severity will be reported weekly by IVRS calls. The rating of constipation severity during the previous 7 days on a 5-point ordinal scale will be provided by the patient answering the following question: On average, how would you rate your constipation during the past 7 days? 1 = none 2 = mild 3 = moderate 4 = severe 5 = very severe Daily Patient Assessment of Abdominal Discomfort Patient assessment of abdominal discomfort will be collected daily by IVRS calls. The rating of abdominal discomfort during the previous 24 hours on a five-point ordinal scale will be provided by the patient answering the following question: How would you rate your abdominal discomfort over the last 24 hours? 1 = none 2 = mild 3 = moderate 4 = severe 5 = very severe Daily Patient Assessment of Bloating Patient assessment of bloating will be collected daily by IVRS calls. The rating of bloating during the previous 24 hours on a five-point ordinal scale will be provided by the patient answering the following question: How would you rate your bloating over the last 24 hours? 1 = none 2 = mild 3 = moderate Amended Protocol LIN-MD-01 Amendment #2

49 Forest Research Institute Page 48 4 = severe 5 = very severe Additional Efficacy Assessments In addition to the primary and secondary efficacy assessments, the following efficacy assessments are used in determining the additional efficacy parameters. Bowel Movement Within 24 Hours of Receiving Study Drug This assessment is the IVRS question asking the patient if a BM occurred within 24 hours of the patient receiving the first dose of study drug. Did this bowel movement occur less than 24 hours after you first took study medication? 1 = yes 2 = no Daily Patient Assessment of Abdominal Pain Patient assessment of abdominal pain will be collected daily by IVRS calls. The rating of abdominal pain during the previous 24 hours on a five-point ordinal scale will be provided by the patient answering the following question: How would you rate your abdominal pain over the last 24 hours? 1 = none 2 = mild 3 = moderate 4 = severe 5 = very severe Weekly Patient Assessment of Degree of Relief of Constipation Symptoms Patient assessment of degree of relief of constipation symptoms will be reported weekly by IVRS calls. The rating of the degree of relief of constipation symptoms during the previous 7 days on a 7-point balanced ordinal scale will be provided by the patient answering the following question: Amended Protocol LIN-MD-01 Amendment #2

50 Forest Research Institute Page 49 Compared to before you started this study, how would you rate your constipation symptoms during the past 7 days? 1 = completely relieved 2 = considerably relieved 3 = somewhat relieved 4 = unchanged 5 = somewhat worse 6 = considerably worse 7 = as bad as I can imagine Per-Protocol Rescue Medicine or Any Other Laxative, Suppository, or Enema Use Per-protocol rescue medicine and any other laxative, suppository, or enema use (as defined in Appendix II) will be reported by the patient daily via the IVRS. The Investigator or designee will review rescue medicine use for each patient during each trial visit following the Screening Visit (Visit 1). Treatment-Satisfaction Assessment A treatment-satisfaction assessment will be performed at Week 2 (Visit 4) and at all subsequent trial visits. Patients will answer the following five-point ordinal scale question: Overall, how satisfied are you with the study medication s ability to relieve your constipation symptoms? 1 = not at all satisfied 2 = a little satisfied 3 = moderately satisfied 4 = quite satisfied 5 = very satisfied Treatment-Continuation Assessment A treatment-continuation assessment will be performed at the EOT Visit (Visit 7). Patients will answer the following five-point ordinal scale question: Amended Protocol LIN-MD-01 Amendment #2

51 Forest Research Institute Page 50 If given the option, how likely is it that you would continue taking the study medication? 1 = not at all likely 2 = a little likely 3 = moderately likely 4 = quite likely 5 = very likely Health Outcome Assessments PAC-QOL Questionnaire The PAC-QOL questionnaire (Appendix VI) is an instrument for assessing the effect of constipation on a patient s quality of life. Evidence of its validity has been published (Marquis et al, 2005). The PAC-QOL questionnaire assesses four dimensions: physical discomfort, psychosocial discomfort, worries/concerns, and satisfaction. It will be self-administered at the Randomization Visit (Visit 3) before the patient receives the first dose of study drug and at the EOT Visit (Visit 7). Treatment-period withdrawal patients should complete the PAC-QOL questionnaire at the EOT Visit (even if out of window). EQ-5D Assessment The EQ-5D (Appendix IV) is a generic measure of health status that is widely used in Europe (The EuroQol Group, 1990). The descriptive system consists of five categories assessing the following dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Responses to the five questions define a health state for which a utility index can be derived from published algorithms. The second component of the EQ-5D is a visual analogue scale, asking patients to rate their health from 0 to 100 (0 represents worst imaginable health state and 100 represents best imaginable health state). The EQ-5D will be self-administered at the Randomization Visit (Visit 3) before the patient receives the first dose of study drug and at all subsequent trial visits. Treatment-period withdrawal patients should complete the self-administration of the EQ-5D at the EOT Visit (Visit 7) (even if out of window). Amended Protocol LIN-MD-01 Amendment #2

52 Forest Research Institute Page 51 HRUQ The HRUQ collects patient demographic and health care resource use in the month before administration at the clinic (Appendix VII). Information is collected on hospitalizations, outpatient visits, emergency care visits, and other health care visits. It will be administered by the Trial Coordinator at the Randomization Visit (Visit 3) before the patient receives the first dose of study drug and at all subsequent trial visits, except at Week 2 (Visit 4). The first question on the HRUQ, What is the highest grade or level of school you have completed? is only required to be asked at the first administration during the Randomization Visit (Visit 3). Treatment-period withdrawal patients should have the HRUQ administered by the Trial Coordinator at the EOT Visit (Visit 7) (even if out of window). Short Form-12 Health Survey The SF-12 (Appendix VIII) is a widely used generic measure of health status (Ware et al, 1996). The SF-12 measures eight concepts: physical functioning, role limitations due to physical health problems, bodily pain, general health, vitality (energy/fatigue), social functioning, role limitations due to emotional problems, and mental health (physiological distress and physiological well being). These eight scales are aggregated into two summary measures: the Physical and Mental Component Summary scores. It will be selfadministered at the Randomization Visit (Visit 3) before the patient receives the first dose of study drug and at all subsequent trial visits. Treatment-period withdrawal patients should complete the self-administration of the SF-12 at the EOT Visit (Visit 7) (even if out of window). Work Productivity and Activity Impairment Questionnaire for Constipation The WPAI: Specific Health Problem is a tool for quantifying the effect of a specific health problem on absenteeism, presenteeism, work productivity loss, and activity impairment (Reilly et al, 1993) (Appendix IX). This version has been adapted to quantify the specific effects of constipation on work productivity and impairment, resulting in the WPAI:C. It will be self-administered at the Randomization Visit (Visit 3) before the patient receives the first dose of study drug and at all subsequent trial visits, except Week 2 (Visit 4). Treatment-period withdrawal patients should complete the selfadministered WPAI:C at the EOT Visit (Visit 7) (even if out of window) Safety Assessments At every visit, patients must be seen by a physician or an appropriately trained health professional listed on Form FDA 1572; and the AE evaluation must be documented. The procedures discussed below will be performed at the designated visits. Amended Protocol LIN-MD-01 Amendment #2

53 Forest Research Institute Page Adverse Events An AE is any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have to have a causal relationship with this treatment (ICH, E2A). An AE, therefore, can be any unfavorable and unintended sign (including an abnormal laboratory finding, for example), symptom, or disease temporally associated with the use of a medicinal product, whether or not considered related to the medicinal product (ICH, E2A). AEs include, but are not limited to, the following: Any unfavorable changes in general condition Any clinically significant worsening of a preexisting condition Any intercurrent diseases or accidents Note: A procedure is not an AE, but the reason for a procedure may be an AE. Laboratory abnormalities, changes in vital signs, 12-lead ECG parameters, and physical examination findings should be considered AEs and reported on the AE-reporting form of the patient s ecrf if they are deemed to be clinically significant, if they necessitate intervention, and/or if the Investigator considers them to be AEs Causality Assessment For all AEs, the Investigator must provide an assessment of causal relationship to study drug. The causality assessment must be recorded on the appropriate AE-reporting form of the patient s ecrf. Causal relationship must be assessed according to the following scale: Unrelated: Unlikely: Possible: Probable: Definite: event can be fully explained by the patient s clinical state or agents or therapies other than the study drug event is most likely to be explained by the patient s clinical state or agents or therapies other than the study drug event may be explained by administration of the study drug, by the patient s clinical state, or by other agents or therapies event is most likely to be explained by administration of the study drug, rather than the patient s clinical state or other agents or therapies event can be fully explained by administration of the study drug Amended Protocol LIN-MD-01 Amendment #2

54 Forest Research Institute Page Severity Assessment The Investigator will provide an assessment of the severity of each AE by recording a severity rating on the appropriate AE-reporting form of the patient s ecrf. Severity, which is a description of the intensity of manifestation of the AE, is distinct from seriousness, which implies a patient outcome or AE-required treatment measure associated with a threat to life or functionality. Severity will be assessed according to the following scale: Mild: Moderate: Severe: The AE was an annoyance to the patient but did not further hinder baseline functioning; the AE may have been intermittent or continuous. The AE caused the patient to experience some discomfort or some interference with normal activities but was not hazardous to health; prescription drug therapy may have been employed to treat the AE. The AE caused the patient to experience severe discomfort or severely limited or prevented normal activities and represented a definite hazard to health; prescription drug therapy and/or hospitalization may have been employed to treat the AE Serious Adverse Events According to ICH guidelines, an SAE is any AE occurring at any dose that meets one or more of the following criteria or outcomes: Results in death Is life threatening Requires inpatient hospitalization or prolongation of an existing hospitalization Results in persistent or significant disability or incapacity Results in a congenital anomaly or birth defect Important medical events that may not result in death, be life threatening, or require hospitalization may be considered serious when, based on appropriate medical judgment, it may jeopardize the patient and may require medical or surgical intervention to prevent one of the outcomes listed in this definition. Examples of such medical events include allergic bronchospasm requiring intensive treatment in an emergency room or at home, blood dyscrasias or convulsions that do not result in inpatient hospitalization, or the development of drug dependency or drug abuse Amended Protocol LIN-MD-01 Amendment #2

55 Forest Research Institute Page 54 Emergency room visits that do not result in admission to the hospital should be evaluated for one of the other serious outcomes (eg, life threatening, other serious [medically important] event) Reporting Adverse Events and Serious Adverse Events General Reporting Requirements It is Forest Research Institute policy to collect and record all AEs (ie, any untoward medical occurrences or unfavorable and unintended signs, symptoms, or diseases) that occur in patients after the time the patients sign the ICF for the trial. At each visit following the first visit, patients are to be queried regarding any AEs that have occurred since the previous visit. Patients will be asked to volunteer information concerning AEs with a nonleading question such as, Have you had any unusual signs or symptoms since your last visit? Trial center personnel will then record all pertinent information verbatim (eg, loose stools, diarrhea ) in the patient s source documentation and subsequently into the ecrf. All AEs must be recorded in the patient s source documentation and subsequently on the appropriate AE-reporting page of the patient s ecrf, whether or not the events are considered causally related to study drug. For every AE, the Investigator must: Provide an assessment of the severity, causal relationship to study drug, and seriousness of the event Document all actions taken with regard to study drug (viz, no action taken, treatment temporarily interrupted, or treatment discontinued). The Investigator may allow a patient to temporarily interupt study drug for up to 3 days should an AE occur. If the Investigator believes that the patient is unable to resume dosing or requires a suspension of dosing on more than one occasion, the Investigator should discuss with the Medical Monitor the patient s continued participation in the trial Detail any other treatment measures taken for the AE Special Situation: Exposure to Study Drug During Pregnancy Trial personnel must report every pregnancy as soon as possible (within 24 hours after notification) even if no AE has occurred and follow the pregnancy to term. Pregnancies, which are not considered AEs, will be reported on a standard pregnancy form. If, however, the pregnancy is associated with an SAE (eg, if the mother is hospitalized for dehydration), the appropriate serious criterion (eg, hospitalization) will be indicated on the SAE form. Amended Protocol LIN-MD-01 Amendment #2

56 Forest Research Institute Page 55 All relevant SAE and pregnancy information must be faxed to Forest Research Institute at Adverse Event Reporting Period At each trial visit following the first visit (and during any communication with a patient or patient representative occurring outside a defined trial visit), all AEs reported by the patient or patient representative or observed or otherwise identified by the Investigator or other trial personnel must be documented. For all AEs, the reporting period will begin at the signing of the ICF and continues until the patient is lost to follow-up or until completion of trial participation (ie, Early Termination Visit or EOT Visit [Visit 7]). Serious Adverse Event Reporting Period Upon learning of an AE considered serious as described in Section , the Investigator or other trial personnel must inform Forest Research Institute of the event as soon as possible (not later than 24 hours from learning of the event). Reporting shall not be delayed pending a resolution or an outcome of the event. If an outcome of an SAE is not available at the time of the initial report, Forest Research Institute expects follow-up to proceed until such time as an outcome is known. The starting point for the collection of SAEs will be from the time the patient signs the ICF. An SAE will be defined as an on-therapy SAE if it occurred on or after the date of the first dose of double-blind study drug and within 30 days of the date of the last dose of double-blind study drug. Fax all relevant SAE or pregnancy information to Forest Research Institute. The notification may be accompanied by a telephone call to the following Forest Research Institute personnel: Steven Shiff, MD, Medical Monitor Associate Director, Clinical Development Telephone: Fax: Paul Eng, PhD Director, Clinical Development Telephone: Fax: Susan Fox, PhD Assistant Director, Clinical Development Telephone: Fax: Forest Research Institute Harborside Financial Center, Plaza V Jersey City, NJ Amended Protocol LIN-MD-01 Amendment #2

57 Forest Research Institute Page 56 SAE fax number: Medical emergency pager number: Follow-Up Procedures for Serious Adverse Events The Sponsor shall promptly investigate all safety information received. Follow-up information to a safety report shall be submitted as soon as the relevant information is available (21 CFR [d]). Relevant information such as discharge summaries, autopsy reports, and medical consultations shall be reviewed in detail by the Investigator. The Investigator shall comment on any event, abnormal laboratory result, or any other finding, noting whether it shall be considered a serious or nonserious AE or considered part of the patient s natural disease history. In addition, the Investigator shall report on an SAE form all subsequent events or other findings determined to be relevant and shall state for each event or finding whether it is related to study drug. All events determined to be nonserious shall be reported on the relevant ecrf form Clinical Laboratory Determinations Blood and urine samples will be collected for clinical laboratory tests and determination of linaclotide and MM levels according to the trial specific manual at the Screening Visit (Visit 1) and other visits defined in the Schedule of Evaluations (Section 2.0). At the Screening Visit (Visit 1), the Investigator will assess the clinical significance of any values outside the reference ranges provided by the central laboratory, and patients with abnormalities judged to be clinically significant will be excluded from the trial. The following clinical laboratory tests will be performed: Hematology: Chemistry: Urinalysis: Absolute and differential white blood cell count, erythrocyte count, hemoglobin level, hematocrit level, platelet count, and red blood cell indices (mean corpuscular volume, mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration) Sodium, magnesium, potassium, calcium, chloride, glucose, blood urea nitrogen, creatinine, total protein, alkaline phosphatase, albumin, total bilirubin, aspartate aminotransferase, alanine aminotransferase, bicarbonate, phosphate, and cholesterol levels Specific gravity, ph, protein, glucose, ketones, and blood Amended Protocol LIN-MD-01 Amendment #2

58 Forest Research Institute Page 57 Other: Urine drug screening (cocaine, barbiturates, amphetamines, opiates, benzodiazepine, alcohol, and cannabinoids) (screening only). Clinical significance of a positive urine drug screen will be assessed by the investigator Pregnancy test: Serum human chorionic gonadotropin pregnancy test (for women of childbearing potential only) should be conducted at the Screening Visit (Visit 1) and at Week 4 (Visit 5). A negative urine pregnancy test must be documented at the Randomization Visit (Visit 3) for the patient to be eligible for randomization and dosing with study drug and at the EOT Visit (Visit 7). Positive results on the pregnancy test will exclude a patient from participating or continuing in the trial A central laboratory will be used to evaluate all urine and blood samples (except for the urine pregnancy test), which will be collected, processed, and stored according to the instructions provided by the laboratory Vital Signs At every trial visit, vital sign measurements will be recorded with the patients in the seated position. The parameters are oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate. Pulse and blood pressure readings will be taken after the patient has been sitting for 5 minutes Electrocardiograms A single 12-lead ECG tracing will be performed at the Screening Visit (Visit 1) and other visits defined in the Schedule of Evaluations (Section 2.0), and the results will be documented on the appropriate ecrf form. Additional ECGs will be performed in triplicate on a subset of the trial patients (refer to Appendix X). ECG results must be available to the Investigator before the first dose of study drug is administered. ECGs will be electronically transmitted for analysis to the central ECG interpretation laboratory per the instructions of the laboratory and analyzed in a semi-automated fashion. Measurements will be recorded for the following parameters: heart rate, PR interval, QRS interval, QT interval, and QTc interval. Amended Protocol LIN-MD-01 Amendment #2

59 Forest Research Institute Page Other Safety Assessments Physical Examination A complete physical examination will be performed at the Screening Visit (Visit 1) and other visits defined in the Schedule of Evaluations (Section 2.0). The examination will be done by the Investigator or a licensed health professional listed on Form FDA 1572 and should include evaluation of general appearance, HEENT (head, ears, eyes, nose and throat), neck, cardiovascular, thorax/lungs, abdomen, musculoskeletal, lymph nodes, skin, and neurologic and mental status. Any physical examination abnormality that the Investigator considers to be potentially clinically significant (PCS) and changed from the baseline will be reported as an AE. A rectal examination should be performed during the screening period in all patients who do not require a colonoscopy. After the screening period, the rectal examination is optional and may be performed at the discretion of the Investigator. For all physical examinations, the breast and genitourinary examinations are optional and may be performed at the discretion of the Investigator Medical and Surgical History A complete medical and surgical history will be provided by the patient at the Screening Visit (Visit 1) Drug Concentration Measurements Samples of blood for determination of the concentration of linaclotide and its metabolite MM will be collected at two time points during the study (Randomization [Visit 3] and Week 4 [Visit 5]) in a pre-defined subset of patients (See Appendix X) Laxative, Suppository, Enema, and Prohibited Medicines Washout If the patient is deemed qualified during the screening period to enter the trial, he/she will discontinue the use of all laxatives, suppositories, and/or enemas at least 1 calendar day before the first day of the pretreatment period. Patients will cease taking all other prohibited medicines (as defined in Appendix II) at least 14 calendar days before the first day of the pretreatment period. Amended Protocol LIN-MD-01 Amendment #2

60 Forest Research Institute Page DATA QUALITY ASSURANCE Data Monitoring Before any patient enters the trial, a representative of Forest Research Institute will meet with the Investigator and his/her staff to review the procedures to be followed while conducting the study and to train them on recording the data on the ecrfs using the electronic data capture (EDC) system. After the first patient is enrolled (ie, signs informed consent), the Forest representative, a Field Monitor (FM), will periodically monitor the progress of the study by conducting on-site visits. This FM will also be able to review data query statuses remotely, possibly warranting more frequent communication with the Investigator and his/her staff. The Investigator will make available to the FM a computer to access the ecrfs, source documents, signed ICFs, and all other study-related documents. The Investigator and his/her staff will be responsible for reviewing ecrfs, resolving data queries generated by the FM via the system, providing missing or corrected data, approving all changes performed on his/her data, and endorsing the patient data within the EDC system. This approval method will include applying an electronic signature, a uniquely assigned username and password that together will represent a traditional handwritten signature Data Recording and Documentation All data collected in the context of this trial will be stored and evaluated in such a way as to guarantee patient confidentiality in accordance with the legal stipulations applying to confidentiality of data. Trial records (eg, essential documents [commonly called regulatory documents], correspondence) will be retained at the trial center, along with adequate source documentation, according to FDA and ICH requirements. All trial records must be available for inspection by Forest Research Institute and the FDA. Data collection will involve the use of the Forest EDC system, to which only authorized personnel will have access. In addition to periodic monitoring occurring within the system by Sponsor FMs, programmatic edit checks will be used to review the data for completeness, logic, and adherence to trial protocol. As a result of this monitoring and these checks, queries may be electronically issued to the clinical trial center and electronically closed by this center. The identifying information (assigned username, date, and time) for both the originator of the query (if created during the monitoring process) and the originator of the data change (if applicable), as well as the PI s approval of all changes performed on his/her patients data, will be collected. Amended Protocol LIN-MD-01 Amendment #2

61 Forest Research Institute Page STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE Patient Populations The following patient populations will be considered in the statistical analysis of the trial Screened Population The Screened Population will consist of all patients who have a Screening Visit (Visit 1) and receive a PID number Randomized Population The Randomized Population will consist of all patients in the Screened Population who are randomized to a treatment group at the Randomization Visit (Visit 3) Safety Population The Safety Population will consist of all patients in the Randomized Population who receive at least one dose of study drug during the treatment period Intent-to-Treat Population The ITT Population will consist of all patients in the Safety Population who have at least one post-randomization entry of the primary efficacy assessment (ie, the daily IVRS information that determines whether an SBM is a CSBM) Patient Disposition The number of patients in each of the trial populations will be summarized by treatment group and trial center, except for the Screened Population, which will only be summarized overall and by trial center. The number of screen failures (ie, patients enter the screening period but not the pretreatment period) and patients ineligible for randomization (ie, patients who entered the pretreatment period but are not randomized at the Randomization Visit [Visit 3]), along with the associated reasons for failure, will be tabulated overall. Amended Protocol LIN-MD-01 Amendment #2

62 Forest Research Institute Page 61 The number and percentage of patients who complete the treatment period and the number and percentage of patients who prematurely discontinue during the treatment period will be presented for each treatment group and pooled across treatment groups for the Randomized Population. The reasons for premature discontinuation from the treatment period as recorded on the trial completion forms of the ecrfs will be summarized (number and percentage) by treatment group and overall for all randomized patients. The percentage of premature discontinuations will be compared overall and for each discontinuation reason between treatment groups using the Fisher exact test Demographics and Other Baseline Characteristics Demographic parameters (eg, age, race, ethnicity, sex, weight, height) and other baseline characteristics will be summarized by treatment group for the Safety and ITT populations. Comparability among treatment groups will be tested using an analysis of variance (ANOVA) model with treatment group and geographic region as the factors for continuous variables and a Cochran-Mantel-Haenszel (CMH) test, controlling for geographic region, for categorical variables Extent of Exposure and Treatment Compliance Study Drug Exposure to double-blind study drug for the Safety Population will be summarized. The exposure will be calculated as the number of days from the date of first double-blind study drug taken to the date of last dose taken in the period, inclusive Prior and Concomitant Medicines Prior medicines are defined as any medicines taken before the date of first dose of double-blind study drug. Concomitant medicines are defined as any medicines taken during the treatment period (ie, between the date of the first dose of study drug in the treatment period and the date of the last dose of study drug in the treatment period, inclusive). Any medicines started after the date of last dose of study drug will not be considered concomitant medicines. Both prior and concomitant medicine use will be summarized by the number and proportion of patients in each treatment group receiving each medicine within each therapeutic class. Concomitant medicine will be summarized for the treatment period using the Safety Population. Multiple medicine use by a patient in the same category (based on Anatomical-Therapeutic-Chemical classification) will only be counted once. Amended Protocol LIN-MD-01 Amendment #2

63 Forest Research Institute Page Measurement of Treatment Compliance Dosing compliance for a specified period will be defined as the total number of capsules actually taken by a patient during that period divided by the number of capsules that were expected to be taken during the same period multiplied by 100. The total number of capsules actually taken will be calculated by subtracting the total number of capsules returned from the total number of capsules dispensed. The total number of capsules expected to be taken for a specific period will be the number of days in that period. For the treatment period, descriptive statistics for study drug compliance in the Safety Population will be presented by treatment group for both the period as a whole and for each of the three consecutive 4-week periods comprising the treatment period (consistent with study drug dispensing) Efficacy Analyses All efficacy analyses will be based on the ITT Population. Baseline values for efficacy parameters will be derived from the IVRS daily diary and ecrf data collected in the pretreatment period, specifically the period of time from 14 days before randomization up to the time of randomization. The baseline CSBM and SBM weekly rates will be derived based on the number of CSBMs and SBMs a patient had during this period. Baseline stool consistency and severity of straining will be calculated as the average of the nonmissing values from the SBMs reported by the patient during this period. Baseline values for patient symptom severity parameters (eg, abdominal discomfort, bloating, abdominal pain, constipation severity, degree of relief of constipation symptoms) will be the average of the nonmissing patient scores reported during this period. An observed-cases approach to missing postbaseline data will be applied. In addition, as sensitivity analyses, for parameters that are defined on a weekly basis, a last-observationcarried-forward approach will also be applied. For efficacy analyses, trial centers will be pooled together by geographic region (details to be provided in the Statistical Analysis Plan). The overall type I family-wise error rate for testing the primary and secondary efficacy parameters will be controlled at the 0.05 significance level (Section ). For the primary and secondary efficacy parameters, subgroup analyses based on gender and age groups ( 65 vs. < 65) will be performed in the future Integrated Summary of Efficacy using the integrated efficacy data from the controlled pivotal efficacy studies for CC. Amended Protocol LIN-MD-01 Amendment #2

64 Forest Research Institute Page Primary Efficacy Parameter The primary efficacy parameter is 12-week CSBM overall responder. A 12-week CSBM overall responder is a patient who is a CSBM weekly responder for at least 9 of the 12 weeks of the treatment period. A CSBM weekly responder is a patient who had a CSBM weekly frequency rate that was 3 or greater and increased by 1 or more from baseline. If a patient does not have CSBM frequency data for a particular treatment period week, the patient will not be considered a CSBM weekly responder for that week. There are two sets of primary efficacy hypotheses: 1. Null hypothesis: There is no difference in the proportion of 12-week CSBM overall responders between patients taking the 300-μg dose and those taking placebo. Alternative hypothesis: There is a difference in the proportion of 12-week CSBM overall responders between patients taking the 300-μg dose and those taking placebo. 2. Null hypothesis: There is no difference in the proportion of 12-week CSBM overall responders between patients taking the 150-μg dose and those taking placebo. Alternative hypothesis: There is a difference in the proportion of 12-week CSBM overall responders between patients taking the 150-μg dose and those taking placebo. The primary efficacy analysis is the CMH test controlling for geographic region. For each of the two linaclotide dose groups, the proportion of 12-week CSBM overall responders will be compared with the proportion in the placebo group using the CMH test controlling for geographic region. The number and percentage of 12-week CSBM overall responders for each treatment group, the difference in responder rates between each linaclotide and placebo group, and the two-sided p-value associated with the above CMH test will be presented. The Mantel-Haenszel estimate of odds ratio (controlling for geographic region) and the corresponding 95% confidence interval for each linaclotide dose group over placebo group will also be provided Secondary Efficacy Parameters For each of the following secondary efficacy parameters, each of the two linaclotide dose groups will be compared to the placebo group using an analysis-of-covariance model with fixed-effect terms for treatment group and geographic region and the patient s corresponding baseline value of the parameter as a covariate. In addition to inferential and descriptive statistics, results for the secondary efficacy parameters will also be analyzed categorically and displayed geographically. Amended Protocol LIN-MD-01 Amendment #2

65 Forest Research Institute Page 64 Change From Baseline in 12-Week CSBM Frequency Rate A patient s 12-week CSBM frequency rate will be the CSBM rate (CSBMs/week) calculated over the 12-weeks of the treatment period. Change From Baseline in 12-Week SBM Frequency Rate A patient s 12-week SBM frequency rate will be the SBM rate (SBMs/week) calculated over the 12-weeks of the treatment period. Change From Baseline in 12-Week Stool Consistency Stool consistency will be measured using the seven-point BSFS. The patient s BSFS score for the treatment period will be the average of the nonmissing BSFS scores from the SBMs reported by the patient during the 12-week treatment period. Change From Baseline in 12-Week Severity of Straining Severity of straining will be measured using a five-point ordinal scale. The patient s straining score for the treatment period will be the average of the nonmissing straining scores from the SBMs reported by the patient during the 12-week treatment period. Change From Baseline in 12-Week Constipation Severity Constipation severity will be measured weekly using a five-point ordinal scale. The patient s constipation-severity score for the treatment period will be the average of the nonmissing weekly patient assessments of constipation severity scores reported during the 12-week treatment period. Change From Baseline in 12-Week Abdominal Discomfort Abdominal discomfort will be measured daily using a five-point ordinal scale. The patient s abdominal discomfort score for the treatment period will be the average of the nonmissing daily patient assessments of abdominal discomfort scores reported during the 12-week treatment period. Change From Baseline in 12-Week Bloating Bloating will be measured daily using a five-point ordinal scale. The patient s bloating score for the treatment period will be the average of the nonmissing daily patient assessments of bloating scores reported during the 12-week treatment period. Amended Protocol LIN-MD-01 Amendment #2

66 Forest Research Institute Page Controlling for Multiplicity The overall type I family-wise error rate for testing the primary and secondary efficacy parameters will be controlled at the 0.05 significance level using the following five-step serial gatekeeping multiple comparisons procedure (MCP). Following this MCP, progression to the next step will only occur if all individual hypotheses within a step are rejected and the previous step(s) are all rejected at the step-specific overall significance level. If all hypotheses within a step are not rejected, the hypothesis tests corresponding to all subsequent steps will be considered not statistically significant. All hypothesis tests will be two-sided. 1. The first step will test the primary efficacy parameter for the 300-μg dose group at the 0.05 significance level 2. The second step will test the primary efficacy parameter for the 150-μg dose group and the first five secondary parameters (ie, CSBM, SBM, BSFS stool consistency, straining severity, constipation severity) for the 300-μg dose group: The six individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure (Hochberg and Tamhane, 1987) to control for multiple parameters within this step 3. The third step will test the last two secondary efficacy parameters (ie, bloating, abdominal discomfort) for the 300-μg dose group. The two individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure to control for multiple parameters 4. The fourth step will test the first five secondary efficacy parameters for the 150-μg dose group. The five individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure to control for multiple parameters 5. The fifth step will test the last two secondary efficacy parameters for the 150-μg dose group. The two individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure to control for multiple parameters within this step Amended Protocol LIN-MD-01 Amendment #2

67 Forest Research Institute Page Additional Efficacy Parameters The role of the additional efficacy parameters is to provide additional support for the primary and secondary efficacy parameters. BM Within 24 Hours of Receiving the First Dose of Study Drug The proportion of patients with a CSBM (SBM) within 24 hours of first receiving study drug in each linaclotide dose group will be compared with the placebo group using the CMH test controlling for geographic region. Change From Baseline in 12-Week Abdominal Pain Abdominal pain will be measured daily using a five-point ordinal scale. The patient s abdominal pain score for the treatment period will be the average of the nonmissing daily patient scores of abdominal pain reported during the 12-week treatment period. Each of the two linaclotide dose groups will be compared with placebo using an analysis-ofcovariance model with treatment group and geographic region as fixed effects and the baseline abdominal pain score as a covariate. Complete Spontaneous Bowel Movement Weekly Responder For each of the 12 weeks during the treatment period, a patient will be a weekly CSBM responder for that week if the CSBM weekly frequency rate is 3 or greater and increased by 1 or more from baseline. For each week during the treatment period, the proportion of CSBM weekly responders in each linaclotide dose group will be compared with the proportion in the placebo group using a separate CMH test controlling for geographic region. 12-Week Constipation Responder A 12-week Constipation Responder is a patient who is a Weekly Constipation Responder for at least 9 out of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Constipation Responder is a patient who meets each of the following 3 criteria: 1. Patient is a Weekly CSBM Responder: Patient has a CSBM weekly rate of at least 3 and an increase of at least 1 from baseline for that week 2. Patient meets at least one of the following two weekly responder criteria Weekly Severity of Straining Responder: Patient has an improvement from baseline of 1 or more in mean Severity of Straining for that week Weekly Stool Consistency Responder: Patient has an improvement from baseline of 2 or more in mean Stool Consistency for that week Amended Protocol LIN-MD-01 Amendment #2

68 Forest Research Institute Page Patient did not have a worsening from baseline in mean Severity of Straining, or mean Stool Consistency for that week. If a patient does not have an SBM during the 2-week baseline period, change from baseline cannot be assessed for the Severity of Straining and Stool Consistency. In these cases, a patient who is a Weekly CSBM Responder for that treatment period week will be considered a Weekly Constipation Responder for that week. For the 12-week Constipation Responder parameter, the proportion of responders in each linaclotide dose group will be compared with the proportion in the placebo group, using a separate CMH test controlling for geographic region. Treatment Period CSBM Rate Change 1 Responder Treatment period CSBM rate change 1 responder is a patient who had an overall weekly CSBM frequency rate that was increased 1 or more from baseline over the treatment period. The proportion of the treatment period CSBM rate change 1 responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week CSBM Rate 3 Responder A 12-week CSBM rate 3 responder is a patient who had a CSBM weekly frequency rate that was 3 or greater for at least 9 of the 12 weeks of the treatment period. The proportion of 12-week CSBM rate 3 responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week CSBM Rate Change 1 Responder A 12-week CSBM rate change 1 responder is a patient who had a CSBM weekly frequency rate that was increased by 1 or more from baseline for at least 9 of the 12 weeks of the treatment period. The proportion of 12-week CSBM rate change 1 responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week SBM Responder A 12-week SBM Responder is a patient who is a Weekly SBM Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly SBM Responder is a patient who has an improvement from baseline of 2 or more in SBM weekly frequency (SBMs/week) for that week. The proportion of 12-week SBM Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. Amended Protocol LIN-MD-01 Amendment #2

69 Forest Research Institute Page Week Stool Consistency Responder A 12-week Stool Consistency Responder is a patient who is a Weekly Stool Consistency Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Stool Consistency Responder is a patient who has an improvement from baseline of 2 or more (ie, a minimum of two full categories improvement) in Stool Consistency for that week. Patients who do not have an SBM at baseline, and, as such, no baseline stool consistency data, will be excluded from this analysis. The proportion of 12-week Stool Consistency Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week Severity of Straining Responder A 12-week Severity of Straining Responder is a patient who is a Weekly Severity of Straining Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Severity of Straining Responder is a patient who has an improvement from baseline of 1 or more (ie, a minimum of a full category improvement) in Severity of Straining for that week. Patients who do not have an SBM at baseline, and, as such, no baseline straining data, will be excluded from this analysis. The proportion of 12-week Severity of Straining Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week Constipation Severity Responder A 12-week Constipation Severity Responder is a patient who is a Weekly Constipation Severity Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Constipation Severity Responder is a patient who has an improvement from baseline of 1 or more (ie, a minimum of a full category improvement) in Constipation Severity for that week. The proportion of 12-week Constipation Severity Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week Abdominal Discomfort Responder A 12-week Abdominal Discomfort Responder is a patient who is a Weekly Abdominal Discomfort Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Abdominal Discomfort Responder is a patient who has an improvement from baseline of 1 or more (ie, a minimum of a full category improvement) in Abdominal Discomfort for that week. The proportion of 12-week Abdominal Discomfort Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. Amended Protocol LIN-MD-01 Amendment #2

70 Forest Research Institute Page Week Bloating Responder A 12-week Bloating Responder is a patient who is a Weekly Bloating Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Bloating Responder is a patient who has an improvement from baseline of 1 or more (ie, a minimum of a full category improvement) in Bloating for that week. The proportion of 12-week Bloating Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. Degree of Relief of Constipation Symptoms Responder Degree of relief of constipation symptoms will be measured weekly using a seven-point balanced ordinal scale. The responder parameter based on the following criteria will be analyzed: A patient s weekly response is somewhat relieved, considerably relieved, or completely relieved (ie, a score 3) for all 12 weeks of the treatment period or A patient s weekly response is considerably relieved or completely relieved (ie, a score of 2) for at least 6 out of 12 weeks of the treatment period For the 12-week treatment period, the proportion of degree of relief of constipation symptoms responders in each linaclotide dose group will be compared with the proportion in the placebo group using a separate CMH test controlling for geographic region. Use of Per-Protocol Rescue Medicine or Any Other Laxative, Suppository, or Enema Use of rescue medication, or any other laxative, suppositories, or enemas during the treatment period in each linaclotide dose group will be compared using the following 3 endpoints: The proportion of patients who report using per-protocol rescue medicines or any other laxative, suppositories, or enemas during the treatment period in each linaclotide dose group will be compared with the proportion in the placebo group using a separate CMH test controlling for geographic region. Amended Protocol LIN-MD-01 Amendment #2

71 Forest Research Institute Page 70 The change from baseline in the percentage of patient reported days of using per-protocol rescue medicine or any other laxative, suppository, or enema during the treatment period. Each of the two linaclotide dose groups will be compared with placebo using an ANCOVA model with treatment group and geographic region as fixed effects and the baseline percentage of days of rescue medication use as a covariate The proportion of patients who have an increase from the baseline in the percentage of days of using per-protocol rescue medicine or any other laxative, suppository, or enema during the treatment period in each linaclotide dose group will be compared with the proportion in the placebo group using a separate CMH test controlling for geographic region. Treatment Satisfaction For Weeks 2, 4, and 8 and for the EOT Visit (Visit 7), the treatment satisfaction question will be analyzed separately at each visit with each of the two linaclotide dose groups compared with placebo using an ANOVA with fixed-effect terms for treatment group and geographic region. Treatment Continuation For the EOT Visit, the treatment-continuation question will be analyzed with each of the two linaclotide dose groups compared with placebo using an ANOVA with fixed-effect terms for treatment group and geographic region Health Outcomes Parameters PAC-QOL The parameters of the PAC-QOL questionnaire consist of the overall average score and the four subscale scores (ie, physical discomfort, psychosocial discomfort, worries/concerns, and satisfaction). The EOT Visit PAC-QOL assessment will be used for analyses. If a patient discontinued from the trial before the EOT Visit and has nonmissing PAC-QOL data from the Early Termination Visit, these data will be used. The change from baseline to Week 12 (Last Observation Carried Forward [LOCF]) for each of the subscales and the overall average of the 28 PAC-QOL questions will be analyzed separately with each of the two linaclotide dose groups compared with placebo using an ANCOVA model with treatment group and geographic region as fixed effects and the baseline PAC-QOL score as a covariate. In addition, descriptive statistics (n, mean, SD, median, minimum, and maximum) will also be presented by treatment group. Amended Protocol LIN-MD-01 Amendment #2

72 Forest Research Institute Page 71 EQ-5D Data from the EQ-5D is being collected for purposes of reimbursement in Europe. Patient responses to the descriptive system (ie, health state) will be converted to the corresponding utility score, and the descriptive statistics (n, mean, SD, median, minimum, and maximum) will be presented for utility score by treatment group. The same statistics will be calculated for the analog scale reflecting the patient s preference for his/her health state. Results will be presented at baseline and Week 12 (LOCF). HRUQ Descriptive statistics (n, mean, SD, median, minimum, and maximum) will be presented for continuous variables (eg, hospitalizations) by treatment group at baseline and Week 12 (LOCF). SF-12 Descriptive statistics (n, mean, SD, median, minimum, and maximum) will be presented for the Physical Component Summary and Mental Component Summary scores of the SF-12 by treatment group at baseline and Week 12 (LOCF). Summary scores for the SF- 12 range from 0 to 100, with higher scores indicating better quality of life. WPAI:C Descriptive statistics (n, mean, SD, median, minimum, and maximum) will be presented for the employed ITT Population for the four summary scores of the WPAI: (1) absenteeism (work time missed); (2) presenteeism (productivity at work); (3) overall work productivity loss (absenteeism plus presenteeism); and (4) daily activity impairment. Scores will be presented by treatment group at baseline and Week 12 (LOCF). Higher percentages indicate greater productivity loss and activity impairment Safety Analyses The safety analysis will be performed using the Safety Population. The safety parameters include AEs, clinical laboratory parameters, vital signs, and ECG parameters. For each safety parameter, the last assessment made before randomization will be used as the baseline for all analyses of that safety parameter. Amended Protocol LIN-MD-01 Amendment #2

73 Forest Research Institute Page Adverse Events AE verbatim terms will be coded using the most current version of the Medical Dictionary for Regulatory Activities (MedDRA) that is available at the start of the trial. An AE (classified by preferred term) that occurs during the treatment period will be considered a TEAE if it was not present before the date of the first dose of double-blind study drug or if it was present before the date of the first dose of double-blind study drug but increased in severity during the treatment period. If more than one AE is reported before the date of the first dose of double-blind study drug and is coded to the same preferred term, the AE with the greatest severity will be used as the benchmark for comparison with the AEs occurring during the treatment period that were also coded to that preferred term. An AE that occurs more than 1 day after the last dose of double-blind study drug will not be counted as a TEAE. For the treatment period, the number and percentage of patients reporting TEAEs in each treatment group and overall linaclotide group (ie, the total of 150 μg and 300 μg linaclotide groups) will be tabulated by system organ class and preferred term; by system organ class, preferred term, and severity; and by system organ class, preferred term, and relationship to study drug. If a patient has more than one TEAE coded to the same preferred term, the patient will be counted only once for that preferred term by identifying those TEAEs with the highest severity and the closest relationship to study drug for the summarization by severity and by relationship to the study drug, respectively. The distribution of TEAEs by severity and relationship to study drug will be summarized by treatment group and overall linaclotide group. The incidence of common TEAEs, on-therapy SAEs, and AEs leading to premature discontinuation of study drug will be summarized by preferred term, treatment group, and overall linaclotide group. In addition, the incidence of fatal SAEs (ie, events that caused death), if any, will be summarized separately by treatment group, overall linaclotide group, and preferred term. Listings will be presented for patients with SAEs, patients with AEs leading to premature discontinuation, and patients who die (if any) Clinical Laboratory Parameters Descriptive statistics for clinical laboratory values (in standard units) and changes from the baseline values at each assessment time point will be presented by treatment group for each clinical laboratory parameter. Amended Protocol LIN-MD-01 Amendment #2

74 Forest Research Institute Page 73 The number and percentage of patients with PCS postbaseline clinical laboratory values will be tabulated by treatment group. The criteria for PCS laboratory values will be detailed in the Statistical Analysis Plan. The percentages will be calculated relative to the number of patients with baseline values and at least one postbaseline assessment. The numerator will be the total number of patients with baseline values and at least one PCS postbaseline value. A supportive listing of patients with PCS postbaseline values will be provided, including the PID number, trial center, and baseline and postbaseline values. A listing of all AEs for patients with PCS laboratory values will also be provided Vital Signs Descriptive statistics for body weight and vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) and changes from baseline values at each visit and at EOT will be presented by treatment group. The number and percentage of patients with PCS postbaseline vital signs will be tabulated by treatment group. A vital sign value will be considered PCS if it meets both the observed value criterion and the change from baseline value criterion. The criteria for PCS vital sign values will be detailed in the Statistical Analysis Plan. The percentages will be calculated relative to the number of patients with available non-pcs baseline values and at least one postbaseline assessment. The numerator will be the total number of patients with available non-pcs baseline values and at least one PCS postbaseline value. A supportive listing of patients with PCS postbaseline values will be provided, including the PID number, trial center, and baseline and postbaseline values. A listing of all AEs for patients with PCS vital sign values will also be provided Electrocardiograms Descriptive statistics for ECG parameters (ie, heart rate, PR interval, QRS interval, QT interval, QTc interval) and changes from baseline values at each assessment time point will be presented by treatment group. QTc interval will be calculated using both Bazett (QTcB = QT/(RR) ½ ) and Fridericia (QTcF = QT/(RR) ⅓ ) formulas; if RR is not available, it will be replaced with 60/HR in the correction formula. The number and percentage of patients with PCS postbaseline ECG values will be tabulated by treatment group for the treatment period. The criteria for PCS ECG values will be detailed in the Statistical Analysis Plan. The percentages will be calculated relative to the number of patients with baseline values and at least one postbaseline assessment. The numerator will be the total number of patients with baseline values and at least one PCS postbaseline value. A supportive listing of patients with PCS postbaseline values will be provided and will include the PID number, trial center, and baseline and postbaseline values. A listing of all AEs for patients with PCS ECG values will also be provided. Amended Protocol LIN-MD-01 Amendment #2

75 Forest Research Institute Page Other Safety Parameters No other safety analyses are planned for this study Interim Analysis No interim analysis is planned for this study Determination of Sample Size The sample size of 600 patients randomized to 150 μg linaclotide, 300 μg linaclotide, or placebo, (1:1:1) was chosen for the following reasons: a. To ensure adequate power for the tests of the primary efficacy parameter b. To ensure that a clinically meaningful number of patients within the male and elderly (older than 65 years) subpopulations receive linaclotide The power calculation for the primary efficacy parameter is based on the results of Ironwood study MCP , a phase IIb study in which 310 patients with CC were randomized to linaclotide or placebo once daily for 4 weeks. The 4-week CSBM overall responder rate for patients treated with placebo was 7.4%; the 4-week CSBM overall responder rates for patients treated with linaclotide were 18.6%, 26.8%, 32.3%, and 29.0% for the 75 μg, 150 μg, 300 μg, and 600 μg linaclotide dose groups, respectively. For the Phase 3 primary efficacy parameter power calculations, the placebo group estimate is taken from the placebo rate (7.4%) in Study MCP The 150 μg linaclotide group estimate is based on the combination of responder rates for the 75 μg and 150 μg dose groups (22.6%), and the 300 μg linaclotide group estimate is based on the combination of responder rates for all (75 μg, 150 μg, 300 μg, and 600 μg) linaclotide dose groups (27.2%). Assuming that 15% more randomized patients would discontinue from a 12-week treatment period and not be responders, the 12-week CSBM overall responder rate estimates used in these power calculations for the placebo, 150 μg, and 300 μg groups were 6.3%, 19.2%, and 23.1%, respectively. Based on 200 patients randomized to each of the three treatment groups, the estimates of the anticipated 12-week CSBM overall responder rates from the phase IIb data, and the MCP described in Section , the trial will have greater than 96% power to reject the 300-μg dose group primary efficacy parameter hypothesis and at least 90% power to reject the 150-μg dose group primary efficacy parameter hypothesis. Amended Protocol LIN-MD-01 Amendment #2

76 Forest Research Institute Page Computer Methods Statistical analyses will be performed using version (or newer) of SAS. 9.8 CHANGES IN THE CONDUCT OF THE TRIAL OR PLANNED ANALYSES Any amendment to this protocol will be provided to the Investigator in writing by Forest Research Institute. No protocol amendment regarding reportable deviations as defined by the IRB may be implemented (with the exceptions noted below) before it has been approved by the IRB and the signature page, signed by the Investigator, has been received by Forest Research Institute. If the protocol is amended to eliminate or reduce the risk to patients, the amendment may be implemented before IRB review and approval. However, the IRB must be informed in writing of such an amendment, and approval must be obtained within reasonable time limits. Deviating from the protocol is permitted only if absolutely necessary for the safety of the patients and must immediately be reported to Forest Research Institute. Amended Protocol LIN-MD-01 Amendment #2

77 Forest Research Institute Page TRIAL SPONSORSHIP 10.1 TRIAL TERMINATION Forest Research Institute reserves the right to terminate the trial in its entirety or at a specific trial center at any time REPORTING AND PUBLICATION All data generated in this study will be the property of Forest Research Institute. An integrated clinical and statistical report will be prepared at the completion of the trial. Publication of the results by the Investigator will be subject to mutual agreement between the Investigator and Forest Research Institute. Amended Protocol LIN-MD-01 Amendment #2

78 Forest Research Institute Page INVESTIGATOR OBLIGATIONS 11.1 DOCUMENTATION The Investigator must provide the following to Forest Research Institute prior to the start of the trial: A completed and signed Form FDA If, during the course of the trial, any changes are made that are not reflected on Form FDA 1572, a new Form FDA 1572 must be completed and returned to Forest Research Institute for submission to the FDA A fully executed contract The curricula vitae for the PI and all Sub-Investigators listed on Form FDA 1572, including a copy of each physician s license A copy of the original IRB approval for conducting the trial. If the trial is ongoing, renewals must be submitted at yearly intervals. All subsequent modifications must be submitted and approved by the IRB, as stated in Section 5.1 A copy of the IRB-approved ICF A copy of the HIPAA authorization form A list of the IRB members or the US Department of Health and Human Services general assurance number A copy of the laboratory certifications and reference ranges The Investigator s Statement page in this protocol signed and dated by the Investigator A financial disclosure agreement completed and signed by the PI and all Sub- Investigators listed on Form FDA If applicable, the PI will provide an updated financial disclosure agreement to the Sponsor 1 year after the completion of the trial 11.2 PERFORMANCE The PI must demonstrate reasonable efforts to obtain qualified patients for the trial. Amended Protocol LIN-MD-01 Amendment #2

79 Forest Research Institute Page USE OF INVESTIGATIONAL MATERIALS The PI will acknowledge that the drug supplies are investigational and as such must be used strictly in accordance with the protocol and only under the supervision of the PI or Sub-Investigators listed on Form FDA Study drug must be stored in a safe and secure place. At study initiation, a representative from Forest Research Institute will inventory the study drug at the trial center. The PI must maintain adequate records documenting the receipt and disposition of all study supplies. Forest Research Institute will supply forms on which to record the date the study drug was received, the lot number and expiration date of the study drug, and a dispensing record in which to record each patient s use. All unused study drugs must be returned to Forest Laboratories, Inc. It is the PI s responsibility to ensure that patients return their study drug CASE REPORT FORMS All data relating to the trial will be recorded on ecrfs to be provided by Forest Research Institute via the EDC system or, if applicable, paper CRFs. The ecrfs are to be completed at the time of the patient s visit, except for results of tests performed outside the PI s office. The PI is responsible for verifying that all data entries on the ecrfs and paper CRFs, if applicable, are accurate and correct. The PI must sign the completed ecrf before its submission to Forest RETENTION AND REVIEW OF RECORDS The PI must maintain the documentation relating to this trial. If Forest Research Institute or the FDA wishes to review any documentation relating to the study, the PI must permit access to such records. Federal regulations require that the PI retain a copy of all records that support ecrfs for this trial (eg, ICFs, clinical laboratory reports, source documents, study drug dispensing records) for whichever of the following is the shortest: Two years following the date of approval by the FDA of the study drug for the purposes that were the subject of the investigation; or Five years following the date on which the results of the investigation were submitted to the FDA in support of, or as part of, an application for a research or marketing permit for the study drug for the purposes that were the subject of the investigation Amended Protocol LIN-MD-01 Amendment #2

80 Forest Research Institute Page 79 If the investigation does not result in the submission of the data in support of, or as part of, an application for a research or marketing permit, records must be retained for 2 years following notification by Forest Research Institute that the entire clinical investigation (not merely the PI s portion) is completed, terminated, or discontinued or for 2 years following withdrawal of the Investigational New Drug application or New Drug Application. If the PI retires, relocates, or for other reasons withdraws from the responsibility of keeping the trial records, custody must be transferred to a person who will accept the responsibility. Forest Research Institute must be notified in writing of the name and address of the new custodian PATIENT CONFIDENTIALITY All patient records will only be identified by initials and PID number. Patients names are not to be transmitted to Forest Research Institute. The Investigator will keep a Master Patient List on which the PID number and the full name, address, and telephone number of each patient are listed. Amended Protocol LIN-MD-01 Amendment #2

81 Forest Research Institute Page INVESTIGATOR S STATEMENT I agree to conduct the trial in accordance with the protocol (and all amendments) and with all applicable government regulations and good clinical practice guidance. Investigator s Signature / / Date Investigator s Name Amended Protocol LIN-MD-01 Amendment #2

82 Forest Research Institute Page APPENDICES Amended Protocol LIN-MD-01 Amendment #2

83 Forest Research Institute Page 82 APPENDIX I. ELEMENTS OF INFORMED CONSENT Procedures will comply with 21 CFR, Parts 50 and 312. Signed informed consent will be obtained from each patient participating in a clinical research study or from the patient s legally authorized representative. This consent must include the following items: A statement that the study involves research and an explanation of the purposes of the research; a description of the procedures to be followed and the identification of any procedures that are experimental; and the expected duration of the patient s participation A description of any reasonably foreseeable risks or discomforts to the patient A description of any benefits to the patient or to others that may reasonably be expected from the research. If the patient is to be paid for participating in the study, the informed consent form must state the amount that he/she will receive and the schedule of payment (to ensure neither coercion nor undue influence) A disclosure of appropriate alternative procedures or courses of treatment, if any, that might be advantageous to the patient A statement describing the extent, if any, to which confidentiality of records identifying the patient will be maintained and noting the possibility that the FDA, Forest Research Institute, the IRB, or an authorized contract research organization may inspect the records For research involving more than minimal risk, an explanation of whether any medical treatment is available if injury occurs and, if so, what it consists of or where further information may be obtained An explanation of whom to contact, including the relevant telephone number, for answers to pertinent questions about the research and the research patient s rights and whom to contact in the event of a research-related injury to the patient. (NOTE: In some cases, it may be necessary to identify a person other than the Investigator as the contact. The guidance of the IRB may be required) A statement that participation is voluntary, that refusal to participate will involve no penalty or loss of benefits to which the patient is otherwise entitled, and that the patient may discontinue participation at any time without penalty or loss of benefits to which the patient is otherwise entitled A statement that the particular treatment or procedures may involve risks to the patient (or to the embryo or fetus if the patient is, or may become, pregnant) that are at present unforeseeable Amended Protocol LIN-MD-01 Amendment #2

84 Forest Research Institute Page 83 The expected circumstances for which the patient s participation may be terminated by the Investigator without regard to the patient s consent Any additional costs to the patient that may result from participation in the research The consequences of a patient s decision to withdraw from the research and procedures for an orderly termination of the patient s participation A statement that significant new findings developed during the course of the research that may relate to the patient s willingness to continue participation will be provided to the patient The approximate number of patients involved in the study A statement of consent (eg, I agree to participate... ) A place for the patient s signature and date of signing A copy of the signed informed consent form should be given to the patient. Amended Protocol LIN-MD-01 Amendment #2

85 Forest Research Institute Page 84 APPENDIX II. CONCOMITANT MEDICINES Rescue Medicine Rescue medicine, which will be selected by and dispensed to patients, will be a choice of bisacodyl 5-mg tablets or bisacodyl 10-mg suppositories. During the pretreatment and treatment periods, patients may use dispensed, protocol-permitted laxatives (bisacodyl tablets or suppositories) as rescue medicine if at least 72 hours have passed since their previous bowel movement or if their symptoms become intolerable. To qualify for randomization to the treatment period, patients must have refrained from using rescue medicine on the calendar day before the Randomization Visit (Visit 3) and on the day of the Randomization Visit until the time of the clinic visit. Patients must agree to refrain from using rescue medicine from the time of the clinic visit through the calendar day after the Randomization Visit. Prohibited Medicine All medicines listed in the sections below (1-Day Washout and 14-Day Washout) will be excluded during the pretreatment and treatment periods. A 1-day washout means that the particular medicine is not allowed during the calendar day before the Pretreatment Visit; a 14-day washout means that the particular medicine is not allowed during the 14 calendar days before the Pretreatment Visit. 1-Day Washout 1. Any over-the-counter or prescription laxative, suppository, or enema (eg, polyethylene glycol, lactulose, Fleet enema) and any herbal or natural agent that might be taken for constipation. (Note: The use of fiber, bulk laxatives, stool softeners [surfactants such as docusate], and probiotics is acceptable, provided that the patient has been on a stable dose for 30 days before the Screening Visit (Visit 1) and plans to continue stable dosing for the duration of the trial) 2. Any medicine used to treat diarrhea (eg, bismuth subsalicylate, kaolin) 3. Nonsteroidal anti-inflammatory drugs if taken for abdominal pain or discomfort Amended Protocol LIN-MD-01 Amendment #2

86 Forest Research Institute Page Day Washout 1. Drugs with known pharmacologic activity at 5-HT4, 5-HT2b or 5-HT3 receptors (eg, cisapride, tegaserod, ondansetron, tropisetron, granisetron, dolasetron, mirtazapine) 2. Any treatment specifically taken for irritable bowel syndrome with constipation or for chronic constipation, alone or in combination, including lubiprostone (a recently approved chloride channel activator that enhances intestinal fluid secretion), colchicine, and misoprostol 3. Prokinetic agents (eg, metoclopramide, itopride, domperidone) 4. Anticholinergic agents (eg, dicyclomine, flavoxate, scopolamine, hyoscyamine, propantheline, oxybutynin, tolterodine, solefenacin, darifenacin, trospium). (Note: inhaled ipratropium and tiotropium are permitted) 5. Bile acid sequestrants (eg, cholestyramine, colestipol) 6. Cholinomimetic agents (eg, bethanechol, pyridostigmine, tacrine, physostigmine). (Note: intraocular cholinomimetic agents such as pilocarpine are permitted) 7. Antipsychotic agents (eg, risperidone, haloperidol, droperidol, chlorpromazine, perphenazine, all phenothiazines, quetiapine, olanzapine, clozapine), unless the patient has been on a stable dose for 30 days before the Screening Visit (Visit 1) and plans to continue stable dosing for the duration of the trial. (Note: paliperidone is permitted without restriction) 8. Antidepressants, unless the patient has been on a stable dose for 30 days before the Screening Visit (Visit 1) and plans to continue stable dosing for the duration of the trial. Specifically included are the following: Tricyclic antidepressants (eg, amitriptyline, imipramine, nortriptyline) Monoamine oxidase inhibitors (eg, furazolidone, isocarboxazid, pargyline, phenelzine, selegiline, tranylcypromine) Selective serotonin reuptake inhibitors (eg, fluoxetine, sertraline, paroxetine, citalopram) Serotonin-norepinephrine-reuptake inhibitors (eg, venlafaxine, desvenlafaxine succinate) Other antidepressants (eg, trazodone, bupropion) Amended Protocol LIN-MD-01 Amendment #2

87 Forest Research Institute Page Calcium-channel blocker verapamil, unless the patient has been on a stable dose for 30 days before the Screening Visit (Visit 1) and plans to continue stable dosing for the duration of the trial. (Note: all other calcium-channel blockers [eg, nifedipine, diltiazem, amlodipine, felodipine, nicardipine, nimodipine, nisoldipine]) are permitted and may be used without restriction 10. Oral and parenteral antibiotics; however, a standard regimen (up to 10 days) of oral antibiotics is permitted 11. Any investigational or imported drugs that have not been approved for human use by the FDA 12. All narcotics (eg, tramadol, codeine, morphine, propoxyphene, loperamide, diphenoxylate, paregoric), either alone or in combination. Note: narcotics used as anesthesia for a colonoscopy require a 5 calendar day wash-out prior to the patient entering into the pretreatment period. 13. Any medicine taken for the purpose of losing weight (eg, orlistat, phentermine, phendimetrazine, diethylpropion, benzphetamine, sibutramine) 14. Any medicine that is known to cause diarrhea (eg, acarbose) 15. Proton pump inhibitors (eg, omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole), unless the patient has been on a stable dose for 30 days before the Screening Visit (Visit 1) plans to continue stable dosing for the duration of the trial 16. Other drugs such as barbiturates (eg, butalbital, phenobarbital) and chronic oral or parenteral glucocorticoids, which must be discontinued at least 3 months before screening; however, one 10-day course of oral or one injection of parenteral glucocorticoids is permitted. Pregabalin, is acceptable, provided the patient has been on a stable dose during the 30 days before the Screening Visit and plans to continue stable dosing throughout the trial. Amended Protocol LIN-MD-01 Amendment #2

88 Forest Research Institute Page 87 APPENDIX III. SUMMARY OF AMERICAN GASTROENTEROLOGICAL ASSOCIATION GUIDELINES 1. Patients aged 50 years and older must have had a colonoscopy with negative findings 10 years before the Screening Visit (Visit 1). If the most recent colonoscopy revealed polyps, the patient may be enrolled, provided that there were two or fewer small (< 1 cm) tubular adenomas without appreciable villous tissue or high-grade dysplasia and provided that the colonoscopy was performed 5 years before the Screening Visit (Visit 1) 2. Patients who have a first-degree relative with colorectal cancer or adenomatous polyps diagnosed before age 60 or two first-degree relatives with colorectal cancer diagnosed at any age must have had a colonoscopy with negative findings 5 years before the Screening Visit (Visit 1). This applies to patients who are 40 years or older and to patients younger than 40 years who are 10 or fewer years from the age at which their youngest relative was found to have one of the aforementioned conditions 3. Patients who have a first-degree relative with colorectal cancer or adenomatous polyps diagnosed at age 60 or older or two second-degree relatives with colorectal cancer diagnosed at any age must have had a colonoscopy with negative findings 10 years before the Screening Visit (Visit 1). This applies to patients who are 40 years or older and to patients younger than 40 years who are 10 years or fewer years from the age at which their youngest relative was found to have one of the aforementioned conditions 4. Patients of any age who have alarm symptoms must have had a colonoscopy with negative findings after the onset of the alarm symptoms and 5 years before the Screening Visit (Visit 1). Alarm symptoms include lower gastrointestinal bleeding (rectal bleeding or heme-positive stool), iron-deficiency anemia; unexplained, clinically-significant weight loss; and systemic signs of infection or colitis. In addition, patients with a family history of celiac disease or inflammatory bowel disease must have had a colonoscopy with negative findings 5 years before the Screening Visit (Visit 1) Note: All information required by the inclusion criterion shall be captured on the ecrfs. Narcotics used as anesthesia for a colonoscopy require a 5 calendar day wash-out prior to the patient entering into the pretreatment period. Source: Winawer et al, Amended Protocol LIN-MD-01 Amendment #2

89 Forest Research Institute Page 88 APPENDIX IV. EQ-5D QUESTIONNAIRE By placing a checkmark in one box in each group below, please indicate which statements best describe your own health state today. Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g., work, study, housework, family, or leisure activities) I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed Amended Protocol LIN-MD-01 Amendment #2

90 Forest Research Institute Page 89 To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today. Best imaginable health state Your own health state today Amended Protocol LIN-MD-01 Amendment #2 0 Worst imaginable health state

91 Forest Research Institute Page 90 APPENDIX V. BRISTOL STOOL FORM SCALE Type 1 - Separate hard lumps like nuts (difficult to pass) Type 2 - Sausage shaped but lumpy Type 3 - Like a sausage but with cracks on surface Type 4 - Like a sausage or snake, smooth and soft Type 5 - Soft blobs with clear-cut edges (passed easily) Type 6 - Fluffy pieces with ragged edges, a mushy stool Type 7 - Watery, no solid pieces (entirely liquid) Amended Protocol LIN-MD-01 Amendment #2

92 Forest Research Institute Page 91 APPENDIX VI. DISEASE-SPECIFIC QUALITY OF LIFE PAC-QOL PATIENT ASSESSMENT OF CONSTIPATION The following questions are designed to measure the impact constipation has had on your daily life over the past 2 weeks. For each question, please check one box. The following questions ask about your symptoms related to constipation. During the past 2 weeks, to what extent or intensity have you felt bloated to the point of bursting? 2. felt heavy because of your constipation? The next few questions ask about how constipation affects your daily life. During the past 2 weeks, how much of the time have you... Not at all 0 A little bit 1 Moderately 2 Quite a bit 3 Extremely 4 None of the time 0 A little of the time 1 Some of the time 2 Most of the time 3 All of the time 4 3. felt any physical discomfort? 4. felt the need to have a bowel movement but not been able to? 5. been embarrassed to be with other people? 6. been eating less and less because of not being able to have bowel movements? Amended Protocol LIN-MD-01 Amendment #2

93 Forest Research Institute Page 92 The next few questions ask about how constipation affects your daily life. During the past 2 weeks, to what extent or intensity have you... Not at all 0 A little bit 1 Moderately 2 Quite a bit 3 Extremely 4 7. had to be careful about what you eat? 8. had a decreased appetite? 9. been worried about not being able to choose what you eat (for example, at a friend s house)? 10. been embarrassed about staying in the bathroom for so long when you were away from home? 11. been embarrassed about having to go to the bathroom so often when you were away from home? 12. been worried about having to change your daily routine (for example, traveling, being away from home)? The next few questions ask about your feelings related to constipation. During the past 2 weeks, how much of the time have you felt irritable because of your condition? None of the time 0 A little of the time 1 Some of the time 2 Most of the time 3 All of the time been upset by your condition? 15. felt obsessed by your condition? 16. felt stressed by your condition? 17. felt less self-confident because of your condition? 18. felt in control of your situation? Amended Protocol LIN-MD-01 Amendment #2

94 Forest Research Institute Page 93 The next questions ask about your feelings related to constipation. During the past 2 weeks, to what extent or intensity have you... Not at all 0 A little bit 1 Moderately 2 Quite a bit 3 Extremely been worried about not knowing when you are going to be able to have a bowel movement? 20. been worried about not being able to have a bowel movement? 21. been more and more bothered by not being able to have a bowel movement? The next questions ask about your life with constipation. During the past 2 weeks, how much of the time have you been worried that your condition will get worse? 23. felt that your body was not working properly? 24. had fewer bowel movements than you would like? None of the time 0 A little of the time 1 Some of the time 2 Most of the time 3 All of the time 4 The next questions ask about your degree of satisfaction related to constipation. During the past 2 weeks, to what extent or intensity have you been satisfied with how often you have a bowel movement? 26. satisfied with the regularity of your bowel movements? 27. satisfied with the time it takes for food to pass through the intestines? Not at all 0 A little bit 1 Moderately 2 Quite a bit 3 Extremely satisfied with your treatment? English (USA) PAC-QOL 2.0-S (28-item, Standard version) PAC-QOL 2001 Johnson & Johnson, All rights reserved Amended Protocol LIN-MD-01 Amendment #2

95 Forest Research Institute Page 94 APPENDIX VII. HEALTH RESOURCE USE QUESTIONNAIRE Demographics and Health Resource Use Questionnaire (HRUQ) (To Be Completed by Trial Coordinator) Section 1: Demographics Read the following instructions to patient: The following questions inquire about your level of education and current employment status. 1. What is the highest grade or level of school you have completed? a. 8th grade or less b. Some high school, but I did not graduate c. High school graduate or GED d. Some college or 2-year degree e. 4-year college graduate f. More than 4-year college degree 2. Are you currently a student? a. No b. Yes, Part-time ( 20 hrs/week) c. Yes, Full-time 3. Are you currently employed? a. No b. Yes, Part-time ( 20 hrs/week) c. Yes, Full-time Section 2: Health Resource Use Read the following instructions to patient: The following questions inquire about your health care needs in the past month. Please answer all the questions to the best of your ability. If you do not remember the answer to a question, please provide your best estimate. A response of 0 indicates no visits, tests, or procedures during the past month. 1. Please report the total number of days of all hospitalizations during the past month (Note: Include only hospitalizations with at least one overnight stay) Total number of inpatient days: days Amended Protocol LIN-MD-01 Amendment #2

96 Forest Research Institute Page Main reason for hospitalization (Note: If more than one hospitalization during the past month, please list reason for each hospitalization separately) Reason for hospitalization #1: Reason for hospitalization #2: Reason for hospitalization #3: 3. Total number of hospital outpatient visits (e.g., outpatient day surgery) during the past month (Note: Please do not include overnight stays) Total number of outpatient visits: visits 4. Total number of Emergency Care Facility visits (e.g., hospital emergency room, after hours urgent care clinic) in the past month Total number of Emergency Care Facility visits: visits 5. Total number of office visits to healthcare providers during the past month (Note: Do not include study visits) Total number of visits to Primary Care Physicians: Total number of visits to GI Specialist (e.g., Gastroenterologist): Total number of visit to other health care providers (e.g., Dentist, Gynecologist): visits visits visits 6. Total number of laboratory and other diagnostic tests, prescribed by a health care provider during the past month: Total number of laboratory tests (e.g., CBC) tests Total number of diagnostic tests (e.g., x-rays) tests Total number of other tests tests Please specify 7. Total number of procedures (e.g., colonoscopy) prescribed by health care providers during the past month (Note: Do not include outpatient surgeries) Total number of procedures: procedures Amended Protocol LIN-MD-01 Amendment #2

97 Forest Research Institute Page 96 APPENDIX VIII. SHORT FORM-12 HEALTH SURVEY Your Health and Well-Being This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Thank you for completing this survey! For each of the following questions, please mark an that best describes your answer. in the one box 1. In general, would you say your health is: Excellent Very good Good Fair Poor The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Yes, limited a lot Yes, limited a little No, not limited at all a Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf b Climbing several flights of stairs Amended Protocol LIN-MD-01 Amendment #2

98 Forest Research Institute Page During the past week, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health? All of the time Most of the time Some of the time A little of the time None of the time a Accomplished less than you would like b Were limited in the kind of work or other activities During the past week, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? All of the time Most of the time Some of the time A little of the time None of the time a Accomplished less than you would like b Did work or other activities less carefully than usual During the past week, how much did pain interfere with your normal work (including both work outside the home and housework)? Not at all A little bit Moderately Quite a bit Extremely Amended Protocol LIN-MD-01 Amendment #2

99 Forest Research Institute Page These questions are about how you feel and how things have been with you during the past week. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past week All of the time Most of the time Some of the time A little of the time None of the time a Have you felt calm and peaceful? b Did you have a lot of energy? c Have you felt downhearted and depressed? During the past week, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)? All of the time Most of the time Some of the time A little of the time None of the time Thank you for completing these questions! SF-12v2 Health Survey 1994, 2002 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved. SF-12 a registered trademark of Medical Outcomes Trust. (SF12v2 Acute, US Version 2.0) Amended Protocol LIN-MD-01 Amendment #2

100 Forest Research Institute Page 99 APPENDIX IX. WORK PRODUCTIVITY AND ACTIVITY IMPAIRMENT QUESTIONNAIRE FOR CONSTIPATION WORK PRODUCTIVITY AND ACTIVITY IMPAIRMENT QUESTIONNAIRE: CONSTIPATION (WPAI:C) The following questions ask about the effect of your constipation on your ability to work and perform regular activities. Please fill in the blanks or circle a number, as indicated. 5. Are you currently employed (working for pay)? NO YES If NO, check NO and skip to question 6 The next questions are about the past seven days, not including today. 6. During the past seven days, how many hours did you miss from work because of problems associated with your constipation? Include hours you missed on sick days, times you went in late, left early, etc. because of constipation. Do not include time you missed to participate in this study. HOURS 7. During the past seven days, how many hours did you miss from work because of any other reason, such as vacation, holidays, time off to participate in this study? HOURS 8. During the past seven days, how many hours did you actually work? HOURS (If 0, skip to question 6) 9. During the past seven days, how much did your constipation affect your productivity while you were working? Think about days you were limited in the amount or kind of work you could do, days you accomplished less than you would like, or days you could not do your work as carefully as usual. If constipation affected your work only a little, choose a low number. Choose a high number if constipation affected your work a great deal. Constipation had no effect on my work Consider only how much constipation affected productivity while you were working CIRCLE A NUMBER Constipation completely prevented me from working Amended Protocol LIN-MD-01 Amendment #2

101 Forest Research Institute Page During the past seven days, how much did your constipation affect your ability to do your regular daily activities, other than work at a job? By regular activities, we mean the usual activities you do, such as work around the house, shopping, child care, exercising, studying, etc. Think about times you were limited in the amount or kind of activities you could do and times you accomplished less than you would like. If constipation affected your activities only a little, choose a low number. Choose a high number if constipation affected your activities a great deal. Consider only how much constipation affected your ability to do your regular daily activities, other than work at a job. Constipation had no effect on my daily activities WPAI:SHP V2.0 (US ENGLISH) CIRCLE A NUMBER Constipation completely prevented me from doing my daily activities Amended Protocol LIN-MD-01 Amendment #2

102 Forest Research Institute Page 101 APPENDIX X ADDITIONAL ECG AND PHARMACOKINETIC (PK) MEASUREMENTS Forest Research Institute will obtain triplicate ECGs from each patient in order to determine if linaclotide has effects on the QT/QTc interval. The ECGs will be obtained in triplicate seven times at six study visits (A pre-dose and post-dose ECG will be collected at the Randomization Visit [Visit 3]). In addition, blood samples will be obtained from each patient at two study visits to determine if linaclotide or its active metabolite, MM , can be detected in plasma. (In a previous study [MCP ], neither linaclotide nor MM could be detected when subjects were dosed with 300 ug of linaclotide per day for 7 days.) All patients who meet the entry requirements for Study LIN-MD-01 will be asked to participate. ECGs will be performed on all patients enrolling into this study until there are at least 300 randomized patients in the CC Phase III program (total of patients in this study and the Ironwood study MCP ). Upon finalization of the planning for the triplicate ECG and PK-measurement program, each clinical site will receive a letter from Forest Research Institute confirming that, after appropriate IRB approval, all subsequent patients should be consented to participate in the ECG and PK procedures set forth in this Appendix. Once the desired number of patients has been enrolled in the triplicate ECG and PK-measurement program, each clinical site will receive a second letter from Forest Research Institute indicating that the triplicate ECG and PK-measurement procedures will not be required for future patients enrolling in the study. Schedule of Evaluations ECG: triplicate ECGs will be obtained in triplicate with each of the three ECGs obtained at 2-10 minute intervals (ie, each ECG tracing will be taken 2-10 minutes apart). At Visit 3 (Randomization Visit, Day 1), blood will be drawn for linaclotide and MM determinations approximately 2 hours after dosing and immediately after the post-dose set of ECGs are obtained. Likewise, at Visit 5 (Week 4 Visit, Day 29 ± 3), blood will be drawn immediately after the ECGs are obtained. The following is the schedule of evaluations for ECGs (and PK sampling where indicated): Screening Visit (Visit 1) Pretreatment Visit (Visit 2) (Note: The Screening Visit and Pretreatment Visit can be combined; if this is the case, only one set of ECGs will be conducted for both visits) Randomization Visit (Visit 3), Pre-dose and Post-dose (Note: The post-dose ECGs should be taken between 1 hour and 45 minutes and 2 hours and 15 minutes after the dose of study medication, and immediately before the PK blood draw.) Amended Protocol LIN-MD-01 Amendment #2

103 Forest Research Institute Page 102 Week 4 Visit (Visit 5) (Note: The ECGs should be obtained immediately before the PK blood draw.) Week 8 Visit (Visit 6) End-of-Trial Visit ( Visit 7) PK: Two (2) PK blood draws will be conducted at the following study visits: Randomization Visit ( Visit 3), Post-dose (Note: PK draw must be performed immediately following the post-dose set of ECGs, which should be obtained between 1 hour and 45 minutes and 2 hours and 15 minutes after the first dose of study medication) Week 4 Visit (Visit 5) (Note: This PK specimen will be obtained during the scheduled blood draw for clinical laboratory tests, as depicted in the Schedule of Evaluations) Please note that for all visits at which ECG measurements and PK blood draws are obtained, the time that the study drug was taken that day and the time of the PK draw and ECG tracings must be documented in the patient s source document and ecrf. For all study visits except the Randomization Visit (study drug taken in the clinic), please have the subject recall the time study drug was taken at home, to the nearest half hour, and record this time in the patient s source document. PK Sample Preparation and Shipment Blood samples for PK analysis of levels of linaclotide and its metabolite MM will be collected via direct venipuncture using 10-mL lavender top Vacutainer evacuated collection tubes containing K2EDTA. Refer to the Laboratory manual for sample handling and shipment guidelines. The PK anaylsis of linaclotide and its metabolite (MM ) will be performed by Advion Bioservices, Ithaca, N.Y. Amended Protocol LIN-MD-01 Amendment #2

104 Forest Research Institute Page LITERATURE CITED Amitiza [package insert]. Bethesda, MD:Sucampo Pharmaceuticals and Deerfield, IL: Takeda Pharmaceuticals, Inc.; June, Drossman DA, ed. ROME II: the Functional Gastrointestinal Disorders. 2nd ed. McLean, VA: Degnon Associates; The EuroQol Group. A new facility for the measurement of health-related quality of life. Health Policy 1990;16: Forte LR. Guanylin regulatory peptides: structures, biological activities mediated by cyclic GMP and pathobiology. Regul Pept 1999;81: Grøndahl ML, Thorbøll JE, Hansen MB, et al. Regional differences in the effect of cholera toxin and enerotoxigenic Escherichia coli infection on electrolyte and fluid transport in the porcine small intestine. Zentralbl Veterinarmed A 1998;45: Hochberg Y, Tamhane AC. Multiple Comparisons Procedures. New York, NY: Wiley; International Conference on Harmonisation. ICH Harmonised Tripartite Guideline E10: choice of control group and related issues in clinical trials Jul 20. Available from: Accessed 01 Feb Ieda H, Naruse S, Kitagawa M, et al. Effects of guanylin and uroguanylin on rat jejunal fluid and electrolyte transport: comparison with heat stable enterotoxin. Regul Pept 1999;79: Johanson JF. Review of the treatment options for chronic constipation. MedGenMed 2007;9:69. Koch A, Voderholzer WA, Klauser AG, Muller-Lissner S. Symptoms in chronic constipation. Dis Colon Rectum 1997;40: Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997;32: Linaclotide: Investigator s brochure. Version 4. Cambridge, MA: Ironwood Pharmaceuticals; 2008 Jul 17. Marquis P, De La Loge C, Dubois D, et al. Development and validation of the Patient Assessment of Constipation Quality of Life questionnaire. Scand J Gastroenterol 2005;40(5): Amended Protocol LIN-MD-01 Amendment #2

105 Forest Research Institute Page 104 Pare P, Ferrazzi S, Thompson WG, Irvine EJ, Rance L. An epidemiological survey of constipation in Canada: definitions, rates, demographics, and predictors of health care seeking. Am J Gastroenterol 2001;96: Reilly C, Zbrozek AS, Dukes EM. The validity and reproducibility of work productivity and activity impairment instrument. Pharmacoeconomics 1993;4: Sandler RS, Drossman DA. Bowel habits in young adults not seeking health care. Dig Dis Sci 1987;32: Sonnenberg A, Koch TR. Physician visits in the United States for constipation: 1958 to Dig Dis Sci 1989;34: Stewart WF, Liberman JN, Sandler RS, et al. Epidemiology of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic features. Am J Gastroenterol 1999;94: Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical Care 1996;34: Winawer S, Feltcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale update based on new evidence. Gastroenterology 2003;124: Amended Protocol LIN-MD-01 Amendment #2

106 1.0 TITLE PAGE Forest Research Institute Harborside Financial Center, Plaza V Jersey City, NJ LIN-MD-01 A Phase III, Randomized, Double-Blind, Placebo-Controlled, Parallel-Group Trial of Linaclotide Administered Orally for 12 Weeks in Patients With Chronic Constipation STATISTICAL ANALYSIS PLAN Final: April 17, 2009 Amendment #1: October 8, 2009 Confidentiality Statement This document is the property of Forest Research Institute, Inc., (a wholly owned subsidiary of Forest Laboratories, Inc.) and may not in full or part be passed on, reproduced, published, distributed to any person, or submitted to any regulatory authority without the express written permission of Forest Laboratories, Inc.

107 Forest Research Institute Page 2 Linaclotide 2.0 TABLE OF CONTENTS 1.0 TITLE PAGE TABLE OF CONTENTS LIST OF ABBREVIATIONS INTRODUCTION OBJECTIVES PATIENT POPULATIONS Screened Population Randomized Population Safety Population Intent-to-Treat Population PATIENT DISPOSITION DEMOGRAPHICS AND OTHER BASELINE CHARACTERISTICS EXTENT OF EXPOSURE AND TREATMENT COMPLIANCE Study Drug Prior and Concomitant Medication Measurement of Treatment Compliance IVRS Diary compliance EFFICACY ANALYSES Primary Efficacy Parameter Secondary Efficacy Parameters Controlling for Multiplicity Additional Efficacy parameters SAFETY ANALYSES Adverse Events Clinical Laboratory Parameters Vital Signs Electrocardiogram (ECG) Triplicate ECG Cohort Physical Examination Other Safety Parameters INTERIM ANALYSIS SAMPLE SIZE justification COMPUTER METHODS DATA HANDLING CONVENTIONS... 39

108 Forest Research Institute Page 3 Linaclotide 15.1 Visit Time Windows for Safety Analysis Visit Time Windows for Efficacy Analysis Pooling of Trial centers Derived Efficacy Variables Patient Recall for IVRS Data Handling of Missing IVRS Data Weekly Stool Frequency Rates Other Weekly Scores Derivation Repeated or Unscheduled Assessments of Safety Parameters Missing Date of Study Drug Missing Severity Assessment for Adverse Events Missing Relationship to Study Drug for Adverse Events Missing Date Information for Adverse Events Missing Date Information for Prior or Concomitant Medications Incomplete Start Date Incomplete Stop Date Character Values of Clinical Laboratory Parameters CHANGES TO ANALYSES SPECIFIED IN PROTOCOL REFERENCE APPENDICES IVRS Questions (copied from the IVRS System User Requirements, version 1.3 (dated 3 March 2009)) General Diary Information (copied from the IVRS System User Requirements, version 1.3 (dated 3 March 2009))... 60

109 Forest Research Institute Page 4 Linaclotide 3.0 AE ANCOVA ANOVA BM BSFS CC CMH CRF CSBM ECG EOT ICF ITT IVRS LOCF LTSS MCH MCHC MCP MCV MedDRA OC PCS PID LIST OF ABBREVIATIONS Adverse Event Analysis of Covariance Analysis of Variance Bowel Movement Bristol Stool Form Scale Chronic Constipation Cochran-Mantel-Haenszel Case Report Form Complete Spontaneous Bowel Movement Electrocardiogram End of Trial Informed Consent Form Intent-to-Treat Interactive Voice Response System Last Observation Carried Forward long-term safety study mean corpuscular hemoglobin mean corpuscular hemoglobin concentration Multiple Comparisons Procedure mean corpuscular volume Medical Dictionary for Regulatory Activities Observed Case Potentially Clinically Significant Patient Identification

110 Forest Research Institute Page 5 Linaclotide QTcB QTcF RM SAE SAP SBM TEAE Corrected QT Interval using Bazett s Formula Corrected QT Interval using Fredericia s Formula Rescue Medication Serious Adverse Event Statistical Analysis Plan Spontaneous Bowel Movement Treatment Emergent Adverse Event

111 Forest Research Institute Page 6 Linaclotide 4.0 INTRODUCTION This is a multicenter, randomized, double-blind, placebo-controlled, parallel-group, multiple-dose, 12-week trial comparing two doses of linaclotide with placebo for patients with a diagnosis of chronic constipation (CC) based on using modified Rome II criteria. The trial consists of three distinct periods defined as follows: Screening period starts with signature of the informed consent form (ICF) and lasts for up to 21 days. During this period, patient eligibility for entry into the next period will be determined. The end of the screening period coincides with the start of the pretreatment period. Pretreatment period is defined as the 14 calendar days (minimum) to 21 calendar days (maximum) immediately before randomization. During this period, patients will provide qualifying bowel habit, symptom severity, and rescue medicine information through daily interactive voice response system (IVRS) calls. Treatment period begins with trial randomization and continues for 12 weeks of the double-blind study treatment. Patients meeting the entry criteria for this trial will be randomized to one of three double-blind treatment groups: 150 μg linaclotide, 300 μg linaclotide, or placebo (1:1:1). The IVRS patient bowel data from the last 14 calendar days (not including the day of randomization) of the pretreatment period will be used to determine whether the patient meets inclusion/exclusion criteria pertaining to bowel habits for randomization, or if ineligible, meets the requirements for the long-term safety study (LTSS). The study drug is in the form of identically appearing capsules supplied in bottles containing 35 capsules. Patients will take their initial dose of study drug at the trial center during the Randomization Visit (Visit 3). After that, patients will be instructed to take the capsules at home, once daily in the morning at least 30 minutes before breakfast but not to take any study drug on the day of the End of Trial (EOT) Visit (Visit 7). The following table (Table 4-1) presents a schematic of the trial design as shown in the most recent amended protocol (Amendment #1 dated Dec 18, 2008). One of the major changes was the inclusion of triplicate electrocardiograms (ECG) measurements from patients in order to determine if linaclotide has effects on the QT/QTc interval. The triplicate ECGs will be performed on all patients enrolling in this trial until there are at least 300 randomized patients in the CC phase III placebo-controlled trials. The CC phase III placebo-controlled trials include this trial (LIN-MD-01) and the Ironwood trial MCP (a phase III, randomized, double-blind, placebo-controlled, parallel-group trial of linaclotide administered orally for 12 weeks followed by a 4-week randomized withdrawal period in patients with CC.).

112 Forest Research Institute Page 7 Linaclotide This statistical analysis plan (SAP) provides a more technical and detailed elaboration of the statistical analyses of efficacy and safety data as outlined and specified in the final study protocol (original version dated Aug 19, 2008, Amendment #1 dated Dec. 18, 2008) and the most recent amended protocol (Amendment #2 dated October 7, 2009). Specifications of tables, figures, and data listings are contained in a separate document. Statistical analysis plans for Pharmacokinetic / Pharmacodynamic (if applicable) and Health Outcome parameters are prepared separately.

113 Forest Research Institute Page 8 Linaclotide Table 4-1. SCHEDULE OF EVALUATIONS: TRIAL LIN-MD-01 Screening Period (Up to 21 days) Pretreatment Period (14-21 days) Treatment Period (12 weeks) Visit Screening Visit Visit 1 Pretreatment Visit Randomization Visit Week 2 Week 4 Week 8 EOT Visit Week a 12 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Trial Day Day 42 through Day 15 Day 21 through Day 14 Day 1 Day 15 ± 3 Day 29 ± 3 Day 57 ± 3 Day 85 ± 3 Informed consent Inclusion and exclusion criteria verification b IVRS registration Medical and surgical history Physical examination c X X X X X X X X X X Body weight and height d X X X X X X X Seated vital signs Single 12-Lead ECG(for patients entering study pre- and postcompletion of triplicate ECG program) f g Triplicate ECG e X X X X X X X X X X X X X X X Prior and concomitant medicines X X X X X X X Clinical laboratory determinations h X X X X i PK Sample X X j Pregnancy test X X X X Laxative, suppository, and enema washout instructions k X X

114 Forest Research Institute Page 9 Linaclotide AE evaluations l X X X X X X IVRS training or IVRS X compliance verification and reminder m X X X X n Rescue medicine dispensed X X X X X Randomization X Patient IVRS call, in clinic X PAC-QOL questionnaire X X EQ-5D questionnaire X X X X X HRUQ X X X X SF-12 X X X X X WPAI:C X X X X Treatment-satisfaction X X X assessment X Rome III status X Study drug dispensed X X X o Study drug administration X Study drug accountability X X X Treatment-continuation assessment X a b c d e f Patients who are randomized but do not complete the treatment period (withdraw consent or are discontinued before they have completed 12 weeks of treatment) shall be considered treatment-period withdrawals and should complete the procedures required at the EOT Visit (even out of window). Trial Coordinator should call IVRS to transition the patient to the next appropriate trial period. Refer to the IVRS Center User Manual. A physical examination should include the following: general appearance, HEENT (head, ears, eyes, nose, and throat), neck, cardiovascular, thorax/lungs, abdomen, rectal, musculoskeletal, lymph nodes, skin, and neurologic and mental status. A rectal examination should be performed during the screening period on all patients who do not require a colonoscopy. After the screening period, the rectal examination is optional and may be performed at the discretion of the Investigator. Breast and genitourinary examinations are optional at the discretion of the Investigator. Height will o67nly be measured at Visit 1 (Screening). Vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) must be obtained from patients who are in the seated position. Single 12-lead ECGs (Single tracing to be performed on trial patients consented prior to and after completion of the triplicate ECG program.) will be performed at the Screening (Visit 1) and EOT Visits (Visit 7).

115 Forest Research Institute Page 10 Linaclotide g Triplicate 12-lead will be performed at the Screening (Visit 1), Pretreatment (Visit 2), Randomization (Visit 3), Week 4 (Visit 5), Week 8 (Visit 6), and EOT Visits (Visit 7), on the trial patients consented during the triplicate ECG program (see Appendix X in the protocol) h Complete blood count, chemistry, urinalysis, and urine drug screen. The drug screen will be performed only at the Screening Visit (Visit 1). i PK sample will be taken for the trial patients consented during the PK sample program (see Appendix X in the protocol) j To be eligible to continue in the trial, a negative serum pregnancy test must be documented at the Screening Visit (Visit 1) and at Week 4 (Visit 5). A negative urine pregnancy test must be documented at the Randomization Visit (Visit 3) before dosing and at the EOT Visit (Visit 7). k Trial Coordinator will instruct patients about the use of laxatives, suppositories, and enemas (refer to Appendix II, Concomitant Medicines). l All AEs occurring after the patient signs the informed consent form will be documented. m At Visit 2 (Pretreatment), the Trial Coordinator will instruct the patients about the use of the IVRS. At subsequent visits, the Trial Coordinator will access the IVRS to verify patient compliance with the daily IVRS call requirement. After determining the patient s compliance, the Trial Coordinator will remind patients to call the IVRS daily. (IVRS questions may be found in the IVRS Center User Manual [refer to Efficacy Measurements, Section 9.5.2]). n Rescue medicine (bisacodyl tablets or bisacodyl suppositories) will be supplied to patients at Visit 2 (Pretreatment) and, if needed, at subsequent visits. o Study drug will be administered in the clinic at the Randomization Visit (Visit 3) (study drug does not need to be taken in the morning before breakfast). On all other days, study drug will be taken once daily in the morning at least 30 minutes before breakfast. Patients will not take study drug on the morning of the EOT Visit (Visit 7). Patients are instructed to fast 2 hours before the Randomization Visit (Visit 3) and EOT Visit (Visit 7). AE = adverse event; ECG = electrocardiogram; EOT = end of trial; EQ-5D = EuroQoL-5D; HRUQ = Health Resource Use Questionnaire; IVRS = interactive voice response system; PAC-QOL = Patient Assessment of Constipation Quality of Life questionnaire; SF-12 = Short Form-12 Health Survey; WPAI:C = Work Productivity and Activity Impairment Questionnaire for Constipation.

116 Forest Research Institute Page 11 Linaclotide 5.0 OBJECTIVES The objective of this trial is to determine the efficacy and safety of linaclotide administered to patients with CC.

117 Forest Research Institute Page 12 Linaclotide 6.0 PATIENT POPULATIONS 6.1 SCREENED POPULATION The Screened Population will consist of all patients who had a Screening Visit (Visit 1) and were assigned a patient identification (PID) number. 6.2 RANDOMIZED POPULATION The Randomized Population will consist of all patients in the Screened Population who were randomized to a treatment group at the Randomization Visit (Visit 3). 6.3 SAFETY POPULATION The Safety Population will consist of all patients in the Randomized Population who received at least one dose of double-blind study drug during the treatment period. 6.4 INTENT-TO-TREAT POPULATION The Intent-to-Treat (ITT) Population will consist of all patients in the Safety Population who had at least one post-randomization entry of the primary efficacy assessment (ie, the daily IVRS information that determines whether a spontaneous bowel movement (SBM) is a complete spontaneous bowel movement (CSBM).

118 Forest Research Institute Page 13 Linaclotide 7.0 PATIENT DISPOSITION The number of patients included in each of the Randomized, Safety, and ITT populations will be summarized overall, by treatment group within the geographic region and trial center. The number of patients included in the Screened Population will be summarized by geographic region and trial center. The number of screen failures (ie, patients who enter the screening period but not the pretreatment period) and patients ineligible for randomization (ie, patients who enter the pretreatment period but are not randomized at the Randomization Visit [Visit 3]), along with the associated reasons for failure/ineligibility, will be tabulated overall for the Screened Population. The number and percentage of patients who complete the treatment period and the number and percentage of patients who prematurely discontinue during the treatment period will be presented for each treatment group and pooled across treatment groups for the Randomized Population. The reasons for premature discontinuation from the treatment period as recorded on the trial completion forms of the ecrfs will be summarized (number and percentage) by treatment group and overall for all randomized patients. The percentage of premature discontinuations will be compared between each of the two linaclotide treatment groups and placebo for overall premature discontinuations and for each discontinuation reason using the Fisher exact test. All patients who prematurely discontinue during the treatment period will be listed by discontinuation reason for the Randomized Population.

119 Forest Research Institute Page 14 Linaclotide 8.0 DEMOGRAPHICS AND OTHER BASELINE CHARACTERISTICS Demographic parameters (eg, age, race, sex, weight, height, and BMI) and other baseline characteristics (include the primary and the secondary efficacy variables, see Sections 10.1 and 10.2) will be summarized by treatment group for the Safety and ITT populations. The comparability among treatment groups will be tested using an analysis of variance (ANOVA) model with treatment group and geographic region as the factors for continuous variables, and the Cochran-Mantel-Haenszel (CMH) test, controlling for geographic region, for categorical variables.

120 Forest Research Institute Page 15 Linaclotide 9.0 EXTENT OF EXPOSURE AND TREATMENT COMPLIANCE 9.1 STUDY DRUG Exposure to double-blind study drug for the Safety Population during the treatment period will be summarized in terms of treatment duration, which is calculated as the number of days from the date of first double-blind study drug taken to the date of last dose taken, inclusive. Descriptive statistics (n, mean, standard deviation, minimum, median, and maximum) will be presented by treatment group. 9.2 PRIOR AND CONCOMITANT MEDICATION The World Health Organization Drug Dictionary, Version 2006/Q4 or newer, will be used to classify prior and concomitant medications by therapeutic class. Prior medicines are defined as any medicines taken before the date of first dose of double-blind study drug. Concomitant medicines are defined as any medicines taken during the treatment period (ie, between the date of the first dose of study drug in the treatment period and the date of the last dose of study drug in the treatment period, inclusive). Any medicines started after the date of the last dose of double-blind study drug will not be considered concomitant medicines. Both prior and concomitant medicine use will be summarized by the number and proportion of patients in each treatment group receiving each medicine within each therapeutic class for the Safety Population. Concomitant medicine will be summarized for the treatment period using the Safety Population. Multiple drug usage by a patient in the same category (based on Anatomical-Therapeutic-Chemical classification) will be counted only once. 9.3 MEASUREMENT OF TREATMENT COMPLIANCE Study drug will be administered to the patient by trial center staff at the Randomization Visit (Visit 3). For all other days in the treatment period, study drug will be taken once daily by the patient in the morning at least 30 minutes before breakfast. Study drug dosing compliance for a specified period is defined as the total number of capsules actually taken by a patient during that period divided by the number of capsules expected to be taken during the same period multiplied by 100. The total number of capsules actually taken will be calculated by subtracting the total number of capsules returned and the number of capsules lost from the total number of capsules dispensed. The number of capsules expected to be taken for a specified period is calculated as the number of days in that period. For patients who drop out of the trial prematurely, the number of capsules expected to be taken within a specified period is calculated only up to the day of the last dose of double-blind study drug or the end date of the specified period, which ever is less.

121 Forest Research Institute Page 16 Linaclotide For the treatment period, descriptive statistics for study drug compliance in the Safety Population will be presented by treatment group for both the treatment period as a whole and for each of the three consecutive 4-week periods comprising the treatment period (consistent with study drug dispensing). 9.4 IVRS DIARY COMPLIANCE Formatted: Highlight

122 Forest Research Institute Page 17 Linaclotide 10.0 EFFICACY ANALYSES All efficacy analyses will be based on the ITT Population. SBM is defined as a bowel movement (BM) that occurs in the absence of laxative, enema, or suppository use on either the calendar day of the BM or the calendar day before the BM. CSBM is defined as an SBM that is associated with a sense of complete evacuation. Baseline values for efficacy parameters will be derived from the IVRS daily diary collected in the pretreatment period, specifically the period of time from 14 days before randomization up to the time of randomization. The baseline CSBM and SBM weekly rates will be derived as the corresponding overall weekly frequency rates based on the number of CSBMs and SBMs a patient had during this period. Baseline stool consistency and severity of straining will be calculated as the average of the nonmissing values from the SBMs reported by the patient during this period. Baseline values for patient symptom and global assessments (eg, abdominal discomfort, bloating, abdominal pain, constipation severity, degree of relief of constipation symptoms) will be the average of the nonmissing patient scores reported during this period. An observed-cases (OC) approach to missing postbaseline data will be applied. In addition, as sensitivity analyses, for all secondary efficacy parameters in Section 10.2 that are defined on a weekly basis, a last-observation-carried-forward approach (LOCF) will also be applied. In the LOCF method, patients' last weekly value will be used in the case of prematurely discontinuation from the trial, or patients previous weekly value will be used in the case of missing the weekly question or missing the whole week of diaries. For efficacy analyses, trial centers will be pooled together by geographic region (details provided in Section 15.3). The overall type I family-wise error rate for testing the primary and secondary efficacy parameters will be controlled at the 0.05 significance level (details provided in Section 10.3). All confidence intervals will be two-sided 95% confidence intervals, unless stated otherwise. For the primary and secondary efficacy parameters, subgroup analyses based on gender and age groups ( 65 vs. <65) will be performed in the future Integrated Summary of Efficacy using the integrated efficacy data from the controlled pivotal efficacy studies for CC.

123 Forest Research Institute Page 18 Linaclotide 10.1 PRIMARY EFFICACY PARAMETER The primary efficacy parameter is 12-week CSBM overall responder. A 12-week CSBM overall responder is a patient who is a CSBM weekly responder for at least 9 of the 12 weeks of the treatment period. A CSBM weekly responder is a patient who had a CSBM weekly frequency rate that was 3 or greater and increased by 1 or more from baseline. If a patient does not have CSBM frequency data for a particular week of the treatment period, the patient will not be considered a CSBM weekly responder for that week. If a patient prematurely discontinues from trial such that the patient s final treatment period week contains less than 4 days, the patient will not be considered a CSBM weekly responder for that week or the subsequent missed weeks of the treatment period. This trial is designed to test the following two sets of primary efficacy hypotheses: 1. Null hypothesis: There is no difference in the proportion of 12-week CSBM overall responders between patients taking the 300-μg dose and those taking placebo. Alternative hypothesis: There is a difference in the proportion of 12-week CSBM overall responders between patients taking the 300-μg dose and those taking placebo. 2. Null hypothesis: There is no difference in the proportion of 12-week CSBM overall responders between patients taking the 150-μg dose and those taking placebo. Alternative hypothesis: There is a difference in the proportion of 12-week CSBM overall responders between patients taking the 150-μg dose and those taking placebo. The primary efficacy analysis is the CMH test controlling for geographic region. For each of the two linaclotide dose groups, the proportion of 12-week CSBM overall responders will be compared with the proportion in the placebo group using the CMH test controlling for geographic region. The number and percentage of 12-week CSBM overall responders for each treatment group, the difference in responder rates between each linaclotide and placebo group, and the two-sided p-value associated with the above CMH test will be presented. The Mantel-Haenszel estimate of odds ratio (controlling for geographic region) and the corresponding 95% confidence interval for each linaclotide dose group over placebo group will also be provided.

124 Forest Research Institute Page 19 Linaclotide 10.2 SECONDARY EFFICACY PARAMETERS For each of the following secondary efficacy parameters, each of the two linaclotide dose groups will be compared to the placebo group using an analysis of covariance (ANCOVA) model with fixed-effect terms for treatment group and geographic region and the patient s corresponding baseline value of the parameter as a covariate. Least square means for each treatment group, difference in least square means between each of the two linaclotide dose treatment groups versus placebo, associated two-sided 95% confidence interval for these differences in least square means, and the corresponding statistical test p-value will be reported. In addition to inferential and descriptive statistics, results for each of the secondary efficacy parameters will also be displayed graphically by plotting the distribution of responses among treatment groups to more fully characterize the treatment effect. Also, for each of these secondary efficacy parameters, corresponding weekly summary statistics will be provided. Categorical analyses of these secondary endpoints are discussed in Section 10.4 (Additional Efficacy Parameters). Change From Baseline in 12-Week CSBM Frequency Rate A patient s 12-week CSBM frequency rate will be the CSBM rate (CSBMs/week) calculated over the 12-weeks of the treatment period. (Details of the calculation of the CSBM frequency rate are provided in Section 15.4.) Change From Baseline in 12-Week SBM Frequency Rate A patient s 12-week SBM frequency rate will be the SBM rate (SBMs/week) calculated over the 12-weeks of the treatment period. (Details of the calculation of the SBM frequency rate are provided in Section 15.4.) Change From Baseline in 12-Week Stool Consistency Stool consistency will be measured daily using the seven-point ordinal Bristol Stool Form Scale (BSFS) provided below: 1 = separate hard lumps like nuts (difficult to pass) 2 = sausage shaped but lumpy 3 = like a sausage but with cracks on surface 4 = like a sausage or snake, smooth and soft 5 = soft blobs with clear-cut edges (passed easily) 6 = fluffy pieces with ragged edges, a mushy stool

125 Forest Research Institute Page 20 Linaclotide 7 = watery, no solid pieces (entirely liquid) The patient s BSFS score for the treatment period will be the average of the nonmissing BSFS scores from the SBMs reported by the patient during the 12-week treatment period. If a patient has no SBMs at baseline, then the baseline BSFS score is missing. Change From Baseline in 12-Week Severity of Straining Severity of straining will be measured daily using a five-point ordinal scale provided below: 1 = not at all 2 = a little bit 3 = a moderate amount 4 = a great deal 5 = an extreme amount The patient s straining score for the treatment period will be the average of the nonmissing straining scores from the SBMs reported by the patient during the 12-week treatment period. If a patient has no SBMs at baseline, then the baseline straining score is missing. Change From Baseline in 12-Week Constipation Severity Constipation severity will be measured weekly using a five-point ordinal scale provided below: 1 = none 2 = mild 3 = moderate 4 = severe 5 = very severe The patient s constipation-severity score for the treatment period will be the average of the nonmissing weekly patient assessments of constipation severity scores reported during the 12-week treatment period.

126 Forest Research Institute Page 21 Linaclotide Change From Baseline in 12-Week Abdominal Discomfort Abdominal discomfort will be measured daily using a five-point ordinal scale provided below: 1 = none 2 = mild 3 = moderate 4 = severe 5 = very severe The patient s abdominal discomfort score for the treatment period will be the average of the nonmissing daily patient assessments of abdominal discomfort scores reported during the 12-week treatment period. Change From Baseline in 12-Week Bloating Bloating will be measured daily using a five-point ordinal scale provided below: 1 = none 2 = mild 3 = moderate 4 = severe 5 = very severe The patient s bloating score for the treatment period will be the average of the nonmissing daily patient assessments of bloating scores reported during the 12-week treatment period CONTROLLING FOR MULTIPLICITY The overall type I family-wise error rate for testing the primary and secondary efficacy parameters will be controlled at the 0.05 significance level using the following five-step serial gatekeeping multiple comparisons procedure (MCP). Following this MCP, progression to the next step will only occur if all individual hypotheses within a step are rejected and the previous step(s) are all rejected at the step-specific overall significance level. If all hypotheses within a step are not rejected, the hypothesis tests involved in all subsequent steps will be considered not statistically significant. All hypothesis tests will be two-sided.

127 Forest Research Institute Page 22 Linaclotide 1. The first step will test the primary efficacy parameter for the 300-μg dose group at the 0.05 significance level 2. The second step will test the primary efficacy parameter for the 150-μg dose group and the following five secondary parameters for the 300-μg dose group: Change from baseline in 12-Week CSBM Frequency Change from baseline in 12-Week SBM Frequency Change from baseline in 12-Week Stool Consistency Change from Baseline in 12-Week Severity of Straining Change from baseline in 12-Week Constipation Severity The six individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure (Hochberg and Tamhane, 1987) to control for multiple parameters within this step. 3. The third step will test the following two secondary efficacy parameters for the 300-μg dose group. Change from baseline in 12-Week Abdominal Discomfort Change from baseline in 12-Week Bloating. The two individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure to control for multiple parameters within this step. 4. The fourth step will test the following five secondary efficacy parameters for the 150-μg dose group: Change from baseline in 12-Week CSBM Frequency Change from baseline in 12-Week SBM Frequency Change from baseline in 12-Week Stool Consistency Change from baseline in 12-Week Severity of Straining Change from baseline in 12-Week Constipation Severity

128 Forest Research Institute Page 23 Linaclotide The five individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure to control for multiple parameters within this step. (Note that this is the same set of secondary parameters tested in step 2 for the 300 μg dose group.) 5. The fifth step will test the following two secondary efficacy parameters for the 150-μg dose group: Change from baseline in 12-Week Abdominal Discomfort Change from baseline in 12-Week Bloating. The two individual hypotheses within this step will be tested using an overall type I error rate of 0.05 by means of a Hochberg procedure to control for multiple parameters within this step. (Note that this is the same set of secondary parameters tested in step 3 for the 300 μg dose group.) 10.4 ADDITIONAL EFFICACY PARAMETERS The role of the additional efficacy parameters is to provide additional support for the primary and secondary efficacy parameters. The statistical test results on these additional parameters for between-treatment group comparisons will be used as descriptive measures only. For the SBM/CSBM responder-based additional efficacy endpoints, if a patient prematurely discontinues from trial such that the patient s final treatment period week contains less than 4 days, the patient will not be considered a weekly responder for that week or the subsequent missed weeks of the treatment period. BM Within 24 Hours of Receiving the First Dose of Study Drug The proportion of patients with a CSBM (SBM) within 24 hours of first receiving study drug in each linaclotide dose group will be compared with the placebo group using the CMH test controlling for geographic region. (Details of the calculation of the CSBM frequency rate are provided in Section 15.4.) Change From Baseline in 12-Week Abdominal Pain Abdominal pain will be measured daily using a five-point ordinal scale provided below: 1 = none 2 = mild 3 = moderate 4 = severe

129 Forest Research Institute Page 24 Linaclotide 5 = very severe The patient s abdominal pain score for the treatment period will be the average of the nonmissing daily patient scores of abdominal pain reported during the 12-week treatment period. Each of the two linaclotide dose groups will be compared with placebo using an ANCOVA model with treatment group and geographic region as fixed effects and the baseline abdominal pain score as a covariate. Complete Spontaneous Bowel Movement Weekly Responder For each of the 12 weeks during the treatment period, a patient will be a weekly CSBM responder for that week if the CSBM weekly frequency rate is 3 or greater and increased by 1 or more from baseline. For each week during the treatment period, the proportion of CSBM weekly responders in each linaclotide dose group will be compared with the proportion in the placebo group using a separate CMH test controlling for geographic region. 12-Week Constipation Responder A 12-week Constipation Responder is a patient who is a Weekly Constipation Responder for at least 9 out of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Constipation Responder is a patient who meets each of the following 3 criteria: 1. Patient is a Weekly CSBM Responder: Patient has a CSBM weekly rate of at least 3 and an increase of at least 1 from baseline for that week 2. Patient meets at least one of the following two weekly responder criteria Weekly Severity of Straining Responder: Patient has an improvement from baseline of 1 or more in mean Severity of Straining for that week Weekly Stool Consistency Responder: Patient has an improvement from baseline of 2 or more in mean Stool Consistency for that week 3. Patient did not have a worsening from baseline in mean Severity of Straining, or mean Stool Consistency for that week. If a patient does not have an SBM during the 2-week baseline period, change from baseline cannot be assessed for the Severity of Straining and Stool Consistency. In these cases, a patient who is a Weekly CSBM Responder for that treatment period week will be considered a Weekly Constipation Responder for that week. For the 12-week Constipation Responder parameter, the proportion of responders in each linaclotide dose group will be compared with the proportion in the placebo group, using a separate CMH test controlling for geographic region.

130 Forest Research Institute Page 25 Linaclotide Treatment Period CSBM Rate Change 1 Responder Treatment period CSBM rate change 1 responder is a patient who had an overall weekly CSBM frequency rate that was increased 1 or more from baseline over the treatment period. The proportion of the treatment period CSBM rate change 1 responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week CSBM Rate 3 Responder A 12-week CSBM rate 3 responder is a patient who had a CSBM weekly frequency rate that was 3 or greater for at least 9 of the 12 weeks of the treatment period. The proportion of 12-week CSBM rate 3 responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week CSBM Rate Change 1 Responder A 12-week CSBM rate change 1 responder is a patient who had a CSBM weekly frequency rate that was increased by 1 or more from baseline for at least 9 of the 12 weeks of the treatment period. The proportion of 12-week CSBM rate change 1 responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week SBM Responder A 12-week SBM Responder is a patient who is a Weekly SBM Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly SBM Responder is a patient who has an improvement from baseline of 2 or more in SBM weekly frequency (SBMs/week) for that week. The proportion of 12-week SBM Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week Stool Consistency Responder A 12-week Stool Consistency Responder is a patient who is a Weekly Stool Consistency Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Stool Consistency Responder is a patient who has an improvement from baseline of 2 or more (ie, a minimum of two full categories improvement) in Stool Consistency for that week. Patients who do not have an SBM at baseline, and, as such, no baseline stool consistency data, will be excluded from this analysis. The proportion of 12-week Stool Consistency Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region.

131 Forest Research Institute Page 26 Linaclotide 12-Week Severity of Straining Responder A 12-week Severity of Straining Responder is a patient who is a Weekly Severity of Straining Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Severity of Straining Responder is a patient who has an improvement from baseline of 1 or more (ie, a minimum of a full category improvement) in Severity of Straining for that week. Patients who do not have an SBM at baseline, and, as such, no baseline straining data, will be excluded from this analysis. The proportion of 12-week Severity of Straining Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week Constipation Severity Responder A 12-week Constipation Severity Responder is a patient who is a Weekly Constipation Severity Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Constipation Severity Responder is a patient who has an improvement from baseline of 1 or more (ie, a minimum of a full category improvement) in Constipation Severity for that week. The proportion of 12-week Constipation Severity Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week Abdominal Discomfort Responder A 12-week Abdominal Discomfort Responder is a patient who is a Weekly Abdominal Discomfort Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Abdominal Discomfort Responder is a patient who has an improvement from baseline of 1 or more (ie, a minimum of a full category improvement) in Abdominal Discomfort for that week. The proportion of 12-week Abdominal Discomfort Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. 12-Week Bloating Responder A 12-week Bloating Responder is a patient who is a Weekly Bloating Responder for at least 9 of the 12 weeks of the treatment period. For each week in the treatment period, a Weekly Bloating Responder is a patient who has an improvement from baseline of 1 or more (ie, a minimum of a full category improvement) in Bloating for that week. The proportion of 12-week Bloating Responders in each linaclotide dose group will be compared to the proportion in the placebo group using a separate CMH test controlling for geographical region. Degree of Relief of Constipation Symptoms Responder

132 Forest Research Institute Page 27 Linaclotide Degree of relief of constipation symptoms will be measured weekly using a seven-point balanced ordinal scale provided below: 1 = completely relieved 2 = considerably relieved 3 = somewhat relieved 4 = unchanged 5 = somewhat worse 6 = considerably worse 7 = as bad as I can imagine The responder parameter based on the following criteria will be analyzed: A patient s weekly response is somewhat relieved, considerably relieved, or completely relieved (ie, a score 3) for all 12 weeks of the treatment period or A patient s weekly response is considerably relieved or completely relieved (ie, a score of 2) for at least 6 out of 12 weeks of the treatment period For the 12-week treatment period, the proportion of degree of relief of constipation symptoms responders in each linaclotide dose group will be compared with the proportion in the placebo group, using a separate CMH test controlling for geographic region. Use of Per-Protocol Rescue Medicine or Any Other Laxative, Suppository, or Enema Use of rescue medication, or any other laxative, suppositories, or enemas during the treatment period in each linaclotide dose group will be compared using the following 3 endpoints: The proportion of patients who report using per-protocol rescue medicines or any other laxative, suppositories, or enemas during the treatment period in each linaclotide dose group will be compared with the proportion in the placebo group using a separate CMH test controlling for geographic region. The change from baseline in the percentage of patient reported days of using per-protocol rescue medicine or any other laxative, suppository, or enema during the

133 Forest Research Institute Page 28 Linaclotide treatment period. Each of the two linaclotide dose groups will be compared with placebo using an ANCOVA model with treatment group and geographic region as fixed effects and the baseline percentage of days of rescue medication use as a covariate The proportion of patients who have an increase from the baseline in the percentage of days where per-protocol rescue medicine or any other laxative, suppository, or enema as reported by patients during the treatment period in each linaclotide dose group will be compared with the proportion in the placebo group using a separate CMH test controlling for geographic region. Since taking the use of rescue medication, or any other laxative, suppositories, or enemas on the day of randomization (prior to randomization) would make the patient randomization ineligible, the day of randomization will be excluded from the calculation of baseline percentages. Treatment Satisfaction Treatment Satisfaction will be measured using a five-point ordinal scale provided below: 1 = not at all satisfied 2 = a little satisfied 3 = moderately satisfied 4 = quite satisfied 5 = very satisfied For Week 2 (Visit 4), Week 4 (Visit 5), and Week 8 (Visit 6) and for the EOT Visit (Visit 7), the treatment satisfaction question will be analyzed separately at each visit with each of the linaclotide dose groups compared with placebo, using an ANOVA model with fixed-effect terms for treatment group and geographic region. Treatment Continuation Treatment Continuation will be measured using a five-point ordinal scale provided below: 1 = not at all likely 2 = a little likely 3 = moderately likely

134 Forest Research Institute Page 29 Linaclotide 4 = quite likely 5 = very likely For the EOT Visit (Visit 7), the treatment-continuation question will be analyzed with each of the linaclotide dose groups compared with placebo, using an ANOVA model with fixed-effect terms for treatment group and geographic region.

135 Forest Research Institute Page 30 Linaclotide 11.0 SAFETY ANALYSES The safety analysis will be performed using the Safety Population. Safety parameters include adverse events, laboratory parameters, vital signs, and ECG parameters. For each safety parameter except for the triplicate ECG data, the last non-missing assessment made before randomization will be used as the baseline for all analyses of that safety parameter. For each triplicate ECG parameter, an average of the three consecutive ECG values at Pre-dose (Visit 3) will be used as the baseline ADVERSE EVENTS Adverse events will be coded using Medical Dictionary for Regulatory Activities (MedDRA), Version 11.0 or newer. An AE (classified by preferred term) that occurs during the treatment period will be considered a TEAE if it was not present before the date of the first dose of double-blind study drug or if it was present before the date of the first dose of double-blind study drug but increased in severity during the treatment period. If more than one AE is reported before the date of the first dose of double-blind study drug and is coded to the same preferred term, the AE with the greatest severity will be used as the benchmark for comparison with the AEs occurring during the treatment period that were also coded to that preferred term. An AE that occurs more than 1 day after the last dose of double-blind study drug will not be counted as a TEAE. For the treatment period, the number and percentage of patients reporting TEAEs in each treatment group and overall linaclotide group (ie, the total of 150 μg and 300 μg linaclotide treatment groups) will be tabulated by system organ class and preferred term; by system organ class, preferred term, and severity; and by system organ class, preferred term, and relationship to study drug. If a patient has more than one TEAE coded to the same preferred term, the patient will be counted only once for that preferred term by identifying those TEAEs with the highest severity and the closest relationship to study drug for the summarization by severity and by relationship to the study drug respectively. The distribution of TEAEs by severity and relationship to study drug will be summarized by treatment group and overall linaclotide group. Relationship will be summarized as both the 5-categories collected: Unrelated, Unlikely, Related, Possible, Probable, and Definite; and dichotomously: Not Related (Unrelated and Unlikely) and Related (Possible, Probable, and Definite).

136 Forest Research Institute Page 31 Linaclotide The incidence of common ( 3% of patients in any treatment group) TEAEs, on-therapy serious AEs (SAE), and AEs leading to premature discontinuation of study drug will be summarized by preferred term and treatment group sorted in decreasing frequency for the overall linaclotide group. An SAE is defined as an on-therapy SAE if it occurred on or after the date of the first dose of double-blind study drug and within 30 days of the date of the last dose of double-blind study drug. In addition, the incidence of fatal SAEs (ie, events that caused death), if any, will be summarized separately by treatment group, overall linaclotide group, and preferred term. For patients experiencing an AE coded as diarrhea, the number of days from first dose of study drug to the onset date of the first occurrence of treatment emergent diarrhea will be summarized by treatment group and overall linaclotide group using the descriptive summary statistics. In addition, the incidence of treatment emergent diarrhea will be calculated for each treatment group and overall linaclotide group by the time of first onset. For the Screened Population, listings will be presented for patients with SAEs, patients with AEs leading to discontinuation, and patients who died (if any) CLINICAL LABORATORY PARAMETERS Descriptive statistics for clinical laboratory values (in standard units) and changes from the baseline values at each assessment time point will be presented by treatment group for the following clinical laboratory parameters: Hematology: Chemistry: Urinalysis: Absolute and differential white blood cell count, erythrocyte count, hemoglobin level, hematocrit level, platelet count, and red blood cell indices (mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) Sodium, magnesium, potassium, calcium, chloride, glucose, blood urea nitrogen, creatinine, total protein, alkaline phosphatase, albumin, total bilirubin, aspartate aminotransferase, alanine aminotransferase, bicarbonate, phosphate, and cholesterol Specific gravity, ph A listing will be provided for the following clinical laboratory parameter: Pregnancy test: Serum human chorionic gonadotropin pregnancy test (for women of childbearing potential only).

137 Forest Research Institute Page 32 Linaclotide Clinical laboratory test values are potentially clinically significant (PCS) if they meet either the low or high PCS criteria listed in Table The number and percentage of patients with PCS postbaseline clinical laboratory values will be tabulated by treatment group. The percentages will be calculated relative to the number of patients with non-pcs baseline values and at least one assessment in the corresponding postbaseline period. The numerator will be the total number of patients with non-pcs baseline values and at least one PCS value in the corresponding postbaseline period. A supportive listing of patients with PCS postbaseline values will be provided, including the PID number, trial center, and baseline and postbaseline values. A listing of all AEs for patients with PCS clinical laboratory values will also be provided. The PCS laboratory test values may not be reported as AEs on trial center because the PCS flags will have to be derived afterwards. Additionally, the shift tables from baseline to EOT for the clinical laboratory parameters will be presented by treatment group. Table Criteria for Potentially Clinically Significant Laboratory Tests Parameter SI Unit Lower Limit Higher Limit CHEMISTRY Albumin g/l <0.9*LLN >1.1 * ULN Alanine Aminotransferase (ALT) U/L 3 * ULN Alkaline Phosphatase U/L 3 * ULN Aspartate Aminotransferase (AST) U/L 3 * ULN Calcium mmol/l <0.9*LLN >1.1 * ULN Chloride mmol/l <0.9*LLN >1.1 * ULN Cholesterol mmol/l >1.6 * ULN Creatinine µmol/l >1.3 * ULN Potassium mmol/l <0.9*LLN >1.1 * ULN Glucose, Non-fasting mmol/l <0.8*LLN >1.4 * ULN Sodium mmol/l <0.9*LLN >1.1 * ULN Total Bilirubin µmol/l >1.5 * ULN Total Protein g/l <0.9*LLN >1.1 * ULN Urea (BUN) mmol/l >1.2 * ULN Magnesium mmol/l <0.9*LLN >1.1*ULN Bicarbonate mmol/l <0.9*LLN >1.1*ULN Phosphate mmol/l <0.9*LLN >1.1*ULN HEMATOLOGY Basophils Absolute Cell Count > 3 * ULN

138 Forest Research Institute Page 33 Linaclotide Table Criteria for Potentially Clinically Significant Laboratory Tests Parameter SI Unit Lower Limit Higher Limit Basophils Percent % > 3 * ULN Eosinophils Absolute Cell Count > 3 * ULN Eosinophils Percent % > 3 * ULN Hematocrit % <0.9 * LLN >1.1 * ULN Hemoglobin g/l <0.9 * LLN >1.1 * ULN Lymphocytes Absolute Cell Count > 3 * ULN Lymphocytes Percent % > 3 * ULN MCH MCHC > 3 * ULN > 3 * ULN MCV fl <0.9*LLN >1.1 * ULN Monocytes Absolute Cell Count > 3 * ULN Monocytes Percent % > 3 * ULN Neutrophils Absolute Cell Count > 3 * ULN Neutrophils Percent % > 3 * ULN Platelet Count 10 9 /L Red Blood Cell Count (Erythrocyte Count) /L <0.9*LLN >1.1 * ULN White Blood Cell Count 10 9 /L URINALYSIS ph <0.9*LLN >1.1 * ULN Specific Gravity PREGNANCY TEST Serum Pregnancy Test - Quant. (IU/ML) LLN: Lower limit of normal value provided by the laboratory. ULN: Upper limit of normal value provided by the laboratory. >1.1 * ULN >1*ULN 11.3 VITAL SIGNS Descriptive statistics for body weight and vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) and changes from baseline values at each visit and at the end of trial will be presented by treatment group.

139 Forest Research Institute Page 34 Linaclotide Vital sign values will be considered PCS if they meet both the observed value criteria and the change from baseline criteria listed in Table The number and percentage of patients with PCS postbaseline vital signs will be tabulated by treatment group. The percentages will be calculated relative to the number of patients with non-missing baseline values and at least one postbaseline assessment. The numerator will be the total number of patients with non-missing baseline values and at least one PCS postbaseline value. A supportive listing of patients with PCS postbaseline values will be provided, including the PID number, trial center, and baseline and postbaseline values. A listing of all AEs for patients with PCS vital sign values will also be provided. Table Criteria for Potentially Clinically Significant Vital Signs Vital Sign Parameter Sitting Systolic Blood Pressure (mmhg) Sitting Diastolic Blood Pressure (mmhg) Sitting Pulse Rate (bpm) Weight (kg) Criteria* Flag Observed Value Change from Baseline High 180 Increase of 20 Low 90 Decrease of 20 High 105 Increase of 15 Low 50 Decrease of 15 High 120 Increase of 15 Low 50 Decrease of 15 High - Increase of 7% Low - Decrease of 7% *A postbaseline value is considered as a PCS value if it meets both criteria for observed value and change from baseline ELECTROCARDIOGRAM (ECG) Descriptive statistics for 12-lead ECG parameters (ie, heart rate, PR interval, QRS interval, QT interval, QTc interval) and changes from baseline values to the end of trial (EOT) will be presented by treatment group. QTc interval will be calculated using both Bazett (QTcB = QT/(RR) ½ ) and Fridericia (QTcF = QT/(RR) ⅓ ) formulas; if RR is not available, it will be replaced with 60/HR in the correction formula. The repeated baseline values and the EOT values will follow the conventions in Section 15.5.

140 Forest Research Institute Page 35 Linaclotide ECG parameters values will be considered PCS if they meet or exceed the upper limit values listed in Table The number and percentage of patients with PCS postbaseline ECG values will be tabulated by treatment group for the treatment period. The percentages will be calculated relative to the number of patients with non-pcs baseline and at least one assessment in the corresponding postbaseline period. The numerator will be the total number of patients with non-pcs baseline values and at least one PCS value in the corresponding postbaseline period. A supportive listing of patients with PCS postbaseline values will be provided and will include the PID number, trial center, and baseline and postbaseline values. A listing of all AEs for patients with PCS ECG values will also be provided. In addition, a listing of patients with postbaseline clinically significant ECG abnormalities as reported by the investigators will also be provided. The shift table from baseline to EOT in investigator overall interpretation of ECG will be presented by treatment group. Table Criteria for Potentially Clinically Significant ECG ECG Parameter Unit Higher Limit QRS duration msec 150 PR interval msec 250 QTc interval msec > Triplicate ECG Cohort For the embedded triplicate ECG cohort, descriptive statistics for the triplicate 12-lead ECG parameters will be presented by treatment group for Screening (Visit 1), pretreatment period, Visit 3 (pre-dose), and by treatment group for Visit 3 (post-dose) and its change from Visit 3 (pre-dose), Visit 5 and its change from Visit 3 (pre-dose), Visit 6 and its change from Visit 3 (pre-dose), and for the EOT Visit (Visit 7) and its change form Visit 3 (pre-dose). An average of the three consecutive ECG values for each parameter at each triplicate ECG visit will be used for generating the summary statistics PHYSICAL EXAMINATION Any new physical examination abnormalities for the postbaseline physical examination or worsening of the change from Screening (Visit 1) will be reported as an AE. No separate data analysis for physical exams is planned OTHER SAFETY PARAMETERS No other safety assessments/parameters are planned for this trial.

141 Forest Research Institute Page 36 Linaclotide 12.0 INTERIM ANALYSIS No interim analysis is planned for this trial.

142 Forest Research Institute Page 37 Linaclotide 13.0 SAMPLE SIZE JUSTIFICATION The sample size of 600 patients randomized to 150 μg linaclotide, 300 μg linaclotide, or placebo, (1:1:1) was calculated based on the following considerations: a. To ensure adequate power for the tests of the primary efficacy parameter b. To ensure that a clinically meaningful number of patients within the male and elderly (older than 65 years) subpopulations receive linaclotide The power calculation for the primary efficacy parameter is based on the results of Ironwood study MCP , a phase IIb study in which 310 patients with CC were randomized to linaclotide or placebo once daily for 4 weeks. The 4-week CSBM overall responder rates for patients treated with placebo was 7.4%; the 4-week CSBM overall responder rate for patients treated with linaclotide were 18.6%, 26.8%, 32.3%, and 29.0% for the 75 μg, 150 μg, 300 μg, and 600 μg linaclotide dose groups, respectively. For the phase III primary efficacy parameter power calculations, the placebo group estimate is taken from the placebo rate (7.4%) in study MCP The 150 μg linaclotide group estimate is based on the combination of responder rates for the 75 μg and 150 μg dose groups (22.6%), and the 300 μg linaclotide group estimate is based on the combination of responder rates for all (75 μg, 150 μg, 300 μg, and 600 μg) linaclotide dose groups (27.2%). Assuming that 15% more randomized patients would discontinue from a 12-week treatment period of this trial as compared to the 4-week treatment period in MCP (20%) and not be responders, the 12-week CSBM overall responder rate estimates used in these power calculations for the for placebo, 150 μg, and 300 μg groups were 6.3%, 19.2%, and 23.1%, respectively. Based on the above estimates of the anticipated 12-week CSBM overall responder rates from the phase IIb data, and the MCP described in Section 10.3, a trial with 200 patients randomized to each of the three treatment groups will have greater than 96% power to reject the 300-μg dose group primary efficacy parameter hypothesis and at least 90% power to reject the 150-μg dose group primary efficacy parameter hypothesis.

143 Forest Research Institute Page 38 Linaclotide 14.0 COMPUTER METHODS Statistical analyses will be performed using Version (or newer) of SAS on a UNIX operating system.

144 Forest Research Institute Page 39 Linaclotide 15.0 DATA HANDLING CONVENTIONS 15.1 VISIT TIME WINDOWS FOR SAFETY ANALYSIS Table below presents the visits assigned for safety analysis corresponding to the range of trial days (window) during which an actual visit may have occurred. Table Visit Time Windows for Safety Analysis a Derived Visit Scheduled Test / Visit Day Window Baseline Day 1 Days 1 Day 15 Visit Day 15 Days [2, 22] Day 29 Visit Day 29 Days [23, 43] Day 57 Visit Day 57 Days [44, 71] Day 85 Visit Day 85 Days 72 End of Trial a b b Final or termination visit during the double-blind treatment period Relative to the date of randomization; Day 1 = the day of randomization. End of Trial will be presented in analysis tables for safety parameters, including ECG, clinical laboratory, and vital signs. Test/Visit Day is calculated by (test/visit date - date of randomization + 1). Except for the triplicate ECG data, if a patient has 2 actual visits within the same window, the last visit with non-missing value will be used for analysis. For the triplicate ECG data, please refer to Section 15.5 for details VISIT TIME WINDOWS FOR EFFICACY ANALYSIS Table below presents the analysis weeks assigned for the efficacy analysis of the patient diary data related to BM characteristics. These analysis weeks will be used in the calculations for all week-based endpoints (eg, SBM weekly frequency rate, BSFS weekly scores, etc.).

145 Forest Research Institute Page 40 Linaclotide Table Analysis Time Windows for Efficacy Analysis Period Analysis Week Begins Ends Pretreatment b (Baseline ) Treatment a Week -2 Day -14 Day -8 Week -1 Day -7 Day 1, time of randomization c Week 1 Day 1, time of randomization Day 7 Week 2 Day 8 Day 14 Week 3 Day 15 Day 21 Week 4 Day 22 Day 28 Week 5 Day 29 Day 35 Week 6 Day 36 Day 42 Week 7 Day 43 Day 49 Week 8 Day 50 Day 56 Week 9 Day 57 Day 63 Week 10 Day 64 Day 70 Week 11 Day 71 Day 77 Week 12 Day 78 the day of last dose (usually on d Day 84) +1 Note: There is no Day 0 or Week 0. For IVRS assessments where a patient is asked to report if an event occurred yesterday or today (eg, a bowel movement or rescue medication use) these windows pertain to when the event occurred, not when the event is reported. For example, if a patient reports in IVRS on Day 78 a bowel movement occurring yesterday that bowel movement (and subsequent stool consistency and straining scores) would be included in Analysis Week 11, not Analysis Week 12. Additionally, the information a patient reports for the day of last dose on the IVRS call occurring on the day after the day of last dose will be included in efficacy analyses. a Relative to the date of randomization; Day 1 = the day of randomization. For the calculation of rates (eg, stool frequency rates) where the duration of a week or the overall time-period is calculated to the nearest hour, a day Begins and Ends at midnight. b Baseline values for efficacy parameters will be derived from the IVRS daily diary and ecrf data collected in the pretreatment period, specifically the period of time from 14 days before randomization up to the time of randomization. c rounding up to the nearest hour (ie, rounding to 1 hour if mm:ss 30:01; otherwise rounding to 0 hour). d. For patients who fail to provide the date of last dose at the patient's last visit, the end date of his/her last week will be the last IVRS diary date. For the treatment period, diary day is calculated as (diary date - date of randomization + 1). For the pretreatment period, diary day is calculated as (diary date - date of randomization). However, the day of randomization is trial Day 1 regardless. Patients will complete their diary entries once per day, with the exception of Day 1 of entry into the treatment period, during which 2 diary data sets will be collected. On Day 1, daily questions will be entered prior to and after the randomization, while weekly questions will be entered prior to but not after randomization. If a patient withdraws during the treatment period, the patient s treatment period shall end at the day of the last dose. The impacted treatment period week shall be shortened to the end of the withdrawn patient s treatment period and all subsequent treatment period weeks will be missing for that patient. a c

146 Forest Research Institute Page 41 Linaclotide 15.3 POOLING OF TRIAL CENTERS Due to the potential of many trial centers having a small number of patients, trial centers will be pooled by the following 6 geographical regions (as illustrated in the Figure below and listed in Table ): Northeast, Southeast, Midwest, Southwest, West and Canada. All analyses utilizing trial center will use this 5-category pooled trial center variable. Table Definition of Geographic Regions Northeast Southeast Midwest Southwest West Canada CT AL IA AZ CA DE AR IL NM CO MA FL IN OK ID MD GA KS TX MT ME KY MI NV NH LA M OR NJ MS MO UT NY NC ND WA PA SC NE WY RI TN OH VT VA SD WV WI

147 Forest Research Institute Page 42 Linaclotide Figure Geographic Regions CANADA 15.4 DERIVED EFFICACY VARIABLES For the definitions of SBM, CSBM, and the baseline values for efficacy parameters, please refer to Section Patient Recall for IVRS Data IVRS-Bowel Habits

148 Forest Research Institute Page 43 Linaclotide IVRS-Rescue Medication Formatted: Highlight Formatted: Highlight Each daily IVRS call will als Formatted: Highlight Formatted: Highlight

149 Forest Research Institute Page 44 Linaclotide IVRS-Post-Randomization Calls on the Evening of Day 1 (Day of Randomization) ighlight included as reported by the patient (note: The impact of a RM being double

150 Forest Research Institute Page 45 Linaclotide The inclusion/exclusion of a reported BM in the analysis will only impact the efficacy Highlight Formatted: Highlight

151 Forest Research Institute Page 46 Linaclotide There will not be any adjustments for these gaps in IVRS data for the efficacy data Formatted: Highlight Formatted: Highlight If a patient reports having a BM but does not provide Formatted: Highlight

152 Forest Research Institute Page 47 Linaclotide Missing Completeness of Evacuation Response Formatted: Highlight Formatted: Highlight Formatted: Highlight Formatted: Highlight Weekly Stool Frequency Rates Components for calculating a patient s stool frequency rates (BM, SBM, and CSBM weekly rates) for a given analysis week are the following: The number of BMs that occurred during that week The number of those BMs that were SBMs The number of those SBMs that were CSBMs The length of time for the week The determination of the length of time of an analysis week is provided in Sections , , and

153 Forest Research Institute Page 48 Linaclotide Length of an Analysis Week With respect to a patient s scheduled analysis weeks, duration of the week is used. In regards to the duration of a week, it is expected that one or more of a patient s weeks may not be exactly 7 24 hours in duration, for example, if a patient withdraws/ discontinues early from the trial. Deviations from the 7 24 hours norm are structural in nature and, as such, the calculations of the weekly rates of SBMs or CSBMs will incorporate the actual duration of the week and standardize to a weekly basis. Following an observed cases approach, no adjustment to the duration of a week will be made for missing IVRS patient daily diary data due to missed calls Weekly Stool Frequency Rate Calculations The weekly frequency rate for SBMs (CSBMs) is based on the number of SBMs (CSBMs) occurring in that week, adjusting for differences in the duration of the week versus the 7 24 hours norm. A description of the corresponding formula is provided below. Weekly stool frequency rates for each analysis week will be calculated as follows: Weekly Frequency Rate (Analysis Week i ) = (7*24) *C i /D i Where: i is an indicator for analysis week number, i = -2, -1, 1,.., 12. C i D i is the number of events (SBMs or CSBMs) reported during analysis week i. is the duration (in hours) of analysis week i, from beginning to end (see Table ) Overall Weekly Stool Frequency Rate Calculations for Each Analysis Period For each of the two analysis periods (pretreatment and treatment), the overall weekly stool frequency rates will be calculated in a manner similar to an individual week. The corresponding formulas are provided below. Overall weekly stool frequency rates for each analysis period will be calculated as follows: Weekly Frequency Rate (Analysis Period j ) = (7*24) *C j /D j

154 Forest Research Institute Page 49 Linaclotide Where: j is an indicator for analysis period number, j = 1 (pretreatment), 2 (treatment). C j D j is the number of events (SBMs or CSBMs) reported during analysis period j. is the duration (in hours) of analysis period j, from beginning to end (see Table ) Other Weekly Scores Derivation For stool consistency, the patient s weekly BSFS score will be the average of the nonmissing BSFS scores from the SBMs reported by the patient during each week. For severity of straining, the patient s weekly straining score will be the average of the nonmissing straining scores from the SBMs reported by the patient during each week. For abdominal discomfort, the patient s weekly abdominal discomfort score will be the average of the nonmissing daily patient assessments of abdominal discomfort scores reported during each week. For bloating, the patient s weekly bloating score for the treatment period will be the average of the nonmissing daily patient assessments of bloating scores reported during each week. For abdominal pain, the patient s weekly abdominal pain score will be the average of the nonmissing daily patient scores of abdominal pain reported during each week REPEATED OR UNSCHEDULED ASSESSMENTS OF SAFETY PARAMETERS Except for the triplicate ECG data, if a patient has repeated assessments prior to the start of double-blind study drug, then the results from the final assessment made prior to the randomization will be used as baseline. If end of trial assessments are repeated or unscheduled, the last postbaseline assessment will be used as the end of trial assessment for generating summary statistics.

155 Forest Research Institute Page 50 Linaclotide For the triplicate ECG data, baseline is defined as the last non-missing average of the three consecutive ECG values for each parameter at each triplicate-ecg visit before taking the first dose of double-blind study drug; End of trial is defined as the last non-missing average of the three consecutive ECG values for each parameter at each triplicate-ecg visit after taking the first dose of double-blind study drug. An average of the three consecutive ECG values for each parameter at each triplicate ECG visit will be used for generating summary statistics. However, all postbaseline assessments will be used for PCS value determination and all assessments will be presented in the data listings. For patient who is not in the triplicate-ecg cohort but with triplicate ECG assessments by mistake, the convention is to treat the patient as a single-ecg patient with repeated measurements. For patient who is in the triplicate-ecg cohort but with only one ECG assessment at some visit, the convention is to treat the patient as a triplicate-ecg patient with the average ECG value at that visit being the ECG value itself for the corresponding parameter MISSING DATE OF STUDY DRUG When the date of the last dose of the double-blind study drug during the treatment period is missing for a patient in the Safety Population, all efforts should be made to obtain the date from the investigator. If it is still missing after all efforts, then the last diary date will be used in the calculation of treatment duration MISSING SEVERITY ASSESSMENT FOR ADVERSE EVENTS If severity is missing for an AE started prior to the first double blind study drug, all efforts should be made to obtain the severity from the investigator. If it is still missing after all efforts, then a severity of Mild will be assigned. If the severity is missing for an AE started on or after the date of the first dose of double blind study drug, then a severity of Severe will be assigned. The imputed values for the missing severity assessment will be used for the incidence summary, while the actual missing values will be presented in data listings MISSING RELATIONSHIP TO STUDY DRUG FOR ADVERSE EVENTS If the relationship to study drug is missing for an AE started on or after the date of the first dose of double-blind study drug, all efforts should be made to obtain the date from the investigator. If it is still missing after all efforts, a causality of Related will be assigned in the corresponding analysis derived data set. The imputed values for the missing relationship to double-blind study drug will be used only for incidence summary, while the actual missing values will be presented in data listings.

156 Forest Research Institute Page 51 Linaclotide 15.9 MISSING DATE INFORMATION FOR ADVERSE EVENTS The following imputation rules apply to cases in which the start date is incomplete (ie, partial missing) for adverse events. a. If AEs occurred during the treatment period (ie, the treatment period is checked on the AE ecrf) Missing day and month If the year is the same as the year of the date of the first dose of double-blind study drug, then the day and month of the date of the first dose of double-blind study drug will be assigned to the missing fields. If the year is prior to the year of the date of the first dose of double-blind study drug, then December 31 will be assigned to the missing fields. If the year is after the year of the date of the first dose of double-blind study drug, then January 1 will be assigned to the missing fields. Missing month only The day will be treated as missing and both month and day will be replaced according to the above procedure. Missing day only If the month and year are the same as the month and year of the date of the first dose of double-blind study drug, then the date of the first dose of double-blind study drug will be assigned to the missing day. If either the year is before the year of the date of the first dose of double-blind study drug or if both years are the same but the month is before the month of the date of the first dose of double-blind study drug, then the last day of the month will be assigned to the missing day. If either the year is after the year of the date of the first dose of double-blind study drug or if both years are the same but the month is after the month of the date of the first dose of double-blind study drug, then the first day of the month will be assigned to the missing day. If the stop date is complete and the imputed start date as above is after the stop date, the start date will be imputed by the stop date. If the start date is completely missing and the stop date is complete, then the following algorithm is used to impute the start date:

157 Forest Research Institute Page 52 Linaclotide If the stop date is after the date of the first dose of double-blind study drug, the date of the first dose of double-blind study drug will be assigned to the missing start date. If the stop date is before the date of the first dose of double-blind study drug, the stop date will be assigned to the missing start date. b. If AEs occurred during the screening or pretreatment period (ie, the screening or pretreatment period is checked on the AE ecrf) Missing day and month If the year is the same as the year of the date of informed consent, then the day and month of the date of informed consent will be assigned to the missing fields. If the year is prior to the year of the date of informed consent, then December 31 will be assigned to the missing fields. If the year is after the year of the date of informed consent, then January 1 will be assigned to the missing fields. Missing month only The day will be treated as missing and both month and day will be replaced according to the above procedure. Missing day only If the month and year are the same as the month and year of the date of informed consent, then the date of informed consent will be assigned to the missing day. If either the year is before the year of the date of informed consent or if both years are the same but the month is before the month of the date of informed consent, then the last day of the month will be assigned to the missing day. If either the year is after the year of the date of informed consent or if both years are the same but the month is after the month of the date of informed consent, then the first day of the month will be assigned to the missing day. If the stop date is complete and it is before the date of randomization and the imputed start date as above is after the stop date, the start date will be imputed by the stop date. If the stop date is complete and it is on or after the date of randomization and the imputed start date as above is after the stop date, the start date will be imputed by the date immediately before the date of randomization.

158 Forest Research Institute Page 53 Linaclotide If the start date is completely missing, then the date of informed consent will be used to impute the start date MISSING DATE INFORMATION FOR PRIOR OR CONCOMITANT MEDICATIONS For prior or concomitant medications, incomplete (ie, partially missing) start date and/or stop date will be imputed. When the start date and the stop date are both incomplete for a patient, impute the start date first Incomplete Start Date The following rules will be applied to impute the missing numerical fields. If the stop date is complete and the imputed start date is after the stop date, then the start date will be imputed using the stop date. Missing day and month If the year of the incomplete start date is the same as the year of the date of the first dose of double-blind study drug, then the day and month of the date of the first dose will be assigned to the missing fields. If the year of the incomplete start date is prior to the year of the date of the first dose of double-blind study drug, then December 31 will be assigned to the missing fields. If the year of the incomplete start date is after the year of the date of the first dose of double-blind study drug, then January 1 will be assigned to the missing fields. Missing month only The day will be treated as missing and both month and day will be replaced according to the above procedure. Missing day only If the month and year of the incomplete start date are the same as the month and year of the date of the first dose of double-blind study drug, then the day of the date of the first dose will be assigned to the missing day. If either the year is before the year of the date of the first dose of double-blind study drug or if both years are the same but the month is before the month of the date of the first dose of double-blind study drug, then the last day of the month will be assigned to the missing day.

159 Forest Research Institute Page 54 Linaclotide If either the year is after the year of the date of the first dose of double-blind study drug or if both years are the same but the month is after the month of the date of the first dose of double-blind study drug, then the first day of the month will be assigned to the missing day Incomplete Stop Date The following rules will be applied to impute the missing numerical fields. If the imputed stop date is before the start date (imputed or non-imputed start date), then the imputed stop date will be equal to the start date. Missing day and month If the year of the incomplete stop date is the same as the year of the date of the last dose of double-blind study drug, then the day and month of the date of the last dose will be assigned to the missing fields. If the year of the incomplete stop date is prior to the year of the date of the last dose of double-blind study drug, then December 31 will be assigned to the missing fields. If the year of the incomplete stop date is after the year of the date of the last dose of double-blind study drug, then January 1 will be assigned to the missing fields. Missing month only The day will be treated as missing and both month and day will be replaced according to the above procedure. Missing day only If the month and year of the incomplete stop date are the same as the month and year of the date of the last dose of double-blind study drug, then the day of the date of the last dose will be assigned to the missing day. If either the year is before the year of the date of the last dose of double-blind study drug or if both years are the same but the month is before the month of the date of the last dose of double-blind study drug, then the last day of the month will be assigned to the missing day. If either the year is after the year of the date of the last dose of double-blind study drug or if both years are the same but the month is after the month of the date of the last dose of double-blind study drug, then the first day of the month will be assigned to the missing day.

160 Forest Research Institute Page 55 Linaclotide CHARACTER VALUES OF CLINICAL LABORATORY PARAMETERS If the reported value of a clinical laboratory parameter cannot be used in a statistical summary table due, for example, to it being a character string rather than a numerical type, a coded value needs to be appropriately determined and used in the statistical analyses. However, the actual values as reported in the database will be presented in data listings. Table Examples for Coding of Special Character Values for Clinical Laboratory Parameters Lab Test Possible Lab Results (in SI unit) Coded Value for Analysis Chemistry: ALT < 5 0 Chemistry: AST < 5 0 Chemistry: Bilirubin, Total Urinalysis: Glucose Urinalysis: Ketones Urinalysis: ph Urinalysis: Protein < 2 0 = OR > 55, >= 55, > 0 Positive <= 0, Negative Negative = OR > 8.0, >=8.0, > 0 Positive <= 0, Negative Negative > 8.0, >= >= 8.5, 8.5 = OR > 3.0, >=3.0, > 0 Positive <= 0 Negative

161 Forest Research Institute Page 56 Linaclotide 16.0 CHANGES TO ANALYSES SPECIFIED IN PROTOCOL There are no major changes to the analyses specified in the most recent Amended Protocol # 2 (dated Oct. 7, 2009).

162 Forest Research Institute Page 57 Linaclotide 17.0 REFERENCE Hochberg Y, Tamhane AC. Multiple Comparisons Procedures. New York, NY: Wiley; 1987.

163 Forest Research Institute Page 58 Linaclotide 18.0 APPENDICES 18.1 IVRS QUESTIONS (COPIED FROM THE IVRS SYSTEM USER REQUIREMENTS, VERSION 1.3 (DATED 3 MARCH 2009)) The following three questions will be asked weekly starting on Day 1 of the pretreatment period and every 7 days thereafter (e.g. Day 8, day 15 etc.). If the patient does not answer the question on the predefined weekly day, the system will ask the questions on the next day once and then on the following day again but only if the questions had not been previously answered in the last two days. No more than three attempts will be made to ask these questions. Patients will be asked to enter the pound (#) key after every entry. 1. On average, How would you rate your constipation during the past 7 days? 1 = none, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe. 2. DELETED - (note: to implement this, the IVR system will automatically skip the presentation of the former Question #2. It will not be asked and no data will be saved for this question. This will prevent additional work that would have been required if the data structure was renumbered and will keep the system design and code the same as that used in the MCP study. 3. Compared to before you started this study, how would you rate your constipation symptoms during the past 7 days? 1 = completely relieved, 2 = considerably relieved, 3 = somewhat relieved, 4 = unchanged, 5 = somewhat worse, 6 = considerably worse, 7 = as bad as I can imagine. Daily questions start For Day 1 of Treatment time reference (i.e. instead of past 24 hours) = since your clinic visit at <time of rand call> applies to questions How would you rate your abdominal pain over the last 24 hours? Please use the following scale where: 1 = none, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe. 5. How would you rate your abdominal discomfort over the last 24 hours? Please use the following scale where: 1 = none, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe. 6. How would you rate your bloating over the last 24 hours? Please use the following scale where: 1 = none, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe.

164 Forest Research Institute Page 59 Linaclotide 7. Have you taken any laxatives, suppositories, or enemas since yesterday s call at <insert time when yesterday s call was completed>? Press 1 for Yes, or 2 for No. If no, skip to Question 11 If no call was reported yesterday, then ask this question format instead of Question 7 7a) Our database indicates that you did not make a call yesterday. Have you taken any laxatives, suppositories or enemas since <day of week that was yesterday> morning starting from 12:01am? Press 1 for Yes, or 2 for No. 8. Please enter 1 = Oral Bisacodyl, 2 = Bisacodyl suppository, or 3 = other laxatives, suppositories, or enemas. If response is (3= other), then play message This is a friendly reminder to use only the laxative or suppository provided to you by the study staff. Please refer to the Investigational Study Medication guide for instructions on how to obtain and use rescue medications., then continue. 9. Was this rescue medication use today, or yesterday? Please enter 1 for today, or 2 for yesterday. 10. To enter additional laxatives, suppositories, or enemas, press 1 or to continue to the next question, press 2. If answer is 1, then loop back to Question 8 and register additional data. 11. How many bowel movements did you have since yesterday s call at < insert time when this question was answered yesterday)? Please enter the pound sign when your entry is complete. (If this is day 1 of pre-treatment, then day/time will be 24 hours prior to time of this call. If no call was reported yesterday, then ask this question format instead of Question 11 11a) Our database indicates that you did not make a call yesterday. How many bowel movements did you have since <day of week that was yesterday> morning starting from 12:01 am? Please enter the pound sign when your entry is complete. For (Question 11 or Question 11a) If response is 0, then save and end diary call. If value entered is > 9, then play alert to patient that entry exceeds expected value. Ask the patient to confirm the value entered is correct or allow them to re-enter.

165 Forest Research Institute Page 60 Linaclotide Next four or five questions to be asked to the patients for each bowel movement (e.g. after all questions are answered for the first bowel movement, the system will start over with the date of the second bowel movement and so on. If the caller exits in the middle of a loop, any subsequent call on same entry date will allow entry at the start of the last incomplete loop. 12. Was this bowel movement today, or yesterday? Please enter 1 for today, or 2 for yesterday. 13. Did you feel like you completely emptied your bowels? Please press 1 for Yes, or 2 for No. 14. Please refer to the laminated Bristol Stool Form Scale given to you. Please describe the consistency of the bowel movement using the following scale where: 1 = separate hard lumps like nuts (difficult to pass), 2 = sausage shaped but lumpy, 3 = like a sausage but with cracks on surface, 4 = like a sausage or snake, smooth and soft, 5 = soft blobs with clear-cut edges (passed easily), 6 = fluffy pieces with ragged edges, mushy stool, 7 = watery, no solid pieces (entirely liquid). 15. How much did you strain during the bowel movement? Please use the following scale where: 1 = not at all, 2 = a little bit, 3 = a moderate amount, 4 = a great deal, 5 = an extreme amount. 16. (For diary entered on the day of Randomization and the day after, the following question will be asked): Did this Bowel Movement occur less than 24 hours after you first took study medication? Press 1 for Yes, or press 2 for No Provide Bowel count entry review at end of this loop before proceeding to the next bowel entry. System will play total bowel movements originally entered and allow caller to reduce this number down to the number of bowel movements that have been previously entered and confirmed (bowel movement is considered confirmed if a valid date was confirmed for a bowel movement) OR to increase it to a larger value. System will adjust loop count accordingly GENERAL DIARY INFORMATION (COPIED FROM THE IVRS SYSTEM USER REQUIREMENTS, VERSION 1.3 (DATED 3 MARCH 2009)) Patients enter diary information daily upon completion of Screening (Visit 1) activities. Diary begins at the pretreatment period (as early as Day -21 through Day -1), continuing through the treatment period (Day 1 to Day 85) until the patient is screen failed during the pretreatment phase or discontinued/completed post-randomization.

166 Forest Research Institute Page 61 Linaclotide Patients may complete up to 21 days of diary data prior to the patient s first dose of study drug, only the last 14 calendar days will be counted for the Pre-treatment period. (not including the day of randomization). Patients will provide answers to daily Bowel Habits and Daily Assessments of Symptom Severity, weekly Patient Global Assessment of Relief of Constipation Symptoms, and Weekly Patient Assessment of Severity of Constipation, and per protocol rescue medication use. Patients must login to their diary between 12:00 noon and 11:59 pm in the patient s local time zone to capture data since the time of last call. There will be certain exceptions to the start of the window that shall be detailed for the particular questions affected in section If patient hangs up or disconnects while entering the diary, they can call back in and pick up where they left off as long as the date of the subsequent call is still the same as the initially confirmed entry date or within one-hour of midnight. Once data are entered and confirmed and the patient completes the call, the patient cannot change data, with the exception of the number of bowel movements question. Diary entry will be available via telephone only. Patients can complete their diary entries once per day, with the exception Day 1 of entry into treatment in which 2 diary data sets will be collected. Diary will be entered prior to, and after the Randomization visit. Trial centers will register the patient into the Pre-Randomization Transition phase visit and if the patient has not already answered diary that day, they will be allowed to do so at this time. Then the trial center will call in to check Elig/Randomization and the patient will also enter diary (if eligible), in the evening of Day 1. Reminder calls During each patient s Pre-treatment visit, trial center staff will assist the patient in setting up optional reminder calls. Once activated, the system will call the patient or send an SMS within the selected time if they have not made their daily diary entry. If the reminder call has not been set then play message to ask patient to activate reminder call function for first 4 days after account is activated. The reminder telephone call will state Please enter your UserID and the text message will state: Please call ICOPhone at to report your Diary. Time Zone changes Patients will need to contact their coordinator who will let ICON know to change the time zone. Patients will not be able to select their own time zone, but it will default to the trial center s time zone at patient set-up.

167 1.0 TITLE PAGE Ironwood Pharmaceuticals, Inc. 320 Bent Street Cambridge, MA A Phase 3, Randomized, Double-blind, Placebo-controlled, Parallel-group Trial of Linaclotide Administered Orally for 12 Weeks Followed by a 4-Week Randomized Withdrawal Period in Patients with Chronic Constipation Original Protocol Date: July 10, 2008 MCP IND Number 63,290 Protocol Amendment 1 Date: November 21, 2008 Protocol Amendment 2 Date: October 7, 2009 The contents of this document are confidential and belong to Ironwood Pharmaceuticals, Inc. Except as may be otherwise agreed to in writing, by accepting or reviewing these materials, you (including any colleagues or subordinates) agree to hold such information in confidence and not to disclose it to others (except where required by applicable law), and shall use it solely for the purpose of conducting the study in accordance with this protocol. In the event of actual or suspected breach of this obligation, Ironwood should be promptly notified. The protocol has been developed and is being executed as part of a program of clinical studies on linaclotide being performed pursuant to a collaboration between Forest Laboratories, Inc. and Ironwood Pharmaceuticals, Inc. (formally known as Microbia, Inc). In connection with such program and pursuant to agreement of the collaboration partners, Forest is responsible for hosting the study database.