Supplementary Appendix

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

Supplement to: Finkel RS, Mercuri E, Darras BT, et al. Nusinersen versus sham control in infantile-onset spinal
muscular atrophy. N Engl J Med 2017;377:1723-32. DOI: 10.1056/NEJMoa1702752
Supplementary Appendix

TABLE OF CONTENTS

STUDY OVERSIGHT ................................................................................................................. 3

DATA SAFETY MONITORING COMMITTEE ..................................................................................... 3
ENDPOINT ADJUDICATION COMMITTEE ........................................................................................ 3
ENDEAR PRINCIPAL INVESTIGATORS AND SITE STUDY PERSONNEL ............................................. 3
ADDITIONAL METHODOLOGICAL DETAILS .......................................................................... 8
STUDY CONDUCT ....................................................................................................................... 8
FULL ELIGIBILITY CRITERIA ......................................................................................................... 8
SECONDARY END POINTS ........................................................................................................... 9
STUDY AMENDMENTS ................................................................................................................10
RATIONALE FOR STUDY END POINTS AND DEFINITIONS ................................................................11
Proportion of motor milestone responders..........................................................................11
Event-free survival .............................................................................................................11
CHOP INTEND responder .................................................................................................12
STATISTICAL ANALYSES ............................................................................................................12
Analysis populations ..........................................................................................................12
Hierarchical end point analysis...........................................................................................13
Proportion of motor milestone responders..........................................................................14
Event-free survival .............................................................................................................14
CHOP INTEND responders................................................................................................15
Survival rate .......................................................................................................................15
Percentage of infants not requiring permanent ventilation ..................................................15
Proportion of CMAP responders ........................................................................................15
Time to death or permanent ventilation in the subgroup of infants below the study median
disease duration.................................................................................................................16
Time to death or permanent ventilation in the subgroup of infants above the study median
disease duration.................................................................................................................16
SAFETY ASSESSMENTS .............................................................................................................16
Standard-of-care guidelines ...............................................................................................18
RESULTS .................................................................................................................................19
PATIENTS .................................................................................................................................19
PRIMARY END POINTS ...............................................................................................................19
Proportion of HINE-2 motor milestone responders .............................................................19
SENSITIVITY ANALYSES FOR THE PRIMARY END POINTS ...............................................................20
Proportion of motor milestone responders..........................................................................20
Event-free survival .............................................................................................................22
SECONDARY END POINTS ..........................................................................................................23
Proportion of CHOP INTEND responders ..........................................................................23
Proportion of CMAP responders ........................................................................................23

Page 1 of 50
 Time to death or permanent ventilation in the subgroup of infants below and above the
study median disease duration...........................................................................................24
SAFETY RESULTS .....................................................................................................................24
SUPPLEMENTARY FIGURES .................................................................................................26
FIGURE S1. ANALYSIS POPULATIONS. ........................................................................................26
FIGURE S2. PATIENT DISPOSITION (CONSORT DIAGRAM). ........................................................27
FIGURE S3A. IMPROVEMENT IN HINE-2 MOTOR MILESTONE SCORE .............................................29
FIGURE S3B. IMPROVEMENT IN TOTAL HINE-2 MOTOR MILESTONE SCORE .................................31
FIGURE S4. HINE-2 MOTOR MILESTONES - QUALITY OF MOTOR RESPONSES ..............................33
FIGURE S5A. CHANGE IN HINE-2 MOTOR MILESTONES EXCLUDING VOLUNTARY GRASP OVER TIME
...............................................................................................................................................34
FIGURE S5B. CHANGE IN HINE-2 TOTAL MOTOR MILESTONES OVER TIME ..................................35
FIGURE S6A. KAPLAN-MEIER PLOT OF TIME TO DEATH OR PERMANENT VENTILATION IN THE
SUBGROUP OF INFANTS BELOW THE MEDIAN DISEASE DURATION AT SCREENING. ........................36
FIGURE S6B. KAPLAN-MEIER PLOT OF TIME TO DEATH OR PERMANENT VENTILATION IN THE
SUBGROUP OF INFANTS ABOVE THE MEDIAN DISEASE DURATION AT SCREENING. ........................37
FIGURE S7. CHOP INTEND MOTOR FUNCTION CHANGE FROM BASELINE SCORES AT END OF
STUDY. ....................................................................................................................................38
FIGURE S8. PERONEAL CMAP AMPLITUDE AT END OF STUDY. ...................................................40
SUPPLEMENTARY TABLES ...................................................................................................41
TABLE S1. BASELINE HINE-2 MOTOR MILESTONES. ...................................................................41
TABLE S2. ADVERSE EVENTS LEADING TO TREATMENT DISCONTINUATION. .................................43
TABLE S3. ADVERSE EVENTS OCCURRING WITHIN 72 HOURS OF NUSINERSEN OR SHAM CONTROL
TREATMENT. ............................................................................................................................44
TABLE S4. ADVERSE EVENTS OCCURRING AT A ≥5% HIGHER FREQUENCY IN NUSINERSEN-
TREATED VERSUS SHAM CONTROL INFANTS. .............................................................................49
REFERENCES .........................................................................................................................50

Page 2 of 50
STUDY OVERSIGHT

Data Safety Monitoring Committee

Walter G. Bradley, D.M., F.R.C.P., Mary K. Schroth, M.D., John B. Bodensteiner, M.D., and

Charles S. Davis, Ph.D.

Endpoint Adjudication Committee

Richard Shell, M.D., Jacob Hen, M.D., and Eric Douglas Austin, M.D.

ENDEAR Principal Investigators and site study personnel

United States: Claudia A. Chiriboga, M.D., Sonya Aziz-Zaman, Joshua Cappell, M.D., Andrei

Constantinescu, M.D., Rosángel Cruz, M.A., B.S., Jahannaz Dastgir, D.O., Darryl De Vivo,

M.D., Sally Dunaway, R.P.T., Kristin Engelstad, M.S., Maurade Gormley, N.P.,Nicole Holuba La

Marca, D.N.P., Alexander Khandji, M.D., Samantha Kramer, B.S., Jonathan Marra, M.A.,

Jaqueline Montes, R.P.T., Courtney Ortiz-Miller, Molly Popolizio, Rachel Salazar, R.P.T., Luz

Sanabria, Louis Weimer, M.D.; Anne M. Connolly, M.D., Pallavi Anand, BMMS, Rebecca

Gadeken, P.T., D.O.T., Paul T. Golumbek, M.D., Catherine Siener, P.T., M.H.S., Craig M.

Zaidman, R.P.T., Ph.D.; Basil T. Darras, M.D., Fouad Al-Ghamdi, M.D., Charles Berde, M.D.,

PhD., Partha Ghosh, M.D., Robert Graham, M.D., Timothy Harrington, Anjali Koka, M.D.,

Regina Laine, P.N.P., Wendy Liew, M.D., Elizabeth Mirek, R.P.T., Grace Ordonez, Amy

Pasternak, D.P.T., Janet Quigley, R.P.T., Navil Sethna, M.D., Michelle Souris, P.N.P., Heather

Szelag, Luke Wand, M.D.; John W. Day, M.D., Ph.D., Genevieve D'Souza, M.D., Trinh Tina

Duong, M.P.T., Ph.Dc., Richard Gee, M.P.T., Janis Kitsuwa-Lowe, M.A., O.T.R./L, Danielle

McFall, Swetapadma Patnaik, Shirley Paulose, Jennifer Perez, Crystal Proud, M.D., Bona

Purse, R.J. Ramamurthi, M.D., Sarada Sakamuri, M.D., Jacinda Sampson, M.D., Ph.D., Bharati

Sanjanwala, Ana Carolina Tesi Rocha, M.D., Karolina Watson, N.P., Lesly Welsh; Loren D. M.

Pena, M.D., Ph.D., Laura Case, R.P.T., Julie Coates, M.P.T., Stephanie DeArmey, P.A.,

Page 3 of 50
M.H.S., M. Mayumi Homi, M.D., Ph.D., Christie Milleson, B.A., Nicole Nelson, M.P.H., Allison

Ross,, M.D., Edward Smith, M.D., Brad Taicher, D.O., M.B.A., Janet Wootton, R.N.; Erika

Finanger, M.D., Danielle Benjamin, R.P.T., Andrea Frank, R.N., Colin Roberts, M.D., Barry

Russman, M.D., Kirsten Zilke, R.P.T.; Richard S. Finkel, M.D., Debbie Berry, B.S.N., Matthew

Civitello, M.P.T., Dawn Cook, M.S..N., C.C.R.C., Julie Duke Endsley, Pharm.D., Craig Johnson,

D.O., Marla Kasper, B.S.N., Wendy Leon, B.S.N., Annie Lim, D.O., Kathleen O'Reardon,

A.R.N.P., Laufey Yr Sigurdardottir, M.D., Jenna Turner, B.S.P.T., Fabiola Weber-Guzman,

M.D., Matthias Zinn, M.D.; Susan T. Iannaccone, M.D., Diana Castro, M.D., Margaret Cowie,

C.C.R.C., Alan Farrow-Gillespie, M.D., Andrew Herbert, R.T., Melissa Kauk, D.P.T., Deborah

McElroy, R.N., Nancy Miller, R.N., Leslie Nelson, R.P.T., Lauren Smith, M.S., Thomas Spain,

Jr., M.D., Stephanie Trest, B.S.; Nicholas Johnson, M.D., Russell Butterfield, M.D., Deanna

DiBella, R.P.T., Katie Mayne, Tara Marie Newcomb, M.S., Nicole Rausch, C.C.R.C.; Nancy

Kuntz, M.D., Colleen Blomgren, R.P.T., Hyoung Won Choi, M.D., Leon Epstein, M.D., Stewart

Goldman, M.D., Kristin Krosschell, R.P.T., Jenna Krueger, M.D., Jonathan Kurz, M.D., Vamshi

Rao, M.D.; Julie Parsons, M.D., Victoria Allen, M.A., Alan Bielsky, M.D., Kaylee Booker, Alicia

Camuto, Terri Carry, R.P.T., Peter Fuhr, M.D., Melissa Gibbons, B.S., Joanne Janas, M.D.,

Hannah Johnson, Carolyn Kelly, R.P.T., Lisa Sierra Lord-Halvorson, M.A., Sarah Nicolarsen,

R.P.T., Stephanie Shea, P.A.-C, Vi Tran, Gina VanderVeen, Michele Yang, M.D., Carl

Zimmerman; Perry Shieh, M.D., Ph.D., Carolyn Kelly, D.P.T., Nicholas Parziale, M.D., Lelha

Rao, M.D., Jonathan William Said, M.D.,Francy Shu, M.D., Christy Skura, Loretta Staudt, M.S.;

Gihan Tennekoon, M.D., Laura Adang, M.D., John Brandsema, M.D., Madeline Chadehumbe,

M.D., Jean Flickinger, R.P.T., Allan Glanzman, R.P.T., Elizabeth Kichula, M.D., Delores

Stanford, R.N., Michele Toms, R.N., Joshua Zigmont, R.N.; Canada: Maryam Oskoui, M.D.,

Stephanie Arpin, R.P.T., Pamela Dinunzio, R.P.T., Pablo Mauricio Ingelmo, M.D., Chantal

Poulin, M.D., Gonzalo Rivera, M.D., Christine Sabapathy, M.D., Myriam Srour, M.D., Sarah

Turgeon-Desilet, R.P.T., David Zielinski, M.D.; Kathryn Selby, M.B., Ch.B., Carol King,

Page 4 of 50
B.S.C.P.T., James Lee, M.D., Apasia Michoulas, M.D., Elke Roland, M.D.; Jiri Vajsar, M.D.,

Vann Chau, M.D., James Dowling, M.D., Renee Haldenby, R.P.T., Melody Miki, R.N., Stephanie

So, R.P.T.; Spain: Samuel Ignacio Pascual Pascual, M.D., Antonio Martinez Bermejo, M.D.,

Sandra Epinosa Garcia, Sara Garcia Guixot, M.D., Maria Mercedes Martinez Moreno, Maria del

Pilar Tirado Requero, Maria del Mar Garcia Romero; Eduardo Tizzano, M.D., Carla Aguilar,

R.N., Francina Munell Casadesus, M.D., Ph.D., Marta Belen Gomez Garcia de la Banda, M.D.,

Mercedes Gallardo, R.N., Gisela Gili, R.N., Mireia Alavarez Molinero, M.D., Maria de Los

Angeles Tormos Munoz, M.D., Natalia Julia Palacios, M.D., Bernat Planas Pascual, B.Sc.,

Maria del Mar Melendez Plumed, M.D., Ana Felipe Rucian, M.D., Ester Toro Tamargo, M.D.,

Margarida Gratacos Vinola, M.D.; Germany: Janbernd Kirschner, M.D., Sabine Borell, M.D.,

Matthias Eckenweiler, M.D., Marcus Krüger, M.D., Astrid Pechmann, M.D., Bianca Rippberger,

Sabine Stein, P.T., Sibylle Vogt, P.T., Sabine Wider; Ulrike Schara, M.D., Barbara Andres,

Adela Della Marina, M.D., Andrea Ganfuss, M.D., Philippe Jachertz, M.D., Heike Koelbel, M.D.,

Katrin Rupprich, M.D., Ester Sarah Schroers, M.D., Nina Sponemann; Italy: Claudio Bruno,

M.D., Chiara Fiorillo, M.D., Alberto Garaventa, M.D., Paola Lanteri, M.D., Valentina Lanzillotta,

Carla Manzitti, M.D., Marina Pedermonte, M.D., Paola Tacchetti, Federica Trucco, M.D., Ambra

Zuffi; Eugenio Mercuri, M.D., Ph.D., Roberto De Sanctis, Lavinia Fanelli, Marco Luigetti,

M.D.,Concetta Palermo, M.D., Marika Pane, M.D., Marco Piastra, M.D., Serena Sivo, M.D.;

France: Laurent Servais, M.D., Elena Gargaun, M.D., Teresa Gidaro, M.D., Stéphanie Gilabert,

Piere-Louis Léger, M.D., Anne-Gaëlle Le Moing, M.D., Charlotte Lilien, Michèle Mayer, M.D.,

Qwenn Ollievier, Jérôme Rambaud, M.D., Jessica Taytard, M.D., Raphaël Vialle, M.D., Thomas

Voit, Ph.D.; Great Britain: Francesco Muntoni, M.D., Luigi D'Argenzio, M.D., Paula Hannah

Lister, Ph.D., Adnan Manzur, M.D., Joana Pisco Domingos, M.D., Danielle Ramsey, Valeria

Ricotti, M.R.C.P.C.H., Lucia Schottlaender, M.D., Mariacristina Scoto, M.D., Stephen M.

Scuplak, M.D., Victoria Selby; Volker Straub, M.D., Simon Baily, M.D., Marta Bertoli, M.D.,

Anna G. Mayhew, Robert Muni Lofra, Alexander Murphy, Claire Wood; Sweden: Már Tulinius,

Page 5 of 50
M.D., Niklas Darin, M.D., Johannes Eldblom, M.D., Eva Kimber, M.D., Anna Karin Kroksmark,

Asa Lindstedt, Eva Michael, M.D., Kalliopi Sofou, M.D.; Belgium: Nicolas Deconinck, M.D.,

Ph.D., Aurelie Christiaens, Sandra Coppens, M.D.,Kevin DeCock, M.D., Elke De Vos voor,

Florence Dorban, Gérarld Gilbert, M.D., Shancy Rooze, M.D., Valentine Tahon, Rudy Van

Coster, M.D., Ph.D., Ruth Van Der Looven, M.D., Arnaud Vanlander, M.D., Ph.D., Daphné

Vens, M.D., Helene Verhelst, M.D., Bernard Wenderickx, Sylvia Wittevrongel; Australia:

Michelle Farrar, M.D., Nisha Berthon-Jones, Michael Arthur Doumit, P.T., Karen Jane Herbert,

P.T., Tejaswi Kandula, M.D., Margot Morrison, R.N., Joanne O’Brien, Stephanie Richardson,

R.N., Hugo Alexandre Ferreira Sampaio, M.D., Hooi Ling Teoh, M.D.; Monique Ryan, M.D.,

Kathryn Mary Carroll, Katherine Louise De Valle, Daniella Villano, Ian Woodcock, M.D., Eppie

Mildred Yiu, M.D.; Turkey: Haluk Topaloğlu, M.D., Didem Ardicli, M.D., Ceren Gunbey, M.D.,

Vildan Goknur Haliloglu, M.D., Ayner Ayse Karaduman, Bahadir Konuskan, M.D., Fatma

Gokcem Yildiz Sarikaya, M.D., Esra Serdaroglu, M.D., Murat Tanyildiz, M.D., Fatma Gokcem

Yildiz Sarikaya, M.D., Cagri Mesut Temucin, M.D., Mirac Yildirim, M.D., Oznur Tunca Yilmaz;

Japan: Kayoko Saito, M.D., Reiko Arakawa, M.D., Yukihide Chiba, M.D., Kaoru Eto, M.D.,

Kyoko Hirasawa, M.D., Tesuo Ikai, M.D., Susumu Ito, M.D., Yasushi Ito, M.D., Yoichiro

Kaburagi, M.D., Hirotaka Kaneko, M.D., Shigeto Matsumaru, M.D., Naho Matsushima, M.D.,

Kiyoshi Mizuochi, M.D., Satoru Nagata, M.D., Hidetsugu Nakatsukasa, M.D., Aiko Nishikawa,

M.D., Yuri Otani, M.D., Takatoshi Sato, M.D., Minobu Shichiji, M.D., Kei Sugimoto, M.D., Akiko

Takeshita, M.D., Tomoe Yanagishita, M.D., Akemi Yamauchi, M.D.; Yasuhiro Takeshima,

M.D., Tetsuro Fujino, M.D., Noriko Fukuda, M.D., Tomoko Lee, M.D., Kyoko Oriyama, M.D.,

Takayuki Shibano, M.D., Hideki Shimomura, M.D., Tomohiro Tachikawa, M.D., Yasuhiko

Tanaka, M.D., Naoko Taniguchi, M.D.; Korea: Jong-Hee Chae, M.D., Sun Ah Choi, M.D.,

Seong-Min Chun, M.D., Hyemi Jo, Hyuna Kim, M.D., Soo Yeon Kim, M.D., Jin Sook Lee, M.D.,

Byung Chan Lim, M.D., Hyung-Ik Shin, M.D., Woo Sung Son; Hong Kong: Sophelia Chan,

M.D., Au Cheuk Chung, M.D., Chim Stella, M.D., Chiu Kam Wah Joseph, P.T., Ph.D., Ho Chi

Page 6 of 50
Chung Alvin, M.D., Ip Jin Kun Janice, M.D., Lam Wai Man Wendy, M.D., Maggie Ng Chui-San,

P.T., Ng Yiu Ki, M.D., Tsoi Nai Shun, M.D., Wan Yuet-mei Connie, B.N., Wong Chun-Nei

Virginia, Yue Yvonne, P.T.; Taiwan: Yuh-Jyh Jong, M.D., Tai-Heng Chen, M.D., Po-Ching

Chou, M.D., Yun-Hui Chou, Hao-Wei Chung, M.D., Jong-Hau Hsu, M.D., Yun-Huei Ju, Wen-

Chen Liang, M.D., Hsiang-Hung Shih, M.D., Hui-Yi Wang, Yi-Ching Wu, Yu-Sheng Zeng, M.D.

Page 7 of 50
ADDITIONAL METHODOLOGICAL DETAILS

Study conduct

Institutional review board/independent ethics committee approval was granted to investigators

at 36 study centers worldwide; 31 centers enrolled and treated infants. Safety data were

reviewed on an ongoing basis by the sponsor’s medical monitor and by an independent data

and safety monitoring board (DSMB). A blinded endpoint adjudication committee (EAC)

reviewed the primary efficacy end point events of death and permanent ventilation. The interim

analysis results were reviewed by an independent DSMB and a joint unblinded senior

management team from Ionis Pharmaceuticals, Inc. and Biogen, who determined that the study

should be stopped and all infants transitioned to active treatment. Trial sites remained blinded to

treatment assignment after the interim analysis through the end of study.

Full eligibility criteria

The study enrolled children with infantile-onset SMA, defined as individuals diagnosed with 5q

SMA and symptom onset at younger than 6 months of age. Inclusion criteria included: signed

informed consent of parent(s) or guardian(s); a genetic diagnosis of 5q-linked spinal muscular

atrophy (SMA) due to homozygous gene deletion or compound heterozygote deletion/mutation

of survival motor neuron 1 (SMN1); two copies of the SMN2 gene; younger than 6 months of

age (180 days) at SMA symptom onset; younger than 7 months of age (210 days) at screening;

receiving adequate nutrition and hydration (with or without gastrostomy) in the opinion of the site

investigator at the time of study entry; measuring to at least the third percentile in body weight

using country-specific guidelines; adherence to the consensus statement for standard of care in

SMA for medical care guidelines; gestational age of 37 to 42 weeks; live within a 9-hour ground

travel time from a study center; ability to complete all study procedures and parent/guardian has

adequate psychosocial support.

Page 8 of 50
 Exclusion criteria included: peripheral oxygen desaturation (O2 saturation below 96%

without ventilation support) during screening; SMA symptoms within the first week of birth;

presence of an active infection requiring systemic antiviral or antibacterial treatment during

screening; history of brain or spinal cord disease that would interfere with lumbar punctures,

cerebrospinal fluid circulation, or safety assessments; presence of an implanted cerebrospinal

fluid drainage shunt or central nervous system catheter; abnormalities in hematology or clinical

chemistry parameters at screening that would prevent inclusion as assessed by the site

investigator; treatment of SMA with an investigational drug, biological agent, or device within 30

days of screening; history of gene therapy, prior antisense oligonucleotide therapy, or cell

transplantation; the parent/guardian is unable to understand a basic description of the study or

does not agree to comply with the schedule of assessments as defined by the protocol; the

infant’s caregiver does not adhere to the standard-of-care guidelines; presence of a medical

condition that would interfere with the infant’s ability to participate in the study as assessed by

the site investigator.

Secondary end points

Secondary end points were the proportion of Children’s Hospital of Philadelphia Infant Test of

Neuromuscular Disorders (CHOP INTEND) responders (≥4-point score increase from baseline

at the later of day 183, 302, or 394 assessments), overall survival rate, percentage of infants not

requiring permanent ventilation, proportion of compound muscle action potential (CMAP)

responders (peroneal CMAP amplitude increasing to or maintained at ≥1 mV versus baseline at

the later of day 183, 302, or 394 assessments), and the two subgroup analyses of time to death

or permanent ventilation in patients below the study median disease duration and time to death

or permanent ventilation in patients above the study median disease duration.

Page 9 of 50
Study amendments

Four amendments have been completed; all were submitted and approved by the ethics

committees of the study centers. Amendment 1 was completed on April 25, 2014 and finalized

the study design. Amendment 2 was completed on June 20, 2014 and added language

explaining that all primary end point events would be reviewed by a blinded central independent

adjudication committee and specified the blinding and responsibilities of personnel making

efficacy and ventilation evaluation decisions.

Amendment 3 (Japan only) was completed on September 26, 2014 and added findings

from nonclinical nusinersen studies, added the Hammersmith Infant Neurological Examination

(HINE) and motor milestones as appendices, described the safety follow-up procedure for

infants who discontinued treatment without withdrawing consent, and clarified that local

anesthesia, but not general anesthesia or sedation, could be used for lumbar puncture

procedures.

Amendment 3 (global) was completed on April 22, 2016 and added language allowing

infants who completed all study assessments to enter a long-term extension study if ENDEAR

was terminated early, added language regarding the unblinding of certain study personnel

during the interim analysis; adjusted the visit schedule for infants who experienced a treatment

delay because of an illness; changed the primary and secondary end points to increase their

interpretability should the study be terminated early; justified sample size; clarified the timing of

the interim and final analyses; updated the clinical experience section; defined the interim

efficacy set; described the end point of the interim analysis; added details regarding the primary,

secondary, and tertiary end point definitions; and added references.

Amendment 3 (Turkey) was completed on May 24, 2016 and included the changes

made in Amendment 3 (global). Amendment 4 (Japan) was completed on May 6, 2016 and

Page 10 of 50
included the changes made in Amendment 3 (global), as well as clarification that DSMB

meetings are held quarterly.

Rationale for study end points and definitions

Proportion of motor milestone responders

The HINE is a clinically relevant measure of motor function in infants with SMA and was used to

assess the achievement of motor milestones in previous studies of infants with SMA.1-3 The

eight HINE Section 2 (HINE-2)3 motor milestone categories (score range: 0-26 with higher

scores indicating greater motor function; Table S1) were assessed by a neurologist investigator

at screening, day 64 predose, day 183 predose, day 302 predose, and day 394. A modified

version of the HINE-2 that excluded voluntary grasp was used to assess motor milestone

responders in the current study. Voluntary grasp, a category in which none of the incremental

changes requires movement against gravity, is more developmentally based and was excluded

from the analysis as some infants with SMA can acquire all milestones in this category.

Additionally, a 2-point increase in the category of ability to kick was used to denote improvement

in this category because the lower extremities do not lift off the exam table while kicking

horizontally (1 point), and therefore this is not a movement against gravity that signifies a clear

increase in strength.

Event-free survival

Event-free survival, defined as time to death or permanent ventilation (tracheostomy or ≥16

hours of ventilator support per day continuously for >21 days in the absence of an acute

reversible event), provides information on the morbidity associated with SMA and accounts for

the effects of supportive care on survival. Chronic ventilatory support for more than 16 hours per

day for 2 to 4 weeks was deemed the cut-off point at which infants are not likely to regain

Page 11 of 50
sufficient respiratory abilities to make ventilator support unnecessary per the European

Neuromuscular Centre.4

CHOP INTEND responder

CHOP INTEND is a validated 16-item 64-point motor assessment designed specifically to

evaluate the motor skills of infants with SMA with higher score indicating greater motor skill.5,6

An increase of ≥4 points in CHOP INTEND score from baseline was chosen as the definition of

a responder for this end point because an increase of ≥4 points is generally considered to be

outside the range of test variability.6,7

Statistical analyses

Analysis populations

For the interim analyses, the analysis populations were the intent-to-treat (ITT) set, the interim

efficacy set, and the safety set, and for the final analyses, the analysis populations were the ITT

set, the efficacy set, and the safety set, as defined below (Fig. S1):

• ITT set: all infants who were randomized and received at least one dose of nusinersen

or sham procedure. Infants were analyzed in the treatment group to which they were

randomized.

o Used for event-free survival, overall survival, percentage of infants not requiring

permanent ventilation, time to death or permanent ventilation in the subgroup of

infants with disease duration below the study median, and time to death or

permanent ventilation in the subgroup of infants with disease duration above the

study median analyses.

• Interim efficacy set: infants in the ITT set who were assessed at the day 183, 302, or 394

visit and had a time difference of at least 190 days between the date of first dose and the

data cut-off date of the interim analysis (June 15, 2016).

Page 12 of 50
 o Used for the proportion of motor milestone responders in the primary end point

analysis.

• Efficacy set: infants in the ITT set who were assessed at the day 183, 302, or 394 visit

and had a time difference of at least 190 days between the date of the first dose and the

data cut-off date of the final analysis (December 16, 2016).

o Used for the proportion of CHOP INTEND responders, proportion of CMAP

responders, and proportion of motor milestone responders at the end-of-study

analysis.

• Safety set: all infants who were randomized and received at least one dose of

nusinersen or sham procedure. Infants were analyzed according to the treatment

received.

o Used for all safety analyses.

Hierarchical end point analysis

At the interim analysis, only the first primary efficacy end point (proportion of motor milestone

responders) was tested; it was expected that too few events would have occurred to evaluate

the second primary efficacy end point (event-free survival).

To control the overall type 1 error rate at 0.05 across the interim and final analyses for

the primary and secondary end points, a stage-wise hierarchical strategy using independent

alpha spending functions for primary and secondary end points was used as prespecified in the

statistical analysis plan, in which statistical significance of the first primary analysis was required

before drawing inferential conclusions about the second primary and secondary analyses.8

Since the second primary end point and secondary end points were not tested at the interim

analysis (i.e., no alpha spending), an alpha of 0.05 was used for these end points in the final

analyses. The first primary end point was tested at an alpha of 0.032 using the Lan-DeMets

linear alpha spending function assuming a 64% (78/121) information fraction at the time of

Page 13 of 50
interim analysis. The final testing of this end point was to be conducted at an alpha level

determined based on the information fraction at the end of the study. Because the first primary

end point was statistically significant at the interim analysis, it was not formally tested for

statistical significance at the final analysis. In the final analysis, the second primary endpoint

and the secondary endpoints were tested for statistical significance. If any end point was not

significant, all subsequent tests were considered exploratory and P values where presented are

denoted as nominal.

Proportion of motor milestone responders

The difference in the percentage of responders between the nusinersen and sham control

groups was compared using logistic regression, with the number of motor milestones at

baseline, age at symptom onset, and disease duration at screening as covariates. If the number

of responders was less than five in either group, Fisher’s exact test was used instead. If Fisher’s

exact test was used, the unconditional confidence interval (CI) for the difference in response

rates was provided.9

Event-free survival

The event-free survival analysis compared the time to death or permanent ventilation between

groups using the log-rank test stratified by disease duration at screening (≤12 or >12 weeks),

which was calculated based on baseline data. The null hypothesis was that nusinersen and

sham control groups have the same “survival” function. The median time to death or permanent

ventilation in each group and associated 95% CIs were estimated using the Kaplan-Meier

product-limit method. The proportion of infants with an event was estimated based on the

Kaplan-Meier curve. A hazard ratio (HR) was calculated using a Cox proportional hazards

model adjusted for each infant’s disease duration at screening (see sensitivity analyses).

Page 14 of 50
CHOP INTEND responders

The proportion of responders was compared using logistic regression (Fisher’s exact test in the

situation of <5 responders in either group).9

Survival rate

Survival rates over time were estimated from the Kaplan-Meier curve for time to death based on

the ITT set as determined by the EAC. Treatment groups were compared using the log-rank test

stratified by the disease duration at screening.

Percentage of infants not requiring permanent ventilation

In the analysis of time to permanent ventilation, death was not counted as an event, and data

for patients who died were censored at the time of death. The proportion of infants not requiring

permanent ventilation was estimated from the probability of requiring permanent ventilation from

the Kaplan-Meier curve of the time to permanent ventilation, i.e., the Kaplan-Meier product-limit

estimator. Treatment groups were compared using the log-rank test stratified by disease

duration at screening, based on the ITT set and using events determined by the EAC.

Proportion of CMAP responders

The difference in the proportion of CMAP responders between nusinersen and sham control

groups was compared using logistic regression, with baseline CMAP amplitude at the peroneal

nerve and age at symptom onset and disease duration at screening as covariates. If the number

of responders was <5 in either group, Fisher’s exact test was used. If Fisher’s exact test was

used, the unconditional CI for the difference in response rates was provided.9

Page 15 of 50
Time to death or permanent ventilation in the subgroup of infants below the study median

disease duration

Based on the ITT set, time to death or permanent ventilation in the subgroup of infants whose

disease duration at screening was below that of the study median was analyzed using the log-

rank test. Only EAC-adjudicated events were analyzed. Infants whose disease duration at

screening fell precisely at the study median were included in this subgroup. A Cox proportional

hazards model was used to estimate the HR and its 95% CI.

Time to death or permanent ventilation in the subgroup of infants above the study median

disease duration

Time to death or permanent ventilation in the subgroup of infants whose disease duration was

above that of the study median disease duration were analyzed in a similar way to that for the

subset whose disease duration at screening was below the study median.

Safety assessments

Safety end points included: assessment of adverse events (AEs) including serious AEs (SAEs)

and relatedness to study drug vital signs including resting blood pressure, pulse, respiratory

rate, temperature, and pulse oximetry awake; neurological examinations including assessment

of mental status, level of consciousness, sensory function, motor function, cranial nerve

function, and reflexes; physical examinations and weight; clinical laboratory tests including

serum chemistry, hematology, coagulation, urinalysis, and immunogenicity evaluation;

electrocardiograms, and assessment of concomitant medications and/or procedures. According

to the New England Journal of Medicine rule on rounding, if the digit immediately to the right of

the last significant digit is 5, with either no digits or all zeros after the 5, the last significant digit

is rounded up if it is odd and down if it is even.

Page 16 of 50
 Any pre-existing conditions and signs or symptoms that were present in an infant before

informed consent was obtained were recorded as Medical History and not recorded as AEs

unless the pre-existing condition worsened. The recording of nonserious AEs started at the time

of informed consent and stopped at the end of the infant’s follow-up period (defined as the

infant’s last visit). AEs were collected at each study visit and by phone call visits.

An AE was defined as any unfavorable and unintended sign, symptom, or disease

temporally associated with the study or use of nusinersen, whether or not the AE was

considered related to nusinersen. Investigators interpreted AE relatedness to study drug at the

time of assessment according to a four category classification system (not related,

unlikely/remotely related, possibly related or related), which provides some insight for

interpretation of the safety data. An AE was characterized as “related” if there was clear

evidence that the event was related to the use of the study treatment, e.g., confirmed by positive

re-challenge test. An AE was characterized as “possibly related” if it could not be explained by

other causes, such as an existing medical condition or concomitant therapy, and there was a

plausible temporal relationship between the event and drug administration. An AE was “unlikely

or remotely related” if an alternative explanation for the event was more likely or the temporal

relationship to study treatment administration and/or exposure made a causal relationship

unlikely. An AE was characterized as “not related” if it was readily explained by other causes,

such as an underlying medical condition (including SMA) or concomitant therapy, and the

investigator believed no relationship between the event and study treatment existed. For

reporting purposes, unlikely/remotely related AEs were grouped with not related AEs.

All SAEs, regardless of relationship to the study drug, were reported to the sponsor

within 24 hours of the study center’s first knowledge of the event. The recording of SAEs started

at the time of informed consent and stopped at the end of the infant’s follow-up period. All SAEs

were followed until resolution. SAEs that were not resolved at the end of the infant’s follow-up

period were evaluated by the investigator and sponsor to determine the follow-up requirement.

Page 17 of 50
An SAE was defined as any AE that meets any of the following criteria in the opinion of the site

investigator: results in death; is life-threatening; requires inpatient hospitalization or prolongation

of hospitalization; results in the incapacity or substantial disturbance in the ability to conduct

normal life functions; results in a congenital abnormality or birth defect in the individual’s

children; any other important medical event that may require medical intervention to prevent any

of the previously listed outcomes.

Standard-of-care guidelines

The following respiratory, gastrointestinal, and nutritional care guidelines were provided to

investigators.4,10

Respiratory standard of care

Shortly after diagnosis, infants should undergo respiratory assessments including evaluation of

cough effectiveness, observation of breathing, and monitoring of gas exchange, and options for

care should be discussed. Acute and chronic respiratory illness care options will be reviewed

and goals of treatment identified. Acute respiratory illness management requires increased

airway clearance and secretion management techniques using mechanical insufflation-

exsufflation or manual cough assist, increased respiratory support (including noninvasive

ventilation), nutrition and hydration management, and a low threshold to start antibiotics.

Chronic respiratory illness management requires providing methods for airway clearance,

including mechanical insufflation-exsufflation or manual cough assist and noninvasive

ventilatory support. Routine immunizations are recommended in this population. If surgery is

deemed necessary, a thorough preoperative evaluation of respiratory status will be conducted,

and postoperative management guidance will be reviewed.

Gastrointestinal and nutritional standard of care

Infants should be monitored for feeding and swallowing problems, as bulbar dysfunction is

universal in individuals with SMA due to severe weakness and can result in feeding and

Page 18 of 50
swallowing difficulties, aspiration pneumonia, and often death. Infants should also be monitored

for gastroesophageal dysmotility problems including constipation, delayed gastric emptying, and

potentially life-threatening gastroesophageal reflux. Without optimal management, growth failure

is universal in individuals with SMA who are unable to sit, whereas excessive weight gain is

more common in individuals with SMA who are able to sit and walk. Appropriate nutritional

support includes receiving feedings orally or via a feeding tube, hydration management, and

medical or surgical gastroesophageal reflux disease management.

RESULTS

Patients

Median (range) time on study was 280.0 (6-442) days in the nusinersen group and 187.0 (20-

423) in the sham control group. The shorter median time on study in the sham control group

was mainly due to the larger percentage of infants who died (nusinersen: 16% [n=13]; sham

control: 39% [n=16]).

Primary end points

Proportion of HINE-2 motor milestone responders

At the interim analysis, nusinersen-treated and sham control infants had demonstrated

increased separation in the proportion of motor milestone responders with continued treatment,

from 39% versus 7%, respectively, in those treated for 6 months, to 47% versus 0% in those

treated for 10 months, and 43% versus 0% in those treated for 13 months. Please note, the

proportion of responders in the sham control group was 7% at the 6 month assessment and 0%

in the overall analysis because infants with the opportunity (based on time of enrollment) to be

assessed at the 6 month visit were included and the later of the 6, 10, and 13 month

assessments were used for the overall analysis, with infants who died or withdrew being

Page 19 of 50
considered non-responders. The differences in the proportions of nusinersen-treated versus

sham control motor milestone responders increased in the end-of-study analysis to 41% versus

5%, respectively, in those treated for 6 months to 45% versus 0% in those treated for 10

months, and 54% versus 0% in those treated for 13 months. Responder analyses by geographic

region were consistent with results in the overall population (North America: nusinersen 43%

[15/35] versus sham control 0% [0/20]; Europe: nusinersen 56% [15/27] versus sham control

0% [0/15]; Asia-Pacific: nusinersen 64% [7/11] versus sham control 0% [0/2]). The median

disease duration at baseline was shorter in motor milestone responders (n = 37; 9.6 weeks)

versus nonresponders (n = 36; 14.9 weeks). Mean changes in HINE-2 motor milestone score

excluding voluntary grasp were similar to mean changes in total HINE-2 motor milestone score,

with nusinersen-treated infants demonstrating progressive improvements over time (Fig. S5A-

B). Additionally, when individual changes in total HINE-2 score including voluntary grasp were

evaluated, the number of nusinersen-treated infants who demonstrated improvements of ≥5

points increased to 19 of the 58 (33%), with 11 of the 18 (61%) nusinersen-treated infants who

developed the need for permanent ventilation while on study demonstrating improvements in

total HINE-2 score (Fig. S3B).

Sensitivity analyses for the primary end points

Proportion of motor milestone responders

Six sensitivity analyses were conducted; four were planned and two were performed post hoc.

In the first sensitivity analysis, infants in the interim efficacy set who were continuing in the study

but did not have assessments available for days 183, 302, and 394 were excluded. As all

infants had at least one of those assessments available, the results of this analysis are the

same as the main analysis.

Page 20 of 50
 The second sensitivity analysis used an alternative definition of response to reassess

the proportion of motor milestone responders. The first part of the definition regarding the

degree of improvement and worsening was the same, but the second part of the definition

required infants to acquire at least one milestone overall compared with baseline instead of

requiring more categories improving than worsening. Using the alternative definition, 43% of

nusinersen-treated and 0% of sham control infants were responders (P<0.001), which is

consistent with the results of the main analysis.

In the third sensitivity analysis, treatment response was defined as a 2-point increase in

motor milestone score from baseline. Using this definition, the proportion of motor milestone

responders was 37% in the nusinersen group and 0% in the sham control group (P<0.001),

which is consistent with the results of the main analysis.

In the fourth sensitivity analysis, the proportion of motor milestone responders was re-

evaluated, with infants grouped by actual treatment received rather than the treatment group to

which they were randomized. Since all infants received the treatment to which they were

randomized, the results of this analysis are the same as the main analysis.

In the two post hoc sensitivity analyses, the population analyzed was expanded to

include all infants who died or withdrew from the study, resulting in 52 nusinersen-treated

infants being compared with 30 sham control infants.

In the first post hoc sensitivity analysis, response was defined as in the main analysis.

Using this definition, the proportion of motor milestone responders was 40% in the nusinersen

group and 0% in the sham control group (P<0.001), which is consistent with the results of the

main analysis.

In the second post hoc sensitivity analysis, treatment response was defined as a 2-point

increase in motor milestone score from baseline. Using this definition in the assessment of the

modified population, the proportion of motor milestone responders was 37% in the nusinersen

Page 21 of 50
group and 0% in the sham control group (P<0.001), which is consistent with the results of the

main analysis.

Event-free survival

Seven sensitivity analyses were conducted. In the first sensitivity analysis, event-free survival

was re-evaluated, with infants grouped by actual treatment received rather than the treatment

group to which they were randomized. Since all infants received the treatment to which they

were randomized, the results of this analysis are the same as the main analysis.

In the second sensitivity analysis, nusinersen and sham control infants were compared

using a Cox proportional hazards model for time to death or permanent ventilation, adjusted for

each infant’s disease duration at screening rather than the binary stratification factor of ≤12 or

>12 weeks used in the main analysis. This analysis resulted in a HR of 0.530 (95% CI, 0.316–

0.890), indicating a 47% reduction in the risk of death or permanent ventilation with nusinersen

treatment, which is consistent with the results of the main analysis.

In the third sensitivity analysis, event-free survival was re-evaluated in the subset of

infants who received at least the first four doses of nusinersen or sham procedure and had

baseline and at least day 183 efficacy assessments with no significant protocol deviations. This

analysis resulted in a HR of 0.690 (95% CI, 0.2973–1.6028), indicating a 31% reduction in the

risk of death or permanent ventilation with nusinersen treatment, which is similar to the results

of the main analysis.

In the fourth sensitivity analysis, a test for equality of nusinersen and sham control

survival functions based on weighted difference in Kaplan-Meier curves was used to assess the

impact of the events occurring within the first 2 months of the study. The results of this analysis

were the same as the main analysis in the percentage of infants who died or required

permanent ventilation and the HR.

Page 22 of 50
 In the fifth sensitivity analysis, infants who had been previously classified as on

permanent ventilation, but who were found at the end of study to be using a ventilation for less

than 16 hours per day, were reclassified as not being on permanent ventilation. This analysis

resulted in a HR of 0.533 (95% CI, 0.3145–0.9026), indicating a 47% reduction in the risk of

death or permanent ventilation with nusinersen treatment, which is consistent with the results of

the main analysis.

In the sixth sensitivity analysis, the definition of event-free survival was modified to

disregard acute reversible events. The results of this analysis were the same as the main

analysis in the percentage of infants who died or required permanent ventilation.

For the seventh sensitivity analysis, greater emphasis was given to events that occurred

later in the study compared with those occurring early in the study, as the between-group

difference in survival time could have increased over time owing to the pharmacological

properties of nusinersen. The results of this analysis were the same as the main analysis in the

percentage of infants who died or required permanent ventilation and the HR.

Secondary end points

Proportion of CHOP INTEND responders

Most nusinersen-treated infants demonstrated improvements in CHOP INTEND score from

baseline; 71% demonstrated improvements of ≥4 points, while only one sham control infant

demonstrated any improvement >0 points (Fig. S7). Additionally, 15 of the 18 (83%) nusinersen-

treated infants who developed the need for permanent ventilation while on study still

demonstrated improvement in CHOP INTEND score.

Proportion of CMAP responders

Thirty-six percent of nusinersen-treated versus 5% of sham control infants were peroneal CMAP

responders (nominal P<0.001). Overall, 37% of nusinersen-treated and 0% of sham control

Page 23 of 50
infants demonstrated a ≥0.5 mV improvement in CMAP peroneal amplitude from baseline, and

4% of nusinersen-treated versus 3% of sham control infants demonstrated ≥0.5 mV worsening

(Fig. S8). At the 6-month, 10-month, and 13-month assessments, differences in the percentages

of nusinersen-treated versus sham control CMAP responders were 23% versus 3%, 35%

versus 4%, and 41% versus 10%, respectively. At the end of study, mean CMAP ulnar

amplitude had increased by 0.354 mV from baseline in nusinersen-treated infants and had

decreased by 0.187 mV in sham control infants.

Time to death or permanent ventilation in the subgroup of infants below and above the study

median disease duration

In the subgroup of infants below the study median disease duration of 13.1 weeks, 23% of

nusinersen-treated versus 67% of sham control infants died or required permanent ventilation

(HR, 0.24; nominal P<0.001; Fig. S6A). The risk of death or permanent ventilation was 76%

lower in nusinersen-treated infants versus sham control infants in this subgroup, and the median

time to death or permanent ventilation was 25.4 weeks in the sham control infants and was not

reached in nusinersen-treated infants. Among infants above the study median disease duration,

there was no significant difference in the proportion of infants who died or required permanent

ventilation between groups (nusinersen, 54%; sham control, 70%; HR, 0.84; nominal P=0.40;

Fig. S6B).

Safety results

The majority of AEs were deemed unlikely/remotely or not related to study treatment and were

more likely or readily explained by another cause such as SMA disease or concomitant therapy

for another identified disorder. Because of the way AEs were collected in this study, without

further sub-classification of these unrelated events, it was not possible to determine objectively

which were definitively due to SMA disease. This is an inherent limitation of the design of the

Page 24 of 50
safety reporting in this study. Of all reported AEs, none was determined to be treatment related

in either treatment group. Possibly related events were reported in 9 (11%) nusinersen-treated

(pyrexia, n=2; body temperature decreased, body temperature increased, tachycardia, naevus

anaemicus, cellulitis, post procedural swelling, nystagmus, suspected vasculitis, n=1 each) and

6 (15%) sham control infants (pyrexia, n=2; pain, diarrhea, vomiting, rash, n=1 each).

All SAEs were deemed unrelated to study drug by the site investigators and sponsor.

Upon medical review by the site investigator and sponsor, the types of events leading to death

in participants in this study were considered consistent with direct or indirect causes of death

observed in the context of infantile-onset SMA.

While vomiting occurred with similar frequency overall (nusinersen, 18% vs. sham

control, 20%), more nusinersen-treated (5%) than sham control (0%) infants were reported to

have vomited within 72 hours following dosing (Table S3). Based on the timing of these

episodes and the known relationship between vomiting and lumbar puncture (LP),11 we

speculate that they are due to the dosing procedure.

At baseline, mean platelet counts were similar between groups. A larger range in values

(lower minimums and higher maximums) was observed in the nusinersen group than sham

control group at baseline and at all but one (day 302) time point thereafter. No sustained

thrombocytopenias or bleeding events associated with thrombocytopenia were observed. The

incidence of shifts from normal to low creatinine was similar between groups, and no infants had

shifts from normal to high creatinine. Low creatinine is typical in infants with SMA Type I as a

result of reduced muscle mass. The incidence of shifts from normal to any elevation in urine

protein was higher in the nusinersen group versus sham control (45% vs. 26%); however, most

elevations in both groups were trace values. The incidence of infants with an increase in urine

protein of potential clinical significance (a shift of ≥1 from baseline) was lower among

nusinersen-treated versus sham control infants (11% vs. 19%).

Page 25 of 50
SUPPLEMENTARY FIGURES

Figure S1. Analysis Populations.

ITT denotes intent-to-treat.

Page 26 of 50
Figure S2. Patient Disposition (CONSORT Diagram).

Reasons for screening failure are listed below. Note several infants who failed screening had

more than one excluding condition: hypoxemia (n = 6); body weight less than the third percentile

for age using appropriate country-specific guidelines (n = 6); SMN2 copy number not 2 (n = 3);

withdrawal of consent before randomization (n = 3); prior injury (e.g., upper or lower limb

fracture) or surgical procedure that impacts the subject's ability to perform any of the outcome

measure testing (n = 2); ongoing medical condition that according to the site investigator would

interfere with the conduct and assessments of the study (n = 2); gestational age of <37 or >42

weeks (n = 2); at screening, clinically significant abnormalities in hematology or clinical

Page 27 of 50
chemistry parameters, as assessed by the site investigator, that would render the subject

unsuitable for inclusion (n = 2); history of brain or spinal cord disease (n = 1); presence of an

untreated or inadequately treated active infection requiring systemic antiviral or antimicrobial

therapy at any time during the screening period (n = 1); severe respiratory distress (n = 1);

worsening of health status (n = 1); respiratory insufficiency (n = 1); at study entry, receiving

inadequate nutrition and/or hydration (with or without gastrostomy) in the opinion of the site

investigator (n = 1). Reasons for voluntary withdrawal included hospitalization for dyspnea and

withdrawal of consent (n=1) and unknown (n=1) in the nusinersen group and poor health

condition (n=1) in the sham control group.

Page 28 of 50
Figure S3A. Improvement in HINE-2 motor milestone score
Changes in motor milestone scores excluding voluntary grasp from baseline to later of day 183,

302, and 394 study visit (last study visit noted for each infant in bottom row below graph) in

surviving infants with opportunity for at least a 6-month assessment at the end-of-study

analysis. Motor milestones were assessed using modified Section 2 of the HINE (HINE-2). Out

of the 110 infants in the final efficacy set, 29 died (13 for nusinersen and 16 for control) and

three withdrew for a reason other than death (two for nusinersen and one for control) and

therefore were not included in this analysis. In total, 78 individuals are ordered from greatest

increase to greatest decrease in motor milestones (left to right). The sham infant demonstrating

a 1-point improvement did so in the ability to kick category and was therefore not a responder.

Shortest bars at the 0 line indicate 0 value. Open diamonds indicate baseline HINE-2 scores.

Closed diamonds indicate end-of-study HINE-2 scores. Triangles indicate infants with disease

Page 29 of 50
duration ≤12 weeks at screening. Stars indicate infants who developed the need for permanent

ventilation during the course of the study. HINE denotes Hammersmith Infant Neurological

Examination.

Page 30 of 50
Figure S3B. Improvement in Total HINE-2 Motor Milestone Score
The total change in motor milestone scores including all 8 assessments from baseline to later of

day 183, 302, and 394 study visit (last study visit noted for each infant in bottom row below

graph) in surviving infants with opportunity for at least a 6-month assessment at the end-of-

study analysis are shown. Motor milestones were assessed using Section 2 of the HINE (HINE-

2). Out of the 110 infants in the final efficacy set, 29 died (13 for nusinersen and 16 for control)

and three withdrew for a reason other than death (two for nusinersen and one for control) and

therefore were not included in this analysis. In total, 78 individuals are ordered from greatest

increase to greatest decrease in motor milestones (left to right). Shortest bars at the 0 line

indicate 0 value. Open diamonds indicate baseline HINE-2 scores. Closed diamonds indicate

Page 31 of 50
end-of-study HINE-2 scores. Triangles indicate infants with disease duration ≤12 weeks at

screening. Stars indicate infants who developed the need for permanent ventilation during the

course of the study. HINE denotes Hammersmith Infant Neurological Examination.

Page 32 of 50
Figure S4. HINE-2 Motor Milestones - Quality of Motor Responses
The HINE-2 motor milestone achievements of infants at the later of days 183, 302, and 394 are

shown. Infants with opportunity for at least a 6-month assessment were included. All infants who

achieved the reported milestones were alive at the end of study. aFull head control was defined

as all the time upright (HINE-2 score = 2). bIndependent sitting includes HINE-2 score

categories: stable sit (5%) and pivots (rotates) (3%). cStanding includes HINE-2 score

categories: stands with support (1%) and stands unaided (0). HINE denotes Hammersmith

Infant Neurological Examination.

Page 33 of 50
Figure S5A. Change in HINE-2 Motor Milestones Excluding Voluntary Grasp over Time
Mean changes from baseline in HINE-2 total motor milestone scores excluding the voluntary

grasp item, obtained at the day 64, 183, 302, and 394 study visits among all infants in the

efficacy set are shown. HINE denotes Hammersmith Infant Neurological Examination; SEM,

standard error of the mean.

Page 34 of 50
Figure S5B. Change in HINE-2 Total Motor Milestones over Time
The mean changes from baseline in HINE-2 total motor milestone scores including all 8

assessments at the day 64, 183, 302, and 394 study visits among all infants in the efficacy set

are shown. Nusinersen-treated infants demonstrated an average gain of 5.92 points by day 394

without plateau, while sham control infants demonstrated an overall decrease of 0.36 points vs.

baseline. HINE denotes Hammersmith Infant Neurological Examination; SEM, standard error of

the mean.

Page 35 of 50
Figure S6A. Kaplan-Meier Plot of Time to Death or Permanent Ventilation in the Subgroup

of Infants below the Median Disease Duration at Screening.

A HR <1 indicates lower risk of event for the nusinersen group. The HR is calculated based on

Cox regression adjusted for each infant’s disease duration at screening. HR denotes hazard

ratio.

Page 36 of 50
Figure S6B. Kaplan-Meier Plot of Time to Death or Permanent Ventilation in the Subgroup

of Infants above the Median Disease Duration at Screening.

A HR <1 indicates lower risk of event for the nusinersen group. The HR is calculated based on

Cox regression adjusted for each infant’s disease duration at screening. HR denotes hazard

ratio.

Page 37 of 50
Figure S7. CHOP INTEND Motor Function Change from Baseline Scores at End of Study.

Infants with opportunity for at least a 6-month (day 183) assessment were included in the

analysis; last available assessment of 6-month (day 183), 10-month (day 302), or 13-month

(day 394) was used. Shortest bars indicate zero value. Of the 110 infants in the efficacy set, 29

died (nusinersen, n = 13; sham control, n = 16) and three withdrew for a reason other than

death (nusinersen, n = 2; sham control, n = 1) and were not included in this analysis. Light

diamonds indicate baseline CHOP INTEND scores. Dark diamonds indicate end-of-study CHOP

INTEND scores. Triangles indicate infants with disease duration ≤12 weeks at screening. Stars

Page 38 of 50
indicate infants who developed the need for permanent ventilation during the course of the

study. CHOP INTEND denotes Children’s Hospital of Philadelphia Infant Test of Neuromuscular

Disorders.

Page 39 of 50
Figure S8. Peroneal CMAP Amplitude at End of Study.

Infants with opportunity for at least a 6-month (day 183) assessment were included in the

analysis; last available assessment of 6-month (day 183), 10-month (day 302), or 13-month

(day 394) was used. CMAP denotes compound muscle action potential.

Page 40 of 50
SUPPLEMENTARY TABLES

Table S1. Baseline HINE-2 Motor Milestones.

Nusinersen Sham Control

HINE-2 Motor Milestones — No. (%) (n = 80) (n = 41)

Head control

Unable to maintain head upright 66 (82) 32 (78)

Wobbles 14 (18) 7 (17)

All the time maintained upright 0 2 (5)

Sitting

Cannot sit 77 (96) 40 (98)

Sits with support at hips 2 (2) 1 (2)

Props 1 (1) 0

Stable sit 0 0

Pivots (rotates) 0 0

Voluntary grasp

No grasp 26 (32) 9 (22)

Uses whole hand 50 (62) 30 (73)

Index finger and thumb but immature grasp 3 (4) 1 (2)

Pincer grasp 1 (1) 1 (2)

Ability to kick

No kicking 56 (70) 32 (78)

Kick horizontally, legs do not lift 23 (29) 8 (20)

Upward (vertically) 1 (1) 0

Touches leg 0 1 (2)

Page 41 of 50
 Touches toes 0 0

Rolling

No rolling 79 (99) 36 (88)

Rolling to side 1 (1) 5 (12)

Prone to supine 0 0

Supine to prone 0 0

Crawling

Does not lift head 80 (100) 41 (100)

On elbow 0 0

On outstretched hand 0 0

Crawling flat on abdomen 0 0

Crawling on hands and knees 0 0

Standing

Does not support weight 80 (100) 41 (100)

Supports weight 0 0

Stands with support 0 0

Stands unaided 0 0

Walking

No walking 80 (100) 41 (100)

Bouncing 0 0

Cruising (walks holding on) 0 0

Walking independently 0 0

HINE-2 denotes Section 2 of the Hammersmith Infant Neurological Examination. In accordance

with journal policy, percentages ending in exactly .5 have been rounded up to the higher integer

if even and down to the lower integer if odd.

Page 42 of 50
Table S2. Adverse Events Leading to Treatment Discontinuation.
MedDRA System Organ Class and Nusinersen Sham Control

Preferred Term — No. (%) (n = 80) (n = 41)

Infants with an event leading to discontinuation of study 13 (16) 16 (39)

drug

Respiratory, thoracic, and mediastinal disorders 7 (9) 12 (29)

Respiratory failure 4 (5) 8 (20)

Acute respiratory failure 1 (1) 1 (2)

Respiratory arrest 1 (1) 0

Respiratory distress 1 (1) 2 (5)

Aspiration 0 1 (2)

Cardiac disorders 2 (2) 3 (7)

Cardiorespiratory arrest 2 (2) 3 (7)

General disorders and administration site conditions 2 (2) 1 (2)

Death 1 (1) 1 (2)

General physical health deterioration 1 (1) 0

Nervous system disorders 2 (2) 0

Brain injury 1 (1) 0

Hypoxic-ischemic encephalopathy 1 (1) 0

An infant was counted only once within each system organ class and preferred term. Preferred

terms are presented by decreasing incidence in the nusinersen column within each system

organ class. MedDRA denotes Medical Dictionary for Regulatory Activities. In accordance with

journal policy, percentages ending in exactly .5 have been rounded up to the higher integer if

even and down to the lower integer if odd.

Page 43 of 50
Table S3. Adverse Events Occurring within 72 Hours of Nusinersen or Sham Control
Treatment.
MedDRA System Organ Class and Nusinersen Sham Control

Preferred Term — No. (%) (n = 80) (n = 41)

Infants with an event 51 (64) 24 (59)

Infections and infestations 20 (25) 4 (10)

Pneumonia 5 (6) 1 (2)

Upper respiratory tract infection 4 (5) 1 (2)

Nasopharyngitis 3 (4) 0

Oral candidiasis 2 (2) 0

Bronchitis viral 1 (1) 0

Conjunctivitis 1 (1) 0

Impetigo 1 (1) 0

Lung infection 1 (1) 0

Respiratory tract infection viral 1 (1) 0

Rhinitis 1 (1) 0

Urinary tract infection 1 (1) 0

Viral upper respiratory tract infection 1 (1) 0

Bacterial tracheitis 0 1 (2)

Otitis media 0 1 (2)

Respiratory, thoracic, and mediastinal disorders 18 (22) 10 (24)

Atelectasis 5 (6) 0

Acute respiratory failure 3 (4) 0

Hypoxia 3 (4) 1 (2)

Respiratory failure 3 (4) 1 (2)

Choking 1 (1) 0

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 Chronic respiratory failure 1 (1) 0

Hypoventilation 1 (1) 0

Nasal congestion 1 (1) 0

Pneumonia aspiration 1 (1) 1 (2)

Respiratory distress 1 (1) 0

Upper respiratory tract congestion 1 (1) 0

Apnea 0 1 (2)

Apparent life-threatening event 0 1 (2)

Bronchial secretion retention 0 2 (5)

Cough 0 4 (10)

Rhinorrhea 0 1 (2)

Sleep apnea syndrome 0 1 (2)

Sputum discolored 0 1 (2)

Gastrointestinal disorders 14 (18) 5 (12)

Constipation 4 (5) 1 (2)

Vomiting 4 (5) 0

Dysphagia 2 (2) 0

Gastroesophageal reflux disease 2 (2) 2 (5)

Aphthous ulcer 1 (1) 0

Salivary hypersecretion 1 (1) 0

Teething 1 (1) 1 (2)

Diarrhea 0 1 (2)

Stomatitis 0 1 (2)

General disorders and administration site conditions 9 (11) 9 (22)

Pyrexia 7 (9) 4 (10)

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 Crying 1 (1) 0

Nodule 1 (1) 0

Application site rash 0 1 (2)

Death 0 1 (2)

Injection site hematoma 0 1 (2)

Pain 0 2 (5)

Vessel puncture site bruise 0 1 (2)

Injury, poisoning, and procedural complications 7 (9) 2 (5)

Agitation postoperative 1 (1) 0

Contusion 1 (1) 0

Femur fracture 1 (1) 0

Postprocedural swelling 1 (1) 0

Procedural pain 1 (1) 0

Procedural site reaction 1 (1) 0

Stoma site irritation 1 (1) 0

Feeding tube complication 0 1 (2)

Head injury 0 1 (2)

Investigations 7 (9) 4 (10)

Oxygen saturation decreased 2 (2) 2 (5)

Blood chloride decreased 1 (1) 0

Blood potassium decreased 1 (1) 0

Blood sodium decreased 1 (1) 0

Body temperature decreased 1 (1) 0

Body temperature increased 1 (1) 0

C-reactive protein increased 1 (1) 0

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 Staphylococcus test positive 1 (1) 0

Respiratory rate increased 0 1 (1)

Weight decreased 0 1 (1)

Cardiac disorders 5 (6) 5 (12)

Tachycardia 3 (4) 3 (7)

Bradycardia 1 (1) 1 (2)

Cyanosis 1 (1) 1 (2)

Ventricular tachycardia 1 (1) 0

Skin and subcutaneous tissue disorders 5 (6) 2 (5)

Dermatitis contact 1 (1) 0

Dermatitis diaper 1 (1) 0

Ecchymosis 1 (1) 0

Rash 1 (1) 1 (2)

Rash papular 1 (1) 0

Hyperhidrosis 0 1 (2)

Psychiatric disorders 4 (5) 0

Irritability 2 (2) 0

Mood swings 1 (1) 0

Restlessness 1 (1) 0

Metabolism and nutrition disorders 3 (4) 2 (5)

Feeding disorder of infancy or early childhood 1 (1) 1 (2)

Feeding intolerance 1 (1) 0

Weight gain poor 1 (1) 0

Dehydration 0 1 (2)

Failure to thrive 0 1 (2)

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Musculoskeletal and connective tissue disorders 2 (2) 2 (5)

Back pain 1 (1) 0

Scoliosis 1 (1) 1 (2)

Joint contracture 0 1 (2)

Eye disorders 1 (1) 0

Dry eye 1 (1) 0

Nervous system disorders 1 (1) 0

Nystagmus 1 (1) 0

Renal and urinary disorders 1 (1) 0

Urinary retention 1 (1) 0

Immune system disorders 0 1 (2)

Hypersensitivity 0 1 (2)

An infant was counted only once within each system organ class and preferred term. Preferred

terms are presented by decreasing incidence in the nusinersen column within each system

organ class. MedDRA denotes Medical Dictionary for Regulatory Activities. In accordance with

journal policy, percentages ending in exactly .5 have been rounded up to the higher integer if

even and down to the lower integer if odd.

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Table S4. Adverse Events Occurring at a ≥5% Higher Frequency in Nusinersen-Treated

Versus Sham Control Infants.

Nusinersen Sham Control

MedDRA Preferred Term — No. (%) (n = 80) (n = 41)

Constipation 28 (35) 9 (22)

Upper respiratory tract infection 24 (30) 9 (22)

Pneumonia 23 (29) 7 (17)

Nasopharyngitis 15 (19) 4 (10)

Teething 14 (18) 3 (7)

Respiratory tract infection 9 (11) 2 (5)

Urinary tract infection 7 (9) 0

Bronchitis 6 (8) 1 (2)

Upper respiratory tract congestion 6 (8) 1 (2)

Bronchitis viral 5 (6) 0

Influenza 5 (6) 0

An infant was counted only once within each preferred term. Preferred terms are presented by

decreasing incidence in the nusinersen column. MedDRA denotes Medical Dictionary for

Regulatory Activities. In accordance with journal policy, percentages ending in exactly .5 have

been rounded up to the higher integer if even and down to the lower integer if odd.

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REFERENCES

1. Finkel RS, Chiriboga CA, Vajsar J, et al. Treatment of infantile-onset spinal muscular
atrophy with nusinersen: a phase 2, open-label, dose-escalation study. Lancet
2016;388:3017-26.
2. De Sanctis R, Coratti G, Pasternak A, et al. Developmental milestones in type I spinal
muscular atrophy. Neuromuscul Disord 2016;26:754-9.
3. Bishop KM, Montes J, Finkel RS. Motor milestone assessment of infants with spinal
muscular atrophy using the hammersmith infant neurological Exam-Part 2: Experience
from a nusinersen clinical study. Muscle Nerve 2017:May 26. doi: 10.1002/mus.25705.
[Epub ahead of print].
4. Bertini E, Burghes A, Bushby K, et al. 134th ENMC International Workshop: Outcome
Measures and Treatment of Spinal Muscular Atrophy, 11-13 February 2005, Naarden,
The Netherlands. Neuromuscul Disord 2005;15:802-16.
5. Glanzman AM, Mazzone E, Main M, et al. The Children's Hospital of Philadelphia Infant
Test of Neuromuscular Disorders (CHOP INTEND): test development and reliability.
Neuromuscul Disord 2010;20:155-61.
6. Glanzman AM, McDermott MP, Montes J, et al. Validation of the Children's Hospital of
Philadelphia Infant Test of Neuromuscular Disorders (CHOP INTEND). Pediatr Phys
Ther 2011;23:322-6.
7. Finkel RS, McDermott MP, Kaufmann P, et al. Observational study of spinal muscular
atrophy type I and implications for clinical trials. Neurology 2014;83:810-7.
8. Glimm E, Maurer W, Bretz F. Hierarchical testing of multiple endpoints in group-
sequential trials. Stat Med 2010;29:219-28.
9. Santner TJ, Snell MK. Small-Sample Confidence Intervals for P1-P2 and P1/P2 in 2x2
Contingency Tables. Journal of the American Statistical Association 1980;75:386-94.
10. Wang CH, Finkel RS, Bertini ES, et al. Consensus statement for standard of care in
spinal muscular atrophy. J Child Neurol 2007;22:1027-49.
11. Morgenlander JC. Lumbar puncture and CSF examination. Answers to three commonly
asked questions. Postgrad Med 1994;95:125-8, 31.

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