Liver events
day month year
boolean
Time period to the onset of ALT ≥ 2xUpper Limit Normal (ULN). Note: Although stopping criteria is ALT 3x ULN, GSK are interested in capturing ALT≥2x ULNto assess the probability of drug relatedness of liver event
boolean
AST
boolean
Total bilirubin
boolean
Alkaline phosphatase
boolean
Other
boolean
Liver events assessment
If Yes, stop investigational product, complete date stopped on lnvestigational Product form, contact GSK within 24 hours of occurrence, complete Liver Events Form and obtain the following tests: PK blood sample within 24 hours of last dose (or 3x the investigational product half-life or t1/2). Hepatitis A: Hepatitis A lgM antibody. Hepatitis B: Hepatitis B surface antigen and Hepatitis B Core Antibody (/gM). Hepatitis C: Hepatitis C RNA. Hepatitis E /gM antibody (if subject resides or hastravelled in past 3 months outside the USA or Canada). Cytomegalovirus lgM antibody (CMV) EBV (Epstein Barr viral capsid antigen /gM antibody) or if unavailable, obtain heterophile antibody or monospot testing. CPK (serum creatine phosphokinase) LDH (factate dehydrogenase) Bilirubin fractionation, if bilirubin ≥ 1,5xULN The following are only needed when ALT ≥ 3xULN and bilirubin ≥ 1,5xULN (>35% direct): Anti-nuclear antibody Anti-smooth muscle antibody Type 1 anti-liver kidney microsomal antibodies (if available) Liver Imaging (ultrasound, magnetic resonance, or computerised tomography
text
Treatment periods applicable to the onset of ALT≥2x ULN
If the liver event occurred during treatment period record start and stop date of investigational product for that treatment period. If the liver event occurred after treatment period record start and stop date of investigational product for the most recent period prior to the liver event. Tick for each period/event
integer
Start Date lnvestigational Date
date
End Date lnvestigational Product
date
Liver events, Diagnositics
Age of subject
text
If Yes, ensure Pregnancy Notification Form has been completed.
text
Performance of diagnostic imaging tests of the liver or hepatobiliary system (liver ultrasound, computerized tomography or CAT scan, magnetic resonance imaging or MRI, or endoscopic retrograde cholangiopancreatography)
text
If No, record the details on the Non-Serious Adverse Events form or Serious Adverse Event form.
text
If Yes, complete Liver Biopsy form.
text
If Yes, record on the appropriate Concomitant Medication form.
text
Dietary Change, Fasting
text
An unscheduled PK blood sample must be obtained within 24 hours of last dose (or 3x the investigational product half-life or t1!2).
text
day month year
date
00:00-23:59
time
day month year
date
00:00-23:59
time
Sample Identifier Label
text
Sample Number
text
Alcohol intake
LIVER DISEASE MEDICAL CONDITIONS
Tick only one response for each condition
integer
Definitions: CURRENT MEDICAL CONDITIONS Conditionsfrom which the subject is currentlysuffering, regardlessof how long they have been present. If the subject has had a recurring condition that is not present at the time of the assessment, it can be classed as current if, in the Investigator's opinion it is likely to recur during the study. PAST MEDICAL CONDITIONS Conditions from which the subject has sufferedin the past, but are no longer present. A past condition may have stoppedas recently as the day prior to being assessed. NO MEDICAL CONDITION No current or past condition.
integer
DRUG RELATED LIVER DISEASE CONDITIONS (All drugs including lnvestigational Product)
OTHER LIVER DISEASE CONDITIONS
Other liver disease
text
Definitions: CURRENT MEDICAL CONDITIONS Conditionsfrom which the subject is currentlysuffering, regardlessof how long they have been present. If the subject has had a recurring condition that is not present at the time of the assessment, it can be classed as current if, in the Investigator's opinion it is likely to recur during the study. PAST MEDICAL CONDITIONS Conditions from which the subject has sufferedin the past, but are no longer present. A past condition may have stoppedas recently as the day prior to being assessed.
integer
OTHER MEDICAL CONDITIONS
Disease
integer
Definitions: CURRENT MEDICAL CONDITIONS Conditionsfrom which the subject is currentlysuffering, regardlessof how long they have been present. If the subject has had a recurring condition that is not present at the time of the assessment, it can be classed as current if, in the Investigator's opinion it is likely to recur during the study. PAST MEDICAL CONDITIONS Conditions from which the subject has sufferedin the past, but are no longer present. A past condition may have stoppedas recently as the day prior to being assessed. NO MEDICAL CONDITION No current or past condition.
integer