WO2014080282A2

WO2014080282A2 - One-and two-point titration methods to determine daily treatment regimens to treat hypogonadism or male testosterone deficiency with an intranasal testosterone bio-adhesive gel, and primary and secondary efficacy and safety endpoints

Info

Publication number: WO2014080282A2
Application number: PCT/IB2013/002920
Authority: WO
Inventors: Paul Jose Pierre Marie Maes; Wayne KREPPNER; Jodi Beth DICKSTEIN; Natalia TKACHENKO
Original assignee: Trimel Biopharma Srl
Priority date: 2012-11-22
Filing date: 2013-11-22
Publication date: 2014-05-30
Also published as: WO2014080282A3

Abstract

The present invention relates to 4.0% and 4.5% intranasal testosterone bio- adhesive gels for providing sustained intranasal delivery of testosterone to a male and intranasal treatment methods for safely providing sustained release testosterone to treat males with hypogonadism. In particular, the present invention relates to improved testosterone replacement therapy (TRT) and sustained intranasal testosterone gel formulations for treating male hypogonadism. The 4.0% and 4.5% intranasal testosterone bio-adhesive gels are effective, are statistically significant regarding improvement in effect on erectile function and mood, provide for favourable trends for effect on body composition and bone mineral density and have safety measures after 360 days of treatment that are consistent with currently marketed topical testosterone products. The present invention also relates to a system for dispensing intranasally a precise dosage amount of such gels in smaller volumes at an optimal anatomical location within each nostril of the male, so that an effective amount of testosterone is deposited within each nostril at the optimal anatomical location for TRT, including to effectively treat testosterone deficiency in male subjects, such as hypogonadism. The present invention is also concerned with a novel titration method to determine the appropriate daily treatment regimen, i.e., a BID or TID treatment regimen, to administer the intranasal gels of the present invention to treat hypogonadism or TRT. The present invention is also concerned with novel titrations method to determine the appropriate daily treatment regimen, i.e., a QD, BID or TID treatment regimen, to administer the intranasal gels of the present invention to treat hypogonadism or TRT in males. In particular, the present testosterone therapy remains effective for treating hypogonadism when an allergic rhinitis event occurs in the male or when the male subject uses a topical nasal vasoconstrictor or a topical intranasal decongestant during the hypogonadism treatment. Further, the present invention relates to a novel method of preventing the occurrence of an allergic rhinitis event in a male, who is undergoing a hypogonadism treatment with an intranasal testosterone bio-adhesive gel formulation. In certain embodiments, the intranasal testosterone bio-adhesive gel formulation according to the invention comprises 4.0% and 4.5% testosterone.

Description

Attorney Docket No. 92745WO(307876)

Date of Deposit: November 22, 2013

ONE- AND TWO-POINT TITRATION METHODS TO DETERMINE DAILY

TREATMENT REGIMENS TO TREAT HYPOGONADISM OR MALE TESTOSTERONE DEFICIENCY WITH AN INTRANASAL TESTOSTERONE BIO- ADHESIVE GEL, AND PRIMARY AND SECONDARY EFFICACY AND SAFETY

ENDPOINTS

Related Applications

This application claims the benefit of and priority to U.S. Provisional Patent Application Nos. 61 /729,406, filed November 22, 2012, 61 /802,297, filed March 15, 2013, 61 /802,354, filed March 15, 2013, 61 /802,388 , filed March 16, 2013, 61 /802,737, filed March 17, 2013, 61 /802,739, filed March 17, 2013, 61 /802,724, filed March 17, 2013, and 61 /802,727, filed March 17, 2013. The entire contents of each of the foregoing applications are hereby incorporated by reference in their entireties.

Field of the Invention

The present invention relates to 4.0% and 4.5% intranasal testosterone bio- adhesive gels for providing sustained intranasal delivery of testosterone to a male and intranasal treatment methods for safely providing sustained release testosterone to treat males with hypogonadism. In particular, the present invention relates to improved testosterone replacement therapy (TRT) and sustained intranasal testosterone gel formulations for treating male hypogonadism. The 4.0% and 4.5% intranasal

testosterone bio-adhesive gels are effective, are statistically significant regarding improvement in effect on erectile function and mood, provide for favourable trends for effect on body composition and bone mineral density and have safety measures after 360 days of treatment that are consistent with currently marketed topical testosterone products. The present invention also relates to a system for dispensing intranasally a precise dosage amount of such gels in smaller volumes at an optimal anatomical location within each nostril of the male, so that an effective amount of testosterone is deposited within each nostril at the optimal anatomical location for TRT, including to

AM 25563714. l1 effectively treat testosterone deficiency in male subjects, such as hypogonadism. The present invention is also concerned with a novel titration method to determine the appropriate daily treatment regimen, i.e., a BID or TID treatment regimen, to administer the intranasal gels of the present invention to treat hypogonadism or TRT. The present invention is also concerned with novel titrations method to determine the appropriate daily treatment regimen, i.e., a QD, BID or TID treatment regimen, to administer the intranasal gels of the present invention to treat hypogonadism or TRT in males. In particular, the present testosterone therapy remains effective for treating hypogonadism when an allergic rhinitis event occurs in the male or when the male subject uses a topical nasal vasoconstrictor or a topical intranasal decongestant during the

hypogonadism treatment. Further, the present invention relates to a novel method of preventing the occurrence of an allergic rhinitis event in a male, who is undergoing a hypogonadism treatment with an intranasal testosterone bio-adhesive gel formulation. In certain embodiments, the intranasal testosterone bio-adhesive gel formulation according to the invention comprises 4.0% and 4.5% testosterone.

Background

Androgens are a group of C19 steroids that cause masculinization of the genital tract and the development and maintenance of male secondary sex characteristics.

They also contribute to muscle bulk, bone mass, libido, and sexual performance in men.

Testosterone is the main androgen secreted by the Leydig cells of the testes, and its production increases during puberty. See. e.g., Tietz: Textbook of Clinical Chemistry and Molecular Diagnostics, 4th edition, Editors: Burtis CA, Ashwood ER, and Bruns DE

(2006.). Androgen deficiency is now recognized to be a relatively common condition in the aging male. See, e.g., 2. Wang C, Swerdloff R.S. : Androgen replacement therapy.

Ann Med, 29: 365-370 (1997); Matsumoto A.M. : Andropause: clinical implications of the decline in serum Testosterone levels with aging in men. J Gerontol A Med Sci, 57: M76-

M99 (2002); and Haren Mtet al. : Andropause: a quality-of-life issue in older males. Med

Clin North Am, 90: 1005-1023 (2006). Testosterone hormone therapy is indicated for replacement therapy and males having conditions associated with a deficiency or absence of endogenous testosterone, such as to treat male hypogonadism. This may cause sexual dysfunction, muscle loss, increase in fat, infertility, decreased beard and body hair and other conditions.

Hypogonadism is defined as testosterone deficiency. Male hypogonadism may be congenital or it may develop later in life due to, e.g., injury, trauma, surgery, infection, disease, drugs and/or aging. Generally, child-onset male hypogonadism has minimal consequences and generally remains undiagnosed until puberty is delayed. The symptoms or signs associated with child-onset male hypogonadism, if left untreated, include poor muscle and body hair development, including poor facial, pubic, chest and axillary hair growth, a high-pitched voice, excessive growth of arms and legs in relation to the trunk of the body, a small scrotum, abnormal phallic and testicular growth, and other growth problems, e.g., growth and maturation of the prostate and seminal vesicles. In adult-onset male hypogonadism, the symptoms may include a deficiency in spermatozoa production, osteoporosis, muscle loss or alterations in body musculature, fat distribution, fatigue and loss of energy, weakness, anemia, mood swings, e.g., depression and anger, a decline in cognitive skills, including memory loss and inability to concentrate, sleep disturbances, gynecomastia, a reduction in both beard and body hair, impotence, erectile dysfunction; a decrease in ejaculate volume, infertility, a decrease in sexual desire (loss of libido), and a regression of other secondary sexual characteristics.

Male hypogonadism is designated as either primary hypogonadism, which is due to a disorder of the testes, or central or secondary hypogonadism that results from a disorder in the hypothalamic-pituitary axis. In primary hypogonadism, there is a lack of testosterone production in the testes because the testes do not respond to FSH and LH.

As a result, elevations in both hormones, FSH and LH, are observed in primary male hypogonadism. The most common cause of primary male hypogonadism is Klinefelter's syndrome. Other congenital causes of primary gonadism may include, e.g., Bilateral

Congenital Anorchia, Leydig Cell Hypoplasia (Leydig Cell Aplasia), undescended testicles (Cryptorchidism), Noonan syndrome, Myotonic Dystrophy (MD) and defects in testosterone enzymatic synthesis. Causes of adult-onset primary hypogonadism may include aging, autoimmune disorders, surgery, chemotherapy, radiation, infection, disease, surgery, alcoholism, drug therapy and recreational drug use. In secondary or central hypogonadism, insufficient amounts of FSH and LH are produced in the hypothalamus. Genital causes of secondary or central hypogonadism include, e.g., Kallmann syndrome, Prader-Willi syndrome (PWS), Dandy-Walker malformation, Isolated luteinizing hormone (LH) deficiency and Idiopathic

hypogonadotropic hypogonadism (IHH). Causes of adult-onset secondary or central hypogonadism may include aging, disease, infections, tumors, bleeding, nutritional deficiencies, alcoholism, cirrhosis of the liver, obesity, weight loss, Cushing's syndrome, hypopituitarism, hyperprolactinemia, hemochromatosis, surgery, trauma, drug therapy, and recreational drug use.

In primary male hypogonadism, the levels observed for testosterone are below normal but are generally above normal for FSH and LH. In secondary or central male hypogonadism, the levels observed for testosterone, FSH and LH are below normal. Thus, diagnosis of primary or secondary male hypogonadism is typically confirmed by hormone levels and, on testing, blood levels of testosterone in both primary and secondary hypogonadism are characterized as low and should be replaced. Treatment generally varies with etiology, but typically includes testosterone replacement therapy. In the United States, testosterone may be administered as an intramuscular injection, a transdermal patch or a transdermal gel. In other countries, oral preparations of testosterone may be available.

In view of the fact that millions of men in the United States, as well as through out the world, suffer from hypogonadism, there is a real and immediate need for an effective and convenient medical therapy that can treat this disorder, so that the quality of life of these individuals can be improved. One therapeutic goal of one such therapy to solve this immediate need might be to restore testosterone levels in men to young adulthood levels in hopes to alleviate the symptoms generally associated with hypogonadism due possibly to testosterone deficiency.

Summary of the Invention

The present invention overcomes the limitations and disadvantages associated with current testosterone replacement therapy (TRT) and, in particular, current testosterone therapy to treat hypogonadism in male subjects through the discovery of novel per nasal testosterone gels and methods of use fort TRT and to treat hypogonadism. Particularly, the present invention overcomes the limitations and disadvantages of currently available options for administration of testosterone through the discovery of novel and improved dosage strength testosterone gel formulations specifically designed for intranasal administration to deliver therapeutically effective amounts of testosterone to treat males who suffer from and/or have been diagnosed with testosterone deficiency, including hypogonadism.

The present invention further offers effective methods for treating hypogonadism in a male with allergic rhinitis. In particular, the methods involve delivering a

therapeutically effective amount of testosterone to the male through an intranasal administration of an intranasal testosterone bio-adhesive gel formulation. The current testosterone therapy remains effective if an allergic rhinitis event occurs in the male during the treatment. In addition, any topical nasal vasoconstrictor or topical intranasal decongestant used by the male during the hypogonadism treatment does not interfere with the efficacy of the testosterone therapy of the invention. Further, the present invention offers advantageous effects in a hypogonadism treatment, including, such as, preventing occurrence of an allergic rhinitis event in a male undergoing a hypogonadism treatment with an intranasal testosterone biadhesive gel of the invention.

The term "a therapeutically effective amount" means an amount of testosterone sufficient to induce a therapeutic or prophylactic effect for use in testosterone

replacement or supplemental therapy to treat male testosterone deficiency, namely, hypogonadism in males.

Thus, generally speaking, the present invention provides for new and improved, substantially less-irritating, novel dosage strength testosterone gel formulations are formulated with testosterone in amounts of between about 4% and 8.0% by weight, and preferably between about 4.0% and about 4.5% by weight, and more preferably about

4.0%, about 4.5% and 8.0% by weight, for nasal administration to deliver a

therapeutically of an effective amount of testosterone to effectively treat males who are diagnosed with testosterone deficiency, including hypogonadism. The 4.0% and 4.5% intranasal testosterone bio-adhesive gels of the prsent invention are effective, are statistically significant regarding improvement in effect on erectile function and mood, provide for favourable trends for effect on body composition and bone mineral density and have safety measures after 360 days of treatment that are consistent with currently marketed topical testosterone products.

Also generally speaking, the present invention provides a novel method for treating hypogonadism in a male by administering intranasally to the male an intranasal testosterone bioadhesive gel formulation to deliver a therapeutically effective amount of testosterone. The hypogonadism treatment remains effective when an allergic rhinitis event occurs in the male during the treatment.

In another aspect, the invention provides a novel method of treating

hypogonadism in a male, who is using a topical nasal vasoconstrictor or a topical intranasal decongestant during the treatment. In particular, the method comprises administering intranasally to the male an intranasal testosterone bio-adhesive gel formulation to deliver a therapeutically effective amount of testosterone.

The present invention also provides a novel method of preventing an allergic rhinitis event in a male, especially when the male is undergoing a hypogonadism treatment. The method of the invention comprises administering intranasally an intranasal testosterone bioadhesive gel formulation to the male to deliver a therapeutic effective amount of testosterone for treating hypogonadism.

In acordance with the present invention, the rates of diffusion of the testosterone in the intranasal gel formulations of the present invention through a Franz cell membrane, as contemplated by the present invention, are between about 28 and 100 slope/mgT%, and preferably about 30 and 95 slope/mgT%. For those intranasal gels formulated with between about 4.0% and 4.5% testosterone, the preferred rates of diffusion of testosterone are between about 28 and 35 slope/mgT%.

The present invention is also directed to novel methods for pernasal

administration of the nasal testosterone gels. Generally speaking, the novel methods involve depositing the intranasal testosterone gels topically into the nasal cavity of each nostril to deliver a therapeutically effective amount of testosterone in smaller volumes over dose life for providing constant effective testosterone brain and/or blood levels for use TRT, especially for effectively treating males in need of testosterone to treat hypogonadism. More specifically, the present invention is directed to bioavailable intranasal testosterone gel formulations suitable for pernasal administration to for use in TRT and to treat hypogonadal subjects. In accordance with the present invention, and by way of example. The present invention contemplates:

• Treatment with unit-dose devices pre-filled with 125 μΙ_ 4.0% testosterone gel to deliver about 5.0 mg of testosterone per nostril (intra-nasal) given, e.g., three times a day (total dose 30 mg/day);

• Treatment with unit-dose devices pre-filled with about 150 μΙ_ 4.5% gel to deliver about 6.75 mg of Testosterone per nostril (intra-nasal) given, e.g., twice daily (total dose 27.0 mg/day); and/or

• Treatment with unit-dose devices pre-filled with about 125 μΙ_ 4.5% gel to deliver about 5.625 mg of Testosterone per nostril (intra-nasal) given, e.g., three times a day (total dose 33.75 mg/day).

Generally speaking, the intranasal testosterone gel formulations of the present invention are formulated with about 4% and 4.5% testosterone by weight, and the testosterone is well absorbed when such gel formulations are administered pernasally to hypogonadal subjects. More specifically, testosterone is rapidly absorbed following pernasal administration with a peak concentration reached within 36 minutes to 1 hour 6 minutes (mean Tmax) following intra-nasal administration and maximal serum

concentration is reached after about 1 -2 hours post nasal administration. The maximum Testosterone concentration over a 24-hour interval is observed during the first administration (0-10 hours) in approximately 57% to 71 % of the hypogonadal men while approximately 29% to 43% of the subjects had their maximum 24-h Testosterone concentration during subsequent administrations.

The formulations containing 4% and 4.5% testosterone by weight provide surprising properties. Importantly, the solubility of testosterone in castor oil pure is 3.6% maximum, falling to 3.36% about with 4% Labrafil. Addition of fumed silica (Aerosil, CabOsil) can increase the solubility of testosterone in castor oil up to 4.5% even with 4.0% Labrafil. This is counter intuitive for a person skilled in the art. However, without wishing to be bound by any particular theory, it is believed that this increase in solubility in the presence of silica is due, at least in part, to the fact that Si0₂ adsorbs about 10% of the testosterone.

In accordance with the novel methods of the present invention, the intranasal testosterone gels are topically deposited on the outer external walls (opposite the nasal septum) inside the naval cavity of each nostril, preferably at about the middle to about the upper section of the outer external wall (opposite the nasal septum) just under the cartilage section of the outer external wall inside the naval cavity of each nostril. Once gel deposition is complete within each nostril of the nose, the outer nose is then gently and carefully squeezed and/or rubbed by the subject, so that the deposited gel remains in contact with the mucosal membranes within the nasal cavity for sustained release of the testosterone over dose life. Typical testosterone gel dosage amounts deposited pernasal application is between about 50 to about 150 microliters per nostril, and preferably about 125 to about 150 microliters per nostril.

In carrying out the methods of the present invention, approximately between about 50 microliters and about 150 microliters of an intranasal testosterone gel of the present invention is applied to each nostril of a subject once or twice daily or three times a day, e.g., for one, two, three, four or more consecutive weeks, or for two, three, four, five or six consecutive days or more, or intermittently such as every other day or once, twice or three times weekly, or on demand once or twice during the same day, as TRT or to treat male testosterone deficiency, including male hypogonadism.

In addition, the present invention contemplates testosterone gel formulations for nasal administration that are pharmaceutically equivalent, therapeutically equivalent, bioequivalent and/or interchangeable, regardless of the method selected to demonstrate equivalents or bioequivalence, such as pharmacokinetic methodologies, microdialysis, in vitro and in vivo methods and/or clinical endpoints described herein. Thus, the present invention contemplates testosterone gel formulations for nasal administration that are bioequivalent, pharmaceutically equivalent and/or therapeutically equivalent, especially testosterone gel formulations for nasal administration that are 0.15% testosterone by weight of the gel formulation, 0.45% testosterone by weight of the gel formulation and 0.6% testosterone by weight of the gel formulation, when used in accordance with the therapy of the present invention to treat anorgasmia and/or HSDD by intranasal administration. Thus, the present invention contemplates: (a)

pharmaceutically equivalent testosterone gel formulations for nasal administration which contain the same amount of testosterone in the same dosage form; (b) bioequivalent testosterone gel formulations for nasal administration which are chemically equivalent and which, when administered to the same individuals in the same dosage regimens, result in comparable bioavailabilities; (c) therapeutic equivalent testosterone gel formulations for nasal administration which, when administered to the same individuals in the same dosage regimens, provide essentially the same efficacy and/or toxicity; and (d) interchangeable testosterone gel formulations for nasal administration of the present invention which are pharmaceutically equivalent, bioequivalent and therapeutically equivalent.

While the intranasal testosterone gels of the present invention are preferred pharmaceutical preparations when practicing the novel methods of the present invention, it should be understood that the novel topical intranasal gel formulations and methods of the present invention also contemplate the pernasal administration of any suitable active ingredient, either alone or in combination with testosterone or other active ingredients, such as neurosteroids or sexual hormones (e.g., androgens and progestins, like testosterone, estradiol, estrogen, oestrone, progesterone, etc.), neurotransmitters, (e.g., acetylcholine, epinephrine, norepinephrine, dopamine, serotonin, melatonin, histamine, glutamate, gamma aminobutyric acid, aspartate, glycine, adenosine, ATP, GTP, oxytocin, vasopressin, endorphin, nitric oxide, pregnenolone, etc.), prostaglandin, benzodiazepines like diazepam, midazolam, lorazepam, etc., and PDEF inhibitors like sildenafil, tadalafil, vardenafil, etc., in any suitable pharmaceutical preparation, such as a liquid, cream, ointment, salve or gel. Examples of additional topical formulations for practice in accordance with the novel methods of the present invention include the topical pernasal formulations disclosed in, for example, U.S. Patent Nos. 5,578,588, 5,756,071 and 5,756,071 and U.S. Patent Publication Nos. 2005/0100564, 2007/0149454 and 2009/0227550, all of which are incorporated herein by reference in their entireties. The present invention is also concerned with a novel titration method to determine the appropriate daily treatment regimen, i.e., a QD, BID or TID treatment regimen, to administer the intranasal gels of the present invention to treat

hypogonadism or TRT in men. While the preferred treatment regimen in accordance with the present invention for administering the intranasal testosterone gels, such as 4.0% or 4.5% TBS-1 as described in Examples 1 , 2, 3, 5, 7, 8, 9 and 10 above, to treat hypogonadism or TRT is twice-daily (BID) treatment regimen, the present invention contemplates that certain subjects may be more effectively treated with a once-a-day or three-times-a-day (TID) treatment regimen. Thus, the novel titrations method of the present invention have been developed to determine which subject will require a QD, BID or TID treatment regimen to more effectively treat hypogonadism or testosterone deficiency when treated with the intranasal testosterone bioadhesive gels of the present invention. See Examples 21 A-21 C.

In carrying out one novel titration method in accordance with the present invention, subjects will have 2 blood draws, preferably at 7 am and at 8:20 am on the test day. The day before the first blood draw, the subject will take at 10 pm, his evening intranasal dose of TBS-1 . On test day, the subject will take at about 8 am, his morning intranasal dose of TBS-1 . See Example 21 A. Alternatively, a blood sample may be drawn at about 9 hours post-evening dose adminstration, e.g., at about 7 am following a 10 pm dose for a single-point titration analysis to determine if the patient's treatment regimen needs to be adjusted, as described in Example 21 C, or the patient may draw blood at about 9 hours post-evening dose adminstration, e.g., at about 7 am following a 10 pm dose, and withdraw a second blood sample at about 1 1 to 1 1 .5 hours post evening dose adminsitartion, e.g., at about 9 am to about 9:30 am following the 10 pm evening dose, for a two-point titration analysis to determine if the patient's treatment regimen needs to be adjusted, as described in Example 21 B.

Under the two-point titration method, as described in Example 21 A, the 24-hour

C_aVg of serum total testosterone will be estimated based on the sum of serum total testosterone levels collected at the 2 sampling points: the sample collected at about 9.0 hours (at 7 am, which is 1 hour before the morning 0800 h intranasal dose) and the sample collected at about 10.33 hours following the last evening's intranasal dose(20 minutes after the morning 0800 h dose +/-20 minutes ). Note that, the blood draw times may be changed (+/- 1 hour) but the delay between the last dose and the first blood draw is preferably 9 hours +/-20 minutes and the delay between the next dose administered at about 10 hours +/- 20 minutes after the last dose and the second blood draw is preferably +/-20 minutes.

Testosterone serum concentrations are preferably measured by a validated method at a clinical laboratory and reported in ng/dL units.

The following titration criteria is preferably used:

• If the sum of the serum total testosterone level values for PK samples collected at 9.0 hours and 10.33 hours is <755 ng/dL, then the estimated 24-hour C_aVg for the male patient is <300 ng/dL

• If the sum of the serum total testosterone level values for PK samples collected at 9.0 hours and 10.33 hours is >755 ng/dL, then the estimated 24-hour C_aVg for the male patient is >300 ng/dL.

With respect to those subjects with an estimated serum total testosterone

C_aVg <300 ng/dL, i.e., those subjects who sum of the serum total testosterone level values for PK samples collected at 9.0 hours and 10.33 hours is <755 ng/dL, their BID treatment regimen should be titrated to a TID treatment regimen of TBS-1 to achieve a 24-hour C_aVg of >300 ng/dL. The decision to titrate the subject's daily dose to TID, however, will be made by the doctor based on the criteria specified above.

With respect to those subjects with an estimated serum total testosterone

C_aVg≥300 ng/dL, i.e., those subjects who sum of the serum total testosterone level values for pK samples collected at 9.0 hours and 10.33 hours is >755 ng/dL, their BID treatment regimen should remain unchanged at a BID treatment regimen of TBS-1 since their 24-hour C_avg is >300 ng/dL. The decision to titrate the subject's daily dose to TID or remain at BID, however, will be made by the doctor based on the criteria specified above.

It should be understood that, while it is preferred to draw blood from a subject to test the subject's serum total testosterone level values for pK samples at 9 hours and at 10.33 hours after the last evening's BID dose, the difference in the total draw time, i.e., 10.33 hours, may vary by as much as about +/- 60 minutes and preferably no more than about +/- 20 minutes between one another. It should also be understood that while, serum total testosterone level values for PK samples is 755 ng/dL is the preferred level to use to determine if titration to TID is necessary, the serum total testosterone level values for PK samples may vary as much as +/- 50 and preferably no more than +/- 25. As an alternative, it should be understood that, while the titration method is described above with starting the titration method based upon the last evening's BID dose, the tirtration method could also be used by starting the titration method based upon the first morning dose. For example, under this alternative embodiment, the first blood draw would be taken at about 9 hours and the second blood draw would be taken at about 10.33 hours after the morning dose, so long as the second blood draw is taken at about 20 minutes after the last BID dose of the day. Still further, under an alternative two- point titration method, such as described in Example 21 B, the two blood samples can be drawn at 9 hours post-evening dose and at 1 1 to 1 1 .5 hours post-evening dose. Under this two-point titration method, if the testosterone concentration value is below the range of between about 815 and 835 ng/dL, the patient should be titrated to a TID treatment regimen and if the testosterone concentration value is above the range of between about 815 and 835 ng/dL, the patient should continue with a BID treatment schedule. The remaining parts of the algorithm are the same as the two-point titration method such as described in Example 21 A, except a down titration from BID to QD, if the testosterone concentration value determined for C1 1 hours is > 1900 ng/dL should be prescribed. In yet another alternative, a single-point titration method can be used, such as described in Example 21 C. Under the single-point titration method, the sole blood sample is drawn at about 7:00 am in the morning at preferably 9 hours after the evening dose, which is administered for example at about 10 pm. If the testosterone concentration value is below the about 280 ng/dL, the patient should be titrated to a TID treatment regimen and if the testosterone concentration value is above 280 ng/dL, the patient should continue with a BID treatment schedule. However, a down titration from BID to QD, if the testosterone concentration value determined at 9 hours is > 700 ng/dL should be prescribed. Thus, a titration method inaccordance with the present invention for optimizing a treatment regimen for treating a male diagnosed with hypogonadism with an intranasal testosterone gel comprises:

(a) administering intranasally to the male the intranasal testosterone gel twice daily for a selected number of days;

(b) extracting a first blood sample from the male at a selected time before a selected dose (first or second dose) of the twice daily treatment regimen on the first day after the selected number of days;

(c) optionally extracting a second blood sample from the male at a selected time after administration of the selected dose of the twice daily treatment regimen on the first day after the selected number of days;

(d) measuring the testosterone serum level in the first blood sample to generate a first testosterone ng/dl measurement;

(e) optionally measuring the testosterone serum level in the second blood sample to generate a second testosterone ng/dl measurement;

(f) optionally adding the first testosterone measurement and the second testosterone measurement together to generate a serum testosterone ng/dl

concentration sum for predicting a testosterone C_avg for the male; and

(g) comparing the serum testosterone concentration sum to a target serum testosterone level to determine an optimized intranasal treatment regimen for treating the male with the intranasal testosterone gel for maintaining in the male a testosterone 24 hour serum average at a level of at least about 300 ng/dl during the optimized treatment regimen; and

wherein, if the serum testosterone concentration sum is (i) less than the target serum testosterone level, titrating the twice daily intranasal treatment regimen for the male to a treatment regimen that is three times a day (TID) to treat the male for hypogonadism, or (ii) is equal to or greater than the target serum testosterone level, continuing with the twice daily intranasal treatment regimen or reducing the twice daily intranasal treatment regimen to once daily for the male to treat the male for

hypogonadism. The present invention is also directed to packaged pharmaceuticals comprising the novel and improved testosterone gel formulations for nasal administration of the invention. For example, the present invention contemplates pre-filled, single or multi- dose applicator systems for pernasal administration to strategically and uniquely deposit the nasal testosterone gels at the preferred locations within the nasal cavity for practicing the novel methods and teachings of the present invention. Generally, speaking the applicator systems of the present invention are, e.g., airless fluid, dip-tube fluid dispensing systems, pumps, pre-filled, unit-dose syringes or any other system suitable for practicing the methods of the present invention. The applicator systems or pumps include, for example, a chamber, pre-filled with a single dose or multiple doses of an intranasal testosterone gel of the present invention, that is closed by an actuator nozzle or cap. The actuator nozzle may comprise an outlet channel and tip, wherein the actuator nozzle is shaped to conform to the interior surface of a user's nostril for (a) consistent delivery of uniform dose amounts of an intranasal testosterone gel of the present invention during pernasal application within the nasal cavity, and (b) deposition at the instructed location within each nostril of a patient as contemplated by the novel methods and teachings of the present invention. Preferably, when inserted into a nasal cavity, the pump design is configured to help ensure that the nasal tip is properly positioned within the nasal cavity so that, when the gel is dispensed, the gel is dispensed within the appropriate location within the nasal cavity. See Steps 3 and 8 in Fig. 10A. Additionally, the nozzles of te pumps are preferably designed to dispense the gels from from the side in a swirl direction, i.e., the tips of the nozzles are designed to dispense in a side distribution direction, as opposed to a direct distribution direction, onto the nasal mucosa, as shown in steps 4 and 9 of Fig. 10A. It is believed that the swirl action allows for better gel adhesion and side distribution from the nozzle tip avoids the dispensed gel from splashing back onto the tip. Finally, it is preferrred to design the nozzle and tip to allow for any residual gel on the nozzle/tip to be wiped off as the tip is removed from the nasal cavity. See, e.g., Fig. 10A and 10 B. Examples of pre-filled, multi-dose applicator systems include, e.g., (a) the COMOD system available from Ursatec, Verpackung-GmbH, Schillerstr. 4, 66606 St. Wendel, Germany, (b) the Albion or Digital airless applicator systems available from

Airlessystems, RD 149 27380 Charleval, France or 250 North Route 303 Congers, NY 10950, (c) the nasal applicators from Neopac, The Tube, Hoffmann Neopac AG, Burgdorfstrasse 22, Postfach, 3672 Oberdiessbach, Switzerland, or (d) the syringes described in the Examples herein below.

A nasal multi-dose dispenser device according to embodiments of the present invention, such as the Albion or Digital airless applicator systems available from

Airlessystems, is comprised of a fluid container and a distributor pump for delivery of multiple doses of a gel or other topical formulation. In one embodiment of the present invention, the nasal multi-dose dispenser device is adapted for an airless fluid

dispensing system. In another embodiment of the present invention, the nasal multi- dose dispenser device is adapted for a dip tube fluid dispensing system.

An example of an airless system that is contemplated by the present invention is one that will deliver a liquid, including gel, without the need for a pressured gas or air pump to be in contact with the liquid (or gel). In general, an airless system of the present invention comprises a flexible pouch containing the liquid, a solid cylindrical container a moving piston, an aspirating pump, a dosing valve and a delivery nozzle, as depicted, for example, in Figs. 1 -4. See also Figs. 7A, 7B, 8A, 8B, 9A, 9B, 10A, 10B and 1 1 .

In accordance with the present invention, the multi-dose dispenser 100 of Fig. 1 is provided with a fluid container 120, a distributor pump 140 and a cap 102.

The fluid container 120 comprises a container body 122, a base 124 and a neck 126. The distributor pump 140 is fastened to the neck by a sleeve 128. The top end of the container body 122 is closed by the distributor pump 140. The sleeve 128 tightly pinches a neck gasket 150 against the top end of the container body 122. The container body 122 forms a vacuum and houses the fluid to be dispensed.

The distributor pump 140 is closed by its actuator nozzle 130, which retains the stem 144 at the stem head. The actuator nozzle 130 comprises an outlet channel 132 and tip 134.

The actuator nozzle 130 is shaped to conform with the interior surface of a user's nostril. The actuator nozzle 130 is moveable between a downward open position and upward closed position. The user removes the cap 102 and inserts the actuator nozzle

130 in the user's nostril. When the user pushes the actuator nozzle 130 downwards to the open position, fluid in the dosing chamber 180 is withdrawn by the distributor pump 140 and exits at the tip 134 via the outlet channel 132 of the actuator nozzle 130.

Fig. 2 shows a cross-sectional view of the distributor pump 140.

The distributor pump has a body 142 provided with a bottom intake having an inlet valve 160 with a ball 162 as its valve member. The ball 162 is held in place by a cage 164 and by a return spring 170.

At its bottom end, the stem 144 carries a spring cap 172. A piston 174 is located above the spring cap 172. The stem 144 passes through an axial orifice of the piston base 176.

The side walls of the piston 174 seals against the distributor pump body 142 via lips. The sleeve 128 tightly pinches a stem gasket 152 against the stem collar 146, distributor pump body 142 and top of the piston 174.

A precompression spring 178 placed between the piston base 176 and the stem collar 146. The precompression spring 178 biases the actuator nozzle 130 via the stem 144 to the closed position.

The return spring 170, which returns the piston 174 back upwards, is

compressed between two opposed seats on the cage 164 and the spring cap 172.

The distributor pump 140 has a dosing chamber 180 formed between the cage 164 and piston 174. When the user pushes the actuator nozzle downwards to the open position, fluid in the dosing chamber is withdrawn by the distributor pump 140 and dispensed from the tip of the actuator nozzle 130.

When the user releases the actuator nozzle 130 upwards to the closed position, a fluid in the container body 122 is withdrawn into the dosing chamber 180 by the distributor pump 140. Thus, a dose of fluid is ready for the next actuation of the actuator nozzle by the user.

In another embodiment of the present invention, the dispenser 200 of Fig. 3 is provided with a fluid container 220, a distributor pump 240 and a cap 202.

The fluid container 220 comprises a container body 222, a base 224 and a neck 226. The distributor pump 240 is fastened to the neck by a sleeve 228. The top end of the container body 222 is closed by the distributor pump 240. The sleeve 228 tightly pinches a neck gasket 250 against the top end of the container body 222. The container body 222 houses the fluid to be dispensed.

The distributor pump 240 is closed by its actuator nozzle 230, which retains the stem 244 at the stem head. The actuator nozzle 230 comprises an outlet channel 232 and tip 234. The actuator nozzle 230 is shaped to conform with the interior surface of a user's nostril. The actuator nozzle 230 is moveable between a downward open position and upward closed position. The user removes the cap 202 and inserts the actuator nozzle 230 in the user's nostril. When the user pushes the actuator nozzle 230 downwards to the open position, fluid in the dosing chamber 280 is withdrawn by the distributor pump 240 and exits at the tip 234 via the outlet channel 232 of the actuator nozzle 230.

Fig. 4 shows a cross-sectional view of the distributor pump 240.

The distributor pump has a body 242 provided with a bottom intake having an inlet valve 260 with a ball 262 as its valve member. The ball 262 is held in place by a cage 264 and by a return spring 270. Optionally, a dip tube 290 can extend downward from the inlet valve 260 and is immersed in the liquid contained in the container body.

At its bottom end, the stem 244 carries a spring cap 272. A piston 274 is located above the spring cap 272. The stem 244 passes through an axial orifice of the piston base 276.

The side walls of the piston 274 seals against the distributor pump body 242 via lips. The sleeve 228 tightly pinches a stem gasket 252 against the stem collar 246, distributor pump body 242 and top of the piston 274.

A precompression spring 278 placed between the piston base 276 and the stem collar 246. The precompression spring 278 biases the actuator nozzle 230 via the stem 244 to the closed position.

The return spring 270, which returns the piston 274 back upwards, is

compressed between two opposed seats on the cage 264 and the spring cap 272.

The distributor pump 240 has a dosing chamber 280 formed between the cage 264 and piston 274. When the user pushes the actuator nozzle downwards to the open position, air enters the dosing chamber 280, which forces the fluid in the dosing chamber to be withdrawn by the distributor pump 240 and dispensed from the tip of the actuator nozzle 230.

When the user releases the actuator nozzle 230 upwards to the closed position, the air contained in the dosing chamber 280 forces the fluid in the container body 222 to be withdrawn into the dosing chamber 280. Thus, a dose of fluid is ready for the next actuation of the actuator nozzle by the user.

The amount of fluid withdrawn by the distributor pump into the dosing chamber may be a fixed volume. The distributor pumps may be of a variety of sizes to

accommodate a range of delivery volumes. For example, a distributor pump may have a delivery volume of 140 μΙ.

The dispensers of the present invention may dispense topical intranasal gel or other topical intranasal formulations, preferably pernasally, which contain alternative or additional active ingredients, such as neurosteroids or sexual hormones (e.g., androgens and progestins, like testosterone, estradiol, estrogen, oestrone,

progesterone, etc.), neurotransmitters, (e.g., acetylcholine, epinephrine, norepinephrine, dopamine, serotonin, melatonin, histamine, glutamate, gamma aminobutyric acid, aspartate, glycine, adenosine, ATP, GTP, oxytocin, vasopressin, endorphin, nitric oxide, pregnenolone, etc.), prostaglandin, benzodiazepines like diazepam, midazolam, lorazepam, etc., and PDEF inhibitors like sildenafil, tadalafil, vardenafil, etc., in the form of a liquid, cream, ointment, salve or gel. The dispensers may be suitable for cosmetic, dermatological or pharmaceutical applications. Examples of topical intranasal formulations for topical pernasal application, which can be dispensed in accordance with the present invention include the pernasal testosterone gels of the present invention or other intranasal topical gels wherein the testosterone is replaced or combined with a another active ingredient in effective amounts, such as those active ingredients discussed herein above. In addition, other testosterone formulations suitable and contemplated for dispensing from the dispensers and/or in accordance with the methods of the present invention include the formulations dislcosed in, for example, U.S. Patent Nos. 5,578,588, 5,756,071 and 5,756,071 and U.S. Patent Publication Nos. 2005/0100564, 2007/0149454 and 2009/0227550, all of which are incorporated herein by reference in their entirties. It should be understood by those versed in this art that the amount of testosterone in a lower dosage strength intranasal testosterone gel of the present invention that will be therapeutically effective in a specific situation will depend upon such things as the dosing regimen, the application site, the particular gel formulation, dose longevity and the condition being treated. As such, it is generally not practical to identify specific administration amounts herein; however, it is believed that those skilled in the art will be able to determine appropriate therapeutically effective amounts based on the guidance provided herein, information available in the art pertaining to

testosterone replacement therapy, and routine testing.

It should be further understood that the above summary of the present invention is not intended to describe each disclosed embodiment or every implementation of the present invention. The description further exemplifies illustrative embodiments. In several places throughout the specification, guidance is provided through examples, which examples can be used in various combinations. In each instance, the examples serve only as representative groups and should not be interpreted as exclusive examples.

In certain aspects and/or embodiments,, the inventions described in the following numbered sentences are provided:

1 . A titration method for optimizing a treatment regimen for treating a male diagnosed with hypogonadism with an intranasal testosterone gel comprises:

(d) measuring the testosterone serum level in the first blood sample to generate a first testosterone ng/dl measurement; (e) optionally measuring the testosterone serum level in the second blood sample to generate a second testosterone ng/dl measurement;

concentration sum for predicting a testosterone C_avg for the male; and

hypogonadism.

2. A titration method of sentence 1 , wherein the target serum testosterone level is at about 755 ng/dl.

3. A titration method of sentence 1 , wherein the target serum testosterone level is in a range of between about 815 ng/dl and about 835 ng/dl.

4. A titration method of sentence 1 , wherein the target serum testosterone level is in a range of between about 280 ng/dl.

5. A titration method of sentence 1 , wherein said extraction of the first blood sample occurs at about 9 hours after nasal administration of an evening dose of an intranasal testosterone gel. 6. A titration method of sentence 1 , wherein said extraction of the second blood sample occurs at between about 1 1 hours and 1 1 .5 hours after nasal administration of an evening dose of the intranasal testosterone gel.

7. A titration method of sentences 1 -6, wherein the intranasal testosterone gel contains about 4.5% testosterone.

8. A titration method for optimizing a treatment regimen for treating a male diagnosed with hypogonadism with an intranasal testosterone gel, said method comprising:

(b) extracting a blood sample from the male at a selected time before a selected dose (first or second dose) of the twice daily treatment regimen on the first day after the selected number of days;

(c) measuring the testosterone serum level in the blood sample to generate a serum testosterone ng/dl concentration measurement for the male;; and

(d) comparing the serum testosterone ng/dl concentration measurement to a target serum testosterone level to determine an optimized intranasal treatment regimen for treating the male with the intranasal testosterone gel for maintaining in the male a testosterone 24 hour serum average at a level of at least about 300 ng/dl during the optimized treatment regimen; and

wherein, if the serum testosterone ng/dl concentration measurement is (i) less than the target serum testosterone level, titrating the twice daily intranasal treatment regimen for the male to a treatment regimen that is three times a day (TID) to treat the male for hypogonadism, or (ii) equal to or greater than the target serum testosterone level, continuing with the twice daily intranasal treatment regimen for the male to treat the male for hypogonadism. 9. A titration method of sentence 8, wherein said administering intranasally to the male the intranasal testosterone gel twice daily for a selected number of days is 30 days.

10. A titration method of sentences 8 or 9, wherein said extracting the blood sample from the male at a selected time is at about 60 minutes before a selected dose of the twice daily treatment regimen on the first day after the selected number of days.

1 1 . A titration method of sentences 8 or 9, wherein said extracting the blood sample from the male at a selected time before a selected dose of the twice daily treatment regimen on the first day after the selected number of days is before the first dose.

12. A titration method of sentences 8 or 9, wherein said extracting the blood sample from the male at a selected time before a selected dose of the twice daily treatment regimen on the first day after the selected number of days is before the second dose.

13. A titration method of sentences 1 -12, the target serum testosterone level is at about 755 ng/dl.

14. A titration method of sentence 1 -12, the target serum testosterone level is at about 280 ng/dl.

15. A titration method of sentences 1 -14, wherein the intranasal testosterone gel contains about 4.5% testosterone.

16. A testosterone gel formulation for nasal administration for treating hypogonadism or testosterone deficiency in males, said testosterone gel formulation comprising:

a. About 4.5% testosterone by weight of said gel formulation; and b. a pharmaceutically acceptable vehicle, wherein the testosterone gel formulation has positive results for primary and secondary efficacy and safety endpoints when a male is treated intranasally with the testosterone gel formulation for hypogonadism or testosterone deficiency.

17. The testosterone gel formulation of sentence 16, wherein the gel formulation comprises a solvent, a wetting agent, and a viscosity increasing agent.

18. The testosterone gel formulation of sentence 17, wherein the solvent is castor oil.

19. The testosterone gel formulation of sentences 17 or 18, wherein said wetting agent is an oleoyl polyoxylglyceride.

20. The testosterone gel formulation of sentences 17, 18 or 19, wherein said viscosity increasing agent is colloidal silicon dioxide.

21 . The testosterone gel formulation of sentence 16, wherein said gel formulation comprises castor oil, oleoyl polyoxylglycerides and colloidal silicon dioxide.

22. The testosterone gel formulation of any one of sentences 16-21 , wherein said gel formulation is a bioequivalent to another testosterone gel formulation.

23. The testosterone gel formulation of any one of sentences 16-21 , wherein said gel formulation is pharmaceutically equivalent to another testosterone gel formulation.

24. The testosterone gel formulation of any one of sentences 16-21 , wherein said gel formulation is therapeutically equivalent to another testosterone gel formulation.

25. A packaged pharmaceutical comprising:

(a) a testosterone gel formulation for nasal administration to treat hypogonadism or testosterone deficiency in a male, wherein said gel formulation comprises about 4.5% testosterone by weight; and (b) associated instructions for using said testosterone gel formulation for testosterone replacement therapy, or to treat hypogonadism or testosterone deficiency, wherein said testosterone gel formulation has positive results for primary and secondary efficacy and safety endpoints, wherein the 4.5% testosterone gel formulation has positive results for primary and secondary efficacy and safety endpoints when a male is treated intranasally with the 4.5% testosterone gel formulation for hypogonadism or testosterone deficiency.

26. The packaged pharmaceutical of sentence 25 further comprising a step of identifying a subject in need of the treatment.

27. A method of treating hypogonadism in a male subject, the method comprising administering intranasally to a male subject said gel formulation of any one of sentences 16-26 to deliver a therapeutically effective amount of testosterone to effectively treat hypogonadism.

28. A method of treating testosterone deficiency in a male subject, the method comprising administering intranasally to a male subject said gel formulation of any one of sentences 16-26 to deliver a therapeutically effective amount of testosterone to effectively treat testosterone deficiency.

29. A method of providing testosterone replacement therapy in a male subject, the method comprising administering intranasally to a male subject said gel formulation of any one of sentences 16-26 to deliver a therapeutically effective amount of testosterone to effectively provide testosterone replacement therapy.

30. The testosterone gel formulation of any one of sentences 16-29, wherein said testosterone gel formulation is a bioequivalent to another testosterone gel formulation. 31 . The testosterone gel formulation of any one of sentences 16-29, wherein said testosterone gel formulation is pharmaceutically equivalent to another testosterone gel formulation.

32. The testosterone gel formulation of any one of sentences 16-29, wherein said testosterone gel formulation is therapeutically equivalent to another testosterone gel formulation.

33. A method for treating hypogonadism or testosterone deficiency in males, said method comprising:

intranasally administering to the males in need of said treatment two or three times daily a testosterone gel formulation formulated with about 4.5% testosterone by weight of said gel formulation to treat hypogonadism or testosterone deficiency in the males;

wherein said intranasal treatment achieves in at least about 75% of the treated males an average total testosterone concentration in normal range for males.

34. An intranasal method of sentence 33, wherein said intranasal treatment achieves in at least about 77% of the treated males an average total testosterone concentration in normal range for males when the treated men are treated three times daily.

35. A method for treating hypogonadism or testosterone deficiency in males, said method comprising:

intranasally administering to the males in need of said treatment about 22 mg of testosterone daily to treat hypogonadism or testosterone deficiency in the males;

wherein 71 % of the treated males achieved a testosterone C_avg within normal range for men at day 90 of said intranasal treatment.

36. A method for treating hypogonadism or testosterone deficiency in males, said method comprising: intranasally administering to the males in need of said treatment about 33 mg of testosterone daily to treat hypogonadism or testosterone deficiency in the males;

wherein 76% of the treated males achieved a testosterone C_avg within normal range for men at day 90 of said intranasal treatment.

37. A method for treating hypogonadism or testosterone deficiency in males, said method comprising:

wherein less than 88.6% of the treated men achieved a maximum serum testosterone concentration (C_max) of less than 1500 ng/dl at day 90 of said intranasal treatment.

38. A method for treating hypogonadism or testosterone deficiency in males, said method comprising:

wherein 3.3% of the treated men achieved a maximum serum testosterone concentration (C_max) of between 1800 ng/dl and 2499 ng/dl on day 90 of said intranasal treatment.

39. A method for treating hypogonadism or testosterone deficiency in males, said method comprising:

intranasally administering to the males in need of said treatment two or three times daily a testosterone gel formulation formulated with about 4.5% testosterone by weight of said gel formulation to treat hypogonadism or testosterone deficiency in the males; wherein the proportion of the treated males with a serum testosterone concentration (C_oax) of greater than 1500 ng/dL is within FDA guidelines for testosterone replacement products.

40. A method for treating hypogonadism or testosterone deficiency in males, said method comprising:

wherein the said treated males experience fewer adverse events selected from a group of adverse events consisting of hematocrit, hemoglobin and PSA levels, as compared to adverse events experienced by men when treated with other commercially marketed testosterone replacement therapies.

41 . A method for treating hypogonadism or testosterone deficiency in males, said method comprising:

wherein no decreases in hemoglobin is observed in the said treated males.

42. A method for treating hypogonadism or testosterone deficiency in males, said method comprising:

wherein about 75% or more of the treated men achieve primary endpoint. 43. An intranasal method of sentence 42, wherein the primary endpoint is a C_avg (0- 24) serum total testosterone within normal range (300 ng/dL to 1050 ng/dl) on Day 90 of said treatment.

44. A method for treating hypogonadism or testosterone deficiency in a male, said method comprising:

intranasally administering to the male in need of said treatment two or three times daily a testosterone gel formulation formulated with about 4.5% testosterone by weight of said gel formulation to treat hypogonadism or testosterone deficiency in the male;

wherein said intranasal treatment achieves an average total testosterone concentration in the treated male in normal range for males when the treated male is treated two or three times daily.

45. A method for treating hypogonadism or testosterone deficiency in a male, said method comprising:

intranasally administering to the male in need of said treatment about 22 mg of testosterone daily to treat hypogonadism or testosterone deficiency in the male;

wherein the treated male achieves a testosterone C_avg within normal range for men at day 90 of said intranasal treatment.

46. A method for treating hypogonadism or testosterone deficiency in a male, said method comprising:

intranasally administering to the male in need of said treatment about 33 mg of testosterone daily to treat hypogonadism or testosterone deficiency in the male;

47. A method for treating hypogonadism or testosterone deficiency in a male, said method comprising: intranasally administering to the male in need of said treatment two or three times daily a testosterone gel formulation formulated with about 4.5% testosterone by weight of said gel formulation to treat hypogonadism or testosterone deficiency in the male;

wherein the treated male achieves a maximum serum testosterone concentration (Cmax) of less than 1500 ng/dl at day 90 of said intranasal treatment.

48. A method for treating hypogonadism or testosterone deficiency in a male, said method comprising:

wherein the treated male achieves a maximum serum testosterone concentration (Cmax) of between 1800 ng/dl and 2499 ng/dl on day 90 of said intranasal treatment.

49. A method for treating hypogonadism or testosterone deficiency in a male, said method comprising:

wherein the said treated male experiences fewer adverse events selected from a group of adverse events consisting of hematocrit, hemoglobin and PSA levels, as compared to adverse events experienced by men when treated with other commercially marketed testosterone replacement therapies.

50. A method for treating hypogonadism or testosterone deficiency in males, said method comprising: intranasally administering to a male in need of said treatment two or three times daily a testosterone gel formulation formulated with about 4.5% testosterone by weight of said gel formulation to treat hypogonadism or testosterone deficiency in the male; wherein no decreases in hemoglobin is observed in the said treated male.

51 . A method for treating hypogonadism or testosterone deficiency in a male, said method comprising:

wherein the treated male achieves primary endpoint on Day 90 of said intranasal treatment.

52. An intranasal method of sentence 51 , wherein the primary endpoint is a C_avg (0- 24) serum total testosterone within normal range (300 ng/dL to 1050 ng/dL) on Day 90 of said intranasal treatment.

Brief Description of the Drawings

The foregoing and other objects, advantages and features of the present invention, and the manner in which the same are accomplished, will become more readily apparent upon consideration of the following detailed description of the invention taken in conjunction with the accompanying figures and examples, which illustrate embodiments, wherein:

Fig. 1 is a side view of a first embodiment of the invention;.

Fig. 2 is a cross-sectional side view of the distributor pump of the first

embodiment of the invention;

Fig. 3 is a side view of a second embodiment of the invention;

Fig. 4 is a cross-sectional side view of the distributor pump of the second embodiment of the invention; Fig. 5 is a side view of a second embodiment of the invention concerning an airless bottle assembly of the invention;

Fig. 6 is a side view of a second embodiment of the invention concerning digital actuator and rounded cap;

Fig. 7 A depicts the right nostril of subject #1 after a single dose syringe administration;

Fig.7B depicts the left nostril of subject #1 after a multiple dose dispenser administration;

Fig. 8A depicts the right nostril of subject #2 after a single dose syringe administration;

Fig. 8B depicts the left nostril of subject #2 after a multiple dose dispenser administration;

Fig. 9A depicts the right nostril of subject #3 after a single dose syringe administration;

Fig. 9B depicts the left nostril of subject #3 after a multiple dose dispenser administration;

Figs. 10A and 10B illustrate use of a multiple dose dispenser in accordance with the present invention;

Fig. 1 1 illustrates a multiple dose dispenser in accordance with the present invention;

Fig. 12 depicts a Franz Cell apparatus position layouts for comparing testing in accordance with Example 5;

Fig. 13 is a graph showing the change in testerosterone levels in serum over time for a 4.5% testosterone bio-adhesive gel administered in each nostril of a hypogonadal male twice daily in accordance with the present invention as compared to normal testosterone pharmacokinetics in young healthy adult males, as reported in Diver MJ. et al: Diurnal rhythms of total, free and bioavailable testosterone and of SHBG in middle- aged men compared with those in young men. Clinical Endocrinology, 58: 710-717 (2003);

Fig. 14 depicts a comparison between TBS 1 A 8% (Part I);

Fig. 15 depicts a comparison between TBS 1 A 8% (Part I); Fig. 16 depicts a comparison between 6 hours and 24 hours run (RD1 1 101 and RD1 1 102)

Fig. 17 depicts a comparison between TBS 1 A 4% (Part I);

Fig. 18 depicts a comparison between TBS 1 A 4% (Part II);

Fig. 19 depicts a comparison between TBS 1 A 4% (Part III);

Fig. 20 depicts a comparison slower diffusion;

Fig. 21 depicts a comparison between 6 hours and 24 hours run (RD1 1063 and RD1 1085);

Fig. 22 depicts a comparison between 400mg and 1 gram of gel (RD1 1063);

Fig. 23 depicts individual amount of testosterone released from the compositions in acoordance with Example 12;

Fig. 24 depicts individual testosterone concentration versus time (linear y-axis), that are grouped by subject in accordance with Example 13. Number. Black: baseline; blue: syringe; salmon: multiple dose dispenser. T=0 is at 21 :00 clock-time (± 30 minutes), t=12 is at 9:00 (± 30 minutes) clock-time;

Fig. 25 depicts individual (blue) and median (black) testosterone concentration versus time (linear y-axis), that are grouped by treatment;

Fig. 26 depicts the probability density of the log ratio of testosterone levels that are reached with the multiple dose dispenser over levels tht are reached with the syringe;

Fig. 27 depicts solubility of testosterone in different vehicles at 32^QC and at 50^QC;

Fig. 28 depicts Ternary solvent mixture optimization: Contour plot shows that, in order to achieve more than 6% testosterone solubility, higher levels of DMI and Transcutol are required;

Fig. 29 depicts a flow diagram for manufacturing TBS-1 .

Fig. 30A and Fig. 30B depict a flow diagram of a manufacturing process of an antranasal testosterone gel of the present invention;

Fig. 31 depicts a mean concentration-time curves of testosterone (solid squares) and DHT (open squares) after single-dose administration of 3 different TBS-1 strengths (7.6 mg = squares; 15.2 mg = circles; 22.8 mg triangles). The lower limit of normal range for testosterone is indicated with the dashed line (based on morning serum samples);

Fig. 32 depicts testosterone diffusion rate of intranasal testosterone gel formulations of Example 13 using Franz cells method; and

Fig. 33 depicts the pharmacokinetic profiles of 15 male subjects using the formulas of Example 13.

Detailed Description

By way of illustrating and providing a more complete appreciation of the present invention and many of the attendant advantages thereof, the following detailed description and examples are given concerning the novel lower dosage strength intranasal testosterone gels, application devices and methods of the present invention.

As used in the description of the invention and the appended claims, the singular forms "a", "an" and "the" are used interchangeably and intended to include the plural forms as well and fall within each meaning, unless the context clearly indicates otherwise. Also, as used herein, "and/or" refers to and encompasses any and all possible combinations of one or more of the listed items, as well as the lack of combinations when interpreted in the alternative ("or").

As used herein, "at least one" is intended to mean "one or more" of the listed elements.

Singular word forms are intended to include plural word forms and are likewise used herein interchangeably where appropriate and fall within each meaning, unless expressly stated otherwise.

Except where noted otherwise, capitalized and non-capitalized forms of all terms fall within each meaning.

Unless otherwise indicated, it is to be understood that all numbers expressing quantities, ratios, and numerical properties of ingredients, reaction conditions, and so forth used in the specification and claims are contemplated to be able to be modified in all instances by the term "about".

All parts, percentages, ratios, etc. herein are by weight unless indicated

otherwise. As used herein, "bioequivalence" or "bioequivalent", refers to nasally administered testosterone gel formulations or drug products which are pharmaceutically equivalent and their bioavailabilities (rate and extent of absorption) after administration in the same molar dosage or amount are similar to such a degree that their therapeutic effects, as to safety and efficacy, are essentially the same. In other words,

bioequivalence or bioequivalent means the absence of a significant difference in the rate and extent to which testosterone becomes available from such formulations at the site of testosterone action when administered at the same molar dose under similar conditions, e.g., the rate at which testosterone can leave such a formulation and the rate at which testosterone can be absorbed and/or become available at the site of action to affect TRT, including hypogonadism. In other words, there is a high degree of similarity in the bioavailabilities of two testosterone gel formulation pharmaceutical products for nasal administration (of the same galenic form) from the same molar dose, that are unlikely to produce clinically relevant differences in therapeutic effects, or adverse reactions, or both. The terms "bioequivalence", as well as "pharmaceutical equivalence" and "therapeutic equivalence" are also used herein as defined and/or used by (a) the FDA, (b) the Code of Federal Regulations ("C.F.R."), Title 21 , (c) Health Canada, (d) European Medicines Agency (EMEA), and/or (e) the Japanese Ministry of Health and Welfare. Thus, it should be understood that the present invention

contemplates testosterone gel formulations for nasal administration or drug products that may be bioequivalent to other testosterone gel formulations for nasal administration or drug products of the present invention. By way of example, a first testosterone gel formulation for nasal administration or drug product is bioequivalent to a second testosterone gel formulation for nasal administration or drug product, in accordance with the present invention, when the measurement of at least one pharmacokinetic parameter(s), such as a Cmax, Tmax, AUC, etc., of the first testosterone gel formulation for nasal administration or drug product varies by no more than about ±25%, when compared to the measurement of the same pharmacokinetic parameter for the second testosterone gel formulation for nasal administration or drug product of the present invention. As used herein, "bioavailability" or "bioavailable", means generally the rate and extent of absorption of testosterone into the systemic circulation and, more specifically, the rate or measurements intended to reflect the rate and extent to which testosterone becomes available at the site of action or is absorbed from a drug product and becomes available at the site of action. In other words, and by way of example, the extent and rate of testosterone absorption from a lower dosage strength gel formulation for nasal administration of the present invention as reflected by a time-concentration curve of testosterone in systemic circulation.

As used herein, the terms "pharmaceutical equivalence" or "pharmaceutically equivalent", refer to testosterone gel formulations for nasal administration or drug products of the present invention that contain the same amount of testosterone, in the same dosage forms, but not necessarily containing the same inactive ingredients, for the same route of administration and meeting the same or comparable compendial or other applicable standards of identity, strength, quality, and purity, including potency and, where applicable, content uniformity and /or stability. Thus, it should be

understood that the present invention contemplates testosterone gel formulations for nasal administration or drug products that may be pharmaceutically equivalent to other testosterone gel formulations for nasal administration or drug products used in accordance with the present invention.

As used herein, "therapeutic equivalence" or "therapeutically equivalent", means those testosterone gel formulations for nasal administration or drug products which (a) will produce the same clinical effect and safety profile when utilizing testosterone drug product for TRT and to treat testosterone deficiency, including hypogonadism, in male subjects in accordance with the present invention and (b) are pharmaceutical equivalents, e.g., they contain testosterone in the same dosage form, they have the same route of administration; and they have the same testosterone strength. In other words, therapeutic equivalence means that a chemical equivalent of a lower dosage strength testosterone formulation of the present invention (i.e., containing the same amount of testosterone in the same dosage form when administered to the same individuals in the same dosage regimen) will provide essentially the same efficacy and toxicity. As used herein a "testosterone gel formulation for nasal administration" means a formulation comprising testosterone in combination with a solvent, a wetting agent, and a viscosity increasing agent.

As used herein, "plasma testosterone level" means the level of testosterone in the plasma of a subject. The plasma testosterone level is determined by methods known in the art.

"Diagnosis" or "prognosis," as used herein, refers to the use of information (e.g., biological or chemical information from biological samples, signs and symptoms, physical exam findings, psychological exam findings, etc.) to anticipate the most likely outcomes, timeframes, and/or responses to a particular treatment for a given disease, disorder, or condition, based on comparisons with a plurality of individuals sharing symptoms, signs, family histories, or other data relevant to consideration of a patient's health status, or the confirmation of a subject's affliction, e.g., testosterone deficiency, including hypogonadism.

A "subject" according to some embodiments is an individual whose signs and symptoms, physical exams findings and/or psychological exam findings are to be determined and recorded in conjunction with the individual's condition (i.e., disease or disorder status) and/or response to a candidate drug or treatment.

"Subject," as used herein, is preferably, but not necessarily limited to, a human subject. The subject may be male or female, and is preferably female, and may be of any race or ethnicity, including, but not limited to, Caucasian, African-American, African, Asian, Hispanic, Indian, etc. Subject as used herein may also include an animal, particularly a mammal such as a canine, feline, bovine, caprine, equine, ovine, porcine, rodent (e.g., a rat and mouse), a lagomorph, a primate (including non-human primate), etc., that may be treated in accordance with the methods of the present invention or screened for veterinary medicine or pharmaceutical drug development purposes. A subject according to some embodiments of the present invention include a patient, human or otherwise, in need of therapeutic treatment of testosterone deficiency, including hypogonadism.

"Treatment," as used herein, includes any drug, drug product, method, procedure, lifestyle change, or other adjustment introduced in attempt to effect a change in a particular aspect of a subject's health (i.e., directed to a particular disease, disorder, or condition).

"Drug" or "drug substance," as used herein, refers to an active ingredient, such as a chemical entity or biological entity, or combinations of chemical entities and/or biological entities, suitable to be administered to a male subject to treat testosterone deficiency, including hypogonadism. In accordance with the present invention, the drug or drug substance is testosterone or a pharmaceutically acceptable salt or ester thereof.

The term "drug product," as used herein, is synonymous with the terms

"medicine," "medicament," "therapeutic intervention," or "pharmaceutical product." Most preferably, a drug product is approved by a government agency for use in accordance with the methods of the present invention. A drug product, in accordance with the present invention, is an intranasal gel formulated with a drug substance, i.e.,

testosterone.

"Disease," "disorder," and "condition" are commonly recognized in the art and designate the presence of signs and/or symptoms in an individual or patient that are generally recognized as abnormal and/or undesirable. Diseases or conditions may be diagnosed and categorized based on pathological changes. The disease or condition may be selected from the types of diseases listed in standard texts, such as Harrison's Principles of Internal Medicine, 1997, or Robbins Pathologic Basis of Disease, 1998.

As used herein, "diagnosing" or "identifying a patient or subject having

testosterone deficiency, such as hypogonadism, refers to a process of determining if an individual is afflicted with testosterone deficiency, such as hypogonadism.

As used herein, "control subject" means a subject that has not been diagnosed with testosterone deficiency or hypogonadism and/or does not exhibit any detectable symptoms associated with these diseases. A "control subject" also means a subject that is not at risk of developing testosterone deficiency or hypogonadism, as defined herein.

The testosterone gel formulations of the invention are viscous and thixotropic, oil- based formulations containing a solution of testosterone intended for intranasal application. The non-irritating formulation is designed to adhere to the inner nose. In addition, it acts as a controlling matrix, thus allowing sustained drug delivery through the nasal mucosa.

Other pharmacologically inactive ingredients in the testosterone intranasal gel are castor oil USP, oleoyi macrogolglycerides EP and colloidal silicon dioxide NF. None of these excipients are of human or animal origin. All excipients are well-known and listed in the "Inactive Ingredient" list for Approved Drug Products issued by the FDA.

The steroid hormone testosterone is the active ingredient in the testosterone gel formulations of the invention. The manufacture of the drug substance presents no potential risk for humans; the synthesis route is well-characterized.

Table 1 : Nomenclature Testosterone

Structural Formula

Molecular Formula

Relative Molecular Mass

288.4

The physical chemical properties of testosterone are listed in Table 2. Table 2: General Properties of Testosterone

Testosterone, for testosterone gel formulations of the invention, appears as white or slightly creamy white crystals or crystalline powder. It is freely soluble in methanol and ethanol, soluble in acetone and isopropanol and insoluble in n-heptane. It can also be considered as insoluble in water (S₂o°c=2.41 x 10^"2 g/L ± 0.04 x 10^"2 g/L); its n- Octanol/Water partition coefficient (log Pow determined by HPLC) is 2.84. The solubility of testosterone in oils was determined to be 0.8% in isopropylmyristate, 0.5% in peanut oil, 0.6% in soybean oil, 0.5% in corn oil, 0.7% in cottonseed oil and up to 4% in castor oil.

Because testosterone is fully dissolved within the formulations of the present invention, physical characteristics of the drug substance do not influence the

performance of the drug product, testosterone gel formulations of the invention. The manufacturability of testosterone gel formulations of the invention, however is

influenced by the particle size of testosterone. When using a particle size of 50% < 25 microns, 90% < 50 microns the solubility of the drug substance in the matrix is especially favorable.

In accordance with the present invention, the testosterone drug can be in, for instance, crystalline, amorphous, micronized, non-micronized, powder, small particle or large particle form when formulating to intranasal testosterone gels of the present invention. An Exemplary range of testosterone particle sizes include from about 0.5 microns to about 200 microns. Preferably, the testosterone particle size is in a range of from about 5 microns to about 100 microns, and the testosterone is in crystalline or amorphous and non-micronized or micronized form. Preferably, the testosterone is in crystalline or amorphous micronized form.

The molecular structure of testosterone contains no functional groups that can be protonated or deprotonated in the physiological pH-range. Therefore testosterone is to be considered as a neutral molecule with no pKa value in the range 1 -14. Because it is neutral, testosterone is compatible with excipients.

According to the "Handbook of Pharmaceutical Additives" oleoyi

polyoxylglycerides are used as hydrophilic oil for topicals, injectables and nasals. In FDA-approved medicinal products it is used as co-emulsifier in topical

emulsions/lotions/creams and in vaginal emulsions/creams. In France this excipient is approved for nasal preparations such as "Rhino-Sulforgan" (Laboratoire Jolly-Jatel, France; containing 10% oleoyi polyoxylglycerides) and "Huile Gomenolee 2%

("Laboratoire Gomenol, France; containing 10% oleoyi polyoxylglycerides). Hence, like for castor oil it can be deduced that oleoyi polyoxylglycerides is suitable for an

application route where safety and tolerability are of highest importance (e.g. injectables and nasal or vaginal preparations).

Oleoyi macrogolglycerides are also referred to as Labrafil M 1944 CS, apricot kernel oil PEG-6 esters, Peglicol-5-oleate, mixture of glycerides and polyethylene esters. The castor oil, which is used as a solvent for testosterone gel formulations of the invention, is a fixed oil. Such oils have the advantage of being non-volatile or spreading (in contrast to essential oils or liquid paraffin), but have the disadvantage of being hydrophobic. The nasal mucosa contains 95-97% water. Without the oleoyl macrogol-glycerides, the castor oil containing the active ingredient would form a non- interactive layer on the mucous membrane. In order to achieve adequate contact between the castor oil layer and the mucous membrane, the hydrophilic oleoyl macrogol-glycerides oil is added to the formulation to form an emulsion between the castor oil and the mucosa fluid.

Oleoyl macrogolglycerides are used in semi-solids at concentrations ranging from about 3 to 20%, depending on the application. The amount of oleoyl macrogol- glycerides in testosterone gel formulations of the invention is high enough to allow for a better contact of the carrier oil with the mucous membrane and low enough to have minimal impact on the amount of testosterone that can be incorporated into the carrier oil. A favourable concentration of oleoyl microgol-glycerides in testosterone gel formulations of the invention is found to be 4% of the formulation.

According to the "Handbook of Pharmaceutical Additives" colloidal silicon dioxide is used as an oil adsorbent, thermal stabiliser and gellant. In FDA-approved medicinal products it is used in dental gels, sublingual tablets, endocervical gel, suppositories, vaginal emulsions/creams/tablets/tampons and capsules for inhalation. Furthermore, it is used as an excipient in "Testoderm with adhesives" (Alza Corporation, approved in 1996) a testosterone transdermal patch. Hence, it can be deduced that colloidal silicon dioxide is suitable for an application route where safety and tolerability are of highest importance (e.g. inhalations, endocervical, vaginal or rectal preparations).

For clinical trial supplies, testosterone intranasal gel is supplied in unit-dose syringes consisting of a syringe body made from polypropylene, a plunger moulded from polyethylene and a syringe cap made from high density polyethylene. The syringes are wrapped in aluminum foil as secondary packaging. The pre-filled unit-dose syringes used in accordance with the study in the Examples are filled as follows: (a) 4% testosterone intranasal bio-adhesive gel - 148 microliters and 5.92 mgs of testosterone; (b) 4.5% testosterone intranasal bio-adhesive gel - 148 microliters and 6.66 mgs of testosterone; and (c) 4.5% testosterone intranasal bio-adhesive gel - 148 microliters and 7.785 mgs of testosterone.

The oil in testosterone gel formulations of the invention is thickened with colloidal silicon dioxide, which acts as a gel-forming agent. This compound is used commonly for stiffening oleogels.

The intended dosage form for testosterone gel formulations of the invention is a semi-solid, not a liquid. The formulation is thickened with colloidal silicon dioxide. It is believed that colloidal silicon dioxide contributes to the thixotropic properties of the gel, simplifying drug delivery to the nostril.

Colloidal silicon dioxide is generally an inert material which is well tolerated as an excipient in mucosal applications such as suppositories. Colloidal silicon dioxide is typically used in these preparations at concentrations ranging from about 0.5 to 10%. The concentration of colloidal silicon dioxide in testosterone gel formulations of the invention is high enough to achieve gel formation but at a level that has minimal impact on testosterone incorporation into the carrier oil.

Preferably, the intranasal testosterone gels of the present invention have in general, a viscosity in the range of between about 3,000 cps and about 27,000 cps. It should nevertheless be understood by those versed in this art that, while the above- mentioned viscosity range is believed to be a preferred viscosity range, any suitable viscosities or viscosity ranges that do not defeat the objectives of the present invention are contemplated.

A detailed description of batches of a testosterone gel formulation of the invention is shown in Table 3.

Table 3: Composition of a testosterone gel formulation of the invention

The testosterone gel formulations of the invention are stored at room

temperature (20-25 °C or 68 to 77 °F). Temperature excursions from 15 to 30 °C or 59 to 86 °F are permissible for the testosterone gel formulations of the inventions. The stability data supports a 12-month shelf life. Unit dose syringes are chosen for the primary packaging of the clinical materials for the clinical trial described below to allow for ease of dosing, ability to generate multiple doses by varying the fill volume and consistency of dose delivered. The syringe consists of a syringe body, a plunger and a syringe cap. The syringes body is moulded from polypropylene, the plunger is moulded from polyethylene and the cap is HDPE. These syringes are designed and

manufactured to deliver sterile and non-sterile solutions, liquids and gels at low volumes. For additional protection from the environment (i.e., exposure to dirt, light, humidity and oxygen), the syringes are packed in a foil-laminate overwrap pouch.

The syringes and caps are designed for use in a clinical setting and meet the requirements of the EU Medical Devices Directive 93/42/EEC of June 14, 1993 and as amended. As this container closure is only intended for use in this portion of the clinical program, no additional studies will be performed on the syringe and syringe

components.

For a further element of protection, two syringes are contained in secondary packaging consisting of an aluminium foil pouch. Two syringes are packaged in the aluminium foil pouch and each pouch is sealed. The pouch consists of a flexible, 3-layered-foil-laminate of a) polyester 12 micron, b) aluminum 12 micron and c) a polyethylene 75 micron. It is manufactured by Floeter Flexibles GmbH, and supplied under the name "CLIMAPAC II 12-12-75".

The invention provides for intranasal bio-adhesive gel formulations of testosterone to be administered intranasally, wherein the dosage of the formulation is from about 4.0% or 4.5% testosterone by weight of said gel.

The methods and treatments of the present invention are suitable for TRT in men and are especially suitable to treat testosterone deficient male subjects, such as those who are diagnosed with hypogonadism.

Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, suitable methods and materials are described below. All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and not intended to be limiting.

EXAMPLES

Having now generally described the invention, the same will be more readily understood through reference to the following Examples which are provided by way of illustration, and are not intended to be limiting of the present invention, unless specified.

The following examples are put forth for illustrative purposes only and are not intended to limit the scope of what the inventors regard as their invention.

EXAMPLE 1

Description and Composition of Testosterone

Gel Formulations of the Invention The compositions of three different concentrations of the drug product to be administered in this clinical trial are provided in the tables below.

Description of Dosage Form

The testosterone gel formulations of the invention are viscous and thixotropic, oil- based formulations containing solubilized testosterone intended for intranasal application. The drug product is formulated with the compendial inactive ingredients: castor oil, oleoyl polyoxylglycerides and colloidal silicon dioxide.

Two different doses of the testosterone gel formulations of the invention are intranasally administered: 0.4% w/w and 0.45% w/w. An overage is added to each syringe to account for the gel that is retained in the syringe after dosing. This overage remains consistent at 23 μΙ, regardless of volume of gel in the syringe.

4.0% and 4.5% Intranasal Testosterone Compositions

Table 1 : Components, Quantity, Quality Standards and Function - 4.0% testosterone gel formulation of the invention

Table 1 A Components, Quantity, Quality Standards and Function - 0.6% testosterone gel formulation of the invention

Table 2: Components, Quantity, Quality Standards and Function, TBS-1 : 5.6mg/125^/ syringe (4.5% gel)

Table 3: Components, Quantity, Quality Standards and Function, TBS-1 : 6.75 mg/150 μΙ/ syringe (4.5% gel)

Container

Testosterone gel formulations of the invention are supplied in unit-dose polypropylene syringes. Two syringes of each dosage are packaged in a protective aluminium foil pouch.

EXAMPLE 2

Intranasal Testosterone Gel Formulations

The testosterone gel formulations of the invention are formulations of

testosterone in an intranasal gel proposed for assessing the pharmacokinetic of two different doses of testosterone gel formulations of the invention for testosterone gel formulations of the invention in hypogonadal men.

The active ingredient, testosterone, is sourced from Bayer Schering.

Challenges for nasal delivery include:

• requirements for larger particles than pulmonary administration (i.e., only

particles > 10 μιτι are sufficiently heavy to avoid entering the respiratory tract);

• concentrations must be higher due to the smaller volumes that can be

administered;

• rapid clearance of the therapeutic agent from the site of deposition results in a shorter time available for absorption;

• potential for local tissue irritation; and

• limited formulation manipulation possibilities to alter drug delivery profiles.

Testosterone is indicated for TRT in males who are testosterone deficient for any number of reasons, including hypogonadism. The currently available options for administration of testosterone are oral, buccal, injectable, implantable and transdermal (patches and gels).

An intranasal testosterone (3.2%) gel is developed for the treatment of hypogonadism in men and has been administered to hypogonadal men in several clinical trials, see e.g., Mattern, C. et al., 2008 The Aging Male 1 1 (4):171 -178 (Dec

2008, which is incorporated herein by reference in its entirety. In a phase II study NCT00975650, which was performed in the U.S. in testosterone deficient men and which was supplemental to the Romanian study reported in Mattern et al., Supra, the 3.2% intranasal gel as reported in Mattern et al, Supra, failed to reach testosterone plasma levels required by the FDA to support TRT efficacy in testosterone deficient men. The intranasal testosterone gels formulations of the present invention are developed at concentrations of about 4.0% and 4.5% testosterone.

EXAMPLE 3

Overages

[Testosterone Gel Formulations of the Invention!

No overage is added to the formulation. An overage is added to each syringe to account for the gel that is retained in the syringe after dosing. This overage remains consistent at 23 μΙ, regardless of volume of gel in the syringe. The theoretical fill and dispensed amounts for testosterone gel formulations of the invention are provided below.

Syringe Dosage Theoretical Fill Theoretical Dispensed

Volume (μΙ)

4.0% Testosterone 148 125

Gel formulation of

the Invention

4.5% Testosterone 148 125

Gel formulation of

the Invention

4.5% Testosterone 173 150

Gel formulation of

the Invention EXAMPLE 4

Physicochemical and Biological Properties

[Testosterone Gel Formulations of the Invention!

The testosterone bio-adhesive gel formulations of the invention has a viscosity in the range of 3,000 to 10,000 mPa x sec. The viscosity is important because it facilitates maintenance of the gel in the nasal cavity in contact with the nasal mucosa. When the viscosity is less than approximately 3,000 mPa x sec (i.e., 3,000 centipoise), the gel tends to be drawn by gravity out of the nasal cavity.

EXAMPLE 5

Batch Formula

[testosterone gel formulations of the invention]

Three different concentrations of testosterone gel formulations of the invention, 0.15%, 0.45% and 0.6%, are manufactured for the proposed clinical trial. The batch formulae for these batches are presented in Table 5 below.

Table 5: 200 KG Batch Formulae for 4.0% and 4.5% bio-adhesive testosterone gel formulations of the invention at the 8 kg Batch Size

EXAMPLE 6

Manufacturing Process and Process Controls

[Testosterone Gel Formulations of the Invention!

Material is manufactured according to the following process.

Flow Diagram of the Manufacturing Process

Compound Activity

Mixing of the Ingredients - Bulk Gel

The Pre-Mix is prepared by mixing, with a propeller mixer, the full amount of Testosterone with portion 1 of the castor oil for 10 minutes. Mixture I is prepared by adding the Pre-Mix to the remaining castor oil and mixing for 60 minutes. The product temperature is maintained below 50 °C for the entire mixing process.

The oleoyl polyxoylglycerides are pre-heated to 40 - 50 °C and mixed for 10 minutes before being added to Mixture I. This is identified as Mixture II. It is mixed for 45 minutes while maintaining product temperature below 50 °C. Mixture II is then screened through a sieve to remove any un-dissolved Testosterone aggregates.

Mixture III is prepared by adding the colloidal silicon dioxide to Mixture II and mixing for 15 minutes while maintaining product temperature below 50 °C. A visual check is conducted after this step, to ensure that the gel is clear.

At the completion of mixing the gel is stirred and cooled to a product temperature below 30 °C. The product is then discharged into stainless steel drums and the bulk gel sample is taken for analytical testing.

Filling and Packaging - Clinical Supplies

After release of the final gel mixture by the quality control laboratory, the filling and packaging process is carried out by filling a pre-determined volume into the syringe followed by the application of the syringe cap. Two syringes are packaged into a foil pouch.

The syringes are filled using a pipette with the gel taken from a holding tank. The tip of the pipette is discarded after the syringe is filled and the syringe cap is applied. Each syringe is individually labeled.

Following the application of the label, two syringes are packaged in a pre-formed foil pouch and the pouch is sealed. Each pouch is labelled.

EXAMPLE 7

Drug Product TBS-1

The drug product, TBS-1 , is a viscous and thixotropic, oil-based formulation containing solubilized testosterone intended for intranasal application for the treatment of hypogonadism in men. The drug product is formulated with the following compendial inactive ingredients: castor oil, oleoyl macrogolglycerides, and colloidal silicon dioxide.

To allow for different doses to be administered in the Phase II program, a syringe is used as the unit dose container for the clinical supplies.

The syringes intended for use in the clinical program are needleless and a twist off cap is applied to the end of the syringe. The syringe consists of the syringe barrel and the plunger. The syringe barrel is formed from polypropylene. The plunger is formed from polyethylene. The syringe cap is formed from High Density Polyethylene (HDPE).

New dose formulation of TBS-1 is manufactured for clinical study TBS-1 -2010-01 (submitted to the Agency on 07/28/2010 Serial Number 0019). The quantity of testosterone in these formulations is 4.0% and 4.5% along with an adjustment of the amount of castor oil. The precise formulation is listed in Tables 1 , 2 and 3. TBS-1 is concentrated so that the same dose is administered intranasally in a smaller volume.

Three different concentrations of TBS-1 gel will be administered in this clinical trial 5.0mg/125Ml/ syringe (4.0% gel), 5.6mg/125Ml/ syringe (4.5% gel) and 6.75 mg/150 μΙ/ syringe (4.5% gel). An overage is added to each syringe to account for the gel that is retained in the syringe after dosing. This overage remains consistent regardless of volume of gel in the syringe.

Composition

The compositions of the three different concentrations of the drug product to be administered in this clinical trial are provided in Tables 1 , 2 and 3.

Table 1 : Components, Quantity, Quality Standards and Function, TBS-1 : 5.0mg/125Ml/syringe (4.0% gel)

Container

TBS-1 gel is supplied in unit-dose polypropylene syringes. Two syringes of each dosage are packaged in a protective aluminium foil pouch. Control of Drug Products [TBS-1 , Gel]

Specification [TBS-1 , Gel]

The TBS-1 bulk gel is tested to the following specifications for batch release.

Table 1 : Specification for TBS-1 Bulk Gel

Finished product TBS-1 gel packaged in unit dose syringes is tested to the following specifications for batch release.

Table 2: Specification for TBS-1 Gel Packaged in Unit Dose Syringes

Impurity I - Δ-6-testosterone < 0.2%

Each individual unknown impurity < 0.1 % Total impurities < 1.0%

Assay HPLC USP <621 > 95 - 105%

Microbial limits USP <61 > and <62> TAMC < 10² cf u/g

TYMC < 10 cf u/g P. aeruginosa 0/g S. aureus 0/g

Mass variation USP <905> Complies with USP <905>

TAMC - total aerobic microbial count

TYMC - total combined yeast/mould count

Batch Analyses [TBS-1 , Gel]

One preliminary batch (Batch No. 100304), four pilot scale batches (Batch No. ED 187, ED 188, ED 189 and ED 014), two pilot non-GMP batches (NA 09081 1 -1 and NA090723-1 ) and three commercial scale (Batch 9256, 0823 and 0743) batches of TBS-1 have been produced. Data from the new batches, 0823 and 0743 are described in Tables 4 and 5.

Table 3: Description of TBS-1 Batches

Batch 0743, bulk 4.5% testosterone gel, is filled into two different dosage strengths, 5.6mg (Batch 0943) and 6.75mg (Batch 0744), by varying the weight of the gel in the finish syringe. Batch 0823, bulk 4.0% testosterone gel, is filled as one dose strength, 5.0mg (Batch 0942).

Table 4: Batch Analysis - TBS-1 Batches 0743 and 0823

TAMC - total aerobic microbial count

TYMC - total combined yeast/mould count Table 5: Batch Analysis - TBS-1 Batches 00744, 0942 and 0943

Stability [TBS-1 , Gel]

Stability Summary and Conclusions [TBS-1 , Gel]

This section has been amended to include additional data on the on-going stability studies for the initial stability batches and to provide stability data on the drug product in the syringes utilized for the Phase II clinical study. Only the updated sections and new information have been included for review. All stability studies of TBS-1 gel have been performed by ACC GmbH Analytical Clinical Concepts, Schontalweg 9-1 1 , 63849 Leidersbach/Aschaffenburg, Germany. Stability studies that meet ICH requirements are on-going.

Table 1 : Stability Studies Conducted in Support of TBS-1

Study Type Container Drug Product Storage Stability Study

Closure Batch No. Conditions Data End

System available

ICH White LDPE ED 187C 25°C/60% RH 12 months Study

unit dose ED 188 40°C/75% RH 6 months completed container;

ED 189

sterile air in

ICH pressure El 014 25°C/60% RH 36 months Study

cushion; plus a 42 completed aluminum month pouch analysis

ICH secondary ED 187B 9 hours≥ 200 Full Study

Photostability package (no Wh/m² (300- exposure completed nitrogen) 400 nm)

22 hours 1 .2

Mill. Lxh.

(400-800 nm)

Thermal Cycling ED 188 12 hr -20 ^<C 4 weeks Study

cycle to completed

12 hr + 40 ^<C

ICH Syringe with Pilot Scale (non 25°C/60% RH 6 months Study

Syringe Cap GMP) 40°C/75% RH completed

4.0 mg

5.5 mg

7.0 mg

ICH Stainless 9256 Ambient 6 months On-going

Steel Drum temperature

under

Nitrogen

ICH Syringe with Bulk 9256 25°C/60% RH 6 months On-going

Syringe Cap 9445 - 4.0 mg 40°C/75% RH

9246 - 5.5 mg

9247 - 7.0 mg

ICH Stainless 0743 25°C/60% RH Initial Ongoing

Steel Drum 0823 40°C/75% RH

under Nitrogen

ICH Syringe with 0943 25°C/60% RH initial Ongoing

Syringe Cap 40°C/75% RH

Overall, stability data provided in this section are concluded to support a 24 month "use by" period for TBS-1 stored at controlled room temperature conditions [i.e., 25^QC (77^QF); excursions 15-30^QC (59-86^QF)]. The data also show that special storage conditions for the drug product are not required. The packaging configuration is adequate to protect the drug product from light and the drug product does not degrade or change physically following exposure to temperature cycling stress.

The clinical supplies are applied a 1 year re-test period, when stored at controlled room temperature conditions [i.e., 25^QC (77^QF); excursions 15-30^QC (59-86^QF)], to reflect the duration of the trial and the data available. As additional data is available the re-test period will be extended as appropriate.

Stability Data [TBS-1 , Gel]

In this section, the updated stability data tables for a commercial size bulk Batch 9256, 0743 and 0823 and finish product lots 9445, 9446, 9447, 0943 are provided.

A 6 month real time stability program is ongoing on the commercial scale bulk (Batch 9256). A 36 month real time and a 6 month accelerated stability program is ongoing on three different doses of Batch 9256 packaged in 1 ml syringes: Batch 9445 4.0 mg (3.2% gel), Batch 9446 5.5 mg (3.2% gel), Batch 9447 7.0 mg (3.2% gel).

A 6 month real time stability program is underway on the commercial scale bulk batch 0743 (4.5% gel) and 0823 (4.0% gel). A 36 month real time and a 6 month accelerated stability program is underway on Batch 0943 (bulk Batch 0743 filled in 1 ml syringes).

Table 2: Stability Schedule for Commerical Scale Bulk TBS-1 gel and Finished Product Filled in 1 ml Syringes Completed Test Intervals

Storage Conditions (°C, % RH) Product

(Outstanding Test Intervals)

Ambient temperature 9256 0m, 3m, 6m

25±2°C, 60 ±5% 9445 0m, 6m (12m, 24m, 36m)

40±2°C, 75 ±5% 9445 0m, 3m, 6m

0m, 6m ( 9m, 18m, 30m,

25±2°C, 60 ±5% 9446

36m)

40±2°C, 75 ±5% 9446 0m, 3m, 6m

25±2Ό, 60 ±5% 9447 Om, 6m, (12m, 24m, 36m)

40±2°C, 75 ±5% 9447 Om, 3m, 6m

Om, (3m, 9m, 18m, 30m,

25±2Ό, 60 ±5% 0943

36m)

40±2°C, 75 ±5% 0943 Om, (3m, 6m)

Ambient temperature 0743 Om, (3m, 6m)

Ambient temperature 0823 Om, (3m, 6m)

Table 3: Stability Data TBS-1 Batch 9256 (3.2% Bulk Gel) Manufactured July 2009 Stored at Ambient Temperature

Acid value FIPO ( mg KOH/g) 1 .98 2.00 2.16

Peroxide FIPO (meq 0₂/kg) 3.56 3.16 2.63 value

Identification a. Retention time Complies Complies Complies

corresponds to RS

b. UV spectrum

corresponds to RS Complies Complies Complies

Impurities Imp C < 0.5 % 0.166 % 0.148 % 0.189%

Imp 1 < 0.1 % < 0.05 % 0.05 % <0.05%

Each individual unknown 0.064 % 0.05 % 0.075% imp. < 0.1 %

Total imp. < 1 .0 % 0.230 % 0.198 % 0.264%

Imp. D < 0.2 % < 0.2 % < 0.2 % 0.2%

Assay 95.0 - 105 % 99.4 % 98.3 % 100.4%

Microbial TAMC < 10 cfu/g < 10 cfu/g < 1 0 cfu/g < 10 cfu/g limits

TYMC < 10 cfu/g < 10 cfu/g < 1 0 cfu/g < 10 cfu/g

S. aureus 0/g Not detected/g Not detected/g Not detected/g

P. aeruginosa 0/g Not detected/g Not detected/g Not detected/g

Table 4: Stability Data 4.0 mg TBS-1 Batch 9445 (3.2 % gel) 1 ml Syringe (25 ± 2 °C, 60 ± 5 % RH, horizontal)

Table 5: Stability Data 4.0 mg TBS-1 Batch 9445 (3.2 % gel) 1 ml Syringe, (40 ± 2 °C, 75 ± 5 % RH, horizontal)

Table 6: Stability Data 5.5 mg TBS-1 Batch 9446 (3.2 % gel) 1 ml Syringe (25 ± 2 °C, 60 ± 5 % RH, horizontal)

Table 7: Stability Data 5.5 mg TBS-1 Batch 9446 (3.2 % gel) 1 ml Syringe (40 ± 2 °C, 75 ± 5 % RH, horizontal)

Each individual unknown < 0.05 % Rel RT 0.38:

imp. < 0.1 % 0.102%

Rel RT 3.01 :

0.070

Total imp. < 1 .0 % 0.125% 0.299%

Imp. D < 0.2 % < 0.2 % < 0.2 %

Assay 95.0 - 1 05 % 99.1 % 97.9%

Microbial TAMC < 1 0 cfu/g < 1 0 cfu/g < 10 cfu/g

limits

TYMC < 1 0 cfu/g < 1 0 cfu/g < 10 cfu/g

S. aureus 0/g Not detected/g Not detected/g

P. aeruginosa 0/g Not detected/g Not detected/g

Table 8: Stability Data 7.0 mg TBS-1 Batch 9447 (3.2 % gel) 1 ml Syringe (25 ± 2 °C, 60 ± 5 % RH, horizontal)

S. aureus 0/g Not detected/g

P. aeruginosa 0/g Not detected/g

Table 9: Stability Data 7.0 mg TBS-1 Batch 9447 (3.2 % gel) 1 ml Syringe (40 ± 2 °C, 75 ± 5 % RH., horizontal)

Table 10: Stability Data 5.6 mg TBS-1 Batch 0943 (4.5% gel) 1 ml Syringe (25 ± 2 °C, 60 ± 5 % RH, horizontal)

Appearance Slightly yellow gel Complies

Colour of Colour < 250 Complies

formulation

Impurities Imp C < 0.5 % 0.3%

Imp I < 0.1 % < 0.05 %

Each individual unknown < 0.05 %

imp. < 0.1 %

Total imp. < 1 .0 % 0.3

Assay 95.0 - 1 05 % 100%

Microbial limits TAMC < 1 0 cfu/g Complies

TYMC < 1 0 cfu/g Complies

S. aureus 0/g Complies

P. aeruginosa 0/g Complies

Table 11 : Stability Data 5.6 mg TBS-1 Batch 0943 (4.5% gel) 1 ml Syringe (40 ± 2 °C, 75 ± 5 % RH, horizontal)

P. aeruginosa 0/g Complies

Table 12: Stability Data TBS-1 Batch 0743 (4.5 % gel) Bulk Stored at Ambient Temperature

Table 14: Stability Data TBS-1 Batch 0823 (4.5 % gel) Bulk Stored at Ambient Temperature

Total imp. < 1 .0 % 0.3

Assay 95.0 - 1 05 % 100%

Microbial limits TAMC < 1 0 cfu/g Complies

TYMC < 1 0 cfu/g Complies

S. aureus 0/g Complies

P. aeruginosa 0/g Complies

EXAMPLE 8

Phase 2 study designed to investigate the intranasal absorption of 4% of the drug three times a day and 4.5% of the drug

administered twice a day and three times a day

This is a Phase 2 study designed to investigate the intranasal absorption of 4% of the drug three times a day and 4.5% of the drug administered twice a day and three times a day, and to compare the absorption from the previous study in the same subjects that responded with a 3.2% testosterone gel. In the previous study, Nasobol- 01 -2009, a 3.2% Testosterone gel is used to deliver 4.0 mg, 5.5 mg and 7.0 mg of Testosterone intra-nasally using gel volumes of 125 μΙ_, 172 μΙ_ and 219 μΙ_,

respectively. In this study, 5.0 mg, 5.65 mg and 6.75 mg of Testosterone is

administered in gel volumes of 125 μΙ_, 125 μΙ_, and 150 μΙ_, respectively. This study allowed investigating the delivery of similar Testosterone amounts in much smaller volumes.

In this open label study, subjects are equally randomized into three treatment arms. The treatments are administered for one week, in a parallel design. At the end of one week, the three treatments are compared by conducting a 24-hour pharmacokinetic investigation of the systemic absorption of the drug product testosterone and its two physiological metabolites dihydrotestosterone and estradiol.

8. Study Objectives

8.1 Primary Objective The primary objective of this study is to determine the bioavailability through PK analysis of a 4% TBS-1 gel (applied three times a day) and 4.5% TBS-1 gel (applied twice a day and three times a day) in hypogonadal men.

8.2 Secondary Objective

The secondary objective of the study is to establish the safety profile for TBS-1 .

9. Investigational Plan

9.1 Overall Study Design and Plan Description

This is an open label, randomized, balanced, three treatment (4.0% t.i.d. 4.5% b.i.d. and 4.5% t.i.d.), parallel design, pharmacokinetic study of TBS-1 , administered intra-nasally. The serum concentrations of total Testosterone, Dihydrotestosterone and Estradiol are measured using validated LC/MS methods.

Hypogonadal subjects are required to visit the Clinic on three (3) occasions, of which one (1 ) visit (Visit 3) required an overnight stay for the previously described 24-hour pharmacokinetic profile.

The following pharmacokinetic parameters are determined for all subjects:

• AUCo C_aVg, Cmin, C_max, Uax, PTF and PTS means and standard error of the

means are calculated for the 24-hour interval.

• The percentage of subjects with a C_avg for Testosterone, Dihydrotestosterone and Estradiol, below, within and above the Reference Range for the respective analyte is calculated.

Erythrocytosis, anemia and infections are monitored by measuring complete blood counts at screening and the Close-Out visit.

It is planned to enroll approximately 30 subjects. Twenty-two (22) subjects completed the study. Study participation is 2 to 3 weeks.

9.2 Discussion of Study Design

Testosterone therapy for hypogonadal men should correct the clinical

abnormalities of Testosterone deficiency, including disturbances of sexual function. Testosterone decreases body fat and increases lean muscle mass and bone density with minimal adverse effects. There are several Testosterone replacement products available, which can be given intra-muscularly, orally, as a buccal tablet to the gums, or topically as a patch or gel. Current replacement therapies have certain drawbacks. Testosterone injections show wide fluctuations in serum Testosterone levels often at values above the reference range (5). Testosterone patches have a high rate of skin irritation (6,7).

Testosterone gels although popular in North America are not always convenient and have a risk of skin-to-skin transfer to family members (8,9). Oral Testosterone undecanoate needs to be administered with a high fat meal and levels obtained are often low (10-12).

Intra-nasal administration of a new formulation of Testosterone (TBS-1 ) has been shown to be effectively absorbed and shows excellent potential as a therapeutic product in the treatment of male hypogonadism (13). The nasal mucosa offers an alternative route of administration that is not subject to the first pass effect, has high permeability and ease of administration with rapid absorption into the systemic circulation producing high plasma levels similar to those observed after intravenous administration.

The advantages of the Testosterone nasal gel, when compared to other formulations, are the following: Convenient application form permitting inconspicuous use, the much smaller amount of active ingredient needed for the subject, and knowing that this type of administration is less likely to contaminate other family members (wife and children).

Several studies have indicated the utility of testosterone administration using the nasal gel. The prior study conducted in 2009 is to demonstrate the efficacy of TBS-1 in the treatment of hypogonadal men requiring Testosterone replacement therapy.

Efficacy is determined by establishing an optimal pharmacokinetic profile for serum

Testosterone levels following a multiple-dose b.i.d. dosing profile for TBS-1 , using three different strengths of Testosterone (8.0 mg, 1 1 .0 mg and 14.0 mg) and comparing it to that of the active control, Androderm^®. The secondary objective of this study is to establish a safety profile for TBS-1 . This is to be achieved by monitoring adverse and serious adverse events during the course of the entire study, and comparing various safety parameters at follow-up to those obtained at baseline. These safety parameters consisted of vital signs, complete blood counts, a chemistry profile, an endocrine profile, and urinalysis. In addition, changes to the nasal mucosa and to the prostate at follow up are compared to baseline.

An important advantage of the power of the dose finding design of this study is that it minimizes the subject selection bias and the different host groups often observed in sequential study designs.

The three clinical sites are monitored by Schiff & Company to ensure the safety of the Subjects and performance of the clinical study according to ICH E6 and FDA guidelines.

A central laboratory is used for the analysis of hematology and biochemistry parameters in order to obtain consistent and unbiased laboratory results. A second central laboratory is used for the PK analysis.

The following are the specific activities in the study design during the subject visits:

Physical Exam on Screen and Day 8 only. Informed consent will be signed prior to Screening Visit 1 In/Ex Period: Inclusion, and Exclusion Period

² If subject had a prior normal prostate exam in Nasobol-01 -2009, it will not be required.

³ Chemistry Profile: Na/K, Glucose, Urea, Creatinine, Total Bilirubin, Albumin, Calcium, Phosphate, Uric Acid, AST, ALT, ALP, GGT and CK.

⁴ Complete Blood Count and Differential.

⁵ Urine dipstick (no microscopic).

⁶ Cocaine, Cannabinoids, Opiates, Benzodiazepines.

⁷ Urine alcohol by dipstick.

⁸ Serum Testosterone, Dihydrotestosterone & Estradiol will be measured by a reference lab using a validated LC-MS/MS method, for T and DHT and a validated LC-MS/MS or immunoassay method, for Estradiol.

Screening visit 1

• Subjects, after having voluntarily signed the Informed Consent Form, are

interviewed by the Clinical Investigator or his/her designee Physician/Nurse Practitioner who took the medical and physical history, record demographic data, and performed a routine physical examination. Body weight and Height is measured and BMI calculated. Vital signs (seated 5 minutes) are measured (Blood Pressure, Heart Rate, Respiratory Rate, and Body Temperature).

• If the subject had a normal digital rectal exam of the prostate in the recent

Nasobol-01 -2009 trial, it is not repeated.

• The Clinical Investigator assessed the subject study eligibility based on the

inclusion/exclusion criteria, and eligible subjects that are currently on

Testosterone replacement therapy needed to undergo a wash-out period; four (4) weeks for depot products administered intra-muscularly (e.g., Testosterone enanthate 200 mg/mL), and two (2) weeks for products administered orally or topically (patch, gel, or buccal). At the end of the wash-out period, subjects are to return to have their serum Testosterone measured.

• Treatment na^'ive subjects did not require a wash-out period.

• Blood for serum Testosterone is drawn under fasting conditions, at 0900 h ± 30 minutes. The serum Testosterone level must be > 150 ng/dL, and < 300 ng/dL.

• Blood is drawn for Clinical Laboratory investigations after an overnight fast (8-10 hour fast) and included the following:

o Complete Blood Count (Hemoglobin, Hematocrit, MCV, MCHC, RBC, WBC & Differential)

o Clinical Chemistry profile (Na/K, Glucose, Urea, Creatinine, Total Bilirubin, Albumin, Calcium, Phosphate, Uric Acid, AST, ALT, ALP, GGT and CK) o Serum PSA

o Testing for HBV, HCV and HIV (Hepatitis B surface antigen, Hepatitis C antibody, HIV antibodies)

o Whole blood sample for Hemoglobin A1 c

o Urine for dipstick urinalysis

o Urine for Drug screen (Cocaine, Cannabis, Opiates and

Benzodiazepines). Subjects with positive test are not enrolled, unless the positive test is due to interference from a drug prescribed by a Physician o Urine for alcohol testing

• The otorhinolaryngologic nasal endoscopy examination is done by an ENT

specialist.

• Subjects that met all of the inclusion and exclusion criteria are enrolled into the study and randomized into one of three treatment groups (A, B or C).

Visit 2 (day 1 )

• Subjects arrived at the Clinic under fasting conditions (6 - 8 hour fast) at 2000 hours or earlier.

• Instructions are given to subjects on the proper technique for intra-nasal dosing of TBS-1 .

• Blood is drawn at 2045 hours for baseline serum Testosterone,

Dihydrotestosterone, and Estradiol concentrations.

• Vital Signs (seated 5 minutes) are measured (Blood Pressure, Heart Rate,

Respiratory Rate, and Body Temperature) to establish a baseline.

• Subjects are given a one week supply of pouches: 18 pouches for treatment A, 12 pouches for treatment B, and 18 pouches for treatment C. Pouches required for dosing during the pharmacokinetic profile remained with the Clinical

Investigator. Each pouch contained two syringes pre-filled with TBS-1 gel for treatment A, B, or C.

• Subjects administered their first dose of TBS-1 at 2100 hours according to their treatment group.

• Vital Signs are measured at 2200 hours and subjects are sent home with their supply of pouches for their treatment group.

Telephone check (day 4) On Day 4, all subjects are called to check compliance of study drug administration, compliance to abstention from alcohol for 48 hours, and to document any adverse events that may have occurred. Subjects are reminded to bring in all syringes for counting at Visit 3.

Visit 3 (day 7)

• Blood is drawn at 2045 hours for baseline serum Testosterone,

Dihydrotestosterone, and Estradiol concentrations.

• Subject underwent a 24-hour pharmacokinetic profile immediately after the 2100 hour dosing. Vital signs are recorded hourly for two hours post dosing.

• Safety parameters are recorded.

• Subjects remained fasting for two hours post dose and then given supper. After supper, the subjects again fasted overnight and remained fasting until 0900 hours on Day 8. Lunch and supper on Day 8 occurred at the regular times and are not subject to fasting conditions.

Pharmacokinetic blood draws

• Administration of the drug should have occurred at ± 5 minutes from the

indicated time (2100 h and 0700 h for b.i.d. dosing and 2100 h, 0700 h and 1300 h for t.i.d. dosing).

• Blood draws should have been within ± 5 minutes from the indicated times when blood draw intervals are < 30 minutes and within ± 15 minutes when blood draws are > 30 minutes.

• Treatment A: Blood draws for serum Testosterone, Dihydrotestosterone, and Estradiol measurements: Blood draws for t.i.d. dosing are done at the following times after the 2100 hour drug administration; 0.33, 0.66, 1 .0, 1 .5, 2.0, 3.0, 6.0, 9.0, 9.75, 10.33, 10.66, 1 1 .0, 1 1 .5, 12.0, 13.0, 14.0, 15.75, 16.33, 16.66, 17.0, 17.5, 18.0, 20.0, 22.0 and 24.0 hours, (total blood draws; 25 + baseline).

• Treatment B: Blood draws for serum Testosterone, Dihydrotestosterone, and Estradiol measurements: Blood draws for b.i.d. dosing are done at the following times after the 2100 hour drug administration; 0.33, 0.66, 1 .0, 1 .5, 2.0, 3.0, 6.0, 9.0, 9.75, 10.33, 10.66, 1 1 .0, 1 1 .5, 12.0, 13.0, 16.0, 19.0, 22.0, and 24.0 hours, (total blood draws; 19 + baseline).

• Treatment C: Blood draws for serum Testosterone, Dihydrotestosterone, and Estradiol measurements: Blood draws for t.i.d. dosing are done at the following times after the 2100 hour drug administration; 0.33, 0.66, 1 .0, 1 .5, 2.0, 3.0, 6.0, 9.0, 9.75, 10.33, 10.66, 1 1 .0, 1 1 .5, 12.0, 13.0, 14.0, 15.75, 16.33, 16.66, 17.0, 17.5, 18.0, 20.0, 22.0 and 24.0 hours, (total blood draws; 25 + baseline).

• The last blood draw in the pharmacokinetic profile included enough blood to

measure the clinical laboratory safety parameters required at Close-out.

Visit 3 (day 8), close out visit

Subjects underwent the following assessments:

. A routine physical examination including vital signs (Blood Pressure, Heart Rate, Respiratory Rate, and Body Temperature).

. Otorhinolaryngologic nasal examination.

• Blood sample is taken for a Complete Blood Count (Hemoglobin, Hematocrit, RBC, WBC and differential, MCV, MCHC).

• Blood sample for Chemistry Profile (Na/K, glucose, urea, creatinine, calcium, phosphate, uric acid, total bilirubin, albumin, AST, ALT, ALP, GGT, and CK).

• Blood sample for PSA.

• Urine sample for dipstick urinalysis.

9.3 Selection of Study Population

Subjects are included in the study according to the following inclusion/exclusion criteria:

9.3.1 Inclusion Criteria

1 . Males who are responders to high-dose intra-nasal Testosterone in the Nasobol- 01 -2009 trial.

2. Written informed consent.

3. Males between 18 and 80 years of age.

4. Men with primary or secondary hypogonadism and a morning (0900 h ± 30

minutes) serum Testosterone levels >150 ng/dL and < 300 ng/dL, on blood drawn under fasting conditions.

5. BMI between 18.5 - 35 kg/m².

6. All clinical laboratory assessments at the Screening Visit are from blood drawn or urine collected following an overnight fast (10 hours), and are within ±15% of the Clinical Laboratory's reference range, except for serum Testosterone.

7. Normal Otorhinolaryngological nasal endoscopy examination. See Appendix 16.1 .1 for exclusion criteria pertaining to endoscopy examination.

8. Prior, normal prostate examination (no palpable prostatic mass) from the

Nasobol-01 -2009 trial.

9. A serum PSA < 4.0 ng/mL. .2 Exclusion Criteria

Significant inter-current disease of any type, in particular liver, kidney, or heart disease, any form of diabetes mellitus or psychiatric illness.

Limitations in mobility, defined as having difficulty walking two blocks on a level surface or climbing 10 steps

Hematocrit > 54% at screening.

History of cancer, excluding skin cancer.

History of nasal surgery, specifically turbinoplasty, septoplasty, rhinoplasty, "nose job", or sinus surgery.

Subject with prior nasal fractures.

Subject with active allergies, such as rhinitis, rhinorrhea, and nasal congestion. Subject with mucosal inflammatory disorders, specifically pemphigus, and Sjogren's syndrome.

Subject with sinus disease, specifically acute sinusitis, chronic sinusitis, or allergic fungal sinusitis.

History of nasal disorders (e.g., polyposis, recurrent epistaxis ( > 1 nose bleed per month), abuse of nasal decongestants) or sleep apnea.

Subject using any form of intra-nasal medication delivery, specifically nasal corticosteroids and oxymetazoline containing nasal sprays (e.g., Dristan 12-Hour Nasal Spray).

History of severe adverse drug reaction or leucopenia.

History of abnormal bleeding tendencies or thrombophlebitis unrelated to venipuncture or intravenous cannulation.

Positive test for Hepatitis B, Hepatitis C, or HIV.

History of asthma and on-going asthma treatment.

History of sleeping problems.

Smokers (> 10 cigarettes per day).

Regular drinkers of more than four (4) units of alcohol daily (1 unit = 300 ml_ beer, 1 glass wine, 1 measure spirit) or those that may have difficulty in abstaining from alcohol during the 48 hours prior to the 24-hour blood sampling visit.

History of, or current evidence of, abuse of alcohol or any drug substance, licit or illicit; or positive urine drug and alcohol screen for drugs of abuse and alcohol. Current treatment with androgens (e.g., Dehydroepiandrostenedione,

Androstenedione) or anabolic steroids (e.g., Testosterone, Dihydrotestosterone).Treatment with Estrogens, GnRH antagonists, or Growth Hormone, within previous 12 months.

Treatment with drugs which interfere with the metabolism of Testosterone, such as Anastrozole, Clomiphene, Dutasteride, Finasteride, Flutamide, Ketoconazole, Spironolactone and Testolactone.

Androgen treatment within the past four weeks (intramuscular, topical, buccal, etc.).

Subject with poor compliance history or unlikely to maintain attendance.

Participation in any other research study during the conduct of this study or 30 days prior to the initiation of this study, with the exception of Nasobol-01 -2009. 26. Blood donation (usually 550 ml_) at any time during this study, and within the 12 week period before the start of this study.

9.3.3 Removal of Subjects from Therapy or Assessment

Subjects are informed that they are free to withdraw from the study at any time without having to give reasons for their withdrawal, and without consequences for their future medical care. They are asked to inform the investigator immediately of their decision. The subject's participation in the study may have been discontinued for any of the following reasons:

• Subject's own wish.

• Significant non compliance with the study protocol and procedures.

• Inter-current illness which interferes with the progress of the study.

• Intolerable adverse event, including clinically significant abnormal laboratory findings, where, in the opinion of the Clinical Investigator, these could interfere with the subject's safety.

• Clinical Investigator's decision that the withdrawal from the study is in the best interest of the subject.

The Clinical Investigator had the right to terminate a study prematurely for safety reasons, after having informed and consulted with the Sponsor. The Sponsor had the right to terminate the study earlier if the clinical observations collected during the study suggested that it might not be justifiable to continue or for other reasons as described in the contract between Sponsor and the clinical sites (e.g., administrative, regulatory, etc.). However this is not necessary. There are no premature terminations or drops outs from the study.

9.4 Treatments

9.4.1 Treatments Administered

Subjects are centrally randomized to the following treatment groups in order to balance the numbers equally within the groups across the three centers:

• Treatment A (n=10): TBS-1 syringes pre-filled with 125 μΙ_ 4.0% gel to deliver 5.0 mg of Testosterone per nostril (intra-nasal) given t.i.d. at 2100, 0700, and 1300 hours, (total dose 30 mg/day)

• Treatment B (n=10): TBS-1 syringes pre-filled with 150 μΙ_ 4.5% gel to deliver 6.75 mg of Testosterone per nostril (intra-nasal) given b.i.d. at 2100 and 0700 hours, (total dose 27.0 mg/day) • Treatment C (n=10): TBS-1 syringes pre-filled with 125 μΙ_ 4.5% gel to deliver 5.625 mg of Testosterone per nostril (intra-nasal) given t.i.d. at 2100, 0700, and 1300 hours, (total dose 33.75 mg/day)

9.4.2 Identity of Investigational Products

Name of the drug: TBS-1 (Syringes are pre-filled to contain 5.0 mg, 5.625 mg, and 6.75 mg of Testosterone/syringe).

Pharmaceutical form: Gel for nasal administration.

Content: Active ingredient: Testosterone.

Excipients: Silicon dioxide, castor oil, Labrafil^®.

Mode of administration: Nasally, as a single dose to each nostril.

Manufacturer: Haupt Pharma Amareg.

Batch numbers: 0744, 0942, and 0943

Storage conditions: Between 20 - 25^QC.

Packaging

The TBS-1 study drug is delivered to the clinical trial site as a ready-for-use syringe in a foil pouch (two syringes per pouch). Examples of Syringe and Pouch Labels are described in Appendix 4 of the protocol.

9.4.3 Method of Assigning Subjects to Treatment

Subjects who met the entry criteria are assigned randomly on a 1 :1 :1 basis to one of the three treatment groups. At Screening, each subject is assigned a subject number by site in sequential order. Subject numbers consisted of 5 digits. The first 2 digits reflected the site number assigned to the investigator, followed by a 3-digit subject number. For example, 01 -001 indicates site (01 ) and the first subject (001 ).

The subject number was used to identify the subject throughout the study and was entered on all documents. The same subject number was not assigned to more than one subject.

9.4.4 Selection of Doses in the Study In a previous study, Nasobol-01 -2009, a 3.2% Testosterone gel is used to deliver 4.0 mg, 5.5 mg and 7.0 mg of Testosterone intra-nasally using gel volumes of 125 μΙ_, 172 L and 219 μΙ_, respectively. In this study, 5.0 mg, 5.65 mg and 6.75 mg of

Testosterone are administered in gel volumes of 125 μΙ_, 125 μΙ_, and 150 μΙ_, respectively. This study permits the investigation of the delivery of similar Testosterone amounts in much smaller volumes.

9.4.5 Selection and Timing of Dose for Each Subject

This was based on the results of the prior study.

9.4.6 Blinding

There is no blinding, because this is an open label study. The rationale for not blinding is that analytical endpoints, which are quantitative rather than qualitative are measured, and are not subject to any bias being introduced by the subjects or the Investigators.

9.4.7 Prior and Concomitant Therapy

The following medications are prohibited during the course of the study:

Subject using any form of intra-nasal medication delivery, specifically nasal corticosteroids and oxymetazoline containing nasal sprays (e.g., Dristan 12-Hour Nasal

Spray).

Current treatment with androgens (e.g., Dehydroepiandrostenedione,

Androstenedione) or anabolic steroids (e.g., Testosterone, Dihydrotestosterone).

Treatment with Estrogens, GnRH antagonists, or Growth Hormone, within previous 12 months.

Treatment with drugs which interfere with the metabolism of Testosterone, such as; Anastrozole, Clomiphene, Dutasteride, Finasteride, Flutamide, Ketoconazole, Spironolactone and Testolactone.

9.4.8 Treatment Compliance

All drugs are dispensed in accordance with the protocol. It is the Principal

Investigator's responsibility to ensure that an accurate record of drugs issues and return is maintained. At the end of the study, the used original packages are returned to the sponsor for destruction. Drug accountability is verified by the monitors during the course of the study and prior to destruction of remaining study drugs.

During Visit 2, the subjects are given a one-week supply of pouches; 18 pouches for treatment A, 12 pouches for treatment B, and 18 pouches for treatment C. Each pouch contained two syringes prefilled with TBS-one gel for treatment A, B, or C. The subjects are instructed on how to administer the gel and are also given a diary to indicate the times of administration at their home.

9.5 Efficacy and Safety Variables

9.5.1 Efficacy and Safety Measurements Assessed

The primary efficacy parameter is the AUC is obtained in the 24 hours post administration of TBS-1 . From the AUC the 24 hour C_avg is calculated.

• Area under the concentration curve (AUC) for both b.i.d. and t.i.d. dosing is

determined for the 0 to 24 hour time interval using the trapezoidal rule.

• The average concentration in the dosing interval (C_avg ) is calculated from the AUC using the following formula: C_avg = AUC₀-_T / τ, with τ = dosing interval time.

• Peak Trough Fluctuation (PTF) and Peak Trough Swing (PTS) is calculated as follows:

O PTF = (Cmax " Cmin ) / C_avg

O PTS = (Cmax " Cmin ) / Cmin

• Cmin, Cmax, and t_max is taken from the actual measured values. Values are

determined relative to the Testosterone administration time in treated subjects.

• The percent of subjects with 24 hour C_avg values for serum Testosterone, DHT and Estradiol concentration above, within, and below the respective reference range are calculated.

• Additional exploratory analyses of PK parameters may have been performed as necessary.

Analysis of Safety Data

Erythrocytosis, anemia, and infections are monitored by measuring complete blood counts at screening, and the Close-Out visit. An Otorhinolaryngological physician examined subjects and identifies any clinically significant changes to the nasal mucosa at follow up compared to baseline.

Clinical chemistry and urinalysis testing at Screening Visit 1 and at Close Out are assessed, hypo or hyperglycemia, renal function, liver function (hepato-cellular or obstructive liver disease), skeletal/heart muscle damage, and changes in calcium homeostasis.

Serum PSA is measured as a cautionary measure to measure possible changes to the prostate, although changes to the prostate and to serum PSA is not expected in a short treatment time frame.

Measurement of serum Testosterone, Dihydrotestosterone and Estradiol, at Screening Visit 1 and Visit 3 permitted any excursions beyond the upper limit of the reference range for the two physiological products of Testosterone; DHT, and Estradiol to be observed.

The safety analysis is performed on all subjects who received TBS-1 .

Occurrence of adverse events are presented by treatment group, by severity, and by relationship to the study drugs. All adverse events are described and evaluated regarding causality and severity. Adverse events are classified using MedDRA.

However they are very few and all but two are not related to the drug.

Subject Safety

• Monitoring of subjects and emergency procedures: Emergency medication, equipment and Subject gurney are available at the Study Center. During the "at home" phase, the subjects have an emergency call number to be able to contact the Clinical Investigator.

• Adverse events are defined as any untoward medical occurrence in a subject or clinical trial subject having administered a medicinal product and which may or may not have a causal relationship with this treatment. An adverse event can therefore be any unfavorable and unintended sign, laboratory finding, symptom or disease temporally associated with the use of an investigational medicinal product, whether considered related to it or not. Any pre-existing condition during the clinical trial which is worsened during the clinical study is to be considered an adverse event.

• An adverse reaction is defined as any untoward and unintended response to an investigational product related to any dose administered. All adverse reactions judged by either the Clinical Investigator or the Sponsor to have reasonable causal relationship to a medicinal product qualified as adverse reactions. This is meant to convey in general that there is evidence or an argument to suggest a causal relationship.

• An unexpected adverse reaction is defined as an adverse reaction, the nature, or severity of which is not consistent with the applicable product information. A serious adverse event or serious adverse reaction is defined as any untoward medical occurrence or effect that, at any dose, results in death, is life threatening, requires hospitalization or prolongation of existing in-Subject hospitalization, results in persistent or significant disability or incapacity, or is a congenital anomaly or birth defect.

The observation period is extended from the time the subject began the study medication through the end of Visit 3 for hypogonadal subjects. AEs that are continuing at the end of the study period are followed until the Investigator believed that the AEs reached a stable clinical endpoint or are resolved.

The percent of subjects with a serum DHT and Estradiol greater than the upper limit of the reference range, for the respective analytes.

The Day 8 close-out findings are compared to the screening results, and clinically significant changes identified in the following: o Vital Signs and Adverse Events: Blood Pressure, Body Temperature,

Respiratory Rate, Heart Rate,

o Otorhinolaryngological examination.

o Complete Blood Count to evaluate changes in white blood count,

hemoglobin and hematocrit,

o Clinical chemistry profile; Na/K, glucose, urea, creatinine, calcium,

phosphate, uric acid, total bilirubin, albumin, AST, ALT, ALP, GGT, CK, and PSA.

Classifications:

o A serious adverse event (SAE) or serious adverse reaction: Defined as any untoward medical occurrence or effect that at any dose; results in death, is life-threatening, requires in-Subject hospitalization or

prolongation of existing in-Subject hospitalization, results in persistent or significant disability or incapacity, is a congenital anomaly or birth defect, a medically important condition, i.e., the AE jeopardized the subject, or requires intervention to prevent one of the outcomes listed above.

o Non-serious AE: Any AE not meeting the SAE criteria.

o Intensity: An adverse event/reaction is classified as Mild, Moderate, or Severe.

o Causality: The adverse event may be considered an adverse reaction to an investigational medicinal product when a "reasonable causal

relationship" exists between the event and the investigational product. The following degree of causal relationship might be considered:

^■ Definite: plausible temporal relationship with drug administration and withdrawal, and re-appears after drug re-start. ^■ Probable: plausible temporal relationship with drug administration.

^■ Possible: plausible temporal relationship with drug administration but can reasonably be associated to other factors.

^■ Unlikely: does not have plausible temporal relationship with drug administration.

^■ Unknown: no sufficient elements to establish a correlation with drug intake.

^■ Not Related: cannot be correlated to the drug administration.

• Procedure to be followed in the case of adverse events: All adverse events

detected by the Clinical Investigator are recorded in the special section of the Case Report Form. Any event that is classified as serious, regardless of causal relationship, is to have been reported to the CRO and Sponsor within 24 hours. There are no serious adverse events.

9.5.2 Appropriateness of Measurements

All measurements used in this study are standard indicies of efficacy, PK and safety and are generally recognised as reliable, accurate and relevant.

9.5.3. Primary Efficacy Variable(s)

Pharmacokinetic profiles of serum Testosterone for subjects dosed in Treatments A, B, and C that have:

1. A 24 hour C_avg value > 300 ng/dL and < 1050 ng/dL.

2. The percent of subjects in each treatment group with a 24 hour C_avg less than, within and above the serum Testosterone reference range of 300 ng/dL - 1050 ng/dL.

9.6 Data Quality Assurance

The CRF entries are verified by the monitors against source documents. All entries into the database included the CRF and Diary Card subject data, the PK results, and laboratory values. All data is 100% audited after being entered into the database for this report.

9.7 Statistical Methods Planned in the Protocol and Determination of Sample Size

9.7.1 Statistical and Analytical Plans The PK Analysis Plan is described above. The Analysis Plan for the Vital Signs and Laboratory Results are compared baseline results with final visit results after PK analysis. Other data including demographic data is descriptive. No statistical analysis is performed because group sizes are not selected on the basis of statistical

significance.

9.7.2 Determination of Sample Size

Based on the results are obtained from conducting several pharmacokinetic studies in groups of 10 subjects per cohort, these are sufficient for an acceptable description of the pharmacokinetic parameters in this population. As this is a relatively modest Phase II PK study with the intent of investigating two higher concentrations of TBS-1 gel, a true sample size calculation is not performed.

9.8 Changes in the Conduct of the Study or Planned Analysis

The protocol is amended on July 27, 2010. The change requested is in the timing of blood draws. The number of blood draws remained the same. This change is required to enable the full capture of the peak of testosterone absorption following the third TID dosing which occurred at 1300 hours on Day 8 or 1600 hours after the initial 2100 hour drug administration on the previous day (Day 7).

10. STUDY SUBJECTS

10.1 Disposition of Subjects

The study is conducted at three centers located in Miami, FL, Shreveport, LA and Tucson, AZ.

The three treatment groups are equally divided amongst the three sites. Eight Subjects received Treatment A, seven Subjects received Treatments B and C, respectively. A total of 22 subjects are in the study. In addition, five subjects who participated in the previous clinical study failed screening and are therefore not randomized to the study. Table 10.1. Disposition of Subjects by Site and Treatment

10.2 Protocol Deviations

There are no meaningful pharmacokinetic deviations.

11. PHARMACOKINETICS AND STATISTICS

11.1 Datasets Analyzed

The PK population is defined as subjects who receive the Treatment A, B or C, and who complete the study without major protocol violation or for whom the PK profile can be adequately characterized. The PK population is used for the analysis of PK data.

Based on the above criteria, twenty-two (22) subjects are included in the PK population. The numbers of subjects by site and by treatment are displayed below.

Table 11.1.1 : Disposition of Subjects in the PK population:

11.2 Demographic and Other Baseline Characteristics

The demographic data and characteristics are presented by dose group for all the treated subjects in Table 1 1 .2. No meaningful differences are observed amongst the three groups for any of the characteristics. Table 11.2: Summary of Demographic Characteristics-All Subjects

The treated populations for Group A have a mean age of 52.38, for Group B 53.86, and for Group C 51 .57. The standard deviations are 12.55, 1 1 .04, and 9.90, respectively. The ethnic and racial distribution are essentially the same in each group.

11.3 Measurement of Treatments Compliance

Compliance of drug utilization during the home portion of the study is determined by a review of the diaries and used returned pouches and syringes. Although the method is not absolute, it is sufficient to establish reasonable compliance. One subject could not find his diary.

11.4 Pharmacokinetics and Statistical Results

11.4.1 Methods

The blood concentrations are received from ABL and transferred electronically from Trimel Biopharma SRL to the statistical unit of PharmaNet. Testosterone and Dihydrotestosterone serum concentrations are provided in ng/mL. However, the serum concentrations are converted to ng/dL for PK calculation to match the units of the literature's reference ranges.

During the trial, clinical site 1 performs PK sampling one day later than specified in the protocol that is it started on Day 8 rather than Day 7. This change is not planned. Consequently, the actual times are calculated relative to the 2100 drug administration on Day 8 for the subjects of clinical site 1 and the drug administration 21 hOO on Day 7 for the subjects of clinical sites 2 and 3.

For subject No. 02-003, the dosing time is not recorded on Day 7. Consequently, the schedule sampling times are used instead of the actual sampling times for PK calculations. The 16.33 h and 16.67 h samples for subject 01 -001 are drawn at the same time due to technical reason. The schedule sampling time is used for sample 16.33 h while the actual sampling time is used for sample 16.67 h.

Excluding the above exceptions, time deviations during sampling are treated as follows: for all sampling times, the difference between the scheduled and the actual sampling time is considered acceptable if it is less than 1 minute. When the difference exceeded this time limit, the actual sampling times (rounded off to three decimal digits) are used to calculate pharmacokinetic parameters, except for pre-dose samples, which are always reported as zero (0.000), regardless of time deviations. Scheduled sampling times are presented in concentration tables and graphs in the statistical report.

PK calculations are performed using WinNonlin™ version 5.2 (or higher), validated according to industry's expectations and regulatory requirements. Descriptive statistical calculations are also performed using Microsoft^® Office Excel 2003. Microsoft^® Office Excel 2003 and Microsoft^® Office Word 2003 are used for report data tabulation. Descriptive statistics (N, mean, standard deviation (SD), coefficient of variation (CV), median, minimum value (Min.), and maximum value (Min.)) of the serum concentrations versus time as well as all pharmacokinetic parameters are provided for each treatment at each dose level using the evaluable population. All figures are presented using both linear (a) and semi-log (b) scales.

For the calculation of the PK parameters from the last three drug administrations (Treatments A and C: 0 hour to 10 hours, 10 hours and 16 hours and 16 hours and 24 hours; treatment B: 0 hour to 10 hours and 10 hours and 24 hours), the serum concentration values for Testosterone, Dihydrotestosterone, and Estradiol at time points 10 hours (pre-dose for the second drug administration) and 16 hours (pre-dose for the third drug administration under Treatments A and C) are obtained by imputing the serum concentration value observed at time points 9.75 hours and 15.75 hours, respectively.

The following pharmacokinetic parameters are determined for all subjects for Testosterone, Dihydrotestosterone and Estradiol:

For Treatments A and C (t.i.d.): AUC₀-_T, AUC₀-io, AUC10-16, AUC16-24J Cmaxj Cmax

0-10; C_max 10-16; C_max 16-24; C_mj_n, C_mj_n o-10; C_mj_n 10-I6; C_mj_n 16-24; C_avg; C_avg 0-10; C_avg 10-16; C_aVg 16-24; tmax; t_max 0-10; t_max 10-16; t_max 16-24; t_max 10-24; PTF, PTS.

For Treatment B (b.i.d.): AUC₀-_T , AUC₀-io, AUC₁₀-₂4, C_max, C_{max 0}-i o, C_{max 10}-24,

Cmin; Cmin O-10; C_mj_n io-24; C_aVg, C_aVg 0-10; C_aVg 10-24; t_max; t_max 0-10; tmax 10-24; PTF, PTS.

Additionally, the percent of subjects with C_avg values for serum Testosterone, Dihydrotestosterone and Estradiol above, within, and below their respective reference range is calculated for each treatment. As well, the mean percent time of serum

Testosterone, Dihydrotestosterone and Estradiol values above (% TimeAbove), within (% TimeWithin), and below (% TimeBelow) the corresponding reference range are provided for each treatment. The calculation of all these pharmacokinetic parameters is explained below. 11.4.1.1 Maximum and Minimum Observed Concentrations and Time of Observed

Peak Concentrations

Cmax, the maximum is observed concentrations and T_max, the time to reach that peak concentrations, as well as C_m\n, the minimum observed concentrations are determined for each subject and for each treatment as follow:

C_max: Maximum observed concentration over the dosing interval. This parameter is calculated for Treatments A, B and C.

Cmax o-1₀: Maximum observed concentration from time zero to 10 hours. This

parameter is calculated for Treatments A, B and C.

Cmax io- Maximum observed concentration from time 10 hours to 16 hours. This 16 : parameter is calculated for Treatments A and C.

Cmax 16- Maximum observed concentration from time 16 hours to 24 hours. This 2₄: parameter is calculated for Treatments A and C.

Cmax io- Maximum observed concentration from time 10 hours to 24 hours. This 2₄: parameter is calculated for Treatment B only.

Cmi_n : Minimum observed concentration over the dosing interval. This parameter is calculated for Treatments A, B and C.

Cmin o-io: Minimum observed concentration from time zero to 10 hours. This

parameter is calculated for Treatments A, B and C.

Cmin 1₀-16 : Minimum observed concentration from time 10 hours to 16 hours. This parameter is calculated for Treatments A and C.

Cmin 1₆-24: Minimum observed concentration from time 16 hours to 24 hours. This parameter is calculated for Treatments A and C.

Cmin 1₀-24: Minimum observed concentration from time 10 hours to 24 hours. This parameter is calculated for Treatment B only.

tma_X: Time of observed C_max over the dosing interval. This parameter is

calculated for Treatments A, B and C.

tmax ₀-1₀: Time of observed C_max from time zero to 10 hours. This parameter is

calculated for Treatments A, B and C.

tmax 1₀-1₆: Time of observed C_max from time 10 hours to 16 hours. This parameter is calculated for Treatments A and C.

tmax 1₆-24: Time of observed C_max from time 16 hours to 24 hours. This parameter is calculated for Treatments A and C.

tmax 1₀-24: Time of observed C_max from time 10 hours to 24 hours. This parameter is calculated for Treatment B only.

11.4.1.2 Areas Under the Concentration-Time Curves

The calculation of AUCs is performed using the linear trapezoidal method.

AUC_O-_T is computed from dose time (0) to dose time□ (□ = 24 h). However, in case the 24-h sample is collected with a time deviation, the AUC₀-T is estimated based on the estimated concentration at 24 hours using the regression line calculated from the elimination phase, and not the concentration at the actual observation time.

In the case where the last concentration value (Y) is missing or does not correspond to a scheduled sampling time (i.e. 10 hours and 16 hours), AUC_X-_Y is extrapolated using the corresponding subject's elimination phase, if calculable.

The following AUCs are calculated:

AUCo : Area under the concentration-time curve for one dosing interval. This parameter is calculated for Treatments A, B and C.

AUCo-10 : Area under the concentration-time curve from time zero to 10 hours. This parameter is calculated for Treatments A, B and C.

AUC10-16 : Area under the concentration-time curve from time 10 hours to 16 hours.

This parameter is calculated for Treatments A and C.

AUC₁₆-24 : Area under the concentration-time curve from time 16 hours to 24 hours.

This parameter is calculated for Treatments A and C.

AUC10-24 : Area under the concentration-time curve from time 10 hours to 24 hours.

This parameter is calculated for Treatment B only.

The C_ava are calculated as follow:

avg - Average concentration during the dosing interval, calculated as AUCO-T/T

(T=24 hours). This parameter is calculated for Treatments A, B and C. avg 0-10 : Average concentration from time zero to 10 hours, calculated as AUC0- 10/10. This parameter is calculated for Treatments A, B and C.

avg 10-16 Average concentration from time 10 hours to 16 hours, calculated as

AUC10-16/6. This parameter is calculated for Treatments A and C.

avg 16-24 Average concentration from time 16 hours to 24 hours, calculated as

AUC16-24/8. This parameter is calculated for Treatments A and C.

avg 10-24 Average concentration from time 10 hours to 24 hours, calculated as

AUC10-24/14. This parameter is calculated for Treatment B only.

11.4.1.3 Average Drug Concentrations

The C_aVg are calculated as follow:

avg - Average concentration during the dosing interval, calculated as AUCO-T/T

(T=24 hours). This parameter is calculated for Treatments A, B and C. avg 0-10 ^: Average concentration from time zero to 10 hours, calculated as AUC0- 10/10. This parameter is calculated for Treatments A, B and C.

avg 10-16 Average concentration from time 10 hours to 16 hours, calculated as

AUC10-16/6. This parameter is calculated for Treatments A and C.

avg 16-24 Average concentration from time 16 hours to 24 hours, calculated as

AUC16-24/8. This parameter is calculated for Treatments A and C.

avg 10-24 Average concentration from time 10 hours to 24 hours, calculated as

AUC10-24/14. This parameter is calculated for Treatment B only. 11.4.1.4 Peak Trough Fluctuation and Peak Trough Swing

The peak trough fluctuation (PTF) and the Peak trough swing are calculated as follow:

PTF: Peak trough fluctuation, calculated as (C_max-C_min)/C_avg. This parameter is calculated for Treatments A, B and C.

PTS: Peak trough swing, calculated as (C_max-C_min)/C_min. This parameter is

calculated for Treatments A, B and C.

1 1 .4.1 .5 Percent Time Above, Within and Below the Reference Range and Percent of aSubjects With C_avg Above, Within and Below the Reference Range

The percent times during which observations fall above (% TimeAbove), within

(% TimeWithin), and below (% TimeBelow) the reference ranges are computed for each subject and treatment for the serum Testosterone, Dihydrotestosterone and Estradiol.

The percent of subjects with C_avg values for serum Testosterone, Dihydrotestosterone and Estradiol above, within, and below their respective reference range is calculated for each treatment. The reference ranges are 300ng/dl_ to 1 050 ng/dL for Testosterone,

25.5 ng/dL to 97.8 ng/dL for Dihydrotestosterone and 3 pg/mL to 81 pg/mL for Estradiol.

PTS: Peak trough swing, calculated as (C_max-C_min)/C_min. This parameter is

calculated for Treatments A, B and C.

11.4.1.6 Statistical Analysis

Only descriptive statistics (N, mean, SD, CV, median, Min., and Max.) are calculated on the serum concentrations and the PK parameters for each treatment. No inferential statistical analysis is performed.

11.4.2 Analysis of Pharmacokinetics and Statistical Issues

11.4.2.2 Handling of Missing Data

Samples that are not analyzed due to an insufficient volume (refer to the bioanalytical report) are recorded as INV (Insufficient volume for analysis) in the concentration tables. These samples are set as missing for pharmacokinetic and statistical analyses. As the PK parameters could be estimated using the remaining data points, subjects with missing data are kept in the pharmacokinetic analysis.

11.4.2.3 Pharmacokinetic Analysis

For Treatments A and C (t.i.d.): AUC₀-_T, AUC₀-io, AUC₁₀-i ₆, AUC₁₆-24, C_max, C_max

0-10; C_max 10-16; C_max 16-24; C_mj_n, C_mj_n 0-10; C_mj_n 10-16; C_mj_n 16-24; C_avg; C_avg 0-10; C_avg 10-16; C_aVg 16-24; tmax; tmax 0-10; tmax 10-16; tmax 16-24; tmax 10-24; PTF, PTS.

For Treatment B (b.i.d.): AUC₀-_T , AUC₀-io, AUCi 0-24; Cmax; Cmax 0-10; Cmax 10-24;

Cmin; Cmin O-10; C_min 10-24; C_aVg, C_aVg 0-10; C_aVg 10-24; t_max; t_max 0-10; tmax 10-24; PTF, PTS.

Additionally, the percent of subjects with C_avg values for serum Testosterone,

Dihydrotestosterone and Estradiol above, within, and below their respective reference range is calculated for each treatment. As well, the mean percent time of serum

Testosterone, Dihydrotestosterone and Estradiol values above (% TimeAbove), within (% TimeWithin), and below (% TimeBelow) the corresponding reference range are provided for each treatment. The calculation of all these pharmacokinetic parameters is explained below.

With the exception of text Tables (numbered as 1 1 .4.2.3-1 to 1 1 .4.2.3-3) and text Figures (numbered as 1 1 .4.2.3-1 to 1 1 .4.2.3-3), all tables and figures referred to in this section are displayed in sections 14.2.1 and 14.2.2, respectively. For brevity, TBS-1 treatments are identified in the text of the statistical report by their treatment code: A (125 μΙ_ of 4% gel given t.i.d. for a total dose of 30 mg/day), B (150 μΙ_ of 4.5% gel is given b.i.d. for a total dose of 27.0 mg/day) and C (125 μΙ_ of 4.5% gel given t.i.d. for a total dose of 33.75 mg/day).

Blood samples for pharmacokinetic analysis are collected prior and post the 2100 hour drug administration on Day 7 at 0.333, 0.667, 1 .00, 1 .50, 2.00, 3.00, 6.00, 9.00,

9.75, 10.33, 10.66, 1 1 .0, 1 1 .5, 12.0, 13.0, 14.0, 15.75, 16.33, 16.66, 17.0, 17.5, 18.0,

20.0, 22.0, and 24.0 hours for Treatments A and C. Blood samples for pharmacokinetic analysis are collected prior and post the 2100 hour drug administration on Day 7 at

0.333, 0.667, 1 .00, 1 .50, 2.00, 3.00, 6.00, 9.00, 9.75, 10.33, 10.66, 1 1 .0, 1 1 .5, 12.0, 13.0, 16.0, 19.0, 22.0, and 24.0 hours for Treatment B. The actual sampling times is used for PK calculation are displayed in Tables 14.2.1 .22, 14.2.1 .23 and 14.2.1 .24 for Treatments A, B and C, respectively.

TESTOSTERONE

The Testosterone serum concentrations measured for each subject at each sampling time appear in Tables 14.2.1 .1 , 14.2.1 .2 and 14.2.1 .3 according to treatment. The plots of the individual serum levels over the sampling period are presented using both linear (a) and semi-log (b) scales in Figures 14.2.2.1 through 14.2.2.22. Lines for the minimum (300 ng/dL) and maximum (1050 ng/dL) bound of the reference range for the testosterone serum concentrations are also presented for information purposes. As well, a line for the average drug concentration (C_avg) during the dosing interval (τ=24 hours) is also presented on the individual profiles.

The plots of the mean serum levels over the sampling period are also presented using both the linear (a) and semi-log (b) scales in Figures 14.2.2.23, 14.2.2.24 and 14.2.2.25 for Treatments A, B and C, respectively. The error bars on these mean profiles correspond to one standard deviation. The lines for the minimum and maximum bound of the reference ranges are also presented on the mean figures.

The mean plot on the linear scale for each treatment is also presented below in the text Figure 1 1 .4.2.3-1 .

Figure 11.4.2.3-1 : Mean Testosterone Serum Concentration (ng/dL) - Time Profile for Each Treatment

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 22.0 24.0

Time (h)

Calculated pharmacokinetic parameters for each subject according to treatment are shown in Tables 14.2.1 .4, 14.2.1 .5 and 14.2.1 .6 for Treatments A, B and C, respectively. They are summarized in the text Table 1 1 .4.2.3-1 .

Table 11.4.2.3-1 : Summary of Testosterone Pharmacokinetic Parameters for Each Treatment

Treatment A¹ (N = 8) Treatment B² (N = 7) Treatment

Parameter Unit C³ (N = 7)

Mean SD cv% Mean SD CV% Mean SD cv% h*ng/d 1210.5 1581.0 1374.0

AUCo-io 4178.68 28.97 4451.64 35.52 4355.19 31.55

L 1 9 7

Cmax 0-10 ng/dL 786 209 26.53 894 500 55.90 857 323 37.72

Cmin 0-10 ng/dL 259 70.3 27.16 256 91.5 35.76 272 69.7 25.61

Cavg 0-10 ng/dL 418 121 28.97 445 158 35.52 436 137 31.55

Tmax 0-10 h 1.01 0.678 67.21 0.695 0.279 40.18 0.905 0.422 46.62 h*ng/d 1062.5

AUdo-16 2635.05 40.32 - - - 2301.51 658.44 28.61

L 6

Cmax 10-16 ng/dL 698 251 35.88 - - - 675 256 37.98

Cmin 10-16 ng/dL 270 90.7 33.63 - - - 230 53.9 23.48

Cavg 10-16 ng/dL 439 177 40.32 - - - 384 110 28.61

Tmax 10-16 h 11.1 1.06 9.54 - - - 10.8 0.562 5.20 h*ng/d 2176.6

AUdo-24 - - - 5264.19 41.35 - - - L 3 Table 11.4.2.3-1 : Summary of Testosterone Pharmacokinetic Parameters for Each Treatment

* Reference Range = 300-1050 ng/dL.

1 = TBS-1, 125 μL 4.0% gel given t.i.d. (total dose 30 mg/day)

2 = TBS-1, 150 μL of 4.5% gel given b.i.d. (total dose 27.0 mg/day)

3 = TBS-1, 125 μL of 4.5% gel given t.i.d. (total dose 33.75 mg/day)

The percent times during which observations fall above (% TimeAbove), within

(% TimeWithin), and below (% TimeBelow) the reference range are computed for each subject and are presented in Tables 14.2.1 .4, 14.2.1 .5 and 14.2.1 .6 for Treatments A, B and C, respectively. These results are also summarized in text Table 1 1 .4.2.3.1 . The percent of subjects with C_avg values for serum Testosterone above, within, and below the reference range is calculated for each treatment and are presented in Table 14.2.1 .7. These results are also summarized in text Table 1 1 .4.2.3.1 .

DIHYDROTESTOSTERONE

The Dihydrotestosterone serum concentrations are measured for each subject at each sampling time appear in Tables 14.2.1 .8, 14.2.1 .9 and 14.2.1 .10 according to treatment. The plots of the individual serum levels over the sampling period are presented using both linear (a) and semi-log (b) scales in Figures 14.2.2.26 through 14.2.2.47. Lines for the minimum (25.5 ng/dL) and maximum (97.8 ng/dL) bound of the reference range for the Dihydrotestosterone serum concentrations are also presented for information purposes. As well, a line for the average drug concentration (C_avg) during the dosing interval (τ=24 hours) is also presented on the individual profiles.

The plots of the mean serum levels over the sampling period are also presented using both the linear (a) and semi-log (b) scales in Figures 14.2.2.48, 14.2.2.49 and 14.2.2.50 for Treatments A, B and C, respectively. The error bars on these mean profiles correspond to one standard deviation. The lines for the minimum and maximum bound of the reference ranges are also presented on the mean figures.

The mean plot on the linear scale for each treatment is also presented below in the text Figure 1 1 .4.2.3-2.

Figure 11.4.2.3-2: Mean Dihydrotestosterone Serum Concentration (ng/dL) - Time Profile for Each Treatment

As per SAP, AUCx-γ is calculated based on the estimated concentration (Y) using the regression line calculated from the elimination phase data when the last

concentration (Y) does not correspond to a schedule sampling time. For subject No. 01 - 002 and 02-007, the elimination phase is not well characterized due to fluctuation in the Dihydrotestosterone serum concentration for the 10 to 16 hours and 0 to 10 hours intervals, respectively. Therefore, AUC-io-i e and C_avg io-i6 (derived from AUC-io-i e) could not be calculated for subject No. 01 -002 for Treatment A (N = 7 for these parameters). As well, AUCo-10 and C_avg o-i o (derived from AUC₀-io) could not be calculated for subject No. 02-007 for Treatment A (N = 7 for these parameters).

Calculated pharmacokinetic parameters for each subject according to treatment are shown in Tables 14.2.1 .1 1 , 14.2.1 .12 and 14.2.1 .13 for Treatments A, B and C, respectively. They are summarized in the text Table 1 1 .4.2.3-2. Table 11.4.2.3-2: Summary of Dihydrotestosterone Pharmacokinetic Parameters for Each Treatment

Table 11.4.2.3-2: Summary of Dihydrotestosterone Pharmacokinetic Parameters for Each Treatment

The percent times during which observations fall above (% TimeAbove), within (% TimeWithin), and below (% TimeBelow) the reference range are computed for each subject and are presented in Tables 14.2.1 .1 1 , 14.2.1 .12 and 14.2.1 .13 for Treatments A, B and C, respectively. These results are also summarized in text Table 1 1 .4.2.3.2. The percent of subjects with C_avg values for serum Dihydrotestosterone above, within, and below the reference range is calculated for each treatment and are presented in Table 14.2.1 .14. These results are also summarized in text Table 1 1 .4.2.3.2.

ESTRADIOL

The Estradiol serum concentrations are measured for each subject at each sampling time appear in Tables 14.2.1 .15, 14.2.1 .16 and 14.2.1 .17 according to treatment. The plots of the individual serum levels over the sampling period are presented using both linear (a) and semi-log (b) scales in Figures 14.2.2.51 through 14.2.2.72. Lines for the minimum (3 pg/mL) and maximum (81 pg/mL) bound of the reference range for the Estradiol serum concentrations are also presented for information purposes. As well, a line for the average drug concentration (C_avg) during the dosing interval (τ=24 hours) is also presented on the individual profiles.

The plots of the mean serum levels over the sampling period are also presented using both the linear (a) and semi-log (b) scales in Figures 14.2.2.73, 14.2.2.74 and 14.2.2.75 for Treatments A, B and C, respectively. The error bars on these mean profiles correspond to one standard deviation. The lines for the minimum and maximum bound of the reference ranges are also presented on the mean figures.

The mean plot on the linear scale for each treatment is also presented below in the text Figure 1 1 .4.2.3-3.

Figure 11.4.2.3-3: Mean Estradiol Serum Concentration (pg/mL) - Time Profile for Each Treatment

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 22.0 24.0

Time (h)

As per SAP (section 8.3), AUCx-γ is calculated based on the estimated concentration (Y) using the regression line calculated from the elimination phase data when the last concentration (Y) does not correspond to a schedule sampling time. However, for some subjects the elimination phase is not well characterized due to fluctuation in the

Estradiol serum concentration as follows:

• Subject No. : 02-007 for the 0 to 10 hours and for the 0 to 24 hours time intervals for Treatment A. The following PK parameters could not be calculated for this subject: AUCo-10, C_aVg 0-10, AUco-T, C_aVg and PTF for Treatment A (N = 7 for these parameters).

• Subject Nos: 01 -002 and 01 -007 for the 10 to 16 hours time interval for Treatment A.

The AUC-io-16 and C_avg 10-16 could not be calculated for these subjects for Treatment A (N = 6 for these parameters).

• Subject Nos. 02-004 and 02-007 for the 16 to 24 hours time interval for Treatment A.

The AUC-I6-24 and C_avg -i e-24 could not be calculated for this subject for Treatment A (N = 6 for these parameters).

• Subject Nos. 02-003 and 02-005 for the 0 to 10 hours time interval for Treatment C.

The AUCo-10 and C_avg 0-10 could not be calculated for these subjects for Treatment C (N = 5 for these parameters). Calculated pharmacokinetic parameters for each subject according to treatment are shown in Tables 14.2.1 .18, 14.2.1 .19 and 14.2.1 .20 for Treatments A, B and C, respectively. They are summarized in the text Table 1 1 .4.2.3-3.

Table 11.4.2.3-3: Summary of Estradiol Pharmacokinetic Parameters for Each Treatment

1 = TBS-1 , 125 μΙ_ 4.0% gel given t.i.d. (total dose 30 mg/day)

2 = TBS-1 , 1 50 μΙ_ of 4.5% gel given b.i.d. (total dose 27.0 mg/day)

3 = TBS-1 , 125 μΙ_ of 4.5% gel given t.i.d. (total dose 33.75 mg/day)

b = For these parameters, N = 7 for Treatment A.

c = For these parameters, N = 6 for Treatment A.

d = For these parameters, N = 5 for Treatment C.

The percent times during which observations fall above (% TimeAbove), within (% TimeWithin), and below (% TimeBelow) the reference range are computed for each subject and are presented in Tables 14.2.1 .18, 14.2.1 .19 and 14.2.1 .20 for Treatments A, B and C, respectively. These results are also summarized in text Table 1 1 .4.2.3.3.

The percent of subjects with C_avg values for serum Estradiol above, within, and below the reference range is calculated for each treatment and are presented in Table 14.2.1 .21 . These results are also summarized in text Table 1 1 .4.2.3.3.

11.4.2.4 Pharmacodynamic Analysis

No pharmacodynamic analysis is planned or performed during this study.

11.4.7 Pharmacokinetic and Statistical Conclusions In this Phase II study, subjects are randomized into three treatment arms (4.0% TBS-1 administered t.i.d. and 4.5% TBS-1 administered bid. and t.i.d.). The treatments are administered for one week by intra-nasal route, in a parallel design. At the end of one week, the three treatments are compared by conducting a 24 hour pharmacokinetic investigation of the systemic absorption of the drug product Testosterone, and its two physiological metabolites Dihydrotestosterone and Estradiol.

TESTOSTERONE

The pharmacokinetic profile of TBS-1 following single and repeat dosing is examined in 2 previous studies (TST-PKP-01 -MAT/04 and TST-DF-02-MAT/05). It is demonstrated in these studies that Testosterone is well absorbed following intra-nasal administration. The maximal serum concentration is reached after 1 -2 hours post administration. In the current study, the Testosterone formulations (4.0% TBS-1 is administered t.i.d. and 4.5% TBS-1 is administered bid. and t.i.d.) are rapidly absorbed with a peak concentration reached within 36 minutes to 1 hour 6 minutes (mean T_max) following intra-nasal administration. The maximum Testosterone concentration over the 24-hour interval is observed during the first administration (0-10 hours) in approximately 57% to 71 % of the hypogonadal men while approximately 29% to 43% of the subjects had their maximum 24-h Testosterone concentration during the subsequent

administrations.

When TBS-1 administrations are compared separately for the t.i.d. treatments, although the mean AUC is similar between formulations, a greater AUC is observed following the first administration compared to the two subsequent administrations (AUCo-10: 4178.68 and 4355.19 h^*ng/dl_ > AUC_{1 0}-i₆ : 2635.05 and 2301 .51 h^*ng/dl_ < AUC16-24 : 3016.52 and 2766.97 h^*ng/dl_ for Treatments A and C, respectively). A greater AUC is observed for the second administration when compared to the first administration for Treatment B (AUC₀-i₀ : 4451 .64 h^*ng/dl_ ~ AUC_{1 0}-₂4 : 5264.19 h^*ng/dl_). The difference in AUC between administrations for both the t.i.d. and b.i.d. formulations could be due to the different time periods elapsed between each administration. The mean AUC₀-_T calculated over the 24-hour dosing interval, is comparable between all treatments (AUC₀-_T: 9920.07, 9781 .39 and 9505.03 h^*ng/dl_ for Treatments A, B and C, respectively).

Although the mean C_max is similar between Treatments A and C, a trend toward a decrease in C_max with subsequent administrations is observed (C_max o-io : 786 and 857 ng/dL > C_max i o-i 6 : 698 and 675 ng/dL > -rnax 16-24 - 556 and 595 ng/dL for Treatments A and C, respectively). Comparable mean Testosterone C_max is observed for both administrations of Treatment B (C_max o-io : 894 ng/dL ~ C_max 10-24 : 846 ng/dL). The difference in C_max between administrations for the t.i.d. formulations could be due to the different time periods that are elapsed between each administration. The mean C_max calculated over the 24-hour dosing interval, is slightly greater for Treatment B (150 μί. of 4.5% gel (b.i.d.)) (C_max: 1050 ng/dL) comparatively to Treatments A and C (C_max: 830 and 883 ng/dL, respectively). The upper limit of the physiological reference range (1050 ng/dL) is exceeded by 1 of 8 subjects for Treatment A and 3 of 7 subjects for Treatments B and C.

A trend toward a slight decrease in C_avg is observed when administrations are compared separately for t.i.d. and b.i.d. treatments (C_avg o-i o : 418 and 436 ng/dL > C_avg 10-16 : 439 and 384 ng/dL > -'avg 16-24 - 377 and 346 ng/dL for Treatments A and C, respectively and C_avg 0-10 : 445 ng/dL > C_avg 10-24 : 376 ng/dL for Treatment B). The difference in C_avg between administrations could be due to the different time periods that are elapsed between each administration. The mean C_avg calculated over the 24-hour dosing interval, is comparable for all treatments (C_avg: 413, 408, 396 ng/dL for

Treatments A, B and C, respectively).

These results suggest a decrease in exposure (AUC, C_avg and C_max) between each dose for the t.i.d. administrations (Treatments A and C), but not for the b.i.d.

administration (Treatment B). This decrease in exposure for the t.i.d. administrations could be partly explained by the negative feedback on endogenous Testosterone production from the HPG axis. In other words, due to the smaller time intervals between each administration for the t.i.d. groups, the recovery of the HPG system from negative feedback would be less that for the b.i.d. group.

Independently of the formulation, approximately 86%-88% of the subjects had an average drug concentration (C_avg) within the physiological reference range (300 to 1050 ng/dL), 13%-14% of the subjects had a C_avg below the reference range and no subjects had a C_avg above the reference range.

The period of time during a day (24 hours) for which serum Testosterone concentrations are below, within and above the physiological reference range is covered respectively 30 to 35%, 59% to 68% and 0% of the 24-hour period for all formulations. That is to say that the testosterone levels are within normal range for about 14 to 16 hours a day.

DIHYDROTESTOSTERONE

The Dihydrotestosterone peak concentration is reached within 1 hour 24 minutes and 2 hours 23 minutes (mean T_max) following the TBS-1 administrations.

When TBS-1 administrations are compared separately for the t.i.d. treatments, although the mean AUC is similar between formulations, a trend toward a decrease in AUC with subsequent administrations is observed (AUC₀-io : 345.77 and 41 1 .10 h^*ng/dl_ > AUC-m- ₁₆: 186.33 and 222.62 h^*ng/dL > AUC₁₆-₂4 : 269.16 and 275.21 h^*ng/dL for Treatments A and C, respectively). Comparable AUC is observed for both administrations of

Treatment B (AUC₀-i₀ : 402.77 h^*ng/dL ~ AUC10-24 : 543.29 h^*ng/dL). The difference in AUC between administrations for the t.i.d. formulations could be due to the different time periods elapsed between each administration. The mean AUC₀-_T calculated over the 24-hour dosing interval, is comparable between all treatments (AUC₀-_T: 818.95, 946.89 and 909.68 h^*ng/dl_ for Treatments A, B and C, respectively).

Although the mean C_max is similar between the t.i.d. formulations, a trend toward a decrease in C_max with subsequent administrations is observed (C_{max 0}-io : 51 .4 and 59.0 ng/dL > C_max i ₀-16 : 44.2 and 48.9 ng/dL > C_max i₆-24 : 41 .3 and 42.6 ng/dL for Treatments A and C, respectively). Comparable mean Testosterone C_max is observed for both administrations of Treatment B (C_max o-io : 56.8 ng/dL ~ -rnax 10-24 - 54.6 ng/dL). The difference in C_max between administrations for the t.i.d. formulations could be due to the different time periods elapsed between each administration. The mean C_max is calculated over the 24-hour dosing interval, is comparable for all treatments (C_max: 52.2, 61 .0 and 60.3 ng/dL for Treatments A, B and C, respectively). The upper limit of the physiological reference range (97.8 ng/dL) is not exceeded by any subjects for any treatment.

The C_aVg calculated by administration are comparable between treatments and administrations (C_avg 0-10 : 34.6 and 41 .1 ng/dL > C_avg -m-ie : 31 .1 and 37.1 ng/dL > C_avg i e- ₂₄: 33.6 and 34.4 ng/dL for Treatments A and C, respectively and C_avg o-io : 40.3 ng/dL > ->avg 10-24 - 38.8 ng/dL for Treatment B). The mean C_avg calculated over the 24-hour dosing interval, is comparable for all treatments (C_avg: 34.1 , 39.5, 37.9 ng/dL for

Treatments A, B and C, respectively).

Approximately 63% of subjects had their C_avg included in the physiological reference range for DHT (25.5 to 97.8 ng/dL) following administration of Treatment A, whereas this number rises to about 86% when Treatments B and C are administered. No subject had their C_avg above the normal range while 38% and 14% of the subjects have their C_avg below the normal range for Treatment A and both Treatments B and C, respectively.

The period of time during a day (24 hours) for which serum DHT concentrations are below, within and above the physiological reference range is covered respectively 32.64%, 67.36% and 0% for Treatment A, 26.22%, 73.78% and 0% for Treatment B and 13.87%, 86.13% and 0% for Treatment C. That is to say that the DHT levels are within normal range for about 16, 18 and 21 hours a day for Treatments A, B and C, respectively.

ESTRADIOL

The Estradiol peak concentration is reached within 1 hour 12 minutes and 2 hours 41 minutes (mean T_max) following the TBS-1 administrations.

When TBS-1 administrations are compared separately for the t.i.d. treatments, although the mean AUC is similar between formulations, a trend toward a decrease in

AUC with subsequent administrations is observed (AUC₀-i o : 234.96 and 267.78 h^*pg/mL

> AUC₁₀-i ₆ : 144.76 and 144.30 h^*pg/mL < AUC₁₆-₂4 : 153.02 and 177.97 h^*pg/mL for

Treatments A and C, respectively). Comparable AUC is observed for both

administrations of Treatment B (AUC₀-i ₀ : 242.02 h^*pg/mL ~ AUC10-24 : 295.12 h^*pg/mL).

The difference in AUC between administrations for the t.i.d. formulations could be due to the different time periods elapsed between each administration. The mean AUC₀-_T calculated over the 24-hour dosing interval, is comparable between all treatments (AUC₀-_T: 530.27, 537.16 and 601 .91 h^*pg/ml_ for Treatments A, B and C, respectively).

Although the mean C_max is similar between the t.i.d. formulations, a trend toward a decrease in C_max with subsequent administrations is observed (C_max o-io: 36.8 and 35.5 pg/mL > Cmax 10-16 : 28.9 and 31 .5 pg/mL > -rnax 16-24 - 27.2 and 26.9 pg/mL for

Treatments A and C, respectively). Comparable mean Testosterone C_max is observed for both administrations of Treatment B (C_max o-io: 35.8 pg/mL ~ C_max 10-24 : 30.6 pg/mL). The difference in C_max between administrations for the t.i.d. formulations could be due to the different time periods elapsed between each administration. The mean C_max calculated over the 24-hour dosing interval, is comparable for all treatments (C_max: 37.9, 36.2 and 36.4 pg/mL for Treatments A, B and C, respectively). The upper limit of the physiological reference range (81 pg/mL) is not exceeded by any subjects for any treatment.

e C_aVg calculated by administration are comparable between treatments and administrations (C_avg o-io: 23.5 and 26.8 pg/mL > C_avg 10-16 : 24.1 and 24.0 pg/mL > C_avg 16-24 : 19.1 and 22.2 pg/mL for Treatments A and C, respectively and C_avg o-io: 24.2 pg/mL > -'avc_j 10-24 - 21 .1 pg/ml_ for Treatment B). The mean C_avg is calculated over the 24-hour dosing interval, is comparable for all treatments (C_avg: 22.1 , 22.4, 25.1 pg/mL for Treatments A, B and C, respectively).

All subjects have their C_avg included in the physiological reference range for E₂ (3 to 81 pg/mL) following administration of all treatments. All subjects have E₂

concentrations within the normal range over the 24 hours period. No subjects have E₂ levels below or above the normal range at any time of the day.

12. Safety Evaluation

12.1 Extent of Exposure

Subjects use the drug for 7 days at two sites and 8 days in another.

12.2 Adverse Events

12.2.1 Brief Summary of Adverse Events There are eight adverse events that occurred in six subjects. Six of the events occur during treatment A and two occur during treatment B. Subjects 01 -002 and 01 -

007 both experience dizziness and both are indicated as possibly related to the study drug. Subject 01 -002 has moderate severity which resolved after 5 days. Seven of the

8 adverse events are mild. Six of the 8 events are not related to study drug.

Individual 02-004 is classified as having anemia by the investigator. The hemoglobin is at the minimal normal level and is deemed unrelated to the drug. Table 12.2.2 summarizes the events.

12.2.2 Display of Adverse Events Table 12.2.2: Adverse Events

12.2.4 Listing of Adverse Events by Subjects

Table 12.2.2 list of adverse events by subject.

12.3 Deaths, Other Serious Adverse Events, and Other Significant Adverse Events

There are no deaths, other serious adverse events or other significant adverse events during the course of this study.

12.4.2 Evaluation of Each Laboratory Parameter

There are no clinically significant changes in laboratory values from the beginning to the end of the study as determined by the principle investigators. All subjects did have some abnormal values at the initial visit and/or at the third visit. There are no consistent changes throughout the visits.

Subject 01 -007 had a uric acid level of 539 U/L with 289 as the upper end of normal at the third visit. There are elevated glucose values in about half the subjects compared to a normal first visit value. This is spread across all three dosages and are only slightly elevated. There is no clinical significance.

12.5 Vital Signs, Physical Findings, and Other Observations Related to

Safety

There are no meaningful or significant changes in vital signs after test drug administration.

12.6 Safety Conclusions

The TBS-1 gel demonstrates in this and other studies that it is safe for use.

There are no serious adverse events or any events of consequence during this PK study or during the seven days of self administration. Tables 14.3.2.1 through 14.3.2.8 show all the laboratory values for visit 1 and visit 3.

13. Discussion and Overall Conclusions

The primary objective of this study is to determine the bioavailability of a 4.0 % TBS-1 gel (applied t.i.d.) and 4.5 % TBS-1 gel (applied b.i.d. and t.i.d.) in hypogonadal men.

In a previous study, Nasobol-01 -2009, a 3.2% Testosterone gel is used to deliver

4.0 mg, 5.5 mg and 7.0 mg of Testosterone intra-nasally using gel volumes of 125 μΙ_,

172 L and 219 μΙ_, respectively. In this study, 5.0 mg, 5.65 mg and 6.75 mg of Testosterone are administered in gel volumes of 125 μΙ_, 125 μΙ_, and 150 μΙ_, respectively. This study allowed investigating the delivery of similar Testosterone amounts in much smaller volumes.

The secondary objective of this study is to establish a safety profile for TBS-1 . In this Phase II study, subjects are randomized into three treatment arms (4.0% TBS-1 administered t.i.d. and 4.5% TBS-1 administered bid. and t.i.d.). The treatments are administered for one week by intra-nasal route, in a parallel design. At the end of one week, the three treatments are compared by conducting a 24 hour pharmacokinetic investigation of the systemic absorption of the drug product Testosterone, and its two physiological metabolites Dihydrotestosterone and Estradiol.

There are eight adverse events described by six subjects. Six of the events occurred during treatment A and two occurred during treatment B. Subjects 01 -002 and 01 -007 both experienced dizziness and both are indicated as possibly related to the study drug. The remainder are unrelated to study drug.

There are no vital signs or laboratory changes that are significant or meaningful. No erythrocytosis, anemia or infections are observed after measurement of complete blood counts at screening and close-out. Clinical chemistry and urinalysis showed no changes at close-out in hypo or hyperglycemia, renal function, liver function,

skeletal/heart muscle damage or changes in calcium homeostasis. There are no clinically significant changes to the nasal mucosa.

The PK population is defined as subjects who received the Treatment A, B or C, and who completed the study without major protocol violation or for whom the PK profile can be adequately characterized. The PK population is used for the analysis of PK data. Based on these criteria, twenty-two (22) subjects are included in the PK population.

TESTOSTERONE

The pharmacokinetic profile of TBS-1 following single and repeat dosing is examined in 2 previous studies (TST-PKP-01 -MAT/04 and TST-DF-02-MAT/05). It is demonstrated in these studies that Testosterone is well absorbed following intra-nasal administration. The maximal serum concentration is reached after 1 -2 hours post administration. In the current study, the Testosterone formulations (4.0% TBS-1 administered t.i.d. and 4.5% TBS-1 administered bid. and t.i.d.) are rapidly absorbed with a peak concentration reached within 36 minutes to 1 hour 6 minutes (mean T_max) following intra-nasal administration. The maximum Testosterone concentration over the 24-hour interval is observed during the first administration (0-10 hours) in approximately 57% to 71 % of the hypogonadal men while approximately 29% to 43% of the subjects had their maximum 24-h Testosterone concentration during the subsequent

administrations.

When TBS-1 administrations are compared separately for the t.i.d. treatments, although the mean AUC is similar between formulations, a greater AUC is observed following the first administration compared to the two subsequent administrations (AUCo-10 : 4178.68 and 4355.19 h^*ng/dL > AUC_{1 0}-i₆ : 2635.05 and 2301 .51 h^*ng/dL < AUC₁₆-24 : 3016.52 and 2766.97 h^*ng/dl_ for Treatments A and C, respectively). A greater AUC is observed for the second administration when compared to the first administration for Treatment B (AUC₀-i₀ : 4451 .64 h^*ng/dL ~ AUC10-24 : 5264.19 h^*ng/dL). The difference in AUC between administrations for both the t.i.d. and b.i.d. formulations could be due to the different time periods elapsed between each administration. The mean AUC₀-t calculated over the 24-hour dosing interval, is comparable between all treatments (AUC₀-_t: 9920.07, 9781 .39 and 9505.03 h^*ng/dL for Treatments A, B and C, respectively).

When TBS-1 administrations are compared separately for the t.i.d. treatments, although the mean C_max is similar between formulations, a trend toward a decrease in Cmax with subsequent administrations is observed (C_max o-i o : 786 and 857 ng/dL > C_max 10-16 : 698 and 675 ng/dL > C_max i 6-24 : 556 and 595 ng/dL for Treatments A and C, respectively). Comparable mean Testosterone C_max is observed for both administrations of Treatment B (C_max o-io : 894 ng/dL ~ C_max 10-24 : 846 ng/dL). The difference in C_max between administrations for the t.i.d. formulations could be due to the different time periods elapsed between each administration. The mean C_max calculated over the 24- hour dosing interval, is slightly greater for Treatment B (150 μί. of 4.5% gel (b.i.d.)) (C_max: 1050 ng/dL) comparatively to Treatments A and C (C_max: 830 and 883 ng/dL, respectively). The upper limit of the physiological reference range (1050 ng/dL) is exceeded by 1 of 8 subjects for Treatment A and 3 of 7 subjects for Treatments B and C.

A trend toward a slight decrease in C_avg is observed when administrations are compared separately for t.i.d. and b.i.d. treatments (C_avg o-i o : 418 and 436 ng/dL > C_avg 10-16 : 439 and 384 ng/dL > -'avg 16-24 - 377 and 346 ng/dL for Treatments A and C, respectively and C_avg 0-10 : 445 ng/dL > C_avg 10-24 : 376 ng/dL for Treatment B). The difference in C_avg between administrations could be due to the different time periods elapsed between each administration. The mean C_avg calculated over the 24-hour dosing interval, is comparable for all treatments (C_avg: 413, 408, 396 ng/dL for

Treatments A, B and C, respectively).

The period of time during a day (24 hours) for which serum Testosterone concentrations are below, within and above the physiological reference range covered respectively 30 to 35%, 59% to 68% and 0% of the 24-hour period for all formulations. That is to say that the Testosterone levels are within normal range for about 14 to 16 hours a day.

DIHYDROTESTOSTERONE

The Dihydrotestosterone peak concentration is reached within 1 hour 24 minutes and 2 hours 23 minutes (mean T_max) following the TBS-1 administrations. When TBS-1 administrations are compared separately for the t.i.d. treatments, although the mean AUC is similar between formulations, a trend toward a decrease in AUC with subsequent administrations is observed (AUC₀-io : 345.77 and 41 1 .10 h^*ng/dl_ > AUC-i o- ₁₆: 186.33 and 222.62 h^*ng/dL > AUC₁₆-₂4 : 269.16 and 275.21 h^*ng/dL for Treatments A and C, respectively). Comparable AUC is observed for both administrations of

Treatment B (AUC₀-i₀ : 402.77 h^*ng/dL ~ AUC10-24 : 543.29 h^*ng/dL). The difference in AUC between administrations for the t.i.d. formulations could be due to the different time periods elapsed between each administration. The mean AUC₀-t calculated over the 24-hour dosing interval, is comparable between all treatments (AUC₀-t: 818.95, 946.89 and 909.68 h^*ng/dl_ for Treatments A, B and C, respectively).

Although the mean C_max is similar between the t.i.d. formulations, a trend toward a decrease in C_max with subsequent administrations is observed (C_max o-io : 51 .4 and 59.0 ng/dL > C_max i o-i 6 : 44.2 and 48.9 ng/dL > -rnax 16-24 - 41 .3 and 42.6 ng/dL for Treatments A and C, respectively). Comparable mean Testosterone C_max is observed for both administrations of Treatment B (C_max o-io : 56.8 ng/dL ~ C_max 10-24 : 54.6 ng/dL). The difference in C_max between administrations for the t.i.d. formulations could be due to the different time periods elapsed between each administration. The mean C_max calculated over the 24-hour dosing interval, is comparable for all treatments (C_max: 52.2, 61 .0 and 60.3 ng/dL for Treatments A, B and C, respectively). The upper limit of the physiological reference range (97.8 ng/dL) is not exceeded by any subjects for any treatment.

The C_aVg calculated by administration are comparable between treatments and administrations (C_avg 0-10 : 34.6 and 41 .1 ng/dL > C_avg 10-16 : 31 .1 and 37.1 ng/dL > C_avg i e- 24: 33.6 and 34.4 ng/dL for Treatments A and C, respectively and C_avg o-io : 40.3 ng/dL > C_avg 10-24 : 38.8 ng/dL for Treatment B). The mean C_avg calculated over the 24-hour dosing interval, is comparable for all treatments (C_avg: 34.1 , 39.5, 37.9 ng/dL for

Treatments A, B and C, respectively).

Approximately 63% of subjects had their C_avg included in the physiological reference range for DHT (25.5 to 97.8 ng/dL) following administration of Treatment A, whereas this number rises to about 86% when Treatments B and C are administered. No subject had their C_avg above the normal range while 38% and 14% of the subjects had their C_avg below the normal range for Treatment A and both Treatments B and C, respectively.

The period of time during a day (24 hours) for which serum DHT concentrations are below, within and above the physiological reference range covered respectively 32.64%, 67.36% and 0% for Treatment A, 26.22%, 73.78% and 0% for Treatment B and 13.87%, 86.13% and 0% for Treatment C. That is to say that the DHT levels are within normal range for about 16, 18 and 21 hours a day for Treatments A, B and C, respectively.

ESTRADIOL

When TBS-1 administrations are compared separately for the t.i.d. treatments, although the mean AUC is similar between formulations, a trend toward a decrease in AUC with subsequent administrations is observed (AUC₀-i o : 234.96 and 267.78 h^*pg/ml_ > AUC₁₀-i ₆ : 144.76 and 144.30 h^*pg/ml_ < AUC₁₆-₂4 : 153.02 and 177.97 h^*pg/ml_ for Treatments A and C, respectively). Comparable AUC is observed for both

administrations of Treatment B (AUC₀-i ₀ : 242.02 h^*pg/ml_ ~ AUC10-24 : 295.12 h^*pg/ml_). The difference in AUC between administrations for the t.i.d. formulations could be due to the different time periods elapsed between each administration. The mean AUC₀-t calculated over the 24-hour dosing interval, is comparable between all treatments (AUCo-t: 530.27, 537.16 and 601 .91 h^*pg/ml_ for Treatments A, B and C, respectively).

Although the mean C_max is similar between the t.i.d. formulations, a trend toward a decrease in C_max with subsequent administrations is observed (C_{max 0}-io : 36.8 and 35.5 pg/mL > C_max 10-16 : 28.9 and 31 .5 pg/mL > -rnax 16-24 - 27.2 and 26.9 pg/mL for

Treatments A and C, respectively). Comparable mean Testosterone C_max is observed for both administrations of Treatment B (C_{max 0}-i o : 35.8 pg/mL ~ C_max 10-24 : 30.6 pg/mL).

The difference in C_max between administrations for the t.i.d. formulations could be due to the different time periods elapsed between each administration. The mean C_max calculated over the 24-hour dosing interval, is comparable for all treatments (C_max: 37.9,

36.2 and 36.4 pg/mL for Treatments A, B and C, respectively). The upper limit of the physiological reference range (81 pg/mL) is not exceeded by any subjects for any treatment.

The C_aVg calculated by administration are comparable between treatments and administrations (C_avg o-io: 23.5 and 26.8 pg/mL > C_avg io-ie: 24.1 and 24.0 pg/mL > C_avg 16-24 : 19.1 and 22.2 pg/mL for Treatments A and C, respectively and C_avg o-io: 24.2 pg/mL > -'avcj 10-24 - 21 .1 pg/ml_ for Treatment B). The mean C_avg calculated over the 24- hour dosing interval, is comparable for all treatments (C_avg: 22.1 , 22.4, 25.1 pg/mL for Treatments A, B and C, respectively).

All subjects had their C_avg included in the physiological reference range for E₂ (3 to 81 pg/mL) following administration of all treatments. All subjects had E₂ concentrations within the normal range over the 24 hours period. No subjects had E₂ levels below or above the normal range at any time of the day.

CONCLUSIONS

The TBS-1 formulations (4.0 % TBS-1 gel (applied t.i.d.) and 4.5 % TBS-1 gel (applied b.i.d. and t.i.d.)) are rapidly absorbed with mean Testosterone peak observed within 1 hour.

Overall, the Testosterone exposure (AUCo-t and C_max) at steady-state is comparable between all treatments.

Independently of the formulation, approximately 86%-88% of the subjects had an average Testosterone drug concentration (C_avg) within the physiological reference range (300 to 1050 ng/dL).

The Testosterone levels are within normal range for about 14 to 16 hours a day.

TBS-1 is safe for intranasal administration at the dosages and frequency indicated. There are no meaningful adverse events, changes in vital signs or changes in laboratory results when compared to baseline.

Based on these results, no clear evidence is found to indicate a better performance from one of the formulations. EXAMPLE 9

TBS1 A Report for 4% and 8% Bulk Gel

Objective:

To follow up on IMP- Clinical batch manufacture. Main points concern process flow and bulk appearance on stability.

• Process flow improvement

• Viscosity of bulk Gel

• Stability (re-crystallization)

• Evaluation of alternate materials sources and grades

• In Vivo results, formulation changes to impact onset of release

• Testing of trials using Franz Cell, trial selection

List of Raw-materials identified for use in trials:

Equipment used:

In addition to the Silverson High Shear mixer, used only during the manufacture of the TBS1 A IMP Clinical batches, included also a propeller type mixing unit for the trials on several pre-mix operations. The only application for the High shear action is for dispersion of the active in the Co-Solvents.

For more uniform mixing and control of temperature, recommend a jacketed container with wiping blades to remove material from inner bowl wall (especially critical for uniform bulk temperature during heating as well as cooling cycles.

Background info on IMP bath manufacture

Observation during the IMP Clinical batch manufacture included high viscosity during preparing the pre-mixture of the DMI/Transcutol co-solvent mix consisting of PVP K17/S640, Klucel HF and Testosterone micronized. Mixture resulting in a sticky mass when added to the Castor oil using the high shear mixer set up. With the same high shear mixer set up for the addition of the Cab-O-Sil (referenced in future to SiO2) could not obtain a vortex to incorporate the material and required additional manual mixing during addition stage, hence the recommendation for propeller type mixing unit). Even though the material was viscous during that addition stage, on further mixing the viscosity of the final Bulk Gel dropped to approximately 1 ,500 - 2,000 cps. Mixing time and speed had to be controlled not to overshoot targeted gel temperature (no cooling system).

Outline of trials:

The initial trials (Placebo) concentrated on changing the order of addition to identify impact on viscosity. Previous process included the addition of the SiO2 at the final stage (see comments above), changed to dispersion of the SiO2 into the Castor oil prior to addition of the alternate active mixture. The resulting viscosity of the Castor Oil/SiO2 mixture, used various percentages, increased with the addition of a small percentage of Arlasolve (DMI).

Next step was to duplicate these results using the active mixture (Co- solvents/PVP/HPC/active) and added that mixture to the premix of Castor oil and SiO2. This however resulted in a low viscosity solution, indicating an impact of the active mixture on formation of a viscous gel. Since the co-solvent mix without additional materials resulted in an increase of viscosity, the quantities of solvent were split into 2 parts, adding part of the solvent mix only to the Oil mixture and remaining solvent mix used to disperse the PVP,HPC and active. The active mixture with the reduced co-solvent ended up more viscose, plus similar low viscosity when added to the castor Oil premix. Additional trials included the prep of active in only DMI (no PVP) and obtained good viscosity. HPC was prepared separately in the Transcutol P, creating problems of stringing when added to the mixture (similar to IMP observations). Addition of SiO2 at a level of 0.1 - 0.3% resolved the problem.

The above process to dissolve active in the Co-solvents is sufficient and doesn't require PVP to increase solubility for the 4% formulation, however not sufficient co- solvents in the formulation to achieve solubility for the 8% strength. Trials on the 8% included an alternate successful approach for preparing the active dispersion containing PVP by including SiO2 into that mixture. As demonstrated on evaluation trials

evaluating impact of SiO2 added to the DMI as well as Transcutol P, resulted in good viscosity forming with DMI, however not with Transcutol. Active dispersion therefore id prepared by dissolving the PVP in DMI only, followed by addition of the active at 55 C (50-60C) and portion of available SiO2.

Please note that this process was only developed during the trial work on the 8%, hence it can be scaled down to the 4% strength if PVP indicate additional functionality (Franz Cell test).

Comments related to addition of purified water (noted in Table xxx) indicate increase in viscosity with trials containing HPC, no viscosity increase in trials using only PVP. These trials were only included for information to study water uptake and impact on viscosity after application into the nasal cavity.

Critical step during HPC set up is to provide at least 24 hours of solvating to obtain a clear solution.

As outlined in the trial objectives, formulation ratios were implemented using also alternate grades and sources of materials and are identified in the formulation table.

To identify the impact of the process change (such as reaction of viscosity increase adding the co-solvents), performed trials to study impact if related to DMI or Transcutol P. Trials were initiated to disperse Si02 (at the same ratio as used for Castor Oil mixture) in DMI only as well as in Transcutol P only. The Mixture with the DMI resulted in a viscous mixture while Transcutol P mixture was very fluid.

Similar trials were initiated to use the co-solvents individually to study solubility of the Polymers as well as active for potential reduction in Transcutol P. No noticeable difference in solubility using the mixture or individual solvents at the 4% strength.

However, if PVP and HPC are prepared only in DMI, observed separation of the two materials when stored overnight (not apparent when mixed in the co-solvent mixture). To eliminate the stickiness of the dispersion when adding the active/polymer mixture, removed the HPC from the formulation and using PVP only (individual grades K17- K29/32-K90, no mixtures). This resulted in various degrees of viscosity related to the grade used.

Material also included the use of Labrafil M 1944 CS and are outlined in batch description and selected for testing in Franz Cell.

Comments:

The various trials are outlined below for 4 % strength as well as 8%.

Trial lots of both strength have been selected for testing on the Franz Cell. Selected lots are identified.

All trials will be monitored for physical evidence of re-crystallization and change in appearance (separation), tested for change in viscosity. Viscosity values of the trials will be documented and updated

Pending Franz Cell result evaluation, optimization of formulation and process can be implemented. This is critical to identify since the trial outline did not include impact on viscosity related to all process parameters (need to include analytical testing and stability data).

Observations during viscosity test using the Brookfield Viscometer Model DV-II+, with Spindle #6, at 50 rpm for 30 seconds, did actually show an increase in viscosity values over the test time in samples prepared with higher viscosity grade HPC. This can be attributed to the stickiness of the Gel causing agglomeration to the spindle shaft and disk creating a drag (not a true viscosity value of the results reported). The bulk Gel of several trials is not thixotropic. Also tested on some trials viscosity at 37 C. Tested several trials using the new Haupt method with spindle 4 at 6 rpm.

The various attached tables show the trial numbers for active Gels, pre-mixes and Placebos

Discussion and Considerations for follow up trials with both strength

Even though Viscosity improvement' was not the primary target to initiate trials, it was certainly a designed effort to study the cause for low viscosity considering the high percentage of Si02 present in the formulation. A cross check against Si02 alternate source comparison did not indicate major differences, nor did various ratios of Co- Solvents, limited adjustment since a certain percentage required to dissolve the

Testosterone. Changes in grades of PVP indicated impact on viscosity when used in the active dispersion, however not when added to the rest of the mixture. Changes in grades of HPC (used alternate source of fine material) showed impact on the final Gel, however the higher the Molecular weight of the HPC, impact of stickiness and stringing in the final Gel. Testing viscosity after several weeks did show a separation in the Gel of viscose settlement on the bottom of the container.

With indication of Si02 retaining Testosterone, adding more to increase viscosity was not an option, aim was to reduce the % used, especially for the TBS1 A 4 % strength which indicated a much higher percentage of T retained compared to the 8% TBS1 A. Target was to at least obtain the same ratio of Si02 to T of the 8% strength for the 4 % strength (hence aimed for scale down to 3 %). With the trials completed and showing impact on viscosity related to process and formulation changes, a reduction in Si02 for the definitely possible for the 4 % strength that would also include the use of PVP in the formulation by taking advantage of the process change on the 8% strength. The above is only based on viscosity; however impact on the changes in formulation to slow down initial absorption rate in vivo can only be evaluated from the data obtained on the trials used for the analytical test using the Franz Cell. These results will be reviewed and evaluated with potential recommendations for further trials to either duplicate earlier trials or based on DOE.

The attached Tables for viscosity show the date of manufacture and latest test results (to help with trial selection on Franz Cell). In the Comment column original data will be reference or referenced in the Trial process description. Further alternate material source evaluation is recommended once a primary formulation and process for each strength has been established for direct comparison.

Formulation/composition of TBS1 A - 4%

Table 1A (See the formulations in the Examples above and including Example 10)

Trial number Active Castor oil Labrafil PVP qrade DMI TranscutolP HPC Nisso Si02 %

_% % % % % % % C=Cabosil

A=Aerosil200 D11037 K17 = 3

4 52 000000 S630 = 2 25 10 0000000 C = 4

RD11038 4 K17 = 3

57 000000 S630 = 2 20 10 0000000 C = 4

RD11039 4 K17 = 3

29 29 S630 = 2 20 10 0000000 C = 3

RD11040 4 25 10

57 0000000 0000000 6 + 4 00000000 C = 4

RD11041 4 K17 = 3 25 10

53 0000000 S630 = 2 6 + 4 0000000 C = 3

RD11042 4 25 10

29 29 00000000 6 + 4 (split) 000000 C = 3

RD11050 4 24

66.7 000000 K17 = 3 20 + 4 0000000 N-H = 0.3 A = 2

RD11050A 4 24 1 % additional

66.7 000000 K17= 3 20 + 4 0000000 N-H = 0.3 to final 11050

RD11051 4 24

66.7 000000 K30 = 3 20 + 4 0000000 N-M = 0.3 A = 2

RD11051A 4 24 1 % additional

66.7 000000 K30 = 3 20 + 4 0000000 N-M = 0.3 to final 11051

RD11053 4 22

61.7 000000 K17 = 3 16 +6 6 N-H = 0.3 A = 3

4+2

RD11054 4 23

61.4 000000 K30 = 3 16 +7 5 N-M = 0.6 A = 3

4+1

RD11055 4 23

62.0 000000 K90 = 3 16 +7 5 0000000 C = 3

4 + 1

RD11056 4 28

62.0 000000 K90 = 3 20 + 8 00000 0000000 C = 3

RD11059 4 14 2

75.0 000000 K30 = 2.5 10 + 4 0000000 C = 2.5

RD11060 4 18

71.5 000000 K30 = 2.0 9 + 9 1 00000000 C= 3.5

RD11061 4

71.0 2 K17 = 2 16 2 0000000 C=3

RD11062 K17=1.5 22 6

4 62.35 0000000 K30=1.0 6+16 2+4 N-H = 0.15 A=3

RD11063 4 K17=1.5 18

Lot # RD11037

Process duplication of IMP batch (4%) without HPC. K17 and S630 dissolved in DMI/Transcutol mixture followed by addition of the active. Clear solution. Castor oil preheated and added the above active mixture. Clear solution observed. Followed with the addition of the Cabosil with low shear. Viscosity at time of manufacture 500 cps, followed with test after 48 hours resulted in 620 cps.

Lower viscosity primarily due to missing HPC (note that IMP 4% had approx 1 ,500 cps) Lot # RD11038

Change in order of addition using the same formulation with a reduction of DMI/Transcutol and adjusted with castor oil. Cabosil was mixed into the Castor oil obtaining a clear viscous solution. The active mixture was prepared as per RD1 1037. Viscosity of the Castor oil/Cabosil mixture changed to 1 180 cps (expected higher viscosity based on addition of Co Solvents during the Placebo trials). Potential impact of PVP and active to solvent mixture.

Lot # RD11039

Duplicated performance based on Placebo mixture also containing Labrafil in castor oil plus Cabosil (for IP). Same reaction of reduced viscosity when adding the active mixture.

Lot# RD11040

Duplicated Placebo process adding to the Castor oil/Cabosil mixture a portion of the DMI/Transcutol P co-solvent mixture. Viscosity of the oil mixture increased.

Prepared the active mixture with the remaining co-solvents without the PVP and added to the oil mixture. Final viscosity of the bulk Gel was 10,400 cps. Potential for F/C . Lot # RD11041

Process was repeated as per RD1 1040 including the PVP K17 and S630 with the active mixture and viscosity was reduced to 500 cps (increased to 1 ,500 cps after 3 weeks). Clear indication of PVP impact on lowering viscosity using K17 and S630.

Lot# RD11042

Repeat of trial with Castor oil/ Labrafil addition as per RD1 1037, and reduced Cabosil, with active co solvent mixture but no PVP. Viscosity of 1 ,750 cps The following trials were designed to identify impact of changing to higher PVP grades as well as alternate source of HPC (2 grades). Pre mixture were made as outlined in table 3 concentrating on mixtures without Labrafil, using Castor oil native and Aerosil 200.

Lot # RD11050

Dispersion (pre-mix I) of Castor Oil and Aerosil 200 was prepared and viscosity increased by adding part of the DMI (4%). The preparation of the active mixture use the pre-mix of RD1 1047A (PVP K17-3%) in DMI only, added 0.3% of HPC Nisso H followed by addition of active. Active mixture was added to the Pre-mix I

Lot # RD11050A

Same basic formulation as RD1 1050 with change of adding to a portion additional 1 % of Aerosil 200

Lot # RD11051

Dispersion (pre-mix I) of Castor Oil and Aerosil 200 was prepared and viscosity increased by adding part of the DMI (4%). The preparation of the active mixture use the pre-mix of RD1 1047B (PVP K30-3%) in DMI only, added 0.3% of HPC Nisso M followed by addition of active. Active mixture was added to the Pre-mix I

Lot # RD11051A

Same basic formulation as RD1 1051 with change of adding to a portion additional 1 % of Aerosil 200

Lot # RD11053

Dispersion (pre-mix I) of Castor Oil and Aerosil 200 was prepared and viscosity increased by adding part of the DMI and Transcutol P. The preparation of the active mixture use the pre-mix of RD1 1048A (PVP K17-3%), added 0.3% of HPC Nisso H followed by addition of active. Active mixture was added to the Pre-mix I

Lot # RD11054

Dispersion (pre-mix I) of Castor Oil and Aerosil 200 was prepared and viscosity increased by adding part of the DMI and Transcutol P. The preparation of the active mixture use the pre-mix of RD1 1048B (PVP K30-3%), added 0.3% of HPC Nisso H followed by addition of active. Active mixture was added to the Pre-mix I

Lot # RD11055 Dispersion (pre-mix I) of Castor Oil and Aerosil 200 was prepared and viscosity increased by adding part of the DMI and Transcutol P. The preparation of the active mixture use the pre-mix of RD1 1048C (PVP K90-3%). No HPC added .Active mixture was added to the Pre-mix I

Lot # RD11056

Dispersion (pre-mix I) of Castor Oil and Aerosil 200 was prepared and viscosity increased by adding part of the DMI. The preparation of the active mixture use the pre- mix of RD1 1047C (PVP K90-3%). No HPC added Active mixture was added to the Pre- mix I

Lot # RD11059

Prepared mixture of Castor Oil and Cabosil (2.5%). Active was dissolved in DMI and Transcutol P. Resulted in milky appearance. Adding that mix to the Castor Oil pre- mix, mixture did not clear up. Prepared the PVP (K30) solution with DMI, added to the mix, no change in appearance however reduced viscosity.

Note, no change in evaluation adding a mixture of 0.1 % HPC to appearance, slight increase in viscosity. Trial not reported under trial a lot number.

Lot # RD11060

Prepared the Castor Oil adding 3.5% Cabosil, followed by addition of a mixture of DMI/ Transcutol P for thickening. The active dispersion was prepared in a PVP (K30) with DMI as co-solvent, (no HPC)

Lot # RD11061

Prepared the Castor Oil adding 3% Cabosil, followed by addition of Labrafil (2%) for thickening. The active dispersion was prepared in a DMI mixture containing PVP K17 (2%). Mix resulted in low viscosity, however could be considered for F/C test.

Lot # RD11062

Castor Oil native mixed with Aerosil 200 (3%) and added a mixture of

DMI/Transcutol P (6+2) for thickening. A PVP mixture of K17 and K30 was dissolved in DMI/Transcutol P and followed with HPC H and solvate for 4 days. Mixture was reheated prior to addition of active. Castor Oil premix was heated prior to adding the active dispersion. Recommended for F/C

Lot # RD11063 Castor Oil native mixed with Aerosil 200 (4%) and added the DMI (6%) resulting in a high viscose mix. A mixture of PVP K17 and L29/32 was dissolved in DMI, plus HPC Nisso H (0.2). On overnight setup, noticed a separation, required re-mixing. Active was added to the high viscosity Castor Oil premix. To be followed up with modification to composition

Potential for F/C or to use RD1 1065

Lot # RD11064

Addition of 0.3% to portion of lot RD1 1062

Lot # RD11065

Addition of 0.3% to portion of lot RD1 1063

Lot # RD11066

Addition of 0.3% to portion of lot RD1 1041

Lot # RD11070

Addition of 0.3% to portion of lot RD1 1037

Lot # RD11071

Addition of 0.3% to portion of lot RD1 1042

Lot # RD11072

Addition of 0.3% to portion of lot RD1 1040

Lot # RD11073

Prepared Castor Oil / Aerosil 200 pre-mixture. Dissolve in DMI (6%) without PVP, the Testosterone and add to the Castor oil pre-mix. Obtained a viscosity of 6,300 cps. In a mixture of Transcutol P and DMI disperse the HPC M (only used 0.25% of prep) and add to main mix. Proposed for F/C

Lot # RD11074

Addition of 0.3% to portion of lot RD1 1072

Lot # RD11075

Prepared a stock mixture to complete 3x500 g trials consisting of Castor-Oil (68%) Aerosil 200 (3%) DMI (6%). To this mix was added PVP K29-32 (1 %) in DMI (10) and active. Bulk split into 3 parts to be completed for 3 trials containing different mixtures and grades of HPC Nisso in Transcutol (ref lots RD1 1067/68/69)

Lot # RD11076 Used bulk from RD1 1075 and added HPC mix RD1 1067 (Transcutol P with Nisso H ( 0.15%)

Lot # RD11077

Used bulk from RD1 1075 and added HPC mix RD1 1068 (Transcutol P with Nisso H (0.2%)

Lot # RD11078

Used bulk from RD1 1075 and added HPC mix RD1 1069 (Transcutol P with Nisso H (0.1 ) and M (0.1 )

Lot # RD11079

Addition of 0.3% to portion of lot RD1 1076

Lot #RD11080

Addition of 0.3% to portion of lot RD1 1077

Lot #RD11081

Addition of 0.3% to portion of lot RD1 1078

Lot #RD11082

Trial attempt to prepare a batch without the use of SiO2 failed

Lot #RD11085

Prepared Castor-Oil pre-mix adding 2.5% Aerosil 200 followed with a mix of DMI (10) and Testosterone. Obtained viscosity of 3,100 cps. Followed with the addition of HPC Nisso L (0.2%) and Nisso M (0.3%) mixed in DMI and Transcutol plus 0.3% Aerosil 200 to reduce stickiness. Material was added without any stringing to the main mixture and obtained a viscosity of 4,800 cps at day of manufacture and 4,900 cps 3 weeks later. Proposed for F/C

Lot #RD11086

Addition of 0.3% to portion of lot RD1 1085 Table 2 TBS1 A 4% strength

Viscosity values using spindle 6, 20 rpm, Repeat test ref to Franz Cell:

F/C

Trial Manuf

Lot number date Test date and values Comments

D11037 Jul 15/11 Oct 04/11 Clear solution, previous results in July 620 cps

940 cps and follow up test 9/15/11 was 900 cps

RD11038 Jul 15/11 Oct 04/11 Clear solution, original test 1,180 cps , follow up

1,800 cps 09/15/11 1,660 cps

RD11039 Jul 20/11 Oct 04/11 Clear solution, previous results in July 980cps

1,380 cps and follow up test 9/15/11 was 1,300 cps

RD11040 Jul 20/11 Oct 04/11 Clear Gel, previous results in July 10,400 cps

11,040 cps and follow up test 9/15/11 was 10,140 cps

RD11041 Jul 21/11 Oct 04/11 Clear solution, previous results in July 500 cps

1,420 cps and follow up test 9/15/11 was 1,500 cps

RD11042 Jul 21/11 Oct 04/11 Clear solution, test 9/15/11 was 1,720 cps

1,430 cps

RD11050 Aug.09/11 Original comment sticky mixture, 09/15/11 results 2,460

Oct 04/11 Do not use trial lot for F/C

Test not valid Poor mixture, HPC settled to bottom as a slug

RD11050A Aug.09/11 Original comment sticky mixture, results

09/15/11 3,000 cps (increased during test from 2,400)

Oct 04/11 Do not use trial lot for F/C

Test not valid Poor mixture, HPC settled to bottom as a slug

RD11051 Aug.09/11 Oct 04/11 Clear , results 09/15/11 1,940 cps

2,100 cps ^A Note: viscosity values increase during 30 sec test

RD11051A Aug.09/11 Oct 04/11 Clear , results 09/15/11 2,560 cps

2,540 cps Note: viscosity values increase during 30 sec test

RD11053 Aug.10/11 Oct 04/11 Clear but sticky with air bubbles , results

4,500 cps ^A 09/15/11 4,060 cps

Note: viscosity values increase during 30 sec test

RD11054 Aug.10/11 09/15/11 test HPC globules, 15,000 cps

Oct 04/11 Do not use trial lot for F/C , Note: viscosity

14,000 cps± values increase during 30 sec test

Build up of HPC on spindle

RD11055 Aug.10/11 09/15/11, EEEEEE Do not use trial lot for F/C

Oct 04/11 Note, error message indicates above 20,000

EEEEEE tester limit at that setting

RD11056 Aug.10/11 09/15/11, EEEEEE

Do not use trial lot for F/C

Oct 04/11 Note, error message indicates above 20,000

EEEEEE tester limit at that setting

RD11059 Aug.22/11 Oct 04/11 Do not use trial lot for F/C

Test not valid Separation of HPC (?)Build up of HPC on spindle

RD11060 Aug.23/11 Oct 05/11

3,540 cps Uniform texture

RD11061 Aug.23/11 Oct 05/11

960 cps Uniform texture

RD11062 Aug.24/11 Oct 05/11 Original viscosity 2,400 cps

3,200 cps

RD11063 Aug.24/11 Oct 05/11 Original viscosity 1,600 cps

3,460 cps

RD11064 Aug.31/11 Oct 05/11 Original viscosity 5,800 cps

6,440 cps Clear, thick,

RD11065 Aug.31/11 Added .3% H20 to RD11063 09/31/11 resulted

Oct 05/11 in 9,100 cps

12,500 cps Air bubbles

RD11066 Aug.31/11 Added .3% H20 to RD11041 09/31/11 resulted

Oct 05/11 in 1,500 cps

2,600 cps Clear , thick

RD11070 Aug.31/11 Added .3% H20 to RD110370 9/31/11

Oct 05/11 resulted in 720 cps

1,540 cps Liquid and clear

RD11071 Aug.31/11 Added .3% H20 to RD11042

Oct 05/11 9/31/11 resulted in 1,760 cps

1,820 cps Liquid and clear

RD11072 Aug.31/11 Added .3% H20 to RD11040 resulted in 7,920

Oct 05/11 cps

7,920 cps Clear and thick, no change in viscosity

RD11073 Sep.07/11 Started off in Sept with viscosity of 5,500 cps

Oct 05/11

9,980 cps

RD11074 Sep.07/11 Added .3% H20 to RD11073 increases viscosity

Oct 05/11 to 7,200 cps.

10,100 cps

RD11076 Sep.06/11 Oct 05/11 Clear, however noticed separation in bulk

1,700 cps

RD11077 Sep.06/11 Oct 05/11

1,600 cps Clear RD11078 Sep.06/11 Oct 05/11

2,700 cps Clear and fluid

RD11079 Sep.06/11 Oct 05/11 Added 0.3% H20 to RD11076

3,500 cps Clear, fluid

RD11080 Sep.06/11 Oct 05/11 Added 0.3% H20 to RD11077

3,900 cps Clear, fluid

RD11081 Sep.06/11 Oct 05/11 Added 0.3% H20 to RD11078

2,600 cps Clear, fluid

RD11085 Sep.14/11 Original test 4,800 cps

Oct 05/11

4,900 cps Thick and clear

RD11086 Sep.20/11 Addition of 0.3% H20 to RD11085 = 5,200 cps

Oct 05/11 original

5,180 cps Thick gel and clear

TBS1 A 8 % Formulation/composition

Table 3

Trial number Active Castor oil Labrafil PVP arade DMI TranscutolP PC Nisso Si02 % micronized Ά Ά C=Cabosil

_% A=Aerosil200

RD11087 27 N-L = 0.2

8 55.9 0000000 0000000 20 + 7 6 N-M = 0.3 A = 2.6

RD11088 Same plus

8 same 0000000 0000000 same same same (0.3% H20)

RD11089 K17 = 3

8 46.5 0000000 S630 = 2 25 10 N- M = 0.5 C = 5

RD11089A Same plus

8 same 0000000 same same same same (0.3% H20)

RD11090 N-H = 0.3

8 39.0 0000000 K17 = 5.0 32 12 N-M = 0.2 C = 3.5

RD11100 Added

8 same 0000000 same same same same C = 2% for total of 5.5

RD11101 N-L = 0.4

8 46.1 0000000 K17 = 5.0 25 10 N-M = 0.4 C = 5.1

RD11102 N-L = 0.4 C = 5.1 plus

8 46.1 0000000 K17 = 5.0 25 10 N-M = 0.4 Addition of 1% for total of 6.1

RD11103 N-L = 0.4 C = 5.1 plus

8 46.1 0000000 K17 = 5.0 25 10 N-M = 0.4 addition of

0.3% water

RD11104 N-L = 0.4

8 42.2 4.0 K17 = 5.0 25 10 N-M = 0.4 A = 5.0

RD11105 A = 5.0

8 same same same same same same addition of

0.5% total 5.5% Process outline for active trials:

Lot # RD11087

Trial was initiated without PVP to identify impact on T solubility. The active dispersion in % DMI used did not provide a clear solution and did not clear up when adding to the Castor Oil/Si02 mix. Even the co-solvents present in the HPC mixture did not provide a clear bulk Gel. To the HPV mixture 0.1 % Si02 was added to reduce stringing and stickiness.

Viscosity at 4,400

This trial however will be selected for the Franz Cell test to identify diffusion rate eliminating PVP.

Lot # RD11088

0.3% water was added to a portion of Lot RD1 1087 to identify impact on viscosity. As observed on 4% trials, increase in viscosity is not evident on the bulk mixed with Si02 in the HPC. This trial not considered for F/C.

Lot # RD11089

This trial used the same quantitative formulation as the IMP Clinical 8%, however using an alternate source of HPC (original HPC source Klucel HF). Also made minor process changes, dissolved PVP in DMI only and added active. HPC was prepared in Transcutol and added to main bulk separately.

Obtained a clear solution when adding the active co-solvent mixture into the Castor-oil and no significant stringing with the addition of the HPC after addition of SiO2.

Viscosity of Gel on day of manufacture was 1 ,800 cps, when retested after 24 hours, 3,700 and after 48 hours up to 4,300. The re-test on October 3 (see table) recorded 4,500 cps.

This trial was selected for F/C test

Lot#RD11089A

0.3% water was added to a portion of Lot RD1 1089 to identify impact on viscosity. Viscosity change over time similar to above trial, day of manufacture 2,700 cps, when retested after 24 hours, 3,920 and after 48 hours up to 4,600. The re-test on October 3 (see table) recorded 5,040 cps.

Selected for study on impact of water

Lot # RD11090

Used higher percentage of DMI and Transcutol to be split for various pre-mixes, similar with SiO2 to be added HPC. Made a pre-mix of Castor oil and SiO2, however due to the lower ratio between the 2 excipients, the mixture became quite thick and further thickened up when adding part of the DMI.

Did finish off the trial, ended up at low viscosity, day of manufacture 900 cps, test Oct 03 -1 ,260 cps. Lower level of SiO2 was considered for study impact, however considering the processing issue (see RD1 1 100)

not suitable for F/C test

Lot# RD11100

Using a portion of above trial RD1 1090, added an additional 2% SiO2 (for total of 5.5%) to study impact on Viscosity. Increased to 1 ,900 cps on day of manufacture and retest October 03 (see table) resulted in a value of 3.060

Lot # RD11101

To potentially reduce the impact of PVP, required to dissolve the active, during the addition to the Castor oil/SiO2 mixture, added 2% of SiO2 to the DMI-PVP- Testosterone mix, obtaining a viscous mix. After addition of that mixture to a dispersion of Castor oil containing 1 % SiO2, maintained a viscous mixture at the temperature of 50% (would thicken up further on cooling). Further increase in viscosity with the addition of the HPC mix and final amount of SiO2.

Viscosity after cooling Gel to 21 C was 3,800 cps. (note that re-testing over time will be required, batch manufactured Oct 03)

This trial selected for F/C

Lot#RD11102

With the target for a 5,000 cps viscosity for the TBS1 A project, the above

RD1 1 101 was so far the best candidate to evaluate impact of further addition of SiO2, hence to a portion of that lot additional 1 % SiO2 was added. The rational for 6% was to obtain the same ratio of active to Si02 as the targeted level of 3% Si02 for the 4% strength.

Viscosity increase to 8,000 cps , this lot was selected for F/C study to identify impact of viscosity on rate of diffusion compared to RD1 1 101 of same composition with exception of 1 % addition in Si02, may need to consider on assay obtained.

Lot#RD11103

Addition of water for impact on viscosity, not considered for follow up testing (see viscosity table for results, increase to RD1 1 101 from 3,800 to 4,500 cps)

Lot#RD11104

Included this trial to evaluate addition of Labrafil. Labrafil was added to the Castor Oil mixed with SiO2 at 1 %. As observed previously, addition of Labrafil to the Castor oil containing SiO2 increases viscosity. All other mixture prepared and added as per trial RD1 1 101 , with addition of 2% SiO2 to complete mixture. This mixture contains a larger percentage of air bubbles, common on formulations containing Labrafil.

Viscosity obtained of 3,300 cps, will be followed up and tested at various time points.

Selected for F/C testing.

Lot#RD11105

Added to RD1 1 104 an additional 0.5% SiO2 (% adjusted to avoid high increase observed on RD1 1 102)

Increase from 3,300 to 4,100 cps

Not selected for F/C test

Note: Placebo trials are drawn up to identify impact on viscosity using the 2 different sources for Castor Oil and SiO2. These trials will also answer potential questions related to TBS1 and TBS2.

TABLE 4 TBS1 A 8 % strength

Viscosity values using spindle #6, 20 rpm, Franz Cell = F/C

D11088 Sept 20/11 Oct 03/11 Added 0.3% H20to RD11087

4,040 cps

RD11089 Sept 25/11 Oct 03/11 Based on original IMP, change in HPC

4,500 cps source and minor process step changes

Selected for Franz Cell

RD11089A Sept 25/11 Oct 03/11 As RD11089 plus 0.3% H20

5,040 cps Selected for Franz Cell

RD11090 Sept 26/11 Oct 03/11 3.5% Si02

1,260 cps Potential for F/C

RD11091 Sept 26/11 Oct 03/11 Added 0.3% H20 to RD11090

RD11100 Sept 26/11 Oct 03/11 Added to RD11090 to reach 5% Si02

3,060 cps content

RD11101 Oct 03/11 Oct 04/11 5% Si02

3,800 cps Selected for Franz Cell

RD11102 Oct 04/11 Oct 04/11 6% Si02

8,000 cps Selected for Franz Cell

RD11103 Oct 04/11 Oct 04/11 0.3% with 5% Si02

4,500 cps

RD11104 Oct 04/11 Oct 05/11 Includes 4% Labrafil, same comp for

3,300 cps polymers as RD11101 (air-bubbles)

Selected or Franz Cell

RD11105 Oct 05/11 Oct 05/11 Added additional 0.5% of Si02

4,100 cps to RD11104

Pre-mix RD Trials (used for addition in active trials)

Table 5

Trial ft/observation Evaluation Composition Results/comments Used in RD trial # test

EV001A (pg 41) Dissolving H PC DM I - 100 g Low viscosity grade

Nisso grade M Transcutol P 50 g Stored for hydration Not transferred for

Nisso H PC M - 2.5 g 72 hrs use to RD trials

Suitable viscosity for

further additions

EV001B (pg 41) Dissolving H PC DM I - 100 g high viscosity grade

Nisso grade H Transcutol P 50 g Stored for hydration Not transferred for

Nisso H PC H - 2.5 g 72 hrs use to RD trials

Viscosity too high

EV002A (pg 41) Dispersing Cabosil in DM I - 125 g Obtained clear and Not transferred for

DM I (purpose to Cabosil 10 g viscous dispersion use to RD trials study impact on Ratio related to

viscosity in final Gel) Castor oil/Cabosil EV002B (pg 41) Dispersing Cabosil in Transcutol P 250 g Obtained no Not transferred for Transcutol P Cabosil 20 g increase viscosity. use to RD trials (purpose to study Ratio related to Solution milky in

impact on viscosity Castor oil/Cabosil appearance

in final Gel)

RD11047 A Addition of PVP K17 DM I- 100 g Suitable for Used in RD trial for in DM I only. PVP K17 15 g additional mixing addition of H PC-H

Ratio represents 3% with H PC H and and active (see of PVP based on active. Note: used RD1150 and final Bulk Gel higher viscosity H PC RD1150A) formula grade with lower

viscosity PVP grade

RD11047B Addition of PVP DM I- 100 g Suitable for Used in RD trial for

K29/32 in DMI only. PVP K29/32 15 g additional mixing addition of H PC-M

Ratio represents 3% with H PC M and and active (see of PVP based on active. Note: used RD1151 and final Bulk Gel lower viscosity H PC RD1151A) formula grade with higher

viscosity PVP grade

RD11047C Addition of PVP K90 DM I- 100 g Not suitable to add Used in RD trial in DM I only. PVP K90 15 g any grade H PC, without H PC

Ratio represents 3% however suitable to addition RD11056 of PVP based on add the active

final Bulk Gel portion.

formula

RD11048 A Addition of PVP K17 DM I- 80 g Suitable for Used in RD trial for in DM I and Transcutol P 20 g additional mixing addition of H PC-H Transcutol P PVP K17 15 g with H PC H and and active (see

Ratio represents 3% active. Note: used RD11053 of PVP based on higher viscosity H PC

final Bulk Gel grade with lower

formula viscosity PVP grade

RD11048B Addition of PVP DM I- 80 g Suitable for Used in RD trial for

K29/32 in DMI and Transcutol P 20 g additional mixing addition of H PC-M Transcutol P. PVP K29/32 15 g with H PC M and and active (see

Ratio represents 3% active. Note: used RD11054 of PVP based on lower viscosity H PC

final Bulk Gel grade with higher

formula viscosity PVP grade

RD11048C Addition of PVP K90 DM I- 100 g Not suitable to add Used in RD trial in DM I and PVP K90 15 g any grade H PC, without H PC Transcutol P Ratio represents 3% however suitable to addition RD11055 of PVP based on add the active

final Bulk Gel portion.

formula

RD11067 Prep of H PC in TP= 40g Used in RD11076

Transcutol P only N-H = 0.75g

RD11068 Prep of H PC in TP= 40g Used in RD11077

Transcutol P only N-H = 1.0 g

RD11069 Prep of H PC in TP= 40g Used in RD11078 Transcutol P only N-H = 0.5 g

N-M=0.5 g

RD11075 Prep of base Castor oil /

solution used Aerosil200/

RD11076/RD11077/ DM I/

RD11078 PVP K30

Details in Table 2 Testosterone

Placebo TBS1 A trials

Table 6

Trial lot # Evaluation Composition Results/comments

Evaluate change in Labrafil M 1944 CS - 500g Viscosity 10,460 cps

RD11032 viscosity using Labrafil Cab-O-Sil - 40 g

versus Castor Oil Cr 0

Evaluate change Castor Oil - 500 g

RD11033 viscosity adding Cabosil Cab-O-Sil— 40 g Viscosity 14 460 cps first in Castor Oil Cr 0 Note: ratio used in IM P

Impact on adding DM I and RD11032- 270 g

RD11034 Transcutol to mixture DMI- 125 g Viscosity reduced to 8,740

RD11032 Transcutol P 50 g

Impact on adding DM I and Impact on adding DM I and

RD11035 Transcutol to mixture Transcutol to mixture Viscosity reduced to 3,600

RD11033 RD11032

Mixture of Castor Oil and Castor oil 125 g

RD11036A Labrafil, adding Cabosil Labrafil 125 g High viscosity out of range followed by Cabosil 20 g

DMI/Transcutol P DMI 125 g

Transcutol P 50 g

Mixture of Castor Oil and Castor oil 0 .. ... 125 g

RD11036B Labrafil followed by Labrafil 125 g

DMI/Transcutol P, add Cabosil 20 g Viscosity 7,680 cps

Cabosil last DMI 125 g

Transcutol P 50 g

Castor oil and CabOsil, Castor oil 0 285 g

RD11043 followed by mixture of Cabosil 20 g

DMI/Transcutol P and DMI .... 100 g

HPC H Transcutol P 50 g

HPC H 2.5 g

RD11043 Castor oil and CabOsil, Castor oil 0 285 g

followed by mixture of Cabosil 20 g

DMI/Transcutol P and DMI .... 100 g

HPC M and PVP K17 Transcutol P 50 g

HPC M 2.5 g

PVP K15 15 g

RD11057P TBS-2 Placebo for

Analytical Lab Method

RD11058P Castor oil an Cabosil A to D represents % RD11058P = 2740 cps

A-B-C-D-E-F Mix followed by addition Labrafil of 2-4% with Part A 2% = 11,400 of Labrafil change in viscosity Part B 3% = 14,000

E impact of adding Oleic Part C 3.5% = 14,440 acid Part D 4% = 14,900

F impact of adding DM I to Part E with Oleic = 1,520 RD11058-A Part F - 10% DMI to part A

= 13,500 cps

(incr. from 11,400)

RD11083P Purpose of trial to HPC mix prep of Viscosity of base prior to decrease stringing and DMI/Transcutol P solvents addition of H PC mixture stickiness of H PC mixture plus Nisso H PC L and M was 5,300 cps, after when adding to base mix Solvated for 48 hours addition of H PC mixture of castor oil/Aerosil and followed by addition of (no stringing

DMI Si02

RD11084P Used part of RD1108P to

add 0.3% H20 to evaluate

impact on viscosity

EXAMPLE 10

Franz Cell Studies - Testosterone Rates of Diffusion

Generally speaking, soak the membrane for 30 minutes in the diffusion solution. After put the membrane on the Franz Cell. Put the ring and the donor chamber on the membrane and clamp it. Add approx. one gram of gel (TBS 1 A 4% or 8%). Check the level of diffusion solution in Franz Cells. It's supposed to be on the mark. Put "parafilm" on the sampling port to avoid evaporation. Withdraw 0.3ml_ of sample at 60, 120, 180, 240, 300 and 360 minutes using syringe. Add diffusion solution to make up to the mark of Franz Cells. Each sample should be collected in insert.

A typical Fanz cell used in accordance with this Example 9 and the invention is depicted in Fig. 12. The materials include:

Diffusion solution: Ethanol/Water 50:50

Membrane: Millipore 0.45μιτι.

Temperature: 37° ± 0.5 °C.

Stirring speed: 600 rpm.

Medium volume: 20ml_.

Surface area: 1 .7671 cm²

Number of Franz Cells: 6.

Sampling time (minutes): 60, 120, 180, 240, 300 and 360.

Aliquot volume: 0.3ml_.

Insert: 0.4ml_.

The TBS1 A formulations are as follows and as reported in the Examples above and herein. The rate of diffusion results of testosterone through the Franz cell mebrane, normalized for each gel concentrations being tested, measured as slope/mgT%, are reported below in the Franz Cell Table. 4% TBS1 A Trial formulations used in Franz Cell

Trial Lot # RD11063 Batch size 500 g

Trial Lot # RD11085 Batch size 500 g

HPCNisso L 0.2 0.3% of Si02 mixed into HPC mixture

HPCNisso M 0.3 Temp range NMT 60C

HPCNisso H 0.0 Homogenize active mixture

Si02 (Cabosil-Aerosil200) 2.8 Viscosity 4,900 cps (10/05/11)

Trial Lot# RD11038 Batch size 500 g

Trial Lot # RD11039 Batch size 500 g

Co PVP S630 2.0 PVP into DMI+Tr-P followed by active

DMI 20.0

Transcutol P 10.0

Labrafil 29.0

HPC Nisso M 0.0

HPC Nisso H 0.0

Si02 (Cabosil -Aerosil 200) 3.0 Viscosity 1,380

Trial Lot # RD11040 Batch size 500 a

Raw Materials/grade % Process comments

6 hr Franz Cell

Testosterone micronized 4.0 Mix in 12% DMI and 6% Tr-P

Castor Oil (V - O) 57.0 Combine Castor oil + Si02+ 13% DMI+4% TrP

PVP K17 0.0

PVP K30 0.0

PVP K90 0.0

Co PVP S630 0.0

DMI 25.0

Transcutol P 10.0

HPC Nisso L 0.0

HPC Nisso M 0.0

HPC Nisso H 0.0

Si02 (Cabosil -Aerosil 200) 4.0 Viscosity 11,040

Trial Lot ft RD11042 Batch size 500 g

Raw Materials/grade % Process comments

6 hr Franz Cell

Testosterone micronized 4.0 Active dissolve in 13% DMI+ 4% Tr-P Castor Oil (V - O) 29.0 Castor oil+Labrafil+ Si02 +12 % DMI+6% Tr-P

PVP K17 0.0

PVP K30 0.0

PVP K90 0.0

Co PVP S630 0.0

DMI 25.0

Transcutol P 10.0

Labrafil 29.0

HPC Nisso M 0.0

HPC Nisso H 0.0

Si02 (Cabosil -Aerosil 200) 3.0 Viscosity 1,430 cps

Trial Lot # RD11051 Batch size 500 g

Trial Lot# RD11055 Batch size 500 g

Trial Lot# RD11078 Batch size 500 g

HPC Nisso H 0.1 Castor oil by 0.2 %

Si02 (Cabosil -Aerosil 200) 3.0 Viscosity 2,700 cps

Trial Lot # RD11054 Batch size 500 g

Raw Materials/grade % Process comments

6 hr Franz Cell

Testosterone micronized 4.0

Castor Oil (V - O) 61.4 Castor Oil +Si02 3% + DMI 7% + Transc 1%

PVP K17 0.0

PVP K30 3.0 DMI 16%+Trans 4%+pvp+HPC +active

PVP K90 0.0

Co PVP S630 0.0

DMI 23.0

Transcutol P 5.0

HPC Nisso L 0.0

HPC Nisso M 0.6

HPC Nisso H 0.0

Si02 (Cabosil -Aerosil 200) 3.0 Viscosity 14,000 cps

Trial Lot # RD11061 Batch size 500 g

Raw Materials/grade % Process comments

6 hr Franz Cell

Testosterone micronized 4.0

Castor Oil (V - O) 71.0 Castor oil + Si02 + Labrafil

PVP K17 2.0 DMI 16% + Transc 2% + PVP+ active

PVP K30 0.0

PVP K90 0.0

Co PVP S630 0.0

DMI 16.0 Transcutol P 2.0

Labrafil 2.0

HPC Nisso M 0.0

HPC Nisso H 0.0

Si02 (Cabosil -Aerosil 200) 3.0 Viscosity 960 cps

Franz Cell Table - Slope/mqT%

PV

Lot Cast P HP HP Interce

nr/compositio Testoster or PVP PVP K9 C0PVP6 La bra D Transcu HPC HPC C C SiO wat Interce pt/mgT Slope/ Povido HPC contr n%/Franz one Oil K17 K30 0 30 fil Ml tol L M H XHF 2 er pt slope % mgT% ne T Total 1

Reference 4 88 0 0 0 0 4 0 0 0 0 0 0 4 0 -241.78 132.62 -60.45 33.16 0.00 0 100

R viscous 4 87.7 0 0 0 0 4 0 0 0 0 0 0 4 0.3 -389.81 135.27 -97.45 33.82 0.00 0 100

TBSla

IMPllOOl 4% 4 50.5 3 0 0 2 0 25 10 0 0 0 0.5 5 0 -1371.8 300.02 -342.95 75.01 5.00 0.5 100

TBSla

IMP11002 4% 4 65.5 3 0 0 2 0 15 5 0 0 0 0.5 5 0 -991.01 220.68 -247.75 55.17 5.00 0.5 100

TBSla

IMP 11003 8% 8 46.5 3 0 0 2 0 25 10 0 0 0 0.5 5 0 -2673.9 613.24 -334.24 76.66 5.00 0.5 100

RD11089 8 46.5 3 0 0 2 0 25 10 0 0.5 0 0 5 0 -1999.2 489.46 -249.90 61.18 5.00 0.5 100

RD11089A 8 46.5 3 0 0 2 0 25 10 0 0.5 0 0 5 0.3 -1454.6 425.39 -181.83 53.17 5.00 0.5 100.

RD11087 8 55.9 0 0 0 0 0 27 6 0.2 0.3 0 0 2.6 0 -2810.2 636.05 -351.28 79.51 0.00 0.5 100

RD11101 8 46.1 5 0 0 0 0 25 10 0.4 0.4 0 0 5.1 0 -2085.1 525.63 -260.64 65.70 5.00 0.8 100

RD11102 8 46.1 5 0 0 0 0 25 10 0.4 0.4 0 0 6.1 0 -2069.9 499.5 -258.74 62.44 5.00 0.8 101

RD11104 8 42.2 5 0 0 0 4 25 10 0.4 0.4 0 0 5 0 -3397.2 755.62 -424.65 94.45 5.00 0.8 100

RD11038 4 57 3 0 0 2 0 20 10 0 0 0 0 4 0 -1265.3 271.06 -316.33 67.77 5.00 0 100

RD11039 4 29 3 0 0 2 29 20 10 0 0 0 0 3 0 -3084.4 508.88 -771.10 127.22 5.00 0 100

RD11040 4 57 0 0 0 0 0 25 10 0 0 0 0 4 0 -312.27 389.27 -78.07 97.32 0.00 0 100

RD11042 4 29 0 0 0 0 29 25 10 0 0 0 0 3 0 -1687.5 366.34 -421.88 91.59 0.00 0 100

RD11051 4 66.7 0 3 0 0 0 24 0 0 0.3 0 0 2 0 -1614.1 313.35 -403.53 78.34 3.00 0.3 100

RD11053 4 61.7 3 0 0 0 0 22 6 0 0 0.3 0 3 0 -1187.7 261.82 -296.93 65.46 3.00 0.3 100

RD11054 4 61.4 0 3 0 0 0 23 5 0 0.6 0 0 3 0 -1214.3 244.7 -303.58 61.18 3.00 0.6 100

RD11055 62 0 0 3 0 23 0 0 -1428.1 307.28 -357.03 76.82 3.00 0 100 RD11061 71 2 0 0 2 16 0 0 -2327.6 397.43 -581.90 99.36 2.00 0 100 RD11063 70.8 1.5 1.5 0 0 18 0 0.2 0 -924.39 187.46 -231.10 46.87 3.00 0.2 100 RD11078 68 0 1 0 0 16 0.1 0.1 0 -1309.9 269.37 -327.48 67.34 1.00 0.2 100. RD11085 70.7 0 0 0 0 16 0.2 0.3 0 0 -1550 272.4 -387.50 68.10 0.00 0.5 100

The TBS-1 A Gel In Vitro Release Rate Validation concerning Release Rate Study Summary for TBS-1 A Gel 4.0% and TBS-1 A Gel 4.5% are presented in Exhibits A and B submitted herewith.

These summaries summarize the release rate experiment data for exemplary TBS-1 A Gels. There are four Nasobol Gels (0.15%, 0.6%, 4.0% and 4.5%) for the method validation. The purpose of the Day1 and Day2 test are to determine the specificity and intraday/interday precision of the slope(release rate), Day3 and Day4 are to evaluate the slope sensitivity to the sample strength variation.

See Exhibit A (4.0%) and Exhibit B (4.5%) submitted herewith, both of which are incorporated herein by reference in their entireties.

EXAMPLE 11

In Vitro Release Rate (Iyrt) Comparison Testing

IVRT experimental approach is used for comparison of products in semi-solid dosage form

through evaluation of the drug release. In order to have fair comparison, products to be compared should be of comparable age and their release rates should be determined on the same day, under the same conditions. To ensure an unbiased comparison, sample position within the bank of Franz cells are randomized. The test (T) product and reference (R) product in each run is randomized or pre-assigned in a mixed arrangement. Method Parameter Main Alternate parameters

Franz Cells Franz Cells membrane : durapore 0.45 μητι , membrane : durapore 0.45 μητι , HVLP02500 HVLP02500

diameter 15 mm

ring diameter 15 mm

surface : 1 .767 mm"

thickness : 1.63 mm

thickness : 3.2 mm

gel Volume: 288.02 mm"

Gel Volume: 565.44 mm"

Volume media recptor : 7.5 ml receiving media volume: 12 ml

Ethanol Water 50/50 ETOH/water 50/50

600 rpm 600 rpm

Assay Assay

UPLC

HPLC

Concentrations from 3 μς/ιηΙ to 200 μς/ιηΙ

Concentrations 5 μς/ιηΙ to 1 00 μς/ιηΙ

The slope comparison test recommended by the FDA is performed and provides the evidence of the reproducibility of the IVRT method.

The two different formulations of the testosterone gel products, Table 1 , are applied on 12 cells of the modified Franz-Cell apparatus system: 6 cells for reference product (R) and 6 cells for test product (T), as depicted in Fig. 13. The two gel products,

Testosterone Nasabol Gel 4%, lot# E10-007, and TBS1 A Testosterone Nasal Gel 4%, lot# IMP 1 1002, are described in Example 6 and designated as 4% TSA-1 A and TBS1 .

Table 1 TBS1 TBS-1A 4 %

Material

(A)

Dimethyl isosorbide 0 25.0

Diethyleneglycol ethyl 0

10.0

ether

Povidone 0 3.0

Copovidone 0 2.0

Hydroxypropyl 0

0.5

cellulose

Testosterone 4.0

4.0

micronized

Castor oil 88.0 50.5

Labrafil M1944CS 4.0 0

Colloidal silicon 4.0

5.0

dioxide

Water 0 0

Total 100.0 100.0

Samples are collected at 1 , 2, 3, 4, 5 and 6 hours and are tested.

Franz Cell Apparatus Position Layouts for Comparison Testing

The Release Rates (slope) from the six cells of T- product and from the other six cells of the

R-product are obtained. A 90% Confidence Interval (CI) for the ratio (T/R) of median release rates is computed.

A table with six rows and seven columns is generated and reference slopes (RS) are listed across the first row and test slopes (TS) are listed down the first column of Table 2. Individual T/R ratios (30) between each test slope and each reference slope are computed and the corresponding values are entered in the table. Table 2

Calculation of T/R Ratios

These 30 T/R ratios are ranked from lowest to highest. The sixth and twenty-fifth

ordered ratios represent low and upper limits of the 90% CI for the ratios of median release rates.

Standard criteria:Tes\ and reference product are considered to be the same if the 90% CI falls within the limits of 75% - 133.3%.

Two batches of Testosterone Nasabol Gel 4%, lot# E10-007, and TBS1A Testosterone Nasal Gel 4%, lot# IMP 1 1002, are tested and evaluated for sameness.

A statistical comparison is carried out by taking the ratio of release rates from 6 cells of the reference lot # E10-007 (R) against 5 cells of the test batch lot# IMP 1 1002 (T).

During the in vitro drug releases test, the reference batch and the test batch are applied in a randomized manner on the cells on Apparatus A and B of the modified Franz Cell System.

Release Rate (slope) from five cells of the test product (T) and six cells of the

reference product (R) are compared. A 90% Confidence Interval (CI) for the ratio (T/R) of median release rates is computed.

The 90% Confidence Interval is represented by the sixth and twenty-fifth Release Rate ratios when ranked from lowest to highest. These ratios correspond to 160.77% and 202.90% respectively and do not meet the limits for sameness (CI 75% - 133.33%). Therefore, the two batches of Testosterone Nasabol Gel 4%, lot# E10-007 and TBS1 A Testosterone Nasal Gel 4%, lot# IMP 1 1002 are not considered the same.

Two gel products, Testosterone Nasabol Gel 4%, lot# E10-007, and TBS1 A

Testosterone Nasal Gel 4%, lot# IMP 1 1002, are tested and evaluated for sameness. The Mean Release Rate (slope) for the Test lot# IMP 1 1002 is about 1 .8 times higher than for the Reference lot# E10-007. The two tested products are found to be not the same.

The In Vitro Release Rate (IVRT) testing results and raw data are in Tables 3-8 below and Fig. 23.

 Table 4

4% eaJ Reteas© Rale Compsfissti

?«stos¾rene T8S1A Testosterone Um&l Gei 4%

Test Lfi«flMP11002

Ausowst &¾«8!¾si ¾jgAisL) C&leiitsssae S¾- Oissr Resressiaa Cisn»

CeS! < 3 ¾5S S CiSs i Ceil a*' sSS E

Hi,® 115.401 122. S4? 523.279 ^■51 ,557 118,895 3Λ

12ϋ.ίΚ> 201.133 2GS..222 •SS¾21 4,4

\m, £8ft,ft¾7 24».,«ββ 274,SS§ 95? SS4.S05 368.434 5.1 ,w 391. $33 320. * 3 34S.S ES 3t7,1S2 324. ''58 32S.6«4 6.Ϊ s . 401. SSI mSSf 378.137 S¾S S S 378.717 7.2 mm 4*2.475 4¾8,¾69 482,433 417 S-6 44S.S83 432.713 7.3

osi.i a« Meats 1-5 %8S» 1-5

7.7S m?.s?4 SS7.1S1 severe 777.93Ϊ §■^■97,400 3.$

50.95 1380.413 usts.sas 13¾i® 44

53,42 SS4.677 17SS.§¾2 :»56.71>3 ¾Η Λ$0 1884,747 m* 1823.C 2 54 iSA9 2607.&,© 2136.684 2404.4S¾ * 2378.251 67 mi 2866.422 24-81.39? 2m2?e 2760332 & 2816.161

3526,0ls7 291W1 3277.707 352S.S12 m^rA 3¾83-¾S1 7.S

2 ;; 187,78 jSff S iy;2o tej

0.*¾T7 tt,9¾S8 0 7 0.2

§ asses ·.

§ * ¾> 6.SS ftOS

' V&I CeS BUSS .« 35sr snjjsc!iesi, reie rate «d∞pi»te «s ¾*it by 5 -sA ~ 30· t!k mm.

Table 5

4%. £M Rsteas© Rate Gerf ssisen

Tesios&erestie asotet <M 4%M

eference Lets 61HM>?

Cen-eciiUatson ef Ai*i (jjg!teii) ΐίίΐΐΐϊ lime

CaEtA*. CdiA i €¾8A*$ CdiS ^'t CeUBSJ CeKDtt l^i ¾HSDM

Μ» 104 ¾« 101.48* 96.8S8 68,984 100,3*1 2.7

^■145.746 153.4152 1*9 Mi 140.111 162.369 1 S.3$$ ■2,8 tss.ee 1S1. m. 1B2.S3S 188,818 2.2 m 2i 21S.65Q 21 S7S 2.2

234,373 343.717 zsmm 336.437 241.174 1,5

3S8.SO ¾8¾,βΐ8 a&i.?ia 253.5053 2SS,219 1.8

Aetasi AfflftSitii er AtS** RiteseS $$fem") raws Tter

€s* (MS CeS A#S CiiS R*S.

Time

7.7S .ra. 68$ 372 2.7 • 0*5 SSS212 B87.186 taao.2i9 ^■10S3.304 102.855 ?fl

13.43 128S,*!K 1371,485 1362.353 i¾¾,stg i jm !¾¾?. r¾o

SIS,*® tSSS SS Ui?i; 125) 1565,197 1608,943 1581340 2.2 I?..52 1769.413 184 .221 18*1:242 wiisss 1TO.351 1&24.76® 1815,069 1..S

2841.513 ssts. es 1S¾t.?18 2Q4S.S6 20tS,1Sg 17 Sic il.f.ff mm ! .&· V> 55*0

¾99» t).9m ¾¾>!5?7

ace im *xm *.so &.se 1&» tasa w.so is.ts ¾M»

BSC* 4*2 AMW O0efl**« *Cii!8*1 AC** 8*3 *t*fi»Si

Table 6

Comparison Study Franz Cell eference L©t# E10-007 Testosterone ftesotsei 0e! 4% Gel

Test Lot* tWP 11002 TBSt A TssiDstersme Nasai Gsf 4%

R

1 i,80 118.04 120,10 119.6» 118,02 120,53

242.85 2.0792 2.0401 2.0221 2.0290 2.0577 2.0138

187,78 18077 1.5775 15635 15689 15811 1.5572

217_*83 18S50 1.8299 18137 18200 18457 18064

239.55 2.0509 2.0123 1.9946 2.0014 2.0297 1_*9885

213.29 18261 17918 1.7759 17S20 18072 17687

Note'. Test IftW Β#β at 2 h w was wissing tajecSfon, Comparison cateutaied fey 5xtJ*30 ireitvwiii* Ti¾ ns8os_> and a» iisntis oi 80% would fee ssxth and iwenty»fi8h oftfer individual

TJR rates.

Table 7

Sixth Ordefed Ratio; 160,77%

Twenty-fifth Ordered Ratio: 202.90%

Tfesi siiif referees* pm mts s £ kfw®& ΐο toe Urn "$mm" tf &&% CI

Table 8

Table 9

In Vitro release Rate Testing

Products: TBS1A Testosterone Nasal Gel 4% and Testosterone Nasobol Gel 4%

Objective: Release rate comparison bewteen the two testosterone gel Products

EXAMPLE 12

A phase-1 open label, balanced, randomized, crossover, two groups,

two-treatments, two-period, pilot study in healthy male subjects

A phase-1 open label, balanced, randomized, crossover, two groups, two-treatments, two-period, pilot study in healthy male subjects to determine the feasibility of a multiple dose dispenser for testosterone intranasal gel as measured by pharmacokinetics Testosterone replacement therapy aims to correct testosterone deficiency in hypogonadal men. Trimel BioPharma has developed an intranasal testosterone gel (TBS-1 ) as alternative to the currently available testosterone administration forms. To date, a syringe was used to deliver TBS-1 in clinical studies. Trimel identified a multiple dose dispenser intended for commercial use. The purpose of this study was to demonstrate the relative performance of the multiple dose dispenser in comparison to the syringe used previously in clinical trials.

This was an open label, balanced, randomized, crossover, two-group, two-treatment, two-period, pharmacokinetic study of TBS-1 testosterone nasal gel in healthy, male subjects aged 18 to 28. Treatment consisted of 4.5% TBS-1 testosterone gel as a single dose of 5.5 mg of testosterone per nostril, delivered using either a syringe or the multiple dose dispenser, for a total dose of 1 1 .0 mg given at 21 :00 hours. Prior to first administration, subjects were admitted to the unit for blood sampling in order to determine a baseline testosterone profile. Wash-out between drug administrations was at least 48 hours.

All subjects completed the study successfully and treatment was well tolerated.

The total exposure to testosterone as estimated by the mean area under the serum concentration-time curve (AUCo-12 in ng-hr/dL), is higher after TBS-1 administration using the dispenser or syringe than endogenous levels alone (7484 and 7266, respectively, versus 491 1 ng^*h/dl_. Mean C_max is higher after administration with the dispenser than after administration using a syringe (1028 versus 778.8 ng/dL, respectively). T_max occurs earlier following administration using the dispenser compared to the syringe (2.75 versus 5.6 hours, respectively. Thus, testosterone absorption seems to be faster with the multiple dose dispenser than with a syringe, but the total absorbed amount is similar. Also, in previous studies the syringe Tmax obtained in patient was closer to 1 .0 or 2.0 hours. When plotting probability density of the log ratio of testosterone levels reached with the multiple dose dispenser over levels reached with the syringe as shown in Figure 3, no significant difference was demonstrated for either AUCo-₁₂ or C_max within the lower and upper limit of the 95% confidence intervals. There is a trend toward a difference for Cmax. However, this data does not confirm bioequivalence at a confidence interval level of 90% for either AUCo-12 or C_max- If the trends found here are confirmed in a larger data set, the routes of administration would be almost equivalent for AUCo-_{12 ,} but t for C_max further investigation may be required as the Cmax/tmax profile obtained in volunteers does not seem to match the one obtained in patients.

Testosterone as a Treatment for Hypogonadism

Endogenous androgens are responsible for the normal growth and development of the male sex organs as well as promoting secondary sex characteristics including the growth and maturation of the prostate, seminal vesicles, penis, and scrotum; the development of male hair distribution, such as beard, pubic, chest, and axillary hair, laryngeal enlargements, vocal cord thickening, alterations in body musculature, and fat distribution.

Hypogonadism in men is characterized by a reduced concentration of serum testosterone resulting in signs and symptoms that may include decreased libido, erectile dysfunction, decreased volume of ejaculate, loss of body and facial hair, decreased bone density, decreased lean body mass, increased body fat, fatigue, weakness and anaemia.

The causes of hypogonadism can be primary or secondary in nature. In primary hypogonadism (congenital or acquired) testicular failure can be caused by cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, orchidectomy, Klinefelter's syndrome, chemotherapy, or toxic damage from alcohol or heavy metals. These men usually have low serum testosterone levels and serum gonadotropin levels (FSH, LH) above the normal range. In secondary hypogonadism (Hypogonadotropic Hypogonadism (congenital or acquired)) the defects reside outside the testes, and are usually at the level of the hypothalamus or the pituitary gland. Secondary hypogonadism can be caused by Idiopathic Gonadotropin or LHRH deficiency, or pituitary hypothalamic injury from tumors, trauma, or radiation. These men have low serum testosterone levels but have serum gonadotropin levels in the normal or low ranges.

Testosterone hormone therapy is indicated as a hormone replacement therapy in males for conditions associated with a deficiency or absence of endogenous testosterone. The currently available options for administration of testosterone are oral, buccal, injectable, and transdermal.

Trimel BioPharma has developed an intranasal testosterone gel (TBS-1 ) as a hormone replacement therapy for the treatment of male hypogonadism. The nasal mucosa offers an alternative route of administration that is not subjected to first pass metabolism, has high permeability, with rapid absorption into the systemic circulation. The advantages of the testosterone intranasal gel when compared to other formulations include ease of administration and no transference of testosterone to other family members.

Investigational Medicinal Product

The investigational medicinal product in this trial was TBS-1 , an intranasal testosterone dosage form. A description of its physical, chemical and pharmaceutical properties can be found in the Investigator's Brochure.

Summary of Non-clinical and Clinical Studies

Summary of Non-clinical Studies An overview of the pharmacology, toxicology and preclinical pharmacokinetics of different testosterone preparations and administration routes is provided in the Investigator's Brochure Product-specific repeat dose toxicity and tolerance studies have been performed in ex vivo models and in different animal species.

Summary of Previous TBS- 1 Clinical Studies

To date, Trimel has completed four Phase II clinical trials in hypogonadal men. The most recently conducted study, TBS-1 -2010-01 , is described below and the other studies are summarized in the Investigator's Brochure.

The objective of study TBS-1 -2010-01 is to examine the efficacy and tolerability of 4.0% and 4.5% TBS-1 testosterone gel in hypogonadal men. In this study, TBS-1 is administered using a syringe, not the commercial multiple dose dispenser. The doses and dosing regimens that were used in study TBS-1 -2010-01 are described in Table 1 below.

The results from all treatment groups met the FDA criteria for efficacy; defined as that at least 75% of subjects should achieve an average total T concentration (C_avg) in the normal range, a 24 hour C_avg value > 300ng/dl_ and < 1050 ng/dL.

Table 1: Summary of previous TBS-1 studies

Summary of Benefits and Risks to Subjects

Benefits

Testosterone replacement therapy for hypogonadal men should correct the clinical abnormalities of testosterone deficiency. Since this was a Phase I study enrolling normal healthy men between the ages of 18 - 45, for a short period of time, it was not anticipated that these volunteers would directly benefit by taking part in this study. Volunteers were financially compensated for their participation.

Risks

The risk to the subject by participating in this study was considered to be minimal. Testosterone replacement therapy is indicated for the treatment of hypogonadism and TBS-1 has been administered to over 100 men with minimal side effects.

As TBS-1 is an investigational drug that is in clinical development, the complete side effect profile was not fully known. Epistaxis, nasal congestion, nasal discomfort, nasal dryness and nasal inflammation have been reported following use of TBS-1 . Side effects from approved (prolonged) testosterone replacement therapy include elevated liver enzymes (alanine aminotransferase, aspartate aminotransferase), increased blood creatine phosphokinase, increase in prostatic specific antigen, decreased diastolic blood pressure, increased blood pressure, gynecomastia, headache, increased hematocrit/hemoglobin levels, hot flushes, insomnia, increased lacrimation, mood swings, smell disorder, spontaneous penile erection, and taste disorder.

The main benefit of the intranasal drug delivery route is that with this method many of the different disadvantages observed with other products would not be expected. This would include skin-to-skin transfer, stickiness, unpleasant smell (gels), skin irritation (patches), elevated DHT (patches and oral), injection pain and high T and DHT peaks (intramuscular injection), food interaction (oral).

Trial Rationale

Trimel identified a multiple dose dispenser that was intended as the commercial dispenser to be used in this clinical trial program. To date, a syringe has been used to deliver TBS-1 in the previous clinical trials. The purpose of this study was to demonstrate the comparability of the pharmacokinetic results obtained with a multiple dose dispenser or a syringe.

References

1 . Nasobol^® Investigator Brochure Release Date 19^th August 2010, Edition No: 5.

2. http://www.androgel.com/pdf/500122-

00127_Rev_1 E_Sep_2009_FPI_with_MedGuide.pdf (Last accessed on 6^th September, 2010).

3. http://www.mattern-pharmaceuticals.com/downloads/Nasobol.pdf (Last accessed on 6^th September, 2010).

4. http://www.medicines.org.uk/EMC/medicine/22159/SPC/Testim+Gel/ (Last

accessed on 6^th September, 2010).

STUDY OBJECTIVES

The primary study objective is to compare a pharmacokinetic profile of testosterone after administration of TBS-1 using two different dispensers in healthy male subjects.

The secondary objective is to assess the safety of TBS-1 .

Investigational Plan Overall Study Design and Plan

This is an open label, balanced, randomized, crossover, two-group, two-treatment, two- period, pharmacokinetic study of testosterone nasal gel formulation in healthy, adult, male human subjects. The study event schedule is summarized in Section ?????in Table 2.

Healthy male volunteers, aged 18 to 45 years (inclusive) were screened for this study. The goal was to randomize 12 male subjects for the study.

There was a washout period of 6 days between each drug administration.

Discussion of Study Design

As this is a relatively small Phase I PK study with the intent to compare a pharmacokinetic profile of testosterone after administration of TBS-1 from two different dispensers in healthy male subjects, a true sample size calculation is not performed. Based on typical early-stage, pharmacokinetic studies, groups of 6 subjects per cohort are sufficient for an acceptable description of the pharmacokinetic parameters after single dose administration.

Selection of Study Population

Inclusion Criteria

The following eligibility assessments have to be met for subjects to be enrolled into the study:

1 . Healthy male human subjects within the age range of 18 to 45 years inclusive

2. Willingness to provide written informed consent to participate in the study

3. Body-mass index of < 35 kg/m² 4. Absence of significant disease or clinically significant abnormal laboratory values on laboratory evaluations, medical history or physical examination during screening

5. Normal otorhinolaryngological examination

6. Non-smokers for at least six months

7. Comprehension of the nature and purpose of the study and compliance with the requirement of the protocol

Exclusion Criteria

A subject is not eligible for inclusion in this study if any of the following criteria applied:

1 . Personal / family history of allergy or hypersensitivity to testosterone or related drugs

2. Past history of anaphylaxis or angioedema

3. Any major illness in the past three months or any clinically significant ongoing chronic medical illness e.g. congestive heart failure, hepatitis, pancreatitis etc.

4. Presence of any clinically significant abnormal values during screening e.g.

significant abnormality of Liver Function Test (LFT), Renal (kidney) Function Test (RFT), etc.

5. Hemoglobin < 13g/dl and Hematocrit > 52% during screening

6. Any cardiac, renal or liver impairment, any other organ or system impairment

7. History of seizure or clinically significant psychiatric disorders

8. Presence of disease markers for HIV 1 and/or 2, Hepatitis B and/or C virus

9. History of nasal surgery, specifically turbinoplasty, septoplasty, rhinoplasty,

("nose job"), or sinus surgery

10. Subject with prior nasal fractures

1 1 . Subject with active allergies, such as rhinitis, rhinorrhea, or nasal congestion

12. Subject with mucosal inflammatory disorders, specifically pemphigus, or

Sjogren's syndrome

13. Subject with sinus disease, specifically acute sinusitis, chronic sinusitis, or allergic fungal sinusitis

14. History of nasal disorders (e.g. polyposis, recurrent epistaxis (> 1 nose bleed per month), abuse of nasal decongestants) or sleep apnea

15. Subject using any form of intranasal medication delivery, specifically nasal

corticosteroids and oxymetazoline containing nasal sprays (e.g. Dristan 12-Hour Nasal Spray)

16. History of asthma and/ or on-going asthma treatment

17. Regular drinkers of more than three (3) units of alcohol daily (1 unit = 300 ml beer, 1 glass wine, 1 measure spirit), or consumption of alcohol within 48 hours prior to dosing and during the study.

18. Volunteer demonstrating a positive test for alcohol consumption (using breath alcohol analyzer) at the time of check-in during the admission periods.

19. History of, or current evidence of, abuse of alcohol or any drug substance, licit or illicit

20. Volunteers demonstrating a positive test for drugs of abuse in urine (Opiates, Benzodiazepines, Amphetamines, THC and cocaine) at the time of check-in during admission periods

21 . Inaccessibility of veins in left and right arm

22. Receipt of any prescription drug therapy within four weeks of the first admission period.

23. Difficulty in abstaining from OTC medication (except occasional

paracetamol/aspirin) for the duration of the study

24. Volunteers demonstrating serum PSA > 4ng/ml

25. Participation in any other research study during the conduct of this study or 30 days prior to the initiation of this study.

26. Blood donation (usually 550 ml) at any time during this study, or within the 12 week period before the start of this study.

Removal of Patients from Therapy or Assessment All 12 subjects who enroll, complete the study successfully, and no subjects are replaced.

Treatments

Treatments Administered

For the drug administration, subjects are instructed on how TBS-1 is applied intranasally with the pre-filled syringes or the multiple dose dispensers. Self-administration of TBS- 1 is monitored by the study personnel. Each subject is instructed not to sniff or blow his nose for the first hour after administration.

Table 2: Treatment schedule

Treatment 1 consists of TBS-1 syringes that are pre-filled with 4.5% testosterone gel to deliver a single dose of 5.5 mg of testosterone per nostril, for a total dose of 1 1 .0 mg that is administered at 21 :00 hours (± 30 minutes) on Day 2 of Period I for Group A and Day 4 of Period II for Group B.

Treatment 2 consists of a TBS-1 multiple dose dispensers that are pre-filled with 4.5% testosterone gel to deliver a single dose of 5.5 mg of testosterone per nostril, for a total dose of 1 1 .0 mg that is administered at 21 :00 hours (± 30 minutes) on Day 2 of Period I for Group B and Day 4 of Period II for Group A.

Identity of Investigational Product(s)

The investigational product in this trial is TBS-1 , an intranasal testosterone dosage form.

Study medication consists of TBS-1 gel and is packed either in a single use syringe that is designed to expel 125 μΙ of gel, with two syringes packaged per foil pouch, or in a multiple dose dispenser that is designed to expel 125 μΙ of gel/actuation .

Study medication is dispensed by the study pharmacist who prepares the individual study kits which contained two syringes in a pouch or the multiple dose dispenser.

Method of Assigning Patients to Treatment Groups

Treatment assignment is determined according to the randomization schedule at the end of Visit 1 . Subjects who met the entry criteria are assigned randomly on a 1 :1 basis to one of the two treatment groups (Group A or Group B). The randomization is balanced and the code is kept under controlled access. The personnel that are involved in dispensing of study drug is accountable for ensuring compliance to the randomization schedule.

Selection and Timing of Dose

As healthy males have endogenous testosterone levels that fluctuate with a circadian rhythm which peaks in the early morning, it is decided to dose the study medication at night.

Blinding

This is an open-label study for both the subjects and the investigator, as the physical differences in the intranasal dosing dispensers prevent blinding. Prior and Concomitant Therapy

None of the subjects use prescription medication immediately prior to, during or the 2 weeks after the study. One subject receives a single dose of paracetamol (2 tablets of 500mg) just before discharge on the morning after the baseline visit (before administration of any study medication). There are no other reports of medication use.

Treatment Compliance

All subjects receive both doses of study medication according to the instructions and are monitored by study personnel for one-hour post-dosing to assure conformity to the TBS-1 instructions. All subjects remain in the clinic during the 12-hour PK sampling time period; during which they are monitored closely.

Screening

The screening visit (visit 1 ) takes place at a maximum of 21 days before the first study day. After giving informed consent, the suitability of the subject for study participation is assessed at screening which consists of the following items:

• Medical history

• Physical examination and Vital Signs.

• A fasting blood sample is taken to determine the following: Complete Blood Count, Chemistry profile; testing for HBV, HCV, HIV and PSA.

• Urinalysis, urine drug screen, and Breath Alcohol Testing.

• An otorhinolaryngological nasal endoscopic examination is performed by an ENT specialist.

Subjects meeting all of the inclusion and no exclusion criteria are enrolled into the study and are randomized into one of two treatment groups (1 or 2). Study Days

Subjects are admitted to the clinical research centre at 19:30 hours on Day 1 (Visit 2, baseline), 2 (Visit 3, Period 1 ) and 4 (Visit 4, Period 2). After check-in tests for drug- abuse and alcohol consumption are performed. Vital signs are recorded and subjects are questioned about changes in their health.

During Visit 2, a 12 hour baseline testosterone profile is measured. Blood for the 12 hour baseline testosterone profile is drawn according to the following schedule: first sample at 20:45 hours and then at 0.33, 0.66, 1 .00, 1 .50, 2.00, 3.00, 4.00, 5.00, 6.00, 8.00, 10.00, and 12.00 hours relative to 21 :00 time point (a total of 13 samples). On Day 2 vital signs are measured and safety parameters (symptoms, AEs) recorded before check-out.

Dosing is performed on the evenings of Day 2 and 4, at 21 :00 hr. Before dosing an ENT examination is performed and a pre-dose, baseline serum testosterone blood sample is drawn. After dosing, a 12 hour testosterone PK profile is measured. The blood samples are drawn according to the following schedule after the 21 :00 hour dosing: 0.33, 0.66, 1 .00, 1 .50, 2.00, 3.00, 4.00, 5.00, 6.00, 8.00, 10.00, and 12.00 hr time points (a total of 13 samples per period).

On Day 3 and 5 vital signs are measured, ENT examination are performed and safety parameters are recorded (symptoms, AEs) after the last PK sampling and before checkout. On Day 5 a final examination is performed, consisting of a general physical examination and clinical laboratory investigation (Complete Blood Count, Chemistry profile and Urinalysis).

Pharmacokinetic Sampling

Blood samples for analysis of testosterone levels are collected in 4ml standard clotting tubes using an intravenous cannula. Tubes are left to clot for 30-45 minutes. Samples are centrifuged within one hour at 2000g for 10 minutes at 4°C. The serum is then transferred directly to two aliquots of 1 ml each and frozen at -40 °C.

Safety

Blood samples for hematology are collected in 4ml EDTA tubes and sent to the hematology laboratory of the Leiden University Medical Center (LUMC) for routine analysis. Blood samples for blood chemistry are collected in 4 ml Heparin tubes and sent to the clinical chemistry laboratory for routine analysis.

Drug Concentration Measurements

Frozen serum samples for PK analysis are stored in the freezer at -40^QC and are shipped on dry ice to the laboratory, at the end of the study. Samples are analyzed using a validated LC-MS method for the determination of testosterone levels. It is not possible to discriminate endogenous and exogenous testosterone from each other using this method.

Quality Assurance

The study is conducted in compliance with the pertaining CHDR Standard Operating Procedures and CHDR's QA procedures.

Calculation of Pharmacokinetic Parameters

A validated LC-MS/MS method is employed to determine serum testosterone. All samples from study participant completing both the periods are analyzed.

Incurred sample reanalysis is performed:

• Cmin, C_max, and t_max actual measured values. Values are determined relative to the testosterone administration time in treated subjects.

• Area under the concentration curve (AUC) is estimated for the 0 to 12 hour time interval using the trapezoidal rule.

• Significance is evaluated using the t-test. Additional exploratory analyses of PK parameters could be performed as necessary. The relative pharmacokinetic profile of the pre-filled syringe and the multiple dose dispenser is determined using the AUC₀-i2h and Cmax₀-i2h corrected for the endogenous serum testosterone concentration. For bioequivalence, the relative mean of the dispenser to the pre-filled syringe using log transformed data for AUC₀-i2h and Cmax₀--i 2h is corrected for the endogenous serum testosterone concentration, is determined to be between 80% to 125%.

Analysis of Safety Parameters

The Day 5 close-out findings is compared to the screening results and clinically significant changes were to be identified in the following:

1 . Vital Signs and Adverse Events: Blood Pressure, Body Temperature,

Respiratory Rate, Heart Rate.

2. Otorhinolaryngological examination with the nasal tolerance data presented in summary tables.

3. Complete Blood Count: white blood count, hemoglobin and hematocrit.

4. Clinical chemistry profile: sodium, potassium, chloride, glucose, urea, creatinine, calcium, phosphate, uric acid, total bilirubin, albumin, AST, ALT, ALP, GGT, CK and cholesterol.

5. Urinalysis.

Determination of Sample Size

As this is a relatively small Phase I PK study with the intent to compare a pharmacokinetic profile of testosterone after administration of TBS-1 from two different dispensers in healthy male subjects, a true sample size calculation is not performed.

Subjects

26 Subjects are enlisted

• 2 subjects are not screened due to planning problems

• 1 subject is not screened because he does not have a general practitioner 23 Subjects are screened

• 3 screening failures due to ENT abnormalities

• 1 screening failure due to positive hepatitis B test

• 1 screening failure due to positive hepatitis C test

18 Subjects passed screening

• 12 subjects are randomized and completed the study

• 1 subject is cancelled before the baseline visit due to concurrent illness

• 5 subjects are reserves, but not needed

No subjects discontinue after randomization.

efficacy evaluation

Data collected is used in the analysis. This yields three PK curves of 12 hours each, one without treatment (baseline), and one each after administration of TBS-1 using the multiple dose dispenser or syringe.

Demographic Characteristics

Subject demographics are summarized in Table 4 below.

Table 4: Subject demographics

Variable N MEAN STD MIN MAX

Age (yrs) 12 23.4 3.0 18 28

BMI (kg/m²) 12 23.55 2.45 20.9 28.4

Height (cm) 12 184.43 8.46 173.5 197.0

Weight (kg) 12 80.08 9.76 63.2 98.2 Measurements of Treatment Compliance

The nasal gel is self-administered by subjects. All administrations are successful. Efficacy Results and Tabulations of Individual Patient Data

Fig. 24 shows the individual serum testosterone levels per occasion (baseline without medication, TBS-1 using the multiple dose dispenser and TBS-1 using syringes), where T=0 occurred at 21 :00 hours clock time. Fig. 24 shows the individual and median testosterone concentration versus time grouped by treatment.

All subjects have testosterone levels within the normal range (24 hour C_mean ≥ 300 ng/dL and < 1050 ng/dL). The baseline curves clearly show the slow circadian fluctuations in testosterone levels that are expected in a young, healthy population with the highest levels in the early morning.

Although dose and volume of TBS-1 that is administered is exactly the same for both forms of administration, the graphs in Figs. 15 and 16 suggest that there are differences in pharmacokinetic profile.

Pharmacokinetic Parameters

The following primary pharmacokinetic parameters, per occasion, are calculated:

• AUCo-12 : Area under the serum concentration-time curve (ng-hr/dL) for each occasion from 21 :00 to 9:00 hrs, is calculated using the linear trapezoidal method.

• Cmean : Mean concentration (ng/dL) during each occasion from 21 :00 to 9:00 hrs, is calculated as AUC_0-12 /12.

• C_max: Maximum is observed concentration (ng/dL) during each occasion. • Cmir, : Minimum is observed concentration (ng/dL) during each occasion.

• t _max^'. Time (hr) at which C_max i s observed.

Tables 5 to 7 below summarize the primary pharmacokinetic parameters for endogenous testosterone during the baseline visit when no treatment is administered, for TBS-1 when administered using the multiple dose dispenser, and for TBS-1 when administered using a syringe.

Testosterone, baseline, no treatment

Table 5: Testosterone, no treatment

Parameter Mean SD Median Min Max N

AUC₀.₁₂ 4911 1156 4726 3337 7164 12

^max 8.833 3.486 10.0 2.0 12 12

c *-max 514.2 117.5 480.0 384.0 746 12

C ■ 298.6 89.01 308.0 134.0 453 12

c *-mean 409.0 96.4 392.8 278.1 597 12

AUC_{0 12} in ng*hr/dL; t_max in hours; C_max C_min and C_mean in ng/dL

Testosterone, TBS- 1 multiple dose dispenser

Table 6 : Testosterone, TBS-1 multiple dose dispenser

Parameter Mean SD Median Min Max N

AUC₀.₁₂ 7484 1798 7347 4847 11350 12

^max 2.751 3.961 1.25 0.3333 12 12

c 1028 283.1 970.5 645 1440 12

C *-m■in 337.9 119.7 328.5 145 565 12

c *-mean 623.6 149.9 612.3 403.9 945.7 12

AUC_{0 12} in ng*hr/dL; t_max in hours; C_max, C_min and C_mean in ng/dL Testosterone, TBS- 1 syringe

Table 7 : Testosterone, TBS-1 syringe

Parameter Mean SD Median Mm Max

AUCo. 7266 1360 7237 5186 9371 12

^max 5.612 4.736 5.0 0.667 12 12 c 778.8 144.1 754.5 543 1100 12 c■ 355.9 66.96 337.0 291 498 12 c 605.4 113.2 603.1 432.2 780.9 12

AUCo in ng*hr/dL; t_max in hours; C_max, C_min and C_mean in ng/dL

The listing of individual primary pharmacokinetic parameters is included in Table 7A.

Table 7 A

Efficacy Data

Individual PK Parameters

Individual PK parameters 0-12 hrs for each occasion

Subject Occasion Treatment AUC 0-12t max C max C mean C min

1 1 No Treatment 5722 10.0000 600 476 .9 321

1 2 TBS-1 mdd 9394 12.0000 1070 782 .9 340

1 3 TBS-1 syringe 7802 12.0000 840 650 .1 400

2 1 No Treatment 3731 10.0000 388 310 .9 242

2 2 TBS-1 syringe 7367 1.5000 779 613 .9 333

2 3 TBS-1 mdd 7592 0.3333 1420 632 .7 386

3 1 No Treatment 4771 3.0000 498 395 .4 332

3 2 TBS-1 mdd 6056 0.6667 645 504 .7 395

3 3 TBS-1 syringe 7107 5.0000 691 592 .3 312

4 1 No Treatment 7164 2.0000 746 597 .0 453

4 2 TBS-1 syringe 8639 6.0000 837 720 .0 498

4 3 TBS-1 mdd 8370 0.3333 1440 697 .5 500

5 1 No Treatment 3337 10.0000 384 278 .1 134

5 2 TBS-1 mdd 4847 0.3500 1280 403 .9 145

5 3 TBS-1 syringe 5439 1.0000 725 453 .3 292

6 1 No Treatment 3673 10.0000 422 305 .2 166

6 2 TBS-1 syringe 5186 10.0200 543 432 .2 304

6 3 TBS-1 mdd 5851 1.0000 715 487 .6 325

7 1 No Treatment 4681 12.0000 456 390 .1 324

7 2 TBS-1 syringe 6250 12.0000 661 520 .8 291 7 3 TBS-1 mdd 6503 1.5000 881 541..2 159

8 1 No Treatment 4632 12.0000 473 386. .0 295

8 2 TBS-1 mdd 7102 1.5000 813 591. .9 332

8 3 TBS-1 syringe 8529 0.6667 1100 710. .7 343

9 1 No Treatment 4222 12.0000 481 351. .8 287

9 2 TBS-1 mdd 11350 3.0000 1350 945. .7 276

9 3 TBS-1 syringe 6992 12.0000 730 582. .7 341

10 1 No Treatment 6503 10.0000 718 541. .9 397

10 2 TBS-1 syringe 9371 5.0000 874 780. .9 445

10 3 TBS-1 mdd 8747 10.0000 820 728. .9 565

11 1 No Treatment 5541 5.0000 525 461. .7 353

11 2 TBS-1 mdd 7823 2.0000 848 651. .9 315

11 3 TBS-1 syringe 8550 1.5000 898 710. .6 408

12 1 No Treatment 4950 10.0000 479 412. .5 279

12 2 TBS-1 syringe 5962 0.6667 668 496. .8 304

12 3 TBS-1 mdd 6171 0.3333 1060 514. .2 317 mdd - multiple dose dispenser

Total testosterone exposure is estimated by the mean area under the serum concentration-time curve (AUCo-12 in ng-hr/dL) is higher after TBS-1 administration using the dispenser or syringe than endogenous levels alone (7484 and 7266, respectively, versus 491 1 ng^*h/dl_). Between the methods of administration, the difference in mean AUCo-12 is small. The significance of this difference is explored below.

Unexpectedly, mean C_max is higher after administration with the dispenser than when with a syringe (1028 versus 778.8 ng/dL, respectively). T_max occurs sooner after administration using the dispenser than after the syringe (2.75 versus 5.6 hours, respectively). Thus, after administration using the multiple dose dispenser serum testosterone seems to be absorbed faster than with a syringe. The significance of these differences is explored below.

Two subjects reach t_max of testosterone only 10 and 12 hours after administration with the dispenser. In three subjects, t_max is 10 and 12 hours after administration with the syringe, and t_max is 5 and 6 hours in two others. Most likely, the endogenous testosterone peak fluctuation exceeded levels that is caused by exogenous testosterone administration. Thus, the calculated mean t_max may be faster when testosterone is dosed high enough that the peak caused by exogenous administration exceeds the endogenous peak. Derived Pharmacokinetic Parameters

The following derived pharmacokinetic parameters, combining results from occasions, are calculated:

• AUC₀-i2_dru_g : difference between AUCo-12 after treatment (syringe or dispenser) and no treatment (baseline occasion)

• Cmax dmg : difference between C_max after treatment (syringe or dispenser) and the observed concentration at t_max in absence of treatment (baseline occasion)

• Ratio AUC₀-i2_dru_g : % ratio between AUC₀-i2_dru_g using dispenser and syringe

• Ratio Cmax _drug : % ratio between C_max_drug using dispenser and syringe

• Mean and uncertainty (95%, 90% and 80% confidence interval) of the log of

RatlO AUCo-l2_drug

• Mean and uncertainty (95%, 90% and 80% confidence interval) of the log of

RatlO Cmax drug

Testosterone Level Using TBS-1, Baseline Subtracted

Tables 8 and 9 below show the AUC and C_max for the different TBS-1 delivery methods after subtracting baseline levels of testosterone.

Table 8: Testosterone level using TBS-1 multiple dose dispenser, baseline subtracted

Parameter Mean SD Median Min Max N

AUC o 2573.0 1679.0 2211 1207 7126 12

630.8 314.7 534 102 1111 12

Table 9: Testosterone level TBS-1 syringe, baseline subtracted

Parameter Mean SD Median Min Max N

AUC 2356.0 900.9 2219 1012 3897 12

379.9 177.1 357 121 782 12 Testosterone Level TBS-1 Dispenser over Syringe Ratio

Table 10 below shows the ratio of serum testosterone levels that are reached with the dispenser or syringe, after subtracting baseline testosterone levels. There is clearly a difference in C_max between the administration forms (mean ratio dispenser over syringe Cmax 2.057), but the AUCs are comparable (mean ratio dispenser over syringe AUC 1 .12).

Table 10: Testosterone, ratio of TBS-1 multiple dose dispenser over syringe

Parameter Mean SD Median Mm Max

Ratio AUC

Ratio C_max

logRatio AUC

logRatio C_max

Table 1 1 below shows the log of the ratio of serum testosterone levels that are reached when administering using the multiple dose dispenser over syringe, after subtracting baseline testosterone levels, with 95%, 90% and 80% confidence intervals.

When plotting probability density of the log ratio of testosterone levels that are reached with the multiple dose dispenser over levels that are reached with the syringe as shown in Figure 17, no significant difference is demonstrated for either AUCo-12 or C_max within 95% confidence intervals. There is a trend toward a difference for C_max. However, this data does not confirm bioequivalence at a confidence interval level of 90% for either AUCo-12 or Cmax, as the study is not powered for 2-one-sided tests. Table 11: Testosterone TBS-1 log ratios with different confidence intervals

Parameter Mean CI (%) LLCI ULCI

logRatio AUC 0.01398 95 -0.27400 0.3019

90 -0.2209574 0.24892

80 -0.16438 0.19234 logRatio C_{max drug} 0.45520 95 -0.09145 1.0020

90 0.00917 0.90127

80 0.11658 0.79386

CI = confidence interval; log(0.8) = -0.22314; log(1.25) = 0.22314

Handling of Dropouts or Missing Data

No subjects drop out of the study. Blinded data review did not lead to removal of any data points.

Extent of Exposure

The pharmacokinetic results show that exposure to testosterone is only higher than the upper level of the normal range very briefly shortly after TBS-1 administration.

Adverse Events (AEs)

Treatment is well tolerated. There are 12 adverse event reports in total. Three events had their onset before the first administration of study medication and are therefore unrelated. Four reports of mild complaints such as sore throat are considered unlikely to be caused by study medication when considering the nature of the complaints and the time lapse after administration. One subject reschedules one occasion because of gastro-intestinal complaints that are unlikely to be related to study medication, onset of symptoms is days after study drug administration. Symptoms resolve without treatment. Reports of bad smell and taste are the only complaints that are considered clearly related to administration of medication. These complaints are mild in intensity and could be considered a product characteristic rather than a medical condition. Bad smell and taste complaints do not lead to discontinuation of the study medication and diminishes with repeated dosing.

Display of Adverse Events

A listing of adverse events is included in Table 12.

Table 12

Listing of Adverse Events

Treatment

Treatment Subject Visit Start Diagnosis

action Symptoms Chronicity Duration Severity

SAE related

TBS-1 mdd 2 3 06APR11 8:30 OROPHARYNGEAL PAIN None

Irritated single occasion 0D01H20M mild No unlikely throat .

3 2 30MAR11 12:00 HEADACHE None

Headache single occasion 0D09H00M mild No unrelated

30MAR11 21:04 APPLICATION SITE ODOUR None Smells nasty, single occasion 0D02H55M mild No definitely

bad taste.

5 2 30MAR11 20:40 APPLICATION SITE ODOUR None

It smells nasty, single occasion 0D00H30M mild No definitely

30MAR11 21:15 DYSGEUSIA None Bad taste. single occasion 0D00H45M mild No definitely

8 2 13APR11 20:45 CATHETER SITE RASH Removed plastic Red rash in single occasion 1D18H15M mild No unrelated tape patch. left armpit,

where cannula is placed.

TBS-1 syringe 1 3 06APR11 8:30 OROPHARYNGEAL PAIN None

Sore throat. single occasion 0D00H40M mild No unlikely

2 2 31MAR11 13:00 AGITATION None

Feeling single occasion 0D20H00M mild No unlikely agitated .

4 2 30MAR11 20:45 APPLICATION SITE ODOUR None

It smells nasty, single occasion 0D00H20M mild No definitely

6 2 30MAR11 20:33 APPLICATION SITE ODOUR None

It smells nasty, single occasion 0D00H27M mild No definitely

10 2 18APR11 23:00 DIARRHOEA None

Nausea, single occasion 1D21H00M mild No unlikely

diarrhoea .

No Treatment 11 1 13APR11 9:19 HEADACHE

Paracetamol, Headache single occasion 0D06H41M mild No unrelated

sleep .

Note: mdd=multiple dose dispnenser M=Missing U=Unknown

Analysis of Adverse Events

All adverse events are considered mild and are transient. Nasal tolerance is good. Initial complaints of bad smell or taste did not lead to discontinuation of the study.

Deaths, Other Serious Adverse Events, and Other Significant Adverse Events

There are no deaths, serious adverse events or other significant adverse events.

Evaluation of Each Laboratory Parameter

There are no abnormal hematology, blood chemistry or urine laboratory findings that are considered clinically significant in the opinion of the investigator.

Vital Signs, Physical Findings and Other Observations Related to Safety

There are no abnormal findings in vital signs, on physical examinations or other observations that are considered clinically significant in the opinion of the investigator. Safety Conclusions

Treatment is well tolerated, nasal tolerance is good. All adverse events are considered mild and are transient. Initial complaints of bad smell or taste did not lead to study discontinuation.

Discussion and Overall Conclusions

This study compares the pharmacokinetic profile of TBS-1 testosterone nasal gel administered using a multiple dose dispenser to the profile of TBS-1 delivery using a syringe. In order to avoid carry-over effects that are caused by repeated dosing, the order of administration is randomized. bPrior to first administration, subjects are admitted to the unit for blood sampling in order to determine a baseline testosterone profile.

All 12 subjects, age range 18 to 28 years, complete the study successfully. Although not assessed at screening, all subjects have baseline testosterone levels within the normal range. Treatment is well tolerated and all reported adverse events are transient and considered mild. Complaints of bad smell and taste are reported, although this did not lead to discontinuation and decreased with repeated dosing.

As expected, the total exposure to testosterone (as estimated by the mean area under the serum concentration-time curve (AUCo-12)) after TBS-1 administration using the dispenser or syringe exceed endogenous levels. The difference in mean AUCo-12 between the two modes of administration is small.

Unexpectedly, mean C_max is considerably higher after administration with the dispenser than when administering using a syringe. T_max is also earlier after administration using the dispenser than after the using the syringe. Thus, testosterone absorption seems to be faster with the multiple dose dispenser than with a syringe, but the total absorbed amount is similar. Two subjects reach t_max of testosterone only 10 and 12 hours after administration with the dispenser. In three subjects, t_max is 10 and 12 hours after the syringe, and t_max is 5 and 6 hours in two others. Most likely, the endogenous testosterone peak fluctuation exceed levels that are caused by exogenous testosterone administration. Thus, the calculated mean t_max may be faster when testosterone is dosed high enough that the peak caused by exogenous administration exceeds the endogenous peak.

When plotting probability density of the log ratio of testosterone levels that are reached with the multiple dose dispenser over levels that are reached with the syringe, no significant difference is demonstrated for either AUCo-12 or C_max within 95% confidence intervals. There is a trend toward a difference for C_max. However, this data does not confirm bioequivalence at a confidence interval level of 90% for either AUCo-12 or C_max. This finding may be due to the fact that the ideal positioning of the delivering tip is easier to find with the multiple dose device than the syinge.

Also, in accordance with this Example 6, see Figs. 23 and 24.

The following formaltions are in Table 13 used in Examples 5-7 and in Figs. 23 and 24.

Table 13

Castor oil 88.0 87.95 50.5 65.5 46.5

Labrafil M 1944CS 4.0 4.0 0 0 0

Colloidal silicon 4.0 4.0

5.0 5.0 5.0 dioxide

Water 0 0.05 0 0 0

Total 100.0 100.0 100.0 100.0 100.0

EXAMPLE 13

A Phase 3, 90-DAY, RANDOMIZED, DOSE-RANGING STUDY, INCLUDING POTENTIAL DOSE TITRATION, EVALUATING THE EFFICACY AND SAFETY OF INTRANASAL TBS-1 IN THE TREATMENT OF MALE HYPOGONADISM WITH SEQUENTIAL SAFETY EXTENSION PERIODS OF 90 AND 180 DAYS

Investigational Product: 4.5% TBS-1 intranasal testosterone gel

Protocol Number: TBS-1 -2011-03

SYNOPSIS

TITLE: A 90-Day, Randomized, Dose-Ranging Study, Including Potential Dose Titration, Evaluating the Efficacy and Safety of Intranasal TBS-1 in the Treatment of Male Hypogonadism With Sequential Safety Extension Periods of 90 and 180 Days

PROTOCOL NUMBER: TBS-1 -201 1 -03

INVESTIGATIONAL PRODUCT: TBS-1 intranasal 4.5% testosterone gel PHASE: 3

INDICATION: Adult male hypogonadism (primary and secondary)

OBJECTIVES: The primary objective of the study is to determine the efficacy of 4.5% TBS-1 gel, administered as 2 or 3 daily intranasal doses of 5.5 mg per nostril, as demonstrated by an increase in the 24-hour average concentration (C_avg) of serum total testosterone to the normal range (>300 ng/dL and <1050 ng/dL) in >75% of male subjects treated for hypogonadism. See also Exhibit C (the contents of which are incorporated herein by reference).

The secondary objectives of this study are the following:

• To determine the efficacy of 4.5% TBS-1 gel, administered 2 or 3 times daily at a dose of 5.5 mg per nostril, in achieving the following for serum total testosterone maximum concentration (C_max):

o Cmax≤1500 ng/dL in >85% of subjects,

o Cmax 1800 to 2500 in <5% of subjects, and

o Cmax >2500 ng/dL in no subjects;

• To determine the safety and tolerability of TBS-1 after 90, 180, and 360 days of treatment;

• To determine the effect of TBS-1 treatment on body composition (total body mass, lean body mass, fat mass, and percent fat);

• To determine the effect of TBS-1 treatment on bone mineral density (lumbar spine and hip);

• To determine the effect of TBS-1 treatment on mood;

• To determine the effect of TBS-1 treatment on erectile function; and

To determine the serum concentration and pharmacokinetics (PK) of total testosterone, dihydrotestosterone (DHT), and estradiol after TBS-1 administration.

POPULATION:

The population for this study is adult men 18 to 80 years of age, inclusive with fasting morning (0900 h ± 30 min) total serum testosterone <300 ng/dL. Subjects currently treated with testosterone must undergo 2 to 4 weeks of washout depending on the route of administration.

STUDY DESIGN AND DURATION:

This is a Phase 3, 2-group, multicenter study consisting of 4 study periods including 2 safety extension periods as follows:

• A 3- to 7-week Screening Period that includes medication washout for subjects currently receiving testosterone treatment;

• A 90-day randomized, open-label Treatment Period during which subjects will receive 5.5 mg per nostril of 4.5% TBS-1 twice daily (BID) or three times daily (TID) with potential daily dose adjustment on Day 45 for subjects in the BID treatment group as determined by the serum total testosterone PK profile;

• A 90-day open-label Safety Extension Period (Safety Extension Period 1 ) for all study subjects; and

• An additional 180-day open-label Safety Extension Period (Safety Extension Period 2) for a subset of 75 subjects.

The approximate total duration of study participation for subjects completing all 4 periods will be up to 406 days (-58 weeks).

Screening Period

The Screening Period will take place over 3 to 7 weeks and will consist of up to 3 study visits. The duration of screening will depend on whether subjects are na^'ive to

testosterone treatment or if they are currently being treated with a testosterone product. Subjects currently being treated with a testosterone product will require a washout. The duration of washout will depend on the type of testosterone therapy and the date of their last dose. For subjects taking testosterone injections, there must be at least 4 weeks between their last testosterone injection and the first measurement of morning serum total testosterone for qualification. For subjects taking oral, topical, or buccal

testosterone, there must be at least 2 weeks between the last administration of testosterone and the first measurement of morning serum total testosterone for qualification. Visit 1 will occur up to 7 weeks (Week -7) prior to randomization for subjects currently receiving testosterone injections, up to 5 weeks (Week -5) prior to randomization for subjects currently receiving oral, topical, or buccal testosterone, and up to 3 weeks (Week -3) prior to randomization for na^'ive subjects. During Visit 1 , informed consent will be obtained and the subject's inclusion and exclusion criteria will be assessed based on medical interview, concomitant medications, physical examination, digital rectal examination (DRE) of the prostate, vital sign measurements, and screening laboratory evaluations. For na^'ive subjects, a fasting morning (0900 h ± 30 min) serum total testosterone level and baseline laboratory measurements will be assessed at Visit 1 . Non-na^'ive subjects will be instructed to discontinue all testosterone therapies at Visit 1 . After Visit 1 , if it is determined that a subject does not qualify for the study, the subject will be notified and instructed to restart prior testosterone therapy.

Subjects undergoing washout from testosterone therapy will return for Visit 1 .1 and will have fasting morning (0900 h ± 30 min) serum total testosterone levels and baseline laboratory measurements obtained. For subjects undergoing washout of testosterone injections, Visit 1 .1 will occur 4 weeks after the last testosterone injection (up to Week - 3). For subjects undergoing washout of oral, topical, or buccal testosterone, Visit 1 .1 will occur 2 weeks after the last administration of testosterone (up to Week -3). Visit 1 .1 is not required for na^'ive subjects.

At Visit 2 (up to Week -2), all subjects will have a fasting morning (0900 h ± 30 min) serum total testosterone level and 12-lead electrocardiogram (ECG) assessed.

At the screening visits (Visits 1 , 1 .1 , and 2), serum total testosterone levels will be measured using a validated assay developed by Medpace Reference Laboratories. The results will be used for determination of a subject's inclusion or exclusion from the study. To be included in the study, subjects must have 2 fasting morning (0900 h ±

30 min) serum total testosterone levels <300 ng/dL. In subjects with a known history of male hypogonadism, if 1 of the 2 serum total testosterone levels is >300 ng/dL, the serum total testosterone level may be retested once. After retesting, if 2 of the 3 levels are <300 ng/dL, then the subject will be eligible to participate in the study. Subjects who qualify for the study based on screening assessments at Visits 1 , 1 .1 , and 2 will be scheduled for an otorhinolaryngological (ENT) examination with nasal endoscopy performed by an ENT specialist. All qualified subjects will also have dual- energy x-ray absorptiometry scans scheduled in the interval between Visit 2 and randomization (Visit 3) for the assessment of body composition and bone mineral density.

Treatment Period

The randomized, open-label Treatment Period will consist of 4 study visits: Visit 3 (Day 1 ), Visit 4 (Day 30), Visit 5 (Day 60), and Visit 6 (Day 90).

Visit 3 (Day 1 ) will take place in the evening. At Visit 3, subjects will be randomized in a 3:1 ratio to 1 of the following 2 treatment groups:

• 5.5 mg per nostril of 4.5% TBS-1 BID or

• 5.5 mg per nostril of 4.5% TBS-1 TID.

Baseline levels of fasting serum total testosterone, DHT, and estradiol will be measured. Study drug (TBS-1 ) will be administered at 2100 h and 0700 h in the BID treatment group (total daily dose of 22 mg/day) and at 2100 h, 0700 h, and 1300 h in the TID treatment group (total daily dose of 33 mg/day). The first dose of study drug will be administered at Visit 3 (Day 1 ) at 2100 h and training on drug administration will be provided to subjects. Subjects will be asked to maintain a daily diary documenting administration of study drug doses throughout the Treatment Period, Safety Extension Period 1 , and Safety Extension Period 2.

At Visit 4 (Day 30 to Day 31 ), study drug will be administered at the site, beginning with the 2100 h dose of TBS-1 . Subjects will be required to remain at the site for 24 hours after the 2100 h drug administration and complete post-dose PK profiles for serum total testosterone, DHT, and estradiol will be obtained. The 24-hour C_avg of serum total testosterone for subjects in the BID group will be estimated based on the sum of serum total testosterone levels collected at 2 sampling points during the 24-hour PK profile: the sample collected at 9.0 hours (at 1 hour before the morning 0700 h dose) and the sample collected at 10.33 hours (20 minutes after the morning 0700 h dose). The following titration criteria will be used:

• If the sum of the serum total testosterone level values for PK samples collected at 9.0 hours and 10.33 hours is <755 ng/dL, then the estimated 24-hour C_avg is <300 ng/dL and

• If the sum of the serum total testosterone level values for PK samples collected at 9.0 hours and 10.33 hours is >755 ng/dL, then the estimated 24-hour C_avg is >300 ng/dL.

Subjects randomized to the BID group with an estimated serum total testosterone Cavg <300 ng/dL, will be contacted by phone and instructed to increase the daily dose of TBS-1 to TID on Day 45. The decision to increase the subject's daily dose to TID will be made by the investigator based on the criteria specified above. This daily dose will be continued throughout the remainder of the Treatment Period and, as applicable, both Safety Extension Periods.

At Visit 6 (Day 90 to Day 91 ), study drug will be administered at the site, beginning with the 2100 h dose of TBS-1 . Subjects will be required to remain at the site for 24 hours after the 2100 h drug administration and complete post-dose PK profiles for serum total testosterone, DHT, and estradiol will be obtained.

At Visits 3, 4, and 6, serum total testosterone, DHT, and estradiol levels will be measured using a sensitive and specific assay developed and validated by Analytisch Biochemisch Laboratorium BV. The results will be used for PK analyses.

Safety Extension Period 1

All subjects will continue into Safety Extension Period 1 and will be instructed to continue their current daily dose of TBS-1 for the 90-day Safety Extension Period (Day 90 to Day 180). Subjects will return to the site for monthly visits. Safety Extension Period 2

A subset of approximately 75 subjects will continue in the study for an additional 180-day Safety Extension Period (Day 180 to Day 360). The subset of subjects who continue into Safety Extension Period 2 will consist of the first subjects to complete Safety Extension Period 1 . For the duration of Safety Extension Period 2, subjects will remain on the same daily dose of TBS-1 administered on Day 90 of the Treatment Period and throughout Safety Extension Period 1 . Subjects will return to the site for monthly visits.

DOSAGE FORMS AND ROUTE OF ADMINISTRATION:

TBS-1 is administered intranasally by the subject. A multiple-dose dispenser will be used for gel deposition into the nasal cavity. The dispenser is a finger-actuated dispensing system designed to deliver 5.5 mg of 4.5% TBS-1 gel per actuation from a non-pressurized container into the nasal cavity. The dispenser is designed to administer 45 doses (90 actuations) of TBS-1 . The key components of the multiple-dose dispenser include a barrel, base, pump, and actuator, which are composed of polypropylene, and a piston, which is composed of polyethylene. EFFICACY VARIABLES:

The primary efficacy variable is the number and percentage of subjects with a serum total testosterone C_avg value within the normal range (>300 ng/dL and <1050 ng/dL) on Day 90.

Secondary efficacy variables include the following:

• The number and percentage of subjects with a serum total testosterone

maximum concentration (C_max) value in the following ranges on Day 90:

o <1500 ng/dL,

o >1500 and <2500 ng/dL, and

o >2500 ng/dL;

• The number and percentage of subjects with a serum total testosterone C_avg value in the normal range (>300 ng/dL and <1050 ng/dL) on Day 30;

• The number and percentage of subjects with a serum total testosterone C_max value in the following ranges on Day 30:

o <1500 ng/dL,

o >1500 and <2500 ng/dL, and

o >2500 ng/dL;

• The complete PK profile (including C_avg, the minimum concentration, C_max, and time to maximum concentration) of serum total testosterone on Day 30 and Day 90;

• The time within the normal range for serum total testosterone based on the PK profile on Day 30 and Day 90;

• The PK profile of serum estradiol on Day 30 and Day 90;

• The PK profile of serum DHT on Day 30 and Day 90;

• The ratio of DHT C_avg to total testosterone C_avg on Day 30 and Day 90;

• The Positive and Negative Affect Schedule scores at baseline, Day 30, Day 60, and Day 90;

• The International Index of Erectile Function scores at baseline, Day 30, Day 60, and Day 90;

• Change in bone mineral density from baseline to Day 180; and

Change in body composition (total body mass, lean body mass, fat mass, and percent fat) from baseline to Day 180. SAFETY VARIABLES:

Safety assessments will include adverse events, clinical laboratory measurements (chemistry profile, liver function tests, fasting lipid profile, hematology, urinalysis, glycosylated hemoglobin, prostate specific antigen, and endocrine profile), 12-lead ECG parameters, vital signs (blood pressure, heart rate, temperature, and respiratory rate), physical examination parameters, DREs of the prostate, and ENT examinations.

STATISTICAL ANALYSES:

The intent-to-treat (ITT) population will consist of all subjects who receive randomized study drug and have at least 1 valid post-baseline efficacy measurement. The safety population will consist of all subjects who receive randomized study drug and have safety measurements during the treated periods. The efficacy analyses will be based on the ITT population and the safety analyses will be based on the safety population.

The primary efficacy parameter, the C_avg of serum total testosterone at Day 90, will be calculated from the area under the curve (AUC) using the following formula:

C_aVg = AUCo - 24h / 24

The AUC curve for both BID and TID dosing regimens will be determined for the 0 to 24-hour time interval by using the linear trapezoidal rule.

The number and percentage of subjects who reach the treatment goal (ie, serum total testosterone C_avg value in the normal range) at Day 90 or Early Termination will be summarized descriptively. The analysis and calculation for the frequency of attaining the secondary study objectives will be performed using similar methods.

The concentrations of serum total testosterone, DHT, and estradiol will be provided for baseline, Day 90 or Early Termination, and the change from baseline to Day 90 or Early Termination. The same summary will be performed at Day 30 for the purpose of comparing the treatment difference between BID and TID after 30 days of treatment.

For other efficacy measurements, descriptive statistics will be provided at each visit. If appropriate, the change from baseline to post-baseline visits will be determined. The descriptive summary will also be provided for the safety extension periods.

In addition, the Day 30 24-hour C_avg serum total testosterone values for all subjects in the BID treatment group will be compared to the estimated value determined by the titration criteria. The acceptability of the titration criteria will be assessed.

Adverse events will be coded using the latest version of the Medical Dictionary for Regulatory Activities. A general summary of the adverse events and serious adverse events for each treatment group will be presented by the overall number of adverse events, the severity, and the relationship to study drug. The incidence of adverse events will be summarized by system organ class, preferred term, and treatment group. The safety laboratory data will be summarized by visit and by treatment group along with the change or percent change from baseline. Vital signs will also be summarized by visit and by treatment group along with the change from baseline. The clinical findings in the physical examination and 12-lead ECG results will be summarized at each scheduled visit. Other safety measurements will be summarized and listed if deemed necessary.

SAMPLE SIZE DETERMINATION:

A sample size of approximately 280 subjects (210 subjects randomized to the BID treatment group and 70 subjects randomized to the TID treatment group) was selected to provide a sufficient number of subjects to determine the efficacy, safety, and tolerability of intranasal 4.5% TBS-1 gel. Since this is an observational study, no formal sample size calculation was performed.

Preliminary data on 139 hypogonadal men who have completed 30 days of BID or TID treatment of the Phase 3 Study exhibit the following results, established by in accordance with the titration methods set forth in Example 15 below and as described herein:

• 107 males were treated with the BID dosing regimen, 4.5% TBS-1 , and 32 males on the TID regimen

• Approximately 80% of the males treated with 4.5% TBS-1 achieved an average testosterone level above 300 ng/dl

• Both the BID and TID treatment groups had more than 75% of the patients above the average testosterone level 300 ng/dl cut-off.

In accordance with the present invention, an exemplay label is provided in Exhibit E (the contents of which are incorporated herein by reference).

EXAMPLE 14

STATISTICAL ANALYSIS PLAN

A 90-Day, Randomized, Dose-Ranging Study, Including Potential Dose Titration, Evaluating The Efficacy and Safety of Intranasal Tbs- 1 in the Treatment of Male Hypogonadism with Sequential Safety Extension Periods of 90 and 180 Days

Investigational Product: 4.5% TBS-1 intranasal testosterone gel

Protocol Number: TBS-1 -2011-03

INTRODUCTION

This example provides a description of the statistical methods and procedures to be implemented for the analyses of data from the study with protocol number TBS-1 -201 1 - 03. See also Exhibit C (the contents of which are incorporated herein by reference). STUDY DESIGN AND OBJECTIVES

Study Objectives

Primary Objective

The primary objective of the study is to determine the efficacy of 4.5% TBS-1 gel, administered as 2 or 3 daily intranasal doses of 5.5 mg per nostril, as demonstrated by an increase in the 24-hour average concentration (C_avg) of serum total testosterone to the normal range (>300 ng/dL and <1050 ng/dL) in >75% of male subjects treated for hypogonadism.

Secondary Objective

The secondary objectives of this study are the following:

• To determine the efficacy of 4.5% TBS-1 gel, administered 2 or 3 times daily at a dose of 5.5 mg per nostril, in achieving the following for serum total testosterone maximum concentration (C_max) : o Cmax≤1500 ng/dL in >85% of subjects,

o Cmax 1800 to 2500 in <5% of subjects, and

o Cmax >2500 ng/dL in no subjects;

• To determine the effect of TBS-1 treatment on mood;

• To determine the effect of TBS-1 treatment on erectile function; and

• To determine the serum concentration and pharmacokinetics (PK) of total testosterone, dihydrotestosterone (DHT), and estradiol after TBS-1 administration.

Study Design and Duration

• A 3- to 7-week Screening Period that includes medication washout for subjects currently receiving testosterone treatment; • A 90-day randomized, open-label Treatment Period during which subjects will receive 5.5 mg per nostril of 4.5% TBS-1 twice daily (BID) or three times daily (TID) with potential daily dose adjustment on Day 45 for subjects in the BID treatment group as determined by the serum total testosterone PK profile;

Screening Period

testosterone, there must be at least 2 weeks between the last administration of testosterone and the first measurement of morning serum total testosterone for qualification.

Visit 1 will occur up to 7 weeks (Week -7) prior to randomization for subjects currently receiving testosterone injections, up to 5 weeks (Week -5) prior to randomization for subjects currently receiving oral, topical, or buccal testosterone, and up to 3 weeks (Week -3) prior to randomization for na^'ive subjects. During Visit 1 , informed consent will be obtained and the subject's inclusion and exclusion criteria will be assessed based on medical interview, concomitant medications, physical examination, digital rectal examination (DRE) of the prostate, vital sign measurements, and screening laboratory evaluations. For na^'ive subjects, a fasting morning (0900 h ± 30 min) serum total testosterone level and baseline laboratory measurements will be assessed at Visit 1 .

Non-na^'ive subjects will be instructed to discontinue all testosterone therapies at Visit 1 . After Visit 1 , if it is determined that a subject does not qualify for the study, the subject will be notified and instructed to restart prior testosterone therapy.

At the screening visits (Visits 1 , 1 .1 , and 2), serum total testosterone levels will be measured using a validated assay developed by Medpace Reference Laboratories. The results will be used for determination of a subject's inclusion or exclusion from the study. To be included in the study, subjects must have 2 fasting morning (0900 h ± 30 min) serum total testosterone levels <300 ng/dL.

Subjects who qualify for the study based on screening assessments at Visits 1 , 1 .1 , and 2 will be scheduled for an otorhinolaryngological (ENT) examination with nasal endoscopy performed by an ENT specialist. All qualified subjects will also have dual- energy x-ray absorptiometry scans scheduled in the interval between Visit 2 and randomization (Visit 3) for the assessment of body composition and bone mineral density. Treatment Period

• 5.5 mg per nostril of 4.5% TBS-1 BID or

• 5.5 mg per nostril of 4.5% TBS-1 TID.

At Visit 4 (Day 30 to Day 31 ), study drug will be administered at the site, beginning with the 2100 h dose of TBS-1 . Subjects will be required to remain at the site for 24 hours after the 2100 h drug administration and complete post-dose PK profiles for serum total testosterone, DHT, and estradiol will be obtained. The 24-hour C_avg of serum total testosterone for subjects in the BID group will be estimated based on the sum of serum total testosterone levels collected at 2 sampling points during the 24-hour PK profile: the sample collected at 9.0 hours (at 1 hour before the morning 0700 h dose) and the sample collected at 10.33 hours (20 minutes after the morning 0700 h dose). The following titration criteria will be used: • If the sum of the serum total testosterone level values for PK samples collected at 9.0 hours and 10.33 hours is <755 ng/dL, then the estimated 24-hour C_avg is <300 ng/dL and

Safety Extension Period 1

All subjects will continue into Safety Extension Period 1 and will be instructed to continue their current daily dose of TBS-1 for the 90-day Safety Extension Period (Day 90 to Day 180). Subjects will return to the site for monthly visits.

Safety Extension Period 2

A table of the schedule of procedures can be found below:

SCHEDULE OF PROCEDURES

Safety Extension Early

Study Phase Screenin Treatment Period Period 1 Safety Extension Period 2^d Terminatio

Testosterone

Prior Testosterone Treatment

Treatment Naive Randomization Efficacy Analysis Safety Analysis Subset Safety Analysis

Week Day 120 Day 210 Day 300

-7or Week Week Week Week Day 30- Day Day 90- and and and Day

Study Timing -5^a -3 -2 -3 -2 Day 1 Day 31^p 60 Day 91^q Day 150 Day 180 Day 240 Day 270 Day 330 360

Visit Number 1 l.l" 2 1 2 3 4^C 5 6 7-8^e 9 10-11⁸ 12 13-14 15

Study Procedures

Inclusion/exclusion criteria

Informed consent

Medical interview

Physical examination

Height and weight

Vital signs (HR, BP, RR, and

temperature)

Concomitant medications

DRE of the prostate

Chemistry profile and hematology'

Fasting lipid profile⁸

Liver function tests'¹

HbA_lc and endocrine profile¹

Urinalysis'

Urine drug and alcohol screen

PSA

Estradiol and DHT^k

Free testosterone

12-lead electrocardiogram

Fasting serum total testosterone^k

ENT exam with nasal endoscopy¹

DEXA^m

IIEF and PANAS questionnaires

Administer study drug at the site

24-h PK profile for serum total

testosterone, DHT, and estradiol

Basic ENT examination

(non-endoscopic)

Potential study drug daily dose

titration

Distribute and/or review daily

diary

Weigh study drug dispensers

Prime study drug dispensers and

distribute to subjects

Assess adverse events

Visit 1 for subjects receiving intramuscular testosterone injections at the time of screening will occur at up to Week -7. Visit 1 for subjects receiving buccal, oral, or topical testosterone will occur at up to Week -5.

Visit 1.1 is only required for subjects who have undergone washout of testosterone therapy and will take place 4 weeks after the last administration of testosterone for subjects taking testosterone injections and 2 weeks after the last testosterone administration for subjects taking buccal, oral, or topical testosterone.

cBased on the PK profile for serum total testosterone performed at Visit 4, some subjects in the BID treatment group will have their daily dose increased to TID. Subjects that require a daily do increase will be contacted by phone and instructed to increase their daily dose on Day 45.

dA subset of approximately 75 subjects will be enrolled in Safety Extension Period 2.

eDuring Safety Extension Period 1 and Safety Extension Period 2, study visits will be conducted once per month.

fChemisty profile includes: creatine kinase, sodium, potassium, glucose, blood urea nitrogen, creatinine, calcium, phosphorus, and uric acid. Hematology includes: hemoglobin, hematocrit, red blood cell count, white blood cell count and differential, platelets, reticulocyte count, mean corpuscular volume, mean corpuscular hemoglobin, , and mean corpuscular hemoglobin concentration.

^BFasting lipid profile includes: total cholesterol, low-density lipoprotein-cholesterol (direct), high-density lipoprotein cholesterol, and triglycerides.

hLiver function tests include: total bilirubin, albumin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma glutamyl transferase.

'Endocrine profile includes: thyroid-stimulating hormone, morning Cortisol, sex hormone-binding globulin, luteinizing hormone, follicle-stimulating hormone, and prolactin.

'Urinalysis includes: specific gravity, glucose, protein, ketones, pH, blood, bilirubin, urobilinogen, nitrite, and leukocyte esterase.

kFasting serum total testosterone, DHT, and estradiol should be collected at 0900 h ± 30 min at Visits 1, 1.1, 2, 9, 12, 15, and Early Termination and at 2045 h at Visit 3. In subjects with a know history of male hypogonadism, if 1 of the 2 serum total testosterone levels collected at screening is >300 ng/dL, the serum total testosterone level may be retested once. After retesting, if 2 the 3 levels are <300 ng/dL, then the subject will be eligible to participate in the study.

'ENT examination with nasal endoscopy performed by an ENT specialist will be scheduled for the interval between Visit 2 and Visit 3 (Day 1 [randomization]) on qualified subjects.

mDEXA scans to evaluate body composition (total body mass, lean body mass, fat mass, and percent fat) and bone density (lumbar spine and hip) will be performed in the interval between Visi 2 and Visit 3 on qualified subjects. Follow-up DEXA will be obtained at Visit 9 (Day 180) and Visit 15 (Day 360), if scheduling is available, or within ±2 weeks of Visit 9 and Visit 15.

"Daily diary will be distributed to subjects to record date and time of study drug administration.

°IIEF and PANAS questionnaires will be administered to subjects at Early Termination if subjects terminate on or before Visit 6 (Day 90).

On Day 31 of Visit 4, the following procedures will be performed: vital sign measurements, basic ENT examination, administer questionnaires (may be performed on Day 30 or Day 31), and dispense daily diary.

qOn Day 91 of Visit 6, the following procedures will be performed: vital sign measurements, basic ENT examination, dispense daily diary, administer questionnaires (may be performed on Day or Day 91), perform DRE (may be performed on Day 90 or Day 91), and perform physical examination (may be performed on Day 90 or Day 91).

rAt Visit 3 (Day 1), vital sign measurements will be obtained prior to first dose of study drug and at approximately 1 hour after the first dose of study drug (at 2200 h). On Day 30 of Visit 4 and Day 90 of Visit 6, vital sign measurements will be obtained once prior to administration of study drug. On Day 31 of Visit 4 and Day 91 of Visit 6, vital sign measurements will be obtained at th following approximate times after administration of study drug: 6 hours (at 0300 h), 12 hours (at 0900 h), 18 hours (at 1500 h), and 24 hours (at 2100 h).

sAt Visit 9, study drug dispensers and daily diaries will only be distributed to subjects entering Safety Extension Period 2.

BID = twice daily; BP = blood pressure; DEXA = dual-energy x-ray absorptiometry; DRE = digital rectal examination; DHT = dihydrotestosterone; ENT = otorhinolaryngological; HbA_lc = glycosylated hemoglobin;

HR = heart rate; 11 E F = International Index of Erectile Function; PANAS = Positive and Negative Affect Schedule; PK = pharmacokinetic; PSA = prostate specific antigen; RR = respiratory rate; TID three times daily.

Efficacy Variables

Primary Efficacy Variable

Secondary Efficacy Variables

Secondary efficacy variables include the following:

The number and percentage of subjects with a serum total testosterone maximum concentration (C_max) value in the following ranges on Day 90:

o <1500 ng/dL,

o >1800 and <2500 ng/dL, and

o >2500 ng/dL. ;

The number and percentage of subjects with a serum total testosterone C_avg value in the normal range (>300 ng/dL and <1050 ng/dL) on Day 30;

The number and percentage of subjects with a serum total testosterone C_max value in the following ranges on Day 30:

o <1500 ng/dL,

o >1800 and <2500 ng/dL, and

o >2500 ng/dL. ;

The complete PK profile (including C_avg, the minimum concentration, C_max, and time to maximum concentration) of serum total testosterone on Day 30 and Day 90;

The time within the normal range for serum total testosterone based on the PK profile on Day 30 and Day 90;

The PK profile of serum estradiol on Day 30 and Day 90;

The PK profile of serum DHT on Day 30 and Day 90;

The ratio of DHT C_avg to total testosterone C_avg on Day 30 and Day 90;

The Positive and Negative Affect Schedule scores at baseline, Day 30, Day 60, and Day 90;

The International Index of Erectile Function scores at baseline, Day 30, Day 60, and Day 90; • Change in bone mineral density from baseline to Day 180 and from baseline to Day 360; and

• Change in body composition (total body mass, lean body mass, fat mass, and percent fat) from baseline to Day 180 and from baseline to Day 360.

Safety Variables

STATISTICAL METHODOLOGY

Baseline, Endpoint, and Other Statistical Considerations

Results will be summarized by the following treatment groups:

• TBS-1 BID,

• TBS-1 BID/TID (for subjects who up-titrated at Day 45), and

• TBS-1 TID.

For time points prior to Day 45, TBS-1 BID, TBS-1 BI D/TID, and TBS-1 TID treatment groups will be presented even though no titration has occurred. Additionally, a Total TBS-1 BID treatment group (combining the TBS-1 BID and TBS-1 BID/TID groups) will be presented.

Baseline for results from the IIEF and PANAS questionnaires, vital signs, estradiol, DHT, and fasting serum total cholesterol will be the Day 1 value.

Baseline for body composition, bone mineral density, and 12-lead electrocardiogram will be the Week -2 value.

Baseline for safety laboratory results will be the Week -3 value. If the baseline value is missing, the last value prior to the first dose of study medication will be used as baseline.

Day 90 LOCF will be the Day 90 value. If missing, the last value during the Treatment Period will be used.

Day 180 LOCF will be the Day 180 value. If missing, the last value during Safety Extension Period 1 will be used.

Day 360 LOCF will be the Day 360 value. If missing, the last value during Safety Extension Period 2 will be used.

Descriptive statistics (n, mean, standard deviation, minimum, median, maximum) will be used to summarize the continuous efficacy and safety variables. For lipids and other measurements that might violate the normal assumption, non-parametric statistics (Q1 , Q3, and inter-quartile range) will be provided in addition to the conventional parametric statistics. The count and frequency will be used to tabulate the categorical

measurements.

Analysis Populations

Randomized Population

The randomized population will consist of all subjects who signed the informed consent form and are assigned a randomization number at Visit 3 (Day 1 ).

Intent-to-Treat Populations

The intent-to-treat (ITT) population for each period will consist of all subjects who receive randomized study drug and have at least one valid post-baseline efficacy measurement in the period. Per-Protocol Population

The per-protocol population will consist of all ITT subjects who complete the 90-day Treatment Period without any major protocol deviations.

Subjects may be excluded from the per-protocol population for the following reasons:

• Major violations of eligibility criteria for randomization,

• Withdrawal Prior to Day 90 or missing Day 90 PK profile,

• Restricted concomitant medications taken during the treatment period, or

• Any other major protocol deviation that may interfere with the assessment of drug efficacy.

Safety Populations

The safety population for each period will consist of all subjects who receive

randomized study drug and have safety measurements in the respective period.

Patient Disposition

Patient disposition will be summarized by counts and percentages for each treatment group and in total. The following categories of patient disposition will be included:

• Subjects who are randomized,

• Subjects who complete the Treatment Period,

• Subjects who complete the Treatment Period and Safety Extension Period 1 ,

• Subjects who enter Safety Extension Period 2, and

• Subjects who complete Safety Extension Period 2.

For randomized subjects who discontinue from the study, the primary reason for discontinuation will be summarized according to the period in which the withdrawal occurred. Reasons for discontinuation will be listed.

The total number of subjects who are screened and the total number of screen failures with reasons for screen failure will be tabulated. The number and percentage of subjects in the ITT populations, PP population, and safety populations will be presented by treatment group and in total.

Demographic and Baseline Characteristics

Demographic and baseline characteristics will be summarized for all subjects in the randomized population by treatment group and in total.

Gender, race, testosterone therapy history, smoking status, and alcohol use will be summarized with counts and percentages. Age, height, weight, body mass index (BMI), and duration of hypogonadism will be summarized with descriptive statistics.

Baseline values for fasting serum total testosterone will be described with descriptive statistics.

Baseline is defined in Section 0

Baseline, Endpoint, and Other Statistical Considerations. Medical history will be listed for all randomized subjects. Prior/Concomitant Medications

Medication start and stop dates that are recorded on the Prior and Concomitant

Medications Case Report Form (CRF) will be used to determine whether the

medications are prior or concomitant to the treatment and safety extension periods. Prior medications are defined as those used prior to and stopped before the first dose of study medication.

Concomitant medications are those that are used during the treatment period or safety extension periods (i.e., start date is on or after the first dose date of study medication, or start prior to the date of first dose and the stop date is either after the first dose date or marked as "continuing"). Concomitant medication/therapy verbatim terms will be coded with Anatomical

Therapeutic Chemical (ATC) class and preferred term by the World Health Organization Drug Dictionary. The numbers and percentages of subjects in each treatment group taking concomitant medications will be summarized by ATC class and preferred term for the safety population for the Treatment Period. Concomitant medications taken during Safety Extension Period 1 and Safety Extension Period 2 will be summarized in a similar manner.

Prior and concomitant medications will be listed. Study Exposure, Dispensation, and Accountability

Days of exposure to study medication during the Treatment Period, Safety Extension Period 1 , and Safety Extension Period 2 will be summarized with descriptive statistics for the safety populations for each treatment group and overall. Contingency tables will be provided to display the number and percentage of subjects with exposure by visit for each treatment group for the safety populations.

Days of exposure is defined as the date of the last dose of study medication (in the respective period) - the date of the first dose of study medication + 1 .

Drug dispensation and accountability data will be listed.

Analysis of Efficacy

Efficacy evaluations will be performed for the ITT populations. The primary efficacy analysis will be repeated for the PP population.

Analysis of the Primary Efficacy Parameter

The primary objective of this study is to determine the efficacy of 4.5% TBS-1 gel, administered intranasally BID and/or TID, in increasing the C_avg of serum total testosterone to the normal range (>300 ng/dL and <1050 ng/dL) in male subjects with hypogonadism after 90 days of treatment. The primary efficacy parameter, C_avg, will be calculated from the AUC using the following formula:

The AUC curve for both the BID and TID dosing regimens will be determined for the 0- 24 hour time interval by using linear trapezoidal and linear interpolation methods. Actual collection times will be used in the calculation.

The number and percentage of subjects who reach the treatment goal (ie, serum total testosterone C_avg value in the normal range) at Day 90 or Early Termination (Day 90 LOCF) will be summarized by treatment group. 95% confidence intervals for the frequency will be approximated by a binomial distribution within each treatment group.

Analysis of the Secondary Efficacy Parameters

The primary efficacy analysis will be repeated for the serum total testosterone C_avg values on Day 30. Additionally, for C_avg on Day 30, the Total BID treatment group and the TID treatment group will be compared using the chi-square test to evaluate the number of subjects with C_avg within the normal range (>300 ng/dL and <1050 ng/dL).

The odds ratio, 95% confidence interval, and p-value will be presented.

The serum total testosterone C_max values on Day 30 and Day 90 will be summarized by counts and percentages for each treatment group for the following categories:

• C_max <1500 ng/dL,

• 1800 ng/dL < C_max < 2500 ng/dL, and

^-rnax 2500 ng/dL.

The PK profile, including AUC₀-24h, C_avg, C_min, C_max, and T_max, for serum total testosterone, serum estradiol, and serum DHT will be summarized with descriptive statistics, including the arithmetic mean, standard deviation, coefficient of variation (CV%), geometric mean, median, minimum, and maximum by treatment at Day 30 and Day 90. Geometric mean and CV% will not be presented for T_max. The same descriptive statistics will be calculated for serum concentrations at each sampling time by treatment and visit.

Data will be listed individually for all subjects. A figure displaying the distribution of the C_aVg values at Day 30 and Day 90 will be provided.

All concentrations below the lower limit of quantification (LLOQ) or missing data will be labeled as such in the concentration data listings. Concentrations below the LLOQ prior to the first measurable concentration will be treated as zero in the summary statistics and for the calculation of PK profile parameters. Concentrations below LLOQ after the time point of the first measurable concentration will be set to missing and not included in the calculation of AUC.

The time within normal range (>300 ng/dL and <1050 ng/dL) for serum total

testosterone and the ratio of DHT C_avg to total testosterone C_avg on Day 30 and Day 90 will be summarized with descriptive statistics for each treatment group.

The concentrations of fasting serum total testosterone, DHT, and estradiol will be summarized with descriptive statistics at baseline, Day 30, Day 90, Day 90 LOCF, Day 180, Day 180 LOCF, Day 270, Day 360, and Day 360 LOCF. The change from baseline will also be summarized.

The change in bone mineral density, total body mass, lean body mass, fat mass, and percent fat will be summarized with descriptive statistics at baseline, Day 180, and Day 360, as well as the change from baseline to Day 180 and the change from baseline to Day 360 for each treatment group.

The Day 30 24-hour C_avg serum total testosterone values for all subjects in the BID treatment group will be assessed for appropriate dose titration (from BID to TID) at Day 45. The IIEF questionnaire will be broken up into five domains: erectile function, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction. Point values will be assigned to each answer in the questionnaire according to Appendix 1 . Domain scores will be the sum of the points of each question making up the domain. The breakdown can be found in the table below:

The scores for each domain will be summarized with descriptive statistics at baseline, Day 30, Day 60, Day 90, Day 90 LOCF, and the change from baseline at each visit.

PANAS scores will be summarized with descriptive statistics for each emotion/feeling as well as the Positive and Negative Affect Score by treatment at baseline, Day 30, Day 60, Day 90, and Day 90 LOCF. Change from baseline to each visit will be provided for the Positive and Negative Affect Scores. Positive Affect Score is found by adding the scores from items 1 , 3, 5, 9, 10, 12, 14, 16, 17, and 19. Negative Affect Score is found by adding the scores from items 2, 4, 6, 7, 8, 1 1 , 13, 15, 18, and 20. A separate summary will be performed to summarized the PANAS scores based on how the subject 'felt over the past week', not including those scores based on how the subject 'feels right now'.

Analysis of Safety

All analyses of safety will be conducted on the safety populations and will be

summarized by treatment group and in total. The safety assessments include adverse events, clinical laboratory measurements, DRE of the prostate, 12-lead ECGs, vital sign measurements, basic ENT examination, and physical examination.

Adverse Events

An adverse event (AE) is defined as any untoward medical occurrence associated with the use of a drug in humans, whether or not considered drug related. An adverse event can therefore be any unfavorable and/or unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of an investigational medication product, whether or not related to the investigational medication product. All adverse events, including observed or volunteered problems, complaints, or symptoms, are to be recorded on the appropriate eCRF. AEs will be coded using the latest version of MedDRA.

Treatment-emergent adverse events (TEAEs) are defined as those AEs that have a start date on or after the first dose of randomized study medication, or occur prior to the first dose and worsen in severity during the treatment period. Drug-related AEs are defined as those AEs with relationship to study drug as "Probable" or "Definitely

Related".

TEAEs will be summarized in which period the AE began. For example, TEAEs during Safety Extension Period 1 will be any TEAEs that occur on or after the first day of Safety Extension Period 1 through the end of the study or the start of Extension Period 2.

A table overview of adverse events will be provided summarizing the counts and percentages of subjects with the following adverse events during the Treatment Period:

• TEAEs,

• Maximum severity of TEAEs,

• Drug-related TEAEs,

• Maximum severity of drug-related TEAEs,

• All serious adverse events (SAEs), • All treatment-emergent SAEs,

• Drug-related SAEs,

• Death due to AEs,

• Withdrawals due to AEs, and

• Withdrawals due to drug-related AEs.

A similar overview for TEAEs with onset date during Safety Extension Period 1 and Safety Extension Period 2 will be provided.

The counts and percentages of subjects with TEAEs during the Treatment Period will be summarized for each treatment group by system organ class and preferred term. Drug- related TEAEs, SAEs, and TEAEs leading to discontinuation of study medication during the Treatment Period will be summarized in the same manner. Summaries of maximum severity for TEAEs and drug-related TEAEs will be provided.

The counts and percentages of subjects with TEAEs during Safety Extension Period 1 and Safety Extension Period 2 will be summarized for each treatment group by system organ class and preferred term. Drug-related TEAEs will be summarized in the same manner.

All SAEs and TEAEs leading to discontinuation of study medication will be listed with detailed information.

Clinical Laboratory Assessments

Continuous laboratory results for selected laboratory parameters (including hematology, chemistry, urinalysis, lipid profile, liver function tests, HbA-i _c and endocrine profile) will be presented by treatment group and summarized with descriptive statistics for each scheduled visit and for the end of each period. The change from baseline will also be presented. Categorical laboratory results will be presented with the frequency and percentage in each category by treatment group for each scheduled visit and for the end of each period.

The number and percentage of subjects with laboratory abnormalities will be

summarized by treatment group and overall for each period. The worst value for each subject in each period will be summarized.

Listings will be provided for all laboratory parameters.

Physical Examination, Digital Rectal Exam, ENT Exam, and Nasal Endoscopy

Physical examination findings will be summarized by treatment group with counts and percentages for each body system for each scheduled visit and for the end of each period. Digital rectal exam, ENT examination, and nasal endoscopy results will be summarized in a similar manner.

Physical examination, digital rectal exam, ENT exam, and nasal endoscopy findings will be listed by subject.

Weight, BMI, Vital Signs, and 12-Lead Electrocardiogram

Weight, BMI, vital signs, and quantitative ECG parameters (Heart Rate, PR Interval, QRS Interval, and QT Interval) will be summarized with descriptive statistics at baseline, each post-baseline visit, and the end of each period. The change from baseline will also be presented. Counts and percentages of subjects with abnormal ECG results will be tabulated.

Vital signs recorded during the PK sampling and overall interpretations from ECG will be listed.

REPORT ANALYSES

Two report analyses will be generated for this study. The first analysis will be conducted after all subjects complete the Treatment Period. The analysis will include all primary and secondary efficacy endpoints. Safety data collected through Safety Extension Period 1 will also be summarized.

After all subjects complete the study, including Safety Extension Period 2, a second analysis will be generated including all safety and efficacy data.

SAMPLE SIZE DETERMINATION

A sample size of approximately 280 subjects (210 subjects randomized to the BID treatment group and 70 subjects randomized to the TID treatment group) was selected to provide a sufficient number of subjects to determine the efficacy, safety, and tolerability of 4.5% TBS-1 gel. Since this is an observational study, no formal sample size calculation was performed.

PROGRAMMING SPECIFICATIONS

The programming specifications, including the mock-up validity listings, analysis tables, figures, and data listings, as well as the derived database specifications, will be prepared in stand-alone documents. The programming specification documents will be finalized prior to database lock.

LIST OF ABBREVIATIONS AND DEFINITION OF TERMS

ALT Alanine transaminase

AST Aspartate transaminase

AUC Area under the curve

BID Twice daily

C_aVg Average concentration

C_max Maximum concentration

C_min Minimum concentration

CRA Clinical research associate

CTIVRS ClinTrak^™ Interactive Voice Response System

DEXA Dual-energy x-ray absorptiometry

DHEA Dehydroepiandrosterone

DHT Dihydrotestosterone

DRE Digital rectal examination

ECG Electrocardiogram eCRF Electronic case report form

EDC Electronic data capture

ENT Otorhinolaryngological

FSH Follicle-stimulating hormone

GnRH Gonadotropin-releasing hormone

H2 Histamine 2

HbA_1c Glycosylated hemoglobin

IIEF International Index of Erectile Function

IRB Institutional Review Board

ITT Intent-to-treat

LH Luteinizing hormone

MedDRA Medical Dictionary for Regulatory Activities

PANAS Positive and Negative Affect Schedule

PDE5 Phosphodiesterase 5

PK Pharmacokinetic

PSA Prostate specific antigen

SAE Serious adverse event

SHBG Sex hormone-binding globulin

TID Three times daily

TWNR Time within the normal range

Tmax Time to maximum concentration

TSH Thyroid-stimulating hormone

TU Testosterone undecanoate

ULN Upper limit of normal

APPENDIX 1

These questions ask about the effect your erection problems have had on your sex life over the past 4 weeks. Please answer these questions as honestly and as clearly as possible. Please answer every question by checking the appropriate box [3]. If you are unsure about how to answer, please give the best answer you can. In answering these questions, the following definitions apply:

* Sexual intercourse: Is defined as vaginal penetration (entry) of the partner.

** Sexual activity: Includes intercourse, caressing, foreplay and masturbation.

*** Ejaculate: Is defined as the ejection of semen from the penis (or the sensation of this).

**** Sexual stimulation: Includes situations such as loveplay with a partner, looking at erotic pictures, etc.

1. Over the past 4 weeks how often were you able to get an erection during sexual activity**? Please check one box only.

No sexual activity □ [0] Point value

Almost always or always □ [5]

Most times (much more than half the time) □ [4]

Sometimes (about half the time) □ [3]

A few times (much less than half the time) □ [2]

Almost never or never □ [1]

2. Over the past 4 weeks when you had erections with sexual stimulation****, how often were your erections hard enough for penetration? Please check one box only.

No sexual stimulation □ [0]

Almost always or always □ [5]

Most times (much more than half the time) □ [4] Sometimes (about half the time) □ [3]

A few times (much less than half the time) □ [2]

Almost never or never □ [1]

The next 3 questions will ask about the erections you may have had during sexual intercourse*.

3. Over the past 4 weeks when you attempted sexual intercourse* how often were you able to penetrate (enter) your partner?

Please check one box only.

Did not attempt intercourse □ [0]

Almost always or always □ [5]

Most times (much more than half the time) □ [4]

Sometimes (about half the time) □ [3]

A few times (much less than half the time) □ [2]

Almost never or never □ [1]

4. Over the past 4 weeks during sexual intercourse* how often were you able to maintain your erection after you had penetrated

(entered) your partner? Please check one box only.

Did not attempt intercourse □ [0]

Almost always or always □ [S]

Most times (much more than half the time) □ [4]

Sometimes (about half the time) □ [3]

A few times (much less than half the time) □ [2]

Almost never or never □ [1]

5. Over the past 4 weeks during sexual intercourse* how difficult was it to maintain your erection to completion of intercourse?

Please check one box only.

Did not attempt intercourse □ [0]

Extremely difficult □ [1]

Very difficult □ [2]

Difficult □ 13]

Slightly difficult □ [4]

Not difficult □ [5]

6. Over the past 4 weeks how many times have you attempted sexual intercourse*? Please check one box only.

No attempts □ [0]

1-2 attempts □ [1]

3-4 attempts □ [2]

5-6 attempts □ [3]

7-10 attempts □ [4]

11 + attempts □ [5]

7. Over the past 4 weeks when you attempted sexual intercourse* how often was it satisfactory for you? Please check one box only.

Did not attempt intercourse □ [0]

Almost always or always □ [5]

Most times (much more than half the time) □ [4]

Sometimes (about half the time) □ [3]

A few times (much less than half the time) □ [2]

Almost never or never □ [1]

Sexual intercourse: Is defined as vaginal penetration (entry) of the partner.

** Sexual activity: Includes intercourse, caressing, foreplay and masturbation.

Over the past 4 weeks how much have you enjoyed sexual intercourse*? Please check one box only.

No intercourse □ [0]

Very highly enjoyable □ [5]

Highly enjoyable □ [4]

Fairly enjoyable □ [3] Not very enjoyable □ [2]

Not enjoyable □ [1]

9. Over the past 4 weeks when you had sexual stimulation**** or intercourse* how often did you ejaculate***? Please check one box only.

No sexual stimulation or intercourse □ [0]

Almost always or always □ [S]

Most times (much more than half the time) □ [4]

Sometimes (about half the time) □ [3]

A few times (much less than half the time) □ [2]

Almost never or never □ [1]

10. Over the past 4 weeks when you had sexual stimulation**** or intercourse* how often did you have the feeling of orgasm with or without ejaculation***? Please check one box only.

No sexual stimulation or intercourse □ [0]

Almost always or always □ [5]

Most times (much more than half the time) □ [4]

Sometimes (about half the time) □ [3]

A few times (much less than half the time) □ [2]

Almost never or never □ [1]

The next 2 questions ask about sexual desire. Let's define sexual desire as a feeling that may include wanting to have a sexual experience (e.g., masturbation or intercourse*), thinking about sex, or feeling frustrated due to lack of sex.

11. Over the past 4 weeks how often have you felt sexual desire? Please check one box only.

Almost always or always □ [5]

Most times (much more than half the time) □ [4]

Sometimes (about half the time) □ [3]

A few times (much less than half the time) □ [2]

Almost never or never □ [1]

12. Over the past 4 weeks how would you rate your level of sexual desire? Please check one box only.

Very high □ [5]

High □ [4]

Moderate □ [3]

Low □ 12]

Very low or none at all □ [1]

13. Over the past 4 weeks how satisfied have you been with your overall sex life? Please check one box only.

Very satisfied □ [5]

Moderately satisfied □ [4]

About equally satisfied and dissatisfied □ [3]

Moderately dissatisfied □ [2]

Very dissatisfied □ [1]

14. Over the past 4 weeks how satisfied have you been with your sexual relationship with your partner? Please check one box only.

Very satisfied □ [5]

Moderately satisfied □ [4]

About equally satisfied and dissatisfied □ [3]

Moderately dissatisfied □ [2]

Very dissatisfied □ [1]

15. Over the past 4 weeks how would you rate your confidence that you could get and keep an erection? Please check one box only.

Very high □ [5]

High □ 14]

Moderate □ [3]

Low □ 12]

Very low □ [1] EXAMPLE 15

Titration Method for dosing BID or TIP Intranasal Testosterone Gels

The present invention is also concerned with a novel titration method to determine the appropriate daily treatment regimen, i.e., a BID or TID treatment regimen, to administer the intranasal gels of the present invention to treat hypogonadism or TRT. While the preferred treatment regimen in accordance with the present invention for administering the intranasal testosterone gels, such as 4.0% or 4.5% TBS-1 as described in Examples 1 , 2, 3, 5, 7, 8, 9 and 10 above, to treat hypogonadism or TRT is twice-daily (BID) treatment regimen, the present invention contemplates that certain subjects may be more effectively treated with a three-times-a-day (TI D) treatment regimen. Thus, the novel titration method of the present invention has been developed to determine which subject will require a BID or TID treatment regimen to more effectively treat

hypogonadism or TRT when treated with the intranasal testosterone gels of the present invention. See also Exhibit C (the contents of which are incorporated herein by reference).

In carrying out the novel titration method in accordance with the present invention, subjects will have 2 blood draws, preferably at 7 am and at 8:20 am on the test day. The day before the first blood draw, the subject will take at 10 pm, his evening intranasal dose of TBS-1 . On test day, the subject will take at about 8 am, his morning intranasal dose of TBS-1 .

The 24-hour C_avg of serum total testosterone will be estimated based on the sum of serum total testosterone levels collected at the 2 sampling points: the sample collected at about 9.0 hours (at 7 am, which is 1 hour before the morning 0800 h intranasal dose) and the sample collected at about 10.33 hours following the last evening's intranasal dose(20 minutes after the morning 0800 h dose +/-20 minutes ). Note that, the blood draw times may be changed (+/- 1 hour) but the delay between the last dose and the first blood draw is preferably 9 hours +/-20 minutes and the delay between the next dose administered at about 10 hours +/- 20 minutes after the last dose and the second blood draw is preferably +/-20 minutes.

The following titration criteria is preferably used:

With respect to those subjects with an estimated serum total testosterone

It should be understood that, while it is preferred to draw blood from a subject to test the subject's serum total testosterone level values for pK samples at 9 hours and at 10.33 hours after the last evening's BID dose, the difference in the total draw time, i.e., 10.33 hours, may vary by as much as about +/- 60 minutes and preferably no more than about +/- 20 minutes between one another. It should also be understood that while, serum total testosterone level values for PK samples is 755 ng/dL is the preferred level to use to determine if titration to TID is necessary, the serum total testosterone level values for PK samples may vary as much as +/- 50 and preferably no more than +/- 25.

As an alternative, it should be understood that, while the titration method is described above with starting the titration method based upon the last evening's BID dose, the tirtration method could also be used by starting the titration method based upon the first morning dose. For example, under this alternative embodiment, the first blood draw would be taken at about 9 hours and the second blood draw would be taken at about 10.33 hours after the morning dose, so long as the second blood draw is taken at about 20 minutes after the last BID dose of the day.

Phase III Study - Rationale for the Titration Protocol for Compleo

(4.5% TBS-1 Gel)

1. Introduction

At the March 14, 201 1 End of Phase II Meeting, the Compleo (4.5% TBS-1 Gel) Phase III study includes the modifications suggested by the Agency ("FDA") and a rationale for the choice of secondary endpoints, the titration scheme and the ENT examination protocol. See Example for the final Phase 3 protocol.

The primary endpoint of this study is the percentage of subjects with a serum total testosterone C_avg value within the normal range on Day 90. This endpoint is consistent with Agency standards used for approval of other testosterone replacement therapy formulations. Although there are no generally accepted lower limits of normal for serum total testosterone, guidelines recommend using the range of 280-300 ng/dL. The sponsor has defined the normal range for Testosterone as 300 ng/dL to 1050 ng/dL for this study. This range is consistent with Agency standards and is in agreement with the

AACF Hypogonadism and Endocrine Society Clinical Practice Guidelines. Secondary Endpoints

The secondary endpoints in the Compleo (4.5% TBS-1 Gel) Phase III study and the rationale are listed below and included in the final protocol. All of the secondary endpoints proposed are well established for testosterone replacement therapies.

DHT - In previous trials with Compleo, following the administration of Compleo, the DHT levels of responders were increased from below normal to within the normal range. These levels remained stable within the normal range during the treatment and returned to basal levels after discontinuation of Compleo. The upper limit of the physiological reference range of DHT was not achieved or exceeded by any subjects for any treatment. As DHT is the major metabolite of Testosterone, an increase in DHT to within the normal range is evidence of Testosterone replacement. A full DHT pharmacokinetic profile will be collected at Day 30 and 90 for comparison against the baseline levels.

Body composition and lean body mass - The effect of testosterone replacement therapy on body composition and lean body mass has been included as an additional objective measurement of efficacy. The sponsor will use DEXA to evaluate the subjects for this criteria at baseline and Day 90.

Bone mineral density - This parameter will be measured by DEXA at baseline and Day 90.

Erectile function - Erectile function was included in the proposed protocol but based on [he recommendations from the Division, erectile function will now be assessed using the IIEF (International Index of Erectile Function Questionnaire).

Mood scales - The sponsor intends to collect data on changes in subject mood compared to baseline using the PANAS scale for information purposes only. The

PANAS scale was chosen as it is a validated instrument that measures the balance between positive and negative mood. Data will be collected for each subject at baseline, Day 30 and Day 90.

Study Design

The study includes a fixed dose arm for the t.i.d. administration and the previously proposed b.i.d. titration arm. The subjects in the b.i.d. group will be evaluated at Day 30 in accordance with the established titration scheme and those subjects that require titiration will be titrated to t.i.d. dosing. The subjects in the b.i.d. group that are not titrated will constitute a second fixed dose arm for b.i.d. dosing.

The sample size has been modified accordingly to ensure that sufficient subjects are available for the safety evaluation. The new sample size of 280 subjects will be split into two groups, with 210 subjects randomized to the b.i.d. titration treatment group and 70 subjects randomized to the t.i.d. treatment group. The sample size (see Table 1 ) incorporates a 50% titration rate from b.i.d. to t.i.d., a 75% responder rate for all t.i.d. patients and a 20% drop out rate.

Table 1 : Sample Size Estimation

Titration Scheme Titration Model Development

Following the discussion with the Division the recommendation to prospectively develop a titration scheme and include this in the Phase III study has been adopted. The titration scheme, based on two individual blood levels, has been designed to consistently titrate subjects from the b.i.d. treatment group to the t.i.d. treatment group, when testosterone replacement is not being acheived with b.i.d. dosing. Two hundred and ten (210) subjects will be randomized to the b.i.d. treatment group. Subjects will recieve Compleo at 2100h and 0700h. On Day 30, all subjects will be required to remain at the site for 24 hours after drug administration to obtain a 24 hour pharmacokinetic profile, actual C_avg. Although a 24 hour profile will be taken, the full profile will not be used for titration decisions. A titration scheme has been developed to allow for a simple and consistent assessment of each subject.

A number of different models were examined in the development of the titration scheme for Compleo that included both single and multiple analysis points. The model fit development and subsequent analysis was completed based on the data from the TBS- 1 -2010-01 study.

The model selected uses two testosterone measurements, one taken one hour prior to the morning dose (sample A, 9.00h post 1 ^st dose) and one taken 20 minutes after the morning dose (sample B, 10.33h (10h20 min) post 1 ^st dose). The C_avg for a given subject was predicted using a ratio of the two testosterone measurements triangulated to predict the area under the curve for the morning peak. This morning peak area was used to predict the total area under the curve for a 24 hour dosing interval which was converted to the 24 hour C_avg for testosterone. This is referred to as the 'model predicted C_avg' or 'calculated C_avg' in this text. The calculated C_avg was then compared against the lower limit of normal of 300 ng/dL as the decision level for titration. If the Cavg is calculated to be greater than 300 ng/dL then the b.i.d. regimen is maintained. If the Cavg is calculated to be less than 300 ng/dL then the patient is titrated to the t.i.d. regimen. The individual data comparing the predicted C_aVg with the actual C_aVg C_aVg is provided in Appendix 2. The model was further challenged on simulated pharmacokinetic profile data from 200 patients based on the 1 1 mg b.i.d. treatment group from the TBS-1 -2010-01 study. Using the sampling points from the model and the individual subject profiles from these 200 subjects, a model predicted C_avg was calculated and compared to the actual C_avg. The individual data from this analysis is provided in Appendix 3. The model was designed to have a high degree of precision, (successful prediction rate of greater than 80%) around the decision level of 300 ng/dL, and the data from both datasets shows a good correlation between the predicted C_avg and the actual C_avg around this key decision level.

The titration model was used to create a titration scheme that will be ultized and challenged in the Phase III study. This scheme uses the two sampling points from the model; one sample taken one hour prior to the morning dose (Sample A) and one sample taken 20 minutes after the morning dose (Sample B). If the sum of Sample A and Sample B is 755 ng/dL or greater, the 24 hour testosterone C_avg is predicted to be greater than 300 ng/dL and titration is not required. If the sum of Sample A and Sample B is less than 755 ng/dL, the 24 hour testosterone C_avg is predicted to be lower than 300 ng/dL and titration is required.

Titration Model Robustness

The robustness of the model and the resulting titration scheme was evaluated using the data from the TBS-1 -2010-01 study and the 200 patient simulated subject profiles. In addition to the two sampling points in the model, analysis was performed on three other sampling timepoints after the morning dose, 30 minutes, 60 minutes and 90 minutes. In each case the titration scheme was used to predict the requirement for titration following which each subject was sorted into one of two groups, Titration Required or Titration Not Required. The actual C_avg for each subject was used to assess the accuracy of the titration scheme with the total number of correct and incorrect titration predictions determined. The incorrect predictions were further separated into two groups in which: (1 ) Titration was not predicted but required - The titration scheme indicated that titration was not required, whereas the actual C_avg was less than 300 ng/dL. The subjects would not be titrated.

(2) Titration was predicted but not required - The titration scheme indicated that titration was required, whereas the actual C_avg was greater than 300 ng/dL. The subjects would be titrated.

The data for this analysis is shown in Table 2. The individual model data for each of the different sample timepoints can be found in Appendix 4, 5 and 6.

Table 2: Success Ratio for the Titration Model Analysis based on a Comparison of Predicted and Actual 24 hour Average Concentration Values (C_avg)

As the data indicates the model is capable of predicting the need for titration on a consistent basis with an over 80% success ratio for correct predictions at the proposed sampling points. This holds true for the sampling point at 40 minutes after the morning dose as well. At sampling points 60 minutes and 90 minutes after the morning dose the prediction success falls below 80%, which is likely explained by the variability of the values in testosterone concentration at these timepoints and the added variability introduced by the simulation analysis. The model performs slightly better using the 90 minute sampling point than the 60 minute sampling point. accurately identify those subjects that would benefit from titration from the b.i.d. to the t.i.d. dosing regimen and, in doing so, kept the number of subjects for which titration was not predicted but required to a minimum. The titration scheme achieved this with very low numbers of subjects from the TBS-1 -2010-01 study data and TBS-1 -2010-01 simulation data across all post dose timepoints.

The remaining subjects that were not correctly predicted by the titration scheme were titrated when it was not necessarily required. Based on the safety and pharmacokinetic profile data from the TBS-1 -2010-01 study, none of the subjects that were on a t.i.d. regimen of 4.5% gel (33.75 mg/day) showed any supra-physiologic levels for testosterone or high Cmax values, meaning there is no safety concern with subjects who are titrated to t.i.d. when they were achieving acceptable testosterone levels on b.i.d. treatment.

Titration Scheme Validation

By including the titration scheme in the Phase III study and correlating the titration decision made with the actual measured C_avg on Day 30 for each subject in the b.i.d. group at the end of the study, the exercise performed above on the simulation data will be repeated to evaluate and assess the accuracy of the titration. This internal valdiation will serve to support the valdiation scheme as proposed or provide the necessary information required to make any modifications for the product label.

ENT Evaluation During Safety Assessment

The detailed synopsis has been updated to clarify the procedure and criteria for the ENT evaluation that will be included in the safety extension for the Phase III study. As previously agreed, a long-term safety assessment will be performed; 200 subjects will be exposed for an addition 3 months months and 50 subjects will be exposed for an additional 6 monhts.

The purpose of the ENT examination is to determine if there have been any adverse reactions related to the nasal cavity that were caused by either the study drug or the multiple dose dispenser. A trained physician will perform the ENT examination as described.

1 . History:

The examining physician will inquire about the following symptoms:

• Excessive nasal dryness,

• Excessive nasal crusting,

• Unexpected nasal bleeding,

• Progressive nasal pain,

• Progressive nasal obstruction, and

• Alternation to sense of smell.

2. Physical exam:

Using an anterior rhinoscope with a headlight or other light source, the trained physician will look for the following:

• Large amounts of nasal crusting,

• Scar tissue blocking the nose,

• Dried or fresh nasal blood, and

• Fissuring of the nasal skin.

The safety evaluation measures (Day 90 to 180) will consist of monthly ENT examinations, vital signs and adverse events assessments. On Day 180 (or early termination), subjects will also undergo a physical examination, 12-lead ECG, DRE of the prostate, and laboratory assessments (CBC, PSA, chemistry profile, liver function tests, lipid profile, urinalysis, fasting morning serum total testosterone, DHT, and estradiol).

A subset of subjects will be asked to continue in the study for a safety extension period (Day 180 to 360). In this period, safety evaluations will consist of monthly ENT examinations, vital signs, and adverse events. On Day 270 and Day 360 (or early termination), subjects will also undergo a physical examination, 12-lead ECG, DRE of the prostate, and laboratory assessments (CBC, PSA, chemistry profile, liver function tests, lipid profile, urinalysis, fasting morning serum total testosterone, DHT, and estradiol). Titration Model Results - TBS-1 -2010-01 Data

Titration Model Results TBS-1-2010 Patient Simulation Data

Testosterone Sample A taken 1 hour before the morning dose

Testosterone Sample B taken 20 minutes after the morning dose

3 406 296 278 358

4 449 665 440 392

5 367 561 367 514

6 254 566 324 334

7 406 832 489 584

8 483 639 444 450

9 108 339 177 175

10 260 827 430 366

11 327 550 347 322

12 522 1430 772 757

13 240 995 488 442

14 278 852 447 288

15 249 448 276 330

16 523 930 574 506

17 497 726 483 423

18 375 945 522 412

19 132 278 162 291

20 231 439 265 306

21 363 844 477 505

22 535 770 516 505

23 340 680 403 673

24 252 630 349 346

25 231 583 322 322

26 156 430 232 362

27 226 719 374 375

28 197 485 270 339

29 466 635 435 459

30 232 920 455 316

31 263 897 459 431

32 183 1260 570 352

33 491 655 453 436

34 277 497 306 475

Testosterone Concentration Model

Subject (ng/dL) Actual

Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +20 min (ng/dL)

35 362 403 302 441

36 140 395 212 233

37 164 410 227 301

38 195 374 225 209

39 381 904 508 527 40 206 464 265 316

41 176 809 389 397

42 200 485 271 282

43 479 2640 1233 877

44 280 511 313 332

45 212 705 363 315

46 246 436 270 300

47 117 358 188 203

48 420 679 434 308

49 262 781 412 406

50 191 688 347 359

51 381 447 327 439

52 321 553 346 422

53 195 424 245 397

54 325 425 296 301

55 413 895 517 472

56 179 952 447 328

57 180 472 258 249

58 206 689 354 359

59 255 563 323 318

60 380 683 420 437

61 226 358 231 317

62 370 628 395 388

63 265 885 455 388

64 163 475 252 245

65 302 756 418 595

66 274 597 344 377

67 250 666 362 456

68 383 789 463 456

69 291 662 377 411

70 430 1060 589 417

71 236 514 296 307

72 248 550 315 248

73 244 692 370 374

Testosterone Concentration Model

Actual

Subject (ng/dL) Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +20 min (ng/dL)

74 362 711 424 572

75 310 1370 664 589

76 467 475 372 367 77 256 465 285 236

78 222 557 308 267

79 198 727 366 333

80 371 397 304 346

81 213 993 477 549

82 288 646 369 386

83 221 538 300 314

84 226 574 316 355

85 168 679 335 286

86 139 507 255 334

87 211 611 325 363

88 225 686 360 412

89 265 456 285 313

90 520 1140 656 510

91 207 1120 525 365

92 191 515 279 304

93 242 689 368 399

94 121 916 410 331

95 105 398 199 294

96 299 686 389 348

97 153 466 245 441

98 242 417 261 260

99 288 697 389 448

100 530 720 494 494

101 178 685 341 211

102 410 424 330 343

103 491 646 449 401

104 443 830 503 408

105 218 489 279 314

106 322 526 335 347

107 404 660 421 420

108 217 491 280 281

109 277 454 289 294

110 200 281 190 229

111 258 425 270 276

112 523 642 461 440

Testosterone Concentration Model

Actual

Subject (ng/dL) Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +20 min (ng/dL)

113 283 568 336 408 114 260 596 338 242

115 231 600 329 389

116 481 757 489 405

117 293 543 330 370

118 261 375 251 311

119 152 226 149 227

120 291 412 278 282

121 383 547 368 440

122 295 352 256 295

123 276 527 317 304

124 113 1100 480 311

125 245 421 263 307

126 421 666 430 499

127 313 514 327 371

128 238 787 405 432

129 256 493 296 380

130 175 278 179 278

131 199 394 234 303

132 296 491 311 363

133 319 879 474 342

134 274 812 429 346

135 140 412 218 220

136 466 441 359 434

137 449 2330 1099 739

138 252 347 237 282

139 330 698 406 440

140 165 513 268 215

141 292 667 379 389

142 306 574 348 473

143 345 319 263 292

144 359 880 490 492

145 399 561 380 449

146 593 932 603 696

147 581 712 511 426

148 222 356 229 229

149 231 640 344 301

150 274 1160 567 460

151 178 764 372 411

Testosterone Concentration Model Actual

Subject

(ng/dL) Predicted 24h Cavg Number

Time From Morning Dose 24h Cavg (ng/dL) -1 hr +20 min (ng/dL)

152 176 1030 477 312

153 346 542 351 491

154 221 378 237 259

155 236 527 302 361

156 257 456 282 358

157 146 609 298 295

158 241 358 237 304

159 199 636 330 434

160 280 1220 593 506

161 370 500 344 417

162 148 710 339 250

163 246 402 256 284

164 263 930 472 349

165 178 537 283 275

166 393 715 438 432

167 193 426 245 246

168 148 449 236 214

169 120 596 283 217

170 262 593 338 307

171 369 652 404 366

172 394 666 419 415

173 289 543 329 396

174 282 548 328 329

175 225 654 347 336

176 255 970 484 544

177 212 548 300 344

178 203 251 179 201

179 488 612 435 560

180 247 809 417 425

181 206 565 305 280

182 134 497 249 252

183 401 442 333 368

184 253 550 317 329

185 252 843 433 352

186 314 677 392 494

187 370 532 357 378

188 368 551 363 342

189 241 511 297 251

190 229 794 404 379

Subject Testosterone Concentration Model Actual Number (ng/dL) Predicted 24h Cavg

Time From Morning Dose 24h Cavg (ng/dL)

-1 hr +20 min (ng/dL)

191 333 636 383 526

192 217 834 415 360

193 264 411 267 263

194 382 1180 618 479

195 283 380 262 344

196 332 1360 669 442

197 310 911 483 321

198 194 610 318 327

199 172 465 252 192

200 335 894 486 473

Titration Model Results TBS-1-2010 Patient Simulation Data

Testosterone Sample A taken 1 hour before the morning dose Testosterone Sample B taken 40 minutes after the morning dose

1 217 1070 509 501

2 286 962 493 393

3 406 399 318 358

4 449 676 445 392

5 367 1420 706 514

6 254 863 441 334

7 406 991 552 584

8 483 758 490 450

9 108 229 133 175

10 260 441 277 366

11 327 432 300 322

12 522 1160 665 757

13 240 565 318 442

14 278 417 275 288

15 249 474 286 330

16 523 1020 610 506

17 497 992 588 423

18 375 1130 595 412

19 132 379 202 291

20 231 439 256 306

21 363 858 483 505

22 535 770 476 505

23 340 630 383 673

24 252 630 366 346

25 231 1130 538 322

26 156 736 353 362

27 226 456 270 375

28 197 324 206 339

29 466 467 369 459

30 232 348 229 316

31 263 1170 566 431

32 183 603 311 352

33 491 660 455 436

34 277 426 278 475

Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

Number 24h Cavg

Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +40 min (ng/dL)

35 362 334 275 441

36 140 485 247 233

37 164 568 289 301 38 195 374 225 209

39 381 1020 554 527

40 206 410 243 316

41 176 588 302 397

42 200 651 336 282

43 479 1750 881 877

44 280 686 382 332

45 212 524 291 315

46 246 353 237 300

47 117 532 256 203

48 420 437 339 308

49 262 988 494 406

50 191 536 287 359

51 381 770 455 439

52 321 591 360 422

53 195 789 389 397

54 325 499 326 301

55 413 702 441 472

56 179 786 381 328

57 180 357 212 249

58 206 662 343 359

59 255 414 264 318

60 380 698 426 437

61 226 465 273 317

62 370 462 329 388

63 265 874 450 388

64 163 279 175 245

65 302 1140 570 595

66 274 615 351 377

67 250 830 427 456

68 383 842 484 456

69 291 848 450 411

70 430 579 399 417

71 236 874 439 307

72 248 400 256 248

Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

Number 24h Cavg

Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +40 min (ng/dL)

73 244 460 278 374

74 362 481 333 572 75 310 676 390 589

76 467 589 417 367

77 256 462 284 236

78 222 462 270 267

79 198 663 340 333

80 371 442 321 346

81 213 740 377 549

82 288 548 330 386

83 221 454 267 314

84 226 742 383 355

85 168 626 314 286

86 139 670 320 334

87 211 811 404 363

88 225 662 351 412

89 265 679 373 313

90 520 681 475 510

91 207 723 368 365

92 191 691 349 304

93 242 431 266 399

94 121 861 388 331

95 105 647 297 294

96 299 663 380 348

97 153 1040 471 441

98 242 336 228 260

99 288 396 270 448

100 530 798 525 494

101 178 494 266 211

102 410 758 462 343

103 491 646 387 401

104 443 603 413 408

105 218 742 379 314

106 322 496 323 347

107 404 897 514 420

108 217 659 346 281

109 277 563 332 294

110 200 438 252 229

Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

Number 24h Cavg

Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +40 min (ng/dL)

111 258 495 298 276 112 523 829 534 440

113 283 486 304 408

114 260 444 278 242

115 231 750 388 389

116 481 609 431 405

117 293 969 499 370

118 261 375 282 311

119 152 335 192 227

120 291 302 234 282

121 383 629 400 440

122 295 640 370 295

123 276 440 283 304

124 113 1050 460 311

125 245 659 357 307

126 421 629 415 499

127 313 533 334 371

128 238 513 297 432

129 256 488 294 380

130 175 617 313 278

131 199 390 233 303

132 296 458 298 363

133 319 675 393 342

134 274 812 440 346

135 140 286 168 220

136 466 862 525 434

137 449 1530 782 739

138 252 489 293 282

139 330 421 297 440

140 165 313 189 215

141 292 609 356 389

142 306 688 393 473

143 345 403 296 292

144 359 880 466 492

145 399 506 358 449

146 593 1040 645 696

147 581 619 474 426

148 222 273 196 229

Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

Number 24h Cavg

Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +40 min (ng/dL) 149 231 814 413 301

150 274 1360 646 460

151 178 1300 584 411

152 176 750 366 312

153 346 904 494 491

154 221 488 280 259

155 236 772 398 361

156 257 538 314 358

157 146 428 227 295

158 241 437 268 304

159 199 568 303 434

160 280 1530 715 506

161 370 476 334 417

162 148 628 307 250

163 246 700 374 284

164 263 602 342 349

165 178 674 337 275

166 393 712 437 432

167 193 437 249 246

168 148 397 215 214

169 120 596 290 217

170 262 573 330 307

171 369 647 402 366

172 394 431 326 415

173 289 949 489 396

174 282 461 294 329

175 225 785 399 336

176 255 1010 500 544

177 212 646 339 344

178 203 386 233 201

179 488 853 530 560

180 247 680 366 425

181 206 532 292 280

182 134 497 427 252

183 401 607 398 368

184 253 640 353 329

185 252 716 383 352

186 314 846 458 494

Subject Testosterone Model Actual Number Concentration (ng/dL) Predicted 24h Cavg

Time From Morning Dose 24h Cavg (ng/dL) -1 hr +40 min (ng/dL)

187 370 552 364 378

188 368 616 389 342

189 241 465 279 251

190 229 645 345 379

191 333 636 387 526

192 217 834 258 360

193 264 231 196 263

194 382 649 407 479

195 283 608 352 344

196 332 730 420 442

197 310 536 334 321

198 194 684 347 327

199 172 285 181 192

200 335 655 391 473

co co σ> σ>

Subject Number

Titration Model Results TBS-1-2010 Patient Simulation Data

Testosterone Sample A taken 1 hour before the morning dose Testosterone Sample B taken 60 minutes after the morning dose

Testosterone Model

Actual

Subject Concentration (ng/dL) Predicted

24h Cavg

Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +60 min (ng/dL)

1 217 1400 225 501 2 286 896 238 393

3 406 372 315 358

4 449 822 324 392

5 367 970 262 514

6 254 554 178 334

7 406 846 312 584

8 483 684 395 450

9 108 212 103 175

10 260 739 212 366

11 327 373 287 322

12 522 1030 546 757

13 240 862 201 442

14 278 444 379 294

15 249 298 200 330

16 523 367 461 506

17 497 615 352 423

18 375 907 307 412

19 132 491 140 291

20 231 415 176 306

21 363 822 258 505

22 535 917 370 505

23 340 859 392 673

24 252 735 199 346

25 231 486 210 322

26 156 856 163 362

27 226 611 186 375

28 197 505 269 339

29 466 450 384 459

30 232 377 220 316

31 263 693 368 431

32 183 791 216 352

33 491 1020 339 436

34 277 762 199 475

Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +60 min (ng/dL)

35 362 371 320 441

36 140 543 117 233

37 164 502 174 301

38 195 303 184 209 39 381 1000 334 527

40 206 557 209 316

41 176 570 183 397

42 200 631 128 282

43 479 1040 385 877

44 280 466 260 332

45 212 229 220 315

46 246 482 188 300

47 117 286 116 203

48 420 386 255 308

49 262 830 220 406

50 191 601 233 359

51 381 405 337 439

52 321 420 263 422

53 195 677 129 397

54 325 364 282 301

55 413 697 315 472

56 179 1390 123 328

57 180 307 156 249

58 206 482 191 359

59 255 491 195 318

60 380 680 341 437

61 226 463 239 317

62 370 573 299 388

63 265 819 265 388

64 163 413 134 245

65 302 1110 246 595

66 274 409 236 377

67 250 609 191 456

68 383 643 314 456

69 291 548 227 411

70 430 966 298 417

71 236 497 185 307

72 248 486 169 248

Testosterone Model

Actual

Subject Concentration (ng/dL) Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +60 min (ng/dL)

73 244 665 183 374

74 362 605 318 572

75 310 571 313 589 76 467 488 308 367

77 256 462 190 236

78 222 277 176 267

79 198 459 168 333

80 371 424 229 346

81 213 1020 233 549

82 288 662 247 386

83 221 373 168 314

84 226 522 243 355

85 168 768 143 286

86 139 842 187 334

87 211 491 235 363

88 225 777 200 412

89 265 480 184 313

90 520 757 488 510

91 207 642 193 365

92 191 673 164 304

93 242 661 211 399

94 121 491 168 331

95 105 541 111 294

96 299 718 235 348

97 153 894 179 441

98 242 509 184 260

99 288 541 263 448

100 530 921 362 494

101 178 258 153 211

102 410 538 270 343

103 491 499 304 401

104 443 665 382 408

105 218 483 198 314

106 322 534 285 347

107 404 521 307 420

108 217 402 198 281

109 277 372 209 294

110 200 392 173 229

Testosterone Model

Actual

Subject Concentration (ng/dL) Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +60 min (ng/dL)

111 258 523 193 276

112 523 804 438 440 113 283 899 247 408

114 260 476 176 242

115 231 486 178 389

116 481 903 361 405

117 293 453 295 370

118 261 416 201 311

119 152 276 140 227

120 291 409 240 282

121 383 547 284 440

122 295 536 173 295

123 276 312 259 304

124 113 865 146 311

125 245 578 191 307

126 421 476 313 499

127 313 545 220 371

128 238 772 190 432

129 256 393 200 380

130 175 437 216 278

131 199 404 170 303

132 296 545 303 363

133 319 465 204 342

134 274 917 200 346

135 140 287 124 220

136 466 794 333 434

137 449 1030 292 739

138 252 347 176 282

139 330 445 321 440

140 165 271 144 215

141 292 460 268 389

142 306 637 217 473

143 345 419 253 292

144 359 852 327 492

145 399 690 292 449

146 593 1770 450 696

147 581 601 380 426

148 222 262 213 229

Testosterone Model

Actual

Subject Concentration (ng/dL) Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +60 min (ng/dL)

149 231 290 186 301 150 274 580 195 460

151 178 871 116 411

152 176 643 158 312

153 346 815 268 491

154 221 815 209 259

155 236 500 203 361

156 257 498 296 358

157 146 385 162 295

158 241 344 240 304

159 199 609 221 434

160 280 976 223 506

161 370 306 386 417

162 148 425 181 250

163 246 487 206 284

164 263 699 222 349

165 178 346 151 275

166 393 645 354 432

167 193 459 201 246

168 148 359 124 214

169 120 352 121 217

170 262 398 180 307

171 369 613 305 366

172 394 518 271 415

173 289 780 186 396

174 282 481 181 329

175 225 691 216 336

176 255 1190 278 544

177 212 466 229 344

178 203 209 150 201

179 488 367 375 560

180 247 501 208 425

181 206 483 152 280

182 134 455 99 252

183 401 605 283 368

184 253 352 199 329

185 252 470 181 352

186 314 721 287 494

Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +60 min (ng/dL) 187 370 789 281 378

188 368 277 255 342

189 241 522 182 251

190 229 711 175 379

191 333 645 326 526

192 217 387 181 360

193 264 472 198 263

194 382 401 421 479

195 283 726 191 344

196 332 582 305 442

197 310 534 252 321

198 194 726 200 327

199 172 286 184 192

200 335 322 363 473

Titration Model Results TBS-1-2010 Patient Simulation Data

Testosterone Sample A taken 1 hour before the morning dose Testosterone Sample B taken 90 minutes after the morning dose

Testosterone Concentration (ng/dL) Model

Actual

Subject Time From Morning Dose Predicted

24h Cavg 24h Cavg

Number -1 hr +90 min (ng/dL)

(ng/dL)

1 217 860 726 501

2 286 633 531 393 3 406 407 349 358

4 449 276 571 392

5 367 949 600 514

6 254 846 363 334

7 406 1360 562 584

8 483 668 524 450

9 108 274 144 175

10 260 565 449 366

11 327 259 314 322

12 522 602 697 757

13 240 651 495 442

14 278 361 324 288

15 249 363 246 330

16 523 614 400 506

17 497 660 499 423

18 375 638 576 412

19 132 672 280 291

20 231 384 290 306

21 363 796 532 505

22 535 869 652 505

23 340 763 538 673

24 252 462 443 346

25 231 250 322 322

26 156 624 454 362

27 226 745 376 375

28 197 237 315 339

29 466 910 411 459

30 232 343 273 316

31 263 704 429 431

32 183 420 437 352

33 491 775 678 436

34 277 1610 466 475

Testosterone Concentration (ng/dL) Model

Actual

Subject Time From Morning Dose Predicted

24h Cavg Number 24h Cavg

-1 hr +90 min (ng/dL)

(ng/dL)

35 362 714 329 441

36 140 212 307 233

37 164 322 299 301

38 195 325 224 209

39 381 1030 620 527 40 206 387 343 316

41 176 766 335 397

42 200 271 373 282

43 479 1500 682 877

44 280 537 335 332

45 212 361 198 315

46 246 342 327 300

47 117 246 181 203

48 420 416 362 308

49 262 812 490 406

50 191 415 356 359

51 381 880 353 439

52 321 755 333 422

53 195 917 392 397

54 325 375 309 301

55 413 472 498 472

56 179 907 704 328

57 180 269 219 249

58 206 490 309 359

59 255 413 335 318

60 380 555 476 437

61 226 494 309 317

62 370 385 423 388

63 265 627 409 388

64 163 228 259 245

65 302 709 634 595

66 274 550 307 377

67 250 477 386 456

68 383 635 461 456

69 291 666 377 411

70 430 636 627 417

71 236 561 329 307

72 248 345 330 248

73 244 554 408 374

Testosterone Concentration (ng/dL) Model

Actual

Subject Time From Morning Dose Predicted

24h Cavg Number 24h Cavg

-1 hr +90 min (ng/dL)

(ng/dL)

74 362 443 434 572

75 310 762 396 589

76 467 317 429 367 77 256 368 322 236

78 222 417 224 267

79 198 585 295 333

80 371 402 357 346

81 213 917 554 549

82 288 426 427 386

83 221 702 267 314

84 226 747 336 355

85 168 455 420 286

86 139 622 440 334

87 211 401 315 363

88 225 658 450 412

89 265 378 334 313

90 520 653 573 510

91 207 525 381 365

92 191 472 388 304

93 242 694 405 399

94 121 605 275 331

95 105 437 290 294

96 299 359 457 348

97 153 504 470 441

98 242 363 337 260

99 288 281 372 448

100 530 593 651 494

101 178 378 196 211

102 410 286 426 343

103 491 530 444 401

104 443 634 497 408

105 218 454 315 314

106 322 390 384 347

107 404 680 415 420

108 217 309 278 281

109 277 319 291 294

110 200 538 266 229

111 258 342 351 276

112 523 774 596 440

Testosterone Concentration Model

(ng/dL) Actual

Subject Predicted

24h Cavg

Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +90 min (ng/dL)

113 283 715 531 408 114 260 612 330 242

115 231 468 322 389

116 481 394 621 405

117 293 431 335 370

118 261 358 304 311

119 152 355 192 227

120 291 448 314 282

121 383 673 418 440

122 295 310 373 295

123 276 368 264 304

124 113 494 439 311

125 245 444 370 307

126 421 524 403 499

127 313 626 385 371

128 238 952 453 432

129 256 499 291 380

130 175 344 275 278

131 199 472 271 303

132 296 301 378 363

133 319 522 352 342

134 274 464 535 346

135 140 626 192 220

136 466 531 566 434

137 449 1200 664 739

138 252 424 337 282

139 330 304 348 440

140 165 252 196 215

141 292 362 338 389

142 306 909 423 473

143 345 269 343 292

144 359 527 544 492

145 399 743 489 449

146 593 1080 1061 696

147 581 448 531 426

148 222 416 217 229

149 231 523 234 301

150 274 551 383 460

151 178 1150 471 411

Testosterone Concentration Model Actual

Subject

(ng/dL) Predicted 24h Cavg Number

Time From Morning Dose 24h Cavg (ng/dL) -1 hr +90 min (ng/dL)

152 176 775 368 312

153 346 667 521 491

154 221 265 340 259

155 236 771 330 361

156 257 558 339 358

157 146 309 238 295

158 241 341 263 304

159 199 528 363 434

160 280 916 564 506

161 370 487 304 417

162 148 380 257 250

163 246 413 329 284

164 263 510 432 349

165 178 421 235 275

166 393 770 466 432

167 193 475 293 246

168 148 262 228 214

169 120 368 212 217

170 262 616 296 307

171 369 606 441 366

172 394 598 409 415

173 289 475 480 396

174 282 427 343 329

175 225 524 411 336

176 255 864 649 544

177 212 531 304 344

178 203 253 185 201

179 488 516 384 560

180 247 546 336 425

181 206 396 309 280

182 134 468 264 252

183 401 663 452 368

184 253 282 272 329

185 252 584 324 352

186 314 750 465 494

187 370 425 520 378

188 368 392 290 342

189 241 234 343 251

190 229 390 422 379

Time From Morning Dose 24h Cavg (ng/dL)

(ng/dL)

-1 hr +90 min

191 333 695 439 526

192 217 695 271 360

193 264 321 330 263

194 382 564 352 479

195 283 630 453 344

196 332 531 410 442

197 310 323 379 321

198 194 454 413 327

199 172 290 206 192

200 335 533 295 473

EXAMPLE 15

A randomized 3-way cross over study to assess the relative bioavailability, safety and tolerability of TBS-1 (4.5%) when administered to male subjects with seasonal allergic rhinitis in symptomatic, symptomatic but treated (oxymetazoline) and asymptomatic states using an environmental challenge chamber (ECC) model Study Title: A randomized 3-way cross over study to assess the

relative bioavailability, safety and tolerability of TBS-1 (4.5%) when administered to male subjects with seasonal allergic rhinitis in symptomatic, symptomatic but treated (oxymetazoline) and asymptomatic states using an environmental challenge chamber (ECC) model

Investigational Intranasal Testosterone Gel (TBS-1 )

Products: Oxmetazoline Nasal Spray (0.05%)

Dactylus gemerata pollen (challenge substance)

EudraCT No.: 201 1 -006098-24

Development Phase: I (Extrinsic Factor Study)

SYNOPSIS

STUDY TITLE:

OBJECTIVES:

Primary:

The primary objective of this study was to determine and compare the pharmacokinetic (PK) profile of 1 1 mg TBS-1 (4.5%) administered intranasally 3 times a day in subjects who suffered from seasonal allergic rhinitis, whilst they were in the symptomatic, symptomatic but treated (with oxymetazoline) and asymptomatic states.

Secondary:

The secondary objective of this study was to determine and compare the local and systemic safety and tolerability, following 3 administrations of TBS-1 in subjects with seasonal allergic rhinitis, whilst they were in the above states.

METHODOLOGY:

This study was an open-label, balanced, randomized 3-way crossover, three-group, three-treatment, three-period pharmacokinetic study. Otherwise healthy male human subjects within the age range of 18 to 45 years with seasonal allergic rhinitis in an asymptomatic state were randomized to 1 of 3 sequence groups (A, B and C). Subjects in sequence group A received treatment 1 in period I, treatment 2 in period II and treatment 3 in period III. Subjects in sequence group B received treatment 2 in period I and treatment 3 in period II and treatment 1 in period III. Subjects in sequence group C received treatment 3 in period I, treatment 1 in period II and treatment 2 in period III. Subjects randomized to Treatment 1 (asymptomatic state) entered the ECC and were exposed to Dactylis glomerata pollen prior to each administration of TBS-1 . Treatment 2 was administered to subjects who were in the symptomatic state of their diagnosed seasonal allergic rhinitis and were treated with oxymetazoline 30 min prior to the 07:00 h dose of TBS-1 and 12 hours ater the first administration. Subjects were exposed to Dactylis glomerata pollen in the ECC prior to each TBS-1 administration. Subjects receiving Treatment 3 were to be in the asymptomatic state (<3 for TNSS and <2 for the congestion score) and received three doses of TBS-1 .

NUMBER OF SUBJECTS:

Planned Sample Size: 18

Actual Sample Size:

Safety Set: 18

Full PK population: 18

PK population for bioequivalence 14

Name of Finished Product:

TBS-1

Name of Active Ingredient:

Testosterone 4.5% (TBS-1 )

DIAGNOSIS AND MAIN INCLUSION CRITERIA:

Diagnosis: otherwise healthy male human subjects with seasonal allergic rhinitis in

asymptomatic state

Main Inclusion Criteria:

1 . Otherwise healthy male human subjects within the age range of 18 to 45 years inclusive with seasonal allergic rhinitis in asymptomatic state, which was defined by a positive case history and a positive skin prick and/or intradermal test for Dactylis glomerata pollen allergen within 12 months of screening. 1. Total Nasal Symptom Score (TNSS) of >6/12 and a congestion score of >2/3 on at least one card during the 2-hour screening challenge.

2. Willingness to provide written informed consent to participate in the study.

3. Body-mass index of <30 kg/m².

4. Absence of significant disease or clinically significant (cs) abnormal laboratory

values on laboratory evaluations, medical history or physical examination during screening.

5. Otorhinolaryngological examination without clinically significant abnormal findings within 4 weeks of screening.

6. Non-smokers or ex-smokers for at least six months.

Comprehension of the nature and purpose of the study and compliance with the requirement of the protocol.

STUDY DRUGS, DOSE AND MODE OF ADMINISTRATION, BATCH NUMBER:

Study drug: Intranasal testosterone gel (TBS-1)

Form and description: Multiple-dose dispenser

Unit strength: 5.5 mg of 4.5% testosterone gel

Daily dose: 33.0 mg of 4.5% testosterone gel

Route of administration: intranasal

Posology: t.i.d.

Batch number:

Oxymetazoline (Nasivin ohne

Study drug:

Konservierungsstoffe)

Form and description: Multiple-dose dispenser

Unit strength: 0.05% oxymetazoline hydrochloride

4 puffs (2 per nostril) of 5.05% oxymetazoline

Daily dose:

hydrochloride

Route of administration: Intranasal

30 min prior to the 07:00 h dose of TBS-1 and 12 h

Posology:

after the first dose (during Treatment Sequence 3)

Study drug: Dactylis glomerata (pollen)

Form and description: Challenge substance for pollen chamber

Unit strength: 6 g

Daily dose: 4000 ± 500 of Dactylis glomerata pollen

Route of administration: Inhalation

STUDY PERIOD: 5 weeks

CRITERIA FOR EVALUATION:

Primary Endpoint (Pharmakokinetics):

The following pharmacokinetic (PK) parameters were determined for all subjects in all treatments: Area under the serum concentration time plot up to 24 h (AUCo-24), the average of the observed concentration of testosterone and DHT in the 24 h interval (C_aVg₎, minimum observed concentration of testosterone and DHT (C_min), maximum observed concentration of testosterone and DHT (C_max), and time of maximum observed concentration testosterone and DHT (t_max) for 3 treatment phases (Treatments 1 -3). The relative PK profiles of the 3 treatments were determined using AUCo-24 and C_max corrected for the serum testosterone concentration.

Secondary Endpoint (Safety):

Safety and tolerability were assessed by monitoring:

• Adverse events

• Otolaryngology examination

• Vital signs

• Complete blood count to evaluate changes in white blood cell (WBC) count, hemoglobin and hematocrit

• Clinical chemistry profile • Urinalysis (urine specific gravity, glucose, protein, ketone, pH, blood, bilirubin, urobilinogen, nitrite, leukocytes)

STATISTICAL METHODS:

Continuous measurements were summarized by means of descriptive statistics (i.e., number of observations, arithmetic mean, standard deviation [SD], minimum, median, maximum).

Categorical variables were summarized by means of frequency tables (i.e. count and

percentages). All baseline corrected PK parameters were tested regarding bioequivalence (ANOVA).

SUMMARY - CONCLUSIONS

The 18 treated subjects were aged between 27 and 44. All 6 subjects in sequence group A completed the study as scheduled. In sequence group B, 4 out of 6 subjects and sequence group C, 5 out of 6 subjects completed the study as scheduled.

Pharmacokinetic Conclusion:

Administration of TBS-1 under asymptomatic, symptomatic and symptomatic but treated conditions of allergic rhinitis demonstrated a reliable increase in testosterone serum concentrations in all three treatment groups. The drug induced exposure to

testosterone and DHT, determined as AUC₀-24,bc was higher in the asymptomatic state compared to symptomatic and symptomatic but treated state. ANOVA analysis failed to demonstrate bioequivalence between the asymptomatic state and either symptomatic or symptomatic but treated state.

A comparison of the AUCbc over 0-24 h between symptomatic and symptomatic but treated state revealed no bioequivalence between these two treatment conditions.

However, given that the point estimates were close to 1 (1 .0903 for testosterone and 0.9944 for DHT) the failure to show bioequivalence may be due to large inter-individual variations. These large variations led to wide confidence intervals, which exceed the threshold values for bioequivalence of 0.8 to 1 .25. While TBS-1 bioavailability during the symptomatic state of allergic rhinitis is lower than during the asymptomatic state, the post-dose concentrations of testosterone still demonstrate a relible increase in levels as compared to baseline. The relative decrease in bioavalability of TBS-1 under symptomatic seasonal rhinitis is not either ameliorated or aggravated by the administration of oxymetazoline.

Safety Conclusion:

TBS-1 was well tolerated. All reported AEs were of mild or moderate intensity and all were transient. All reported AEs were deemed treatment emergent with no causality to TBS-1 . Physical examination, vital signs and clinical laboratory results did not reveal any clinically significant finding.

EXAMPLE 16

An open label, randomized, balanced, three treatments, parallel design, pharmacokinetic study of intra-nasal TBS-1 administration to hypoqonadal men

PHARMACOKINETIC SIMULATION REPORT

See Exhibit D (the contents of which are incorporated herein by reference).

It should be understood that the present invention contemplates any effective pharmacokinetic parameter for the intra-nasal TBS-1 gels of the present invention, including those that may vary as much as about ±25% of the pharmacokinetic parameters set forth in Exhibit D. Preferably, the present invention contemplates pharmacokinetic parameters for the intra-nasal TBS-1 gels that are about 25% greater and/or about 20% lesser than those pharmacokinetic parameters set forth in Exhibit D.

EXAMPLE 17

Stability Intra Nasal Testosterone Gels and Diffusion Rates

The present invention also contemplates stable intranasal TBS-1 testosterone gels as set forth in Exhibits F, G, H, I, J, K1 , K2, L, M1 , M2 and M3 (the contents of which are incorporated herein by reference) and intranasal TBS-1 testosterone gels having diffusion rates as set forth in Exhibit N (the contents of which are incorporated herein by reference).

EXAMPLE 18

A randomized 3-way cross over study to assess the relative bioavailability, safety and tolerability of 4.5% TBS-1 when administered to male subjects with seasonal allergic rhinitis

Composition of TBS-1

This study assessed the relative bioavailability, safety and tolerability of 4.5% TBS-1 when administered to patients with symptomatic untreated and treated (oxymetazoline) seasonal allergic rhinitis as well as asymptomatic subjects using an environmental challenge chamber (ECC) model.

The purpose of this study was to determine effect of allergic rhinitis and the treatment of allergic rhinitis, oxymetazoline, on the absorption of TBS-1 . This was achieved by determining the testosterone pharmacokinetic profile following administration of 1 1 mg TBS-1 (4.5%) three times a day in subjects that suffer from seasonal allergic rhinitis, while in the symptomatic, symptomatic but treated (with Oxymetazoline) and asymptomatic states. The secondary objective of the study was to determine the local and systemic safety and tolerability, following three administrations of TBS-1 in subjects with seasonal allergic rhinitis and while taking oxymetazoline. Symptoms of allergic rhinitis were induced in 18 male patients using allergen challenge with Dactylis glomerata pollen in and Environmental Challenge Chamber. The study was a 3-period cross over design in which all subjects received each of the following treatments:

A: TBS-1 (symptomatic state)

Symptoms of allergic rhinitis were induced in men with seasonal allergic rhinitis by exposing them to pollen of Dactylis glomarata in an environmental challenge chamber (ECC) prior to each administration of TBS-1 .

B: TBS-1 and Oxymetazoline (symptomatic and treated)

Oxymetazoline nasal spray was administered 30 minutes prior to the 0700 hr dose of TBS-1 and again 12 hrs after the first dose. Symptoms of allergic rhinitis were induced in men with seasonal allergic rhinitis by exposing them to pollen in an Environmental Challenge Chamber.

C: TBS-1 (asymptomatic state)

TBS-1 was administered 3 times a day to men in the asymptomatic state.

This is a single site study with a planned enrolment of 1 8 healthy men. A 24 hour pharmacokinetic profile of testosterone and DHT will be performed on all subjects in all treatments.

Safety Results

Eighteen (1 8) healthy men with allergic rhinitis were exposed to TBS-1 . TBS-1 was well tolerated by subjects. There were no deaths in the study and none of the subjects experienced any SAEs. Fifteen (1 5) adverse events were

encountered in the study: 2 in asymptomatic state; 6 in the symptomatic state; and 7 in the symptomatic but treated state. None of the adverse events were considered related to the study drug. All events were of mild to moderate severity. None of the subjects were discontinued from the treatment because of an AE (see results in the following table).

Table : Adverse Events Unrelated to TBS-1

Test results are also presented in Exhibit M (the contents of which are incorporated herein by reference).

EXAMPLE 19

A randomized 3 way cross over study to assess relative bioavailability, safety and tolerability of 4.5% TBS 1 TBS-1 (4.5%) when administered to male subjects with seasonal allergic rhinitis in symptomatic, symptomatic but treated (oxymetazoline) and asymptomatic states An environmental challenge chamber (ECC) model was used in this study. Objectives:

General Study Design:

The chosen cross over design allows to control for non-treatment effects such as period and sequence. Intra-individual measurements allow to detect treatment effects with a higher sensitivity as compared to inter-individual measurements based on smaller intra- individual variation.

This was an open-label study, as the physical differences in the intranasal dosing devices prevent blinding. Since pharmacokinetic parameters are objective measures, they were likely not affected by the open-label design of the study.

Methodology:

This study was an open-label, balanced, randomized 3-way crossover, three-group, three-treatment, three-period pharmacokinetic study. Otherwise healthy male human subjects within the age range of 18 to 45 years with seasonal allergic rhinitis in an asymptomatic state were randomized to 1 of 3 sequence groups (A, B and C).

Subjects in sequence group A received treatment 1 in period I, treatment 2 in period II and treatment 3 in period III. Subjects in sequence group B received treatment 2 in period I and treatment 3 in period II and treatment 1 in period III. Subjects in sequence group C received treatment 3 in period I, treatment 1 in period II and treatment 2 in period III (as shown in the following table).

PERIOD I PERIOD II PERIOD III

Visit 3 Visit 4 Visit 5

Time 04:00-07:00 (+1 day) 04:00-07:00 (+1 day) 04:00-07:00 (+1 Day)

Sequence group A Treatment 1 Treatment 2 Treatment 3

Sequence group B Treatment 2 Treatment 3 Treatment 1

Sequence group C Treatment 3 Treatment 1 Treatment 2

Treatments in the Three Dose Sequences

Subjects randomized to Treatment 1 (asymptomatic state) entered the ECC and were exposed to Dactylis glomerata pollen prior to each administration of TBS-1 . Treatment 2 was administered to subjects who were in the symptomatic state of their diagnosed seasonal allergic rhinitis and were treated with oxymetazoline 30 min prior to the 07:00 h dose of TBS-1 and 12 hours after the first administration. Subjects were exposed to Dactylis glomerata pollen in the ECC prior to each TBS-1 administration. Subjects receiving Treatment 3 were to be in the asymptomatic state (<3 for TNSS and <2 for the congestion score) and received three doses of TBS-1 .

Number of Subjects: 18

Safety Set: 18

Full PK population: 18

PK population for Bioequivalence: 14

Subject Population:

A male subject population with a history of seasonal allergic rhinitis, aged 18-45 years was chosen for this study in order to investigate the effect of allergic rhinitis on the absorption of TBS-1 in an asymptomatic, symptomatic and symptomatic but treated state. Diagnosis criteria: otherwise healthy male human subjects with seasonal allergic rhinitis in asymptomatic state.

Main inclusion criteria:

1 . Otherwise healthy male human subjects within the age range of 18 to 45 years inclusive with seasonal allergic rhinitis in asymptomatic state, which was defined by a positive case history and a positive skin prick and/or intradermal test for Dactylis glomerata pollen allergen within 12 months of screening.

2. Total Nasal Symptom Score (TNSS) of >6/12 and a congestion score of >2/3 on at least one card during the 2-hour screening challenge.

3. Willingness to provide written informed consent to participate in the study.

4. Body-mass index of <30 kg/m².

5. Absence of significant disease or clinically significant (cs) abnormal laboratory values on laboratory evaluations, medical history or physical examination during screening.

6. Otorhinolaryngological examination without clinically significant abnormal findings within 4 weeks of screening.

7. Non-smokers or ex-smokers for at least six months.

8. Comprehension of the nature and purpose of the study and compliance with the requirement of the protocol.

Study drug: Intranasal testosterone gel (TBS-1 )

Form and description: Multiple-dose dispenser

Unit strength: 5.5 mg of 4.5% testosterone gel

Daily dose: 33.0 mg of 4.5% testosterone gel

Route of administration: intranasal

Posology: t.i.d.

Batch number: 2372

Oxymetazoline (Nasivin ohne

Study drug:

Konservierungsstoffe)

Form and description: Multiple-dose dispenser

Unit strength: 0.05% oxymetazoline hydrochloride

4 puffs (2 per nostril) of 5.05% oxymetazoline

Daily dose:

hydrochloride

Route of administration: Intranasal

30 min prior to the 07:00 h dose of TBS-1 and 12 h Posology:

after the first dose (during Treatment Sequence 3)

Study drug: Dactylis glomerata (pollen)

Form and description: Challenge substance for pollen chamber

Unit strength: 6 g

Daily dose: 4000 ± 500 of Dactylis glomerata pollen

Route of administration Inhalation

Study Period : 5 Weeks

CRITERIA FOR EVALUATION:

Primary Endpoint (Pharmakokinetics):

The following pharmacokinetic (PK) parameters were determined for all subjects in all treatments: Area under the serum concentration time plot up to 24 h (AUCo-24), the average of the observed concentration of testosterone and DHT in the 24 h interval (C_aVg), minimum observed concentration of testosterone and DHT (C_min), maximum observed concentration of testosterone and DHT (C_max), and time of maximum observed concentration testosterone and DHT (t_max) for 3 treatment phases

(Treatments 1 -3).

The relative PK profiles of the 3 treatments were determined using AUCo-₂₄ and C_max corrected for the serum testosterone concentration.

Secondary Endpoint (Safety):

Safety and tolerability were assessed by monitoring:

• Adverse events

• Otolaryngology examination

• Vital signs

• Clinical chemistry profile

• Urinalysis (urine specific gravity, glucose, protein, ketone, pH, blood, bilirubin, urobilinogen, nitrite, leukocytes)

Statistical Methods:

Continuous measurements were summarized by means of descriptive statistics (i.e., number of observations, arithmetic mean, standard deviation [SD], minimum, median, maximum). Categorical variables were summarized by means of frequency tables (i.e. count and percentages). All baseline corrected PK parameters were tested regarding bioequivalence (ANOVA).

Subjects participating in this study were at risk for the side effects common to all formulations of testosterone. In addition to risks inherent to all testosterone

administration, subjects receiving TBS-1 in prior clinical studies have experienced mild nasal symptoms including dryness, inflammation, congestion, and discomfort. None of these AEs prevented subjects from continuing the medication.

The exposure to pollen in order to induce symptoms of allergic rhinitis was associated with a minimal risk of anaphylactic reactions. Allergen challenges with Dactylis glomerata pollen in the Fraunhofer ECC were designed to mimic the situation for the subject under quasi-natural conditions. Therefore, the pollen exposure in the ECC did not present a greater risk than natural exposure during the grass pollen season in summer. The experimental setting was validated and used in numerous clinical trials. Inhalation of pollen can cause bronchoconstriction in asthmatic subjects. However, asthmatic subjects were excluded from the study. For risk minimization measures with respect to pollen challenge.

Subjects receiving oxymetazoline (Nasivin^®) were at risk of the described side-effects of this product. Frequent side-effects are burning and dryness of the nasal mucosa and sneezing. Uncommon side effects are agitation, fatigue, headache, hallucinations (mainly observed in children), tachycardia, hypertension, arrhythmia, nose bleeding, convulsions (mainly observed in children) and hypersensitivity reactions, such as, itching and rash. However, since each subject received only 2 doses of oxymetazoline, the risk of developing side-effects was minimal.

Testosterone replacement therapy for hypogonadal men should correct the clinical abnormalities of testosterone deficiency. Since this was a Phase I study enrolling men not suffering from hypogonadism between the ages of 1 8-45 years it was not

anticipated that these volunteers would directly benefit by taking part in this study.

CONCLUSIONS:

The 18 treated subjects were aged between 27 and 44. All 6 subjects in sequence group A completed the study as scheduled. In sequence group B, 4 out of 6 subjects and sequence group C, 5 out of 6 subjects completed the study as scheduled. Pharmacokinetic Conclusion:

However, given that the point estimates were close to 1 (1 .0903 for testosterone and 0.9944 for DHT) the failure to show bioequivalence may be due to large inter-individual variations. These large variations led to wide confidence intervals, which exceed the threshold values for bioequivalence of 0.8 to 1 .25.

Administration of 4.5% TBS-1 under asymptomatic, symptomatic and symptomatic but treated conditions of allergic rhinitis demonstrated a reliable increase in testosterone serum concentrations under all three treatment conditions. 4.5% TBS 1 bioavailability during the symptomatic state of allergic rhinitis was 21 % lower compared to the asymptomatic state, based on AUCO-24 values.

While TBS-1 bioavailability during the symptomatic state of allergic rhinitis is lower than during the asymptomatic state, the post-dose concentrations of testosterone still demonstrate a relible increase in levels as compared to baseline. The relative decrease in bioavailability of 4.5% TBS 1 under symptomatic seasonal rhinitis was neither ameliorated nor aggravated by the administration of oxymetazoline.

Safety Conclusion:

A linear-scale mean serum concentration time plot for testosterone is presented in the following figures:

<ί Baseline — «-— SynipiosneB- S!sie — - Sysr^wmaSa But Knrne Slats — "" teynttvmtic Siaie

Serum D!IT (na/dL): Arithmetic mean concentration vs. time carve, linear scale (PK. set)

EXAMPLE 20

Drug-Drug Interaction study to evaluate administration route of

intranasal application of testosterone and to investigate potential

interaction of testosterone with a nasal decongestant spray

A drug-drug Interaction study was completed, which was an extrinsic factor study to evaluate whether intranasal application of testosterone is a reliable route of administration during naturally occurring nasal inflammation such as allergic rhinitis and to investigate the potential interaction of TBS-1 with a nasal decongestant spray, oxymetazoline. The study was conducted at one site in Germany.

Treatment Regimen. Subjects were randomly assigned to a treatment sequence comprised of TBS-1 when they were asymptomatic, symptomatic and untreated and symptomatic and treated with oxymetazoline nasal spray. The symptomatic state was induced by exposure to Dactylis glomerata pollen in an environment exposure chamber (EEC).

The symptomatic state was defined by a positive case history, a positive skin prick and/or interdermal test for Dactylis glomerata allergen and a Total nasal Symptom Score (TNSS) of > 6/12 and a congestion score of > 2/3. TBS-1 administration to subjects in a symptomatic and treated arm received oxymetazoline 30 minutes prior to the 07:00 hour dose of TBS 1 and 12 hours after the first administration. All patients received 3 doses of TBS-1 at 07:00, 13:00 and 21 :00 hrs.

Primary Objective

Subject Disposition

The 18 treated subjects were healthy subjects with seasonal allergic rhinitis aged between 27 and 44. All 6 subjects in sequence group A completed the study as scheduled. In sequence group B, 4 out of 6 subjects and sequence group C, 5 out of 6 subjects completed the study as scheduled. In total, the number of subjects completing each of the 3 states were: asymptomatic (N=18), symptomatic but treated (N=17), and symptomatic untreated (N=15).

Analysis of Primary Endpoint

Administration of TBS-1 under asymptomatic, symptomatic and symptomatic but treated conditions of allergic rhinitis demonstrated a reliable increase in testosterone serum concentrations under all 3 treatment conditions as presented in the following table and the following figure . Table: AUC Values for Serum Testosterone by Treatment Condition Including Non- Corrected Values, Corrected Values and Pre-dose Corrected Values

* Corrected values = uncorrected values - baseline 24 hour

^# Pre-dose corrected values = PK values were corrected for treatment specific pre-dose levels

Fl Serum Testosterone (ng/dL): Arithmetic Mean Concentration vs. Time Curve, Linear Scale (PK set) The testosterone exposure as estimated by the mean baseline-corrected area under the serum concentration-time curve from 0 to 24 hours post-dose AUC₀-24,bc was higher for subjects in the asymptomatic state compared to symptomatic and symptomatic but treated state. An analysis of variance did not demonstrate bioequivalence between the asymptomatic state and either symptomatic and symptomatic but treated state.

The difference in AUC₀-2₄,bc between the symptomatic untreated and the symptomatic treated states was small, indicating that administration of oxymetazoline did not relevantly affect the absorption of TBS-1 ; however, they were not bioequivalent. Given that the point estimates were close to 1 (1 .0903) the failure to show bioequivalence may be due to large interindividual variations. These large variations led to wide confidence intervals, which exceed the threshold for bioequivalence of 0.8 to 1 .25.

TBS 1 bioavailability during the symptomatic state of allergic rhinitis was 21 % lower compared the asymptomatic state, based on AUC₀-2₄ values. However, the post-dose concentrations of testosterone still demonstrate a reliable increase in levels as compared to baseline. The relative decrease in bioavailability of TBS-1 under symptomatic seasonal rhinitis is neither ameliorated nor aggravated by the

administration of oxymetazoline.

Additional exploratory analysis revealed that the different treatment conditions influenced the pre-dose value of testosterone. A student t-test showed significant differences in the pre-dose testosterone between the asymptomatic treatment condition compared to the symptomatic and the symptomatic and treated conditions. Subjects were exposed to an EEC in the symptomatic and symptomatic and treated condition but not in the asymptomatic condition. It is hypothesized that the earlier wake up time and/or stress caused by procedures associated with confinement in the EEC may have led to lower testosterone values in both symptomatic states compared to the

asymptomatic state. As such, the baseline profile collected under the EEC conditions and used for correction purposes was not truly representative of the non-treated state under all study conditions. The additional analysis corrected for endogenous testosterone by pre-dose values instead of correction by 24 hour baseline profile. This analysis showed that the differences between asymptomatic and both symptomatic treatment conditions were less pronounced with respect to AUC_bc, C_aVg,bc, and C_maXibc- However, bioequivalence could not be shown between treatment conditions.

EXAMPLE 21 A

Titration Method for dosing BID or TIP tntranasal Testosterone gels

hypogonadism or TRT when treated with the intranasal testosterone gels of the present invention.

The following titration criteria is preferably used:

With respect to those subjects with an estimated serum total testosterone

Cavg≥300 ng/dL, i.e., those subjects who sum of the serum total testosterone level values for pK samples collected at 9.0 hours and 10.33 hours is >755 ng/dL, their BID treatment regimen should remain unchanged at a BID treatment regimen of TBS-1 since their 24-hour C_aVg is >300 ng/dL. The decision to titrate the subject's daily dose to TID or remain at BID, however, will be made by the doctor based on the criteria specified above.

Preliminary data on 139 hypogonadal men who have completed 30 days of BID or TID treatment of the Phase 3 Study, reported in Example , exhibit the following results, established following the titration methods herein:

Phase III Study - Rationale for the Titration Protocol for Compleo

(4.5% TBS-1 Gel)

1. Introduction

At the March 14, 201 1 End of Phase II Meeting, the Compleo (4.5% TBS-1 Gel) Phase III study includes the modifications suggested by the Agency ("FDA") and a rationale for the choice of secondary endpoints, the titration scheme and the ENT examination protocol. See Example for the final Phase 3 protocol. The primary endpoint of this study is the percentage of subjects with a serum total testosterone C_avg value within the normal range on Day 90. This endpoint is consistent with Agency standards used for approval of other testosterone replacement therapy formulations. Although there are no generally accepted lower limits of normal for serum total testosterone, guidelines recommend using the range of 280-300 ng/dL. The sponsor has defined the normal range for Testosterone as 300 ng/dL to 1050 ng/dL for this study. This range is consistent with Agency standards and is in agreement with the AACF Hypogonadism and Endocrine Society Clinical Practice Guidelines.

Secondary Endpoints

Erectile function - Erectile function was included in the proposed protocol but based on the recommendations from the Division, erectile function will now be assessed using the NEF (international index of Erectile Function Questionnaire), Mood scales - The sponsor intends to collect data on changes in subject mood compared to baseline using the PANAS scale for information purposes only. The PANAS scale was chosen as it is a validated instrument that measures the balance between positive and negative mood. Data will be collected for each subject at baseline, Day 30 and Day 90.

Study Design

Table 1 : Sample Size Estimation

Safety Evaluation

Titration Scheme

Titration Model Development

The model selected uses two testosterone measurements, one taken one hour prior to the morning dose (sample A, 9.00h post 1 ^st dose) and one taken 20 minutes after the morning dose (sample B, 10.33h (10h20 min) post 1 ^st dose). The C_avg for a given subject was predicted using a ratio of the two testosterone measurements triangulated to predict the area under the curve for the morning peak. This morning peak area was used to predict the total area under the curve for a 24 hour dosing interval which was converted to the 24 hour C_avg for testosterone. This is referred to as the 'model predicted C_avg' or 'calculated C_avg' in this text. The calculated C_avg was then compared against the lower limit of normal of 300 ng/dL as the decision level for titration. If the C_avg is calculated to be greater than 300 ng/dL then the b.i.d. regimen is maintained. If the Cavg is calculated to be less than 300 ng/dL then the patient is titrated to the t.i.d. regimen. The individual data comparing the predicted C_avg with the actual C_avg C_avg is provided in Appendix 2.

The model was further challenged on simulated pharmacokinetic profile data from 200 patients based on the 1 1 mg b.i.d. treatment group from the TBS-1 -2010-01 study. Using the sampling points from the model and the individual subject profiles from these 200 subjects, a model predicted C_avg was calculated and compared to the actual C_avg. The individual data from this analysis is provided in Appendix 3. The model was designed to have a high degree of precision, (successful prediction rate of greater than 80%) around the decision level of 300 ng/dL, and the data from both datasets shows a good correlation between the predicted C_avg and the actual C_avg around this key decision level.

Titration Model Robustness

The robustness of the model and the resulting titration scheme was evaluated using the data from the TBS-1 -2010-01 study and the 200 patient simulated subject profiles. In addition to the two sampling points in the model, analysis was performed on three other sampling timepoints after the morning dose, 30 minutes, 60 minutes and 90 minutes. In each case the titration scheme was used to predict the requirement for titration following which each subject was sorted into one of two groups, Titration Required or Titration Not Required. The actual C_avg for each subject was used to assess the accuracy of the titration scheme with the total number of correct and incorrect titration predictions determined. The incorrect predictions were further separated into two groups in which: (3) Titration was not predicted but required - The titration scheme indicated that titration was not required, whereas the actual C_avg was less than 300 ng/dL. The subjects would not be titrated.

(4) Titration was predicted but not required - The titration scheme indicated that titration was required, whereas the actual C_avg was greater than 300 ng/dL. The subjects would be titrated.

As the data indicates the model is capable of predicting the need for titration on a consistent basis with an over 80% success ratio for correct predictions at the proposed sampling points. This holds true for the sampling point at 40 minutes after the morning dose as well. At sampling points 60 minutes and 90 minutes after the morning dose the prediction success falls below 80%, which is likely explained by the variability of the values in testosterone concentration at these timepoints and the added variability introduced by the simulation analysis. The model performs slightly better using the 90 minute sampling point than the 60 minute sampling point.

In cases where the titration scheme prediction was not correct, it was important that the model accurately identify those subjects that would benefit from titration from the b.i.d. to the t.i.d. dosing regimen and, in doing so, kept the number of subjects for which titration was not predicted but required to a minimum. The titration scheme achieved this with very low numbers of subjects from the TBS-1 -2010-01 study data and TBS-1 - 2010-01 simulation data across all post dose timepoints.

Titration Scheme Validation

ENT Evaluation During Safety Assessment

1 . History:

The examining physician will inquire about the following symptoms: • Excessive nasal dryness,

• Excessive nasal crusting,

• Unexpected nasal bleeding,

• Progressive nasal pain,

• Progressive nasal obstruction, and

• Alternation to sense of smell.

2. Physical exam:

• Large amounts of nasal crusting,

• Scar tissue blocking the nose,

• Dried or fresh nasal blood, and

• Fissuring of the nasal skin.

A subset of subjects will be asked to continue in the study for a safety extension period (Day 180 to 360). In this period, safety evaluations will consist of monthly ENT examinations, vital signs, and adverse events. On Day 270 and Day 360 (or early termination), subjects will also undergo a physical examination, 12-lead ECG, DRE of the prostate, and laboratory assessments (CBC, PSA, chemistry profile, liver function tests, lipid profile, urinalysis, fasting morning serum total testosterone, DHT, and estradiol).

Titration Model Results - TBS-1-2010-01 Data Testosterone Model Actual

Subject Concentration (ng/dL) Predicted 24h

Number Time From Morning Dose 24h Cavg Cavg

-1 hr +20 min (ng/dL) (ng/dL)

CI 399 600 428 518

C2 251 327 248 360

C3 344 604 406 387

C4 463 648 476 429

C5 292 558 364 410

C6 161 304 199 179

C7 316 1140 624 489

Al 284 482 328 372

A2 249 363 262 308

A3 303 611 392 337

A4 216 549 328 325

A5 552 872 610 523

A6 320 671 425 603

A7 347 979 568 582

A8 185 424 261 248

Bl 308 847 495 369

B2 333 1100 614 446

B3 226 492 308 311

B4 249 658 389 351

B5 195 472 286 295

B6 446 959 602 723

B7 355 370 311 359

Titration Model Results TBS-1-2010 Patient Simulation Data

Testosterone Sample A taken 1 hour before the morning dose Testosterone Sample B taken 20 minutes after the morning dose

5 367 561 367 514

6 254 566 324 334

7 406 832 489 584

8 483 639 444 450

9 108 339 177 175

10 260 827 430 366

11 327 550 347 322

12 522 1430 772 757

13 240 995 488 442

14 278 852 447 288

15 249 448 276 330

16 523 930 574 506

17 497 726 483 423

18 375 945 522 412

19 132 278 162 291

20 231 439 265 306

21 363 844 477 505

22 535 770 516 505

23 340 680 403 673

24 252 630 349 346

25 231 583 322 322

26 156 430 232 362

27 226 719 374 375

28 197 485 270 339

29 466 635 435 459

30 232 920 455 316

31 263 897 459 431

32 183 1260 570 352

33 491 655 453 436

34 277 497 306 475

Testosterone Concentration Model

Actual

Subject (ng/dL) Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +20 min (ng/dL)

35 362 403 302 441

36 140 395 212 233

37 164 410 227 301

38 195 374 225 209

39 381 904 508 527

40 206 464 265 316

41 176 809 389 397 42 200 485 271 282

43 479 2640 1233 877

44 280 511 313 332

45 212 705 363 315

46 246 436 270 300

47 117 358 188 203

48 420 679 434 308

49 262 781 412 406

50 191 688 347 359

51 381 447 327 439

52 321 553 346 422

53 195 424 245 397

54 325 425 296 301

55 413 895 517 472

56 179 952 447 328

57 180 472 258 249

58 206 689 354 359

59 255 563 323 318

60 380 683 420 437

61 226 358 231 317

62 370 628 395 388

63 265 885 455 388

64 163 475 252 245

65 302 756 418 595

66 274 597 344 377

67 250 666 362 456

68 383 789 463 456

69 291 662 377 411

70 430 1060 589 417

71 236 514 296 307

72 248 550 315 248

73 244 692 370 374

Testosterone Concentration Model

Subject (ng/dL) Actual

Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +20 min (ng/dL)

74 362 711 424 572

75 310 1370 664 589

76 467 475 372 367

77 256 465 285 236

78 222 557 308 267 79 198 727 366 333

80 371 397 304 346

81 213 993 477 549

82 288 646 369 386

83 221 538 300 314

84 226 574 316 355

85 168 679 335 286

86 139 507 255 334

87 211 611 325 363

88 225 686 360 412

89 265 456 285 313

90 520 1140 656 510

91 207 1120 525 365

92 191 515 279 304

93 242 689 368 399

94 121 916 410 331

95 105 398 199 294

96 299 686 389 348

97 153 466 245 441

98 242 417 261 260

99 288 697 389 448

100 530 720 494 494

101 178 685 341 211

102 410 424 330 343

103 491 646 449 401

104 443 830 503 408

105 218 489 279 314

106 322 526 335 347

107 404 660 421 420

108 217 491 280 281

109 277 454 289 294

110 200 281 190 229

111 258 425 270 276

112 523 642 461 440

Testosterone Concentration Model

Actual

Subject (ng/dL) Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +20 min (ng/dL)

113 283 568 336 408

114 260 596 338 242

115 231 600 329 389 116 481 757 489 405

117 293 543 330 370

118 261 375 251 311

119 152 226 149 227

120 291 412 278 282

121 383 547 368 440

122 295 352 256 295

123 276 527 317 304

124 113 1100 480 311

125 245 421 263 307

126 421 666 430 499

127 313 514 327 371

128 238 787 405 432

129 256 493 296 380

130 175 278 179 278

131 199 394 234 303

132 296 491 311 363

133 319 879 474 342

134 274 812 429 346

135 140 412 218 220

136 466 441 359 434

137 449 2330 1099 739

138 252 347 237 282

139 330 698 406 440

140 165 513 268 215

141 292 667 379 389

142 306 574 348 473

143 345 319 263 292

144 359 880 490 492

145 399 561 380 449

146 593 932 603 696

147 581 712 511 426

148 222 356 229 229

149 231 640 344 301

150 274 1160 567 460

151 178 764 372 411

Testosterone Concentration Model

Actual

Subject (ng/dL) Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +20 min (ng/dL)

152 176 1030 477 312 153 346 542 351 491

154 221 378 237 259

155 236 527 302 361

156 257 456 282 358

157 146 609 298 295

158 241 358 237 304

159 199 636 330 434

160 280 1220 593 506

161 370 500 344 417

162 148 710 339 250

163 246 402 256 284

164 263 930 472 349

165 178 537 283 275

166 393 715 438 432

167 193 426 245 246

168 148 449 236 214

169 120 596 283 217

170 262 593 338 307

171 369 652 404 366

172 394 666 419 415

173 289 543 329 396

174 282 548 328 329

175 225 654 347 336

176 255 970 484 544

177 212 548 300 344

178 203 251 179 201

179 488 612 435 560

180 247 809 417 425

181 206 565 305 280

182 134 497 249 252

183 401 442 333 368

184 253 550 317 329

185 252 843 433 352

186 314 677 392 494

187 370 532 357 378

188 368 551 363 342

189 241 511 297 251

190 229 794 404 379

Testosterone Concentration Model Actual

Subject

(ng/dL) Predicted 24h Cavg Number

Time From Morning Dose 24h Cavg (ng/dL) -1 hr +20 min (ng/dL)

191 333 636 383 526

192 217 834 415 360

193 264 411 267 263

194 382 1180 618 479

195 283 380 262 344

196 332 1360 669 442

197 310 911 483 321

198 194 610 318 327

199 172 465 252 192

200 335 894 486 473

Titration Model Results TBS-1 -2010 Patient Simulation Data

1 217 1070 509 501

2 286 962 493 393

3 406 399 318 358

4 449 676 445 392

5 367 1420 706 514

6 254 863 441 334

7 406 991 552 584

8 483 758 490 450

9 108 229 133 175

10 260 441 277 366

11 327 432 300 322

12 522 1160 665 757

13 240 565 318 442

14 278 417 275 288

15 249 474 286 330

16 523 1020 610 506

17 497 992 588 423

18 375 1130 595 412

19 132 379 202 291

20 231 439 256 306

21 363 858 483 505

22 535 770 476 505

23 340 630 383 673

24 252 630 366 346

25 231 1130 538 322

26 156 736 353 362

27 226 456 270 375

28 197 324 206 339

29 466 467 369 459

30 232 348 229 316

31 263 1170 566 431

32 183 603 311 352

33 491 660 455 436

34 277 426 278 475

Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

Number 24h Cavg

Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +40 min (ng/dL)

35 362 334 275 441

36 140 485 247 233

37 164 568 289 301 38 195 374 225 209

39 381 1020 554 527

40 206 410 243 316

41 176 588 302 397

42 200 651 336 282

43 479 1750 881 877

44 280 686 382 332

45 212 524 291 315

46 246 353 237 300

47 117 532 256 203

48 420 437 339 308

49 262 988 494 406

50 191 536 287 359

51 381 770 455 439

52 321 591 360 422

53 195 789 389 397

54 325 499 326 301

55 413 702 441 472

56 179 786 381 328

57 180 357 212 249

58 206 662 343 359

59 255 414 264 318

60 380 698 426 437

61 226 465 273 317

62 370 462 329 388

63 265 874 450 388

64 163 279 175 245

65 302 1140 570 595

66 274 615 351 377

67 250 830 427 456

68 383 842 484 456

69 291 848 450 411

70 430 579 399 417

71 236 874 439 307

72 248 400 256 248

Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

Number 24h Cavg

Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +40 min (ng/dL)

73 244 460 278 374

74 362 481 333 572 75 310 676 390 589

76 467 589 417 367

77 256 462 284 236

78 222 462 270 267

79 198 663 340 333

80 371 442 321 346

81 213 740 377 549

82 288 548 330 386

83 221 454 267 314

84 226 742 383 355

85 168 626 314 286

86 139 670 320 334

87 211 811 404 363

88 225 662 351 412

89 265 679 373 313

90 520 681 475 510

91 207 723 368 365

92 191 691 349 304

93 242 431 266 399

94 121 861 388 331

95 105 647 297 294

96 299 663 380 348

97 153 1040 471 441

98 242 336 228 260

99 288 396 270 448

100 530 798 525 494

101 178 494 266 211

102 410 758 462 343

103 491 646 387 401

104 443 603 413 408

105 218 742 379 314

106 322 496 323 347

107 404 897 514 420

108 217 659 346 281

109 277 563 332 294

110 200 438 252 229

Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

Number 24h Cavg

Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +40 min (ng/dL)

111 258 495 298 276 112 523 829 534 440

113 283 486 304 408

114 260 444 278 242

115 231 750 388 389

116 481 609 431 405

117 293 969 499 370

118 261 375 282 311

119 152 335 192 227

120 291 302 234 282

121 383 629 400 440

122 295 640 370 295

123 276 440 283 304

124 113 1050 460 311

125 245 659 357 307

126 421 629 415 499

127 313 533 334 371

128 238 513 297 432

129 256 488 294 380

130 175 617 313 278

131 199 390 233 303

132 296 458 298 363

133 319 675 393 342

134 274 812 440 346

135 140 286 168 220

136 466 862 525 434

137 449 1530 782 739

138 252 489 293 282

139 330 421 297 440

140 165 313 189 215

141 292 609 356 389

142 306 688 393 473

143 345 403 296 292

144 359 880 466 492

145 399 506 358 449

146 593 1040 645 696

147 581 619 474 426

148 222 273 196 229

Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

Number 24h Cavg

Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +40 min (ng/dL) 149 231 814 413 301

150 274 1360 646 460

151 178 1300 584 411

152 176 750 366 312

153 346 904 494 491

154 221 488 280 259

155 236 772 398 361

156 257 538 314 358

157 146 428 227 295

158 241 437 268 304

159 199 568 303 434

160 280 1530 715 506

161 370 476 334 417

162 148 628 307 250

163 246 700 374 284

164 263 602 342 349

165 178 674 337 275

166 393 712 437 432

167 193 437 249 246

168 148 397 215 214

169 120 596 290 217

170 262 573 330 307

171 369 647 402 366

172 394 431 326 415

173 289 949 489 396

174 282 461 294 329

175 225 785 399 336

176 255 1010 500 544

177 212 646 339 344

178 203 386 233 201

179 488 853 530 560

180 247 680 366 425

181 206 532 292 280

182 134 497 427 252

183 401 607 398 368

184 253 640 353 329

185 252 716 383 352

186 314 846 458 494

Time From Morning Dose 24h Cavg (ng/dL) -1 hr +40 min (ng/dL)

187 370 552 364 378

188 368 616 389 342

189 241 465 279 251

190 229 645 345 379

191 333 636 387 526

192 217 834 258 360

193 264 231 196 263

194 382 649 407 479

195 283 608 352 344

196 332 730 420 442

197 310 536 334 321

198 194 684 347 327

199 172 285 181 192

200 335 655 391 473

m m m m oo oo σ> σ>

Subject Number

Titration Model Results TBS-1-2010 Patient Simulation Data

Testosterone Sample A taken 1 hour before the morning dose

Testosterone Sample B taken 60 minutes after the morning dose Testosterone Model

Subject Concentration (ng/dL) Actual

Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +60 min (ng/dL)

1 217 1400 225 501

2 286 896 238 393

3 406 372 315 358

4 449 822 324 392

5 367 970 262 514

6 254 554 178 334

7 406 846 312 584

8 483 684 395 450

9 108 212 103 175

10 260 739 212 366

11 327 373 287 322

12 522 1030 546 757

13 240 862 201 442

14 278 444 379 294

15 249 298 200 330

16 523 367 461 506

17 497 615 352 423

18 375 907 307 412

19 132 491 140 291

20 231 415 176 306

21 363 822 258 505

22 535 917 370 505

23 340 859 392 673

24 252 735 199 346

25 231 486 210 322

26 156 856 163 362

27 226 611 186 375

28 197 505 269 339

29 466 450 384 459

30 232 377 220 316

31 263 693 368 431

32 183 791 216 352

33 491 1020 339 436

34 277 762 199 475

Testosterone Model Actual

Subject

Concentration (ng/dL) Predicted 24h Cavg Number

Time From Morning Dose 24h Cavg (ng/dL) -1 hr +60 min (ng/dL)

35 362 371 320 441

36 140 543 117 233

37 164 502 174 301

38 195 303 184 209

39 381 1000 334 527

40 206 557 209 316

41 176 570 183 397

42 200 631 128 282

43 479 1040 385 877

44 280 466 260 332

45 212 229 220 315

46 246 482 188 300

47 117 286 116 203

48 420 386 255 308

49 262 830 220 406

50 191 601 233 359

51 381 405 337 439

52 321 420 263 422

53 195 677 129 397

54 325 364 282 301

55 413 697 315 472

56 179 1390 123 328

57 180 307 156 249

58 206 482 191 359

59 255 491 195 318

60 380 680 341 437

61 226 463 239 317

62 370 573 299 388

63 265 819 265 388

64 163 413 134 245

65 302 1110 246 595

66 274 409 236 377

67 250 609 191 456

68 383 643 314 456

69 291 548 227 411

70 430 966 298 417

71 236 497 185 307

72 248 486 169 248

Subject Testosterone Model Actual Number Concentration (ng/dL) Predicted 24h Cavg Time From Morning Dose 24h Cavg (ng/dL)

-1 hr +60 min (ng/dL)

73 244 665 183 374

74 362 605 318 572

75 310 571 313 589

76 467 488 308 367

77 256 462 190 236

78 222 277 176 267

79 198 459 168 333

80 371 424 229 346

81 213 1020 233 549

82 288 662 247 386

83 221 373 168 314

84 226 522 243 355

85 168 768 143 286

86 139 842 187 334

87 211 491 235 363

88 225 777 200 412

89 265 480 184 313

90 520 757 488 510

91 207 642 193 365

92 191 673 164 304

93 242 661 211 399

94 121 491 168 331

95 105 541 111 294

96 299 718 235 348

97 153 894 179 441

98 242 509 184 260

99 288 541 263 448

100 530 921 362 494

101 178 258 153 211

102 410 538 270 343

103 491 499 304 401

104 443 665 382 408

105 218 483 198 314

106 322 534 285 347

107 404 521 307 420

108 217 402 198 281

109 277 372 209 294

110 200 392 173 229

Time From Morning Dose 24h Cavg (ng/dL)

(ng/dL)

-1 hr +60 min

111 258 523 193 276

112 523 804 438 440

113 283 899 247 408

114 260 476 176 242

115 231 486 178 389

116 481 903 361 405

117 293 453 295 370

118 261 416 201 311

119 152 276 140 227

120 291 409 240 282

121 383 547 284 440

122 295 536 173 295

123 276 312 259 304

124 113 865 146 311

125 245 578 191 307

126 421 476 313 499

127 313 545 220 371

128 238 772 190 432

129 256 393 200 380

130 175 437 216 278

131 199 404 170 303

132 296 545 303 363

133 319 465 204 342

134 274 917 200 346

135 140 287 124 220

136 466 794 333 434

137 449 1030 292 739

138 252 347 176 282

139 330 445 321 440

140 165 271 144 215

141 292 460 268 389

142 306 637 217 473

143 345 419 253 292

144 359 852 327 492

145 399 690 292 449

146 593 1770 450 696

147 581 601 380 426

148 222 262 213 229 Testosterone Model

Concentration (ng/dL) Actual

Subject Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +60 min (ng/dL)

149 231 290 186 301

150 274 580 195 460

151 178 871 116 411

152 176 643 158 312

153 346 815 268 491

154 221 815 209 259

155 236 500 203 361

156 257 498 296 358

157 146 385 162 295

158 241 344 240 304

159 199 609 221 434

160 280 976 223 506

161 370 306 386 417

162 148 425 181 250

163 246 487 206 284

164 263 699 222 349

165 178 346 151 275

166 393 645 354 432

167 193 459 201 246

168 148 359 124 214

169 120 352 121 217

170 262 398 180 307

171 369 613 305 366

172 394 518 271 415

173 289 780 186 396

174 282 481 181 329

175 225 691 216 336

176 255 1190 278 544

177 212 466 229 344

178 203 209 150 201

179 488 367 375 560

180 247 501 208 425

181 206 483 152 280

182 134 455 99 252

183 401 605 283 368

184 253 352 199 329

185 252 470 181 352

Subject Number

Titration Model Results TBS-1-2010 Patient Simulation Data Testosterone Sample A taken 1 hour before the morning dose

Testos terone Sample B taken 90 minutes after the morning dose

Testosterone Concentration (ng/dL) Model

Actual

Time From Morning Dose Predicted

Subject 24h Cavg

24h Cavg

Number -1 hr +90 min (ng/dL)

(ng/dL)

1 217 860 726 501

2 286 633 531 393

3 406 407 349 358

4 449 276 571 392

5 367 949 600 514

6 254 846 363 334

7 406 1360 562 584

8 483 668 524 450

9 108 274 144 175

10 260 565 449 366

11 327 259 314 322

12 522 602 697 757

13 240 651 495 442

14 278 361 324 288

15 249 363 246 330

16 523 614 400 506

17 497 660 499 423

18 375 638 576 412

19 132 672 280 291

20 231 384 290 306

21 363 796 532 505

22 535 869 652 505

23 340 763 538 673

24 252 462 443 346

25 231 250 322 322

26 156 624 454 362

27 226 745 376 375

28 197 237 315 339

29 466 910 411 459

30 232 343 273 316

31 263 704 429 431

32 183 420 437 352

33 491 775 678 436

34 277 1610 466 475

Subject Testosterone Concentration (ng/dL) Model Actual Number Time From Morning Dose Predicted 24h Cavg

-1 hr +90 min 24h Cavg (ng/dL)

(ng/dL)

35 362 714 329 441

36 140 212 307 233

37 164 322 299 301

38 195 325 224 209

39 381 1030 620 527

40 206 387 343 316

41 176 766 335 397

42 200 271 373 282

43 479 1500 682 877

44 280 537 335 332

45 212 361 198 315

46 246 342 327 300

47 117 246 181 203

48 420 416 362 308

49 262 812 490 406

50 191 415 356 359

51 381 880 353 439

52 321 755 333 422

53 195 917 392 397

54 325 375 309 301

55 413 472 498 472

56 179 907 704 328

57 180 269 219 249

58 206 490 309 359

59 255 413 335 318

60 380 555 476 437

61 226 494 309 317

62 370 385 423 388

63 265 627 409 388

64 163 228 259 245

65 302 709 634 595

66 274 550 307 377

67 250 477 386 456

68 383 635 461 456

69 291 666 377 411

70 430 636 627 417

71 236 561 329 307

72 248 345 330 248

110 200 538 266 229

111 258 342 351 276

112 523 774 596 440

Testosterone Concentration Model

Subject (ng/dL) Actual

Predicted

24h Cavg

Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +90 min (ng/dL)

113 283 715 531 408

114 260 612 330 242

115 231 468 322 389

116 481 394 621 405

117 293 431 335 370

118 261 358 304 311

119 152 355 192 227

120 291 448 314 282

121 383 673 418 440

122 295 310 373 295

123 276 368 264 304

124 113 494 439 311

125 245 444 370 307

126 421 524 403 499

127 313 626 385 371

128 238 952 453 432

129 256 499 291 380

130 175 344 275 278

131 199 472 271 303

132 296 301 378 363

133 319 522 352 342

134 274 464 535 346

135 140 626 192 220

136 466 531 566 434

137 449 1200 664 739

138 252 424 337 282

139 330 304 348 440

140 165 252 196 215

141 292 362 338 389

142 306 909 423 473

143 345 269 343 292

144 359 527 544 492

145 399 743 489 449

146 593 1080 1061 696 147 581 448 531 426

148 222 416 217 229

149 231 523 234 301

150 274 551 383 460

151 178 1150 471 411

Testosterone Concentration Model

Subject (ng/dL) Actual

Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +90 min (ng/dL)

152 176 775 368 312

153 346 667 521 491

154 221 265 340 259

155 236 771 330 361

156 257 558 339 358

157 146 309 238 295

158 241 341 263 304

159 199 528 363 434

160 280 916 564 506

161 370 487 304 417

162 148 380 257 250

163 246 413 329 284

164 263 510 432 349

165 178 421 235 275

166 393 770 466 432

167 193 475 293 246

168 148 262 228 214

169 120 368 212 217

170 262 616 296 307

171 369 606 441 366

172 394 598 409 415

173 289 475 480 396

174 282 427 343 329

175 225 524 411 336

176 255 864 649 544

177 212 531 304 344

178 203 253 185 201

179 488 516 384 560

180 247 546 336 425

181 206 396 309 280

182 134 468 264 252

183 401 663 452 368 184 253 282 272 329

185 252 584 324 352

186 314 750 465 494

187 370 425 520 378

188 368 392 290 342

189 241 234 343 251

190 229 390 422 379

Testosterone Concentration Model

Subject (ng/dL) Actual

Predicted

24h Cavg Number Time From Morning Dose 24h Cavg

(ng/dL)

-1 hr +90 min (ng/dL)

191 333 695 439 526

192 217 695 271 360

193 264 321 330 263

194 382 564 352 479

195 283 630 453 344

196 332 531 410 442

197 310 323 379 321

198 194 454 413 327

199 172 290 206 192

200 335 533 295 473

EXAMPLE 21 B Alternative 2-Point Titration Method

Introduction:

The phase III clinical study TBS1 -201 1 -03 (4.5% TBS-1 ) uses an algorithm for titration based on simulated pk profiles.

The results of the phase III PK study shows successful clinical endpoints. Nonetheless, the phase III PK study also shows:

1 - The number of patients switched according to the algorithm (2 point >< 755) set forth in Example 21 A herein was too low and led to low Testosterone levels in the BID to TID group (also it was unfortunate, but random that the baseline T was very low for this group: about 230 ng/dL for close to about 250 patients in the TID only. For reference, Testim patients baseline was close to about 280 ng/dL)

2- BID patients maintained on BID for 90 days had very safe levels and the trigger point could be increased significantly (see also Example 21 C on single point titration); therefore, a single point titration has also been developed, and back calculations were performed and good results were achieved.

3- However, 3 subjects in the BID group did show levels over 1050 ng/dL and would therefore potentially require "down-titration" to once a day. The 9 hours single- point titration method of Example 1 1 C, though, was less effective at capturing accurately the patients with high levels: Either not all patients were spotted, or a limited number were spotted for titration down.

We therefore re-considered a 2 points titration but with variation of time and/or concentration for titrating the treatment regimen for men using 4.5% TBS-1 .

We discovered that the best was to keep 9 hours a first sampling point after the evening dose (about 7am the next morning) was to vary S2 (2^nd sampling point) to close to 1 1 to

1 1 .5 hours after the evening dose (about 9 am to 9:30 am). Amongst other things, this modified 2-point titration method was able to capture patients with a need to be down titrated under 1050ng/dL (from BID to QD; in fact, amongst the 306 patients enrolled, only one patient, possibly 2, needed to be down titrated to QD).

We also analyzed the surface of response of the 3 populations of patients treated: a- Properly titrated;

b- Titrated while they should not have been (titrated wrong or over titrated); and c- Not titrated while they should have been (under titrated).

90 Compleo: Investigation of ^ titration Sl= 9hs

9.Ξ 10 10.Ξ 11 11.5 12 12.S 13 13.5

S 2 Time {Hours}

We also changed the trigger concentration (addition of the 2 points as per original Compleo P ill protocol, as discussed in Example 21 A).

We then analyzed the surface response of the 3 groups versus time and Cone, and plotted these as a resulting percentage of patients (from total N in BID at 30 days).

Table 21 B

Compleo titration Surface response analysis: Titrated wrong (over)

time of S2

Compleo Surface response nalysis:

Good titration { subjects)

time for $2 Compleo Titration surface analysis: NOT

titrated wrong (under)

time of S2

The purpose of this improvement is to preferably keep the number of Not Titrated patients wrong as low as possible, without preferably titrating more than 25% of the patients. It is believed that a 25% titrated wrong would lead to about 45% patients being switched from BID to TID, about one (1 ) % being switched from BID to QD and about 4% being missed, (the rest would be properly BID treated).

According to this improved 2-point titration method, the optimal combined surface is printed in yellow in Table 21 B above in this Example 21 B.

The optimal region therefore will be a S2 point (S1 being about 9 hours from the evening dose adminstered at about 10 pm the evening before) being at about 1 1 to 1 1 .5 hours after the same evening dose or at between about 9:00 am and 9:30 am the next morning, and a trigger added concentration (C @ S1 + C @ S2) between 815 and 835 ng/dL to adjust or titrate the treatment regimen. If the T level is below the range of between 815 and 835 ng/dL, the patient should be titrated to a TID treatment regimen and if the T level is above the between 815 and 835 ng/dL, the patient should continue with a BID treatment schedule. The remaining parts of the algorithm are the same as the two-point titration method described in Example 21 A, except a down titration from BID to QD, if the testosterone concentration value determined for C1 1 hours is > 1900 ng/dL.

EXAMPLE 21 C

Single-Point Titration: Bullet points, Data analysis and graphs

A single-point titration method is developed that is based on simulations and the 2-point titration method described in Example 21 A.

The placement of the single titration point was based on a balance of safety versus success rate, and with attempt to have a maximal amount of good titration and a balance if not titrated or titrated wrong

Compleo titration analysis: titration %

correctness versus trigger concentration

Correct titration

HIHUnder titrated

····:¾ Ov« titrated i )

720 740 760 780 800

Trigger concentration {ng/DL*2)

Chosen value is 755ng/DL in an effort to minimize over-titration. The correlation is quite good. The single-point value is about 280 ng/dl. Compleo : Correlation between titration

points 755 and real Cavg at Day 30

0 500 1000 1500 2000 2500 3000 3500

Titration points summ

However, 2 key point:

-The full data set for TID without titration did show SAFETY and EFFICACY

-1 point titration may be acceptable

Several testing single points (see also Wayne's graph) 3, 6, 9, 10.66, 1 1 and 9 hours from evening dose administered, for example, at 10 pm have been analyzed.

A single-point at 9 hours from evening dose, at about 7:00 am the next morning, is one preferred method, as it represents the morning pre-dose sample.

The relation between trigger concentration and titration adequateness is then challenged

Compleo TRT Day 30 review of potential 9

hours testing for Testosterone Titration

43 Correct titration {%)

-♦" Under titrated { } Over titrated (%}

ISO 200 220 240 260 280 300 320

9 hours trigger T concentration {ng/dL)

Correlation was similar:

We then selected patients that may have been wrongfully titrated to determine: (1 ) safety (Cmax); and (2) Dose increase from BID to TID (Cavg)

The Analysis of data shows on group TID, a slight increase in C_max and a more significant increase in AUC (and therefore C_avg).

The success rate is also analyzed for REAL patients on BID according to the 9 hours single-point 280 algorithm, as well as from the mixed data from REAL (when they were available) and simulated (from the ANOVA).

The results are summarized in Table 21 C as follows:

The rates of success using 280ng/dl a target point in the single-point titration method for the 4.5% intranasal testosterone gel are more acurate than the actual 755 study 2- points described in Example 21 A.

Table 21 C

77 107 71.96262 for BID to TID

n n total

85 98 86.73469 for BID

162 205 79.02439 for both BID and BID to TID

84.59775 g

Example 22

CLINICAL

Efficacy

The sponsor has completed the efficacy portion of its Phase III study evaluating the efficacy and safety of 4.5% TBS-1 when administered BID and TID. Patients in the BID arm that did not meet the titration model criteria based on PK blood draw on Day 30, were switched to the TID administration regimen on Day 45. The primary efficacy endpoint was the proportion of subjects with an average serum concentration of testosterone at Day 90 within the normal range. A total of 274 men completed the efficacy portion of the study and the results have met the primary efficacy endpoint. Safety

6 months of safety data from > 200 patients and 1 year of safety data from 50 patients is under study. Preliminary data is available for over 200 subjects with 6 months data and 25 patients with 1 year data is included. See Draft Label herein. Titration Mechanism

Based on a simulated titration model from data obtained from Phase II clinical studies, a two-point titration scheme on Day 30 in the Phase III pivotal study protocol that allowed prediction of the requirement subjects to titrate from BID dosing to TID dosing. This titration scheme was very effective (72% overall success rate; with less than 12% not titrated when needed) in correctly predicting appropriate Day 90 testosterone levels. See Example 1 1 A. See also Examples 1 1 B-1 1 C.

Analysis of the Phase III data demonstrated that a single point titration at Day 30 with prediction success levels for appropriate Day 90 testosterone concentrations is higher than the two-point scheme. See Example 1 1 C.

Label

A draft of the proposed Package Insert is provided in this Example 14 below.

Warnings and Precautions

Administration of 4.5% TBS-1 under asymptomatic, symptomatic and symptomatic but treated conditions of allergic rhinitis demonstrated a reliable increase in testosterone serum concentrations under all three treatment conditions. 4.5% TBS-1 bioavailability during the symptomatic state of allergic rhinitis was 21 % lower compared to the asymptomatic state, based on AUCo-24 values. The relative decrease in bioavailability of 4.5% TBS-1 under symptomatic seasonal rhinitis was neither ameliorated nor aggravated by the administration of oxymetazoline.

Drug Product

The product, TBS-1 , is a bioadhesive intranasal gel containing 4.5% testosterone administered as a single dose into each nostril. The drug product is formulated with the following compendial inactive ingredients: castor oil, oleoyl polyoxylglycerides, and colloidal silicon dioxide, a repeat dose toxicology study in male rabbits and local tolerance studies in 2 species (rabbits and rats) to support the safety of this excipient for an intranasal preparation have been performed.

Viscosity

The viscosity of the gel packaged in the dispenser is measured using a Brookfield viscometer, equipped with a S06 spindle, with a rotation speed of 50rpm at 20 °C ±1 °C.

Table 3: Viscosity Results of TBS-1 11.0mg/dose Phase III Batches at Room Temperature (25^/60%ΒΗ)

The viscosity results of the TBS-1 for all 3 pivotal batches show similar viscosities between the batches as well as at different stability time points. There is an increasing trend in the viscosity from the initial time point to 18 months real time at room temperature conditions. This difference does not impact the performance of the gel stored in the multidose dispensers in terms of delivered dose uniformity, diffusion rate and degradation products. In particular, the delivered dose data at the initial time point and throughout the stability studies establish that, even with the slight increase in the apparent viscosity of the gel, the data meets the acceptance criteria as per USP <601 >. Albeit the DDU data is generated using a validated HPLC method, the weights of the actuations and doses have also been monitored throughout the stability studies and these concur that the change in viscosity does not influence the potency and delivered dose uniformity of the gel.

In addition, moisture levels (in terms of water by Karl Fischer titration) were monitored and was found these to be between 0.3% and 0.4% at 18 months time point. No net fill weight gain or loss for the multiple dose dispensers during the stability studies were observed, thus indicating these dispensers to be providing sufficient protection for the gel against moisture uptake. Based on the stability study results, a viscosity specification as a lower limit of NLT 5000 mPa.s may be applied to the bulk gel and finished product at a release testing. A lower limit for the viscosity specification is believed to be necessary to control batch consistency for all future manufactured batches. An upper limit for the viscosity specification will not be applied based upon the stability data since it i sbelieved that the increase in viscosity does not impact the potency, purity and release rate of the delivered dose.

Franz Cell

In vitro release testing for the TBS-1 is based on modified Franz diffusion cells fitted with synthetic membranes. The formulation is applied to one side (upper side) of the membrane in the open donor chamber of the diffusion cell and the receptor medium is placed on the other side of the membrane in a receptor cell. Diffusion of the drug from the gel and across the membrane is monitored by assay of sequentially collected samples of the receptor medium.

The membrane selected for the diffusion cell has an inert holding surface for the nasal gel formulation but does not act as a barrier. From the commercially available synthetic membranes, Durapore HVL membrane (0.45μιτι pore size, diameter 25mm) was chosen for its acceptable reproducibility, pore size, and compatibility with the receptor medium. This membrane also offers the lowest diffusion resistance, as a high porosity and minimal thickness and furthermore does not exhibit drug binding and no interaction with the receptor medium. The selection of the receptor medium was based on the testosterone solubility and stability in the medium. An acceptable receptor medium provides sink conditions and drug stability throughout the in vitro release test. In addition, for an in vitro drug release test, a requirement is that the percentage of drug release is less than 30% of the drug placed in the donor chamber. The relationship of the cumulative amount released versus the square root of time is derived from the Higuchi model with the assumption that there is a reservoir of the drug always available to diffuse through. The receptor medium selected is a mixture of ethanol/water in a 1 :1 ratio.

Multiple sampling times (6 time points) were selected over a period of 6 hours to generate an adequate release profile and to determine the drug release rate. The sampling times selected are 1 h, 2h, 3h, 4h, 5h and 6h intervals. An aliquot is removed at each sampling interval from the receptor cell, and reconstituted with the receptor medium to ensure the membrane remains in contact with the receptor medium over the experimental time period. Each aliquot is then analysed using a HPLC assay method to determine the testosterone concentration and the amount of testosterone released.

The in vitro release rate is calculated from the plot of the amount of testosterone released per unit membrane area ^g/cm²) versus the square root of time, yielding a straight line. The slope or regression line represents the release rate of testosterone. For each batch of TBS-1 Testosterone nasal gel, the product was tested and the release rate calculated. The three phase III batches have been tested using the modified Franz cell release rate method and the results of the Amount Released ^g/cm²) at a given time (t1 , t2) are summarized in Table 4 for the initial and 18 months time point.

Table 4 Summary of Release Rate Profile TBS-1 Testosterone Nasal gel ll.Omg/dose, Batch 2372, 2373 &

2374 at Time 0 and at 18 Months Stability Time point 25C/65%RH

Figure 1: Diffusion Rate Comparison of TBS-1 Mean Amount Released ^g/cm²) vs Time

q . o me

In addition, the in vitro release comparison test as outlined in the FDA guidance document "Scale-up and Post Approval Changes: Chemistry, Manufacturing and Controls; In Vitro Release Testing and In Vivo Bioequivalence Documentation" was performed by assigning the Reference (R) as batch 2372 at time 0, and the Test (T) batch being the additional two batches and stability samples.

A 90% confidence interval for the ratio of the median release rate for the Test batch over the median release rate of the Reference batch is calculated and the results should fall within the limits of 75% to 133.33% for no further in vitro testing.

The release rate for the six cells for the Reference batch and the Test batch were used to calculate the T/R ratios, as summarized in Table 5. The 90% confidence interval was calculated and the acceptance criteria as outlined in the FDA guidance document described above applied to each Test batch.

The results for the release rates for all the batches in the stability program, all pass the first stage of the in vitro release comparison test with no further in vitro testing being necessary. All these ratios fall within the range of 75% to 133.33%.

Table 5: Summary of the Slope of the Actual Amount (mean, in μ₉ cnr) and

Confidence Intervals, Upper and Lower

CI Upper - 101.98 107.25 89.33 89.24 86.34

Based on the above results, the diffusion rate meets the FDA guidance requirements in terms of sameness.

Table: Nonclinical Studies

Rabbit (New 3.4 mg of TBS-1 (right nostril) 100304/3.5%

Zealand White); or 0.1 ml of Mygliol* (left

nostril)

3 males

[single dose]

Repeat Dose Local Rat (Sprague 3.4 mg of TBS-1 (right nostril) 100304/3.5%

Tolerance Dawley); or 0.1 ml of Mygliol* (left

nostril)

3 males

[14 days/daily]

Rabbit (New 3.4 mg of TBS-1 (right nostril) 100304/3.5%

Zealand White); or 0.1 ml of Mygliol* (left

3 males nostril)

[14 days/daily]

Summary of Findings

Data to support the efficacy of TBS-1 are derived from the Phase III clinical study TBS- 1 -201 1 -03. Trial TBS-1 -201 1 -03 was a Phase III open label titration study to evaluate the effectiveness and safety of intranasal testosterone in hypogonadal men. The study was conducted at 39 sites in the United States.

Per the FDA, in order to be considered an effective treatment at least 75% of subjects should achieve an average total T concentration in the normal range (Primary Efficacy Variable), with the lower bound of the 2-sided 95% confidence interval no less that 65% (Secondary Efficacy Variable). Overall, the study met the primary endpoint for both BID and TID on a per protocol basis with 75% and 77% of patients respectively achieving testosterone levels in the normal range (95% CI : 71 %-81 %). Furthermore, C_max levels were in line with the FDA requirements.

Study TBS-1 -2011-03 - Primary Efficacy and Safety Study

Treatment Regimen

Patients were randomly assigned in a 3:1 ratio to 1 1 mg TBS-1 BID or 1 1 mg TBS-1 TID. On Day 30, patients underwent a 24-hour pharmacokinetic evaluation to determine the 24-hour C_aVg of serum total testosterone. Men in the BID group were titrated to the TID group if their estimated 24 hour C_avg was below 300 ng/dL. The estimated 24 hour C_avg was based on the sum of serum total testosterone levels collect at 2 sampling points (1 hr before the morning 0700h dose and 20 minutes after the morning 0700h dose) during the 24 hour PK profile.

Primary Efficacy

The primary efficacy endpoint for the study was the 24-hour average concentration (C_aVg) for total testosterone in the defined normal range (>300 ng/dL and <1050 ng/dL). The 4.5% TBS-1 gel is considered to have achieved this endpoint if >75% of the subjects had a C_avg within the normal range, with the lower bound of the 2-sided 95% confidence interval no less than 65% on Day 90.

The following secondary efficacy endpoints were evaluated at day 90 (unless otherwise noted):

• Cmax <1500 ng/dL in >85% of subjects

• Cmax 1800 to 2500 in <5% of subjects

• Cmax >2500 ng/dL in no subjects

• Time Cavg within the normal range

• To determine the effect of TBS-1 treatment on body composition (total body

mass, lean

• body mass, fat mass, and percent fat) at Day 180 and 360

• To determine the effect of TBS-1 treatment on bone mineral density (lumbar

spine and

• hip) Day 180 and 360

• To determine the effect of TBS-1 treatment on mood

• To determine the effect of TBS-1 treatment on erectile function; and

• To determine the serum concentration and pharmacokinetics (PK) of total

testosterone,

dihydrotestosterone (DHT), and estradiol after TBS-1 administration.

Table 7 summarizes subject disposition for the 90-day Treatment Period of the study. In total, 306 subjects were randomized (228 subjects to TBS-1 BID and 78 subjects to TBS-1 TID). In total, 32 (10.5%) subjects discontinued the study during the Treatment Period. The primary reason for discontinuation during the Treatment Period was subject withdrawal of consent (18 [5.9%] subjects). In total, 274 (89.5%) subjects completed the 90-day Treatment Period.

Subject Disposition - Randomized Population

Table 8 summarizes demographic and baseline characteristics for the Randomized Population.

In total, there were 306 (100.0%) male subjects. The majority of subjects were White/Caucasian race (88.6%). The mean age of subjects at the time of informed consent was 54.4 years. The mean weight at screening was 93.34 kg, mean height was 177.1 cm, and mean BMI was 29.69 kg/m². In total, 71 .6% of subjects had primary hypogonadism, and 28.4% had secondary hypogonadism. The mean duration of hypogonadism was 4.6 years. In general, the treatment groups were comparable with respect to demographic and baseline characteristics.

Table 8: Demographic and Baseline Characteristics - Randomized Population

Mean (SD) 177.1(7.61) 177.2 (5.89) 176.9 (6.64) 177.1(6.91)

BMI at Screening (kg/m²)

n 143 85 78 306

Mean (SD) 29.34 (3.652) 30.07 (3.760) 29.89 (3.237) 29.69 (3.585)

BMI Category - n (%)

BMI <30 kg/m² 78 (54.5) 44 (51.8) 43(55.1) 165 (53.9)

BMI >30 kg/m² 65 (45.5) 41 (48.2) 35 (44.9) 141(46.1)

Hypogonadism Etiology - n %)

Primary 111(77.6) 56(65.9) 52 (66.7) 219 (71.6)

Secondary 32 (22.4) 29 (34.1) 26(33.3) 87 (28.4)

Testosterone Therapy at Visit 1 - n (%) [1]

Naive 105 (73.4) 63(74.1) 56(71.8) 224(73.2)

Injection 21 (14.7) 8 (9.4) 10(12.8) 39(12.7)

Oral 1 (0.7) 0 (0.0) 2 (2.6) 3(1.0)

Topical 17 (11.9) 14(16.5) 9(11.5) 40(13.1)

Buccal 0 (0.0) 0 (0.0) 1(1.3) 1 (0.3)

Previous Treatment for Naive Subjects - n (%) [1

None 64 (44.8) 34 (40.0) 32 (41.0) 130 (42.5)

Injection 15(10.5) 15(17.6) 11(14.1) 41 (13.4)

Oral 2(1.4) 3(3.5) 1(1.3) 6 (2.0)

Topical 25(17.5) 13(15.3) 13(16.7) 51 (16.7)

Buccal 1 (0.7) 3(3.5) 1(1.3) 5(1.6)

Duration of Hypogonadism years) [2]

N 143 85 78 306

Mean (SD) 4.2(3.52) 5.1(4.71) 5.0(5.67) 4.6 (4.49)

Qualifying Fasting Serum Total Testosterone during Screening (ng/dL)

N 143 85 78 306 Mean (SD) 200.71 (67.5) 192.25 (68.6) 210.35 (51.5) 200.82 (64.3)

1. More than 1 option could be selected.

2. Duration of Hypogonadism was calculated by the year of informed consent - the year of diagnosis + 1.

BID = twice daily; BMI = body mass index; SD = standard deviation; TID = three times daily

Analysis of Primary Endpoint

The primary assessment of efficacy, as agreed to at the EOP2 meeting, was based on the proportion of subjects with Cavg (0-24h) total testosterone within the normal range (300 - 1050 ng/dL) on Day 90 of the trial. In order to be considered an effective treatment, this proportion was pre-defined to be >75%, with the lower bound of the 95% confidence interval > 65%. As per the SAP, the primary endpoint is evaluated based on ITT and PP. Overall, the study met the primary endpoint for both BID and TID on a per protocol basis.

Of the 273 patients who completed the 90-Day treatment period, 71 % (86/122) receiving 22 mg of testosterone daily and 76% (1 14/151 ) receiving 33 mg of testosterone daily had C_avg within the normal range at Day 90 as presented in Table 9. The pharmacokinetic profile of TBS-1 is presented in Figure 2.

Table 9: Proportion of Subjects with Serum Total Testosterone C_avg in the

Range of 300 - 1050 ng/dL of all Patients who Completed the 90 Day Treatment

* All subjects in TID group at Day 90, includes titration group

** Did not require titration

Figure 2: Mean Serum Testosterone Concentrations on Day 90 in Patients

Administered TBS-1 BID and TID

Treatment TBS- 1 BID Combined TBS— I TID

Program Name: figures add2.sas Run Date: 07JAN2013 1 1 :12 Database Last Modified; 1 3N0V2012 16:29

Time 0 corresponds to 2100

Of the 274 patients who completed the 90-day treatment, 237 patients did so with no deviation from the protocol. Protocol deviations included subjects who didn't meet inclusion/exclusion criteria, took prohibited medications that interfered with testosterone metabolism and were either inappropriately titrated or not titrated up when necessary. On Day 90, average serum testosterone concentration was within normal range for 75% of subjects receiving 22 mg TBS-1 and in 77% of subjects receiving 33 mg 4.5% TBS-1 . Table 10 summarizes the testosterone concentration data in the patients who completed 90 days. 10: Proportion of Subjects with Serum Total Testosterone C_avg in the Range of 300 - 1050 ng/dL of all Patients who Completed the 90 Day Treatment Per Protocol

All subjects in TID group at Day 90, includes titration group

** Did not require titration

Analysis of Secondary Endpoints

The secondary endpoints were the percentage of patients with C_max above 3 predetermined limits as per the guidance from the Division on October 23, 2010. In all the subjects having at least 1 24- hour PK value, the percentages of patients with maximum serum testosterone concentration (C_max) less than 1500 ng/dL was 88.6% and between 1800 and 2499 ng/dL on Day 90 was 3.3%. 1 patient had a C_max >2500 ng/dL on Day 90 (3070 ng/dL). This subject was considered a protocol violator as he was taking Avodart, a dual 5-a reductase inhibitor that inhibits conversion of testosterone to dihydrotestosterone (DHT). Data are presented in Table 1 1 .

The proportion of subjects with C_max greater than 1500 ng/dL is within FDA's guidelines for testosterone replacement products.

Table 11 : Secondary Serum Total Testosterone Pharmacokinetic Endpoints

TITRATION

On Day 30, PK blood samples were collected to determine the 24 hour C_avg and serum testosterone levels. Subjects in the BID group were titrated to the TID group if their estimated 24 hour C_avg was below 300 ng/dL. A titration scheme was designed, based on a simulated titration model from data obtained from Phase II clinical studies, to predict C_avg values and separate those with C_avg above and below 300ng/dl_ at day 30. The estimated 24 hour C_avg was based on the sum of serum total testosterone levels collected at 2 sampling points during the 24 hour PK profile (1 hour before the morning 0700h dose and 20 minutes after the morning 0700h dose). If the sum of the two serum total testosterone levels were <755 ng/dL, then the estimated 24-hour C_avg <300 ng/dL and if the sum of the two serum total testosterone levels >755 ng/dL, then the estimated 24-hour C_avg is >300 ng/dL. This titration scheme was very effective (72% success rate) in correctly predicting appropriate Day 90 testosterone levels.

As part of the study analysis, the data was reviewed to determine if it was possible to define a better titration scheme, using either a single sample. We have evaluated single points across the pharmacokinetic profile and the likelihood that this sampling point would predict the eventual 24 hour C_avg value and would result in a correct titration decision.

Figure 3: Percentage of subjects at each time point with a correct titration

decision

Time of blood draw (hours}

Due to the unique pharmacokinetic profile, the analysis centered on not only a given time point at which the sample should be taken but also the "trigger concentration" at each individual time point that best predicts the need for titration. Only the time points and trigger concentrations that had a higher success percentage than the current two- point titration scheme were considered for further analysis.

Based on the safety and pharmacokinetic data, subjects that were achieving acceptable testosterone replacement on a BID regimen and for which titration was predicted, although not required, did not show any supra-physiologic levels for testosterone and did not demonstrate that the dose was too high, meaning there is little safety concern with titrating patients to TID when they were achieving acceptable testosterone levels on BID treatment. The selected titration point and trigger concentration with the lowest number of subjects that were not titrated when required and had too low a dose was determined. This analysis identified the point immediately prior to the morning dose and at least 9 hours after the evening dose as a suitable single point at a trigger concentration of 280 ng/dL. A review of the Day 90 pharmacokinetic data from this study confirms that at this single-point with the 280ng/dl_ trigger concentration, predicts the C_aVg at Day 30 for 80% of the subjects in the study as opposed to 72% with the two point scheme. The one-point titration scheme is further described in Example 1 1 C. SAFETY

Safety data from the Phase III study shows the 4.5% TBS-1 has a favourable safety profile. Six subjects had a total of 9 SAEs reported during the study. None were classified as related to the study drug. During the Treatment Period, 153 (50.0%) subjects had a treatment-emergent adverse event (TEAE): 67 (46.9%) subjects in the TBS-1 BID group, 86 (52.7%) subjects in the TBS-1 TID group. In total, 86 (28.1 %) subjects had a TEAE that was considered by the Investigator to at least be possibly related to study drug during the Treatment Period: 32 (22.4%) subjects in the TBS-1 BID group, 54 (33.1 %) subjects in the TBS-1 TID group. Most of the TEAEs during the Treatment Period were mild or moderate in severity.

4.5% TBS-1 was well tolerated locally in the nasal mucosa across all treatment groups. The majority of application site adverse events was mild in intensity and didn't lead to study drug discontinuation or interruption. The most frequent drug related local adverse events were rhinorrhoea and epistaxis reported by 4.2 and 3.3% of subjects respectively after 90 days of treatment. This relatively low percentage showed a further decrease to 1 .5% after 180 days of treatment for both events.

The safety profile of TBS-1 is similar to that of other testosterone replacement therapies. In comparison with other marketed testosterone replacement therapies, fewer subjects experienced increases in hematocrit, hemoglobin and PSA levels. No decreases in hemoglobin were observed.

Common Adverse Events

Safety data from the Phase III treatment period is presented in Table 12 and Table 13. The data from the safety extension is presented in Table 14 and Table 15. The most common treatment emergent adverse events were rhinorrhoea, epistaxis, nasal discomfort, nasal congestion, nasal dryness, nasopharyngitis upper respiratory infections, back pain and parosmia.

Table 12: Summary of Treatment-Emergent Adverse Events (>2% of Subjects per Treatment Arm) by System Organ Class and Preferred Term - Safety Population - Treatment Period - Day 90 TBS-1

TBS-1 BID BID/TID TBS-1 TID

System Organ Class

Total

(N=143) (N=85) (N=78) (N=306)

Preferred Term

n (%) n (%) n (%) n (%)

Subjects with any TEAE 64 (44.8) 38 (44.7) 45 (57.7) 147 (48.0)

Gastrointestinal disorders 2 (1.4) 3 (3.5) 4 (5.1) 9 (2.9)

Nausea 1 (0.7) 1 (1.2) 2 (2.6) 4 (1.3)

Retching 0 (0.0) 2 (2.4) 0 (0.0) 2 (0.7)

General disorders and

administration site

conditions 1 (0.7) 5 (5.9) 3 (3.8) 9 (2.9)

Chills 0 (0.0) 1 (1.2) 2 (2.6) 3 (1.0)

Pyrexia 0 (0.0) 1 (1.2) 2 (2.6) 3 (1.0)

Infections and infestations 15 (10.5) 9 (10.6) 14 (17.9) 38 (12.4)

Nasopharyngitis 4 (2.8) 4 (4.7) 3 (3.8) 11 (3.6)

Bronchitis 2 (1.4) 0 (0.0) 3 (3.8) 5 (1.6)

Tooth abscess 0 (0.0) 1 (1.2) 3 (3.8) 4 (1.3)

Upper respiratory tract

infection 1 (0.7) 0 (0.0) 3 (3.8) 4 (1.3)

Sinusitis 0 (0.0) 0 (0.0) 3 (3.8) 3 (1.0)

Injury, poisoning and

procedural complications 6 (4.2) 2 (2.4) 5 (6.4) 13 (4.2)

Muscle strain 1 (0.7) 0 (0.0) 2 (2.6) 3 (1.0)

Investigations 3 (2.1) 8 (9.4) 12 (15.4) 23 (7.5)

Blood creatine

phosphokinase increased 1 (0.7) 2 (2.4) 2 (2.6) 5 (1.6)

Prostatic specific antigen

increased 0 (0.0) 2 (2.4) 3 (3.8) 5 (1.6)

Blood pressure increased 0 (0.0) 1 (1.2) 2 (2.6) 3 (1.0)

Blood thyroid stimulating

hormone increased 1 (0.7) 0 (0.0) 2 (2.6) 3 (1.0) Musculoskeletal and

connective tissue disorders 11 (7.7) 4 (4.7) 7 (9.0) 22(7.2)

Back pain 4 (2.8) 1(1.2) 2(2.6) 7(2.3)

Arthralgia 0 (0.0) 0 (0.0) 2(2.6) 2 (0.7)

Myalgia 0 (0.0) 0 (0.0) 2(2.6) 2 (0.7)

Nervous system disorders 10 (7.0) 5 (5.9) 8(10.3) 23 (7.5)

Parosmia 4 (2.8) 2 (2.4) 2(2.6) 8(2.6)

Headache 2(1.4) 0 (0.0) 3 (3.8) 5(1.6)

Dysgeusia 1 (0.7) 1(1.2) 2(2.6) 4(1.3)

Respiratory, thoracic and

mediastinal disorders 29 (20.3) 20 (23.5) 16(20.5) 65 (21.2)

Rhinorrhoea 8(5.6) 6(7.1) 2(2.6) 16(5.2)

Epistaxis 4 (2.8) 4 (4.7) 3 (3.8) 11(3.6)

Nasal discomfort 6 (4.2) 2 (2.4) 3 (3.8) 11(3.6)

Nasal congestion 5(3.5) 3(3.5) 2(2.6) 10(3.3)

Nasal dryness 3(2.1) 1(1.2) 2(2.6) 6(2.0)

Nasal mucosal disorder 4 (2.8) 0 (0.0) 0 (0.0) 4(1.3)

Upper airway cough

syndrome 1 (0.7) 2 (2.4) 1(1.3) 4(1.3)

Cough 0 (0.0) 1(1.2) 2(2.6) 3(1.0)

Skin and subcutaneous tissue

disorders 7 (4.9) 4 (4.7) 5 (6.4) 16(5.2)

Scab 1 (0.7) 2 (2.4) 2(2.6) 5(1.6)

/

Table 13: Summary of Drug Related Adverse Events (>2% of Subjects per

Treatment Arm) by System Organ Class and Preferred Term - Safety Population - Treatment Period - Day 90 TBS-1

TBS-1 BID BID/TID TBS-1 TID

System Organ Class

Total

(N=143) (N=85) (N=78) (N=306)

Preferred Term

n (%) n (%) n (%) n (%)

Subjects with any study drug-

32 (22.4) 28(32.9) 24 (30.8) 84(27.5) related TEAE

Investigations 2(1.4) 5 (5.9) 4(5.1) 11(3.6)

Prostatic specific antigen

0 (0.0) 2 (2.4) 1(1.3) 3(1.0)* increased

Musculoskeletal and

1 (0.7) 0 (0.0) 2(2.6) 3(1.0) connective tissue disorders

Myalgia 0 (0.0) 0 (0.0) 2(2.6) 2 (0.7)

Nervous system disorders 5(3.5) 3(3.5) 7 (9.0) 15 (4.9)

Parosmia 3(2.1) 2 (2.4) 2(2.6) 7(2.3)

Dysgeusia 1 (0.7) 1(1.2) 2(2.6) 4(1.3)

Respiratory, thoracic and

20 (14.0) 19 (22.4) 12(15.4) 51(16.7) mediastinal disorders

Rhinorrhoea 6(4.2) 6(7.1) 1(1.3) 13 (4.2)

Epistaxis 3(2.1) 4 (4.7) 3 (3.8) 10(3.3)

Nasal discomfort 4(2.8) 1(1.2) 3 (3.8) 8(2.6)

Nasal congestion 1 (0.7) 3(3.5) 2(2.6) 6(2.0)

Nasal dryness 2(1.4) 1(1.2) 2(2.6) 5(1.6)

Upper-airway cough

1 (0.7) 2 (2.4) 1(1.3) 4(1.3) syndrome

Skin and subcutaneous tissue

4 (2.8) 3(3.5) 3 (3.8) 10(3.3) disorders

Scab 1 (0.7) 2 (2.4) 2(2.6) 5(1.6)

Two subjects were discontinued from the trial after Day 90 due to increase in serum PSA concentration > 1.4 ng/mL above baseline (actual values 4.2 and 2.08 ng/mL). Follow-up care for both subjects included additional PSA testing and urology consults. PSA values showed a decrease after drug discontinuation. One subject, who also experienced an increase in serum PSA concentration > 1.4 ng/mL on Day 90 (3.15ng/mL) interrupted study drug for 2 weeks and was re-challenged after. His PSA returned to baseline values (0.72 ng/mL) after de-challenge and was reported as 0.87 ng/mL on Day 360.

Table 14: Summary of Treatment Emergent Adverse Events (>2% of Subjects per

Treatment Arm) by System Organ Class and Preferred Term - Safety Population - at Day 180 and 360 a) Day 180

Respiratory tract congestion 2(2.1) 0 (0.0) 2(1.0)

Skin and subcutaneous tissue

5(5.2) 1 (0.9) 6(2.9) disorders

Scab 2(2.1) 0 (0.0) 2(1.0)

Bursitis 0 (0.0) 1(5.9) 1 (3.8)

Musculoskeletal pain 1(11.1) 0 (0.0) 1 (3.8)

Nervous system disorders

1(11.1) 1(5.9) 2(7.7)

Parosmia 1 (11.1) 1(5.9) 2(7.7)

Renal and urinary disorders 1(11.1) 1(5.9) 2(7.7)

Nephrolithiasis 1(11.1) 0 (0.0) 1 (3.8)

Urine flow decreased 0 (0.0) 1(5.9) 1 (3.8)

Respiratory, thoracic and

1(11.1) 2(11.8) 311.5) mediastinal disorders

Epistaxis 0 (0.0) 1(5.9) 1 ( 3.8)

Nasal dryness 00.0) 1(5.9) 1 (3.8)

Rhinorrhoea 1(11.1) 0 (0.0) 1 (3.8)

Skin and subcutaneous tissue

1(11.1) 15.9) 2(7.7)

disorders

Scab 1 (11.1) 1(5.9) 2(7.7)

Skin fissures 1(11.1) 0 (0.0) 1 (3.8)

Vascular disorders 0 (0.0) 1(5.9) 1 (3.8)

Hypertension 0 (0.0) 1(5.9) 1 (3.8)

Table 15: Summary of Drug Related Adverse Events (>2% of Subjects per

Respiratory, thoracic and

13(13.5) 4(3.7) 17 (8.3) mediastinal disorders

Nasal discomfort 5(5.2) 2(1.8) 7 (3.4)

Nasal mucosal disorder 2(2.1) 0 (0.0) 2(1.0)

Rhinorrhoea 3(3.1) 0 (0.0) 3(1.5)

Skin and subcutaneous tissue

4(4.2) 1 (0.9) 5 ( 2.4) disorders

Scab 2(2.1) 0 (0.0) 2(1.0)

Nasal Tolerability

Monthly ENT examinations were performed. As presented in Table 16, 4.5% TBS-1 was well tolerated locally in the nasal mucosa across all treatment groups.

Table 16: Summary of ENT Examination and Nasal Endoscopy Results by Treatment

"Other symptoms and findings reported were slight intermittent soreness, alteration of smell, small scab on nostril, erythema at posterior septum, obstruction, and intermittent increased secretion. Summary of Digital Rectal Exam by Treatment

Per Table 17, no changes were observed in the digital rectal exam over the duration of the treatment period and the safety extensions.

Table 17: Summary of Digital Rectal Exam by Treatment

*CS Prostate abnormalities reported at Week -5 were 'small prostate' (subject withdrew consent after V4) and 'enlarged prostate, normal for age' (subject successfully completed the trial with no further increase in prostate size or PSA values reported).

** CS Prostate abnormalities reported on Day 90 were 'internal haemorrhoid' and 'slightly enlarged prostate'. Both subjects completed the trial. No increase in PSA values.

Laboratory Values

Hematology parameters remained stable across all treatment groups and did not demonstrate significant changes from baseline. Data is presented in Table 18.

Table 18: Changes in Laboratory Result from Baseline

No significant changes from baseline were observed in the lipid profile of HDL, LDL and triglycerides. Results are presented in Table 19. In addition, no significant changes from baseline were observed in mean PSA values as presented in Table 20 . Table 19: Changes in Lipid Values

Deaths, Other Serious Adverse Events, and Other Significant Adverse Events

One subject in the TBS-1 TID group died during the Treatment Period as a result of internal injuries sustained from a motorcycle accident. This SAE was classified as definitely unrelated to the study drug.

Six (6) subjects had a total of 9 SAEs: 3 subjects in the TBS-1 BID group and 3 subjects in the TBS-1 TID group. None were classified as related to the study drug. Study TBS-1 -2011-04 - Supportive Interaction and Extrinsic Factor Study

A Drug-Drug Interaction study (TBS-1 -201 1 -04) is completed. Trial TBS-1 -201 1 -04 was an extrinsic factor study to evaluate whether intranasal application of testosterone is a reliable route of administration during naturally occurring nasal inflammation such as allergic rhinitis and to investigate the potential interaction of TBS-1 with a nasal decongestant spray, oxymetazoline. The study was conducted at one site in Germany. Treatment Regimen

Subjects were randomly assigned to a treatment sequence comprised of TBS-1 when they were asymptomatic, symptomatic and untreated and symptomatic and treated with oxymetazoline nasal spray. The symptomatic state was induced by exposure to Dactylis glomerata pollen in an environment exposure chamber (EEC). The symptomatic state was defined by a positive case history, a positive skin prick and/or interdermal test for Dactylis glomerata allergen and a Total nasal Symptom Score (TNSS) of > 6/12 and a congestion score of > 2/3. TBS-1 administration to subjects in a symptomatic and treated arm received oxymetazoline 30 minutes prior to the 07:00 hour dose of TBS-1 and 12 hours after the first administration. All patients received 3 doses of TBS-1 at 07:00, 13:00 and 21 :00 hrs.

Primary Efficacy

Subject Disposition

The 18 treated subjects were healthy subjects with seasonal allergic rhinitis aged between 27 and 44. All 6 subjects in sequence group A completed the study as scheduled. In sequence group B, 4 out of 6 subjects and sequence group C, 5 out of

6 subjects completed the study as scheduled. In total, the number of subjects completing each of the 3 states were: asymptomatic (N=18), symptomatic but treated

(N=17), and symptomatic untreated (N=15). Analysis of Primary Endpoint

Administration of TBS-1 under asymptomatic, symptomatic and symptomatic but treated conditions of allergic rhinitis demonstrated a reliable increase in testosterone serum concentrations under all 3 treatment conditions as presented in Table 21 and Figure 4.

Table 21 : AUC Values for Serum Testosterone by Treatment Condition Including

Non- Corrected Values, Corrected Values and Pre-dose Corrected Values

* Corrected values = uncorrected values - baseline 24 hour

Pre-dose corrected values = PK values were corrected for treatment specific pre-dose levels

Figure 4: Serum Testosterone (ng/dL): Arithmetic Mean Concentration vs.

Time Curve, Linear Scale (PK set)

l⁵ ¾ ¾ * Ό, '¾

Baseiirs ~— —

The testosterone exposure as estimated by the mean baseline-corrected area under the serum concentration-time curve from 0 to 24 hours post-dose AUC₀-24,bc was higher for subjects in the asymptomatic state compared to symptomatic and symptomatic but treated state. An analysis of variance did not demonstrate bioequivalence between the asymptomatic state and either symptomatic and symptomatic but treated state,

TBS-1 bioavailability during the symptomatic state of allergic rhinitis was 21 % lower compared the asymptomatic state, based on AUC₀-2₄ values. However, the post-dose concentrations of testosterone still demonstrate a reliable increase in levels as compared to baseline. The relative decrease in bioavailability of TBS-1 under symptomatic seasonal rhinitis is neither ameliorated nor aggravated by the administration of oxymetazoline.

Additional exploratory analysis revealed that the different treatment conditions influenced the pre-dose value of testosterone. A student t-test showed significant differences in the pre-dose testosterone between the asymptomatic treatment condition compared to the symptomatic and the symptomatic and treated conditions. Subjects were exposed to an EEC in the symptomatic and symptomatic and treated condition but not in the asymptomatic condition. It is hypothesized that the earlier wake up time and/or stress caused by procedures associated with confinement in the EEC may have led to lower testosterone values in both symptomatic states compared to the asymptomatic state. As such, the baseline profile collected under the EEC conditions and used for correction purposes was not truly representative of the non-treated state under all study conditions. The additional analysis corrected for endogenous testosterone by pre-dose values instead of correction by 24-hour baseline profile. This analysis showed that the differences between asymptomatic and both symptomatic treatment conditions were less pronounced with respect to AUCbc, C_avg,bc, and C_max,bc- However, bioequivalence could not be shown between treatment conditions.

Safety

TBS-1 was well tolerated. All reported AEs were of mild or moderate intensity and all were transient. All reported AEs were judged to be not related to treatment with TBS-1 . Physical examination, vital signs and clinical laboratory results did not reveal any clinically significant finding.

DRAFT PACKAGE INSERT

FULL PRESCRIBING INFORMATION: CONTENTS'

1. Indications and Usage 6. adverse reactions

6.1. Clinical Trial Experience

2. Dosage and administration

2.1. Dosing and Dose Adjustment 7. Drug Interactions

2.2. Administration Instructions 7.1. Insulin

7.2. Oral Anticoagulants

3. Dosage forms and strengths

7.3. Corticosteroids

4. Contraindications

7.4. Oxymetazoline

5. Warnings and Precautions

8. Use in Specific Populations

5.1. Worsening of Benign Prostatic Hyperplasia and

8.1. Pregnancy

Potential Risk of Prostate Cancer

8.2. Nursing Mothers

5.2. Polycythemia

8.3. Pediatric Use

5.3. Use in Women

8.4. Geriatric Use

5.4. Potential for Adverse Effects on Spermatogenesis

8.5. Renal Impairment

5.5. Hepatic Adverse Effects

8.6. Hepatic Impairment

5.6. Edema

8.7. Use in Men With Body Mass Index >35 kg/i

5.7. Gynecomastia

9. Drug Abuse and Dependence

5.8. Sleep Apnea

9.1. Controlled Substance

5.9. Lipids

9.2. Abuse

5.10. Hypercalcemia

9.3. Dependence

5.11. Decreased Thyroxine-binding Globulin

10. Overdosage

11. Description 16. How Supplied/Storage and Handling

12. Clinical Pharmacology 16.1. How Supplied

16.2. Storage and Handling

12.1. Mechanism of Action

12.2. Pharmacodynamics 17. Patient Counseling Information

12.3. Pharmacokinetics 17.1. Use in Men With Known or Suspected Prostate

13. Nonclinical Toxicology Breast Cancer

17.2. Potential Adverse Reactions With Androgens

13.1. Carcinogenesis, Mutagenesis, and Impairment of

17.3. Patients Should be Advised of These

Fertility

Administration Instructions

13.2. Animal Toxicology and/or Pharmacology

14. Clinical Studies

14.1. Clinical Studies in Hypogonadal Men

* Sections or subsections omitted from the full prescribing information are not listed

FULL PRESCRIBING INFORMATION

1. INDICATIONS AND USAGE

TBS-1 is an androgen indicated for replacement therapy in males for conditions associated with a deficiency or absence of endogenous testosterone.

• Primary hypogonadism (congenital or acquired): testicular failure due to conditions such as cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, orchiectomy, Klinefelter' s syndrome, chemotherapy, or toxic damage from alcohol or heavy metals. These men usually have low serum testosterone concentrations and gonadotropins (follicle- stimulating hormone [FSH], luteinizing hormone [LH]) above the normal range.

• Hypogonado tropic hypogonadism (congenital or acquired): idiopathic gonadotropin or luteinizing hormone-releasing hormone (LHRH) deficiency or pituitary - hypothalamic injury from tumors, trauma, or radiation. These men have low testosterone serum concentrations but have gonadotropins in the normal or low range.

Important limitations of use— Safety and efficacy of TBS-1 in males <18 years old have not been established (see Use in Specific Populations [8.3]).

2. DOSAGE AND ADMINISTRATION

2.1. Dosing and Dose Adjustment

The recommended starting dose of TBS- 1 (testosterone) is 11 mg of testosterone (2 actuations; 1 actuation per nostril) administered intranasally twice daily for a total daily dose of 22 mg.

To ensure proper dosing, serum testosterone concentrations should be measured after initiation of therapy to ensure that proper serum tersoterone levels are achieved. To ensure proper dosing, the dose should be titrated based on the concentration from a single blood draw prior to the morning dose and at least 9 hours after the evening dose. If the measured serum

concentration is below 280 ng/dL or if the desired clinical response is not achieved, the daily dose may be increased from 22 mg (twice daily administration) to 33 mg (thrice daily administration).

2.2. Administration Instructions

TBS-1 is administered intranasally twice daily at 7 am and 9 pm. Do not administer TBS-1 to other parts of the body including scrotum, penis, abdomen, shoulders, axilla, or upper arms.

When using TBS-1 for the first time, patients should be instructed to prime the pump by depressing the pump 10 times, discard any product dispensed directly into a basin, sink, or toilet and then wash the gel away thoroughly. This priming should be done only prior to the first use of each dispenser. After priming, patients should completely depress the pump 1 time per nostril to dispense 5.5 mg testosterone/nostril (total dose 11 mg).

Keeping the dispenser upright, in front of a mirror, patients should advance the tip of the actuator into the left nostril until the finger on the pump reaches the base of the nose and aim the tip of the actuator to the inner corner of the left eye. The opening on the tip of the actuator must face the skin that lines the inner nose. Depress the pump until it stops and slowly remove the actuator from the nose. Any gel that remains on the tip of the actuator should be wiped using a clean dry tissue. The process is repeated for the right nostril. Once the gel is administered into the nose, the nostrils may be pressed lightly together and massaged for 3 seconds. The patient should refrain from blowing his nose or sniffing for 15 to 30 minutes after administration.

After use, any gel remaining on the dispenser should be removed with a clean dry tissue. Patients should replace the cap on the dispenser for storage. 3. DOSAGE FORMS AND STRENGTHS

TBS-1 is a testosterone intranasal gel available in a dispenser with a metered dose pump. One pump actuation delivers 5.5 mg of testosterone/nostril (total dose 11 mg).

4. CONTRAINDICATIONS

TBS-1 is contraindicated in men with carcinoma of the breast or known or suspected carcinoma of the prostate (see Warnings and Precaution [5.1]).

TBS-1 is contraindicated in women who are or who may become pregnant, or who are breastfeeding. TBS-1 may cause fetal harm when administered to a pregnant woman. TBS-1 may cause serious adverse reactions in nursing infants. If a pregnant woman is exposed to TBS-1, she should be apprised of the potential hazard to the fetus (see Use in Specific

Populations [8.1, 8.2]).

5. WARNINGS AND PRECAUTIONS

5.1. Worsening of Benign Prostatic Hyperplasia and Potential Risk of

Prostate Cancer

• Monitor patients with benign prostatic hyperplasia (BPH) for worsening of signs and symptoms of BPH.

• Patients treated with androgens may be at increased risk for prostate cancer.

Evaluate patients for prostate cancer prior to initiating treatment. It would be appropriate to re-evaluate patients 3 to 6 months after initiation of treatment and then in accordance with prostate cancer screening practices (see Contraindications [4]).

5.2. Polycythemia

Increases in hematocrit, reflective of increases in red blood cell mass, may require lowering or discontinuation of testosterone. Check hematocrit prior to initiating testosterone treatment. It would be appropriate to re-evaluate the hematocrit 3 to 6 months after starting testosterone treatment, and then annually. If hematocrit becomes elevated, stop therapy until hematocrit decreases to an acceptable level. An increase in red blood cell mass may increase the risk of thromboembolic events.

5.3. Use in Women

Due to lack of controlled studies in women and potential virilizing effects, TBS-1 is not indicated for use in women (see Contraindications [4] and Use in Specific Populations [8.1, 8.2]).

5.4. Potential for Adverse Effects on Spermatogenesis

At large doses of exogenous androgens, including TBS-1, spermatogenesis may be suppressed through feedback inhibition of pituitary FSH, which could possibly lead to adverse effects on semen parameters, including sperm count.

5.5. Hepatic Adverse Effects

Prolonged use of high doses of orally active 17-alpha-alkyl androgens (methyltestosterone) has been associated with serious hepatic adverse effects (peliosis hepatitis, hepatic neoplasms, cholestatic hepatitis, and jaundice). Peliosis hepatitis can be a life-threatening or fatal complication. Long-term therapy with intramuscular testosterone enanthate has produced multiple hepatic adenomas. TBS-1 is not known to cause these adverse effects. 5.6. Edema

Androgens, including TBS-1, may promote retention of sodium and water. Edema, with or without congestive heart failure, may be a serious complication in patients with pre-existing cardiac, renal, or hepatic disease.

5.7. Gynecomastia

Gynecomastia may develop and may persist in patients being treated with androgens, including TBS-1, for hypogonadism.

5.8. Sleep Apnea

The treatment of hypogonadal men with testosterone may potentiate sleep apnea in some patients, especially those with risk factors such as obesity and chronic lung disease.

5.9. Lipids

Changes in serum lipid profile may require dose adjustment or discontinuation of testosterone therapy.

5.10. Hypercalcemia

Androgens, including TBS-1, should be used with caution in cancer patients at risk of hypercalcemia (and associated hypercalciuria). Regular monitoring of serum calcium concentrations is recommended in these patients.

5.11. Decreased Thyroxine-binding Globulin

Androgens, including TBS-1, may decrease concentrations of thyroxin-binding globulins, resulting in decreased total T4 serum concentration and increased resin uptake of T3 and T4. Free thyroid hormone concentrations remain unchanged; however, there is no clinical evidence of thyroid dysfunction.

6. ADVERSE REACTIONS

6.1. Clinical Trial Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Clinical Trials in Hypogonadal Men

Table 1 shows adverse reactions considered possibly, probably, or definitely related to TBS-1 that were reported by >1 of patients through Day 180 of the Phase 3 study, in which

96 patients received 22 mg daily and 109 patients received 33 mg daily.

Table 1: Adverse Reactions (>1% in either treatment group) Considered Possibly, Probably, or Definitely Related to TBS-1 Seen With 22 mg Daily and 33 mg Daily Administration of Testosterone Through Day 180

Treatment-emergent adverse reactions considered possibly, probably, or definitely related to TBS-1 that were reported by >1 of patients during the first 90 days of the Phase 3 study included rhinorrhea, epistaxis, nasal discomfort, parosmia, nasal congestion, nasal dryness, scab, dysgeusia, and upper-airway cough syndrome.

Adverse reactions reported among the 26 patients in the final 180-day safety extension period (Days 180 to 360) were similar to those reported during the first 180 days of treatment. Two adverse reactions were reported by more than 1 of the patients during this period: parosmia and scab.

TBS-1 was well tolerated locally in the nasal mucosa.

PSA values increased in 3 men (1.5%) at Day 180. 7. DRUG INTERACTIONS

7.1. Insulin

Changes in insulin sensitivity or glycemic control may occur in patients treated with androgens. In diabetic patients, the metabolic effects of androgens may decrease blood glucose and, therefore, insulin requirement.

7.2. Oral Anticoagulants

Changes in anticoagulant activity may be seen with androgens. More frequent monitoring of international normalized ration and prothrombin time is recommended in patients taking anticoagulants, especially at the initiation and termination of androgen therapy.

7.3. Corticosteroids

The concurrent use of testosterone with adrenocorticotropic hormone or corticosteroids may result in increased fluid retention and should be monitored cautiously, particularly in patients with cardiac, renal, or hepatic disease.

7.4. Oxymetazoline

Concomitant use of oxymetazoline for the relief of allergic rhinitis may lessen testosterone levels by 21%. For patients requiring prolonged use of frequent and/or higher dose

decongestants, temporary dose increases might need to be considered.

8. USE IN SPECIFIC POPULATIONS

8.1. Pregnancy

Pregnancy Category X (see Contraindications [4])— TBS-1 is contraindicated during pregnancy or in women who may become pregnant. Testosterone is teratogenic and may cause fetal harm. Exposure of a female fetus to androgens may result in varying degrees of virilization. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to a fetus.

8.2. Nursing Mothers

Although it is not known how much testosterone transfers into human milk, TBS-1 is contraindicated in nursing women because of the potential for serious adverse reactions in nursing infants. Testosterone and other androgens may adversely affect lactation (see

Contraindications [4]).

8.3. Pediatric Use

Safety and efficacy of TBS-1 has not been established in males <18 years of age. Improper use may result in acceleration of bone age and premature closure of epiphyses.

8.4. Geriatric Use

There have not been sufficient numbers of geriatric patients involved in controlled clinical studies utilizing TBS-1 to determine whether efficacy in those over 65 years of age differs from younger subjects. Of the 306 patients enrolled in the Phase 3 clinical trial utilizing TBS-1, 60 were 65 years of age or older. Additionally, there is insufficient long-term safety data in geriatric patients to assess the potential for increased risks of cardiovascular disease and prostate cancer.

Geriatric patients treated with androgens may also be at risk for worsening of signs and symptoms of BPH.

8.5. Renal Impairment

No formal studies were conducted involving patients with renal impairment.

8.6. Hepatic Impairment

No formal studies were conducted involving patients with hepatic impairment. 8.7. Use in Men With Body Mass Index >35 kg/m²

Safety and efficacy of TBS-1 in males with body mass index >35 kg/m has not been established.

9. DRUG ABUSE AND DEPENDENCE

9.1. Controlled Substance

TBS-1 contains testosterone, a Schedule III controlled substance as defined by the Anabolic Steroids Control Act.

9.2. Abuse

Anabolic steroids, such as testosterone, are abused. Abuse is often associated with adverse physical and psychological effects.

9.3. Dependence

Although drug dependence is not documented in individuals using therapeutic doses of anabolic steroids for approved indications, dependence is observed in some individuals abusing high doses of anabolic steroids. In general, anabolic steroid dependence is characterized by any three of the following:

• Taking more drug than intended

• Continued drug use despite medical and social problems

• Significant time spent in obtaining adequate amounts of drug

• Desire for anabolic steroids when supplies of the drug are interrupted

• Difficulty in discontinuing use of the drug despite desires and attempts to do so

• Experience of withdrawal syndrome upon discontinuation of anabolic steroid use

10. OVERDOSAGE

No cases of overdose with TBS-1 have been reported in clinical trials. There is 1 report of acute overdosage by injection of testosterone enanthate: testosterone concentrations of up to 11,400 ng/dL were implicated in a cerebrovascular accident.

Treatment of overdosage would consist of discontinuation of TBS-1, together with appropriate symptomatic and supportive care.

11. DESCRIPTION

TBS-1 (testosterone) intranasal gel is a slightly yellow gel containing 5.5 mg of testosterone in 122.5 mg of TBS-1 gel for intranasal administration. The active pharmacologic ingredient in TBS-1 is testosterone. Testosterone, United States Pharmacopeia (USP), is a white to practically white crystalline powder chemically described as 17P-Hydroxyandrost-4-en-3-one. The structural formula is:

The inactive ingredients are castor oil, oleoyl polyoxylglycerides, and colloidal silicon dioxide.

12. CLINICAL PHARMACOLOGY

12.1. Mechanism of Action

Endogenous androgens, including testosterone and dihydrotestosterone (DHT), are responsible for the normal growth and development of the male sex organs and for maintenance of secondary sex characteristics. These effects include the growth and maturation of prostate, seminal vesicles, penis, and scrotum; the development of male hair distribution, such as facial, pubic, chest, and axillary hair; laryngeal enlargement, vocal cord thickening, alterations in body musculature, and fat distribution. Testosterone and DHT are necessary for the normal development of secondary sex characteristics. Male hypogonadism results from insufficient secretion of testosterone and is characterized by low serum testosterone concentrations.

Signs/symptoms associated with male hypogonadism include erectile dysfunction and decreased sexual desire, fatigue and loss of energy, mood depression, regression of secondary sexual characteristics, and osteoporosis.

Male hypogonadism has 2 main etiologies. Primary hypogonadism is caused by defects of the gonads, such as Klinefelter' s Syndrome or Leydig cell aplasia, whereas secondary

hypogonadism is the failure of the hypothalamus (or pituitary) to produce sufficient gonadotropins (FSH, LH).

12.2. Pharmacodynamics

No specific pharmacodynamic studies were conducted using TBS-1.

12.3. Pharmacokinetics

Absorption

TBS-1 delivers physiologic circulating testosterone that restores testosterone levels following intranasal administration to the normal concentration range seen in healthy men (ie, 300 to 1050 ng/dL). TBS-1 is rapidly absorbed, rapidly cleared, and has a half-life of 10 hours (see Clinical Studies in Hypogonadal Men [14.1 Figure 1]).

Use in patients with allergic rhinitis and oxymetazoline: The effects of allergic rhinitis and the use of oxymetazoline on the absorption of testosterone were investigated in a 3-way cross-over clinical study. Eighteen males who suffered from seasonal allergic rhinitis received 3 doses of 11 mg of testosterone intranasally (the maximum testosterone dose of 33 mg/day) while they were in the asymptomatic, symptomatic, and symptomatic but treated (with oxymetazoline) states using an environmental challenge chamber model.

Administration of TBS-1 under asymptomatic, symptomatic, and symptomatic but treated conditions of allergic rhinitis demonstrated a reliable increase in testosterone serum

concentrations under all 3 treatment conditions. The drug-induced exposure to testosterone and DHT, determined as area under the concentration-time curve from time 0 to 24 hours (AUCo- 24), was higher in the asymptomatic state compared to symptomatic and symptomatic but treated states. Analysis of variance did not demonstrate bioequivalence between the asymptomatic state and either symptomatic or symptomatic but treated state.

TBS-1 bioavailability during the symptomatic state of allergic rhinitis was 21% lower compared with the asymptomatic state, based on AUCo-24 values. The relative decrease in bioavailability of TBS 1 under symptomatic seasonal rhinitis is neither ameliorated nor aggravated by the administration of oxymetazoline. Consult your doctor if prolonged use of frequent and/or higher dose decongestants is required for allergic rhinitis treatment.

Distribution

Circulating testosterone is primarily bound in the serum to sex hormone-binding globulin (SHBG) and albumin. Approximately 40% of testosterone in plasma is bound to SHBG, 2% remains unbound (free), and the rest is loosely bound to albumin and other proteins.

Metabolism

There is considerable variation in the half-life of testosterone as reported in the literature, ranging from 10 to 100 minutes.

Testosterone is metabolized to various 17-keto steroids through 2 different pathways. The major active metabolites of testosterone are estradiol and DHT. Testosterone is metabolized to DHT by steroid 5a-reductase located in the skin, liver, and urogenital tract of the male. DHT binds with greater affinity to SHBG than does testosterone. In many tissues, the activity of testosterone depends on its reduction to DHT, which binds to cytosol receptor proteins. The steroid-receptor complex is transported to the nucleus where it initiates transcription and cellular changes related to androgen action. In reproductive tissues, DHT is further

metabolized to 3a and 3β androstanediol. Inactivation of testosterone occurs primarily in the liver.

DHT concentrations increased in parallel with testosterone concentrations during TBS-1 treatment. After 90 days of treatment, mean DHT concentrations remained generally within the normal range for TBS-1 treated patients.

Excretion

About 90% of a dose of testosterone given intramuscularly is excreted in the urine as glucuronic and sulfuric acid conjugates of testosterone and its metabolites; about 6% of a dose is excreted in the feces, mostly in the unconjugated form. Inactivation of testosterone occurs primarily in the liver.

13. NONCLINICAL TOXICOLOGY

13.1. Carcinogenesis, Mutagenesis, and Impairment of Fertility

Testosterone has been tested by subcutaneous injection and implantation in mice and rats. In mice, the implant induced cervical-uterine tumors, which metastasized in some cases. There is suggestive evidence that injection of testosterone into some strains of female mice increases their susceptibility to hepatoma. Testosterone is also known to increase the number of tumors and decrease the degree of differentiation of chemically induced carcinomas of the liver in rats. Testosterone was negative in the in vitro Ames and in the in vivo mouse micronucleus assays. The administration of exogenous testosterone has been reported to suppress spermatogenesis in the rat, dog, and non-human primates, which was reversible on cessation of the treatment.

13.2. Animal Toxicology and/or Pharmacology

Animal Toxicology

The accumulated animal data on TBS-1 have not demonstrated toxicity-related concerns that would preclude the use of Trimel's TBS-1 in the clinical trial program. A large number of nonclinical pharmacology and toxicology studies have been conducted to support the efficacy and safety of testosterone cited in the literature and in previously submitted applications.

No evidence of systemic drug-related toxicity was observed in rabbits after repeated twice daily administration of TBS-1 over a 90-day period up to a dose level of 6-fold the maximum clinical daily dose. Local tolerance studies in rat and rabbit following single dose and repeated dose administrations showed that testosterone intranasal gel was well tolerated. Testosterone intranasal gel was classified as a nonirritant in the Hen's Egg Test Chorioallantoic Membrane test.

14. CLINICAL STUDIES

14.1. Clinical Studies in Hypogonadal Men

TBS-1 4.5% was evaluated in a multicenter, open-label, 90-day trial that enrolled

306 hypogonadal men at 39 clinical research centers in the US. Patients were randomized 3: 1 to 22 mg of testosterone daily (11 mg twice daily; 228 patients) or 33 mg of testosterone daily (11 mg 3 times daily; 78 patients). The median age of patients was 54 years with a range of 28 to 80 years. Of the 306 patients, 271 (89%) were Caucasian, 18 (6%) were African-American, 16 (5%) were Asian, and 1 (<1%) had race recorded as "Other".

During the initial TBS-1 treatment period (Days 1 to 30), 228 patients were treated with 22 mg of testosterone daily and 78 patients were treated with 33 mg of testosterone daily. On Day 45 of the trial, patients were maintained at the same dose or were titrated up, based on their 24-hour average serum testosterone concentration measured on Day 30.

On Day 90, 63% of responding patients finished the study on the starting dose of 22 mg of testosterone daily, while 37% had been titrated to 33 mg.

In patients treated with TBS-1, 71% (86/122) who received 22 mg of testosterone daily and 76% (114/151) who received 33 mg of testosterone daily had C_avg within the normal range at Day 90.

Of the 273 patients who completed the 90-day treatment, 237 patients did so with no deviation from the protocol.

For this population, the 75% (76/102) of the subjects who received 22 mg of testosterone daily and 77% (104/135) who received 33 mg of testosterone daily had C_avg within the normal range at Day 90. Table 2 summarizes the testosterone concentration data in the patients that completed 90 days.

Table 2: Baseline Unadjusted Arithmetic Mean (±SD) Steady-State Serum Testosterone Conentration on Day 90 in Patients Who Completed 90 days of Treatment

Figure 1 summarizes the pharmacokinetic profiles of total testosterone in patients completing 90 days of TBS-1 treatment administered as either 22 mg or 33 mg of testosterone daily.

Figure 1: Mean Serum Total Testosterone Concentrations on Day 90 in Patients Following TBS-1 22 mg Daily (N=131) and 33 mg Daily (N=158) Administration of Testosterone - ITT Population

Time 0 corresponds to the 2100 dose.

16. HOW SUPPLIED/STORAGE AND HANDLING

16.1. How Supplied

TBS-1 (testosterone) intranasal gel 4.5% is available as a metered dose pump containing 11 g of gel dispensed as 60 metered pump actuations. One pump actuation delivers 5.5 mg of testosterone.

16.2. Storage and Handling

Keep TBS-1 out of reach of children.

Store at 25°C (77°F). Excursions are permitted to 15°C to 30°C (59°F to 86°F). See USP Controlled Room Temperature. Used TBS-1 dispensers should be discarded in household trash in a manner that prevents accidental exposure of children or pets.

17. PATIENT COUNSELING INFORMATION

See FDA- Approved Medication Guide. Patients should be informed of the following information:

17.1. Use in Men With Known or Suspected Prostate or Breast Cancer

Men with known or suspected prostate or breast cancer should not use TBS-1 (see

Contraindications [4] and Warnings and Precaution [5.1]).

17.2. Potential Adverse Reactions With Androgens

Patients should be informed that treatment with androgens may lead to adverse reactions which include:

• Changes in urinary habits such as increased urination at night, trouble starting your urine stream, passing urine many times during the day, having an urge that you have to go to the bathroom right away, having urine accident, being unable to pass urine, and having a weak urine flow.

• Breathing disturbances, including those associated with sleep, or excessive daytime sleepiness.

• Too frequent or persistent erections of the penis.

• Nausea, vomiting, changes in skin color, or ankle swelling.

17.3. Patients Should be Advised of These Administration Instructions

See Patient Information [X] for full instructions.

The pump should be primed by depressing it 10 times prior to its first use. No priming is needed with subsequent uses of that pump.

TBS-1 should NOT be administered to the scrotum, penis, abdomen, shoulders, underarms, or upper arms.

TBS-1 should be administered twice daily at approximately the same time each day (7 am and 1 pm).

Example 23

POSITIVE COMPLEOTRT™ (4.5%) PHASE III RESULTS FOR SECONDARY

EFFICACY AND SAFETY ENDPOINTS

• Statistically significant improvement on erectile function and mood • Favourable trends for body composition and bone mineral density

• Safety measures after 360 days of treatment consistent with currently

marketed topical testosterone products

Positive secondary efficacy endpoint and 360-day safety results from the 4.5%

CompleoTRT™ pivotal Phase III clinical study are achieved. These results complement the previously announced Phase III pivotal clinical trial results indicating that

CompleoTRT™ met its primary efficacy endpoints. See Example 22.

The pivotal study protocol included evaluations of the impact of treatment with

CompleoTRT™ on body composition (total body mass, lean body mass, fat mass, percent body fat) , bone mineral density, mood and erectile function. Following 90 days of CompleoTRT™ treatment, a statistically significant improvement over baseline was observed in all domains related to erectile function and mood. As well, CompleoTRT™ treatment demonstrated favourable trends with respect to its effect on bone mineral density and improvements in body composition parameters.

DEXA and IIEF Study Scores

Results for IIEF are not only statistically significant, but clinically meaningful, especially in erectile dysfunction, sexual desire and intercourse satisfcation The summary below (last column provides max scores for each domain, results for the healthy controls and patients.

The IIEF study scores at baseline are comparable to patients' results, but increased for all domains and were close to 'normals' for sexual desire. It is believed that the T level achieved may correlate to the IEFF response.

See Exhibit P for interpreation of the IIEF. PANAS Results

The PANAS results showed statistical significance, but it is difficult to interpret from clinical perspective, as it looks like PANAS may not be used by clinicians, but for research applications only, therefore 'norms' for this tool may not exist.

When comparing our data to what seems to be the average (male) population score for how they feel over the past week, the results look comparable on day 90 and are 'closer' to the average male population. See data below.

The safety study results demonstrated that after 360 days of treatment, the

CompleoTRT™ safety profile was consistent with currently marketed topical

testosterone replacement therapies. There were no drug related serious adverse events at any safety time point during the study, with a decrease in mild and moderate drug related adverse events over time. Measures of nasal tolerability demonstrated that CompleoTRT™ was well tolerated in the nasal mucosa, with no adverse event trends. The collection of the safety data from the Phase III study represents the completion of the clinical development for CompleoTRT. See Example 22 and Exhibit M.

CompleoTRT™ (4.5%) is a bioadhesive intranasal gel formulation of testosterone.

CompleoTRT™ is designed with a view to providing hypogonadal patients with superior safety and enhanced convenience over currently available treatment options.

Subject to FDA approval, CompleoTRT™ is designed to be applied to the interior lateral wall of the nasal cavity, where internal studies have demonstrated that the gel is fully absorbed into the nasal mucosa within 15-30 minutes. There is virtually no smell or taste associated with the gel. It is expected that, as a result of the "no touch" targeted delivery to the nasal mucosa, CompleoTRT™ should avoid skin-to-skin transference to spouses or other family members, a health risk that led the FDA to issue a "black-box" warning in May 2009 for secondary transference for all topical non-nasal testosterone gel preparations.

Introduction:

The data of the Phase III study TBS-1 201 1 -03 reveal unexpected results with respect to the secondary clinical parameters analysis and safety data.

While most parameters are unchanged or slightly changed in an expected way (lipids, hormones, hematology, DEXA etc ..) 3 topics have demonstrated unexpected results. These parameters were:

- Clinical assessment of sexual dysfunction using IIEF

- Mood assessment using PANAS scale

- Frequency of rhinitis in known allergic patients (to be discussed in a separate document)

We will review the state of the art information; summarize published information on testosterone clinical use by competitor and validate info, when possible with FDA published summary basis of approval (SBOA). We will then focus on data using validated scales and compare what is available with Compleo clinical findings.

In summary, the clinical response , in terms of Erectile Function and Mood modulation with Compleo, occurs faster, more consistently and with much lower doses (22 to 33 mg/day versus 50 to 125 mg/day) than topical gels and injectable solutions.

Testosterone: effect on sexual dysfunction and mood disorders:

General Considerations:

Testosterone is known, after Meta-analysis and some key studies (10, 1 1 , 12), to improve Sexual function in hypogonadal patients and may affect mood (positively or negatively) of patients and any persons in contact with bioavailable testosterone.

An international scale for erectile dysfunction has been developed by Rosen & al (1997) and widely used in large validated clinical trials mostly testing PDE-5 inhibitors activity. Rosen has validated the method and published an important paper on its possible use for clinical evaluation without placebo control (1 ). This was supported by other international researchers (2) This Scoring system is based on a validated questionnaire covering 15 aspects and enables the researchers to extract clinical information in various male sexual function domains, leading to possible evaluation of 5 function models:

a- Erectile function (EF)

b- Orgasmic function (OF)

c- Sexual Desire (SD)

d- Intercourse satisfaction (IS)

e- Overall Satisfaction (OS)

Also a Total Score (TS- sum of all) domain is frequently analyzed.

Several studies on Testosterone effect on sexual function have used the validated IIEF scale but not all, some used unvalidated scales, for unknown reasons.

The Mood analysis for testosterone is generally performed using a validated method comparing the Positive and negative affects developed in 1988 by D Watson and all(3). This scale has been widely used in mood disorders, however not by many authors testing Testosterone (probably for the fear of increased negative affect after treatment).

Injectable T and undisclosed:

Yassin & al have reported (4,5) the use of IIEF to assess the testosterone effect on sexual and mood functions, they found definitive and significant (both clinically and statistically) improvement in IIEF scores after 24 weeks of treatment using Nebido injections (T undecanoate).

However, they stated that the onset was slow: after 6 weeks of treatment only 13% of the patients EF function was improved, while 54% improvement could be seen at 24 weeks.

Yassin did not study specifically the Mood component to testosterone effect on patients. The ED domain of the IIEF under Nebido treatment went from a score of 12 at baseline to 25 after 24 weeks of treatment.

Reyes Vallejo (6) studied the IIEF response to testosterone based on initial T levels and found some correlation between response and either baseline T levels and/or age, but could not resolve the relation between original T levels and Erection function. On the other hand Gray and al (7) did study the dose dependent effect of T on IIEF and mood after Nebido treatment. Using doses of 25 to 600 mg Nebido per week for 24 weeks.

Some correlation was found for IIEF score and dose, but not dependent on original baseline T levels.

G ray 's TABLE 2. Sexual function descriptive data

Variable 25 mg 50 mg 125 mg 300 mg 600 mg

Sexual function score

Baseline 5.9 (1 .0) 6.3 (1 .0) 7.3 (1 .2) 5.0 (1 .0) 7.2 (1 .4)

Wk 20 3.8 (1 .0) 6.4 (1 .0) 9.0 (1 .4) 9.5 (1 .4) 9.8 (2.6)

Changea _2.1 (1 .2) 0.1 (1 .0) 1 .7 (0.4) 5.2 (1 .0) 2.2 (2.6)

Waking erection frequency

Baseline 3.7 (0.7) 2.6 (0.6) 3.1 (0.8) 2.3 (0.9) 4.0 (1 .1 )

Wk 20 1 .6 (0.6) 2.9 (0.9) 4.9 (1 .0) 4.9 (0.9) 3.5 (1 .2)

Changeb _2.2 (1 .1 ) 0.1 (0.7) 0.9 (0.6) 2.6 (1 .0) _0.6 (1 .6)

Spontaneous erection frequency

Baseline 1 .3 (0.7) 1 .9 (0.7) 1 .2 (0.6) 0.1 (0.1 ) 0.4 (0.2)

Wk 20 1 .3 (0.9) 2.4 (1 .0) 1 .3 (0.8) 2.3 (0.8) 3.2 (1 .3)

Change 0.2 (1 .5) 0.3 (0.8) _0.1 (1 .0) 1 .7 (0.7) 3.0 (1 .6)

Intercourse frequency

Baseline 1 .3 (0.4) 0.3 (0.4) 0.8 (0.6) 0.6 (0.3) 2.2 (0.6)

Wk 20 0.0 (0.6) 0.4 (0.4) 1 .1 (0.8) 1 .1 (1 .1 ) 1 .8 (1 .5)

Change _1 .5 (0.6) 0.4 (0.2) 0.3 (0.6) _0.1 (0.8) 0.0 (1 .3)

Masturbation frequency

Baseline 0.4 (0.3) 0.8 (0.6) 2.3 (0.8) 0.0 (0.0) 1 .2 (1 .2)

Wk 20 0.1 (0.1 ) 1 .0 (0.7) 2.1 (0.7) 1 .1 (0.6) 0.2 (0.3)

Change _0.3 (0.3) 0.0 (0.4) 0.2 (0.5) 1 .3 (0.7) _1 .2 (1 .5)

Libido

Baseline 12.9 (1 .3) 14.0 (1 .0) 15.1 (0.8) 12.3 (0.9) 14.2 (0.8)

Wk 20 1 1 .0 (0.9) 14.3 (1 .6) 15.2 (0.9) 16.3 (1 .0) 1 5.8 (1 .7) Change _2.2 (2.0) 0.3 (0.8) 0.1 (1 .0) 2.7 (1 .0) 1 .8 (2.4)

Data are means (SE). Baseline values refer to baseline scores, wk

20 values refer to scores at wk 20, and change scores refer to baseline

scores subtracted from wk 20 scores. All frequencies refer to the

average number of days a behavior occurred during a 7-d period. By

ANOVA, no differences in baseline sexual function scores (P_0.423),

waking erections (P _ 0.535), spontaneous erections (P_ 0.268),

intercourse frequency (P_ 0.1 13), masturbation frequency (P _

0.230), or libido (P_ 0.513) were observed among testosterone treatment groups.

Overall ANOVA P_ 0.003.

Overall ANOVA P_ 0.024.

It is also interesting to see that not all parameters were statistically impacted by treatment.

Mood scores did not differ between groups and were not correlated to free or total testosterone.

The following picture summarizes Gray's findings.

On the same product (Nebido) , Kurbatov did show that patients with or without venous leakage did show Improved EF functions after 18 weeks and even more after 30 weeks of treatment.

(EF domain of IIEF was 1 1 .0 at baseline, 22.5 after 18 weeks and 27 after 30 weeks of treatment.

Finally, without specifying what product was used, Amiaz (9), did report that IIEF scores of patients under serotoninergic antidepressant therapy improved after 6 weeks of treatment.

Most, but not all of the IIEF domain scores were significantly improved. Interestingly this study was placebo controlled and confirmed Rosen 's postulate that Placebo has no effect on IIEF scores.

They also confirmed that there was no correlation between original testosterone plasma levels in patients and their EF response to treatment.

LOO 200 300 400 500

Saselirse total testostero e $ev«l

Testim review:

McNichols did publish his own study results (14) and a review (13) of Testim clinical studies.

His comments in the "expert opinion" is that EF improves significantly and rapidly ( "... quote: "Based on the results of the START study, it seems that

Improvement in sexual activity and mood can be seen within

2 weeks of initiating treatment with Testim gel"...) after Testim gel treatment was neither supported by his own study results, nor by a bigger study published by Steidle (15) , and even less by the FDA reviewer. (16)

McNichols results show in fact that, using a non IIEF scale, only some sexual parameters were improved.

See table 2 on page 72 of (14). Another study was performed in the US by Steidle with a bigger sample (n= 406 versus n= 208 in Europe) for FDA filing and did also show that 50 mg did not separate from placebo (no effect as Rosen stated), and 100 mg has some effect on motivation, desire and performance)

No effect was clearly seen on Mood (some on positive affect, no real trend on negative affect)

The FDA review SBOA refers to Auxilium comments on these studies

For subjects with secondary hypogonadism with no clear etiology besides "aging" who used AA2500 100 mg, every parameter of sexual function was improved relative to baseline. The mean change from baseline was statistically significant compared to subjects who used placebo. No inferential statistics were performed in the subgroup with primary hypogonadism with respect to sexual function or mood due to insufficient sample size. Neither dose of AA2500 demonstrated any significant improvement in mood from baseline for subjects with secondary hypogonadism of any etiology.

The FDA reviewer's interpretation was

Reviewer's comment: The reviewer's analysis of the sponsor's data concludes the following:

1. Sexual function in older subjects with secondary hypogonadism of no clear etiology was improved with the 100 mg dose compared to placebo.

2. Sexual function_, ώ other subjects with secondary hypogonadism was not significantly improved with either dose. .

3. Mood was not significantly improved with Testim™ use in any subgroup.

4. Treatment with the 100 mg dose had generally positive effects on body composition; the 50 mg dose was beneficial only for decrease in FM.

Androgel: Wang published 2 papers about her contribution to Androgel clinical efficacy. The first one in 2000 with full details (18) and a second time (19) in 2004 with mostly reworded statement about the 2000 study.

The wording of the 2 studies was quite positive (fast significant improvement) , but not fully convincing as she did not use validated scales (and avoided to use IIEF and PANAS or equivalent scales), the statistics at short term are missing from the papers, the graphical representation seems to suggest no statistical differences before 8 weeks of treatment (see graph under). h

For mood she did find some changes but not clinically significant.

The FDA review does not seem to corroborate their findings, and a recent study using IIEF scale (17) sponsored by Solvay did show somewhat positive but not as clearly stated as before, (see after)

In his well-designed recent study (17) Chiang confirmed that activity was best achieved after 12 weeks of treatment at least and confirmed that not all scores of IIEF were significantly improved (Total score , EF, O and IS domains were improved, but not the other 2 domains) , interestingly, again, the placebo group did not respond at all.

Table 2. Change from baseline of total and different sexual functions assessed by IIEF-15 scores and 5 sexual function domains after 3 months of testosterone therapy

AndroGel Group Placebo Group

Difference Effect l!EF 15 Base! ine Difference Baseline Difference {P Value) Size*

Total score 34.1 ± 14.0 14.4 ± 15.9 (P = .003} 42.4 ± 16.S i -5.2 ± 15.3 (P -- = .209) ,002

EF 13.3 ± 6.8 7.3 ± 7.8 <P = .003) 16.9 ± 8.2 -1.6 ± 8.5 (P = .476) ,007 0.173

OF 6.0 ± 3.1 2.1 ± 3.5 (P == .036) 6.3 ± 3.2 -2.0 ± 3.5 (P = .045) .004 0.042

SD 5.0 ± 1.6 1.4 ± 1.8 (P = .008) 6.3 ± 2.4 0.0 ± 2.3 (P = 1.0) .086 0.005

IS 5.5 ± 3.2 2.3 ± 3.1 (P = .011) 6.7 ± 3.8 -1.9 ± 4.0 (P = .089) .004 0.045

OS 4.4 ± 1.1 1.3 ± 1.9 (P .017) 6.2 ± 2.3 0.3 ± 2.8 (P = .719) .246 0.003

IS EF, International index of Erectile Function; EF, erectile function; OF, orgasmic function; SD, sexual desire; IS, intercourse satisfaction; OS, overall satisfaction.

EF sum of IIEF questions 1-5 and 15 (score range 1-30); OF sum of fiEF questions 9 and 10 (score range 0-10): SD sum of l!EF questions 11 and 12 (score range 2-10); fS sum of IIEF questions 6-8 (score range 0-15); OS sum of IIEF questions 13 and 14 (score range 2-10). The excerpts of the FDA SBOA review speak for themselves

Mood. Libido and Sexual Activity: The sponsor assessed mood, libido and sexual activity by means of a single composite questionnaire completed 7 days prior to clinic visits on Day 0, 30, 60. 90. 1 20, 150 and 1 80. There were no baseline differences in the treatment groups. In general_, all parameters improved for the periods Days 0-90 and Days91 - 180. in all treatment groups.

Libido was assessed from linear responses to questions about sexual desire, enjoyment of sexual activity without a partner, and enjoyment of sexual activity with a partner. These responses appeared to indicate an improvement in libido at Days 90 and 1 80 in all groups. In addition, there was a checklist for sexual events (e.g. sexual daydreams, sexual interactions with a partner, flirting, masturbation, intercourse, etc) in which patients were asked to indicate whether they did or did not experience the event.

Reviewer's comments: Results from the libido and sexual event checklist were difficult to interpret.

Mood was assessed by including a "mood assessment" section in the 7-day questionnaire.

Patients were asked to rate their mood on a 0 ("not at all true") to 7 ("very true") scale, to reflect how they were feeling on a given day about several mood parameters (e.g. angry, alert, irritable, full of pep, sad/blue, tired/friendly, nervous, etc.). In general, improvement was noted in various assessments of mood, in all 3 treatment groups.

Reviewer's comment: Although the reviewer has some concerns regarding the

validation of the composite mood, libido and sexual activity questionnaire, the

results appear biologically plausible in treatment of hypogonadal men with

androgen replacement.

Axiron:

Axiron did not publish any scientific paper on T secondary efficacy we could locate. The information we have are the Printed labeling (no info on sexual dysfunction) and SBOA.

Seemingly some parameters were significantly improved after 120 days but not all.

testosterone with the:Survey:response.

Fortesta. Striant. Androderm. Testoderm:

We could not locate any information.

Compleo:

For Compleo phase III study: all secondary clinical endpoints related to IIEF and total mood scores were improved statistically at all times for all doses. Clinically, some parameters were also significantly improved (see yellow highlights).

IIEF at day 90 versus references

For mood analysis, patients treated were significantly trending to towards the "normal" population:

It is important to note that, despite a much lower dose (22 to 33 mg/day of Compleo) than the topical gel products (50 to 100 mg/day), Compleo , tested for secondary psycho sexual parameters using validated scales performs faster , and more

consistently (and sometime stronger when comparable scales are used) than the existing products on the market.

This, also despite the fact that Compleo PK parameters achieve a slightly lower success (or increase) rate when compared to the Gel formulations;

Attached, imbedded, are the key results for all treatments at all times (34 tables selected out of 663 pages). See Exhibit P also.

Reference List

1 . Tietz Textbook of Clinical Chemistry and Molecular Diagnostics, 4th edition, 2006. Editors; Burtis CA, Ashwood ER, and Bruns DE.

2. Wang C, Swerdloff RS. Androgen replacement therapy. Ann Med 1997; 29: 365-370.

3. Matsumoto AM. Andropause: clinical implications of the decline in serum

Testosterone levels with aging in men. J Gerontol A Med Sci 2002; 57: M76-M99.

4. Haren MT, Kim MJ, Tariq SH, Wittert GA, Morley JE. Andropause: a quality-of-life issue in older males. Med Clin North Am 2006; 90: 1005-1023.

5. Nieschlag E. Testosterone treatment comes of age: new options for hypogonadal men. Clin Endocrinol (Oxf) 2006: 65: 275-281 .

6. Tenover JL. The androgen-deficient aging male: current treatment options. Rev Urol 2003; 5 (Suppl): S22-S28.

7. Jockenhovel F. Testosterone therapy - what, when and to whom? Aging Male 2004; 7: 319-324.

8. Kunz GH, Klein KO, demons RD, Gottschalk ME, Jones KL. Virilization of young children after topical androgen use by their parents. Pediatrics 2004; 1 14: 282-284.

9. Brachet C, Vermeulen J, Heinrichs C. Children's virilisation and the use of a

Testosterone gel by their fathers. Eur J Pediatr 2005; 164: 646-647.

10. Bagchus WM, Hust R, Maris F, Schnabel PG, Houwing NS. Important effect of food on the bioavailability of oral Testosterone undecanoate. Pharmacotherapy 2003; 23: 319-325.

1 1 . Haren M, Chapman IM, Haren MT, MacKintosh S, Coates P, Morley JE. Oral Testosterone supplementation increases muscle and decreases fat mass in healthy elderly males with low normal gonadal status. J Gerontol A Biol Sci Med Sci 2003; 58: 618-625.

12. Haren M, Chapman I, Coates P, Morley JE, Wittert G. Effect of 12 month oral Testosterone on Testosterone deficiency symptoms in symptomatic elderly males with low-normal gonadal status. Age Ageing 2005; 34: 123-130.

13. Mattern C, Hoffmann C, Morley JE, Badiu C. The Aging Male 2008; 1 1 : 171 -178. In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

NASOBOL GEL IN ViTRO RELEASE RATE VALIDATION UPDATE

Release Rate Study Summary

Part 3: Nasobol Gel 4.0%

Purpose

This summary summarized all release rate experiment data for Nasobol Gels. There are four Nasobol Gels (0.15%, 0.6%, 4.0% and 4.5%) for the method validation. The purpose of the Dayl and Day2 test are to determine the specificity and intraday/interday precision of the slope(release rate), Day3 and Day4 are to evaluate the slope sensitivity to the sample strength variation

Exhibit A In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

Nasobol Gel 4.0% Release Rate

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

4% Dayl Release Rate

Testosterone 4% Gel

Amount Released ^g/mL) Calculation by Linear Regression Curve

CellA#l Cell A#2 Cell A#3 Cell A#4 Cell#5 Cell#6 Mean 1 -6 %RSD 1 -6

Time

60.00 100.615 100. 156 101.259 104.065 96.829 102.531 100.909 2.4

120.00 151.286 149.754 151 .980 154.908 150.156 156.241 152.388 1 .7

180.00 193.494 190.313 193.585 197.317 188.895 198.299 193.651 1 .9

240.00 222.232 221.742 222.845 228.588 218.647 229.252 223.884 1 .9

300.00 248.200 246.21 1 245.509 247.784 240.822 252.989 246.919 1 .6

360.00 263.765 264.893 269. 185 269.287 256.350 273.175 266. 108 2.2

Actual Amount of Active Released ^g/cm²) versus Time ^{6 5}

Amount Released g/cm²)

Cell A#l Cell A#2 Cell A#3 Cell A#4 Cell A#5 Cell A#6 Mean 1 -6 %RSD 1 -6 r-p- 0.5

1 lme

7.75 683.255 680. 138 687.628 706.683 657.545 696.266 685.253 2.4

10.95 1055.820 1045.287 1060.715 1081.392 1047.075 1090.010 1063.383 1 .7

13.42 1385.252 1363.087 1386.248 1413.214 1352.630 1419.826 1386.709 1 .9

15.49 1635.154 1630.364 1639.722 1681.399 1608.1 17 1686.130 1646.814 1 .9

17.32 1874.378 1859.269 1856.682 1876.434 1820.569 1912.189 1866.587 1 .6

18.97 2050.237 2055.800 2086.927 2092.567 1994.157 2120.851 2066.756 2. 1

Slope 123.44 123.83 124.46 123.99 120.04 127.49 123.87 1.9

R^ 0.9994 0.9995 0.9995 0.9993 0.9995 0.9998 0.9995 0.0

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

System Suitability for 4% Gel Dayl

1 : Medium (Diluent)

2: Injection Reproducibility RT, Tailing Factor and Theoretical Plate Number from Six Replicate Injections of STD-4

3: Calibration Curve Y=16016.225515x 601.167936

4: Check STD Rec. (%)

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

4% Day2 Release Rate

Testosterone 4% Gel

Concentration of Active ^g/mL) versus Time

Amount Released ^g/mL) Calculation by Linear Regression Curve Cell A#2 Cell A#4 Cell A#6 Cell B#l Cell B#3 Cell B#5 Mean 1 -6 %RSD 1 -6

Time

60.00 98.828 102.754 103.493 100.481 97.477 101.409 100.740 2.3

120.00 147.568 153.454 156.309 150.502 143.917 151.716 150.578 2.9

180.00 181.258 190.061 184.198 185.232 181.807 185.787 184.724 1.7

240.00 216.954 213.139 220.725 218.545 212.788 199.829 213.663 3.5

300.00 238.102 241.620 251.876 240.200 235.770 218.192 237.627 4.6

360.00 257.241 261.849 264.068 253.383 252.537 245.490 255.761 2.7

Actual Amount of Active Released ^g/cm ) versus Time

Amount Released g/cm²)

Cell A#2 Cell A#4 Cell A#6 Cell B#l CellB#3 CellB#5 Mean 1 -6 %RSD 1 -6-p- 0.5

1 lme

7.75 671. 120 697.781 702.799 682.345 661.946 688.647 684. 106 2.3

10.95 1030.066 1071.148 1090.744 1050.458 1004.891 1058.965 1051.045 2.9

13.42 1300.602 1363.158 1324.360 1328.887 1302.915 1333.262 1325.531 1.7

15.49 1594.293 1573.653 1624.526 1607.519 1564.743 1481 .186 1574.320 3.2

17.32 1799.291 1827.369 1898.520 1816.41 1 1781.017 1662.427 1797.506 4.3

18.97 1996.631 2033.106 2052.581 1973.898 1961.589 1909.539 1987.891 2.6

Slope 1 19.08 1 18. 14 122.09 1 16.96 1 17.37 104.35 1 16.33 5.3

R^ 0.9988 0.9989 0.9959 0.9989 0.9993 0.9939 0.9976 0.2

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

System Suitability for Nasobol Gel 4% Day2

1 : Medium (Diluent)

3: Calibration Curve Y = 16191.313821x559.963706

4: Check STD Rec. (%)

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

4% Day3 Release Rate

Testosterone Gel 2.0%

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell #2 Cell A#6 Cell B#3 Cell B#4 Mean 1-4 %RSD 1-4

Time

60.00 48.687 51.463 48.815 48.993 49.490 2.7

120.00 73.695 78.583 73.975 75.427 75.420 3.0

180.00 90.962 97.059 91.673 93.652 93.337 2.9

240.00 104.753 1 1 1.751 104.737 107.587 107.207 3.1

300.00 1 14.343 121.973 1 15.610 1 18.793 1 17.680 2.9

360.00 122.380 131.256 123.836 127.772 126.31 1 3.2

Actual Amount of Active Released ^g/cm²) versus Time^0'5

Amount Released ( -g/ cm ²)

Cell A#2 Cell A#6 Cell B#3 Cell B#4 Mean 1-4 %RSD 1-4

Time ^{u i}

7.75 330.623 349.474 331.492 332.701 336.073 2.7

10.95 514.223 548.202 516.161 526.071 526.164 3.0

13.42 652.332 695.903 657.275 671.175 669.171 2.9

15.49 771.721 823.136 771.929 792.304 789.773 3.1

17.32 866.484 924.172 875.400 898.843 891.225 2.9

18.97 953.415 1021.723 963.973 993.430 983.135 3.1

Slope 55.61 59.82 56.40 58.83 57.66 3.4

R² 0.9996 0.9997 0.9999 0.9999 0.9998 0.0

¾_:SSS >. ·:>$· ·¾:■.-;·:·: ·* ·:¾·:¾· ■:■:> :¾* ! i :*:· *-S::0<>

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

4.0% Day3 Release Rate

Testosterone Gel 4.0%

Amount Released ^g/mL) Calculation by Linear Regression Curve CellA#l CellA#5 Cell B#2 Cell B#6 Mean 1-4 %RSD 1-4

Time

60.00 100.960 101.116 102.665 95.377 100.030 3.2

120.00 154.364 154.139 154.940 147.997 152.860 2.1

180.00 186.594 184.120 190.461 181.262 185.609 2.1

240.00 208.156 214.565 216.224 209.841 212.197 1.8

300.00 233.787 235.816 238.251 229.168 234.256 1.6

360.00 254.064 253.085 253.819 240.556 250.381 2.6

Actual Amount of Active Released g/cm²) versus Time ⁰⁵

Amount Released g/cm²)

Cell A#l Cell A#5 Cell B#2 Cell B#6 Mean 1-4 %RSD 1-4 0.5

1 lme

7.75 685.598 686.657 697.176 647.685 679.279 3.2

10.95 1076.820 1075.336 1081.214 1032.003 1066.343 2.2

13.42 1339.364 1322.544 1366.269 1299.774 1331.988 2.1

15.49 1538.584 1581.386 1595.111 1545.136 1565.054 1.8

17.32 1771.536 1786.408 1805.872 1735.756 1774.893 1.7

18.97 1975.383 1970.402 1979.004 1877.932 1950.680 2.5

Slope 112.89 114.01 114.24 110.57 112.93 1.5

R² 0.9985 0.9994 0.9996 0.9981 0.9989 0.1

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

4.0% Day3 Release Rate

Testosterone Gel 8.0%

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell A#3 Cell A#4 Cell B#l Cell B#5 Mean 1 -4 %RSD 1 -4

Time

60.00 194.025 206.537 196.509 200.268 199.335 2.7

120.00 291.732 312.939 296.662 301.987 300.830 3.0

180.00 366.623 382.831 355.576 367. 135 368.041 3.0

240.00 420.979 432.753 416.896 429.097 424.931 1.7

300.00 462.747 469.037 459.1 1 1 469.069 464.991 1. 1

360.00 500. 130 507.265 493.510 507.861 502.192 1.3

Actual Amount of Active Released g/cm²) versus Time^0'5

Amount Released g/cm²)

Cell A#3 Cell A#4 Cell B#l Cell B#5 Mean 1 -4 %RSD 1 -4

I lme

7.75 1317.582 1402.549 1334.451 1359.977 1353.640 2.7

10.95 2035.989 2183.542 2070.171 2107.395 2099.274 3.0

13.42 2627.103 2746.709 2554.183 2635.248 2640.81 1 3.0

15.49 3099.959 3194.041 3071.205 3159.900 3131.276 1.8

17.32 3502.713 3562.885 3475.838 3552.754 3523.547 1.2

18.97 3887.507 3955.197 3839.340 3948.905 3907.737 1.4

Slope 229.29 225.09 223.05 230. 19 226.91 1.5 2 0.9999 0.9991 0.9994 0.9997 0.9995 0.0

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

System Suitability for Nasobol Gel 4% Day3

1 : Medium (Diluent)

3: Calibration Curve Y = 16400.350881x586.919769

4: Check STD Rec. (%)

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

Testosterone Gel 2% Day4 Release Rate

Concentration of Active ^g/mL) versus

Cell Cell

Cell Al# Cell A#5 B#2 13#16 Mean 1-4 %RSD 1 -4

Time

60.00 46.1 14 45.990 46.957 48.744 46.951 2.7

120.00 71.036 70.056 70.143 74.792 71.507 3.1

180.00 86.556 87.932 89.263 87.432 87.796 1.3

240.00 101.793 102.943 101.472 102.594 102.201 0.7

300.00 1 14.336 1 15.560 1 16.237 1 16.744 1 15.719 0.9

360.00 124.001 124.783 128.162 124.530 125.369 1.5

Actual Amount of Active Released ^g/cm² versus Time^0'5

Amount Released ( g/cm2)

Cell A#l Cell A#2 Cell B#2 Cell B#6 Mean 1-4 %RSD 1 -4

1 lme

7.75 313.150 312.308 318.875 331.010 318.836 2.7

10.95 495.438 488.748 489.613 521.689 498.872 3.1

13.42 620.931 629.963 639.299 628.687 629.720 1.2

15.49 748.893 756.779 747.465 756.387 752.381 0.6

17.32 862.872 871.586 876.442 881.506 873.102 0.9

18.97 960.856 966.916 990.312 967.412 971.374 1.3

Slope 57.62 58.68 59.48 56.59 58.09 2.2

R^r 0.9990 0.9994 0.9971 0.9971 0.9982 0. 1

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

Testosterone Gel 4% Day4 Release Rate

Concentration of Active ^ /mL) versus

Cell A#3 Cell A#4 Cell B#l Cell B5 Mean 1 -4 %RSD 1 -4

Time

60.00 97.536 101.702 92.098 101.777 98.278 4.7

120.00 139.740 145.279 136.327 149.357 142.676 4.1

180.00 174.342 184.915 173.585 185.982 179.706 3.7

240.00 202.707 208.453 197.1 16 207.509 203.946 2.6

300.00 240.715 238.723 227.099 238.562 236.275 2.6

360.00 252.426 248.202 226.276 250.303 244.302 5.0

Actual Amount of Active Release ( g/cm") versus Time ^{0 5}

Amount Released ^g/cm²)

Cell A#3 Cell A#4 Cell B#l Cell B#5 Mean 1 -4 %RSD 1 -4

Time"^"5

7.75 662.346 690.637 625.418 691.146 667.387 4.7

10.95 976.542 1015.335 951.827 1043.049 996.688 4.1

13.42 1251.057 1325.602 1243.412 1334.022 1288.523 3.7

15.49 1493.007 1537.765 1452.321 1532.831 1503.981 2.6

17.32 1808.467 1802.303 171 1 .703 1802.420 1781 .224 2.6

18.97 1956.104 1934.220 1770.372 1949.652 1902.587 4.7

Slope 1 18.16 1 13.57 106.62 1 13.31 1 12.92 4.2

R" 0. 27 0.9973 0.9925 0.9981 0.9952 0.3

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

Testosterone Gel 8% Day4 Release Rate

Testosterone Gel 8%

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell A#2 Cell A#6 Cell B#3 Cell B#4 Mean 1 -4 %RSD 1 -4

Time

60.00 225.146 222.059 224.685 222.320 223.553 0.7

120.00 317.633 309.500 316.071 313.279 314.121 1.1

180.00 370.322 367.146 370.947 369.41 1 369.457 0.5

240.00 418.459 415.671 421.783 418.698 418.653 0.6

300.00 480.398 469.438 476.809 478.279 476.231 1.0

360.00 494.787 483.727 487.877 490.443 489.209 0.9

Actual Amount of Active Released g/cm²) versus Time^{0 5}

Amount Released g/cm²)

Cell A#2 Cell A#6 Cell B#3 Cell B#4 Mean 1 -4 %RSD 1 -4 -p- 0.5

1 lme

7.75 1528.919 1507.955 1525.788 1509.728 1518.097 0.7

10.95 2220.683 2164.580 2209.945 2190.316 2196.381 1.1

13.42 2668.357 2643.615 2672.029 2660.139 2661.035 0.5

15.49 3100.027 3077.021 3122.204 3099.361 3099.654 0.6

17.32 3639.045 3559.756 3615.218 3622.433 3609.1 13 1.0

18.97 3872.686 3789.616 3825.291 3840.365 3831.990 0.9

Slope 21 1.76 207. 16 209.08 21 1.75 209.94 1. 1

R² 0.9959 0.9976 0.9968 0.9964 0.9967 0.1

In Vitro Release Rate Method Validation For Nasobol Gel 4.0%

System Suitability

1 : Medium (Diluent)

3: Calibration Curve Y = 16123.2297X - 239.5651

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

NASOBOL GEL IN ViTRO RELEASE RATE VALIDATION UPDATE

Release Rate Study Summary

Part 4: Nasobol Gel 4.5%

Purpose

This summary summarized all release rate experiment data for Nasobol Gels

There are four Nasobol Gels (0.15%, 0.6%, 4.0% and 4.5%) for the method validation. The purpose of the Dayl and Day2 test are to determin the specificity and intraday/interday precision of the slope (release rate), Day3 and Day4 are to evaluate the slope senistivity to the sample strength variation.

Exhibit B In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

Nasobol Gel 4.5% Release Rate

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

4.5% Dayl Release Rate

Testosterone 4.5% Gel

Concentration of Active (^g/mL) versus

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell A#l Cell A#2 Cell A#3 Cell A#4 Cell #5 Cell #6 Mean 1-6 %RSD 1 -6

Time

60.00 111.296 111.319 113.485 115.937 112.831 118.159 113.838 2.4

120.00 169.171 167.895 170.642 175.455 172.935 177.272 172.228 2,1

180.00 212.183 206.080 211.257 213.547 211.031 219.479 212.263 2.0

240.00 243.968 240.483 243.556 245.903 243.442 249.362 244.452 1.2

300.00 265.616 264.479 266.919 269.161 264.241 272.660 267.179 1.2

360.00 289.376 284.952 288.553 292.152 287.059 297.115 289.868 1.5

Actual Amount of Active Released (μ$»Λ!ΐη ²) versus Time 0

Amount Released ^g/ cm²)

Cell A#l Cell A#2 Cell A#3 Cell A#4 Cell A#5 Cell A#6 Mean 1-6 %RSD 1 -6

Time^{0 5}

7.75 755.787 755.944 770.652 787.303 766.211 802.393 773.048 2.4

10.95 1180.295 1171.637 1190.904 1224.282 1206.290 1237.249 1201.776 2.1

13.42 1520.248 1478.449 1514.995 1532.601 1513.924 1574.027 1522.374 2.0

15.49 1796.130 1770.383 1794.106 1812.747 1793.731 1839.058 1801.026 1.3

17.32 2012.167 2001.379 2021.673 2040.265 2003.855 2067,826 2024.528 1.3

18.97 2248.672 2215.241 2244.109 2272,551 2233.574 2311.044 2254.199 1.5

Slope 132.51 130.29 131.17 131.37 129.66 133.29 131.38 1.0

R² 0.9997 0.9998 0.9999 0.9998 0.9995 0.9997 0.9998 0.0

f Q CM fll A eitAdR OWAKS * C«1 A*4 Ca:Wti In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

Suitability for 4% Gel Dayl

: Medium (Diluent)

: Injection Reproducibility RT, Tailing Factor and Theoretical Plate Number from Six Replicate Injections of STD-4

: Calibration Curve Y=16214.013222x -404.968835

: Check STD Rec. (%)

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

4.5% Day2 Release Rate

Testosterone 4.5% Gel

Concentration of Active (μ¾/ιηΙ ) versus Time

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell A#2 Cell A#4 Cell A#6 Cell B#l Cell B#3 Cell B#5 Mean 1-6 %RSD 1-6

Time

60.00 108.443 114.787 116.970 110.229 103.462 112.806 111.116 4.4

120.00 165.786 171.091 175.955 165.082 160.313 168.966 167.866 3.2

180.00 205.096 212.317 217.530 208.624 199.765 214.561 209.649 3.1

240.00 236.056 241.544 254.045 236.272 228.447 245.676 240.340 3.7

300.00 262.962 267.630 280.500 266.963 255.981 273.553 267.932 3.2

360.00 284.142 294.602 303.353 289.922 277.465 298.212 291.283 3.3

Actual Amount of Active Released ^g/cm ²) versus Time

Amount Released ^g/cm²)

Cell A#2 Cell A#4 Cell A#6 Cell B#l Cell B#3 Cell B#5 Mean 1-6 %RSD 1-6

Time

7.75 738.413 779.494 794.318 748.542 702.588 766.042 754.566 4.4

10.95 1156.501 1194.321 1227.970 1152.226 1117.926 1179.331 1171.379 3.2

13.42 1470.356 1522.689 1560.083 1494.620 1431.197 1536.765 1502.618 3.1

15.49 1738.631 1781.238 1869.598 1741.402 1682.493 1808.771 1770.356 3.7

17.32 1988.136 2026.727 2121.131 2016.671 1934.110 2067.591 2025.728 3.2

18.97 2206.369 2285.614 2355.688 2248.118 2152.433 2312.447 2260.111 3.3

Slope 130.70 132.72 139.44 133.37 128.58 137.72 133.75 3.1

R^ 0.9999 0.9992 0.9998 0.9992 0.9998 0.9996 0.9996 0.0

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

System Suitability for Nasobol Gel 4.5% Day2

1: Medium (Diluent)

2: In ection Re roducibilit RT Tailin Factor and Theoretical Plate Number from Six Re licate In ections of STD-4

3: Calibration Curve Y=16354.946833x-532.850889

4: Check STD Rec. (%)

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

4.5% Day3 Release Rate

Testosterone Gel 2.25%

Concentration of Active (μ¾/ιηΙ ) versus Time

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell A#2 Cell A#6 Cell B#3 Cell B#4 Mean 1-4 %RSD 1-4

Time

60.00 54.994 57.714 54.019 54.717 55.361 2.9

120.00 82.496 86.872 80.964 82.932 83.316 3.0

180.00 102.145 108.350 101.811 103.469 103.944 2.9

240.00 116.492 123.255 116.098 117.953 118.450 2.8

300.00 127.040 135.982 128.371 129.901 130.324 3.0

360.00 137.604 148.125 139.169 142.064 141.741 3.3

Actual Amount of Active Released ^g/cm ²) versus Time 0.5

Amount Released ^g/cm²)

Cell A#2 Cell A#6 Cell B#3 Cell B#4 Mean 1-4 %RSD 1-4 lime

7.75 373.453 391.923 366.832 371.572 375.945 2.9

10.95 575.773 606.259 565.094 578.656 581.446 3.0

13.42 732.548 776.692 729.570 741.584 745.098 2.9

15.49 858.877 908.567 855.398 869.218 873.015 2.8

17.32 963.468 1029.868 971.591 983.729 987.164 3.0

18.97 1071.151 1150.804 1081.240 1103.081 1101.569 3.2

Slope 61.87 67.19 63.58 64.65 64.32 3.5

R¹ 0.9998 0.9998 0.9999 0.9997 0.9998 0.0

1SC0.030

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soo.ooa

0.080

< E o.ce 3.00 800 10 ® S2 00 t*.8Q SS«S 23«

Ttraa"

OCai A#2 5Ce« S#3

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

4.5% Day3 Release Rate

Testosterone Gel 4.5% Gel

Concentration of Active (μ¾/ιηΙ ) versus Time

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell A#l Cell A#5 Cell B#2 Cell B#6 Mean 1-4 %RSD 1-4

Time

60.00 114.924 110.831 111.525 108.299 111.395 2.5

120.00 170.368 168.304 167.373 164.053 167.525 1.6

180.00 208.336 206.437 208.201 202.691 206.416 1.3

240.00 239.862 235.028 233.826 232.401 235.279 1.4

300.00 261.230 258.500 258.483 255.056 258.317 1.0

360.00 287.153 282.227 279.233 280.592 282.301 1.2

Actual Amount of Active Released ^g/cm ²) versus Time 0.5

Amount Released ^g/cm²)

Cell A#l Cell A#5 Cell B#2 Cell B#6 Mean 1-6 %RSD 1-4 lime 0.5

7.75 780.424 752.630 757.343 735.435 756.458 2.5

10.95 1189.451 1174.276 1168.150 1144.692 1169.142 1.6

13.42 1495.489 1480.851 1492.763 1453.493 1480.649 1.3

15.49 1768.524 1733.417 1725.687 1712.599 1735.057 1.4

17.32 1981.498 1959.312 1959.288 1932.202 1958.075 1.0

18.97 2231.450 2193.579 2173.335 2177.779 2194.036 1.2

Slope 127.93 126.91 125.41 127.04 126.82 0.8

R¹ 0.9994 0.9997 0.9996 0.9995 0.9996 0.0

nC.el! ASi * Cell i¾ftj

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

4.5% Day3 Release Rate

Testosterone Gel 9.0%

Concentration of Active (μ¾/ιηΙ ) versus Time

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell A#3 Cell A#4 Cell B#l Cell B#5 Mean 1-4 %RSD 1-4

Time

60.00 216.929 227.909 217.968 223.670 221.619 2.3

120.00 328.565 344.343 328.394 334.315 333.904 2.2

180.00 405.724 411.232 407.217 415.860 410.008 1.1

240.00 461.177 470.177 455.528 469.412 464.074 1.5

300.00 508.616 517.603 508.752 523.012 514.496 1.4

360.00 556.120 561.780 553.943 584.663 559.127 0.9

Actual Amount of Active Released ^g/cm ²) versus Time 0

Amount Released ^g/cm²)

Cell A#3 Cell A#4 Cell B#l Cell B#5 Mean 1-4 %RSD 1-4 lime

7.75 1473.119 1547.682 1480.174 1518.895 1504.967 2.3

10.95 2292.595 2402.847 2291.728 2333.549 2330.180 2.2

13.42 2909.533 2954.507 2919.917 2981.898 2941.464 1.1

15.49 3400.901 3471.148 3363.208 3483.226 3424.621 1.5

17.32 3853.539 3926.244 3853.533 3960.032 3898.337 1.4

18.97 4320.042 4372.697 4304.366 4390.861 4346.991 1.0

Slope 250.91 248.45 248.81 254.97 250.79 1.2

R¹ 0.9996 0.9994 0.9993 0.9998 0.9995 0.0

<J 6000.000

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2000.000

1000.000

I 0,000

2,00 4.00 e.oo 300 10.00 12 00 14.00 16,00 18.00 20.00

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OCel! a#1 ♦ Cell BfJi

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

System Suitability for Nasobol Gel 4.5% Day3

1: Medium (Diluent)

3: Calibration Curve Y=16446.511438x-909.542212

4: Check STD Rec. (%)

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

4.5% Day4 Release Rate

Testosterone Gel 2.25%

Concentration of Active (μ¾/ιηΙ ) versus Time

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell A#l Cell A#5 Cell B#2 Cell B#6 Mean 1-4 %RSD 1-4

Time

60.00 55.058 54.174 55.844 54.942 55.005 1.2

120.00 82.450 81.172 83.609 82.010 82.310 1.2

180.00 103.031 102.307 103.860 102.854 103.013 0.6

240.00 119.731 117.894 120.468 118.790 119.221 0.9

300.00 132.888 130.313 134.287 131.764 132.313 1.3

360.00 143.479 138.721 143.770 141.399 141.842 1.6

Actual Amount of Active Released ^g/cm ²) versus Time

Amount Released ^g/cm²)

Cell A#l Cell A#5 Cell B#2 Cell B#6 Mean 1-4 %RSD 1-4 lime

7.75 373.887 367.884 379.225 373.099 373.524 1.2

10.95 575.479 566.550 583.572 572.458 574.515 1.2

13.42 738.569 733.041 744.749 737.210 738.392 0.7

15.49 881.128 867.837 886.918 874.531 877.603 0.9

17.32 1004.352 985.530 1014.846 996.246 1000.243 1.2

18.97 1113.874 1079.499 1117.240 1098.958 1102.392 1.6

Slope 66.23 64.08 66.22 65.12 65.41 1.6

R¹ 0.9998 0.9996 0.9997 0.9998 0.9997 0.0

0.90 2M 4.00 8.00 8.00 10CC 12.5» W.CC moo tWI »00

DC»:I A#f is Ce8 A«5 C«8 Q« *C»S (M6

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

4.5% Day4 Release Rate

Testosterone Gel 4.5%

Concentration of Active (μ¾/ιηΙ ) versus Time

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell A#3 Cell A#4 Cell B#l Cell B#5 Mean 1-4 %RSD 1-4

Time

60.00 112.124 114.480 112.222 115.806 113.658 1.6

120.00 170.342 175.929 170.587 175.841 173.175 1.8

180.00 211.969 215.483 212.348 219.092 214.723 1.5

240.00 245.587 250.181 244.691 252.851 248.328 1.6

300.00 268.986 276.034 270.206 282.540 274.442 2.3

360.00 290.134 298.167 293.638 305.212 296.788 2.2

Actual Amount of Active Released ^g/cm²) versus Time

Amount Released g/cm²)

Cell A#3 Cell A#4 Cell B#l Cell B#5 Mean 1-4 %RSD 1-4 lime

7.75 761.410 777.409 762.076 786.414 771.827 1.6

10.95 1188.482 1227.088 1190.173 1226.866 1208.152 1.8

13.42 1519.360 1545.470 1522.031 1570.329 1539.297 1.5

15.49 1807.629 1842.068 1801.749 1861.571 1828.254 1.6

17.32 2036.016 2088.419 2044.251 2134.726 2075.853 2.2

18.97 2255.737 2316.823 2279.827 2368.632 2305.255 2.1

Slope 133.35 136.81 134.82 141.11 136.52 2.5

R² 0.9999 0.9999 0.9999 0.9998 0.9999 0.0

0Ccli £»1

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

4.5% Day4 Release Rate

Testosterone Gel 9.0%

Concentration of Active (μ¾/ιηΙ ) versus Time

Amount Released ^g/mL) Calculation by Linear Regression Curve

Cell A#2 Cell A#6 Cell B#3 Cell B#4 Mean 1-4 %RSD 1-4

Time

60.00 215.853 222.792 211.379 219.348 217.343 2.2

120.00 329.810 344.136 321.102 337.453 333.125 3.0

180.00 411.198 428.858 404.979 421.971 416.752 2.6

240.00 474.841 493.977 462.253 487.875 479.737 2.9

300.00 522.127 550.136 512.332 540.898 531.373 3.2

360.00 565.951 593.682 555.027 584.821 574.870 3.1

Actual Amount of Active Released ^g/cm²) versus Time

Amount Released g/cm²)

Cell A#2 Cell A#6 Cell B#3 Cell B#4 Mean 1-4 %RSD 1-4 lime

7.75 1465.812 1512.933 1435.430 1489.546 1475.930 2.2

10.95 2300.745 2399.993 2240.345 2353.636 2323.680 3.0

13.42 2946.753 3072.695 2900.791 3023.062 2985.825 2.6

15.49 3495.287 3636.250 3404.316 3589.998 3531.463 2.9

17.32 3950.753 4157.384 3875.186 4088.110 4017.858 3.2

18.97 4396.088 4608.756 4310.082 4539.429 4463.589 3.0

Slope 260.67 275.63 255.83 271.79 265.98 3.5

R² 1.0000 1.0000 0.9999 1.0000 1.0000 0.0

In Vitro Release Rate Method Validation For Nasobol Gel 4.5%

System Suitability for Nasobol Gel 4.5% Day4

1: Medium (Diluent)

3: Calibration Curve Y=16050.748753x-354.26124

4: Check STD Rec. (%)

EXHIBIT C

TBS-1 Investigator's Brochure

Product: TBS-1 , testosterone intranasal gel

Name(s) : Testosterone

Summary

TBS- 1 , a testosterone intranasal gel, is used for the treatment of primary and secondary hypogonadism. TBS- 1 is alternatively referred to as Nasobol^® or testosterone nasal gel; however, TBS- 1 will be used throughout the Investigator' s Brochure.

Testosterone, an androgen responsible for masculinization of the genital tract and the development and maintenance of male secondary sex characteristics, is indicated for the treatment of hypogonadism in men. Men with primary hypogonadism experience low testosterone levels as a result of dysfunction of the testes. In secondary hypogonadism, low serum testosterone levels are a result of defects at the level of the hypothalamus or pituitary gland. Testosterone in approved for the treatment of hypogonadism in men.

TBS- 1 is an innovative galenic formulation of testosterone for nasal administration. The nasal mucosa offers an alternative route of administration with its high permeability and ease of administration with rapid absorption into the systemic circulation. The advantages of TBS- 1 nasal gel, when compared to other formulations, include the convenient application form, the much smaller amount of active ingredient required, and lack of transference to other family members.

A large number of non-clinical, toxicology and clinical studies have been performed to support the safety and efficacy of testosterone. Testosterone replacement after castration restores both body composition and gender dependent behaviour, including sexual behaviour, in all investigated animal species. Animal toxicology studies show that an acute intoxication is nearly impossible. No evidence of systemic drug related toxicity was observed in rabbits following repeated daily administration of TBS- 1 over a 90 day period at a dose level up to 10-fold the anticipated maximum clinical daily dose. Local tolerance studies in rat and rabbit following single and repeated dose administrations showed that TBS- 1 was well tolerated. TBS- 1 was classified as a non-irritant in the HET-CAM test.

Clinical investigations in humans using different testosterone preparations have shown that testosterone replacement is generally well tolerated and safe. Studies have shown that testosterone has positive effects on sexual function (both libido and erectile function). Testosterone increases muscle mass and decreases fat mass, improves strength and increases bone mineral density. There are also data suggestive that testosterone has other beneficial effects (e.g. to improve mood, cognition).

Similar to other testosterone replacement therapies, the evaluation of TBS- l ' s efficacy for hypogonadism is primary based on PK study results. The clinical experience with TBS- 1 includes one Phase I/II study evaluating the pharmacokinetic profile of a single dose of TBS- 1 and three Phase II studies evaluating the pharmacokinetic profile following multiple doses of TBS- 1. A Phase III efficacy study and an extrinsic factor study evaluating the absorbance of TBS- 1 in men with allergic rhinitis while in symptomatic and symptomatic and treated (Oximetazoline) states are ongoing. TBS- 1 leads to transient increases in testosterone levels restoring the serum testosterone levels to normal serum testosterone ranges of young adult men (approximately 300 - 1050 ng/dL). TBS- 1 is rapidly absorbed, rapidly cleared and has a half life of 10 hours. TBS- 1 has been administered to more than 400 hypogonadal men to date. TBS- 1 has a favourable safety profile.

The clinical development program is intended to establish an optimal dosing regimen for TBS- 1 aimed at achieving physiological serum testosterone levels in the mid to lower normal range of young adult male as recommended by relevant clinical practice guidelines.

TBS- 1 is currently not approved for marketing in any country.

INTRODUCTION

Testosterone is a steroid hormone from the androgen group. It is the primary sex hormone in males and is responsible for primary and secondary sex characteristics.

Testosterone effects during puberty include the growth and maturation of the prostate, seminal vesicles, penis, and scrotum; the development of male hair distribution, such as beard, pubic, chest, and axillary hair; laryngeal enlargements, vocal chord thickening, alterations in body musculature, and fat distribution. In the adult, testosterone is necessary for spermatogenesis, stimulation of libido and normal sexual function. Testosterone also has anabolic properties in men that cause an increase in bone density and muscle mass.

TBS- 1 contains 4.5% testosterone (w/w) as the active substance. The description of the pharmaceutical formulation is provided in Section 0.

Immediately after its chemical isolation and synthesis, testosterone was introduced into clinical medicine and used for the treatment of hypogonadism. Since testosterone was ineffective when administered orally, it was either compressed into pellets and applied subcutaneously or it was used in the form of 17a -methyltestosterone. In the 1950s, longer- acting injectable testosterone esters became the preferred therapeutic modality. In the 1950s and 1960s, chemists and pharmacologists concentrated on the chemical modification of androgens in order to emphasize their erythropoetic or anabolic effects. These preparations never played an important role in the treatment of hypogonadism and were abandoned for purposes of clinical medicine. In the late 1970s, the orally effective testosterone undecanoate (TU) was added to the spectrum of testosterone preparations used clinically. In the mid 1990s, transdermal testosterone patches, applied either to scrotal or non-scrotal skin, were introduced into clinical practice. In 2000, a transdermal testosterone gel (Androgel) became available for treatment of male hypogonadism [Nieschlag and Behre, 2004] . Since then several other gels (e.g. Testim) have entered the market as well as a buccal tablet (Striant) and long-acting injectables (Depo-Testosterone, Delatestryl, Nebido [currently only outside the US]). Currently the transdermal gels are the most prescribed treatment option (IMS data 2008).

All these preparations have the ability to supplement testosterone to normal physiological levels. Gels and patches give stable testosterone in the mid or high physiological range depending on the dose applied. Injectable TU gives high levels during the first weeks after injection which gradually decline in approximately 12 weeks to low normal physiological. By providing steady state levels the normal circadian physiology is ignored.

Some of the preparations (oral TU, scrotal patches) have elevated DHT or DHT/T ratios that result in high T levels which, in individual cases, may lead to supraphysiological levels for a distinct period of time (long-acting injectables). The patches bear the risk of skin irritation, while the gels have the risk of skin-to-skin transfer of testosterone. Several cases of transfer leading to negative effects in the transferal partner have been described [Kunz et al., 2004; Brachet et al., 2005; Spielberg, 2005; Merhi and Santoro, 2007; Bhowmick et al., 2007] . Data from different groups [Cooke et al., 1993 (and references cited therein); Diver et al., 2003; Walton et al., 2007] have clearly shown that testosterone levels in young eu gonadal males are secreted in a pulsatile manner following a diurnal pattern. An example of this pattern is provided in Figure 2. 1. Testosterone levels peak in the early morning (approx. between 8-9 am) and show a nadir between 8-9 pm. Individual testosterone concentrations in 10 healthy young men fluctuate from a minimum of 1 18 ng/dL to maximally 1 1 16 ng/dL, an almost 10-fold difference. Diver et al. (2003) describe that "In each group, 50% of the subjects reached a nadir of <300 ng/dL". The lowest values are 60% below the lower limit of the physiological reference range. It should be noted that the often used normal reference ranges (300 — 1050 ng/dL) given by Meikle et al [ 1996] were derived by taking the 95% confidence intervals from morning hormone levels measured in normal men between 20-65 years old.

The height of the peak might be dependent on age or disease. In young boys before puberty [Albertsson-Wikland et al., 1997, Ankarberg 2004] and in elderly men, or men suffering from low sperm count [Hayes 2004] , sleep disturbances [Luboshitzky et al., 2001] or shift work [Touitou 1990] the peak is somewhat blunted. The evening levels are less age-dependent. If supplementation with testosterone gives stable steady state levels that are relatively low the morning testosterone peak is omitted, whereas if relatively high steady state levels are supplied the evening nadir is omitted.

Figure 2.1 : Average (± SEM) testosterone levels in eugonadal young men (n=10, age: 23- 33 year). Data from Diver et al., 2003.

0 3 6 9 12 1 5 18 21 24

Time of day

While the precise reason for the dynamics of testosterone secretion is unknown it is suggested that episodic testosterone secretion is required for the operation of the neuroendocrine axis governing testicular function [Mermall et al., 1995, Schofl 1995, Zwart et al., 1997] . Continuous exposure to testosterone might cause down-regulation of receptors and desensitization of target cells. TBS- 1 provides a transient increase in testosterone serum levels. By carefully timed application of TBS-1 , it is expected that the normal physiological increase that is seen in eugonadal men can be mimicked [Ohdo 2007, Kriegsfeld 2006, Lincoln et al., 2003, FDA 1997] . After having reached its peak, the testosterone levels will start to decrease and will approach the lower limit of what is physiologically considered to be normal.

The further development of TBS- 1 aims to explore the possibility of twice and three times daily application to provide a better and more physiological approach to testosterone supplementation in hypogonadal men.

References

Alberts son- Wikland K, Rosberg S, Lannering B, Dunkel L, Selstam G and Norj avaara E ( 1997) Twenty-Four- Hour Profiles of Luteinizing Hormone, Follicle-Stimulating Hormone, Testosterone, and Estradiol Levels: A Semilongitudinal Study throughout Puberty in Healthy Boys.' ./ Clin Endocrinol Met ab 82(2): 541 -549.

Ankarberg-Lindgren C, Norj avaara E (2004) Changes of diurnal rhythm and levels of total and free testosterone secretion from pre to late puberty in boys: testis size of 3 ml is a transition stage to puberty. Eur J Endocrinol 151:747-757.

Bhowmick SK, Ricke T, Rettig KR (2007) Sexual Precocity in a 16-Month-Old Boy Induced by Indirect Topical Exposure to Testosterone. Clinical Pediatrics 46(6): 540-543.

Brachet C, Vermeulen J, Heinrichs C (2005) Children's virilization and the use of a testosterone gel by their fathers. Eur J Pediatr. , 164( 10):646-647.

Cooke RR, Mcintosh JEA, Mcintosh RP ( 1993) Circadian variation in serum free and non-SHBG-bound testosterone in normal men: measurements, and simulation using a mass action model. Clin. Endocrinol., 39, 163-171 .

Diver MJ, Imtiaz KE, Ahmad AM, Vora JP, Fraser WD (2003) Diurnal rhythms of serum total, free and bioavailable testosterone and of SHBG in middle-aged men compared with those in young men. Clin.

Endocrinol. , 58, 710-717.

FDA Homepage (Stehlin I), A Time to Heal: Chronotherapy Tunes In to Body's Rhythms,

http://www.fda.gov/fdac/features/1997/397_chrono.html, 1997.

Hayes and Pitteloud, H ypo go n ado trophic hypogonadism (HH) and gonadotropin therapy,

http://www.endotext.org/male/, 2004.

Kriegsfeld LJ, Silver R (2006) The regulation of neuroendocrine function: Timing is everything. Horm Behav. 49(5): 557-574.

Kunz GJ, Klein KO, Clemons RD, Gottschalk ME, Jones KL (2004) Virilization of young children after topical androgen use by their parents. Pediatrics, 114( l ):282-284.

Lincoln GA, Andersson H, Loudon A (2003) Clock genes in calendar cells as the basis of annual timekeeping in mammals--a unifying hypothesis. J Endocrinol 179( 1 ): 1 - 13.

Luboshitzky R, Zabari Z, Shen-orr Z, Herer P, Lavie P (2001 ) Disruption of the Nocturnal Testosterone Rhythm by Sleep Fragmentation in Normal Men. J. Clin. Endocrinol. Metab.86(3): 1 134- 1 139.

Meikle AW, Arver S, Dobs AS, Sanders SW, Raj aram L, Mazer NA ( 1996) Pharmacokinetics and metabolism of a permeation-enhanced testosterone transdermal system in hypogonadal men: influence of application site- - a clinical research center study J Clin Endocrinol Metab; 81: 1832 - 1840.

Merhi ZO, Santoro N (2007) Postmenopausal virilization after spousal use of topical androgens. Fertil Steril. , 87(4):976.e l 3-5.

Mermall H, Sothern RB, Kanabrocki EL, Quadri SF, Bremner FW, Nemchausky BA, Scheving LE ( 1995) Temporal (Circadian) and functional relationship between prostate-specific antigen and testosterone in healthy men. Urology 46:45-53.

Ohdo S (2007) Chronopharmacology focused on biological clock. Drug Metab Pharmacokin 22( 1 ):3- 14.

Schofl C, Prank K, Brabant G. ( 1995) Die Bedeutung pulsatiler Hormonsekretion fur die Steuerung von Zielorganen. Wien Med Wochenschr.17/18:43 1 -435. Spielberg TE (2005) Abnormal testosterone levels in partners of patients using testosterone gels. J Sex Med. ^ 2(2):278.

Touitou Y, Motohashi Y, Reinberg A, Touitou C, Bourdeleau P, Bogdan A, Auzeby A. ( 1990) Effect of shift work on the night-time secretory patterns of melatonin, prolactin and testosterone. Eur J Appl Physiol 60:288- 292.

Walton MJ, Anderson RA, Kicman AT, Elton RA, Ossowska K, Baird DT (2007) A diurnal variation in testicular hormone production is maintained following gonadotrophin suppression in normal men. Clin.

Endocrinol. , 66, 123- 129.

Zwart AD, Iranmanesh A, Veldhuis JD ( 1997) Disparate Serum Free Testosterone Concentrations and Degrees of Hypothalamo-Pituitary-Luteinizing Hormone Suppression Are Achieved by Continuous Versus Pulsatile Intravenous Androgen Replacement in Men: A Clinical Experimental Model of Ketoconazole-Induced

Reversible Hypoandrogenemia with Controlled Testosterone Add-Back, J Clin Endocrinol Metab 82(7):2062- 2069.

Physical, Chemical, and Pharmaceutical Properties, and Formulation

TBS- 1 is a bioadhesive intranasal gel containing 4.5% testosterone.

Drug Substance

The steroid hormone testosterone is the active ingredient in TBS- 1 gel. The manufacture of the drug substance presents no potential risk for humans; the synthesis route is well- characterized.

Table 3.1- 1 : Nomenclature Testosterone

Figure 3. 1- 1 : Structural Formula

Molecular Formula

C19H28O2

Relative Molecular Mass

288.4 Physical Chemical Properties

The physical chemical properties of testosterone are listed in Table 3. 1.1- 1.

Table 3.1. 1- 1 : General Properties of Testosterone

Drug Product

Composition

TBS- 1 gel is a viscous and thixotropic, oil-based formulation containing testosterone intended for intranasal application. The non-irritating formulation is designed to adhere to the inner nose. In addition, it acts as a controlling matrix, thus allowing sustained drug delivery through the nasal mucosa.

Other pharmacologically inactive ingredients in the testosterone intranasal gel are castor oil USP, oleoyl polyoxylglycerides Ph.Eur./NF and colloidal silicon dioxide NF. None of these excipients are of human or animal origin. All excipients are well-known and listed in the "Inactive Ingredient" list for Approved Drug Products issued by the FDA.

A detailed description of the batches is shown in Table 3.2. 1- 1.

Table 3.2.1- 1 : Composition of TBS- 1

For clinical trial supplies, testosterone intranasal gel is supplied in a multiple dose dispenser. The dispenser is a finger actuated dispensing system designed to dispense 5.5 mg of 4.5% TBS- 1 gel per actuation from a non-pressurized container into the nasal cavity. The dispenser is designed to deliver 45 doses (90 actuations) of TBS- 1. The key components of the multiple dose dispenser include a barrel, base, pump, and actuator, which are composed of polypropylene and a piston, which is composed of polyethylene. 3.2.2 Administration of TBS- 1

No preparation of TBS- 1 is required before administration.

TBS- 1 is administered by the patient. Specific administration instructions are appended to each protocol. In general, the patient is instructed to:

• Blow your nose to clear your nostrils.

• Place your finger on the pump of the actuator and, in front of a mirror, advance the tip of the actuator into your left nostril until the finger on the pump reaches the base of the nose.

• Aim the tip of the actuator to the inner corner of your left eye. The opening on the tip of the actuator must face the skin that lines the inner nose.

• Depress the pump until it stops.

• Slowly remove the actuator from your nose.

• Wipe away any gel that remains on the tip of the actuator using a clean dry swab.

• Repeat process for the right nostril.

• Press the nostrils together lightly and massage for 1 second.

• Do not blow your nose or sniff for 1 hour after administration of the medication.

3.2.3 Recommended Storage Conditions

TBS- 1 is stored at room temperature (20 - 25°C or 68 - 77°F) . Temperature excursions from 15 to 30°C or 59 to 86°F are permissible for TBS- 1 . The stability data available to date are conclusive to support a 24-month shelf life.

Nonclinical Studies

Since the isolation and chemical synthesis of testosterone by Brnst Laqueur and his group in 1935, a large number of non clinical pharmacology and toxicology studies have been conducted to support the safety of testosterone in humans . In addition to the studies referenced in the literature (summarized by Nieschlag and Behre (2004)), the sponsor has performed repeat dose toxicity and single and repeat dose local tolerance studies to support the safety of TBS- 1 .

4.1 Pharmacology

4. 1 . 1 Primary Pharmacodynamics

The pharmacodynamic effects of testosterone were evaluated in intact, castrated, and aged animals.

The density of androgen receptors depends on the testosterone concentration, i.e., the number of receptors significantly decreases following castration and can be restored up to the control levels with testosterone replacement. Testosterone replacement also restored functional deficits caused by castration or aging of the animals. However, in castrates, the success of hormone replacement was dependent on how much time has passed since castration. The function regulation due to testosterone replacement was dependent on how much time has passed since castration. The functional regulation due to testosterone replacement included either sexual or behavioral functions. Typical male aggressive behavior which is steered by testosterone concentration is restored in both castrated and aged animals following testosterone replacement.

4.1.2 Secondary Pharmacodynamics

In men, testosterone significantly influences the body composition. Androgen deficiency is associated with reduced bone mineral density, increase in body fat and decrease in lean body weight. Studies have been performed in animals to determine the role of testosterone on body composition. Supraphysiological testosterone administration successfully prevents orchiectomy- induced skeletal catabolism (Turner 1990) and enhances bone strength and mass in gonadectomised male and female rats (Yarrow et al., 2008). Gentile et al. (2010) showed that aged castrated rats develop increased fat mass, reduced muscle mass and strength and lower bone mass. Treatment with testosterone or DHT reverses the effects on muscle and adipose tissue while only aromatizable testosterone increased bone mass.

4.2 Pharmacokinetics and Metabolism in Animals

4.2. 1 Nasal Administration

A toxicokinetic study has been performed as supportive data to the 90-day repeat-dose intranasal toxicity studies in female rabbits (#227422) using TBS-2. TBS-2 is a testosterone gel manufactured by the applicant in which the concentration of testosterone is ten times less than TBS- 1. In the repeat-dose toxicology study, blood samples were collected on Day 1 and Day 90 for determination of serum levels of testosterone and its metabolites, DHT and estradiol. Testosterone was rapidly absorbed and exhibited dose-proportional kinetics. After 90 days of dosing and in comparison to Day 1 , there were no significant differences between the serum exposure and TK parameters for testosterone at the low TBS-2 gel dose, however there was an apparent 30% reduction of C_max and 31 % reduction of the AUCo-8 hr- At the high dose TBS-2 gel and in comparison to Day 1 , the serum exposure to testosterone was lower as indicated by a significant reduction of AUCo-8hr (59%) and C_max (45%) accompanied by a significant increase (2.6-fold) in the Vz/F (apparent fluid volume in the body necessary to maintain the total dose of drug at the concentration found in the serum) and an apparent increase (2.3-fold) in CL/F (apparent volume of serum per unit time from which drug is completely removed). Thus, 90-day dosing with low and high dose TBS-2 gel did not result in accumulating levels of testosterone in the serum. Rather, 90-day dosing with TBS-2 gel resulted in dose-dependent decreases of the serum levels of testosterone compared to Day 1 likely due to the increased clearance and volume of distribution of testosterone.

DHT levels were above the limit of detection in most but not all serum samples on Day 1 post treatment with high dose TBS-2 gel, while at the lower dose, DHT levels were below either the limit of quantification or limit of detection. At Day 90 for both the high and low doses of TBS-2 gel, the majority of serum samples were below the limit of detection (BLD) for DHT. Estradiol could not be detected in any of the serum samples analyzed.

Figure 4.2.1- 1 : Mean Serum Concentration-Time Profiles of Testosterone on Day 1 and Day 90: Testosterone concentration-time profiles are shown following low (0.6%) and high (0.9%) dose TBS-2 gel treatment to rabbits on (A) Day 1 and (B) Day 90. Data are presented as the mean ± SE.

Day 90

Time (hr) 4.2.2 Metabolism

Testosterone is extensively metabolized by cytochrome P450 3A4 (CYP3A4) aromatase, and 5-alpha-reductase. CYP3A4 metabolizes testosterone primarily in the liver by conversion to various hydroxyl steroids. The active metabolites of testosterone are DHT and estradiol. Testosterone is metabolized to DHT by steroid 5-alpha reductase in many tissues. Testosterone is metabolized to estradiol by aromatase.

4.2.2.1 Metabolism in Nasal Mucosa

The nasal mucosa is a metabolically active tissue and is able to metabolize xenobiotics.

Experiments in animals showed that testosterone is minimally metabolized in the nose. The main metabolites of testosterone after nasal administration were 4-androstene-3, 17-dione, 5cx- dihydrotestosterone, 3cx-hydroxy-5cx-androstane- 17-one, and 5cx-androstane-3alpha, 17-beta- diol (Brittebo 1984). These metabolites were identified in in vitro investigations using the nasal septa of F-344 rats and indicated the presence of 5cx-reductase, 3- and 17- hydroxysteroid dehydrogenase in the nasal mucosa.

The main metabolites in men and minipigs were dihydrotestosterone and estradiol, indicating that the minipig is a very suitable model for testosterone kinetics in men, including absorption behavior. In rhesus monkeys, dihydrotestosterone is also an important metabolite. In contrast to humans, minipigs and rhesus monkeys, DHT is not a main metabolite in dogs.

4.2.3 Distribution

Circulating testosterone in plasma exists either tightly bound to SHBG (sex hormone binding globulin; a plasma protein synthesized in the liver that specifically binds steroid sex hormones — approximately 65-80%), weakly and reversibly bound to albumin (approximately 20-30%) or as free testosterone (0.5— 2%). The albumin bound fraction and the unbound fractions are collectively termed "bioavailable" testosterone.

4.2.4 Elimination

About 90% of a dose of testosterone given intramuscularly is excreted in the urine as glucoronide and sulfate conjugates of testosterone and its metabolites; about 6% of a dose is excreted in the faeces, mostly in unconjugated form.

4.3 Safety Pharmacology

4.3. 1 Safety Pharmacology Studies Performed by the Sponsor

Separate safety studies have not been performed; however, safety pharmacology evaluations of TBS-2, including effects on function of the nervous system, cardiovascular and respiratory system were incorporated into a 90 day repeat dose toxicity study in rabbits (Study #227422). TBS-2 is a testosterone gel manufactured by the applicant in which the concentration of testosterone is ten times less than TBS- 1.

A neurological examination for motor activity and sensory activity to visual, audio and proprioceptive stimuli was conducted in this GLP compliant 90-day repeat-dose toxicity study. In this study, rabbits received TBS-2 daily for 90-days at a dose of 0 (vehicle control), 0.12 mg/kg, 0.24 mg/kg or no treatment. Neurological evaluation (FOB — Functional Observation Battery testing) which included approach response, touch response, auditory response, pain perception, eye blink response, righting reflex, pupil response, pinna reflex and proprioception were performed on all animals during the pre-treatment period, once on study Day 45 and again during the last week of dosing, and on all recovery animals during the last week of the study. Cardiovascular and respiratory safety assessments were also performed evaluating heart rate, blood pressure and respiratory rate.

There were no significant differences in the neurological, cardiovascular and respiratory evaluations between the control groups and the two TBS-2 groups.

4.3.2 Safety Pharmacology Studies Reported in the Literature

4.3.2.1 Influence on the cardiovascular and renal system

Androgen treatment in men has been linked to increases in blood pressure. Experiments were conducted by Seachrist (2000) in spontaneously hypertensive rats (SHR) to determine the mechanism by which testosterone elevates blood pressure. In the SHR rats, testosterone significantly increased blood pressure while castration significantly decreased blood pressure. Testosterone replacement in the castrated rats increased blood pressure but not completely to that of the control levels. The increase in blood pressure was partially caused by a structural change of increased collagen deposition to the coronary arteries in addition to a testosterone induced increase of angiotensin II. Further evidence of the influence of androgen with the rennin-angiotensin system has been demonstrated in Wistar Kyoto rats. Castration lowered angiotensinogen mRNA levels in male rats while female rats with T implants showed an increase in renal angiotensinogen mRNA levels. Testosterone has also been shown to increase plasma levels of endothelin- 1 which can act as a vasoconstrictor (Polderman, 1993).

4.3.2.2 Influence on lipid and liver function

In men, androgen therapy is associated with a shift in lipoprotein fractions. This shift is a known risk factor for coronary artery disease. Furthermore, androgen use is known to increase liver transaminases in certain ethnic populations. Therefore, there is a need to monitor the effects of repeated and long-term use of androgen on lipid and liver function parameters.

A study was performed by Tyagi et al. (1999a, 1999b) in rhesus monkeys to further understand the influence of long term testosterone intramuscular administration on lipid metabolism and liver function. Monkeys received bimonthly administration of 50 mg testosterone enanthate (TE) for 32 months. TE increased serum testosterone levels into the supraphysiological range one day after injection and peak levels were seen on Day 3, followed by a decrease to above baseline levels by Day 14.

Long-term treatment with intramuscular testosterone enanthate (TE) altered the pattern of testosterone metabolism by the liver. In control animals, the liver converted testosterone to androstenedione as the major metabolite whereas androsterone was the major metabolite in chronically TE treated animals. The percentage of DHT formed was significantly higher in animals chronically treated with TE. The percentage of testosterone which remained un- metabolized was similar in TE treated and control animals.

Long-term treatment with TE also altered lipid parameters. In TE treated animals, high density lipoprotein cholesterol (HDL-C) levels decreased gradually compared to baseline values and the decrease was significant from the 19^th month of injections until the first month of recovery. This decrease in HDL-C was significant when compared to control animals from the 12^th month of injection until the first month of recovery. Low density lipoprotein cholesterol (LDL-C) levels increased significantly in TB treated animals compared to control levels from the 12^th month of injections until the end of the study period. The BD /HDB-C ratio was also elevated following TE injections.

TB injections did not change the levels of triglycerides, alkaline phosphatise or bilirubin compared to baseline or control animals. Transaminase (SGOT and SGPT) levels increased following TE injections and remained elevated until the end of injections followed by a return to baseline values or below during the recovery period.

Toxicology

TBS- 1 is an intranasal gel that contains the following ingredients: testosterone, castor oil, olyeol polyoxylglycerides (Labrafil^®), and colloidal silicon dioxide. Testosterone, the active ingredient of TBS- 1 , has an established safety record with over 50 years of accumulated clinical experience. Testosterone' s animal toxicology, mutagenicity and teratogencity are already well described in the individual product monographs or currently approved products as well as in the published literature.

Castor oil, olyeol polyoxyglycerides and colloidal silicon dioxide have a long history of use as inactive ingredients in human topical, intravenous, ophthalmic, vaginal, nasal and inhalation products.

To supplement the toxicology studies referenced in the literature, a series of studies has been performed to assess the toxicology and local tolerance of the TBS- 1 and TBS-2 testosterone intranasal gels. The only difference between TBS- 1 and TBS-2 is the testosterone concentration. The concentration of testosterone in TBS- 1 is ten times greater than that of TBS-2.

Four GLP compliant nonclinical toxicology studies have been completed with TBS- 1 intranasal gel as presented in Table 4.4- 1. The results of each study are summarized in sections 4.4.2. 1 through 4.4.2.2 that follow.

Table 4.4- 1 : Summary of GLP Animal Toxicity Studies with TBS- 1

4.4. 1 Single Dose Toxicity Studies

Data on the toxicity of testosterone after single-dose administration have been compiled in Table 4.4. 1- 1.

Table 4.4. 1- 1 : Toxicity of Testosterone after Single Dose Administration

Species Parameter Route Dose Symptoms/effect Reference (mg/kg)

Arc ti tons a LC₁₀ water 2.5 mg/1 Not reported. [Andersen, H. R. (copepod) 2001 ]

Arcatia tonsa LC₅₀ water 5.6 mg/1 Not reported. [Andersen, H. R. (copepod) 2001 ]

Mammal, not LD₅₀ p .o > 5 ,000 Not reported. [RTECS 2002] specified

Rat LDLo i.p . 326 Lungs, thorax, respiration [RTECS 2002]

(other effects)

4.4.2 Repeat Dose Toxicity Studies

4.4.2.1 Repeat Dose Toxicity Study Performed by the Sponsor

4.4.2.1. 1 Repeat Dose Toxicity Study of High Dose Testosterone Intranasal Gel in Male Rabbits (Study number 227120417)

Testosterone intranasal gel was administered intranasally to male rabbits twice a day for three month (90 days) at concentrations of 0.093 mg/kg, 0.550 mg/kg and 1.867 mg/kg ( lx, 5x and lOx the proposed clinical concentration for the treatment of hypogonadism in males; approximately lOx, 50x and lOOx the proposed clinical concentration for the treatment of anorgasmia). Study controls included a negative control (no treatment) and a placebo control (gel base minus testosterone). Testosterone and DHT levels were assessed on Day 0, 45 and 90 of the study. Animals were observed daily for signs of systemic toxicity and sacrificed at the end of the study to determine any signs of tissue pathology. This study was performed in accordance to GLP requirements.

The rabbits did not show any evidence of systemic toxicity during the in-life observations in the treatment and control animals. There were no abnormal histopathological findings in the nasal turbinates, brain, testes, heart, kidneys, and lungs. Incidence and severity of centrilobular/midzonal glycogenic vacuolation in the liver were marginally greater in the high-dose testosterone group in comparison with the untreated control. All other changes were considered to be part of the normal background, including minimal inflammatory foci seen in the nasal turbinates, heart, lungs, and liver.

In summary, administration of testosterone intranasal gel for three months at doses up to the 100-fold of the proposed female dose was not associated with any local or systemic toxicity in the organs examined, including the nasal turbinates, brain, testes, heart, kidneys, and lungs.

4.4.2.1 .2 Repeat Dose Toxicity Study of Low Dose Testosterone Intranasal Gel in Female Rabbits (Study number 227422)

The toxicity of intranasal TBS-2 was investigated in a 90-day repeat dose study in female rabbits. The rabbits were dosed intranasally at the following dose levels 0. 12 mg/kg and 0.24 mg/kg daily for 90 days. A third group of animals received a placebo gel (TBS-2 gel minus testosterone) and a fourth group (control) were not dosed. Each group of rabbits (n=10) consisted of a Main Study group (n=5) and a Recovery period group (n=5).

At the end of the treatment period, all Main Study animals were sacrificed and submitted for gross necropsy. The Recovery animals were sacrificed at the end of the 30-day recovery period. Clinical reactions to treatment were monitored as well as body weight assessment, food consumption, ophthalmology, clinical pathology, gross pathology and organ weights. Blood samples were collected on Day 1 and Day 90 for determination of serum levels of testosterone and its metabolites. Histopathology evaluations were performed on a comprehensive range of organs from the placebo and high-dose groups (Main Study and Recovery). The study was performed in accordance to GLP requirements.

The rabbits did not show any evidence of systemic toxicity during the in-life observations in the treatment and control animals. There were no abnormal histopathological findings in any organ/tissue examined.

Testosterone was rapidly absorbed and exhibited dose-proportional toxicokinetics. DHT levels in the serum were approximately 15% of serum testosterone levels, which is consistent with the literature. Bstradiol could not be detected in the serum.

In summary, under the conditions of this experiment, the no observed effect level (NOBL) of TBS-2 testosterone gel, when administered intranasally to female rabbits for 90 days, was considered to be equal to 0.24 mg/kg/day, the highest dose tested, based on lack of toxicity during the 90-day study period. The dose levels of 0. 12 mg/kg and 0.24 mg/kg represent approximately 7.5x and 15x anticipated human therapeutic dose of 1.2 mg (based on 75 kg woman) .

4.4.2.2 Repeat Dose Toxicity Studies from the Literature

Repeat-dose toxicity studies were performed on rodents. The results have been compiled in Table 4.4.2.2- 1. Depending on the mode of administration, the lowest toxic dose ranged from 6.25 mg/kg to 400 mg/kg. The main results were the development of tumours in the experimental animals. The role of testosterone in tumourigenicity is discussed in detail under "Carcinogenicity" (including supportive toxicokinetics evaluations).

The toxicity of repeated doses of testosterone depends on the dose and duration of administration. Testosterone stimulated the tumourigenesis in rodents. No special problems concerning the gastrointestinal tract, blood and blood formation or any other frequent adverse events of drug use were observed.

Table 4.4.2.2- 1 : Repeat Dose Toxicity in Animals

Species Parameter Route Dose Symptoms/effect Reference

(mg/kg)

Mouse TDLo p .o. 6,25ο¹ Tumourigenic — ovarian [RTECS 2002] tumours

Mouse TDLo s .c. 30² Tumourigenic— adrena! cortex [RTECS 2002] tumours, other reproductive

system tumors

Mouse TDLo Implant 400³ Tumourigenic — ovarian [RTECS 2002] tumours

Mouse⁴ Implant 1 -2 mg⁵ Cervicai/uterine tumours [HSDB 2002]

(6 1 .9%), metastases/

infi!tration into the lungs

(38.5% of anima!s with

tumours)

Rat⁶ Imp!ant 1 -3x 10 prostatic carcinoma (0%, [HSDB 2002] mg⁷ 16.7 %, 20%), metastasis

(about 40%), incidence in

untreated contro!s 0.48 %

52 d continuous

5 d intermittent

50 d continuous

Strain: C57BLXDBA

twice weekly for life span

Strain: NB

up to 91 weeks, change of implants every 6-8 weeks 4.4.3 Geno toxicity

The genotoxicity profile of testosterone has been evaluated in a wide range of well designed (including all ICH endpoints) in vivo and in vitro studies reported in the literature and have been compiled in Table 4.4.3- 1.

Table 4.4.3- 1 : Mutagenic and Genotoxic Activity of Testosterone

Type of test Route of exposure Test system Dose duration Reference

Cell transformation in vitro Syrian hamster 1 -30 μg/ml [Tsutusi, T. 1995] embryo cells

Cytogenetic in vitro Human kidney 100 μπιο1/1 [RTECS 2002] analysis

DNA damage in vitro Mammal 1 μ mo 1/1 [RTECS 2002]

(unspecified) liver

DNA damage in vitro Mammal 10 μπιο1/1 [RTECS 2002]

(unspecified)

lymphocytes

DNA damage in vitro Mouse liver 100 μπιο1/1 [RTECS 2002]

DNA inhibition in vitro Human kidney 100 μπιο1/1 [RTECS 2002]

DNA inhibition in vitro Human lymphocyte 50 μιτιοΐ/l [RTECS 2002]

DNA inhibition in vitro Rat liver 100 μπιοΐ/ΐ [RTECS 2002]

Mitotic Acute/chronic Drosophila 0-4 mmol/1 [Vogel, E. W. recombination feeding, surface me la nog a s te r (eye 1993]

treatment, mosaic assay)

inhalation

Morphological in vitro Hamster embryo 5 mg/1 [RTECS 2002] transformation

Recombination in vitro Saccharomyces 0- 10 mg/ml [Fahrig, R. 1996] (without metabolic cerevisiae MPI

activation)

Recombination in vitro Saccharomyces 0- 10 mg/ml [Fahrig, R. 1996] cerevisiae MPI

(with metabolic

activation)

Sperm morphology Parenteral Non-mammalian 12 mg/8 wk, [RTECS 2002] species intermittent

Unscheduled DNA Parenteral Rat 10 mg/kg [RTECS 2002] synthesis

Testosterone was reported as being non-mutagenic in a range of assays evaluating effects on chromosomes: in the Ames test in bacteria, in a mouse lymphoma assay and in chromosomal aberration tests (HeLa cells, human synovial cells, Chinese hamster Don cells) except in the Chinese hamster lung cells where a clastogenic response was observed at the highest dose tested corresponding to cytotoxic dose levels. Three mouse micronucleus tests were reported from different laboratories, and all were negative. An absence of DNA adducts was further reported. In in vivo tests, testosterone was non-mutagenic in two micronucleus tests in mice and in one chromosomal aberration test (sperm head morphology and chromosomal aberrations bone marrow) in rats. The results of these studies consistently confirm the lack of a genotoxic effect with testosterone.

4.4.4 Carcinogenicity

A substantial body of literature demonstrates that as expected for a hormonally active compound, tumour incidence can be increased in hormonally responsive organs and tissues including endometrium, mammary glands, liver and prostate. A summary of these animal studies is listed in Table 4.4.4- 1.

In 1987, the International Agency for Research on Cancer (IARC Supplement 7) concluded in the overall evaluation that androgenic (anabolic) steroids are probably carcinogenic in humans.

Table 4.4.4- 1 : Carcinogenity of Testosterone

Species Organ Route Dose Symptoms/effect Reference

system (mg/kg)

Rat (Lobund Prostate TP Depot + 50mg Prostate adenocarcinoma [Pollard 1986] Wistar) N-nitrioso-N- every 2m

methylurea

Rat (Wistar) Prostate BOP + 100 Prostate adenocarcinoma, [Pour 1987] mg/kg urinary bladder papillomas

TP

every 21 and carcinomas

injection

d

Pellet

35-45 mg

every 6 w

Rat (F344) Prostate TP implant Every Reduced incidence of atypical [Cui 1998]

40d hyperplasia of the ventral

prostate

Rat (Noble) Prostate TP implant 30 mg/6- Increase in carcinoma of the [Noble 1977] prostate

Rat (F344) Prostate TP 40 mg/6 Decrease in incidence of [Shirai 1994]

DMAB weeks typical hyperplasia of the

ventral prostate and seminal

vesicles; increased the

incidence of atypical

hyperplasia and carcinomas of

the dorsolateral and anterior

prostate

Rat (NBL/Cr Prostate TP + Every 6m Prostatic adenocarcima (lower [Bosland 1995] and Sprague estradiol incidence in Sprague Dawley

Dawley) 17β rats)

Rat (F344 NCr) Testicular T implant Addition of T abolished [Waalkes 1997] cadmium induction of leydig

Cadmium

cell tumours. Increased incidence of histiocytic

sarcoma; reduced incidence of

fibrosarcoma

Rat (Noble) Mammary TP implant 120 mg Mammary gland [Xie 1999] carcinogenesis

Rat (Wistar) Mammary TP implant 50 mg Acinotubular differentiation, [Chambo-Filho gland hyperplasia 2005]

Guinea pig Ovarian TC 232 benign cysts, small adenomas [Silva 1997]

500ng/m in the ovary parenchyma and

papillomas on the ovarian

surface

Mice Cervical- TP implant l -2mg Cervical uterine tumours [HSDB 2002]

(c757BLXDBA) uterine

2x/wk

4.4.5 Reproductive and Developmental Toxicity

4.4.5.1 Prenatal Development

Mammalians -Fertility and early embryonic development

Both female and male animals showed changes in the structure and function of the genital organs if the animals were treated with testosterone before mating (RTBCS 2002). These disturbances probably contributed to the effects observed with regard to the fertility of the animals.

The administration of testosterone before mating or after conception disturbed different parameters of fertility (e.g. female fertility index, increased pre-implantation mortality). These effects were observed in rodents (e.g. rats, rabbits, hamsters) and other domestic animals (RTECS 2002).

Mammalians— Embryo-fetal development

Besides a higher incidence of fetal death in testosterone-treated animals, specific developmental abnormalities were observed in animals and human beings (RTBCS 2002).

The specific developmental abnormalities included the urogenital tract, endocrine organs and skin and skin appendages. Female offspring was masculinised dependent on the dose and time of testosterone administration.

In a study in rats, high levels of testosterone treatment on the 14^th day of gestation caused the mammary glands in the offspring of both sexes to be smaller or absent, and the nipples were absent in female offspring. Testosterone had no effect on female masculinisation at 0. 1 mg (HSDB 2002).

4.4.5.2 Postnatal development

In mice, it was shown that the live birth index and the viability index were lower; in other animals behavioural disturbances were observed (HSDB 2002, RTBCS 2002).

4.4.6 Bocal Tolerance Experimental studies on an ex vivo model and animal experiments in rats and rabbits were performed to determine the local tolerance of a high dose of testosterone intranasal gel (Confarma Study Report 208040401 , 208040402, 208040403). All studies were performed according to European Union medicinal product testing guidelines. The high dose testosterone intranasal 3.5% gel, TBS- 1 was used in the local tolerance studies. The only difference between TBS- 1 and TBS-2 is a 10 fold greater concentration of testosterone (3.5 mg/ml vs 0.3 mg/ml). Therefore, the results of local tolerance studies using the high dose testosterone intranasal gel also apply for the low dose testosterone intranasal gel.

HET-CAM (#208040403)

This ex vivo test system⁸ is widely used for assessing the dermal and mucosal tolerance. The test was carried out according to GLP both for the testosterone intranasal gel test product and for the neutral oil (Mygliol DAC) used as a negative control. The overall result showed that TBS- 1 is not an irritant.

Local tolerance after single-dose administration (#208040401)

Single dose local tolerance studies have been conducted in rats and rabbits, in which 0.1 ml of 3.5% testosterone intranasal gel was introduced in one nostril and the same amount of control (neutral oil Myogliol DAC) was applied to the other nostril. Local reactions were observed for a period of 4 hours whereupon the animals were sacrificed and the nasal mucosa was subjected to histopathology examination. No reactions were observed during the 4 hours observation period and no abnormal histopathological findings were observed following administration of testosterone intranasal gel or the control. Hence, the testosterone intranasal gel is well tolerated intranasally following single-dose administration.

Local tolerance after repeat-dose administration (#208040402)

Repeat dose local tolerance studies have been conducted in rats and rabbits, in which 0. 1 ml of 3.5% testosterone intranasal gel was introduced in one nostril and the same amount of control (neutral oil Myogliol DAC) was applied to the other nostril for a duration of 14 days. Local reactions were observed throughout the 2-week study following which the animals were sacrificed and the nasal mucosa was subjected to histopathology examination. No reactions were observed during the 2 week study period and no abnormal histopathological findings were observed following administration of the testosterone intranasal gel (3.5%) or the control. Hence, testosterone intranasal gel (3.5%) is well tolerated intranasally following repeat-dose administration.

4.5 TBS- 1 Inactive Ingredients

Excipients

None of the excipients in TBS- 1 is of human or animal origin. All excipients are well-known, have USP and EP monographs and are listed in the "Inactive Ingredient" list for Approved Drug Products issued by the FDA.

Castor oil

The chorion allantois membrane of chicken eggs incubated for 10 days is exposed. Although this already contains blood vessels, it does not yet contain any neuronal pathways. Solutions or suspensions applied on this thin membrane induce hyperalgia, thrombosis or bleeding in the blood vessels within seconds to minutes. Castor oil has been widely used as an excipient in EME A/FDA- approved approved medicinal products applied by different administration routes, e.g., i.m. injection, ophthalmic emulsions, sublingual tablets or topical emulsions/creams/ointments/solutions including an intramuscular testosterone product Depot 250 and Primbolan Depot from Schering.

Hence, it can be deduced that since castor oil is suitable for an application form where safety and tolerance are of highest importance as in injectables and ophthalmic preparations, it should be safe in a nasal product. Castor oil has not yet been approved in nasally applied preparations .

Oleoyl polyoxylglycerides

According to the "Handbook of Pharmaceutical Additives" oleoyl polyoxylglycerides is used as a hydrophilic oil for topicals, injectables and nasal products. In FDA-approved drugs, it is used as a co-emulsifier in topical emulsion/lotion/cream and vaginal emulsion/cream.

In France, this excipient is approved for nasal preparations such as "Rhino-Sulforgan" from Laboratoire Jolly-Jatel/France and "Huile Gomenolee 2%" from Laboratoire Gomenol/France. Rhino-Sulforgan contains 10% of oleoyl polyoxylglycerides in peanut oil (active ingredient sulfur) and is intended for patients suffering from infections of the nasal mucus, of rhinopharyngitis and of sinus ostium permeable. Huile Gomenolee containing 10% of oleoyl polyoxylglycerides in olive oil is an antiseptic (active ingredient gomenol).

It can be deduced that since oleoyl polyoxylglycerides oil is suitable for an application form where safety and tolerance are of highest importance as in injectables, nasal and vaginal preparations, and is approved in a nasal preparation, it should be safe as an excipient in TBS- 1.

Colloidal silicon dioxide

According to the "Handbook of Pharmaceutical Additives" colloidal silicon dioxide is used as an oil adsorbent, thermal stabilizer and gellant.

In FDA-approved drugs, it is used as an excipient in dental gel, sublingual tablet, endocervical gel, suppository, vaginal emulsion/cream/tablet/tampon, and capsules for inhalation. Furthermore, it is used as an excipient in "Testoderm" with adhesives (Alza Corporation) for a transdermal testosterone patch and it is an excipient in Testoderm (adhesive layer of TTS) from Alza Corporation.

Hence, it can be deduced that colloidal silicon dioxide is suitable for an application form where safety and tolerance are of highest importance as in preparations for endocervical, inhalation, rectal and vaginal use, it should be safe as an excipient in TBS- 1.

4.6 References to the Nonclinical Chapter

Andersen, H. R., Wollenberger, L., Halling-Sorensen, B. et al. Development of copepod nauplii to copepodites— a parameter for chronic toxicity including endocrine disruption. Environ. Toxicol Chem 2001 : 20, 2821 -2829.

Bosland, MC, Ford H, Horton L. Induction at high incidence of ductal prostate adenocarcinomas in NBL/Cr and Sprague-Dawley Hsd:SD rats treated with a combination of testosterone and estradiol- 17 b or diethylstilbestrol Carcinogenesis 1995: 16, 131 1- 17.

Brittebo EB, Rafter JJ. Steroid metabolism by rat nasal mucosa: studies on progesterone and testosterone. J Steroid Biochem. 1984:20(5), 1 147-51.

Chambo-Filho A, Camargos AF, Pereira FEL. Morphological changes induced by testosterone in the mammary gladns of female Wistar rats. Br J Med Biol Res. 2005: 38, 553-58.

Confarma Study Report 208040401 : Study of local tolerance single application. 2004 Confarma Study Report 208040402: Study of local tolerance repeated application during 2 weeks. 2004

Confarma Study Report 208040403: Study of HETC AM according to the official method for the assessment of the irritation potential through application of the chorio-allantois membrane of the Hen's Egg. 2004

Confarma Study Report 227120417: Three month toxicity study. 2005

Cui L, Mori T, Takahashi S, et al., Slight promotion effects of intermittent administration of testosterone propionate and/or diethylstilbestrol on 3,2'-dimethyl-4-aminobiphenyl-initiated rat prostate carcinogenesis. Cancer Letters 1998: 122, 195- 199

Fahrig, R. Anti-mutagenic agents are also co-recombinogenic and can be converted into co-mutagens. Mutat.Res 1996: 350 (1), 59-67.

Gentile MA, Nantermet PV, Vogel RL Androgen-mediated improvement of body composition and muscle function involves a novel early transcriptional program including IGFl , mechano growth factor and induction of β-catenin. J Mol Endo. 2010: 44, 55-73

Giuliano F, Rampin O, Allard J. Neurophysiology and pharmacology of female genital sexual response. J Sex Marital Ther. 2002;28 Suppl 1 : 101 -21.

HSDB. Testosterone. Hazardous Substances Data Bank 2002. 1 -34.

IARC Monographs on the evaluation of carcinogenic risks to humans overall evaluations of carcinogenicity: An updating of ISRC monographs Volume 1 to 42. Supplement 7. 1987Kim, N. N., Min, K., Pessina, M. A. et al. Effects of ovariectomy and steroid hormones on vaginal smooth muscle contractility. Int. J Impot.Res 2004: 16 (1), 43-50.

Nieschlag E and Behre HM, Eds. (2004) Testosterone, Action, Deficiency, Substitution. Cambridge Press, 3^rd edition.

Noble RL. The development of prostatic adenocarcinoma in Nb rats following prolonged Sex hormone administration. Cancer Research. 1977: 37, 1929-33.

Nucro -technics Study Report 227422: A 90-day repeated intranasal dose toxicity sutdy with TBS-2 gel in rabbits followed by a 30-day recovery period. 201 1.

Polderman KH, Stehouwer CD, van Kamp gJ et al. Influence of sex hormones on plasma endothelin levels. Ann Intern Med. 1993: 1 18(6), 429-32.

Pollard M, Luckert PH. Production of autochthonous prostate cancer in Lobund-Wistar rats by treatments with N-Nitroso-N-methylurea and testosterone. JNCI 1986:77,583-587

Pour PM, Stepan K. Induction of prostatic carcinomas and lower urinary tract neoplasms by combined treatment of intact and castrated rats with testosterone propionate and N-Nitrosobis(2-oxopropyl)amine. Cancer Research 1987:47, 5699-5706.

RTECS. Testosterone. Registry of Toxic Effects of Chemical Substances 2002. 1 -1 1.

Seachrist, D., Dunphy, G., Daneshvar, H. et al. Testosterone increases blood pressure and cardiovascular and renal pathology in spontaneously hypertensive rats. Blood Press 2000: 9 (4), 227-238.

Sharma UR, Rissman EF. Testosterone implants in specific neural sites activate female sexual behaviour. J Neuroendocrinology 1994: 6, 423-432.

Shirai T, Sano M, Imaida K et al. Duration dependent induction of invasive prostatic carcinomas with pharmacological dose of testosterone propionate in rats pretreated with 3,2' -dimethyl-4-aminobiphenyl and development of androgen- independent carcinomas after castration. Cancer Letters 1994: 83, 1 1 1 - 16.

Silva EG, Tornos C, Fritsche HA et al. The induction of benign epithelial neoplasms of the ovaries of guinea pigs by testosterone stimulation: a potent animal model. Mol Pathol. 1997: 10(9)879-83.

Tavares, M. C, Topic, B., Abreu, C. et al. Effects of intra-nasally administered testosterone on sexual proceptive behavior in female capuchin monkeys (Cebus apella). Behav. Brain Res 2007: 179 (1), 33-42.

Topic, B., Tavares, M. C, Tomaz, C. et al. Prolonged effects of intra-nasally administered testosterone on proceptive behavior in female capuchin monkeys (Cebus apella). Behav. Brain Res 2007: 179 (1), 60-68.

Turner RT, Wakley GK, Hannon KS. Differential effects of androgens on cortical bone histomorphometry in gonadectomized male and female rats^. J Ortho Res. 1990:8(4), 612-7.

Traish AM, Kim NN, Huang YH. Sex steroids hormones differentially regulate nitric oxide synthase and arginase activity in the proximal and distal rabbit vagina. Int J Impot Res. 2003: 15(6), 397-404. Traish AM, Kim SW, Stankovic M et al. Testosterone increases blood flow and expression of androgen and estrogen receptors in the rat vagina. J Sex Med. 2007: 4, 609-619.

Tsutusi, T., omine, A., Huff, J. et al. Effects of testosterone, testosterone propionate, 17beta-trenbolone and progesterone on cell transformation and mutagenesis in Syrian hamster embryo cells. Carcinogenesis (Oxford) 1995 : 16 (6), 1329- 1333.

Tyagi A, Raj alakshmi M, Baj aj JS, Mohan Kumar V. Effects of long term treatement with testosterone enanthate in rhesus monkeys: I. Pharmacokinetics of testosterone, testicular volume and liver metabolism of testosterone. Int J Andrology. 1999: 22, 139- 147.

Tyagi A, Raj alakshmi M, Jeyaraj DA, Sharma RS, Baj aj JS . Effects of long-term use of testosterone enanthate. II. Effects on lipids, high and low density lipoprotein cholesterol and liver function parameters. Int J Andrology. 1999: 22, 347-355.

Vogel, E. W. and Nivard, M. J. Performance of 18 1 chemicals in a Drosophila assay predominantly monitoring interchromosomal mitotic recombination. Mutagenesis 1993 : 8 ( 1 ), 57-8 1 .

Waalkes MP, Rehm S, Devor DE. The effects of continuous testosterone exposure on spontaneous and cadmium induced tumors in the male fischer (F344/ Cr) rat: Loss of testicular response. Tox and Appl Pharm 1997: 142, 40-46.

Xie B, Tsao SW, Wong YC. Sex hormones induced mammary carcinogenesis in female Noble rats: the role of androgens. Carcinogenesis 1999: 20, 1597— 1606.

Yarrow JD, Conover CF, Purandare AV et al. Supraphysiological testosterone enanthate administration prevents bone loss and augments bone strength in gonadectomised male and female rats. Am J Physiol Endocrinol Metab. 2008: 295, E1213 - E l 222.

Pharmacokinetics and Clinical Efficacy and Safety in Humans

5.1 TBS-1 Clinical Efficacy and Safety

Clinical experiences with TBS- 1 include a Phase I/II single dose pharmacokinetic study in 8 hypogonadal men, a Phase II multi-dose pharmacokinetic study in 21 hypogonadal men, a Phase II multi-dose study in 57 hypogonadal men, a Phase II multi-dose study in 22 hypogonadal men, a Phase III multi-dose study in 280 hypogonadal men and an extrinsic factor study in 18 healthy men with allergic rhinitis.

Table 5.1- 1 : Summary of Ongoing Clinical Studies with TBS- 1

Table 5.1-2: Summary of Completed Clinical Studies with TBS- 1

5.1. 1 A 90-Day, Randomized, Dose-Ranging Study, Including Potential Dose Titration, Evaluating the Bfficacy and Safety of Intranasal TBS- 1 in the Treatment of Male Hypogonadism With Sequential Safety Bxtension Periods of 90 and 180 Days

(Study: TBS- 1-201 1-03)

The primary objective of the study is to determine the efficacy of 4.5% TBS- 1 gel, administered as 2 or 3 daily intranasal doses of 5.5 mg per nostril, as demonstrated by an increase in the 24-hour average concentration (C_avg) of serum total testosterone to the normal range (>300 ng/dB and ≤1050 ng/dB) in >75% of male subjects treated for hypogonadism. Secondary objectives include safety, the effect of TBS- 1 on body composition, bone mineral density, mood, erectile function and the pharmacokinetics of DHT and estradiol.

This is a multi-centre, open-label dose-titration study with a planned enrolment of 280 patients. Two hundred and ten (210) patients were randomized to receive TBS- 1 gel b.i.d. (at 2100 and 0700 hours; total daily dose 22 mg/day) and 70 patients were randomized to receive TBS- 1 gel t.i.d. (at 2100 and 0700 and 1300 hours; total daily dose 33 mg/day). A testosterone serum PK profile is performed on Day 30. Patients who do not achieve a testosterone serum C_avg of 300 ng/dB on Day 30 will be switched from the b.i.d. group to the t.i.d. group on Day 45. The final testosterone serum PK profile will be performed on Day 90. The study included a 3 month and a 9 month safety extension.

5.1.1.1 Efficacy Results

As the trial is ongoing, efficacy results are not available.

5.1.1.2 Safety Results

The interim safety analysis showed that TBS- 1 is well tolerated by subjects. Bour serious adverse events occurred in this study; 3 were deemed unrelated while 1 was unlikely related to study medication as presented in Table 5. 1.1.2- 1. A total of 252 AEs were reported in 103 patients. Twenty six (26) of these AEs, experienced by 14 patients, were judged to be related to the study drugs. Related AEs are presented in Table 5.1. 1.2-2. Table 5.1. 1.2- 1 : Tabulation of Serious Adverse Bvents and Relatedness

SAE occurred during the screening phase. Subjected was not randomized and did not receive study drug.

Table 5.1. 1.2-2: Adverse Events Related to TBS- 1

syndrome |

Skin and subcutaneous tissue disorder

Acne 1 , 1 0,0 1 , 1

N = number of adverse events N'= number of subjects who reported adverse event

5.1.2 A randomized 3-way cross over study to assess the relative bioavailability, safety and tolerabilitv of 4.5% TBS- 1 when administered to male subjects with seasonal allergic rhinitis in symptomatic, symptomatic but treated (Oxymetazoline) and asymptomatic states using an environmental challenge chamber (ECC) model (Study: TBS- 1-201 1-

The purpose of this study was to determine effect of allergic rhinitis and the treatment of allergic rhinitis, oxymetazoline, on the absorption of TBS- 1. This was achieved by determining the testosterone pharmacokinetic profile following administration of 1 1 mg TBS- 1 (4.5%) three times a day in subjects that suffer from seasonal allergic rhinitis, while in the symptomatic, symptomatic but treated (with Oxymetazoline) and asymptomatic states. The secondary objective of the study was to determine the local and systemic safety and tolerability, following three administrations of TBS- 1 in subjects with seasonal allergic rhinitis and while taking oxymetazoline.

Symptoms of allergic rhinitis were induced in 18 male patients using allergen challenge with Dactylis glomerata pollen in and Environmental Challenge Chamber.

The study was a 3-period cross over design in which all subjects received each of the following treatments:

A: TBS- 1 (symptomatic state)

Symptoms of allergic rhinitis were induced in men with seasonal allergic rhinitis by exposing them to pollen of Dactylis glomarata in an environmental challenge chamber (ECC) prior to each administration of TBS- 1.

B: TBS- 1 and Oxymetazoline (symptomatic and treated)

Oxymetazoline nasal spray was administered 30 minutes prior to the 0700 hr dose of TBS- 1 and again 12 hrs after the first dose. Symptoms of allergic rhinitis were induced in men with seasonal allergic rhinitis by exposing them to pollen in an Bnvironmental Challenge Chamber.

C: TBS- 1 (asymptomatic state)

TBS- 1 was administered 3 times a day to men in the asymptomatic state.

This is a single site study with a planned enrolment of 18 healthy men. A 24 hour pharmacokinetic profile of testosterone and DHT will be performed on all subjects in all treatments.

5.1.2.1 Efficacy Results

As the trial is ongoing, efficacy results are not available.

5.1.2.2 Safety Results

Eighteen ( 18) healthy men with allergic rhinitis were exposed to TBS- 1. TBS- 1 was well tolerated by subjects. There were no deaths in the study and none of the subjects experienced any SAEs. Fifteen (15) adverse events were encountered in the study; 2 in asymptomatic state, 6 in the symptomatic state and 7 in the symptomatic but treated state. None of the adverse events were considered related to the study drug. All events were of mild to moderate severity. None of the subjects were discontinued from the treatment because of an AE.

Table 5. 1.2.2- 1 : Adverse Events Unrelated to TBS- 1

5.1.3 Open Label, Randomized, Balanced, Three Treatments, Parallel Design,

Pharmacokinetic Study of Intranasal TBS- 1 Administration to Hypogonadal Men (Study: TBS- 1-2010-01)

The efficacy of TBS- 1 was evaluated in a parallel group, randomized, open label Phase II study. The primary efficacy parameters were the percentage of subjects that had an average 24-hour serum Testosterone level (C_avg) > 300ng/dL and < 150 ng/dL and the percent of subjects in each treatment group with a 24 hour C_avg less than, within and above the serum Testosterone reference range of 300 ng/dL— 1050 ng/dL. The secondary objective of the study was to determine the safety of TBS- 1 based on adverse events and the percent of patients with a serum DHT and Estradiol greater than the upper limit of the reference range. The doses and dosing regimens in study TBS- 1-2010-01 are described below:

• Treatment A: 10.0 mg TBS- 1 (4.0%) t.i.d. at 2100, 0700 and 1300 hours; total daily dose 30.0 mg

• Treatment B : 13.5 mg TBS- 1 (4.5%) b.i.d. at 2100 and 0700 hours; total daily dose 27.0 mg • Treatment C: 1 1.25 mg TBS- 1 (4.5%) t.i.d. at 2100, 0700 and 1300 hours; total daily dose 33.75 mg

Twenty two (22) hypogonadal men (mean age 52.6 ± 10.8 yrs) received TBS- 1 . Bight (8) men received 30 mg/day t.i.d. administration, 7 men received 27 mg/day b.i.d. administration and 7 men received 33.75 mg/day t.i.d. administration. The treatments were administered for one week following which a 24-hour pharmacokinetic profile of Testosterone, Dihydrotestosterone (DHT) and Estradiol was performed.

5.1.3.1 Efficacy Results

Data from 22 subjects were included in the pharmacokinetic (PK) analysis.

All three TBS- 1 treatments show appreciable increases in serum testosterone levels above baseline. The 24 hour C_avg testosterone level from all the treatment groups in the study met the FDA criteria for efficacy of at least 75% of subjects should achieve an average total Testosterone concentration (C_avg) in the normal range, a 24-hour C_avg value > 300ng/dL and < 1050 ng/dL. Treatment groups A (total daily dose 30.0 mg) and C (total daily dose 33.75 mg) met the FDA criteria of at least 85% of subjects should have a maximal total Testosterone concentration (C_max) < 1500 ng/dL; in treatment group B (total daily dose 27 mg), 2 subjects (29%) had C_max values > 1500 ng/dL. No subject had a C_max greater than 1800 ng/dL.

The mean serum testosterone pharmacokinetic profile results are summarized in Figure 5.1.3.1- 1 and Table 5.1.3. 1- 1.

Figure 5. 1.3. 1- 1 : Pharmacokinetic Profile of Testosterone Following TBS- 1 Administration

Mean Testosterone Serum Concentration (ng/dL) - Time Profile

(h)

Table 5.1.3.1- 1 : Treatment Groups and Mean Serum Testosterone PK Parameters

A 30 8 9920 ± 413 ± 830 ± 239 ± 1 (12.5 %) 7 (87.5 %) 0 (0%)

3300 138 188 78

B 27 7 10058 ± 419 ± 1050 ± 228 ± 0 (0%) 7 (100%) 0(0%)

3493 146 463 97

C 33.75 7 9505 ± 396 ± 883 ± 222 ± 1 ( 14.3%) 6(85.7%) 0(0%)

2650 1 10 346 57

The normal reference range for DHT is 25.5— 97.8 ng/dL. Approximately 86% of patients recieving Treatment B and C and 63% of patients recieiving Treatment A had DHT levels within the normal reference range. No subject had a DHT C_avg above the reference range while 38% of subjects in Treatment A and 14% of subjects in Treatment B and C had a DHT C_avg below the reference range. The mean serum DHT pharmacokinetic profile data are summarized in Figure 5. 1.3. 1-2 and Table 5. 1.3. 1-2. The normal reference range for estradiol is 3— 81 pg/mL. All subjects had a C_avg estradiol within the normal reference range.

Figure 5. 1.3. 1-2: Pharmacokinetic Profile of DHT Following TBS- 1 Administration

Mean Dihydrotestosterone Serum Concentration (ng/dL) - Time Profile

(h)

Table 5.1.3.1-2: Treatment Groups and Mean Serum DHT PK Parameters

Twenty-two (22) hypogonadal men were exposed to TBS- 1. All three dose levels were well tolerated by subjects. There were no deaths in the study and none of the subjects experienced any SAEs. Bight (8) adverse events were encountered in the present study. Two adverse events were classified as possibly related and six (6) as not related to the study drug. All events were of mild to moderate severity. None of the subjects were discontinued from the treatment because of an AE. Adverse events are tabulated in Tables 5.1.3. 1-3 and 5. 1.3. 1-4.

The pharmacokinetic profile of DHT and Bstradiol showed appropriate increases following TBS- 1 administration. The increases in serum DHT and Estradiol all remained well within the reference ranges for serum DHT and Bstradiol respectively, and returned to basal levels after discontinuation of treatment. Physical and nasal examination, vital signs and clinical laboratory evaluation results did not reveal any additional clinically significant findings related to study treatment.

Table 5.1.3.1-3: Adverse Events Related to TBS-1

Table 5.1.3.1-4: Adverse Events Unrelated to TBS- 1

5.1.4 Efficacy and Tolerability of TBS- 1 , an Intranasal Testosterone Product, for

Testosterone Replacement Therapy in Hypogonadal Men (Study: Nasobol-01-2009)

This study was a Phase II randomized, open-label, cross-over design to determine pharmacokinetics and safety of TBS- 1 in hypogonadal men. Efficacy was evaluated by assessing the pharmacokinetic profile for serum testosterone levels following TBS- 1 treatment and comparing it to that of the active control, Androderm. The secondary objective was to establish a safety profile for TBS- 1. The study was a 4-period cross over design in which all subjects received each of the following doses of TBS- 1 and an active control, Androderm, for 7 days:

• 8.0 mg TBS- 1 (3.2%) b.i.d. at 0700 and 2100 hours; total daily dose 16.0 mg

• 1 1 .0 mg TBS- 1 (3.2%) b.i.d. at 0700 and 2100 hours; total daily dose 22.0 mg

• 14.0 mg TBS- 1(3.2%) b.i.d. at 0700 and 2100 hours; total daily dose 28.0 mg

• 5.0 mg Androderm^® Patch at 2100 hours

Fifty seven (57) hypogonadal men (mean age 52 ± 12 yrs) received TBS- 1. An extra 17 subjects were enrolled in this study as a result of a protocol amendment in which the administration of TBS- 1 to the subject was assigned to a single individual (Nurse, Nurse Practitioner or Physician).

5.1.4.1 Efficacy Results

Data from 56 subjects were included in the pharmacokinetic (PK) analysis. One patient voluntarily withdrew from the study. All three TBS- 1 treatments show appreciable increases in serum testosterone levels above baseline, and show sizeable increases in AUC with increasing doses administered (total daily dose 16 mg, 22 mg and 28 mg). In this study, 52% of the subjects recieving a total daily dose of 28 mg TBS- 1 acheived a C_avg testosterone serum value within the reference range > 300ng/dL and < 1050 ng/dL. The C_avg values following administration of a total daily dose of 22.0 mg and 16 mg were within the reference range in 36.5% and 49.1 % of the subjects respectively. In the Androderm^® arm, 79.63% of the subjects had a C_avg value within the reference range > 300ng/dL and < 1050 ng/dL.

None of the TBS- 1 treatment groups met the FDA' s acceptance criteria for standard testosterone therapies of "at least 75% of subjects should acheve an average total testosterone concentration of > 300 ng/dL and < 1050 ng/dL.

In order to achieve the three different strength of TBS- 1 , 3.2% TBS- 1 gel was filled as 126 μΐ for the 8.0 mg dose, 177 μΐ for the 1 1.0 mg dose and 223 μΐ for the 14.0 mg dose. There was no linear increase in the testosterone serum values following TBS- 1 treatment in the three escalating doses suggesting that the larger gel volumes were not completely absorbed. This can be explained by an inconsistency in dosing as a result of administering too great a volume into the nasal cavity. Figure 5. 1.4. 1- 1 shows the changes in mean serum testosterone concentrations following TBS- 1 and Androderm administration. Figure 5. 1.4. 1-2 shows the changes in mean serum DHT concentrations following TBS- 1 and Androderm administration. This study showed that all three strengths of TBS- 1 increased mean serum DHT levels well above mean baseline levels and well into the DHT normal range (25— 98 ng/dL).

Figure 5.1.4.1-1: Pharmacokinetic Profile of Testosterone Following TBS-1 and Androderm Patch Administration (time "0" means 2100 hours)

Mean Graph

10 12 14 16 18 20 22 24

Time ( Ho r s )

Figure 5.1.4.1-2: Pharmacokinetic Profile of Dihydrotestosterone Following TBS-1 and Androderm Patch Administration (time "0" means 2100 hours)

5.1.4.2 Safety Results

The safety analysis showed that all treatments were well tolerated by subjects. There were no serious ABs or discontinuations due to AEs in this study. The majority of reported ABs were mild in intensity. Most AEs were considered unrelated to study drug. A total of 56 ABs were reported; 46 were considered mild, 22 of which were related to the study drugs. Ten (10) AEs were considered moderate, 2 of which were related to study treatments. Safety data is presented in Tables 5.1.4.2- 1-3. The data is presented in terms of the number of patients reporting each adverse event.

Table 5. 1.4.2- 1 : Adverse Events Related to TBS- 1

Nasal septum deviation 1 (1.8%)

All other ABs were classified as mild intensity.

Table 5.1.4.2-2: Adverse Events Unrelated to TBS-1

Table 5.1.4.2-3: Adverse Bvents of Unknown Causality

b.i.d.) b.i.d.) b.i.d.) mg

General disorders and administration site conditions

Fatigue 1 (1.8%)

Investigation

Prostatic specific antigen 1 (1.8%)

increase

5.1.5 Multiple Dose Pharmacokinetics of Testosterone after TBS- 1 Administration in

Severely Hypogonadal Men (Study TST-DF-02-MAT/05)

This was a randomized, open label, 3-arm parallel group Phase II study to determine the PK profile for testosterone after nasal administration of TBS- 1 in three different dose schedules to identify the optimum schedule for treatment in hypogonadal men. The secondary objective of the study was to determine the safety of TBS- 1 based on adverse events and DHT levels. The doses and dosing regimens in study TST-DF-02-MAT/05 are described below.

Treatment A: 7.6 mg testosterone b.i.d. (8:00 h, 14:00 h)

Treatment B: 7.6 mg testosterone b.i.d. (8:00 h, 20:00 h)

Treatment C: 7.6 mg testosterone t.i.d. (8:00 h, 14:00 h, 20:00 h)

Twenty-one (21) hypogonadal men mean age 32.5 ± 10.4 yr (range 19-57) received

TBS- 1.

5.1.5.1 Efficacy Results

All three TBS- 1 dosing schemes showed increases in serum testosterone levels above baseline. The mean of average steady-state concentrations remained within the physiological range in all 3 treatment groups. The highest AUC was observed after t.i.d. administration. In each group, there was a single patient who exceeded the upper limit of the normal range (1050 ng/dL). The mean serum testosterone pharmacokinetic profile is summarized in Table 5.1.5.1- 1 and Figure 5.1.5. 1- 1. The mean serum DHT profile is summarized in Table 5.1.5.1- 2.

The secondary objective of this study measured the change in general and sexual well being (measured using the Aging Male Symptom Scale (AMS) and the Clinical Global Scale (CGS) following 14 days of treatment. The AMS Scale did not provide significant results but a trend to lower values (i.e. improvement of condition) on Day 14 compared to Day 1. The overall CGS score significantly increased (i.e. improved) after 14 day of treatment. Analyses of the separate groups revealed significant increases from baseline during treatment for group A and C indicating a clinical improvement (B also improved, but change was not significant).

Table 5.1.5.1-1 : Pharmacokinetic Parameters of Testosterone (Mean ± SD or geometric mean and 95% CI)

AUC [ng*h/dL] 7,545 (5,785-9,840) 7,846 (5206-11,824) 11,327 (7,984-16,071)

C_avg [ng/dL] 314 (236-419) 327 (210-509) 472 (323-689)

[ng/dL] 102 (55-189) 157 (98-251) 220 (116-419)

C_max [ng/dL] 859 (632-1,167) 854 (465-1,570) 1,137 (895-1,444) [h ¹] 0.076 ± 0.044 0.098 ± 0.038 0.064 ± 0.022 t½ M 14.29 ± 12.86 8.74 ± 5.65 11.92 ± 3.62

Table 5.1.5.1-2: Pharmacokinetic Parameters of DHT (Mean ± SD or geometric mean and 95% CI)

Figure 5. 1 .5. 1 - 1 : PK profile of testosterone and DHT after nasal application of TBS- 1 in different dosing schemes (Groups A, B and C) after 14 days treatment. Time "O" means 8 :00

h; dashed lines = upper (testosterone and DHT) and lower (testosterone) limits of

Group B

Group C

'normal" 5.1.5.2 Safety Results

A total of 36 AEs were observed and were of mild to moderate severity. None of the AEs were considered drug related. No serious AB were reported. The PK parameters of DHT (high levels being a risk factor for prostate safety) showed that the average steady-state concentration of DHT did not exceed the upper limit of the physiological range (85 ng/dB), indicating no safety concern due to increased DHT levels. An overview of the reported adverse events is given in Table 5.1.5.2- 1.

Table 5. 1.5.2- 1 : Adverse Events

NR = Not Related ANOVA analysis of clinical laboratory parameters showed that there were significantly lower values at follow-up for hemoglobin, red blood cells and hematocrit. The differences were not judged to be clinically relevant and were probably related to the high number of blood samples taken during the study. Furthermore, there were significantly higher values for platelets, urea and testosterone at follow-up. Again, these differences were judged to be not clinically relevant by the investigator.

No statistically significant differences were seen for vital signs between baseline and follow- up.

5. 1.6 Single-dose Pharmacokinetics of Testosterone after TBS- 1 Administration (Study TST-PKP-01 -MAT/04)

This was a three period single dose pharmacokinetic Phase I/II study in hypogonadal men. The aim of the study was to assess the PK profile of testosterone and DHT following the nasal administration of three different single doses of TBS- 1 (7 days washout period in- between) for up to 24 hours. The second study objective was to determine tolerance to the different testosterone doses.

Eight (8) adult hypogonadal men (mean age 39.3 ± 14.8 yr (range 22-62)) received TBS- 1. Bach subject received TBS- 1 at three different doses: 7.6, 15.2 and 22.8 mg of testosterone, sequentially ordered with a wash-out period of at least three days between each dosing. The highest dose was investigated for safety reasons to determine whether

supraphysiological concentrations of testosterone would be reached following this dose.

5.1.6.1 Efficacy Results

Testosterone is well absorbed after nasal administration of different doses of testosterone intranasal gel. The maximum serum concentration is reached approximately 1 to 2 hours after administration (which is significantly shorter than those periods known from transdermal administration, i.e. gel and patches) indicating a rapid absorption of testosterone from the nasal cavity. Testosterone is cleared from serum with a half- life of approximately 10 hours. The concentration of DHT remained low over the observation period and the half- life ranged from 20-23 hours. Figure 5.1.6.1- 1 and 5. 1.6.1-2 and Table 5.1.6.1 - 1 presents the mean concentration-time curves of testosterone and DHT after administration of the three different strengths of testosterone intranasal gel.

Figure 5. 1.6.1 - 1 : Mean concentration-time curves of testosterone after single-dose administration of different doses of TBS- 1. The normal range for testosterone is indicated with (red) dashed lines.

0.00 5.00 10.00 15.00 20.00 25.00

Time after administration (h)

Figure 5. 1.6.1 -2: Mean concentration-time curves of DHT after single-dose administration of different doses of TBS- 1. The normal range for DHT is indicated with (red) dashed lines.

Time after administration (h)

Table 5. 1.6. 1- 1 : Pharmacokinetic Parameters of Testosterone after Single-dose Administration of Different Doses of TBS- 1 in Hypogonadal Men

5.1.6.2 Safety Results

Bach of the eight (8) hypogondal men were exposed to single doses of 7.6 mg, 15.2 mg and 22.8 mg of TBS- 1. There were no deaths in the study and none of the subjects experienced any SAEs. Two adverse events in 1 patient (fever and nausea), not related to testosterone intranasal gel occurred (patient was excluded from the study before first administration). None of the AEs were considered study drug-related.

5.2 Information of Approved Testosterone Products

The use of testosterone as hormone replacement therapy in the treatment of hypogonadism has established for decades. The currently available options for administration of testosterone are oral, buccal, injectable, implantable and transdermal in the United States and the European Union. The following testosterone-containing medicinal products for systemic therapy are currently approved:

• Transdermal gels, e.g. Androgel^®, Testim^®, Testogel^®, Axiron^®

• Transdermal patches, e.g. Testopatch^®, Andropatch^®, Androderm^®

• Injectables, e.g. Nebido^®, Reandron^®

• Capsules, buccal tablets, e.g. Andriol^®, Striant^®

All these preparations aim at achieving physiological testosterone levels thereby restoring symptoms such as sexual function, libido and sense of well-being but also improving bone mineral density, muscle strength, body composition and mood. According to WHO, NIH and FDA recommendations and relevant guidelines drawn up by specialist panels (ISA; ISSAM, EAU, EAA and ASA) "the major goal of therapy is to replace testosterone levels (but also the metabolites) at as close to physiologic concentrations as is possible" (Nieschlag et al. 1992, Nieschlag et al. 2005, Wang et al. 2009).

5.2.1 Efficacy Results

Numerous placebo controlled studies have demonstrated that testosterone replacement therapy is efficacious in treating symptoms of hypogonadism. These have been summarized in a number of recent meta-analyses (Isidori et al. 2005a and 2005b, Ottenbacher et al. 2006), although there seem to be differences in the inter- individual responses to T treatment (Zitzmann 2006, 2007). Testosterone clearly improves sexual function (both libido and erectile function) in older men. In addition, it improves the quality of erections when hypogonadal men are treated with testosterone before receiving a phosphodiesterase-5 inhibitor (Shabsigh 2004 and Greco et al. 2006) and, in some cases, can reverse total failures to respond to phosphodiesterase-5 inhibitors (Tariq et al., 2003). In addition, testosterone in low doses in borderline hypogonadal men increases muscle mass and decreases fat mass (Wittert et al. 2003, Snyder et al. 1999), and in higher doses, in men with testosterone less than 12 nmol/L, improves strength (Isidori et al. 2005b, Ottenbacher et al. 2006). In a recent large study (N=322 men over 50 years of age), Testosterone Undecanoate (TU) improved sexual function, increased lean body mass, decreased body fat mass, and increased bone mineral density at both the hip and the spine (Geurts et al. 2007). In another large study (N=237 healthy men between 60-80 years of age and with total T levels below 13.7 nmol/L), TU was shown to decrease body fat and to increase muscle mass (Emmelot-Vonk et al. 2008). There are also data suggestive that testosterone will improve cognition and mood and perhaps even be useful in treating some persons with Alzheimer' s disease (Morley et al. 1997, Zitzmann 2006, Lu et al. 2006, Cherrier et al. 2005, Flood et al. 1995).

For most approved testosterone (-ester) products, it has been shown that they restore low testosterone serum levels to within the physiological normal range and that they have one or more of the above mentioned effects.

A complete overview of the effects of testosterone and the underlying studies has been given by Nieschlag and Behre (eds), 2004.

5.2.2 Safety

The following adverse reactions have been associated with androgen therapy in general:

One of the biggest concerns in testosterone replacement therapy (TRT) has been the prostate. TRT has been associated with Benign Prostate Hyperplasia (BPH) and prostate cancer by some researchers. However, prostate cancer and BPH occur in older men at a time when testosterone levels have declined to low levels [Morley, 2000] . The meta-analysis by Baton et al. [ 1999] showed no prospective evidence that either testosterone or non-sex hormone- binding globulin-bound testosterone was correlated with the development of prostate cancer. Retrospective studies have failed to demonstrate an increase in prostate cancer in men treated with testosterone. In a prospective study, Marks et al. [2006] took prostate biopsies from 40 men receiving TRT at baseline and 6 months after start of treatment. Median prostate tissue levels of testosterone (0.91 ng/g) and dihydrotestosterone (6.79 ng/g) did not change significantly in the treatment group. No treatment-related change was observed in prostate histology, tissue biomarkers (androgen receptor, Ki-67, CD34), gene expression (including AR, PSA, PAP2A, VEGF, NXK3, CLU [Clustering), or cancer incidence or severity. Treatment-related changes in prostate volume, serum prostate-specific antigen, voiding symptoms, and urinary flow were minor. They concluded that in aging men with late-onset hypogonadism, 6 months of TRT normalizes serum androgen levels but appears to have little effect on prostate tissue androgen levels and cellular functions.

A systematic review of testosterone therapy in men with low or on the lower range of normal testosterone levels included 37 randomized controlled testosterone trials in hypogonadal men, healthy older men, men with sexual dysfunction, HIV-infected men with weight loss, and in men with a variety of other conditions. This meta-analysis of low quality evidence, mostly because of large loss to follow-up and inconsistent results across studies, found that testosterone therapy was associated with greater increases in hemoglobin, hematocrit, and PSA, and a greater decrease in high density lipoprotein (HDL) cholesterol level than placebo. These effects were most marked in studies enrolling older patients with low testosterone levels using intramuscular testosterone preparations. Overall mortality, cardiovascular event rates, prostate cancer, lower urinary tract symptom scores, and systolic and diastolic blood pressure did not differ among testosterone-and placebo-treated men.

5.3 Marketing Experience

TBS- 1 is not approved for marketing authorization and is currently not marketed.

5.4 References

Cherrier MM, Matsumoro AM, Amory JK, Asthana S, Bremner W, Peskind ER, Raskind MA, Craft S (2005) Testosterone improves spatial memory in men with Alzheimer disease and in mild cognitive impairment.

Neurology, 64:2063-8.

Eaton NE, Reeves GK, Appleby PN, Key TJ ( 1999) Endogenous sex hormones and prostate cancer: A quantitative review of prospective studies. Br J Cancer, 80:930-934.

Eirimelot-Votik MH, Verba ar H.T.T. NaJkhai Pour HR, Aleman A, Lock TMTW. u ud Bosch JLH, Grobbee DE, van der Schouw YT (2008) Effect o Testosterone S upplementation on Functional Mobility, Cognition, and Other Parameters in Older Men. A Randomized Controlled Trial. JAMA, 299( l ):39--52.

Fernandez-Balsells HM, Murad MH, Melanie L, Lampropulos JF, Albuquerque F, Erwin PJ, Bhasin S, Montori VM 2010 A dverse effects of testosterone therapy in adult men: a systematic review and meta-analysis. J Clin Endocrinol Metab, 95(6):2560-2575

Flood JF, Fan SA., Kaiser FE, La Regina M, Morley JE ( 1995) Age-related decrease of plasma testosterone in SAMP8 miee: Replacement improves age-related impairment of learning and memory. Physiol Behav, 57 :669- 673.

Geurts TBP, Legros JJ, Meuleman EJ, Bouloux PMC, Kaspers MJG, Elbers JMH (2007) Testosterone replacement with Andriol Testocaps in symptomatic late-onset hypogonadism-Clinical and metabolic responses in a randomized, placebo-controlled study. Abstracts. 2nd CSSAM North American Congress on Aging Male, p. 23, Montreal, Canada.

Greco EA, Spera G, Eversa A (2006) Combining testosterone and PDE5 inhibitors in erectile dysfunction: Basic rationale and clinical evidences. Eur Urol, 50:940-947. Hussain AA, Al-Bayatti AA, Dakkuri A, Okochi K, Hussain MA. Testosterone 17beta-N,N-dimethylglycinate hydrochloride: A prodrug with a potential for nasal delivery of testosterone. J Pharm Sci. 2002 Mar;91 (3):785- 789.

Isidori AM, Giannetta E, Greco EA, Gianfrilli D, Bonifacio V, Isidori A, Lenzi A, Fabbri A. (2005a) Effects of testosterone on body composition, bone metabolism and serum lipid profile in rniddle-aged men: A metaanalysis. Clin Endoerinol, 63: 280-293.

Isidori AM, Giannetta E, Gianfrilli D, Greeo EA, Bonifaeio V, Aversa A~ Isidori A, Fabbri A, Lenzi A. (2005b) Effects of testosterone on semal function in men; Results of a meta-analysis. Clin Endocrinol, 63:38 1 -394.

Ko KT, Needham TE, Zia H. Emulsion formulations of testosterone for nasal administration. J Microencapsul. 1998 Mar-Apr; 15(2): 197-205.

Lu PH, Masterman DA., Mulnard R, Cotman C, Miller B, Yaffe K, Reback E, Porter V, Swerdloff R, Cummings JL (2006) Effects of testosterone on cognition and mood in male patiellts with miJd Alzheimer disease and healthy elderly men. Arch Neurol, 63: 177- 185.

Marks LS, Mazer NA, Mostaghel E, Hess DL, Dorey FJ, Epstein JI, Veltri RW, Makarov DV, Partin AW, Bostwick DG, Macairan ML, Nelson PS (2006) Effect of Testosterone Replacement Therapy on Prostate Tissue in Men With Late-Onset Hypogonadism. A Randomized Controlled Trial. JAMA, 296:235 1 -2361

Morley JE, Kaiser F, Raum WJ, Perry HM 3rd, Flood JF, Jensen J, Silver AJ, Roberts E ( 1997) Potentially predictive and manipulable blood serum correlates of aging in the healthy human male: Progressive decreases in bioavailable testosterone, dehydroepiandrosterone sulfate, and the ratio of insulin-like growth factor 1 to growth hormone. Proc Natl Acad Sci USA, 94:7537-7542.

Morley J (2000) Testosterone treatment in older men: Effects on the prostate. Endocr Pract 6:218-221 .

Nieschlag E, Wang C, Handelsman DJ, Swerdloff RS, Wu FCW, Einer-Jensen N et al. Guidelines for the use of androgens. WHO Special Programme of Research, Development and Research Training in Human

Reproduction. Geneva, 1992.

Nieschlag E and Behre HM (Eds.). 2004. Testosterone, Action, Deficiency, Substitution. Cambridge Press, 3^rd edition.

Nieschlag E, Swerdloff R, Behre HM, Gooren LJ, Kaufman JM, Legros JJ et al. Investigation, treatment and monitoring of late-onset hypogonadism in males. ISA, ISSAM, and EAU recommendations. Eur Urol. 2005 Jul;48( l ): l -4.

Ottenbacher KJ, Ottenbacher ME, Ottenbacher AJ, Aeha AA, Ostir GV (2006) Androgen treatment and rousele strength in elderly men: A meta-analysis. J Am Geriatr Soc, 54: 1666- 1673.

Shabsigh R. (2004) Testosterone therapy in erectile dysfunction. Aging Male, 7:3 12-3 18.

Shalender Bhasin, Glenn R. Cunningham, Frances J. Hayes, Alvin M. Matsumoto, Peter J. Snyder,Ronald S . Swerdloff, and Victor M. Montori (2010) Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes: An Endocrine Society Clinical Practice Guideline, Journal of Clinical Endocrinology &

Metabolism, June 2010, Vol. 95(6):2536-2559.

Snyder PJ, Peachey H, Hannoush P, BerIin]A., Loh L, Lenrow DA, HolmesJH, Dlewati A, SantannaJ, Rosen CJ, Strom BL ( 1999) Effect of testosterone treat- ment on body composition and muscle strength in men over 65 years of age../ Clin Endocrinol Metab, 84:2647-2653.

Study Report TBS- 1 -2010-01 : An open label, randomized, balanced, three treatment parallel design pharmacokinetic study of intranasal TBS- 1 administration to hypogonadal men (201 1 ).

Study Report Nasobol-01 -2009: Efficacy and tolerability of TBS- 1 , an intranasal testosterone product, for testosterone replacement therapy in hypogonadal men (2010).

Study Report TST-DF-02 -MAT/05 : Multiple-doses, one period, three arms, parallel-group, open, randomised dose finding study conducted using testosterone intranasal gel for nasal application administered to hypogonadal men for 14 consecutive days (2005).

Study Report TST-PKP-01 -MAT/04: 24-h pharmacokinetics of testosterone after nasal administration of single doses of 7.6 mg, 15.2 mg and 22.8 mg of testosterone in hypogonadal men (2004).

Tariq SH, Haleem U, Omran ML, Kaiser FE, Perry HM 3rd, Morley JE (2003) Erectile dysfunction: Etiology and treatment in young and old patients. Clin Geriatr Med, 19:539-551 . Wang C, Nieschlag E, Swerdloff RS, Behre H, Hellstrom WJ, Gooren LJ et al. ISA, ISS AM, EAU, EAA and ASA recommendations: investigation, treatment and monitoring of late-onset hypogonadism in males. Aging Male. 2009 Mar; 12( l ):5- 12.

Wittert GA, Chapman IM, Haren MT, Mackintosh S, Coates P, Morley JE. (2003) Oral testosterone supplementation increases musele and decreases fat mass in healthy elderly males with low-normal gonadal status. J Gerontol A Biol Sci Med Sci, 58:61825.

Zitzmann M (2006) Testosterone and the brain. Aging Male, 9: 195-200.

Zitzmann M, Faber S, Nieschlag E (2006) Association of Specific Symptoms and Metabolic Risks with Serum Testosterone in Older Men, J. Clin. Endocrinol. Metab, 91 : 4335 - 4343.

Zitzmann M (2007) Mechanisms of Disease: Pharmacogenetics of testosterone therapy in hypogonadal men, Nature Clinical Practice Urology 4(3): 161 - 166. Summary of Data and Guidance for the Investigator

Discussion and Conclusion on Nonclinical and Clinical Data

The accumulated animal and human data on TBS- 1 or its components (castor oil, oleoyl polyoxylglycerides and colloidal silicon dioxide) have not demonstrated toxicity related concerns that would preclude the use of TBS- 1 in a continued program of Phase III studies.

The toxicity of repeated doses of testosterone depends on the dose and duration of administration. No evidence of systemic drug related toxicity was observed in rabbits after repeated daily administration of TBS- 1 over a 90 day period up to a dose level of 10-fold the maximum clinical daily dose. Local tolerance studies in rat and rabbit following single dose and repeated dose administrations showed that testosterone intranasal gel was well tolerated. Testosterone intranasal gel was classified as a non-irritant in the HET-CAM test.

Four pharmacokinetic studies in hypogonadal men have been completed following TBS- 1 treatment. In each of these studies, physiological levels of testosterone and DHT are restored to physiological levels following administration.

The maximum testosterone serum concentration is reached between one and two hours after administration indicating a rapid absorption of the nasally administered product. The serum terminal half- life of testosterone ranged from 8 to 12 hours.

6.2 Mechanism of Action and Use

TBS- 1 is an innovative pharmaceutical formulation of testosterone for nasal administration which supplements low levels of testosterone in men avoiding a number of disadvantages of other pharmaceutical formulations including contamination to other family members, skin irritation, elevated DHT levels and interaction with food.

The physiological role of testosterone is well established, and the effects and risks of hormone replacement are well described. In males, TRT is indicated for conditions associated with a deficiency or absence of endogenous testosterone. Hypogonadism in men is a clinical syndrome that results from failure of the testis to produce physiological levels of testosterone (androgen deficiency) and a normal number of spermatozoa due to disruption of one or more levels of the hypothalamic-pituitary-testicular (HPT) axis.

Abnormalities of the HPT axis at the testicular level cause primary testicular failure, whereas central defects of the hypothalamus or pituitary cause secondary testicular failure. Hypogonadism can also reflect dual defects that affect both the testis and the pituitary:

1. Primary hypogonadism (congenital or acquired) - testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, orchiectomy, Klinefelter's syndrome, chemotherapy, or toxic damage from alcohol or heavy metals. These men usually have low serum testosterone levels and gonadotropins (FSH, LH) above the normal range. 2. Secondary hypogonadism (congenital or acquired) - idiopathic gonadotropin or luteinizing hormone-releasing hormone (LHRH) deficiency or pituitary- hypothalamic injury from tumors, trauma, or radiation. These men have low testosterone serum levels but have gonadotropins in the normal or low range.

3. Combined primary and secondary testicular failure results in low testosterone levels and variable gonadotropin levels, depending on whether primary or secondary testicular failure predominates.

The age-related decline on testosterone levels results from defects in both testicular and hypothalamic-pituitary function.

6.2. 1 Potential Side Effects

Based on prior clinical experiences and the human studies conducted to date, the risk associated with the use of TBS- 1 are no greater than those associated with the use of any other testosterone replacement therapy (TRT) on the market. Adverse events for which there is evidence of association with testosterone administration include decreased diastolic blood pressure, increased blood pressure, gynecomastia, headache, increased hematocrit/hemoglobin levels, erythrocytosis, induction or worsening of obstructive sleep apnea, hot flushes, insomnia, increased lacrimation, acne and oily skin, male pattern holding, mood swings, smell disorder, taste disorder, spontaneous penile erection, reduced sperm production and fertility, detection of subclinical prostate cancer, growth of metastatic prostate cancer and growth of breast cancer .

6.2.2 Precautions

Men with benign prostatic hyperplasia (BPH) are at an increased risk for worsening of BPH. In addition, men treated with androgens may be at an increased risk for prostate cancer.

Patients receiving TRT should be monitored for the following parameters at regular intervals:

• Liver function, prostate specific antigen (PSA) cholesterol and high density lipoprotein

• Hematocrit and hemoglobin to detect polycythemia.

Since treatment with testosterone may cause priapism, changes in electrolyte balance, changes in insulin sensitivity and sleep apnea, investigators should instruct patients to report any of the following:

• Too frequent or persistent erections of the penis.

• Any nausea, vomiting, changes in skin color, or ankle swelling.

• Breathing disturbances, including those associated with sleep.

6.2.3 Medical Considerations/Contraindications

Androgens are contraindicated in men with carcinoma or the breast or know or suspected carcinoma of the prostate.

ABBREVIATIONS λ_ζ Slope of the terminal log-linear phase of a concentration-vs-time curve

AE Adverse Bvent

AMS Aging Male Symptom Scale

ANOVA Analysis of Variance

AUC Area Under the Curve (AUC = AUC from 0 to 24 hours)

b.i.d. bis in die which means twice-daily dosage

BMI Body Mass Index BPH Benign Prostate Hyperplasia

Co Baseline Concentration

CGS Clinical Global Scale

CAS Registry of the American Chemical Society

CI Confidence Interval

C_avg Average Concentration

C_max Maximum Concentration

Cmin Minimum Concentration

DHT Dihydrotestosterone

dL decilitre

ENT Ear Nose and Throat

FDA Food and Drug Administration

Gm grams

GLP Good Laboratory Practice

HDL High Density Lipoprotein

HDPE High Density Polyethylene

HET-CAM Hen' s Egg Test Chorioallantoic Membrane

HPLC High Pressure Liquid Chromatography

IB Investigator' s Brochure

ICH International Conference on Harmonization

INN International Nonproprietary Name i.m. Intramuscular

i.v. Intravenous

L litre

LDL Low Density Lipoprotein

MedDRA Medical Dictionary for Regulatory Activities

Mmol mole

NF National Formulary

ng/dl Nanograms per decilitre

PK Pharmacokinetic

PSA Prostate Specific Antigen

PTF Peak- Trough Fluctuation

SAE serious adverse events

SD Standard Deviation

SHBG Sex Hormone Binding Globulin

t_½ (Terminal) Half-life

T Testosterone

TE Testosterone Enanthate

t.i.d. ter in die which means thrice-daily dosage t_max Time at which C_max occurs

TRT Testosterone Replacement Therapy

TU Testosterone Undecanoate

USP United States Phamacopeia EXHIBIT D

An open label, randomized, balanced, three treatments, parallel design, pharmacokinetic study of intra-nasal TBS-1 administration to hypogonadal men

PHARMACOKINTIC SIMULATION REPORT

4. Introduction

various dosing regimens be simulated to estimate testosterone exposure following long term TBS-1 administrations. The requested dosing regimens were:

• TBS-1, 125 iL of 4.0% Gel, 30 days b.i.d.

. TBS-1, 125 pL of 4.0% Gel, 90 days b.i.d.

• TBS-1, 125 μΐ of 4.0% Gel, 45 days b.i.d followed by 45 days t.i.d.

. TBS-1, 125 liL of 4.5% Gel, 30 days b.i.d.

. TBS-1, 125 pL of 4.5% Gel, 90 days b.i.d.

. TBS-1, 125 μΐ of 4.5% Gel, 45 days b.i.d followed by 45 days t.i.d.

.used the data from study TBS-1-2010-01 to update a model previously developed (see 2007 simulation report),

Non-linear mixed-effect modeling was peiformed by first fitting the updated model to study TBS- 1-2010-01 data and then by performing stochastic simulation on the final model parameters. The obtained simulated profiles were analyzed using standard non-comparlmental method. The reported pharmacokinetic parameters were the area under the curve over 24h (AUC0-24h), the minimum observed concentration (Cmin), the average concentration (Cavg), the maximum observed concentration (Cmax), the time below 300 ng/dL within a 24h period (TLow), the time within 300-1500 ng/dL within a 24h period (TDur), the time above 1500 ng/dL within a 24h period (THgh) and the percent fluctuation (Fluctuation%).

4.1 Objectives

Obtain estimates of steady-state exposure following TBS-1 4,0% or 4.5% gel administration for 30 or 90 days under b.i.d. or t.i.d. dosing,

4.2 Basic Assumptions

• TBS-1 steady-state was assumed following seven days of b.i.d. or t.i.d, dosing.

• No further time-related change in TBS-1 kinetics was assumed following seven days of b.i.d. or t.i.d. dosing.

• The baseline testosterone in liypogonadal patients was assumed to be constant (no feedback inhibition) and linear (no circadian variations).

5. Method

5,1 Tools

Non-linear mixed effect modeling was perfonncd using NONMEM VI (). Tlrc selected minimization algorithm was the first-order with conditional eslimales (FOCE) method. Fipres and plots were generated using R 2,12.2.

5.2 Data

The analysis dataset consisted of all the concentrations from the available subjects in study TBS- 1-2010-01 and was extracted from the Winonlin datafileused to perform the pharmacokinetic analysis presented in the main report. The analysis dataset comprised the following variables,

Tahle 1 ; Analysis Dataset Variables

Variable Description

ID Subject identifier [from l to 22]

SCHT Scheduled PK sampling time [h]

TIME Actual PK sampling time [h]

AMT Amount [dose, in ng]

DV Dependent variable [testosterone, in ng/dL]

DSEQ Dose sequence [daily dose number 1 , 2 or 3]

CMT Compartment [Hosing, 2=observation]

MDV Missing data variable [0=available, l=missing]

EVID Event identification [O=observation, Hosing]

5.3 Modeling steps

The available data from study TBS-1 -2010-01 and previous modeling experience suggested that TBS-1 exhibited single compartment kinetics, as illustrated in the figure 1 below showing the day 7 mean concentration- time profiles of the different treatment groups.

Figure 1

Mean Testosterone Serum Concentration (ng/dL) - Time Profile

Time (10

Therefore, the primary structural model selected was composed of a single-compartment with first-order extravascular input and elimination, parameterized in terms of clearance and volume (NONMEM's THETA elements).

The basic model consisted of the above structural model with inter-subject variability (NONMEM's ETA elements) modeled as exponential and residual enor (NONMEM's SIGMA) as additive. The ETA variance matrix was set as diagonal without covenants between the ETAs. Appendix Figure 1 shows the NONMEM model definition (control file) of the basic model.

Model 1 was successfully fit and Table 1 shows the model parameter estimates

Table 1: Model 1 Parameter Estimates

Parameter Estimate %RSE 95% C.I.

Lower Upper

Theta

CL (ml/ti) 3.64E3 7.55 3.10E3 4.18E3

V (mL) 533 22.0 304 762

KA (Mi) 0.202 9.80 0.163 0.241

Omega nv η CL 0.0734 41.7 0.0134 0.133 CV% = 27.1 η V 0.175 110 -0.201 0.551 CV% = 41,8 η_ΚΑ 0.0886 38.6 0.0216 0.156 CV% = 29.8

Residual 3.60E4 13,9 2.62E4 4.58E4 SD = 190ng error 2014/080282

PCT/lB2013/002920

%CV= coefficient of variation; %RSE= percent relative standard error; !IV= inter-individual variability

Tk second model was similar the basic model but incorporated an additional statural

parameter, the baseline testosterone concentration (defined as BASE in the control file),

Model 2 was successfully fit and Table 3 shows the model parameter estimates

Table 3: Model 1 Parameter Estimates

Parameter Estimate %RSE 95% C.I.

Lower Upper

Theta

CL (mLW ΙΜ Α 13.9 1.05E4 1.83E4

V (ml) 3.29E3 38.9 781 5Mi

KA (Mi) 0.60i 12.5 0.455 0.751

BASE (ngflL) 284 6.44 248 320

Omega nv

1_CL 0.309 32.7 0.111 0.507 cv% = 55.6

η V 0.237 41.9 M424 0.432 cv%= 48.7

'ΚΑ 0.0211 85.3 -0.0142 CV°/o = 14.5

η_ΒΑ≤Β 0.06Ώ 41.9 o.ora 0,112 cv%= 24.8

Residual I.89E4 22.6 1.05B4 2.73E4 SD = 137 nj

error

%CV= coefficient of variation; %RSE- percent relative standard enor; tIV= inrer-individuat variability

It was observed during the analysis of die testosterone concentration that TBS-1 exposure

decreased with additional daily doses. This may be observed in Figure 1 above, The second

daily dose showed slightly lower exposure compared to the first dose even if the same amount

was administered and likewise, the third daily dose had a lower exposure compared to the

preceding dose and the fast dose. The reason for this observation has not been determined but

could be due to decreased TBS-1 bioavailability with the addition of doses or from negative

feedback inhibition on the remaining endogenous testosterone levels. In order to account for this,

an additional parameter (BA, for bioavailability) was added to the model, It was modeled as a

linear function of the daily dose number with the first dose having a BA value of 1 and an

estimable slope to model the bioavailability of the second and third doses.

Model 3 was successfully fit and Table 4 shows die model parameter estimates

Table 4: Model 3 Parameter Estimates

Parameter Estimate %RSE 95% CI.

Lower Upper

Theta

CL (mlA) 9.57E3 15.7 6.63E3 1.25E4

V (mL) 1.87E3 28,0 845 2.90E3

KA (Mi) 0.576 7.99 0.486 0.666

BASE 260 8,12 219 301

BA SLOPE 0.238 13,9 0.173 0,303

Omega IIV

TLCL 0,265 28,8 0.115 0.415 cv%= 51.5 η V 0.178 46.0 0.0177 0.338 cv% = 42.2 η KA 0.0279 83,5 •0.0178 0.0736 cv%= 16.7 i)_BASE 0.0840 33,8 0,0283 0,140 cv%= 29.0

Residual 0.0627 11,1 0.0490 0.0764 cv%= 25.0 error

%CV= coefficient of variation; %liSE= percent relative standard error; iiV= in!er-kiividua! variability

No subject specific covariate was added to the model since the study subjects population was reasonably homogeneous with regards to weight, age, sex and medical condition.

5.4 Model Diagnostics

Model 3 was considered the final model, The objective function of the fit of the three models is presented in Table 5 below. The lower the objective function value, the better.

Table 5: Objective Function Values

Model Number Parameters in Model OFV AOFV

5939.752

5637.704

5375.574

OFV objective function value; AOF = difference in OFV compared to previous model

The figures below present the population predicted TBS-1 versus the observed concentrations (Figure 2), the relationship between observed concentrations and population predicted concentrations (Figure 3) and individual predicted concentrations (Figure 4).

Histograms of observed and model predicted baseline values are presented below (Figure 6), Figure 2: Xotal Testosterone Concentration Time Profiles - Observed (DV) and Population Predicted (PRED)



 Figure 5^ζ Density Plot of Observed Total Testosterone Concentrations <TJV vs Individual Predicted Concentrations ( PRE)

6. Simulation

Based on model 3, simulations the following dosing regimens were performed:

. TBS-1, 125 of 4.0% Gel, 30 days b.i.d.

. TBS-1, 125 ill of 4,0% Gel, 90 days b.i.d.

. TBS-1, 125 μίοΐ4.0% Gel, 45 days b.i.d followed by 45 days t.i.d.

. TBS-1, 125 \il of 4,5% Gel, 30 days b.i.d.

. TBS-1, 125 μί of 4.5% Gel, 90 days b.i.d.

. TBS-1, 125 fiL of 4.5% Gel, 45 days b.i.d followed by 45 days t.i.d.

The resulting pharmacokinetic parameters are presented below. Individual pharmacokinetic parameters can be found in the Appendix. Figures of the resulting concentration - time profiles (Figures 6 , are presented below as well.

Table 6: Ti eatment A (TBS-1, 125 μί of 4% Gel), bid dosing 30 days

AUCo-24), ™ C_avs C„,_M TLow TDur THgh Fluctuation (h¾g/dL) (ng/dL) (ng dL) (ng/dL) (h) (h) (h) (%)

N 200 200 200 200 200 200 200 200

Mean 8827,19 194.15 367.80 937.95 10.27 13.71 0.02 202.93

SD 2332.95 62.57 97.21 309.61 6.49 6.48 0.09 58,97

Min 4596,52 96.80 191.52 449.00 0,00 2.05 0.00 57.12

Median 8590.36 184.00 357.93 886.00 10,08 13.92 0,00 190.88

Max 17689.24 523.00 737.05 2120.00 21.95 24.00 0.78 418.46

CV% 26.43 32.23 26.43 33.01 63,25 47.23 504.31 29.06

Table 7: Treatment A (TBS-1, 125 μΐ, of 4% Gel), bid dosing 90 days

AUCo._¾h C_mi„ C,_»g C_mlx TLow TDur THgh Fluctuation

(h'lig/dL) (ng/dL) (ng/dL) (ng/dL) (h) (h) (h) (%)

N 200 200 200 200 200 200 200 200

Mean 8892.17 192,61 370.51 959.47 10.09 13.89 0.02 207.40

SD 2406.79 60.65 100.28 381.54 6.77 6.75 0.10 76.82

Min 4211.73 56.80 175.49 382.00 0.00 0.73 0.00 89.56

Median 8500.55 185.00 354.19 917.00 10.65 13.35 0.00 193.91

Max 15419.83 372.00 642.49 3420.00 23.27 24.00 0.88 536.05

CV% 27.07 31.49 27.07 39.77 67.07 48.60 483.69 37.04

Table 8; Treatment A (TBS-1, 125 μΐ of 4% Gel), bid dosing45 days followed by tid dosing

45 day:

. Cjvg TLow TDur THgh Fluctuatic

(hugfdL) (ng/dL) (ng/dL) (ng/dL) 00 00 (h) (%)

N 200 200 200 200 200 200 200 200

Mean 9189.46 183.79 382.89 934,08 9.54 14.41 0.05 196.85

SD 2683.16 59.88 111.80 346.02 6.27 6,23 0,34 67.50

Min 3823.04 74.70 159.29 318.00 0.00 0,18 0.00 81.34

Median 8703.79 176.00 362.66 874.50 9.58 14.33 0,00 184.06

Max 22043.49 531.00 918.48 2490.00 23.82 24.00 4,19 483.57

CV% 29.20 32.58 29.20 37.04 65.70 43.20 734.32 34.29

Table 9; Treatment C (TBS-1, 125 μί of 4.5% Gel), bid dosing 30 days

UCo-Mi C_min C_lvs C_mi TLow TDur THgh Fluctuation

(Irng/dL) (ng/dL) (ng/dL) (ng/dL) (ti) 00 00 (%)

N 200 200 200 200 200 200 200 200

Mean 9204.38 193.94 383.52 1038.21 9.69 14.24 0.07 219.31

SD 2653.82 62.19 110.58 401.22 6.64 6,59 0.40 68.72

Min 4284.10 70.20 178.50 370,00 0.00 1,08 0.00 92.25

Median 9005.50 183.50 375.23 963.50 9.75 14.25 0.00 212.55

Max 21978,67 384,00 915.78 3470,00 22.92 24.00 5.24 550.44

CV 28.83 32.07 28.83 38.65 68.54 46.28 599.61 31.34

Table 10: Treatment C (TBS-1, 125 μί of 4.5% Gel), bid dosing 90 days

AUQ.24I, C_iaill C,_e C_ TLow TDur THgh Fluctuation

(h ng dL) (ng/dL) (ng/dL) (ng/dL) 00 0^») 00 (%)

N 200 200 200 200 200 200 200 200

Mean 8967.33 194.12 373.64 990.84 10.29 13,66 0.05 215.17

SD 2564,19 65,50 106.84 376.88 6.75 6.71 0.32 73.86

Min 4213,05 82.00 175.54 411.00 0.00 0.84 0.00 88.88

Median 8624.26 185.00 359.34 910.50 11.18 12.71 0.00 203.94

Max 21054,46 460.00 877.27 3060.00 23.16 24,00 3,21 517.76

CV% 28.59 33.74 28.59 38.04 65,64 49,12 618.97 34.33

Tabic 11: Treatment C (TBS-1, 125 iL of 4.5% Gel), bid dosing 45 days followed by tid dosing 45 days

AUC₀-24h C_Bin C_Jvi C_m„ TLow TDur THgh Fluctuation (Irng/dL) (ng/dL) (ng/dL) (ng/dL) (h) (h) (h) (%)

N 200 200 200 200 200 200 200 200

Mean 9744.34 197.55 406,01 988.81 7.93 16.05 0.01 197.71

SD 2502.56 66,36 104,27 289,65 6.12 6,11 0.09 57.61

Min 4297.48 68,20 179,06 411,00 0.00 1.78 0.00 94.73

Median 9591,03 187,00 399,63 976.00 7.60 16,39 0.00 195.96

Max 16919.51 441,00 704,98 1850.00 22.22 24,00 0.81 404.41

CV% 25.68 33.59 25.68 29.29 77.20 38,09 631.24 29.14

484

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490

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EXHIBIT E

Target Product Profile: TBS-1

(COMPLEOTRT)

1 Indications and Usage

Target

COMPLEOTRT is an androgen indicated for replacement therapy in males for conditions associated with a deficiency or absence of endogenous testosterone.

• Primary hypogonadism (congenital or acquired): testicular failure due to conditions such as cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, orchiectomy, Klinefelter' s syndrome, chemotherapy, or toxic damage from alcohol or heavy metals . These men usually have low serum testosterone concentrations and gonadotropins (FSH, LH) above the normal range.

• Hypogonadotropic hypogonadism (congenital or acquired): idiopathic gonadotropin or luteinizing hormone-releasing hormone (LHRH) deficiency or pituitary-hypo thalamic injury from tumors, trauma, or radiation. These men have low testosterone serum concentrations but have gonadotropins in the normal or low range.

Important limitations of use— Safety and efficacy of COMPLEOTRT in males < 18 years old have not been established [see Use in Specific Populations (8.4)] .

2 Dosage and Administration

Target

2.1 Dosing and dose adjustment

The recommended starting dose of COMPLEOTRT (testosterone) is 22 mg of testosterone (4 pump actuations) applied intranasally twice daily ( 1 pump actuation per nostril)

To ensure proper dosing, serum testosterone concentrations should be measured after initiation of therapy to ensure that the desired concentrations (300 ng/dL- 1050 ng/dL) are achieved. The COMPLEOTRT dose can be adjusted based on the serum testosterone concentration from two blood draw taken 9 hr and 10.3 hrs after applying COMPLEOTRT and at least 30 days after starting treatment or following dose adjustment.

If the measured serum concentration sum is below 755 ng/dL, the daily testosterone dose may be increased from 22 mg (twice daily administration) to 33 mg (thrice daily administration). If the serum testosterone concentration exceeds 1050 ng/dL, the daily testosterone dose should be decreased from 22 mg (twice daily administration) to 1 1 mg (daily administration) as instructed by a physician.

2.2 Administration Instructions

COMPLEOTRT is administered intransally twice daily. Do not apply COMPLEOTRT to other parts of the body including scrotum, penis, abdomen, shoulders, axilla or upper arms.

When using COMPLEOTRT for the first time, patients should be instructed to prime the pump by depressing the pump 10 times, discard any product dispensed directly into a basin, sink or toilet and then wash the gel away thoroughly. This priming should be done only prior to the first use of each pump. After priming, patients should completely depress the pump one time per nostril to dispense 5.5mg testosterone/nostril, (total dose l l mg)

Keeping the dispenser upright, in front of a mirror, patients should advance the tip of the actuator into the left nostril until the finger on the pump reaches the base of the nose and aim the tip of the actuator to the inner corner of the left eye. The opening on the tip of the actuator must face the skin that lines the inner nose. Depress the pump until it stops and slowly remove the actuator from the nose. Any gel that remains on the tip of the actuation should be wiped using a clean dry swab. The process is repeated for the right nostril. Once the gel is administered into the nose, the nostrils are pressed lightly together and massaged for 3 seconds. The patient should not blow his nose or sniff for 1 hour post administration.

After use, any gel remaining on the dispenser should be removed with a clean dry swab. The cap is replaced on the dispenser for storage. Forms and Strengths

Target

COMPLEOTRT is a (testosterone) intranasal gel available as a metered dose pump. One pump application delivers 5.5mg of testosterone (total dose 1 l mg).

4 Contraindications

Target

• COMPLEOTRT is contraindicated in men with carcinoma of the breast or known or suspected carcinoma of the prostate [see Warnings and Precaution (5.1 )].

• COMPLEOTRT is contraindicated in women who are, or who may become pregnant, or who are breastfeeding. COMPLEOTRT may cause fetal harm when administered to a pregnant woman. COMPLEOTRT may cause serious adverse reactions in nursing infants. If a pregnant woman is exposed to COMPLEOTRT, she should be apprised of the potential hazard to the fetus . [See Use in Specific Populations (8.1, 8.2)].

Warnings and Precautions

Target

5.1 Worsening of Benign Prostatic Hyperplasia and Potential Risk of Prostate Cancer

• Patients treated with androgens may be at increased risk for prostate cancer. Evaluate patients for prostate cancer prior to initiating treatment. It would be appropriate to reevaluate patients 3 to 6 months after initiation of treatment, and then in accordance with prostate cancer screening practices. [See Contraindications (4)].

5.2 Polycythemia

5.3 Use in Women

Due to lack of controlled studies in women and potential virilizing effects, COMPLEOTRT is not indicated for use in women [see Contraindications (4) and Use in Specific Populations (8.1, 8.2)].

5.4 Potential for Adverse Effects on Spermatogenesis

At large doses of exogenous androgens, including COMPLEOTRT, spermatogenesis may be suppressed through feedback inhibition of pituitary follicle-stimulating hormone (FSH) which could possibly lead to adverse effects on semen parameters including sperm count.

5.5 Hepatic Adverse Effects

Prolonged use of high doses of orally active 17-alpha-alkyl androgens (methyltestosterone) has been associated with serious hepatic adverse effects (peliosis hepatitis, hepatic neoplasms, cholestatic hepatitis, and j aundice). Peliosis hepatitis can be a life-threatening or fatal complication. Long-term therapy with intramuscular testosterone enanthate has produced multiple hepatic adenomas. COMPLEOTRT is not known to cause these adverse effects.

5.6 Edema

Androgens, including COMPLEOTRT, may promote retention of sodium and water. Edema, with or without congestive heart failure, may be a serious complication in patients with preexisting cardiac, renal, or hepatic disease.

5.7 Gynecomastia

Gynecomastia may develop and may persist in patients being treated with androgens, including COMPLEOTRT, for hypogonadism.

Target

5.8 Sleep Apnea

5.9 Lipids

5.10 Hypercalcemia

Androgens, including COMPLEOTRT, should be used with caution in cancer patients at risk of hypercalcemia (and associated hypercalciuria). Regular monitoring of serum calcium concentrations is recommended in these patients.

5.11 Decreased Thyroxine- binding Globulin

Androgens, including COMPLEOTRT, may decrease concentrations of thyroxin -binding globulins, resulting in decreased total T4 serum concentration and increased resin uptake of T3 and T4. Free thyroid hormone concentration remain unchanged, however there is no clinical evidence of thyroid dysfunction.

6 Adverse Reactions

Target

6.1 Clinical Trial Experiences

Based on prior clinical experiences and the human studies conducted to date, the risk associated with the use of COMPLEOTRT are no greater than those associated with the use of any other testosterone replacement therapy (TRT) on the market.

Clinical Trials in Hypogonadal Men

Treatment emergent adverse reactions after 21 days of COMPLEOTRT reported by at least by 5 % of the patients studied include nasal dryness and nasal inflammation.

Other treatment emergent adverse reactions after 21 days of COMPLEOTRT include dizziness, increased alanine aminotranserase, increased aspartate aminotranserase, increased blood creatine phosphokinase, increased blood pressure, increased prostatic specific antigen, epistaxis, nasal congestion and nasal discomfort.

7 Drug Interactions

Target ulin

al anticoagulants

Changes in anticoagulant activity may be seen with androgens. More frequent monitoring of INR and prothrombin time is recommended in patients taking anticoagulants, especially at the initiation and termination of androgen therapy.

rticosteroids

The concurrent use of testosterone with ACTH or corticosteroids may result in increased fluid retention and should be monitored cautiously, particularly in patients with cardiac, renal or hepatic disease.

8 Use in Specific Populations

Target

8.1 Pregnancy

Pregnancy Category X [see Contraindications (4)] COMPLEOTRT is contraindicated during pregnancy or in women who may become pregnant. Testosterone is teratogenic and may cause fetal harm. Exposure of a female fetus to androgens may result in varying degrees of virilization. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to a fetus.

8.2 Nursing Mothers

Although it is not known how much testosterone transfers into human milk, COMPLEOTRT is contraindicated in nursing women because of the potential for serious adverse reactions in nursing infants. Testosterone and other androgens may adversely affect lactation. [See Contraindications (4)].

8.3 Pediatric Use

Safety and efficacy of COMPLEOTRT has not been established in males < 18 years of age. Improper use may result in acceleration of bone age and premature closure of epiphyses.

8.4 Geriatric Use

The Phase III study is enrolling men over the age of 65. Recommendations for geriatric use will be made upon completion of the Phase III study.

8.5 Renal Impairment

No formal studies were conducted involving patients with renal impairment.

8.6 Hepatic Impairment

No formal studies were conducted involving patients with hepatic impairment.

8.7 Use in Men with Body Mass Index (BMI) >35 kg/m'

Safety and efficacy of COMPLEOTRT in males with BMI >35 kg/m has not been established.

9 Drug Abuse and Dependence

Target

9 DRUG ABUSE AND DEPENDENCE

9.1 Controlled Substance

COMPLEOTRT contains testosterone, a Schedule III controlled substance as defined by the Anabolic Steroids Control Act.

9.2 Abuse

9.3 Dependence

• Taking more drug than intended

• Continued drug use despite medical and social problems

• Significant time spent in obtaining adequate amounts of drug

• Desire for anabolic steroids when supplies of the drug are interrupted

10 Overdosage

Target

No cases of overdose with COMPLEOTRT have been reported in clinical trials. There is one report of acute overdosage by injection of testosterone enanthate: testosterone concentrations of up to 1 1 ,400 ng/dL were implicated in a cerebrovascular accident. Treatment of overdosage would consist of discontinuation of COMPLEOTRT together with appropriate symptomatic and supportive care.

Description

Target

COMPLEOTRT (testosterone) intranasal gel is a slightly yellow gel containing 5.5 mg of testosterone in 122.5 mg of COMPLEOTRT gel for intranasal administration. The active pharmacologic ingredient in COMPLEOTRT is testosterone. Testosterone USP is a white to practically white crystalline powder chemically described as 17 -Hydroxyandrost-4-en-3-one. The structural formula is:

C₁₉H₂₈0₂ MW = 288.4

The inactive ingredients are castor oil, oleoyl polyoxylglycerides and colloidal silicon dioxide.

12 Clinical Pharmacology

Target

12.1 Mechanism of Action

Endogenous androgens, including testosterone and dihydro testosterone (DHT), are responsible for the normal growth and development of the male sex organs and for maintenance of secondary sex characteristics. These effects include the growth and maturation of prostate, seminal vesicles, penis and scrotum; the development of male hair distribution, such as facial, pubic, chest and axillary hair; laryngeal enlargement, vocal cord thickening, alterations in body musculature and fat distribution. Testosterone and DHT are necessary for the normal development of secondary sex characteristics. Male hypogonadism results from insufficient secretion of testosterone and is characterized by low serum testosterone concentrations. Signs/symptoms associated with male hypogonadism include erectile dysfunction and decreased sexual desire, fatigue and loss of energy, mood depression, regression of secondary sexual characteristics and osteoporosis.

Male hypogonadism has two main etiologies. Primary hypogonadism is caused by defects of the gonads, such as Klinefelter' s Syndrome or Leydig cell aplasia, whereas secondary hypogonadism is the failure of the hypothalamus (or pituitary) to produce sufficient gonadotropins (FSH, LH).

12.1 Pharmacodynamics

Pharmacodynamic data will be available upon the completion of the Phase III clinical study.

12.1 Pharmacokinetics

Absorption — COMPLEOTRT delivers physiologic circulating testosterone that restores testosterone to normal concentration range (i.e., 300 - 1050 ng/dL) seen in healthy men following intranasal application. COMPLEOTRT is rapidly absorbed, rapidly cleared and has a half -life of 10 hours.

Target

Excretion— About 90% of a dose of testosterone given intramuscularly is excreted in the urine as glucuronic and sulfuric acid conjugates of testosterone and its metabolites; about 6% of a dose is excreted in the feces, mostly in the unconjugated form. Inactivation of testosterone occurs primarily in the liver.

Metabolism - Testosterone is metabolised primarily in the liver by cytochrome P450 3A4 (CYP3A4) aromatase, and 5 -alpha-reductase. CYP3A4 metabolizes testosterone primarily in the liver by conversion to various hydroxyl steroids. The active metabolites of testosterone are DHT and estradiol. Testosterone is metabolized to DHT by steroid 5-alpha reductase in many tissues. Testosterone is metabolized to estradiol by aromatase.

Nonclinical Toxicology

Target

3.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Testosterone has been tested by subcutaneous injection and implantation in mice and rats. In mice, the implant induced cervical-uterine tumors, which metastasized in some cases. There is suggestive evidence that injection of testosterone into some strains of female mice increases their susceptibility to hepatoma. Testosterone is also known to increase the number of tumors and decrease the degree of differentiation of chemically induced carcinomas of the liver in rats . Testosterone was negative in the in vitro Ames and in the in vivo mouse micronucleus assays. The administration of exogenous testosterone has been reported to suppress spermatogenesis in the rat, dog and non-human primates, which was reversible on cessation of the treatment.

Mammalians -Fertility and early embryonic development

Both female and male animals showed changes in the structure and function of the genital organs if the animals were treated with testosterone before mating (RTECS 2002). These disturbances probably contributed to the effects observed with regard to the fertility of the animals.

Mammalians— Embryo-fetal development

In addition to a higher incidence of fetal death in testosterone-treated animals, specific developmental abnormalities were observed in animals and human beings (RTECS 2002).

3.2 Animal Toxicology and/or Pharmacology:

Animal Toxicology: The accumulated animal data on COMPLEOTRT have not demonstrated toxicity related concerns which would preclude the use of Trimel' s COMPLEOTRT in the clinical trial program. A large number of non-clinical pharmacology and toxicology studies have been conducted to support the efficacy and safety of testosterone cited in the literature and in previously submitted applications.

No evidence of systemic drug related toxicity was observed in rabbits after repeated twice daily administration of COMPLEOTRT over a 90 day period up to a dose level of 6-fold the maximum clinical daily dose. Local tolerance studies in rat and rabbit following single dose and repeated dose administrations showed that testosterone intranasal gel was well tolerated. Testosterone intranasal gel was classified as a non-irritant in the HET-CAM test. Target

Pharmacology: Testosterone, the active ingredient in COMPLEOTRT, is an endogenous androgen necessary for normal male growth and development. Through nuclear receptors located throughout the body, testosterone influences the transcription of genes involved in statural growth, protein anabolism, bone remodeling, immune modulation, hematopoesis, and lipid metabolism. Via conversion to dihydro testosterone (DHT), testosterone also maintains adult male secondary sex characteristics. Deficiency leads to male hypogonadism with a clinical presentation determined by the age of onset and the duration and severity of deficit. In adults, symptoms vary widely, ranging from depression and cognitive decline to infertility and osteopenia.

ical Studies

Target

14.1 Clinical Studies in Hypogonadal Men

Preliminary efficacy data indicates that COMPLEOTRT is rapidly absorbed and restores testosterone levels to normal reference ranges > 300 ng/dL < 1050 ng/dL.

A Phase III study is ongoing evaluating the efficacy of 4.5 % COMPLEOTRT. Clinical efficacy data will be available upon the completion of the Phase III clinical study.

ow Supplied/Storage and Handling

Target

16.1 How Supplied

4.5 % COMPLEOTRT (testsotsterone) nasal gel is available as a metered dose pump containing 15g of gel dispensed as 90 metered pump actuations. One pump actuation delivers 5.5 mg of testosterone in 122.5 mg of gel.

16.2 Storage and Handling

Keep COMPLEOTRT out of reach of children.

Store at 25°C (77°F). Excursions are permitted to 15°C to 30°C (59°F to 86°F). See USP Controlled Room Temperature. Used COMPLEOTRT dispensers should be discarded in household trash in a manner that prevents accidental exposure of children or pets.

17 Patient Counseling Information

Target

See FDA-Approved Medication Guide. Patients should be informed of the following information:

17.1 Use in Men with Known or Suspected Prostate or Breast Cancer

Men with known or suspected prostate or breast cancer should not use

COMPLEOTRT. [See Contraindications (4) and Warnings and Precaution (5.1 )].

17.2 Potential Adverse Reactions with Androgens

• Changes in urinary habits such as increased urination at night, trouble starting your urine stream, passing urine many times during the day, having an urge that you have to go to the bathroom right away, having urine accident, being unable to pass urine and having a weak urine flow.

• Too frequent or persistent erections of the penis.

• Nausea, vomiting, changes in skin color, or ankle swelling.

17.3 Patients Should be Advised of these Application Instructions

• The pump should be primed by depressing it 10 times prior to its first use. No priming is needed with subsequent uses of that pump.

• COMPLEOTRT should NOT be applied to the scrotum, penis, abdomen, shoulders, underarms or upper arms.

• COMPLEOTRT should be applied twice daily at approximately the same time each day (7am and 1pm).

509 STABILITY SUMMARY REPORT ANALYTICAL LAB

STABILITY SUMMARY REPORT ANALYTICAL LAB

BRT= Below Reporting Threshold (0.1%)

STABILITY SUMMARY REPORT ANALYTICAL LAB

STABILITY SUMMARY REPORT ANALYTICAL LAB

PRODUCT NAME: TBS1 Testonsterone Nasal Gel BATCH NO: TBP-109 STORAGE CONDITION 30C/65%RH

ACTIVE INGREDIENT: -Testosterone- MANUFACTURING DATE: PROTOCOL NO PRO'ST-11'015

LA3EL CLAIM: llmg/dose (4.5%) PACKAGING DESCR|Aptar multidose airless filling Bottle Orientat^'on Upright

DRUG SUBSTANCE MANUFACTURER PACKAGING DATE: PACKAGING SITE

DRUG SUBSTANCE BATCH NO BATCH SIZE: Manufacturer's Ba:ci ¾ 2374

PRODUCT DESCRIPTION Slightly yellow gel packaged In Aptar multidose bottle

Page 1 of 2

STABILITY SUMMARY REPORT ANALYTICAL LAB

BRT = Below Reporting Threshold (0.1%)

STABILITY SUMMARY REPORT

PRODUCT DESCRIPTION Slightly yellow gel ackaged in Aptar muitldose bottle

STABILITY SUMMARY REPORT ANALYTICAL LAB

Comments:

* Test upon request for information only

BRT= Below Reporting Threshold (0.1%)

Stability Summary Report Analytical i.sb

m * Below Reporting Threshold :C,1K)

Stability Summary Report Analytical Lab

BRT = Below Reporting Threshold (0.1%)

524 Stability Summary Report Analytical Lab

BRT = Below Reporting Threshold 10.1%)

Stability Summary Report Analytical Laboratory

Stability Summary Report Analytical Laboratory

Stability Summary Report Analytical Laboratory

Stability Summary Report

Comments:

530 Stability Summary Report Analytical Laboratory

Stability Summary Report

Comments: ' Assay not performed at litis tlmepoint

532 Stability Summary Report Analytical Laboratory

Comments:

Stability Summary Report Analytical Laboratory

StabllltySummary Report

•J\

Stability Summary Report Analytical Laboratory

Stability Sumrriiiry Report

Stability Summary Report Analytical Laboratory

Stability Summary Report

2013/002920

539

540

02920

1. Patients with the AR in MH, AEs and treatment responses:

EXHIBIT (inactive) Nasal Soreness (Jul2012) 22-042(GLT) UNK/1995 Sporadic Allergies No

SEASONAL No

23-007(CAE) UNK/1974 ALLERGIES

24-006<WGK) U /1994 Mild Hay Fever No

Hay Fever/seasonal Allergy worsening (March 24-009(PKB) Mar-07 allergies inactive 2012)

Nasal Erythema

(March2012), Excess mucus

029-014(LAC) U /1996 seasonal allergies (Jun2012)

Allergic reaction (face swollen) (May-Jun2012)

043-004(DDM) Jun-09 seasonal allergies Drop-out

Nose bleed and mucus

043-007(ADC) Mar-95 seasonal allergies (March and Jul)

043-008(DFT) Aug-00 seasonal allergies No

Allergies, seasonal, No

acute/not active at

044-003 (DJS) U /1980 start of study

044-008{KTH) Jan-85 Seasonal Allergies No

046-004(HRR) UN /2008 Allergic rhinitis cats No

046-014(JCZ) UNK/2000 Seasonal allergies No

047-022(WCN) Jan-08 Seasonal Allergies No

047-031(KLS) UNK/2011 Seasonal Allergies No

Nasal irritation (Jun-

047-035(RDI) Apr-11 Seasonal Allergies Jul2012)

048-003(ALB) U /2006 Seasonal Allergies No

048-009(JAJ) UNK/1956 Seasonal Allergies No

048-011(MSI) UN /2000 Seasonal Allergies No

Nasal congestion with

048-013(HWN) UNK/2010 Seasonal Allergies application (Jul2012)

052-002(DWK) Feb-Ol allergic rhinnitis No

Allergic Rhinnitis No

052-009(WAH) May-99 (mild)

ALLERGIC RHINNITIS Nasal congestion and Smell

052-015(MAR) U K/1995 (CONTROLLED) alteration )Jul2012

Allergic Rhinnitis No

052-019(JED) Mar-02 (mild)

ALLERGIC RHINNITIS Rhinorrhea (Sep2012)

052-027(AEU) Oct-OS (NOT ACTIVE)

052-034(GWB) Sep-07 ALLERGIC RHINNITIS No

51 pts with- MH of AR^', 2 drop-outs due to AEs, 3 AR exacerbations,

Total: 17 other respiratory AEs (Feb2012) and 003-046 (Oct2012)— A AE without prior M H

Hematology:

a. Hematocrit (40-52(54)%)-No significant difference between treatment groups

Clinically significant Hematology results:

Per literature: The effects of a non-scrotal transdermal patch system and IM T enthanate were compared in a randomized trial. Both treatment modalities stimulated erythropoesis significantly. IM treatment demonstrated abnormal hematocrit elevations in 43.8% of patients and transdermal system in 15.4% of patients. Dose dependent increase above the range in RBC counts were also seen.

Our data showed an increase in HCT values above the range in much lower percentages of patients (table above). No elevations in Hgb or erythrocites values above the upper range of normal were seen.

Overall, mean Hematology values showed insignificant decrease from baseline on Day 90 (likely due to PK blood draws) and demonstrated a slight increase from baseline on Day 180. All changes were within the range of normal for men.

PSA (0.01-4ng/L):

1.08 (0.01-3.93) 1.18 (θ.18-4.42)/θ.1(- 1.13 (0.15 -3.95)/0.04 1.53 (0.27-8.94)/0.04 1.49;2.8) (-1.62; 1.58) (-0.85;5.49)

Clinically significant PSA results:

*4 subjects were discontinued from the trial due to increase in PSA values greater than 1.4ng/dL: 3 after V6 ( one subject from each treatment group) and 1 after V9 (TID patient). All subjects were monitored and showed a decrease comparable to baseline values after treatment termination. One subject (TID) stopped study drug administration for two weeks and was re- challenged after. He completed 360 days of treatment with PSA levels comparable to his baseline values.

Overall, mean values changes at V6 and V9 didn't exceed a threshold of 0.4 ng/ml-yr recommended by the Endocrine society Clinical Practice guideline (vl5 is not a full dataset, therefore is not considered here).

Five subjects (1.8%) had PSA >4ng/dL after 3 months of treatment The majority of subjects with PSA >4ng/dL were older than 50.

DRE:

DRE results: CS Prostate abnormalities reported at baseline were 'small prostate' (subject withdrew consent after V4) and 'enlarged prostate, normal for age' (subject successfully completed the trial with no further increase in prostate size or PSA values reported).

CS Prostate abnormalities reported on Day 90 were 'internal haemorrhoid' and 'slightly enlarged prostate'. Both subjects completed the trial. No increase in PSA values.

No other new abnormal clinically significant findings were reported during the study.

Three pts (all from one site):two in BID and one in TID group, had AEs of an enlarged prostate reported. Two events were mild and one moderate. None led to study drug discontinuation. Lipids:

5 J45J r a. HDL (35-60 mg/dL, 0.91-1.55nmol/L)* :

Per literature: In the majority of studies, substitution of T in hypogonadal men had no impact on total cholesterol, LDL and triglycerides but decreased HDL-C levels.

Our data showed that: 1) No significant decreases in HDL levels were seen after either 90 or 180 days of treatment^ Per literature, treatment with supraphysiological doses of testosterone in normal men can decrease HDL by 20% and more. However, the epidemiological association of low HDL with CAD has not been proven to be casual). 2)There was a trend towards a decrease of LDL and total cholesterol mean values, but no significant changes were seen. 3) Baseline triglycerides mean levels were above the ULN at the baseline and didn't demonstrate significant changes either after Day 90 or Day 180.

Stability Summary Report Analytics! Laboratory

548 Stability Summary Report Analytical Laboratory

Stability Summary Report

Comments: ' Appearance Cloudy yellow gel

Stability Summary Report Analytical Laboratory

Stability Summary Report

Comments: ** Appearance Investigated 1(1-11-001

920

553 Stability Summary Report Analytical Laboratory

Stability Summary Report

Stability Summary Report Analytical laboratory

Stability Summary Report

556

Diffusion Me Analytical lab TBS Testosterone Steal Ss! !LOmg/doss

Mean{6 cells]

Amount Released

Actual of Active Released {ug/cm²} vsTime^i,s

VTimeS Ceil I Ceil 2 Ceil 3 _. ^' Cell 4 CifS _. C 6 :

7.75 691,94 730,54 722,42 653,79 729,00 737,93 712,62

10.95 1057,70 1119.52 1112,28 1028.83 1122,38 1105,53 1091.04

13,42 1396,90 1430.55 1441,43 1320.35 1442,88 1423.58 1409,28

15,49 1675,26 1731.811 1719,78 1574.08 1745,79 1892.25 [ 1689.83

17,32 1321,77 1982.04 1959.45 1795,36 1964,96 1924.92 1924.75

2109.67 2210.23 2175.06 i <2f> 2159,53 2134,24 2130,33

SLOPE 128,61 132.54 130.21j ll8.82 129,14 125.29 127,44

0.9989 0.9988 0.9997p 0.9S98 0.9992 0.9995 0,9995

SqR ofTime

[TBS-1 Testosterone Masai Gel ltOttig/dose, 16.7g

Batch

Con ition 12 mcf!ih

iTime oint 30^?C/55¾l

Table D17.1

Summary of IIEF Questionnaire: Erectile Function Domain by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (N=B5) (N=226) (N=77) (N-162) ^■ (N=303|

Day 30 . n [1] 131 85 216 73 2B9

Baseline Mean 14.7 13.2 14.1 14. B 14.3

Standard deviation 10.14 9.96 10.0B 9.43 9.91

Median 14.0 11.0 13.0 14.0 13.0

Minimum 1 0 0 1 0

Maximum 30 30 30 30 30

Value Mean IB.3 16.5 17.6 19.8 10.1

Standard deviation 10.29 10.74 10.46 9.57 10.29

Median 20.0 18.0 19.5 22.0 20.0

Minimum 1 1 1 1 1

Maximum 3Ό 30 30 30 30

Change Mean 3.S 3.3 3.5 5.0 3.9

Standard deviation 7.95 7.15 7.63 e.oe 7.76

Median 2.0 2.0 2.0 2.0 2.0

Minimum -17 -20 -20 -10 -20

Maximum 27 24 27 27 27 p-value [2] <.0001 <.0001 <-0001 <.0001 OOOl

Combined TBS-1 BID vs. TID

Mean [p-value [2] ) -1.5 (0.1611⁾

Note: Baseline is the Day 1 value. If missing, the last value prior to the first dose of study medication is used.

The score for the Erectile Function Domain is the sum of the results from questions 1, 2, 3, 4, 5, and 15 from the IIEF questionnaire.

[1] n is the number of subjects with both baseline and endpoint measurements.

[2] t-test is used for the p-value calculation of change from baseline within treatment group and between treatment groups.

Program name: qs.saa Run date: 27FEB201310:17 Database last modified: 15FEB201314:33

EXHIBIT O

©

Table D17.1

©

β Summary of IIEF Questionnaire: Erectile F-anction Domain by Treatment and Visit

Intent-to-Treat Population - Treatment Period

CO Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total Variable Statistic ( =141) (H=85) (N=226) (N=77) (N=162) (N=303)

Day 30 n ;i] 131 85 216 73 289 Baseline Mean 14.7 13.2 14.1 14.8 14.3

Standard deviation 10.14 9.98 10.08 9.43 9.91

Median 14.0 11.c 13.0 14.0 13.0

Minimum 1 0 0 1 0

Maximum 30 30 30 30 30

Value Mean 18.3 16.5 17.6 19.8 18.1

Standard deviation 10.29 10.74 10.48 9.57 10.29

Median 20.0 18.0 19.5 22.0 20.0

Minimum 1 1 1 1 1

Maximum 30 30 30 30 30

Change Mean 3.6 3.3 3.5 5.0 3.9

Standard deviation 7.96 7.15 7.63 3.08 7.76

Median 2.0 2.0 2.0 2.0 2.0

Minimum -17 -20 -20 -10 -20

Maximum 27 24 27 27 27 p-value [2] <.0001 <.0001 <.0001 <.0001 <.0001

Combined TBS-1 BID vs. TID

Mean (p-value [2]) -1.5 (0.1641)

Hote: Baseline is the Day 1 value. If missing, the last value prior to the first dose of study medication is used.

[1] n is the number of subjects with both baseline and endpoint measurements,

ac ^*2] t-test is used for the p-value calculation of change from baseline within treatment aroup and between treatment groups.

©

∞ Program name: qs.sas Run date: 27FEB201310:17 Database last modified: 15FEB201314:33

©

o

Table D17.1

Summary of II2F Questionnaire: Erectile Function Domain by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-i TID TBS-1 TID Total

Variable Statistic (N=i41) (N=85) |N=226) (N=77) (N=162) (N=303)

Day 50 n [11 128 84 212 69 153 281

Baseline Mean 14.6 13.3 14.1 14.6 13.9 14.2

Standard deviation 10.15 10.00 10.09 9.42 9.73 9.91

Median 14.0 11.5 ^•13.0 13.0 13.0 13.0

Minimum 1 0 0 1 0 0

Maximum 30 30 30 30 30 30

Value Mean 19.8 17.6 18.9 20.2 18.8 19.2

Standard deviation 9.57 10.88 10.14 9.57 10.37 10.00

Median 23.0 19.0 22.0 23.0 22.0 23.0

Minimum 1 1 1 1 1 1

Maximum 30 30 30 30 30 30

Change Mean 4.3 4.9 5.7 4.9 5.1

Standard deviation 8.B2 7.55 8.33 9.42 8.45 8.60

Median 3.5 3.0 3.0 3.0 3.0 3.0

Minimum -15 -13 -16 -26 -26 -26

Maximum 28 29 29 27 29 29 p-value [2] <.0001 <.0001 <.0001 <.0001 <.O001 <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [2]) 0.3 (0.7524)

The score for the Erectile "unction Domain is the sum of the results from questions 1, 2, 3, 4, 5, and 15 from the IIEF questionnaire.

(1J n is the number of suijects with both baseline and endpoint measurements.

Frocram name: qs.sas Run date: 27FEB201310:17 Database last modified: 15FEB201314:33

Table D17.1

Summary of IIEF Questionnaire: Erectile Function Domain by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Comb; Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) ( =85) (N=226) (N=77) (N=162) (N=303)

Day 90 n [1] 122 82 204 69 151 273

Baseline Mean 14.7 13.3 14, .1 14:5 13.8 14.2

Standard deviation 10.22 9.97 10. .12 9.32 9.67 9.91

Median 14.0 11.5 13. .0 13.0 13.0 13.0

Minimum 1 0 0 1 0 0

Maximum 30 30 30 30 30 · 30

Value Mean 20.2 18.9 19. .7 20.7 19.7 19.9

Standard deviation 9.33 10.40 9. .77 9.17 9.87 9.62

Median 23.0 22.0 23. .0 25.0 22.0 23.0

Minimum 1 1 1 1 1 1

Maximum 30 30 30 30 30 30

Change Mean 5.5 5.6 5. 6 6.2 5.9 5.7

Standard deviation B.48 9.00 8. 67 9.33 9.13 8.83

Median 3.0 4.0 3. 0 3.0 3.0 3.0

Minimum -16 -12 -16 -26 -26 -26

Maximum 25 30 30 28 30 30 . p-alue [2] <.0C01 <.0001 <.0001 <.0001 <.0001 <.0001

Combined TID

Mean (p-alue [2]) ■0.4 (0.7157)

[1] n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 27FEB201310:17 Database last modified: 15FEB201314:33

Table D17.2

Summary of IIEF Questionnaire: Intercourse Satisfaction Domain by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Combined Combined

Visit T3S-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (N=85) (N=226) (N=77) (N=162) (N=303)

Day 3C n [1] 131 85 216 73 289

Baseline Mean 5.5 4.3 5.2 6.1 5.4

Standard deviation 4.73 4.BT 4.79 4.48 4.72

Median 6.0 5.0 5.0 7.0 6.0

Minimum 0 0 0 0 0

Maximum 15 13 15 15 15

Value Mean 7.0 6.1 6.7 7.8 7.0

Standard deviation 5,04 5.20 5.11 4.97 5.09

Median 9.0 8.0 8.0 10.0 9.0

Minimum 0 C 0 0 0

Maximum 15 15 15 15 15

Change Mean 1.5 1.3 1.4 1.8 1.5

Standard deviation 4.20 3.89 4.07 3.51 3.93

Median 1.0 0.0 0.5 i.O 1.0

Minimum -10 -12 -12 -8 -12

Maximum 14 11 14 13 14 p-value [2 OOOl 0.0029. <.0001 <■ 00C1 <.0001

Combined TBS-1 BID vs. TID

Mean (p-value [2]) -0.3 (0.5452)

Note: Baseline is the Day I value. If missing, the last value prior to the first dose of study medication is used.

The score for the Intercourse Satisfaction Domain is the sum of the results from questions 6, 7, and 8 from the IIEF questionnaire.

[1] n is the number of subjects with both baseline and endpoint measurements.

[2; t-test is used for the p-value calculation of change from baseline within treatment group and between treatment groups.

Program name: qs.sas Run date: 27FE3201310:17 Database last modified: 15FEB201314:33

Table D17.2

Intent-to-Treat Population - Treatment Period

Combined Combined

Visit TBS-13ID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=U1) (N=85) (N=226) (N=77] (N=162) (N=303)

Day 60 n [1] 128 212 153 281 Baseline Mean 5.4 5.2 6.0 5.4 5.4

Standard deviation 4.75 4.87 4.79 4.47 4.71 4.72

Median 6.0 5.0 5.0 7.0 6.0 6.0

Minimum 0 0 0 0 0 0

Maximum 15 13 15 15 15 15

Value Mean 7.6 6.7 7.3 8.1 7.3 7.5

Standard deviation 4.92 5.44 5.14 5.13 5.32 5.13

Median 9.0 9.0 9.0 10.0

Minimum 0 0 0 0 0 0

Maximum 15 15 15 15 15 15

Chance Mean 2.2 1.8 2.1 2.1 1.9 2.1

Standard deviation 4.72 3.82 4.38 4.50 4.13 4.40

Median 0.0 1.0 2.0 1.0 1.0

Minimum -10 -3 -10 -10 -10 -10

Maximum 14 1 14 13 14 14 p-value [2] <.0001 <.0001 <.0001 0.0002 <.0001 <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [2]) 0.3 (

[1] n is the number of subjects with both baseline and endpoint measurements.

Program name qs.sas Run date: 27FEB201310:17 Database last modified: 15FEB201314:33

Table D17.2

Intent-to-Treat Population - Treatment Period

Combined Combined

Visit TBS-1 BID TBS-1 BID/TID T3S-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic ( =141) (N=E 15! (H=226) (N=77) (N=162) (N=303I

Day 90 n [1] 122 82 204 69 151 273

Baseline Mean 5.5 4. 5. 2 6.0 5.4 5.4

Standard deviation 4.75 8B 4. 80 4.42 4.69 4.71

Median 5.0 5. 0 5. .0 7.0 6.0 6.0

Minimum 0 0 0 0 0 0

Maximum 15 13 15 15 15 15

Value Mean 7.8 7. 4 7. 5 8.6 7.9 7.9

Standard deviation 4.99 c 16 5. OS 4.82 5.04 5.01

Median 9.5 0 9. 0 11.0 10.0 10.0

Minimum 0 0 0 0 0 0

Maximum ^' 15 15 15 15 15 15

Change Mean 2.4 2. .5 2. .4 2.6 2.6 2.5

Standard deviation 4.22 4. .57 4. .35 4.45 4.50 4.37

Median 1.0 1, .5 1. ,0 2.0 2.0 1.0

Minimum -10_. -10 -10 -10 -10 -10

Maximum 14 15 15 12 15 15 p-value [2] <.0O01 <.00C1 <.0001 <- 0001 <.0001 <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [2]) -0.2 (0.7138)

Note; Baseline is the Day 1 value. If missing, the last value prior to the first dose of study medication is used.

The score for the Intercourse Satisfaction Domain is the sura of the results from questions 6, 7, and 8 from the IIEF questionnaire.

[1) n is ihe number of subjects with both baseline and endpoint measurements.

|2] ;-test is used for the p-value calculation of change^' from baseline within treatment group and between treatment groups.

Program, name: qs.sas Run date: 27FEB2013 10:17 Database last modified: 15FEB201314:33

Table D17.3

Summary of IIEF Questionnaire: Orgasmic Function Domain by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID T3S-1 TID TBS-1 TID Total

Variable Statistic (B=141) (N=85) (N=226) (N=77) (K=162) (N=303)

Day 33 n [I; 130 32 212 73 285 Baseline Mean 5.1 5.3 5.2 5.7 5.3

Standard deviation 3.51 3.97 3.65 3.51 3.65

Median 6.0 5.0 6.0 6.0 6.0

Minimum 3 0 0 C

Maximum 10 10 10 10

Value Mean 6.3 ' 6.3 6.3 6.8 6.4

Standard deviation 3.87 3.73 3.81 3.19 3.66

Median 7.0 6.5 7.0 7.0 7.0

Minimum 0 0 0 0 0

Maximum 10 10 10 10 10

Change Mean 1.2 1.0 1.1 1.1 1.1

Standard deviation 3.27 2.81 3.10 3.63 3.24

Median 0.0 0.0 0.0 0.0 0.0

Minimum -8 -5 -8 -10 -10

Maximum 10 10 10 10 10 p-value [2) <.0001 0.0021 <.C001 0.0101 <.0001

Combined TBS-1 BID vs. TID

Mean (p-value [2]) -0.0 (0.9646

The score for the Orgasmic Function Domain is the sum of the results from questions 9 and 10 from the IIEF questionnaire.

[1] n is the number of subjects with both baseline and endpoint measurements.

[2j t-test is used for the p-value calculation of change from baseline within treatment group and between treatment groups.

Program name: qs . sas Run date: 27FEB201310:17 Database last modified: 15FEB201314:33

Table D17.3

Summary of IIEF Questionnaire: Orgasmic Function Domain by Treatment and Visit

Intent-to-Ireat Population - Treatment Period

Combined Combined

Visit TBS-1 BID TBS-I BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (N=85) (N=226) (N=77) (N=162) (N=303)

Day 60 n [1] 127 81 20S 69 150 277

Baseline Mean 5. 5.4 5.2 5 , .6 5.4 5.3

Standard deviation 3, .53 3.55 3.69 3. .53 3.75 3.65

Median 6. ,0 5.0 6.0 5. .0 5.C 6.0

Minimum 0 0 0 0 0 0

Maximum 10 10 10 10 10 10

Value Mean 6. .7 6.6 6.7 6, .6 6.6 6.7

Standard deviation 3. .37 3.75 3.52 3. 38 3.58 3.43

Median ^' 7. .0 8.0 7.0 7, 0 7.5 7.0

Minimum C 0 0 0 0 0

Maximum 10 10 10 10 10 10

Change Mean 1. .6 1.3 1.5 .1 1.2 1.4

Standard deviation 3. .59 3.01 3.37 3, .11 3.05 3.31

Median 1. .0 0.0 0.0 0. .0 0.0 0.0

Minimum -9 -5 -9 -7 -7 -9

Maximum 10 10 10 10 10 10 p-value [2] <.0001 0.0002 <.0001 0.0063 OOOl <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [2]) 0.5 (0.2521)

[1] n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 27FS32C1310:17 Database last modified: 15FEB2013 14:33

Table D17.3

Summary of IIEF Questionnaire: Orgasmic Function Domain by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) IN=B5) |K=226) (K=77) (11=162) (N=303)

Day 90 n [1] 122 79 201 148 270 Baseline Mean 5.0 5.3 5.2 5.5 5.4 5.2

Standard deviation 3.55 3.95 3.70 3.49 3.73 3.65

Median 6.3 5.0 5.0 5.0 6.0

Minimum C 0 0 0 0 0

Maximum 10 10 ^'10 10 10 10

Value Kean 6.7 7.1 6.9 6.9

Standard deviation -3.53 3.59 3.54 2.91 3.28 3.39

Median 8.C 8.C 8.0 7.0 7.5 8.0

Minimum 0 0 0 0 0 0

Maximum 10 1 10 10 10 10

Change Mean 1.8 1.3 1.5 1.6 1.4 1.6

Standard deviation 3.53 3.45 3.53 3.43 3.47

Median 0.5 0.0 0.0 1.0 0.0 CO

Minimum -8 -8 -8 -7

Maximum 10 10 10 10 10 10 p-value [2] <.0001 O.O00E <.0001 0.0004 OOOl <.0001

TBS-1 BID vs. Combined TID

Mean (p-value 0.4 (

The score for the Orgasmic Function Domain is the sura of the results from questions 9 and 10 from the IIEF questionnaire.

[1] n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 27FS3201310:17 Database last modified: 15FE3201314:33

Table D17.4

Summary of IIEF Questionnaire: Sexual Desire Domain by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Combined Combined

Visit TBS-1 BID TBS-i BIDTID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (N=85) (N=226) (N=77) (N=162) (N=303)

Day 30 n [1] 130 212 73 285 3aseline Mean 5.2 5.1 5.1 5. 5.2

Standard deviation 2.14 1.94 2.06 2. 2.12

Median 5.0 5.0 5.0 5. 5.0

Minimum 1 2 1 2 1

Maximum 10 10 10 10 10

Value Mean 6.3 6. 6.2 6.8 6.4

Standard deviation 2.05 2. 2.04 2.03

Median 6.0 6.

Minimum 2 1

Maximum 10 10 10 10

Change Mean 1.1 1.0 1.1 .3 1.1

Standard deviation 1.S7 1.69 1.86 .10 1.93

Median l.C 1.0 1.0 1.0

Minimum -3

Maximum 5

p-value [2] <.0001 .0001 <.0001 < .0001 <.0001

Combined TBS-1 BID vs. TID

Mean (p-value -0.3 (0.3245)

The score for the Sexual Desire Domain is the sum of the results from questions 11 and 12 from the IIEF questionnaire.

[1] n is the number of subjects with both baseline and endpcint measurements.

[2] t-test is usee for the p-value calculation of change from baseline within treatment group and between treatment groups.

Program name: qs. as Run date: 27FEB20I310:17 Database last modified: 15FEB201314:33

Table D17.4

Summary of IIEF Questionnaire: Sexual Desire Domain by Treatment and Visit

Intent-to-Traat Population - Treatment Period

Combined Combined

Visit TBS-1 I BID TBS-1 BID/TID TBS-1 BID TBS-] . TID TBS-1 TID Total

Variable Statistic (K=141) (H=85) (K=226) -(H=77) (N=162) |N=303]

Day 60 n [1] 127 81 208 69 150 277

3aseline Mean 5. .2 5.1 5. 2 5. 5 5. 3 5.2

Standard deviation 2. .15 1.95 2. 07 2. .34 2. 14 2.14

Median 5. .0 5.0 5. 0 5. .0 5. 0 5.0

Minimum 1 2 1 2 2 1

Maximum 10 10 10 10 10 10

Value Mean 6. .6 6.6 6. .6 6. .9 6. 8 6.7

Standard deviation 1. .93 . 1.76 1. .86 2. .04 1, 89 1.91

Median 7. .0 6.0 7. .0 7. .0 7. 0 7.0

Minimum 2 2 2 2 2 2

Maximum 10 10 13 10 10 10

Change Mean 1 .5 1.5 1, .5 1. .4 i, .4 1.5

Standard deviation 2 .21 1.89 2, .09 2. .07 1, .97 2.08

Median 2 .0 1.0 2. .0 1. .0 1. .0 1.0

Minimum -5 -4 -5 -4 -4 -5

Maximum 6 7 7 3 8 B p-value [2] <.0001 <.0001 <.0001 <.0001 <.0001 <. G001

TBS-1 BID vs. Combined TID

Mean (p-value [2]) 0.0 (0.9682)

The score for the Sexual Desire Domain is the sum of the results from questions 11 and 12 from the IIEF questionnaire,

[i; n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 27FEB2C1310:17 Database last modified: 15FEB201314:33

Table D17.4

Summary of IIEF Questionnaire: Sexual Desire Domain by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (N=85) (N=226) (N=77) (N=162) (N=303)

Day 90 n [1] 122 79 201 69 148 270

Baseline Mean 5.1 5.1 5.1 5.4 5.3 5.2

Standard deviation 2.15 1.96 2.08 2.31 2.13 2.14

Median 5.0 5.0 5.0 5.0 5.0 5.0

Minimum 1 2 1 2 2 1

Maximum 10 10 10 10 10 10

Value Mean 5.8 6.6 6.7 7.1 6.8 6.8

Standard deviation 1.99 1.74 1.89 1.99 1.B7 1.92

Median 7.0 7.0 7.0 7.0 7.0 7.0

Minimum 2 2 2 2 2

■ Maximum 10 10 10 10 10 10

Chance Mean 1.6 1.5 1.6 1.6 1.6 1.6

Standard deviation 2.12 1.82 2.00 2.16 1.98 2.04

Median 2.0 1.0 2.0 1.0 1.0 1.5

Minimum -4 -2 -4 -5 -5 -5

Maximum 8 6 8 6 6 8 p-value [2] <.0001 <.0001 <.0001 <- 0001 <.0001 <.0001

TBS-1 Bi; vs. Combined TID

Mean (p-value [2]) 0.0 (0.9189)

;i] n is the number of subjects with both baseline and endpoint measurements.

'2] t-test is used for the p-value calculation of change from baseline within treatment group and between treatment groups.

Program name: qs.sas Run date: 27FEB2013 10:17 Database last modified: 15FEB2013 14:33

©

Table D17.5

©

Intent-to-Treat Population - Treatment Period

CO Combined Combined

visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total Variable Statistic (N=141) (N=B5) (N=226) (N=77) (N=162) (N=303)

Day 30 n [1] 129 32 211 72 283 Baseline Mean 4.6 4.6 4.6 4.6

Standard deviation 2.51 .39 2.46 2.30 2.42

Median 4.0 .0 4.0 4.0

Minimum 1 1 1 1

Maximum 10 10 10 10 10

Value Mean 5.7 6.0 6.4 6.1

Standard deviation 2.58 2.70 2.63 2.52 2.61

Median 6.0 6.0 6.0 7.0 6.0

Minimum 2 2 2 2 2

Maximum 10 10 10 10 10

Change Mean 1.5 1.3 1.4 1.7 1.5

Standard deviation 2.45 2.03 2.29 2.19 2.26

Median 1.0 1.0 1.0 2.0 1.0

Minimum -5 -5 -6

Maximum 9 9 6

p-value [2] ■ <.0001 <- 0001 <.0001 <.0001 <.0001

Corr.bir.ed TBS-1 BID vs. TID

Mean (p-value [2]) -0.3 (0.2750)

The score for the Overall Satisfaction Domain is the sum of the results from questions 13 and H from the IIEF questionnaire. \ n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 27FEB20131C : 17 Database last modified: 15FEB201314:33 o

Table D17.5

Summary of IIEF Questionnaire: Overall Satisfaction Domain by Treatment and Visit

Intent-tc-Treat Population - Treatment Period

Combined Combined

Visit T3S-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 . TID TBS-1 TID Total

Variable Statistic (N=141) (N=85) (N=226j (N=77) (N=162) (N=303;

Day 60 n [1] . 127 81 208 68 149 276

Baseline Mean 4.6 4. .5 4. 6 4. .6 4.5 4.6

Standard deviation 2.51 2. .39 2. 46 2. .34 2.36 2.43

Median 4.0 4. .0 , 0 4. .0 4.0 4.0

Minimum 1 1 1 1 1 1

Maximum 10 10 10 10 10 10

Value Mean 6.4 6. 1 6. 3 6. .5 6.3 6.4

Standard deviation 2.50 2. 71 2. 56 2, .43 2.59 2.54

Median 6.0 6. 0 6. 0 7. .0 7.0 7.0

Minimum 2 2 2 2 2 2

Maximum 10 10 10 10 10 10

Change Mean 1.8 1, 7 1. 8 1. .9 1.8 1.8

Standard deviation 2.48 2. 29 2. 40 2, .29 2.29 2.37

Median 2.0 1. 0 1. 0 1. .0 1.0 1.0

Minimum -4 -6 -6 -2 -6 -6

Maximum 7 9 8 8 9 p-value [2J <-0001 <.000i <-0001 <-0001 <.0OOl <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [2]l 0.0 (0.9689)

The score for the Overall Satisfaction Domain is the sum of the results from questions 13 and 14 from the IIEF questionnaire.

[1] n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 27FSB201310:17 Database last modified: 15FEB201314:33

Table D17.5

Intent-to-Treat Pooulation - Treatment Period

Combined Combined

TBS-1 BID TBS-1 BID/TID TBS-1 BID TB3-1 TID TBS-1 TID Total

Statistic (N=141) (N=85) (H=226) (N=77) (N=162) (N=303)

Day 90 n [lj 122 79 201 68 147 269 Baseline Mean 4.6 4.5 4.5 4.5 4.5 4.5

Standard deviation 2.45 2.40 2.43 2.31 2.35 2.39

Median 4.0 4.0 4.0 4.0 4.0 4.0

Minimum 1 1 i 1 1

Maximum 10 10 10 10 10 10

Value Mean 6.3 6.3 δ.Β 6.6 6.4

Standard deviation 2.44 2.50 2.46 2.68 2.59 2.52

Median 6.0 6.0 6.0 8.0 7.0 7.0

Minimum 2 2 2 2 2 2

Maximum 10 10 10 10 10 10

Change Mean 1.8 1.8 1.8 2.3 2.0 1.9

Standard deviation 2.70 2.43 2.59 2.48 2.45 2.57

Median 2.0 2.0 2.0 2.0 2.0 2.0

Minimum -6 -6 -3 -6 -6

Maximum 9 9 8 8 9 p-value [2] <.0001 <.0001 <- 0001 <.0001 <.O001 <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [2]) -0.3 (0.3630)

[1] n is the number of subjects with both baseline and endpoint measurements.

[21 t-test is used for the p-value calculation of change from baseline within treatment group and between treatment groups.

Table D17.6

Summary of IIEF Questionnaire: Total Score' by Treatment and Visit

Intent-tc-Treat Population - Treatment Period

Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (K=85) (N=226) <N=77) (N=162) (N=303)

Day 30 n [1] 151 S5 216 73

Baseline Mean 34.9 32.4 33.9 36.6 34.6

Standard deviation 20.24 20.33 20.27 18.25 19.79

Median 34.0 31.0 33.0 37.0 34.0

Minimum 0 0 5 0

Maximum 72 74 73 74

Value Mean 44.0 40.5 42.6 47.6 43.9

Standard deviation 21.54 21.86 21.69 IB. 4 21.00

Median 49.0 43.0 46.0 52.0 49.0

Minimum 5 4 4 5 4

Maximum 74 73 74 74 74

Change Mean 6.2 8.7 11.0 9.3

Standard deviation 16.04 14.88 15.56 15.54 15.56

Median 6.0 5.0 6.0 7.0 6.0

Minimum -34 -26 -34 -12 -34

Maximum 58 5 58 60 60 p-value [2] <.0001 <.0001 <.0001 <.0001 OOOl

Combined TBS-1 BID vs. TID

Mean (p-value [2;) -2.3 (0.2717

The total score is the sum of the results across all domains from the IIEF questionnaire.

[1] n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 22FEB201317:08 Database last modified: 15FEB20L314:33

oa

Variable Statistic (N=141) (K=85) (N=226) (N=77) (N=162) (N=303)

Day 50 n [1] 128 84 212 69 153 281

Baseline Mean 34.8 32.6 33.9 36.2 34.2 34.5

Standard deviation 20.31 20.31 20.29 18.29 19.45 19.81

Median 33.5 31.5 33.0 37.0 34.0 34.0

Minimum 4 0 0 5 0 0

Maximum 74 72 74 73 73 74

Value Mean 47.0 43.5 45.6 48.5 45.8 46.3

Standard deviation 19.62 22.21 20.71 19.54 21.17 20.45

Median 54.0 46.0 52.0 54.0 50.0 52.0

Minimum 5 4 4 5 4 4

Maximum 75 74 75 75 75 75

Change Mean 12.2 10.9 11.7 12.3 11.6 11.9

Standard deviation 18.01 ■ 16.28 17.32 18.00 17.03 17.46

Median 8.5 8.0 8.0 8.0 8.0 ^■ 8.0

Minimurr_L -34 -21 -34 -37 -37 -37

Maximum 53 59 53 61 61 53 p-value [2] <.0001 <.0001 <.0001 <.0001 <-0001 <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [2]) 0.7 (0.7490)

[1] n is the number of subjects with both baseline and endpoint measurements.

[2: t-test is used for the p-value calculation of change from baseline within treatment group and between treatment groups.

Program name: qs.sas Run date: 22FEB201317:08 Database last modified: 15FEB201314:33

Table D17.6

Summary of IIEF Questionnaire: Total Score by Treatment and Visit

Intent-to-Ireat Population - Treatment Period-

Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (K=141) (N=B5) (K=22S) (N=77) (N=162) ■ (N=303)

Day 90 ^" n [1] 122 82 204 69 151 273

Baseline Mean 34, 9 32.6 34.0 35.9 34. 1 34.5

Standard deviation 20. 42 20.31 20.36 17.95 19. 27 19.76

Median 34, 5 31.5 33.0 37.0 34. ,0 34.0

Minimum 4 0 0 5 0 0

Maximum 74 72 74 73 73 74

Value Mean 48. 0 45.9 47.1 50.3 47. 9 47.9

Standard deviation 19. 55 20.90 20.08 18.56 19. 92 19.72

Median 54. .5 51.0 53.0 55.0 53. 0 53.0

Minimum 5 5 5 5 5 5

Maximum 75 73 75 75 75 75

Change Mean 13. ,0 13.3 13.2 14.4 13. ,B 13.5

Standard deviation 17. ,20 18.56 17.72 18.35 18. ,41 17.85

Median 3, .5 9.0 .9.0 9.0 ,0 9.0

Minimum -35 -25 -35 -37 -37 -37

Maximum 54 67 67 63 67 67 p-value [2] •C.0001 <.0001 <.0001 <.0001 <.0001 <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [2]) -0.8 (0.7163)

[1] n is the number of subjects with both baseline and endpoint measurements.

Table D16.1

Summary of PANAS Questionnaire: Affect Scores by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TB3-1 BID TBS-13IDTID TBS-1 BID TBS-i TID TBS-1 TID Total

Variable Statistic (N=141) (K=85) (N=226) tN=77) (N=162) (N=303)

Positive Affect Score [1]

Day 30 n [3] 130 215 73 288

3aseline Mean 29.3 30.2 30.5 30.3

Standard deviation 8.60 8.B3 8.71 8.79

Median 30.0 30.0 32.0 30.0

Minimum 12 12 10 10

Maximum 47 50 50 50

Value Mean 31.8 32.3 33.7 32.7

Standard deviation 8.24 8.07 7.22 7.87

Median 33.0 33.0 34.0 34.0

Minimum 10 10 17 10

Maximum 50 50 50 50

Chance Mean 2.0 2.2 3.C

Standard deviation 3.02 7.55 8.52 7.80

Median 1.5 2.0 4.0 2.0

Minimum -24 -24 -ie -24

Maximum 21 21 28 28 p-value [4] 0.0055 <.0001 0.0033 <.0001

Combined TBS-1 BID vs. TID

Mean (p-value [4]) -0.9 (0.4141)

[1] The Positive Affect Score is found by adding the scores from the following feelings/emotions: Interested, Excited, Strong,

Enthusiastic, Proud, Alert, Inspired, Determined, Attentive, and Active. Higher scores represent higher levels of positive affect.

[2] The Negative Affect Score is found by adding the scores from the following feelings/emotions: Distressed, Upset, Guilty, Scared,

Hostile, Irritable, Ashamed, Nervous, Jittery, and Afraid. Lower scores represent lower levels of negative affect.

[3] n is the number of subjects with both baseline and endpoint measurements.

[4] t-test is used for the p-value calculation of change from baseline within treatment group and between treatment groups.

Table D18.1

Summary of PANAS Questionnaire: Affect Scores by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit . TBS-1 BID TBS-1 E JID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total Variable Statistic (N=141) !5) (N=226) (H=77) (N=162) (N=303)

Positive Affect Score [1]

Day 6C n [3] 127 84 211 69 153 230

Baseline Mean 29. 30. 7 30. 1 30. 4 30.5 30.2

Standard deviation 8. 63 9. .24 8. 87 8. 61 8.94 8.79

Median 30. 0 30. .0 30. 0 32. .0 30.0 30.0

Minimum 12 13 12 10 10 10

Maximum 47 50 50 50 50 50

Value Mean 32. .0 33. .7 32. .7 34. .7 34.2 33.2

Standard deviation 3. .10 7. .48 7, .68 7. .31 7.39 7.78

Median 33. .0 3 .0 33. .0 35. .0 35.0 34.0

Minimum 13 15 10 17 15 10

Maximum 50 50 50 50 50 50

Change Mean 2. ,3 3 ,1 2. .6 4. .3 3.6 3.0

Standard deviation 7. .78 6. .71 7 .37 g .09 7.87 7.84

Median 2 ,0 2 ,0 2 .0 3 .0 2.0 2.0

Minimum -21 -14 -21 -23 -23 -23

Maximum 22 27 27 25 27 27 o-value [4] 0.0C11 <.0001 <.0001 0.0002 <.000i <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [4]) -1.3 (0.1567]

[i; The Positive Affect Score is found by adding the scores from the following feelings/emotions: Interested, Excited, Strong,

[3] n is the number of subjects with both baseline and endpoint measurements.

Table D18.1

Summary of PANAS Questionnaire: Affect Scores by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TBS-1 BID TBS-13ID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (51=141) (K=35) (N=226) (N=77) (N=162) (N=303)

Positive Affect Score [1]

Day 90 n [3] 121 81 202 69 150 271

Baseline Mean 29.8 30.5 30.1 30.3 30.5 30.2

Standard deviation 8.60 9.40 8.92 B.55 8.99 8.81

Median _i 30.0 30.0 30.0 32.0 30.0 30.0

Minimum 13 13 13 10 10 10

Maximum 47 50 50 50 50 50

Value . Mean 33.0 34.7 33.7 34.2 34.5 33.8

Standard deviation 7.90 7.36 7.72 7.78 7.54 7.72

Median 34.0 35.0 35.0 35.0 35.0 35.0

Minimum 14 15 14 17 15 14

Maximum 50 50 50 50 50 50

Change Mean 3.2 4.1 3.6 4.0 ^' 4.0 3.7

Standard deviation 8.35 8.47 8.40 9.36 B.87 8.64

Median 3.0 3.0 3.0 4.0 3.0 3.0

Minimum -23 18 -23 -28 -2B -28

Maximum 26 28 28 31 31 31 p-value [4] <.0001 .0001 <.0001 0.0008 OOOl <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [ ] ) -0.8 (0.4468)

Mote: Baseline is the Day 1 value. If missing, the last value prior to the first dose of study medication is used.

;i] The Positive Affect Score is found by adding the scores from the following feelings/emotions: Interested, Excited, Strong,

Hostile, Irritable, Ashamed, Hervous, Jittery, and Afraid. Lower scores represent lower levels of negative affect.

;3] n is the number of subjects with both baseline and endpoint measurements.

Program name: gs.sas Run date: 22FEB2013 17:08 Database last modified: 15FEB2013 14:33

Table D13.1

Summary of PAKAS Questionnaire: Affect Scores by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TBS-1 BID TBS-1 BID/TD TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (N=85) (N=226) (N=77) (N=162) (N=303)

Negative Affect Score [2]

Day 30 n [3] 130 85 215 73 288

Baseline Mean 15.8 15.9 16.4 16.8 16.5

Standard deviation 7.04 5.32 6.42 6.78 6.50

Median 14.5 15.0 15.0 15.0 15.0

Minimum 10 10 10 10 10

Maximum 39 32 39 50 50

Value Mean 14.6 14.3 14.5 13.7 14.3

Standard deviation 5.-72 4.60 5.3C 4.44 5.10

Median 13.0 14.0 13.0 12.0 13.0

Minimum 10 10 10 10 10

Maximum 41 31 41 33 41

Change Mean -2.2 -1.5 -2.0 -3.0 -2.2

Standard deviation 5.53 4.92 5.29 4.91 5.21

Median -1.0 -1.0 -1.0 -2.0 -1.0

Minimum -22 -19 -22 -22 -22

Maximum 16 B 16 6 16 p-value [4] <.0001 0.0049 C.OOOl <.00C1 <.0001

Combined TBS-1 BID vs. TID

Mean (p-value [ ] ) 1.1 (0.1237)

[2] The Negative Affect Score is found by adding the scores from the following feelings/'emotions : Distressed, Upset, Guilty, Scared,

[3] n is the number of subjects with both baseline and endpoint measurements.

Program name: qs .sas Run date: 22FE3201317:08 Database last modified: 15FEB201314:33

Table D18.1

Summary of PANAS Questionnaire: Affect Scores by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (=141) (N=35) (N=226) (N=77) (N=162) (N=303)

Negative Affect Score [2]

Day 60 [3] 127 84 211 69 153 280

Baseline Mean 16.7 15.9 16.4 16.9 16.3 16. 5

Standard deviation 6.97 5.34 6.37 6.90 6.09 6. 49 Median 14.0 15.0 15.0 15.0 15.0 15. .0 Minimum 1C 10 10 10 10 10 Maximum 39 32 39 50 50 50

Value Mean 15. 13.6 14.7 13.2 13.4 14. .3

Standard deviation 6.6B 4.07 5.83 4.08 4.07 5. .48 Median 13.0 12.0 13.0 12.0 12.0 12. .5

Minimum 10 10 10 10 10 10 Maximum 50 25 50 26 26 50

Change Mean -1.3 -2.3 -1.7 -3.7 -2.9 -2. .2

Standard deviation 7.16 5.31 6.49 5.93 5.62 6. .40 Median -l.C -l.C -1.0 -3.0 -2.0 -1. .0

Minimum -21 -22 -22 -25 -25 -25 Maximum , 39 10 39 11 11 39 p-value [4; 0.0406 0.0002 0.0002 <.0001 < .0001 <.0001

TBS-1 BID vs. Combined TID

Mean (p-value 1.1 5 (⁽

[3] n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 22JEB201317:08 Database last modified: 15FEB201314:33

Table D1B.1

Summary of PANAS Questionnaire: Affect Scores by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-I TID Total

Variable Statistic (N=141) (N=85) (N=226) (N=77) (N-162) (N=303)

Negative Affect Score [2]

Day SO n [3] 121 81 202 69 150 271 Baseline ean 16.0 16.5 16.8 16.4 16.6

Standard deviation 7.05 5.37 6.43 6.93 6.14 6.55

Median 15.0 15.0 15.0 15.0 15.0 15.0

Minimum 10 10 10 10 10 10

Maximum 39 32 39 50 50 50

Value Mean 15.3 13.3 14.5 13. B 13.5 14.3

Standard deviation 5.35 3.94 5.58 5.46 4.69 5.55

Median 13.0 12.0 12.0 11.0 12.0 12.0

Minimum 10 10 10 10 10 10

Maximum 41 24 ^■41 39 39 41

Change Mean -1.6 -2.7 -2.0 -3.0 -2.8 -2.3

Standard deviation 6.54 _.5.29 6.08 5.76 5.50 6.00

Median -1.0 -2.0 -1.0 -2.0 -2.0 -2.0

Minimum -22 -20 -22 -23 -23 -23

Maximum 27 10 27 13 13 27 p-value [4] C.0069 <.C001 <. COOl <- 0001 <.0001 <.0001

T3S-13ID vs. Combined TID

Mean (p-value [41) 1.2 (0.1136)

Bote: Baseline is the Day 1 value. If missing, the last value prior to the first dose of study medication is used.

[2] The Negative Affect Score is found by adding the scores from the following feelings/emotions: Distressed, Dpset, Guilty, Scared,

[3] n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 22FEB2013 17:08 ■Database last modified: 15FEB2013 14:33

Table D13.4

Summary of PANAS Questionnaire; Affect Scores Over the Past Week by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TBS-1 BID TBS-1 BID/TIC TBS-1 BID TBS-1 TID TB3-1 TID Total

Variable Statistic (N=141) (K=85) (N=226) (K=77) (N=162) (ΙΉ03)

Positive Affect Score il]

Baseline

Value n 133 79 212 71 150 283

Mean 29.3 30.2 29.7 30.5 30.4 29.9

Standard deviation 8.48 9.15 8.73 8.95 9.03 8.77

Median 30.0 30.0 30.C 32.0 30.0 30.0

Minimum 12 13 12 10 10 10

Maximum 47 50 50 50 50 50

[2J The Negative Affect Score is found by adding the scores from the following feelings/emotions: Distressed, Upset, Guilty,- Scared,

[3] n is the number of subjects with both baseline and endpoint measurements.

Table D16.4

Summary of PA AS Questionnaire: Affect Scores Over the Past Week by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic IN=141) (N=85) (N=226) (N=77) (H=162) (N=303)

Positive Affect Score [1]

Day 30 n [3] 123 78 201 66 267

Baseline Mean 29.6 30.0 29.8 30.4 29.9

Standard deviation 8.53 8.93 8.67 9.01 8.74 Median 30.0 30.0 30.0 31.5 30.0 Minimum 12 13 12 10 10 Maximum 47 50 50 50 50

Value Mean 31.6 32.7 32.0 33.8 32.4

Standard deviation 8.39 7.63 8.10 7.44 7.97 Median 33.0 34.0 33.0 34.0 33.0 Minimum 10 13 10 17 10 Maximum 50 50 50 50 50

Change Mean 2.0 2.7 2.3 3.4 2.5

Standard deviation 8.08 6.82 7.61 8.72 7.90 Median 1.0 2.0 2.0 4.5 2.0

Minimum -24 -15 -24 -16 -24 Maximum 21 20 21 28 2B p-value [4] 0.0084 0.0007 <.0001 0.0025 <.0001

Combined TBS-1 BID vs. TID

Mean (p-vaiue -1.1 (0.3162)

[II The Positive Affect Score is found by adding the scores from the following feelings/emotions: Interested, Excited, Strong,

[2] The Negative Affect Score is found by adding the scores from the following feelings/emotions: Distressed, Opset, Guilty, Scared,

[3J n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 22-ΈΒ201317:08 Database last modified: 15FEB201314:33

Table D13.4

Summary of PANAS Questionnaire: Affect Scores Over the Past Week by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TBS-i BID TBS-1 BID/TID TBS-1 BID TBS-i TID TBS-1 TID Total

Variable Statistic (N=141) (N=85) (N=226) (N=77) (N=162) (N=303)

Positive Affect Score [1]

Day 50 n [3] 120 75 195 61 136 256

Baseline Mean 29.6 29.6 29.6 30.2 29.9 29.8

Standard deviation 8.51 8.94 8.66 8.93 8.91 8.71

Median 30.0 29.0 30.0 31.0 30.0 30.0

Minimum 12 13 12 10 10 10

Maximum 47 50 50 50 50 50

Value Mean 31.9 32.8 32.3 34.7 33.7 32.8

Standard deviation 3.16 7.12 7.77 7.41 7.28 7.74

Median 32.0 33.0 33.0 35.0 34.0 33.0

Minimum 10 15 10 17 15 10

Maximum 50 48 50 50 50 50

Change Mean 2.3 3.2 2.6 4.5 3.8 3.1

Standard deviation 7.88 6.83 7.49 9.13 7.94 7.93

Median 2.0 2.0 2.0 3.0 2.0 2.0

Minimum -21 -14 -21 -23 -23 -23

Maximum 22 27 27 25 27 27 p-value [4] 0.0019 0.0001 <.0001 0.0003 <.0001 . <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [4]) -1.5 (0.1366)

[3] n is the number of subjects with both baseline and endpoint measurements.

■4] t-test is used for the p-value calculation of change from baseline within treatment group and between treatment groups.

Table D18.4

Intent-to-Treat Population - Treatment Period arameter Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (M=141) (N=85) (N=226) (N=77) (N=162) (N=303)

Positive Affect Score [1]

Day 90 n [3: 112 73 185 62 135 247

Baseline Mean 29.5 30.0 29.7 30.0 30.0 29.8

Standard deviation 8.57 8.97 8.71 8.89 8.90 8.74

Median 30. C 29.0 30.0 30.5 30.0 30.0

Minimum 13 14 13 10 10 10

Maximum 47 50 50 50 50 50

Value Mean 32.8 34.2 33.4 33.7 34.0 33.4

Standard deviation 8.08 7.13 7.73 7.8-2 7.43 7.74

Median 34.0 35.0 35.0 35.0 35.0 35.0

Minimum 14 15 14 17 15 14

Maximum 50 50 50 50 50 50

Change Mean 3.4 4.2 ^' 3.7 3.6 4.0 3.7

Standard deviation 8.46 8.48 3.46 9.73 9.04 8.77

Median 3.0 3.0 3.0 3.5 3.0 3.0

Minimum -23 -18 -23 -28 -28 -28

Maximum 25 28 28 31 31 31 p-value [4] <.0001 <.0001 <.0001 0.0045 <.OO01 <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [4]) . , -0.6 (0.5946)

Note: 3aseline is the Day 1 value. If missing, the last value prior to the first dose of study medication is used.

[3] n is the number of subjects with both baseline and endpoint measurements.

[<] t-test is used for the p-value calculation of change from baseline within treatment group and between treatment groups.

Program name: qs.sas Run date: 22FEB201317: OB Database last modified: 15FEB201314:33

©

^ Table D18.4

O Summary of PAAS Questionnaire: Affect Scores Over the Past Week by Treatment and Visit

® Intent-to-Treat Population - Treatment Period

O

CQ Parameter Combined Combined

¾ Visit TBS-1 BID TBS-i BIO/TID TBS-1 BID TBS-1 TID TBS-1 TID Total y Variable Statistic (N=141) (N=85) (N=22S) (H=77) (N=162) (N=303)

&- :

Positive Affect Score [1]

Day 90 LOCF n [3] 133 78 211 71 149 282

Baseline Mean 29.3 3C.0 29.6 30.5 30.2 29.8

Standard deviation 8.48 8.93 8.63 8.95 8.91 8.71

Median 30.0 30.0 30.0 32.0 30.0 30.0

Minimum 12 13 12 10 10 10

Maximum 47 50 50 50 50 50

Value Mean 32.4 34.0 33.0 33.6 33.8 33.1

Standard deviation 8.18 7.21 7.86 7.53 7.34 7.77

Median 33.0 35.0 35.0 35.0 35.0 35.0

Minimum 10 15 10. 17 15 10

Maximum 50 50 50 50 50 50

Change Mean 3.0 4.0 3.4 3.1 3.6 3.3

Standard deviation B .40 8.39 B.39 9.40 8.86 8.63

Median 3.0 3.0 3.0 3.0 3.0 3.0

Minimum -23 -18 -23 -28 -28 -28

Maximum 26 28 28 31 31 31 p-value [ ] <.0001 <.0001 <.0001 0.0068 <.0001 oooi

TBS-1 BID vs. Combined TID

Mean (p-value [4;) -0.5 (0.

[1] The Positive Affect Score is found by adding the scores from the following feelings/emotions : Interested, Excited, Strong, f Enthusiastic, Proud, Alert, Inspired, Determined, Attentive, and Active. Higher scores represent higher levels of positive affect.

¾ [2; The Negative Affect Score is found by adding the scores from the following feelings/emotions: Distressed, Upset, Guilty, Scared,

® Hostile, Irritable, Ashamed, Nervous, Jittery, and Afraid, lower scores represent lower levels of negative affect.

2 [4j t-test is used for the p-value calculation of change from baseline within treatment group and between treatment groups.

©

^Μ Program name: qs.sas Run date: 22FEB201317:08 Database last modified: 15FEB2.01314:33

Table D13.4

Summary of PAKAS Questionnaire: Affect Scores Over the Past Week by Treatmen

Intent-to-Ireat Population - Treatment Period

Parameter Combined Combined

Visit TBS-i BID TBS-l BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (H=85) (N=226) (N=77) (N=162) (N=303)

Negative Affect Score [2]

Value n 133 79 212 71 150 283

Mean 17.2 16.2 16.8 15.5 16.3 16.7

Standard deviation 7.20 5.38 6.59 6.75 6.04 6.62

Median 15.0 15. C 15.0 14.0 15.0 15.0

Minimum 10 10 10 10 10 10

Maximum . 39 32 39 50 50 50

[V The Positive Affect Score is found by adding the scores from the following feelings/emotions: Interested, Excited, Strong,

[3] n is the number of subjects with both baseline and endpoint measurements.

Program name: qs.sas Run date: 22FEB2013 17:08 Database last modified: 15FEB201314:33

Table D18.4

Summary of PARAS Questionnaire: Affect Scores Cver the Past Keek by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (N=B5) (K=226) (K=77) (N=162) (N=303)

Negative Affect S

Day 30 n ;3] 123 78 201 66 267 3aseline Mean 16.9 16.2 16.6 16.8 16.7

Standard deviation 7.13 5.41 6.51 6.39 6.59

Median 15.0 15.0 15.0 15.0 15.0

Minimum 10 10 10 10 10

Maximum 39 32 39 50 50

Mean 14.6 14.6 14.6 13.8 14.4

Standard deviation 5.84 4.71 . 5.42 4.49 5.21

Median 12.0 14.0 13.0 12.0 13.0

Minimum 10 10 10 10 10

Maximum 41 31 41 33 41

Change Mean -2.3 -1.6 -2.0 -3.0 -2.3

Standard deviation 5.60 5.C4 5.39 4.78 5.25

Median -1.0 -0.5 -1.0 -2.0 -1.0

Minimum -22 -19 -22 -22 -22

Maximum 16 8 16 6 16 p-value [4] <.0001 0.0056 <.0001 <.00C1 <.0001

Combined TBS-1 BID vs. TID

Mean (p-value [4])

Enthusiastic, Froud, Alert, Inspired, Determined, Attentive, and Active. Higher scores represent higher levels of positive affect.

[3] n is the number of subjects with both baseline and endpoint measurements.

Table DIB.

Summary of PANAS Questionnaire: Affect Scores Over the Past Keek by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (N=85) (Ν=22δ) (N=77) (N=162) (11=303)

Negative Affect Score [2]

Day 60 n ;3] 12C 75 195 61 136 256

Baseline Mean 16.9 16.3 16.7 16. S 16.5 16.7

Standard deviation 7. OB 5.43 6.49 7.11 6.22 6.63

Median 15.0 15.0 15.0 14.0 15.0 15.0

Minimum 10 10 10 10 10 10

Maximum 39 32 39 50 50 50

Value Mean 15.4 13.7 14.8 13.1 13.5 14.4

Standard deviation 6.74 4.03 5.90 4.13 4.07 5.56

Median 13.C 12.C 13.0 12.0 12.0 12.5

Minimum 10 10 10 10 10 . 10

Maximum 50 25 50 26 26 50

Change Mean -1.5 -2.5 -1.9 -3.7 -3.1 -2.3

Standard deviation 7.24 5.50 6.63 6.10 5.78 6.54

Median -1.0 -2.0 -1.0 -3.0 -2.0 -1.0

Minimum -21 -22 -22 -25 -25 -25

Maximum 39 10 39 11 11 39 p-value [4] 0.0228 0.0002 OOOl <.0001 <.0001 <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [4]) 1.5 (0.0660)

Kote: Baseline is the Day 1 value. If missing, the last value prior to the first dose of study medication is used.

[3] n is the number of subjects with both baseline and endpoint measurements.

Prcgram name: qs.sas Run date: 22FEB2013 17:08 Database last modified: 15FEB2013 14:33

Table DIB.4

■ Intent-to-Treat Population - Treatment Period

Parameter Combined- Combined

Visit TBS-1 BID TBS-1 BID/TID TBS-1 BID TBS-1 TID TBS-1 TID Total

Variable Statistic (N=141) (N=85) (N=226) (K=77) (N=162) (N=303)

Negative Affect Score [2)

Day 90 n [3] 112 73 185 62 135 ' 247

Baseline Mean 17.2 16.2 16.8 16.9 16.5 16.8

Standard deviation 7.21 5.47 6.58 7.04 6.22 6.68

Median 15.0 15.0 15.0 15.0 15.0 15.0

Minimum 10 . 10 10 10 10 10

Maximum 39 32 39 50 50 50

Value Mean 15.4 13.4 14.6 13.9 13.7 14.4

Standard deviation 6.49 4.03 5.72 5.63 4.82 5.69

Median 13.0 12.0 12.0 11.0 12.0 12.0

Minimum 10 1C 1C 10 10 10

Maximum 41 24 41 39 39 41

Change Mean -1.8 -2.B -2.2 -3.0 -2.9 -2.4

Standard deviation 6.55 .5.33 6.17 5.85 5.55 6.08

Median -1.0 -2.0 -1.0 -2.0 -2.0 -2.0

Minimum -22 -20 -22 -23 -23 -23

Maximum 27. 10 27 13 13 27 p-value [4] 0.0041 <.0001 <.0001 0.0002 •C.OOOl <.0001

T3S-1 BID vs. Combined TID

Mean (p-value [4]) 1.0 (0.1913)

[3] n is the number of subjects with both baseline and endpoint measurements.

Table DIB.

Summary of PARAS Questionnaire: Affect Scores Over the Past Keek by Treatment and Visit

Intent-to-Treat Population - Treatment Period

Parameter Combined Combined

Visit TB3-1 BID TBS-1 BID/TID TBS-1 BID TBS-I TID T3S-1 TID Total

Variable Statistic (N=141) (H=65) (N=226) (8=77) (N=162) (H=303)

Necative Affect Score [2]

Day 90 IOCF n [3j 133 78 211 71 149 282

Baseline Mean 17.2 15.2 16.8 16.5 16.3 16.7

Standard deviation 7.23 5.41 6.60 6.75 6.06 6.63

Median ^'.5.0 15.0 15.0 14.0 15.0 15.0

Minimum 10 10 10 10 10 10

Maximum 39 32 39 50 50 50

Value Mean 15.9 13.4 15.0 13.9 13.6 14.7

Standard deviation 7.20 3.93 6.31 5.49 4.73 6.12

Median 14.0 12.0 13.0 11.0 12.0 12.0

Minimum 10 10 10 10 10 10

Maximum 50 24 50 39 39 50

Change Mean -1.2 -2.B -1.8 -2.6 -2.7 -2.0

Standard deviation 7.32 5.22 6.66 5.80 5.49 6.45

Median -1.0 -2.0 -1.0 -2.0 -2.0 -1.0

Minimum -22 -20 -22 -23 -23 -23

Maximum 39 10 39 13 13 39 p-value [<] C.0543 <.0001 0.0001 0.0003 <.0001 <.0001

TBS-1 BID vs. Combined TID

Mean (p-value [4j 1.5 (0.0586)

[I) The Positive Affect Score is found by adding the scores from the following feelings/emotions: Interested, Excited, Strong,

;3] n is the number of subjects with both baseline and endpoint measurements.

INTERNATIONAL INDEX OF ERECTILE FUNCTION (IIEF)

Guidelines on Clinical Application of IIEF Patient Questionnaire

Background

The 1 5-question International Index of Erectile Function (IIEF) Questionnaire is a validated, multi-dimensional, self-administered investigation that has been found useful in the clinical assessment of erectile dysfunction and treatment outcomes in clinical trials. A score of 0-5 is awarded to each of the 1 5 questions that examine the 4 main domains of male sexual function: erectile function, orgasmic function, sexual desire and intercourse satisfaction.

In a recent study'¹', the IIEF Questionnaire was tested in a series of 1 1 1 men with sexual dysfunction and 109 age-matched, normal volunteers. The following mean scores were recorded:

Maximum Mean Scores

Function Score

Domain Possible Controls Patients

A. Erectile Function (Q1 ,2, 3,4, 5, 5 ) 30 25.8 10.7

B. Orgasmic Function (Q9, 10) 10 9.8 5.3

C. Sexual Desire (Q1 1 , 1 2) 10 7.0 6.3

D. Intercourse Satisfaction (Q6,7,8) 1 5 10.6 5.5

E. Overall Satisfaction (Q1 3. 1 ) 10 8.6 4.4

Clinical Application

IIEF assessment is limited by the superficial assessment of psychosexual background and the very limited assessment of partner relationship, both important factors in the presentation of male sexual dysfunction. Analysis of the questionnaire should, therefore, be viewed as an adjunct to, rather than a substitute for, a detailed sexual history and examination . The following guide-lines may be applied:

1 . Patients with low IEEF scores (<14 out of 30) in Domain A (Erectile Function) may be considered for a trial course of therapy with Sildenafil unless contraindicated. Specialist referral is indicated if this is unsuccessful.

2. Patients demonstrating primary orgasmic or ejaculatory dysfunction (Domain B) should be referred for specialist investigation.

3. Patients with reduced sexual desire (Domain C) require testing of blood levels of androgen and prolactin.

4. Psychosexual counselling should be considered if tow scores are recorded in Domains D and E but there is only a moderately lowered score (14 to 25) in Domain A.

Reference

1. Roseji R, Riley A, Wagner G, et al. The International Index of Erectile Function (IIEF) : A multidimensional scale for assessment of erectile dysfunction. Urology, 1 97, 49: 822-830.

EXHIBIT P INTERNATIONAL INDEX HOSPITAL NUMBER (IF KNOWN)

OF ERECTILE FUNCTION

NAME

(IIEF)

DATE OF BIRTH /

ADDRESS

Patient Questionnaire

TELEPHONE

These questions ask about the effects that your erection problems have had on your sex life over the last four weeks. Please try to answer the questions as honestly and as clearly as you are able. Your answers will help your doctor to choose the most effective treatment suited to your condition. In answering the questions, the following definitions apply:

- sexual activity includes intercourse, caressing, foreplay & masturbation

- sexual intercourse is defined as sexual penetration of your partner

- sexual stimulation includes situation such as foreplay, erotic pictures etc.

- ejaculation is the ejection of semen from the penis (or the feeling of this)

- orgasm is the fulfilment or climax following sexual stimulation or intercourse

Over the past 4 weeks: Please check one box only

0 No sexual activity

How often were you able to get an erection during 1 Almost never or never

Q1 2 A few times (less than half the time) sexual activity? 3 Sometimes (about half the time)

4 Most times (more than half the time)

5 Almost always or always

0 No sexual activity

When you had erections with sexual stimulation, how 1 Almost never or never

Q2 2 A few times (less than half the time) often were your erections hard enough for 3 Sometimes (about half the time) penetration? 4 Most times (more than half the time)

5 Almost always or always

0 Did not attempt intercourse

When you attempted intercourse, how often 1 Almost never or never

Q3 2 A few times (less than half the time) you able to penetrate (enter) your partner? 3 Sometimes (about half the time)

4 Most times (more than half the time)

5 Almost always or always

0 Did not attempt intercourse

During sexual intercourse, how often were you able 1 Almost never or never

Q4 2 A few times (less than half the time) to maintain your erection after you had penetrated 3 Sometimes (about half the time) (entered) your partner? 4 Most times (more than half the time)

5 Almost always or always 0 Did not attempt intercourse

During sexual intercourse, how difficult was it to 1 Extremely difficult

Q5 2 Very difficult

maintain your erection to completion of intercourse? 3 Difficult

4 Slightly difficult

5 Not difficult

0 No attempts

How many times have you attempted sexual 1 One to two attempts

Q6 2 Three to four attempts

intercourse? 3 Five to six attempts

4 Seven to ten attempts

5 Eleven or more attempts

0 Did not attempt intercourse

When you attempted sexual intercourse, how often 1 Almost never or never

07 2 A few times (less than half the time) was it satisfactory for you? 3 Sometimes (about half the time)

4 Most times (more than half the time)

5 Almost always or always

0 No intercourse

How much have you enjoyed sexual intercourse? 1 No enjoyment at all

Q8 2 Not very enjoyable

3 Fairly enjoyable

4 Highly enjoyable

5 Very highly enjoyable

0 No sexual stimulation or intercourse

When you had sexual stimulation or intercourse, how 1 Almost never or never

Q9 2 A few times (less than half the time) often did you ejaculate? 3 Sometimes (about half the time)

4 Most times (more than half the time)

5 Almost always or always

1 Almost never or never

When you had sexual stimulation or intercourse, how 2 A few times (less than half the time)

Q10 3 Sometimes (about half the time) often did you have the feeling of orgasm or climax? 4 Most times (more than half the time)

5 Almost always or always

1 Almost never or never

How often have you felt sexual desire? 2 A few times (less than half the time)

Q1 1 3 Sometimes (about half the time)

4 Most times (more than half the time)

5 Almost always or always

1 Very iow or none at all

How would you rate your level of sexual desire? 2 Low

Q12 3 Moderate

4 High

5 Very high

1 Very dissatisfied

How satisfied have you been with your overall sex 2 Moderateiy dissatisfied

Q1 3 3 Equally satisfied & dissatisfied life? 4 Moderately satisfied

5 Very satisfied

1 Very dissatisfied

How satisfied have you been with your sexual 2 Moderateiy dissatisfied

Q1 3 Equafly satisfied & dissatisfied relationship with your partner? 4 Moderately satisfied

5 Very satisfied

1 Very low

How do you rate your confidence that you could get 2 Low

Q1 5 3 Moderate

and keep an erection? 4 High

5 Very high

Claims

What is claimed is:

concentration sum for predicting a testosterone C_avg for the male; and

wherein, if the serum testosterone concentration sum is (i) less than the target serum testosterone level, titrating the twice daily intranasal treatment regimen for the male to a treatment regimen that is three times a day (TID) to treat the male for hypogonadism, or (ii) is equal to or greater than the target serum testosterone level, continuing with the twice daily intranasal treatment regimen or reducing the twice daily intranasal treatment regimen to once daily for the male to treat the male for hypogonadism.

2. A titration method of claim 1 , wherein the target serum testosterone level is at about 755 ng/dl.

3. A titration method of claim 1 , wherein the target serum testosterone level is in a range of between about 815 ng/dl and about 835 ng/dl.

4. A titration method of claim 1 , wherein the target serum testosterone level is in a range of between about 280 ng/dl.

5. A titration method of claim 1 , wherein said extraction of the first blood sample occurs at about 9 hours after nasal administration of an evening dose of an intranasal testosterone gel.

6. A titration method of claim 1 , wherein said extraction of the second blood sample occurs at between about 1 1 hours and 1 1 .5 hours after nasal administration of an evening dose of the intranasal testosterone gel.

7. A titration method of claims 1 -6, wherein the intranasal testosterone gel contains about 4.5% testosterone.

(b) extracting a blood sample from the male at a selected time before a selected dose (first or second dose) of the twice daily treatment regimen on the first day after the selected number of days; (c) measuring the testosterone serum level in the blood sample to generate a serum testosterone ng/dl concentration measurement for the male;; and

wherein, if the serum testosterone ng/dl concentration measurement is (i) less than the target serum testosterone level, titrating the twice daily intranasal treatment regimen for the male to a treatment regimen that is three times a day (TID) to treat the male for hypogonadism, or (ii) equal to or greater than the target serum testosterone level, continuing with the twice daily intranasal treatment regimen for the male to treat the male for hypogonadism.

9. A titration method of claim 8, wherein said administering intranasally to the male the intranasal testosterone gel twice daily for a selected number of days is 30 days.

10. A titration method of claims 8 or 9, wherein said extracting the blood sample from the male at a selected time is at about 60 minutes before a selected dose of the twice daily treatment regimen on the first day after the selected number of days.

1 1 . A titration method of claims 8 or 9, wherein said extracting the blood sample from the male at a selected time before a selected dose of the twice daily treatment regimen on the first day after the selected number of days is before the first dose.

12. A titration method of claims 8 or 9, wherein said extracting the blood sample from the male at a selected time before a selected dose of the twice daily treatment regimen on the first day after the selected number of days is before the second dose.

13. A titration method of claims 1 -12, the target serum testosterone level is at about 755 ng/dl.

14. A titration method of claim 1 -12, the target serum testosterone level is at about 280 ng/dl.

15. A titration method of claims 1 -14, wherein the intranasal testosterone gel contains about 4.5% testosterone.

c. About 4.5% testosterone by weight of said gel formulation; and d. a pharmaceutically acceptable vehicle, wherein the testosterone gel formulation has positive results for primary and secondary efficacy and safety endpoints when a male is treated intranasally with the testosterone gel formulation for

hypogonadism or testosterone deficiency.

17. The testosterone gel formulation of claim 16, wherein the gel formulation comprises a solvent, a wetting agent, and a viscosity increasing agent.

18. The testosterone gel formulation of claim 17, wherein the solvent is castor oil.

19. The testosterone gel formulation of claims 17 or 18, wherein said wetting agent is an oleoyl polyoxylglyceride.

20. The testosterone gel formulation of claims 17, 18 or 19, wherein said viscosity increasing agent is colloidal silicon dioxide.

21 . The testosterone gel formulation of claim 16, wherein said gel formulation comprises castor oil, oleoyl polyoxylglycerides and colloidal silicon dioxide.

22. The testosterone gel formulation of any one of claims 16-21 , wherein said gel formulation is a bioequivalent to another testosterone gel formulation.

23. The testosterone gel formulation of any one of claims 16-21 , wherein said gel formulation is pharmaceutically equivalent to another testosterone gel formulation.

24. The testosterone gel formulation of any one of claims 16-21 , wherein said gel formulation is therapeutically equivalent to another testosterone gel formulation.

25. A packaged pharmaceutical comprising:

(a) a testosterone gel formulation for nasal administration to treat hypogonadism or testosterone deficiency in a male, wherein said gel formulation comprises about 4.5% testosterone by weight; and

(b) associated instructions for using said testosterone gel formulation for testosterone replacement therapy, or to treat hypogonadism or testosterone deficiency, wherein said testosterone gel formulation has positive results for primary and secondary efficacy and safety endpoints, wherein the 4.5% testosterone gel formulation has positive results for primary and secondary efficacy and safety endpoints when a male is treated intranasally with the 4.5% testosterone gel formulation for hypogonadism or testosterone deficiency.

26. The packaged pharmaceutical of claim 25 further comprising a step of identifying a subject in need of the treatment.

27. A method of treating hypogonadism in a male subject, the method comprising administering intranasally to a male subject said gel formulation of any one of claims 16- 26 to deliver a therapeutically effective amount of testosterone to effectively treat hypogonadism.

28. A method of treating testosterone deficiency in a male subject, the method comprising administering intranasally to a male subject said gel formulation of any one of claims 16-26 to deliver a therapeutically effective amount of testosterone to

effectively treat testosterone deficiency.

29. A method of providing testosterone replacement therapy in a male subject, the method comprising administering intranasally to a male subject said gel formulation of any one of claims 16-26 to deliver a therapeutically effective amount of testosterone to effectively provide testosterone replacement therapy.

30. The testosterone gel formulation of any one of claims 16-29, wherein said testosterone gel formulation is a bioequivalent to another testosterone gel formulation.

31 . The testosterone gel formulation of any one of claims 16-29, wherein said testosterone gel formulation is pharmaceutically equivalent to another testosterone gel formulation.

32. The testosterone gel formulation of any one of claims 16-29, wherein said testosterone gel formulation is therapeutically equivalent to another testosterone gel formulation.

34. An intranasal method of claim 33, wherein said intranasal treatment achieves in at least about 77% of the treated males an average total testosterone concentration in normal range for males when the treated men are treated three times daily.

36. A method for treating hypogonadism or testosterone deficiency in males, said method comprising:

intranasally administering to the males in need of said treatment about 33 mg of testosterone daily to treat hypogonadism or testosterone deficiency in the males;

intranasally administering to the males in need of said treatment two or three times daily a testosterone gel formulation formulated with about 4.5% testosterone by weight of said gel formulation to treat hypogonadism or testosterone deficiency in the males; wherein 3.3% of the treated men achieved a maximum serum testosterone concentration (C_max) of between 1800 ng/dl and 2499 ng/dl on day 90 of said intranasal treatment.

wherein the proportion of the treated males with a serum testosterone

concentration (C_oax) of greater than 1500 ng/dL is within FDA guidelines for testosterone replacement products.

intranasally administering to the males in need of said treatment two or three times daily a testosterone gel formulation formulated with about 4.5% testosterone by weight of said gel formulation to treat hypogonadism or testosterone deficiency in the males; wherein no decreases in hemoglobin is observed in the said treated males.

wherein about 75% or more of the treated men achieve primary endpoint.

43. An intranasal method of claim 42, wherein the primary endpoint is a C_avg (0-24) serum total testosterone within normal range (300 ng/dL to 1050 ng/dl) on Day 90 of said treatment.

47. A method for treating hypogonadism or testosterone deficiency in a male, said method comprising:

wherein the treated male achieves a maximum serum testosterone concentration (C_max) of less than 1500 ng/dl at day 90 of said intranasal treatment.

intranasally administering to the male in need of said treatment two or three times daily a testosterone gel formulation formulated with about 4.5% testosterone by weight of said gel formulation to treat hypogonadism or testosterone deficiency in the male; wherein the said treated male experiences fewer adverse events selected from a group of adverse events consisting of hematocrit, hemoglobin and PSA levels, as compared to adverse events experienced by men when treated with other commercially marketed testosterone replacement therapies.

50. A method for treating hypogonadism or testosterone deficiency in males, said method comprising:

intranasally administering to a male in need of said treatment two or three times daily a testosterone gel formulation formulated with about 4.5% testosterone by weight of said gel formulation to treat hypogonadism or testosterone deficiency in the male; wherein no decreases in hemoglobin is observed in the said treated male.

52. An intranasal method of claim 51 , wherein the primary endpoint is a C_avg (0-24) serum total testosterone within normal range (300 ng/dL to 1050 ng/dL) on Day 90 of said intranasal treatment.