Effect of SGLT2 Inhibition on Aging-related Biomarkers in Older Obese Adults With Pre-diabetes
Phase: PHASE1
Conditions: Aging
Sponsor: The University of Texas Health Science Center at San Antonio

 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
 
 
 
CONFIDENTIAL 
CLINICAL RESEARCH PROTOCOL 
IRB# HSC20190766H v2.4 
 
 
 
COVER PAGE FOR PROTOCOL AND STATISTICAL ANALYSIS 
PLAN 
 
 
 
 
 
Official Study Title: SGLT2 Inhibition in Older Obese Adults With Pre-
diabetes 
 
NCT number: NCT04401904 
 
IRB Approval Date: 10-30-2020 
 
Unique Protocol ID: HSC20190766H 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

HSC 20190766H 
 
Page ii 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
 
 
 
 
 
 
 
 
 
 
Effect of SGLT2 inhibition on aging-related biomarkers in older 
obese adults with pre-diabetes 
 
 
 
 
 
Principal Investigator: 
Carolina Solis-Herrera, MD 
Assistant Professor/Clinical 
Department of Medicine, Division of Diabetes 
7703 Floyd Curl, MC 7886 
210-567-6691 
 
Funding Sponsor: 
San Antonio Older Americans Independence Center, Pilot 
and Exploratory Studies Core 
 
 
Study Product: 
Dapagliflozin 
Protocol Number: 
HSC 20190766H 
NCT#: 
NCT04401904 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 

HSC 20190766H 
 
Page iii 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
 
 
 
 
Initial version: v1.0 09/10/2019 last revised v2.4_10-29-2020 
 

HSC 20190766H 
 
Page iv 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
 
 
                                                           TABLE OF CONTENTS 
 
STUDY SUMMARY ................................................................................................................................................ 1 
1. INTRODUCTION ................................................................................................................................................ 3 
1.1. 
BACKGROUND .......................................................................................................................................... 3 
1.2. 
INNOVATION ............................................................................................................................................. 3 
1.3. 
PRELIMINARY DATA .................................................................................................................................. 4 
1.4. 
DOSE RATIONALE AND RISK/BENEFITS ...................................................................................................... 5 
2. 
STUDY OBJECTIVE ................................................................................................................................. 5 
3. 
STUDY DESIGN ........................................................................................................................................ 5 
3.1. 
SUBJECTS ............................................................................................................................................... 5 
3.2. 
GENERAL DESIGN .................................................................................................................................... 5 
3.3. 
STUDY ENDPOINTS .................................................................................................................................. 6 
3.4 
POTENTIAL RISKS TO SUBJECT SAFETY .................................................................................................... 6 
4. 
SUBJECT SELECTION AND WITHDRAWAL ......................................................................................... 7 
4.1. 
INCLUSION CRITERIA ................................................................................................................................ 7 
4.2. 
EXCLUSION CRITERIA ............................................................................................................................... 8 
4.3. 
SUBJECT RECRUITMENT AND SCREENING ................................................................................................. 8 
4.4. 
EARLY WITHDRAWAL OF SUBJECTS .......................................................................................................... 8 
4.4.1. 
When and How to Withdraw Subjects .......................................................................................... 8 
4.4.2. 
Data Collection and Follow-up for Withdrawn Subjects ................................................................ 9 
5. 
STUDY DRUG ......................................................................................................................................... 10 
5.1. 
DESCRIPTION ......................................................................................................................................... 10 
5.2. 
TREATMENT REGIMEN ............................................................................................................................ 10 
5.3. 
ADMINISTRATION OF STUDY DRUG AND COMPLIANCE TO REGIMEN ........................................................... 10 
5.4. 
PRIOR AND CONCOMITANT THERAPY ...................................................................................................... 10 
5.5. 
PACKAGING ........................................................................................................................................... 11 
5.6. 
HANDLING OF STUDY DRUG .................................................................................................................... 11 
5.6.1. 
Receipt of Drug Supplies ............................................................................................................ 11 
5.6.2. 
Storage........................................................................................................................................ 11 
5.6.3. 
Dispensing of Study Drug ........................................................................................................... 11 
5.6.4. 
Return or Destruction of Study Drug ........................................................................................... 12 
6. 
STUDY PROCEDURES .......................................................................................................................... 12 
6.1. 
STUDY VISITS. ........................................................................................................................................ 12 
6.1.1 Visit 1 (Day -17 to -21) ............................................................................................................................................... 12 
6.1.2 Visit 2 (Day -12 to -17) ............................................................................................................................................... 12 
6.1.3 Visit 3 (Day -12 to -17) ............................................................................................................................................... 12 
6.1.4 Visit 4 (Day -12 to -17) ............................................................................................................................................... 13 
6.1.5 Visit 5 (Day -12 to -17) ............................................................................................................................................... 13 
6.1.6 Visit 6 (Day -12 to -17) ............................................................................................................................................... 13 
6.1.7 Visit 7 (Week 8)........................................................................................................................................................... 13 
6.1.8 Visit 8 (Week 10-11) ................................................................................................................................................... 13 
6.1.9 Visit 9 (Week 10-11) ................................................................................................................................................... 14 
6.1.10 Visit 10 (Week 10-11) .............................................................................................................................................. 14 
6.1.11 Visit 11 (Week 11-12) .............................................................................................................................................. 14 
6.1.12 Visit 12 (Week 10-11) .............................................................................................................................................. 14 
6.2. 
VISIT SCHEDULE SUMMARY. ................................................................................................................... 14 
6.3. 
ANALYSES. ............................................................................................................................................ 15 

HSC 20190766H 
 
Page v 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
 
7. 
STATISTICAL PLAN ............................................................................................................................... 16 
7.1. 
SAMPLE SIZE DETERMINATION ................................................................................................................ 16 
7.2. 
STATISTICAL METHODS .......................................................................................................................... 16 
8. 
SAFETY AND ADVERSE EVENTS ........................................................................................................ 16 
8.1. 
DEFINITIONS .......................................................................................................................................... 16 
8.2. 
RECORDING OF ADVERSE EVENTS .......................................................................................................... 18 
8.3. 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS ........................................... 18 
8.4. 
MEDICAL MONITORING ........................................................................................................................... 19 
8.4.1. 
Investigator reporting of Protocol Deviations/Violations ............................................................. 19 
8.4.2. 
Definitions of Protocol Deviations/Violations .............................................................................. 20 
8.5. 
SAFETY PROCEDURES ........................................................................................................................... 20 
8.5.1. 
Designated Safety Officer ........................................................................................................... 20 
8.5.2. 
Research Drug Manager............................................................................................................. 20 
8.5.3. 
Sponsor Investigator ................................................................................................................... 20 
8.5.4. 
Clinical Study Coordinator .......................................................................................................... 20 
8.6. 
STOPPING RULES .................................................................................................................................. 22 
9. 
DATA HANDLING AND RECORD KEEPING ........................................................................................ 22 
9.1. 
CONFIDENTIALITY ................................................................................................................................... 22 
9.2. 
REGISTRATION WITH CLINICALTRIALS.GOV .............................................................................................. 22 
9.3. 
SOURCE DOCUMENTS ............................................................................................................................ 22 
9.3.1. 
Research Electronic Data Capture (REDCap) and origination of electronic source data .......... 22 
9.3.2. 
Paper source data ....................................................................................................................... 23 
9.3.3. 
Handwritten entries ..................................................................................................................... 23 
9.3.4. 
Remote and/or virtual research interactions ............................................................................... 23 
9.4. 
DATA MANAGEMENT .............................................................................................................................. 23 
9.5. 
RECORDS RETENTION ............................................................................................................................ 23 
10. 
STUDY MONITORING, AUDITING, AND INSPECTING ........................................................................ 24 
10.1. 
STUDY MONITORING PLAN ..................................................................................................................... 24 
10.2. 
AUDITING AND INSPECTING ..................................................................................................................... 24 
11. 
ETHICAL CONSIDERATIONS ................................................................................................................ 24 
12. 
STUDY FINANCES ................................................................................................................................. 25 
11.1. 
FUNDING SOURCE .................................................................................................................................. 25 
11.2. 
CONFLICT OF INTEREST .......................................................................................................................... 25 
11.3. 
SUBJECT STIPENDS OR PAYMENTS ......................................................................................................... 25 
13. 
PUBLICATION PLAN .............................................................................................................................. 25 
14. 
REFERENCES ........................................................................................................................................ 26 
15. 
ATTACHMENTS ...................................................................................................................................... 28 
SUMMARY OF PROTOCOL CHANGES ............................................................................................................. 29 
 

HSC 20190766H 
 
Page vi 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
 
 
List of Abbreviations 
SGLT: Sodium-glucose co-transporter 
T2DM: Type 2 Diabetes Mellitus 
AGE: Advanced Glycation End products 
RAGE: Receptor for Advanced Glycation End products 
GFR: Glomerular Filtration Rate 
OGTT: Oral Glucose Tolerance Test 
CPET: Cardio Pulmonary Exercise Test 
 
 
 

HSC 20190766H 
 
page 1 
Version 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
 
 
 
CONFIDENTIAL 
       Study Summary 
Title 
Effect of SGLT2 inhibition on aging-related biomarkers in older obese adults 
with pre-diabetes 
Protocol Number 
HSC20190766H 
Phase 
2b Pilot 
Rationale 
Inhibitors of the sodium-glucose co-transporter (SGLT2) are FDA-approved for 
the treatment of type 2 diabetes (T2DM).  Their mechanism of action involves 
lowering of blood glucose concentration secondary to increased glucose 
excretion of glucose by the kidney.  These drugs also improve body weight, 
blood pressure, and cardiac function.  Based on these pleiotropic effects, 
including its calorie restriction-mimetic properties, we hypothesize that SGLT2 
drugs will impact several basic aging-related processes, including reductions in 
oxidative damage to DNA and proteins, advanced glycation end products 
(AGE) and receptor for AGE (RAGE), cellular senescence, and mitochondrial 
function.  
Study Duration 
Treatment duration 12 weeks; complete study participation up to 6 months 
Study Center(s) 
UTHSCSA (MARC, FORU, BICRC) 
Objective 
Primary Endpoint: Determine if dapagliflozin significantly reduces aging-
associated biomarkers (AGE-RAGE, oxidative stress in DNA and protein, 
cellular senescence, skeletal muscle mitochondrial function.) 
Secondary Endpoint: Determine healthspan benefits of dapagliflozin treatment 
(VO2Max, insulin sensitivity, 6-minute walk test, grip strength, quadriceps 
strength) 
Number of Subjects 
20 
Inclusion Criteria 
Men and post-menopausal women age 60 and above; BMI 30-38 (BMI _29.5 
will be rounded up); diagnosis of pre-diabetes (HbA1c 5.7-6.4%); stable body 
weight (±3% for ≥3 months); Montreal Cognitive Assessment 21 and above; 
Subjects must be in good general health as determined by physical exam, 
medical history, blood chemistries, CBC, TSH, lipid profile, EKG and urinalysis.  
Exclusion Criteria 
Diagnosis of diabetes based on ADA criteria; impaired renal function with 
eGFR < 45 mL/min/1.73m2; impaired liver function with labs 3x ULN and 
above; hematocrit with LLN 30% and below; triglycerides with ULN 600 mg/dL 
and above; abnormal TSH of 0.3 and below to 10 and above; urinalysis with 
>5-10 WBC; history of frequent UTI; poorly controlled blood pressure (sysBP 
>180, diaBP > 100 mmHg); history of recent cardiovascular event in prior 6 
months, heart failure, active heart disease; current treatment with drugs known 
to affect glucose and lipid homeostasis; current treatment with anticoagulants 
(aspirin <326 mg and clopidogrel permitted if held 7 days prior to biopsies; 
active 
inflammatory, 
autoimmune, 
gastrointestinal, 
hepatic, 
infectious, 
malignant or uncontrolled psychiatric disease (controlled depression, anxiety, 
PTSD, etc. enrollment allowed); ; blood donation within 2 months prior to 
enrollment. 
Concomitant 
Medications 
Allowed: Standard of care medications for the management of hypertension, 
hyperlipidemia and other drugs that at the discretion of the investigator will not 
interfere with the results of the study. If patient on drugs that affect metabolism 
like levothyroxine, should be on a stable dose for the last 3 months. 
 
Prohibited: Any medications known to adversely affect glucose and lipid 
metabolism. Additionally, patients on warfarin or other blood thinners except 
for aspirin up to 325mg and clopidogrel will be excluded. 

HSC 20190766H 
 
Page 2 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
Study Product, Dose, 
Route, Regimen 
Dapagliflozin, 10mg, Oral, Daily 
Duration of 
administration 
12 weeks 
Statistical 
Methodology 
Comparisons of means between all the groups will be done by ANCOVA.  
Associations, within a group, between aging-related biomarkers vs metabolic 
outcomes and vs. healthspan outcomes will be determined by Pearson’s 
correlation. For tests of correlation coefficients between groups, we will use the 
Fisher’s Z transformation.  We will also determine the relationship between 
aging-related biomarkers vs metabolic outcomes and vs. healthspan 
outcomes, by using multiple regression analysis.  Scatter plots will be done to 
look for outliers and to verify linearity.   

HSC 20190766H 
 
Page 3 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
1. Introduction 
 
This document is a protocol for a human research study. This study will be conducted according to Good 
Clinical Practice guidelines as adopted by FDA, applicable government regulations, and Institutional research 
policies and procedures.  
1.1. 
Background 
 
Type 2 diabetes mellitus (T2DM) occurs in 9% of the US population, affects ~30 million individuals and its 
prevalence has increased dramatically (1) due to multiple factors: (i) increased longevity, (ii) increased 
incidence of obesity, (iii) decreased physical activity, (iv) rapid growth of minority populations at high diabetes 
risk. T2DM patients experience significant morbidity and mortality from microvascular and macrovascular 
complications. The cost of treating diabetes and associated complications in 2007 was $174 billion and is 
predicted to double by year 2030 (2). 
 
The Diabetes Control and Complications Trial (DCCT) (3) and United Kingdom Prospective Diabetes Study 
(UKPDS) (4,5) have documented that hyperglycemia is the major risk factor for microvascular and, to lesser 
extent, macrovascular (6,7) complications. Insulin resistance and impaired insulin secretion are characteristic 
features of T2DM (8,9,10).  The earliest expression of this insulin resistance and impaired insulin secretion is 
called prediabetes. Prediabetes is characterized either by impaired fasting glucose (IFG) or abnormal plasma 
glucose after a 75gm oral glucose tolerance test (OGTT) or an A1c value of 5.7% to 6.4% There are 
approximately 84.1 million adults with prediabetes (33.9% of the population) and 23.1 of these adults are 65 
years or older (1). Prediabetes has been shown to increase the risk of developing type 2 diabetes, heart 
disease and stroke. Other classic cardiovascular risk factors are frequently present in prediabetic individuals 
including classic hypertension, dyslipidemia, procoagulant state, obesity, endothelial dysfunction, insulin 
resistance, and inflammation (3,4).Since most of the morbidity and mortality in T2DM arises from long term 
complications, early detection and effective intervention to delay or prevent development of T2DM would be 
expected to have enormous beneficial clinical, social and economic impact. 
 
The inhibitors of the sodium-glucose co-transporter-2 (SGLT2i) are FDA-approved for the treatment of type 2 
diabetes (T2DM). This class of drugs have a unique mechanism of action that involves lowering of plasma 
glucose concentration secondary to an increase in glucose excretion by the kidney. This glucosuric effect 
results in a durable reduction in HbA1c, weight loss, improved insulin sensitivity, and enhanced beta cell 
function (11). Beyond the glucocentric effects of SGLT2i, they have now been shown in patients with 
cardiovascular disease (CVD) to reduce mortality and hospitalization for heart failure and provide renal 
protection. A variety of potential mechanisms have been invoked to explain the beneficial effects of SGLT2i on 
CV mortality and hospitalization for heart failure and these have been the subject of recent reviews (12,13,14).  
Of the potential mechanisms responsible for the improved CV benefit, hemodynamic factors, including the 
simultaneous reduction in preload (12) (secondary to mild intravascular volume depletion) and afterload 
(secondary to reduced blood pressure (12) and improved aortic distensibility (15) most commonly have been 
cited. These attributes have elevated SGLT2i’s to second- or third-line therapy for the treatment of T2DM 
patients in patients with or without CVD (16,17,18).  
1.2. 
Innovation 
Investigations into the aging process have identified major cellular dysfunctions that contribute to aging, 
including but not limited to increased burden of damaged DNA and protein, reduction in mitochondrial 
respiration, and the development of pro-inflammatory senescent cells (19). Developing and testing 
interventions that interact with multiple points of this spectrum may delay the aging process. Based on prior 
investigations, we believe the SGLT2 inhibitor class of drugs may target these basic mechanisms involved in 
the aging process and propose testing in a high-risk human population to evaluate their effectiveness in 

HSC 20190766H 
 
Page 4 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
ameliorating aging-associated dysfunctions. Specifically, we hypothesize that SGLT2i drugs will lead to 
reductions in oxidative damage to DNA and proteins, AGE-RAGE, and cellular 
senescence, which will be accompanied by improvements in mitochondrial 
function. If our hypothesis is correct, these findings could lead to the 
development of new approaches to increase both healthspan and lifespan. 
1.3. 
Preliminary data 
SGLT2 inhibitors have shown effects on systemic and tissue low-grade 
inflammation (20) In the CANTATA-SU study, 52 weeks of canagliflozin 300 mg 
daily to individuals with T2DM decreased IL-6 by 22% and CRP by 4.4% versus 
glimepiride (21) (Figure 1). CRP and other inflammatory marker data following 
SGLT2 administration are relatively scarce in humans, but in animals, several 
reports have shown reductions in cytokine and chemokine concentrations in 
parallel with protective effects against progression of atherosclerotic lesions 
(20). Experimental findings in rodents also suggest that part of the reno-
protective effects of SGLT2 inhibition may be related to anti-inflammatory and 
anti-fibrotic actions at the kidney level. Entry of glucose into the tubule cells 
may induce inflammatory and fibrosis genes, as well as increase apoptosis.  
Experimental administration of an SGLT2i prevents tubulointerstitial injury in 
obese T2DM mice (22). Underlying mechanisms to explain this anti-
inflammatory effect are varied, but may involve weight loss, reduction in 
adipose tissue inflammation and attenuation of oxidative stress (20). 
It is clear that the elevated glycemia can accelerate the formation of advanced 
glycation end-products (AGE’s) (23). There is also evidence that engagement 
of the AGEs receptor (RAGE) by AGE’s may elicit oxidative stress as well as 
generation of inflammatory and fibrotic reactions in tissues (23). Importantly, these implicated AGEs 
inflammatory/fibrotic pathways cause widespread tissue damage including the pancreatic beta-cells, renal 
cells, and the vascular system. This directly or indirectly increases the risk of progression to T2DM, increases 
the risk of complications of diabetes such as nephropathy, neuropathy, and 
retinopathy, and the development of CVD (24). In addition, RAGE may play a 
critical role in reactive oxygen species (ROS) production.  RAGE expression and 
activation may worsen AGE accumulation through decreased expression of key 
antiglycation enzymes (23). 
The effects of SGLT2i on AGEs have yet to be extensively studied in humans, 
though we have shown that these drugs additionally increase mitochondrial fatty 
acid oxidation, cause a small increase in ketone levels, a decrease in uric acid 
levels and are associated with attenuation of oxidative stress (25). Terami et al., 
showed in male db/db mice given SGLT2i for 12 weeks that SGLT2i reduced 
renal mesangial matrix expansion and renal fibrosis.  Proinflammatory genes, 
oxidative stress, and apoptosis were all decreased in renal tissue.  In addition, 
SGLT2i restored pancreatic beta-cell mass to non-diabetic (non-diabetic db/m 
mice) levels (26). In streptozotocin-induced diabetic rats (STZ) treated for 4 
weeks of SGLT2i versus a placebo buffer, SGLT2i decreased the expression 
levels of AGEs, and its receptor (RAGE) and other markers of oxidative stress at 
the kidney level (27) (Figure 2).  Additionally, Osorio et al. reported in a similar 
streptozotocin-induced diabetic rat model that SGLT2i restored several oxidative 
stress markers to control levels and prevented renal tissue 3-nitrotyrosine 
accumulation, a tissue marker of oxidative stress (28).  
In prediabetes there is limited information regarding the role of SGLT2 inhibitors, 
but the available data in humans show that prediabetic obese subjects treated with an SGLT2i had significant 
reductions in weight (29), which is an independent CV risk factor (30) and is associated with insulin resistance, 
Figure 1. Effects on Inflammatory
Biomarkers 
at 
Week 
52.
Canagliflozin 300 mg was associated 
with a 22%reduction in median 
serum IL-6 compared to glimepiride.
Change from baseline in serum 
inflammatory biomarkers at Week
52. IL-6, interleukin-6. 
Figure 
2. 
Effects 
of 
empagliflozin on AGE-modified 
protein 
levels 
and 
RAGE 
immunostaining. 
Total RNAs 
extracted from the kidney of 
control, 
STZ 
and 
STZ 
rats+empagliflozin 
with 
RNAqueous-4PCR kit.  
 

HSC 20190766H 
 
Page 5 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
diabetes, dyslipidemia, hypertension, cancer, stroke and nonalcoholic fatty liver disease (31-34). It is likely that 
the other known glucose and non-glucose lowering effects of SGLT2i could be extrapolated to prediabetic 
individuals. 
1.4. 
Dose Rationale and Risk/Benefits 
 
In the DPP trial, weight loss was proportional to diabetes prevention. There are no serious risks to losing 
weight at a reasonable rate.  Dapagliflozin 10mg daily is the maximum daily dose and has been shown to 
increase glucose urinary excretion more than 5mg daily. Dapagliflozin 10mg/day has been assessed in 
combination with exenatide treatment in prediabetic patients for one year and shows similar safety and 
tolerability to previous trials in diabetic patients (35). Dapagliflozin 10mg/day is also in use for the DAPA-HF 
study in a study population that includes prediabetics (36). Another SGLT2i, empagliflozin, has been assessed 
in prediabetics at a comparably high dose (25mg/day) for two weeks and did not show AE among treated 
subjects (37). The SAE’s associated with dapagliflozin include acute kidney injury, fall from orthostasis, 
gangrene of the perineum, and diabetic ketoacidosis. These risks will be mitigated in this study by monitoring 
subject status with biweekly phone check-ins with patients as well as monthly in-person visits during drug refill 
visits.  
2. Study Objective 
The primary objective is to determine whether SGLT2 inhibitors improve biomarkers of aging in older obese 
adults with pre-diabetes. 
 
The secondary objective is to determine whether changes in aging-related biomarkers resulting from SGLT2i 
therapy are linked to changes in glucose metabolism and healthspan.  
3. Study Design 
 
3.1. 
Subjects 
Recruited subjects for this study will be men and post-menopausal women aged 60 years and above, with a 
diagnosis of obesity as measured by BMI (30-38 kg/m2; BMI >29.5 will be rounded up) and who qualify as pre-
diabetic (HbA1c 5.7-6.4%). Screening at visits 1 and 2 will identify participants who meet entry criteria for the 
study. The target enrollment for this pilot study is 20 completed subjects, split evenly between experimental 
and control groups. Because this study seeks to identify novel SGLT2i effects on biomarkers of aging, we do 
not have direct data on the potential impact of dapagliflozin on biomarkers such as cellular senescence, AGE-
RAGE, or mitochondrial function to power our study. 
3.2. 
General Design 
This is a single center, open-label, randomized controlled trial.  20 completed subjects are planned.  Each 
subject will be randomized to either the experimental group of dapagliflozin 10mg daily for 12 weeks or the 
control group of nutritional counseling for weight loss.  Healthspan and clinical evaluations will be taken at 
baseline and at weeks 10-12 of the study.  
 
Screening data will be reviewed to determine subject eligibility.  Subjects who meet all inclusion criteria and 
none of the exclusion criteria will be entered into the study.  
 
The following treatment regimens will be used: 
• 
Dapagliflozin: 10mg per day for 12 weeks. Subjects will return to refill drug medication and perform 
compliance check at 4 weeks and 8 weeks after beginning treatment. 
• 
Control Group: Subjects will meet with a dietitian every 1-2 weeks throughout the study to discuss 
nutritional counseling with a goal to lose 3-5% of body weight over 12 weeks to mirror expected SGLT2 

HSC 20190766H 
 
Page 6 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
inhibitor-derived weight loss over the same period. During these hour-long sessions, volunteers will learn 
how to adjust their eating habits by following the recommendations of the American Heart Association for 
reducing dietary fat and substituting complex carbohydrates and reducing energy intake to induce gradual 
weight loss while maintaining recommended dietary composition. Volunteers also will receive education on 
portion sizes, meal timing, and meal preparation. Participants receive a notebook of course content and will 
weigh in prior to each session. Additional counseling visits and/or phone calls may be instituted if desirable 
weight loss is not achieved. Subjects may be asked to record their dietary intake for a 24-hour period 
throughout the intervention for review by the dietitian.   
 
Total duration of subject treatment will be 12 weeks.  Total duration of the study is expected to be 16-18 
weeks. 
 
3.3. 
Study Endpoints 
 
Primary outcome: The primary endpoint for this study is a reduction in urine AGE-RAGE measurements as a 
result of dapagliflozin treatment. We will be assessing AGE-RAGE in all subjects at baseline and after 
intervention 
 
Secondary outcomes:  Mitochondrial function: This measurement will assess changes in muscle 
mitochondrial respiration after dapagliflozin treatment. Measurements will occur using muscle samples 
obtained at baseline and after intervention. 
Insulin Sensitivity: This measurement will be obtained before and after the intervention using the HOMA-IR 
index derived from the fasting insulin and glucose concentrations. 
Oxidative Stress: This measurement will be assessed in muscle samples obtained at baseline and after 
intervention. 
Healthspan Measurements: These assessments will include grip strength, isometric knee extension, 6-minute 
walking distance, and a VO2Max obtained from CPET. We will be assessing these outcomes in all subjects at 
baseline and after intervention. Measurements obtained from these exams will evaluate the effect of 
dapagliflozin treatment on physical indicators of aging. 
Cellular Senescence: Senescent cell burden will be assessed in adipose tissue obtained at baseline and after 
intervention, using both senescence-associated beta-galactosidase staining as well as senescence-associated 
gene expression assays.  
DNA methylation: DNA methylation, a key biological marker of aging, will be evaluated in peripheral blood cells 
before and after intervention. 
3.4       Potential Risks to Subject Safety 
 
a) Dapagliflozin.  
Likely and not serious: 
These risks are expected to occur in more than 20 out of 100 subjects: None 
 
Less likely and not serious: 
These risks are expected to occur in 5-20 subjects or less out of 100 subjects: Genital mycotic 
infections (about 4%) Nasopharingytis and UTI (about 1%) and in less than 4 out of 100 
individuals low blood sugar (also called Hypoglycemia)  
 
Rare and serious: loss of consciousness (or syncope), decrease in blood pressure, and 
dehydration (less than 1%) 

HSC 20190766H 
 
Page 7 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
 
b) Blood Withdrawal. All studies involve the withdrawal of blood. Any subject who has donated blood in the 
previous two months will not be studied. The subjects will be instructed not to donate blood for two months 
after the study.  Any subject with a hematocrit of less than 34% will not be studied.  The maximal amount of 
blood to be drawn during the entire study for any given subject will be approximately 200 mL. Hematology 
comprehensive metabolic panel with lipids and liver function tests will be obtained to assess effects on 
blood cell count, liver function and lipid metabolism. Pain, bleeding, bruising or swelling may occur at the 
site of the needlestick. Study participants may also experience light headedness or fatigue. Local 
hematomas occur in 1-5% of blood draws. Infection and nerve damage are possible (<1%). A qualified 
phlebotomist will perform venipunctures to minimize these risks. 
c) IV lines.  Intravenous catheters may be used for venipuncture.  Local hematomas occur in about 1% of 
catheterizations.  Infection is possible (<1%), but we have not experienced this complication.   
d) Muscle biopsy.  At the time of biopsy, subjects may feel pain, discomfort, or pressure (variably described 
by different subjects) for about 5-10 seconds.  Pain or discomfort ceases as soon as the cannula is 
withdrawn. Some localized bruising is expected after biopsy. Local hematomas occur in <2% of subjects.  
One patient experienced a moderately painful hematoma that resolved within 2 weeks (0.1%).  About 1 in 
50 subjects report non-clinically evident numbness or altered sensation at the biopsy site, which is 
transient. There is the possibility that a future biopsy may not be done at the discretion of the PI in case the 
subject did not tolerate well a prior biopsy. 
e) Adipose tissue biopsy.  A burning discomfort will be felt for about 5-10 seconds during the application of 
lidocaine.  Subjects are likely to bruise at the biopsy site, which generally resolves within one week of the 
biopsy. Mild wound infections occur in <2% subjects.   
f) Radiation exposure. Subjects will also be exposed to a very small amount of radiation during the DEXA 
exam (0.04 mrem), which equals one day of natural background radiation. 
g) Home visits. When necessary to perform home visits, study staff will use precautions to reduce the risk of 
improper disclosure or loss of research records and research specimens. The study staff will not remove 
any original records from the research site and will only use the minimal amount of PHI necessary to 
accomplish the home visit. All study records being transported will be secured in a locked file case. 
Research specimens will be labeled and packed in accordance with the site’s laboratory regulations and 
returned to the research site (FORU) in a carrier regulated for biohazardous materials. Study records and 
specimens will never be left unattended during the home visit or when being transported to and from the 
study site.   
 
4.    Subject Selection and Withdrawal 
4.1. 
Inclusion Criteria 
1) Men or post-menopausal women. 
2) Age= 60+ years.  
3) All ethnic groups. 
4) BMI between 30-38 kg/m2 (BMI >29.5 will be rounded up). 
5) Diagnosis of pre-diabetes (HbA1c 5.7-6.4%). 
6) Stable body weight (±3% for ≥3 months). 
7) Willing to adhere to medication regimen for three months. 
8) Montreal Cognitive Assessment score ≥21. 
 

HSC 20190766H 
 
Page 8 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
4.2.      Exclusion Criteria 
1) Diagnosis of diabetes based on ADA criteria  
2) Impaired renal function with eGFR < 45 mL/min/1.73m2. Unstable or rapidly progressing renal 
failure. 
3) Impaired liver function with labs ≥3 times upper limits of normal range 
4) Abnormal hematocrit with lower limits of ≤30%  
5) Abnormal triglycerides with upper limits ≥600 mg/dL 
6) Abnormal TSH values ≤0.3 and ≥10 
7) Urinalysis results with >5-10 white blood cell count 
8) Current medications known to affect glucose and lipid homeostasis (anti-diabetes medications, 
glucocorticoids, atypical antipsychotics, anti-transplant rejection medications, anti-retrovirals). 
9) Current treatment with anticoagulants (warfarin). Aspirin (up to 325 mg) and clopidogrel will be 
permitted if these can be held for seven days prior to the biopsies. 
10) History of recent cardiovascular event in the last 6 months or Heart Failure (New York Heart 
Classification greater than class III-IV; recent EKG changes that suggest active heart disease 
11) Poorly controlled blood pressure (systolic BP>180, diastolic BP>100 mmHg) 
12) Active inflammatory, autoimmune, infectious, hepatic, gastrointestinal, malignant, and uncontrolled 
psychiatric disease (Subjects with depression, anxiety, PTSD, etc. can enroll if controlled and on 
stable medication) 
13) Blood donation within 2 months prior to enrollment 
14) History of frequent UTI 
 
4.3. 
Subject Recruitment and Screening 
We will screen up to 100 potentially eligible candidates to achieve the target enrollment of 20 completes. 
More candidates will be screened if attrition (est. 20%) requires it.  
 
Subjects will be recruited by advertisement, web-based notices including social media, digital outlets, referrals 
from the Barshop Clinical Research Call Center, flyers distributed and posted in senior centers, private 
geriatric offices, and through the outpatient clinics of UT Health San Antonio/UT Medicine Physicians, and 
University Health System (UHS). 
 
Screening will be performed during Visits 1 and 2.   
 
4.4. 
Early Withdrawal of Subjects 
4.4.1. When and How to Withdraw Subjects 
Subjects have the right to withdraw fully or partially from the study at any time and for any reason without 
prejudice to his or her future medical care by the physician or at the institution. 
 
Withdrawal of full consent for a study means that the subject does not wish to receive further investigational 
treatment and does not wish to or is unable to continue further study participation including any follow-up in 
person, by phone, through third parties including relatives or friends, via discussion with other treating 
physicians, and by use of medical records; subject data up to withdrawal of full consent will be included in the 

HSC 20190766H 
 
Page 9 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
analysis of the study. Any subject may withdraw full consent to participate in the study at any time during the 
study. The Sponsor Investigator or sub-investigator will discuss with the subject appropriate procedures for 
withdrawal from the study. 
4.4.2. Data Collection and Follow-up for Withdrawn Subjects 
If subjects are withdrawn prematurely from the study, appropriately designated research staff will make efforts 
to collect at least survival data throughout the protocol defined follow-up period for that subject.  
 
Investigator will consult with Study Statistician with regard to any incomplete data set as compared to the full 
data set that fully supports the analysis.  If a subject withdraws consent to participate in the study, attempts 
will be made to obtain permission to record survival data up to the protocol-described end of subject follow-up 
period.  
 
Investigator and designated research staff make it a high priority to obtain survival data on all subjects lost to 
follow up. Lost to follow up will be defined as a subject missing 2 or more consecutive visits, not answering or 
responding to 3 follow up phone calls to subject or emergency contacts, or returned receipt of 1 certified 
letter.  
 

HSC 20190766H 
 
Page 10 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
5. Study Drug  
5.1. 
Description 
The inhibitors of the sodium-glucose co-transporter-2 (SGLT2i) are FDA-approved for the treatment of type 
2 diabetes (T2DM). This class of drugs have a unique mechanism of action that involves lowering of plasma 
glucose concentration secondary to an increase in glucose excretion by the kidney. This glucosuric effect 
results in a durable reduction in HbA1c, weight loss, improved insulin sensitivity, and enhanced beta cell 
function (11). Beyond the glucocentric effects of SGLT2i, they have now been shown in patients with 
cardiovascular disease (CVD) to reduce mortality and hospitalization for heart failure and provide renal 
protection.  These attributes have elevated SGLT2i’s to second- or third-line therapy for the treatment of 
T2DM patients in patients with or without CVD (16-18). Approximately 1/3 of older adults are pre-diabetic.  
In prediabetes there is limited information regarding the role of SGLT2 inhibitors, but the available data in 
humans show that prediabetic obese subjects treated with an SGLT2i had significant reductions in weight 
(19), which is an independent CV risk factor (20) and is associated with insulin resistance, diabetes, 
dyslipidemia, hypertension, cancer, stroke and nonalcoholic fatty liver disease (21-24). It is likely that the 
other known glucose and non-glucose lowering effects of SGLT2i could be extrapolated to prediabetic 
individuals. Dapagliflozin is an SGTL2 inhibitor given for the management and treatment of type 2 diabetes 
and will be the study drug used for these experiments.   
 
Dapagliflozin (Brand name Farxiga) is administered orally as a yellow pill in either 5mg or 10mg doses. The 
10mg dose that will be used in this study is a 4-sided yellow pill with 10 and 1428 printed on opposite sides.  
5.2. 
Treatment Regimen 
Administration Protocol.  
Following the completion of informed consent, screening visits, enrollment into the study, and baseline 
measurements, subjects will be provided study drug by the Study Coordinator at the conclusion of Visit 5. 
Subjects will take 1 pill daily (10mg) as directed during the study period. Subjects will self-administer drug 
according to product packaging, and compliance calls every two weeks from study investigators will ensure 
proper scheduling of drug administration as well as to monitor AE development. Subjects randomized to 
treatment group will receive a 30-day supply of drug during their Visit 5 randomization and will be required to 
return 4 weeks and 8 weeks later for refilling study drug. Method for Assigning Subjects to Treatment 
Groups 
 
The randomization key will be designed by an objective researcher or statistician not on the study team at 
the Barshop Institute or from Clinical Research Unit and provided to the Clinical Study Coordinator at the 
site.  The Study Coordinator, as assigned, stores the Enrollment key, which is kept in a locked cabinet. Study 
staff maintains source documents, data records and specimens in a de-identified manner using only the 
unique Subject ID/Randomization number. 
5.3. 
Administration of Study Drug and Compliance to Regimen 
Study Coordinator orders and obtains medication dispensed from the Research Drug Manager (or research 
pharmacy unit if available). Subjects will self-administer medication and will be instructed to bring back 
empty or partially empty bottles to each in-person study visit for medication reconciliation and compliance 
procedures. Subjects will be interviewed by phone every two weeks to ensure compliance with study 
regimen as well as to note potential AEs. 
 
5.4. 
Prior and Concomitant Therapy 
Exclusionary medications:  
Drugs that affect glucose and lipid homeostasis. Anti-diabetes drugs (including but not limited to 

HSC 20190766H 
 
Page 11 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
metformin, 
sulfonylureas, 
other 
SGLT2i, 
DPP 
inhibitors, 
etc). 
Glucocorticoids 
(prednisone, 
methylprednisone, hydrocortisone). Atypical antipsychotics (olanzapine, clozapine, etc). Anti-rejection 
medications (prograf, cellcept). Anti-retrovirals (protease inhibitors).  
Treatment with anticoagulants (warfarin). Aspirin (up to 325 mg) and clopidogrel will be permitted if these 
can be held for seven days prior to the biopsies. 
5.5. 
Packaging    
 
Nature and Contents of the Container – bottle of 30 tablets 
 
 
.  
5.6. 
Handling of Study Drug 
Research Drug Manager will be responsible for receipt, storage, dispensing, handling and destruction of 
Study Drug. 
5.6.1. Receipt of Drug Supplies 
 
Any damaged or unusable study drug in a given shipment will be documented by the Research Drug 
Manager.  The Research Drug Manager will notify the Material Sponsor of any damaged study drug. 
5.6.2. Storage 
The drug product used for clinical studies should be stored at USP recommended room temperature.  
Excursions from the recommended room temperature will be documented by the Research Drug Manager 
and acted upon after consultation with Material Sponsor (or AstraZeneca, manufacturer).  Expirations on 
the study product will be honored. 
 
For more details, please see also Farxiga Package Insert or Farxiga Health Care Provider website: 
https://www.farxiga-hcp.com/  
 
5.6.3. Dispensing of Study Drug 
Designated staff from the Research Drug Management unit will maintain the Drug Administration Logs to 
track how, when and to whom the investigational drug was dispensed and assigned to subjects. Study 
clinical staff will keep administration records regarding dosing, unused drug, drug damaged, or wasted. 
 
Study drug may be dispensed to participants in person, at home visits, curbside delivery, or by U.S. mail.  
 

HSC 20190766H 
 
Page 12 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
Labeling study drug will include FDA required language including "Caution: New Drug--Limited by Federal 
(or United States) law to investigational use." 
 
Routine Study Drug reconciliation will be performed based on clinical site policy and standard operating 
procedures. 
5.6.4. Return or Destruction of Study Drug 
The procedures for final reconciliation of the site’s drug supply at the end of the study will be in accordance 
with local site Drug Management standard operating procedures. 
 
There are no special precautions cited for disposal of dapagliflozin. 
 
6. Study Procedures 
 
6.1. 
Study visits.   
Visits will be performed at the UT Health San Antonio Medical Arts and Research Center (MARC) or at the 
Barshop Institute Clinical Research Center (BICRC), except for magnetic resonance studies that will be done 
at the Research Imaging Institute.  Participants will arrive fasting (10-12 h) for visits involving lab work, 
imaging, or biopsies. If the study investigator determines that it is in the greater interest of the safety of the 
study staff and study participants, the study staff may perform home visits or video telehealth visits. . 
Participants will be given a Fitbit Bluetooth scale to obtain their weight measurement at home. The data will 
be transmitted to the research staff electronically through the Fitbit app. The study staff will receive the 
information in an individual, non-identifiable email account that the study staff will create for each study 
participant. If the participant does not have access to a mobile device or cannot access the Fitbit app, the 
study staff will collect the data during home visits or by telephone. The scales will be provided to study 
participants at no charge.  Visits that require DXA scans and MRI scans may be performed 
interchangeably due to availability of  the DXA and MRI scanners. 
6.1.1. Visit 1 (Day -17 to -21) 
Eligible subjects present to the research unit at appointed time for informed consent. Consenting subjects will 
arrive fasting to undergo vital sign evaluation, medical history, physical exam, safety labs [comprehensive 
metabolic panel (CMP), complete blood count with differential (CBC), coagulation labs (PT/PTT/INR), 
HbA1c, TSH, routine urinalysis, lipid panel,  insulin and FFA, and the Montreal Cognitive Assessment 
(participants must score ≥21 to be eligible). Visit results will help determine eligibility for study inclusion (i.e. 
HbA1c 5.7-6.4%).  
Investigators will routinely assess laboratory value excursions for clinical significance.  
 
Adverse events are assessed at every visit once subjects are consented and enrolled to undergo research 
procedures and study intervention. 
6.1.2. Visit 2 (Day --7 to -17 [+/- 2 weeks])+ 
Eligible subjects will present to the MARC research unit for vital signs, walk distance, grip strength, isometric 
knee extension strength testing, a body composition DXA scan and liver fibroscan.    
6.1.3. Visit 3 (Day -7 to -17 [+/- 2 weeks])+ 
Subjects will come to the Research Imaging Institute for intrahepatic liver fat measurement by Magnetic 
Resonance Spectroscopy/Imaging. 
 
+ Visits 2 and 3 may be performed interchangeably based on DXA and MRI scanner availability. 
 

HSC 20190766H 
 
Page 13 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
6.1.4. Visit 4 (Day -1 to -6) -- "Optional" 
Participants who opt in will come to the research unit for vital signs and VO2max testing. 
 
Cardiorespiratory fitness is determined by a CPET on an electronically braked cycle ergometer per the 
American College of Sports Medicine (ACSM) Testing Guidelines. Oxygen consumption and carbon 
dioxide production are measured by indirect calorimetry. ECG (12-lead) recordings and blood pressure 
are monitored at rest prior to testing and during the testing. A clinician interprets for contraindications to 
exercise prior to testing. AHA criteria are used to halt exercise testing [43].  
6.1.5. Visit 5 (Day 0) 
Eligible subjects present to the research unit fasting at appointed time for a vastus lateralis muscle biopsy 
(39) and subcutaneous fat biopsy (40). We apply local lidocaine for muscle and adipose biopsies.  The 
muscle biopsy is done using a modified Bergstrom technique with suction and the adipose biopsy is done 
using a mini-liposuction technique. Urine and blood samples also will be collected. These samples will be 
used for baseline assays of tissue cellular senescence, DNA methylation, oxidative stress and mitochondrial 
function. After the muscle and adipose tissue biopsies, subjects will be given breakfast and will receive 
assignment to treatment intervention (randomized) before being discharged to home. Both treatment and 
control groups will be given a brochure highlighting healthier eating habits. Subjects in the treatment group 
will be given a 30-day supply of dapagliflozin to begin use the next day. Subjects in the control group will 
receive a nutritional consultation with a dietician, which may also be conducted by video telehealth visit, with 
the goal of losing 3-5% body weight during the 3-month period of the study.   
 
• 
Once intervention phase begins, the study staff will contact subjects assigned to study drug for 
telephone follow up at Visit 5 +1 week and at or near midpoint between visits to the research unit up 
to Visit 8.  
• 
Subjects assigned to nutritional counseling group will receive weekly phone calls/video telehealth 
visits during the intervention phase which will last for 12 weeks. 
• 
Study team members may contact the subjects by phone at any time for AE follow up as needed. 
6.1.6. Visit 6 (Week 4) 
Subjects will come to the research unit for evaluation of the biopsy sites and undergo blood draw for CMP 
to monitor kidney function. Subjects will also have current weight checked at this visit. If necessary, the 
study coordinator may conduct Visit 6 by home visit and perform the biopsy site check by video telehealth 
visit. Control group subjects will receive nutritional counseling, which may be performed by home visit or a 
video telehealth visit. 
 
Drug Refill: Subjects in the treatment group will be given a 30-day supply of dapagliflozin by the Research 
Drug Manager to begin when their current supply runs out. Study coordinators will ensure treatment 
compliance by asking subjects to bring drug containers and any remaining dapagliflozin tablets to their 
visits. 
6.1.7. Visit 7 (Week 8) 
Subjects in the treatment group will return for T+8 drug refill (in person, by mail, or curbside delivery), and 
control group subjects will be weighed and receive nutritional counseling, which may be performed by home 
visit or a video telehealth visit. Control group subjects will receive nutritional counseling, which may be 
performed by home visit or a video telehealth visit. 
 
6.1.8. Visit 8 (Week 10-11 [+/- 2 weeks])+ 
Subjects will undergo post-treatment measurement of cognition (Montreal Cognitive Assessment), walk 

HSC 20190766H 
 
Page 14 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
distance, grip strength, isometric knee extension strength, DXA scan and liver fibroscan. Control group 
subjects will receive nutritional counseling, which may be performed by home visit or a video telehealth visit. 
6.1.9. Visit 9 (Week 10-11 [+/- 2 weeks])+ 
Subjects will return to the Research Imaging Institute to undergo post-treatment Magnetic Resonance 
Spectroscopy/Imaging for intrahepatic liver fat measurement. Control group subjects will receive nutritional 
counseling, which may be performed by home visit or a video telehealth visit. 
 
+ Visits 8 and 9 may be performed interchangeably based on DXA and MRI scanner availability. 
 
6.1.10. Visit 10 (Week 11-12) -- "Optional" 
Participants will come to the research unit for vital signs and VO2max testing (same as Visit 4) Control 
group subjects will receive nutritional counseling, which may be performed by home visit or a video 
telehealth visit. 
6.1.11. Visit 11 (Week 11-12)  
Subjects will arrive fasting to undergo vastus lateralis muscle biopsy, subcutaneous fat biopsy, and collection 
of blood and urine samples for research purposes. These samples will be used to evaluate treatment effects 
on tissue cellular senescence, oxidative stress, DNA methylation and mitochondrial function. Post-
intervention blood laboratory assays also will be done for CMP, CBC, HbA1c, and lipid panel. Control group 
subjects will receive nutritional counseling, which may be performed by home visit or a video telehealth visit. 
 
6.1.12. Visit 12 (Week 13) 
Subjects will come to the research unit for evaluation of the biopsy sites. This visit may be conducted by 
home visit, telephone visit or a video telehealth visit. Control group subjects will receive nutritional 
counseling, which may be performed by home visit or a video telehealth visit. 
 
6.2. 
Visit Schedule Summary 
 
VISIT   1 
VISIT     
2** 
VISIT   
3** 
VISIT 
 4  
VISIT 
5 
VISIT 
6 
VISIT 
7 
VISIT 
8*** 
VISIT 
9*** 
VISIT 
10  
VISIT 
11 
VISIT 
12 
Schedule 
-17 days 
to -21 
-7 days 
to -17, 
+/- 
2wks 
-7 days 
to -17, 
+/- 
2wks 
-1 days 
to -6 
Day 0 
Week 
4 
Week 
8 
Week 
10-11, 
+/- 
2wks 
Week 
10-11, 
+/- 
2wks 
Week 
11-12 
Week 
11-12 
Week 
13 
  
  
  
  
  
  
  
  
  
  
  
  
  
Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
Vital Signs 
X 
 
 
X 
 
 
 
 
 
X 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
Physical Exam 
X 
 
 
 
 
 
 
 
 
 
 
 
MoCA 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Safety Labs (fasting):  
  
  
  
  
  
  
  
  
  
  
  
CBC 
X 
 
 
 
 
 
 
 
 
 
X 
 
CMP 
X 
 
 
 
 
X 
 
 
 
 
X 
 
Lipid Panel 
X 
 
 
 
 
 
 
 
 
 
X 
 
PT/PTT/INR 
X 
 
 
 
 
 
 
 
 
 
 
 
HbA1c 
X 
 
 
 
 
 
 
 
 
 
X 
 
Insulin 
X 
 
 
 
 
 
 
 
 
 
X 
 
FFA 
X 
 
 
 
 
 
 
 
 
 
X 
 
TSH 
X 
 
 
 
 
 
 
 
 
 
 
 

HSC 20190766H 
 
Page 15 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
Routine UA 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DXA 
 
X 
 
 
 
 
 
X 
 
 
 
 
Liver Fibroscan 
 
X 
 
 
 
 
 
X 
 
 
 
 
MRS/MRI - RII 
 
 
X 
 
 
 
 
 
X 
 
 
 
Physical Performance: 
  
  
  
  
  
  
  
  
  
  
  
Walk Distance 
 
X 
 
 
 
 
 
X 
 
 
 
 
Grip Strength 
 
X 
 
 
 
 
 
X 
 
 
 
 
Isom. Knee Ext 
 
X 
 
 
 
 
 
X 
 
 
 
 
VO2max  CPET* 
 
 
 
X  
 
 
 
 
 
X  
 
 
Muscle Biospy 
 
 
 
 
X 
 
 
 
 
 
X 
 
SQ Fat Biopsy 
 
 
 
 
X 
 
 
 
 
 
X 
 
Research Labs: 
  
  
  
  
  
  
  
  
  
  
  
  
Blood  
 
 
 
 
X 
 
 
 
 
 
X 
 
Urine 
 
 
 
 
X 
 
 
 
 
 
X 
 
Nutrition consult and weight (controls) 
 
 
X 
X 
X 
 
 
 
 
 
Nutrition Phone Follow Up 
 
 
weekly 
weekly 
weekly 
 
 
 
 
 
Treatment dispensed 
 
 
 
X 
X 
X 
 
 
 
 
 
Treatment Phone Follow Up 
 
 
 
V5+1w 
V6+2w 
V7+2w 
 
 
 
 
 
Biopsy check 
 
 
 
 
 
X 
 
 
 
 
 
X 
Assess AE 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
*CPET is optional (Visits 4 & 10) 
**Visits 2 and 3 may be performed interchangeably 
***Visits 8 and 9 may be performed interchangeably 
6.3. 
Analyses.  
Muscle (frozen): Protein oxidative damage will be evaluated from muscle biopsy tissue using 
immunoblotting against carbonylated protein side chains. DNA from muscle samples will be extracted and 
tested for 8-hydroxydeoxyguanosine (8-OHdG) content to evaluate oxidative DNA damage and total DNA 
methylation will be evaluated. 
Muscle (fresh): Tissue obtained will be evaluated by an Oroboros Oxygraph-2k high-resolution respirometer 
to measure mitochondrial respiration capacity. Skeletal muscle fibers will be mechanically separated and 
permeabilized in BIOPS as described previously to allow uptake of mitochondrial electron transport chain 
substrates (25). Tissue will then be tested in MiRO6 buffer using a substrate-uncoupler-inhibitor titration 
(SUIT) protocol to evaluate oxidative phosphorylation capacity. 
Fat (frozen): will be subjected to reverse-transcriptase qPCR for measurement of gene expression levels of 
senescence and SASP markers, including IL-6, TNFα, p16, p21, and MCP1. 
Fat (fresh): tissue will be subjected to beta galactosidase staining to test cellular senescence in the tissue 
as described previously (42).  
Blood/plasma: Circulating factors that include inflammatory markers IL-6 and IL-6R, AGE-RAGE levels, and 
SASP biomarkers such as plasminogen activator inhibitor (PAI) -1 and 2, intracellular adhesion molecule 
(ICAM)-1 and 2 will be tested using ELISA kits on blood samples obtained during study. 20mL of blood 
will be drawn (two (2) 10mL EDTA lavender top tubes), centrifuged to obtain 10mL of plasma, and stored 
in 0.5-1 ml aliquots to evaluate whether the treatment reduces pro-inflammatory blood markers of aging. 
Blood samples obtained during the glucose tolerance tests will be analyzed for insulin and free fatty acid 
concentrations. DNA methylation assays will be done in peripheral blood cells. 
Urine: A fasted urine sample will be obtained at baseline and post treatment for urinalysis, microalbumin, 
excreted IL-6, and AGE-RAGE levels to evaluate changes with treatment. 2-5 ml aliquots will be stored 
frozen for analysis. 

HSC 20190766H 
 
Page 16 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
7. Statistical Plan 
7.1. 
Sample Size Determination 
The effect of SGLT2 inhibitors on aging-related biomarkers in pre-diabetic subjects is not known.  The data 
generated through this study will guide sample size and power calculations for future studies. 
7.2. 
Statistical Methods 
Analytical Approach. 
Experimental results will be expressed as means ± SE.  Comparisons of means between all the groups will 
be done by ANCOVA.  Associations, within a group, between aging-related biomarkers vs metabolic 
outcomes and vs. healthspan outcomes will be determined by Pearson’s correlation. For tests of correlation 
coefficients between groups, we will use the Fisher’s Z transformation.  We will also determine the 
relationship between aging-related biomarkers vs metabolic outcomes and vs. healthspan outcomes, by 
using multiple regression analysis.  Scatter plots will be done to look for outliers and to verify linearity.   
 
We will use natural logarithmic transformation to evaluate median percent change. This pilot study is not 
powered to achieve statistical significance with a p <0.05 and is of exploratory nature. The data included in 
this study will be only of completers. A larger trial in the future based on this pilot data would follow an 
intention-to-treat analysis. 
 
The Biostatistics Core of the San Antonio Pepper Center, led by Dr. Gelfond, will guide the statistical 
analyses.   
 
8. Safety and Adverse Events 
8.1. 
Definitions 
Unanticipated Problems Involving Risk to Subjects or Others (UPIRSO) 
Any incident, experience, or outcome that meets all of the following criteria:  
• Unexpected in nature, severity, or frequency (i.e. not described in study-related documents such as 
the IRB-approved protocol or consent form, the investigators brochure, etc.) 
• Related or possibly related to participation in the research (i.e. possibly related means there is a 
reasonable possibility that the incident experience, or outcome may have been caused by the 
procedures involved in the research) 
• Suggests that the research places subjects or others at greater risk of harm (including physical, 
psychological, economic, or social harm). 
 
Adverse Event (AE) 
In general, AE is used very broadly and encompasses physical and psychological harms and includes:   
 
Any untoward or unfavorable medical occurrence in a human subject, including any abnormal sign (for 
example, abnormal physical exam or laboratory finding), symptom, or disease, temporally associated 
with the subject’s participation in the research, whether or not it is considered related to the subject’s 
participation in the research. 
Intercurrent illnesses or injuries should be regarded as adverse events.  Abnormal results of diagnostic 
procedures are considered to be adverse events if the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse event 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 

HSC 20190766H 
 
Page 17 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
• is considered by the investigator to be of clinical significance 
 
Serious Adverse Event (SAE) 
Adverse events are classified as serious or non-serious.  A serious adverse event is any AE that:  
• results in death; 
• is life-threatening (places the subject at immediate risk of death from the event as it occurred); 
• results in inpatient hospitalization or prolongation of existing hospitalization; 
• results in a persistent or significant disability/incapacity; 
• results in a congenital anomaly/birth defect; or 
• based upon appropriate medical judgment, may jeopardize the subject’s health and may require 
medical or surgical intervention to prevent one of the other outcomes listed in this definition 
(examples of such events include allergic bronchospasm requiring intensive treatment in the 
emergency room or at home, blood dyscrasias or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse). 
 
Adverse Event Reporting Period 
The study period during which adverse events must be reported is normally defined as the period from the 
initiation of any study procedures to the end of the study treatment follow-up.  For this study, the study 
treatment follow-up is defined as 30 days following the last administration of study treatment.  
 
Pre-existing Condition 
A preexisting condition is one that is present at the start of the study.  A pre-existing condition should be 
recorded as an adverse event if the frequency, intensity, or the character of the condition worsens during 
the study period. 
 
General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting condition.  At the end 
of the study, any new clinically significant findings/abnormalities that meet the definition of an adverse event 
must also be recorded and documented as an adverse event.  
 
Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an adverse event if any one of the following 
conditions is met:  
• The laboratory abnormality is not otherwise refuted by a repeat test to confirm the abnormality 
• The abnormality suggests a disease and/or organ toxicity 
• The abnormality is of a degree that requires active management; e.g. change of dose, 
discontinuation of the drug, more frequent follow-up assessments, further diagnostic investigation, 
etc. 
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be documented and 
reported as a SAE unless specifically instructed otherwise in this protocol.  Any condition responsible for 
surgery should be documented as an AE if the condition meets the criteria for and adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an AE in the 
following circumstances: 
• Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures for a 
preexisting condition.  
• Surgery should not be reported as an outcome of an adverse event if the purpose of the surgery was 
elective or diagnostic and the outcome was uneventful. 
• Hospitalization or prolonged hospitalization required to allow efficacy measurement for the study. 
• Hospitalization or prolonged hospitalization for therapy of the target disease of the study, unless 

HSC 20190766H 
 
Page 18 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
judged by the clinical investigator as worsening or increase in frequency of hospital admissions. 
8.2. 
Recording of Adverse Events 
At each contact with the subject, the investigator or study staff will seek information about adverse events 
by specific questioning and, if appropriate, by examination.  Information on all AEs will be recorded 
immediately in the source document, and also in the appropriate AE section of the case report form (CRF).  
AEs will be tracked using the HSC IRB AE tracking form or data management tool (See Section 9.3) to be 
reviewed by Site Investigator on a monthly and ad hoc basis, depending on severity and 
expected/unexpected nature of the event. All subjects will have study compliance calls every two weeks 
during which AEs can also be reported.  
 
All AEs occurring during the study period will be recorded. The clinical course of each event will be followed 
until resolution, stabilization, or until it has been determined that the study treatment or participation is not 
the cause.  SAEs that are still ongoing at the end of the study period will be followed up to determine the 
final outcome.  Any SAE that occurs after the study period and is considered to be possibly related to the 
study treatment or study participation will be recorded and reported per Institutional policy and according to 
FDA requirements. 
8.3. 
Reporting of Serious Adverse Events and Unanticipated Problems 
 
Each participant will be evaluated for any adverse events (AE). Any incidents, experiences, and outcomes 
either reported by the subject to the PI or designated research staff or medical staff caring for the subject, 
and which meet AE criteria will be documented.  Any AE reported as serious (SAE) requires submitting a 
Prompt Report Form to the IRB and, if deemed appropriate by PI, SAE and or unanticipated risks to 
subjects or others (UPIRSO) may be reportable to the Pepper Center DSMB. A copy of the SAE or UPIRSO 
prompt report is submitted to the Pepper DSMB for review as well as the NIA Program Officer within 24 
hours of notification to PI. All AE that are not serious or UPIRSO will be summarized annually and submitted 
to the IRB and R&D Committees. 
 
SAE and or UPIRSO will be reported per IRB policy and procedure. Events that do not involve AE or SAE 
(non-AE UPIRSO), and which are a result of study participation are also promptly reported to the IRB per 
local policy. The report will include a description of the event, when and how it was reported, as well as any 
official chart records or documentation to corroborate the event or the reporting of the event. All AE will be 
graded as mild, moderate, or severe.    Any action resulting in a temporary or permanent suspension of this 
study (e.g. local site IRB actions) will be reported to FDA per IRB stipulations. Additionally, the PI will report 
SAE to the drug sponsor Astra-Zeneca. 
 
Serious adverse events (SAE) still ongoing at the end of the study period will be followed up to determine 
the final outcome and or referred to participants’ primary care provider.  Any SAE that occurs after the study 
period that is considered to be possibly related to the study treatment or study participation will be recorded 
and reported per Institutional policy and according to FDA requirements. 
Investigator responsibilities - The PI is responsible for: 
• Reviewing all incidents, experiences, and outcomes that may represent UPIRSO. 
• Determining whether event represents a possible UPIRSO 
• Promptly reporting to IRB per local policy 
• Contacting institutions involved 
• Implementing actions necessary to eliminate immediate hazard 
• Submitting follow up reports to IRB 
• Submitting amendments to IRB, if applicable or stipulated 
 

HSC 20190766H 
 
Page 19 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
Report SAE and UPIRSO immediately by phone and or secure email to: 
 
Carolina Solis-Herrera, MD 
Professor, Medicine-Diabetes 
210-619-3264 
SolisHerrera@uthscsa.edu 
 
 
Within the following 48 hours, the PI provides further information on the SAE or UPIRSO in the form of a 
written narrative.  This should include a copy of the completed Prompt Report Form, and any other 
diagnostic information that will assist the IRB to understand of the event.  A copy of the SAE or UPIRSO 
prompt report is submitted to the Pepper DSMB for review as well as the NIA Program Officer. 
 
For further special reporting requirements, please refer to the NIA DSMP document approved by the NIA 
Program Officer. 
 
Additional reporting requirements 
 
The site PI reports to the regulatory sponsor of the study. The study sponsor (or sponsor-investigator if 
investigator initiated) is responsible for reporting to FDA when applicable, according to 21 CFR 312 
regulations. Contact FDA for guidance. 
 
Reporting Process 
Adverse events may be submitted on FDA Form 3500A or in a narrative format. The contact information for 
submitting safety reports is noted below: 
 
Food and Drug Administration 
Center for Drug Evaluation and Research 
Division of Metabolism and Endocrinology Products 
5901-B Ammendale Road 
Beltsville, MD 20705-1266 
Phone: (301) 796-2290 
Fax: (301) 796-9712  
8.4. 
Medical Monitoring 
The Sponsor (or investigator initiating the study) will review the safety and progress of this study on a 
monthly basis or when needed if protocol deviations/violations, SAE or SAE-UPIRSO occurs.  The 
Designated Safety Officer is Devjit Tripathy, MD, PhD a Professor in the Department of Medicine, 
UTHSCSA, and Staff Physician at the Audie L Murphy VA Hospital.   
 
The PI and or Co-PI will review source documentation in the research record and or medical record when 
study coordinator provides an electronic alert or secure email to review.   
 
8.4.1. Investigator reporting of Protocol Deviations/Violations 
Departures during the conduct of a research study constitute a protocol deviation, violation or exception 
and as such must be reported to the UTHSCSA IRB. 
 
Tracking and reporting of protocol deviations and violations to the IRB is the responsibility of the PI. To 
determine whether deviations or violations require prompt reporting or other action, refer to the IRB 
document entitled “Decision Tree – Evaluating Departures” on the IRB website. Failure to report 

HSC 20190766H 
 
Page 20 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
departures from the protocol according to IRB policy may constitute possible non-compliance, which will 
require a Prompt Report Form and possible FDA reporting by IRB. 
 
Deviations and violations may be identified in a number of ways including:  
• 
A report by an individual can be made directly to the IRB Office.  
• 
The IRB may learn of event through its continuing review of ongoing research.  
• 
Compliance reviews (audits) conducted by the Office of Regulatory Affairs and Compliance or one 
of the HSC affiliated institutional compliance offices.  
• 
A report by an individual can be made directly to the Office of Regulatory Affairs and Compliance 
(Hotline) or one of the HSC affiliated institutional compliance offices.  
• 
A report by another committee, department, institution, or official.  
• 
An audit or report from the study sponsor or sponsor’s monitoring entity. 
8.4.2. Definitions of Protocol Deviations/Violations  
• 
Protocol deviations 
• 
Protocol violations  
• 
Emergency violations  
• 
For more information , refer to UTHSCSA IRB Policy website: 
https://research.uthscsa.edu/irb/policy/deviations  
 
8.5. 
Safety Procedures 
See Section 5.8 – If, in the case of SAE or SAE-UPIRSO, the Clinical Study Coordinator or appropriately 
designated study staff will contact the Designated Safety Officer (Section 8.6) to assess the need for 
stopping research activities until further information can be gathered. 
 
8.5.1. Designated Safety Officer 
 
• 
Assess SAE or SAE-UPIRSO to determine if prompt reporting is required and, if yes, notify 
pharmacist to halt dispensing until further information is obtained. 
• 
Compare event data to intervention/assignment to determine if SAE is related to study intervention 
• 
Assess study and subject safety to determine if stopping rules should be invoked 
• 
Create the Safety Officer record without personal identifiers and communicate to Sponsor 
Investigator and Clinical Study Coordinator with overall impression and recommended plan of action 
 
8.5.2. Research Drug Manager 
 
• 
Suspend dispensing of study drug until SAE reporting is complete 
 
8.5.3. Sponsor Investigator 
 
• 
Receive and review Safety Officer report with Clinical Study Coordinator, Pharmacist and Study 
Statistician 
• 
Assess and implement stopping rules, if required 
• 
Ensure that IRB, FDA, and funding sponsor are notified as appropriate to local or agency policy 
• 
If applicable, notify Pepper Center DSMB 
 
8.5.4. Clinical Study Coordinator  
 
• 
Obtain a copy of Safety Officer or DSMB report/record to file in study binder/file and forward a copy 
to the Regulatory Coordinator 
• 
Ensure appropriate medical care and follow up is scheduled and implemented until SAE resolved 

HSC 20190766H 
 
Page 21 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
• 
Create FDA report, if applicable 
 

HSC 20190766H 
 
Page 22 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
 
 
8.6. 
Stopping Rules  
 
In the unlikely event that a study-related death or SAE occurs, the decision to stop the trial, either temporarily 
or permanently, will be the responsibility of the Designated Safety Officer in collaboration with the Principal 
Investigator. 
There are several reasons why the researchers may need to end the subject’s participation in the study. 
Some reasons are: 
1. The researcher believes that it is not in the subject’s best interest to stay in the study 
a. Adverse drug reaction that does not resolve by dosing titration or if reaction is severe 
b. Subject becomes ineligible to participate due to concomitant use of an exclusionary 
medication 
2. Subject’s health condition changes and needs treatment that is not allowed while participating in the 
study 
3. Subject does not follow instructions from the research team. 
4. The study is stopped 
The research team will discuss options for medical care with the subject when participation in the study ends. 
 
9. Data Handling and Record Keeping 
9.1. 
Confidentiality 
Information learned about all subjects will be kept confidential.  All data and protected health information in 
paper form will be kept confidential by assigned uniquely coded identifier and kept secured (password 
protected and/or double locked). Subjects will not be identified in any way in any publication.   
9.2. 
Registration with Clinicaltrials.gov 
 
As per UT Health San Antonio (UTHSA) Office of Clinical Research policy 1.1.3, this study and other 
investigator initiated studies that meet criteria of “applicable clinical trial” must be registered by the 
“Responsible Party” in the Protocol Registration and Results System/PRS (https://register.clinicaltrials.gov ). 
Results must be conveyed within one year of study completion as defined by PRS. 
9.3. 
Source Documents 
Source data will be originated both electronically and on paper. Electronic data may be originated in either 
the medical record or in REDCap (questionnaires answered verbally). The study team will maintain a list of 
forms to identify where source data are generated for this protocol. 
 
Print all entries legibly in black ink.  Erasures and white-out material are prohibited. If any entry error has 
been made on paper, to correct such an error, draw a single straight line through the incorrect entry and 
enter the correct data above it.  All such changes must be initialed and dated.  For clarification of illegible or 
uncertain entries, print the clarification above the item, then initial and date it. 
 
9.3.1. Research Electronic Data Capture (REDCap) and origination of electronic source data 
Contemporaneous medical histories, physical exams, concomitant medications, checklists of consent 
processing, and documentation of eligibility criteria may be originated electronically in REDCap with date and 
time stamp and e-signed by the study team member obtaining the data. Then REDCap forms will be 
downloaded in PDF format containing saved source data and printed to file in the paper participant record at 
the research site. Other electronically originated data in REDCap include: adverse event (AE) assessments 
and AE logs, enrollment logs, protocol deviation logs, and other study management checklists. Other 

HSC 20190766H 
 
Page 23 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
electronic medical record data including pre-existing history, exams, medication lists, and such may be 
accepted as source data. 
 
All missing data will be routinely queried, corrected, and or explained.  If a space on the CRF is left blank 
because the procedure was not done or the question was not asked, write “N/D”.  If the item is not applicable 
to the individual case, write “N/A”.   
 
9.3.2. Paper source data 
Paper source data will be collected from handwritten subject diaries, drug management logs, then entered 
into the REDCap database. All missing data will be routinely queried, corrected, and or explained.  If a space 
is left blank on paper because the procedure was not done or the question was not asked, write “N/D”, 
initialed and dated by the staff member.  If the item is not applicable to the individual case, write “N/A”.   
• 
Lab reports originating from medical records will be printed and filed in paper participant files to 
facilitate investigator review.  Lab data will be entered to REDCap to facilitate analysis. 
• 
Questionnaires and assessments (e.g., cognitive assessments verbally administered according to 
purchased test booklets and copyrighted material) may be originated electronically in REDCap. 
Otherwise, it may be necessary to originate survey data on a paper source and transfer the data 
elements to REDCap for calculation, data management and analysis. Paper sources will be filed in 
paper subject records. 
• 
Supervising physician investigators will sign and date paper records upon review. 
 
9.3.3. Handwritten entries 
All handwritten entries will be created contemporaneously to the visit or phone call, and legibly in blue or 
black ink. Erasures and white-out material are prohibited. If any entry error has been made on paper, to 
correct such an error, draw a single straight line through the incorrect entry and enter the correct data above 
it.  All such changes must be initialed and dated.  For clarification of illegible or uncertain entries, print the 
clarification above the item, then initial and date it. 
 
9.3.4. Remote and/or virtual research interactions 
This study involves remote and/or virtual research interactions with participants by the research staff. 
Research activities will be audio and/or video recorded by the conferencing platform, Zoom. Therefore, 
privacy and confidentiality are not guaranteed due to the nature of the electronic conferencing platform that 
will be used. 
 
9.4. 
Data Management 
Database Management Software: All data collection for this project will be maintained using the UT Health 
San Antonio REDCap platform which is managed by the Department of Epidemiology and Biostatistics.  
Data System: REDCap is a computing environment developed by Vanderbilt University consisting of a 
collection of instruments, under the management of UT Health San Antonio’s Information Management 
systems, policies, and procedures that govern its informatics operations. Data projects are designed to be end-
user oriented and constructed to optimize workflow and minimize errors.  
All data will be input using a web front-end interface. All users are individually assigned authorization for 
access to specific components of the database application based on approved study roles and responsibilities. 
Information that is input is checked for logical and range consistency and mandatory data fields must be 
entered in order to input a record.  
9.5. 
Records Retention 
The regulatory binder is maintained by a designated regulatory coordinator. 
 
The Principal Investigator is responsible for maintaining study essential documents for at least 3 years after 
the funding grant period ends or at least 2 years have elapsed since the formal discontinuation of clinical 

HSC 20190766H 
 
Page 24 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
development of the investigational product, whichever is longer. Records retention policy is 6 years after the 
study is inactivated. 
 
These documents should be retained for a longer period if required by a funding agency, the FDA or other 
institutional retention policy.  In such an instance, it is the responsibility of the sponsor or Principal 
Investigator to inform the institution as to when these documents no longer need to be retained.  
10.   Study Monitoring, Auditing, and Inspecting 
10.1. Study Monitoring Plan 
The Principal Investigator (PI) will be responsible for ensuring the timely monitoring of the data and safety of 
study participants. The PI will communicate with other members of the study staff to review adverse events 
and protocol compliance on a weekly basis within 7-10 calendar days of the most recent study visit or phone 
encounter.  
 
This study will be reviewed by the Pepper Center Data and Safety Monitoring Board (Pepper DSMB) at least 
annually. The Pepper Center DSMB meets 2-3 times a year, by teleconference call, to review study progress 
and participants’ safety of designated studies. The PI will be required to submit DSMB reports of study 
progress, adverse events summaries and protocol deviation logs to the Pepper DSMB when requested by 
the Pepper DSMB Chair. 
 
The Diabetes Division assigns a staff member to conduct quarterly assessments for data quality 
control/assurance on collected data, which is also reviewed on an annual basis by the designated regulatory 
coordinator and the PI at the time of preparing continuing review documentation for IRB submission. 
 
The Principal Investigator will ensure that the designated regulatory coordinator or other quality assurance 
reviewer is given access to all the above noted study-related documents and study related facilities (e.g. 
Research Drug Manager, diagnostic laboratory, etc.), and has adequate space to conduct study monitoring 
visits as assigned. 
10.2. Auditing and Inspecting 
The Principal Investigator will permit study-related monitoring, audits, and inspections by the IRB, the funding 
sponsor, the OAIC Pepper Center Data Safety and Monitoring Board (Pepper DSMB), government regulatory 
bodies, and University compliance groups of all study related documents (e.g. source documents, regulatory 
documents, data collection instruments, study data etc.).  The investigator will ensure the capability for 
inspections of applicable study-related facilities (e.g. drug management unit, diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by government 
regulatory authorities and applicable University compliance and quality assurance offices. 
11.    Ethical Considerations 
This study is to be conducted according to US and international standards of Good Clinical Practice (FDA 
Title 21 part 312) applicable government regulations and Institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to the Institutional Review Board (IRB), in agreement 
with local legal prescriptions, for formal approval of the study conduct.   
 
All subjects for this study will be provided a consent form describing this study and providing sufficient 
information for subjects to make an informed decision about their participation in this study.  

HSC 20190766H 
 
Page 25 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
12.  Study Finances 
12.1. Funding Source 
This study is financed through a grant from the San Antonio Older Americans Independence Center Pilot and 
Exploratory Studies Core. 
12.2. Conflict of Interest 
UT Investigators are required to submit Conflict of Interest disclosures, if any, with every new study 
submitted for review by UTHSA IRB and VA Research and Development Committee.  
12.3. Subject Stipends or Payments 
This study will reimburse subjects for time and transportation.  A schedule of payments is shown below. The 
total potential reimbursement to a subject is $470 for the study for all visits, or payments may be prorated to 
include the last visit completed if study participation is terminated early. Manual payments for additional 
visits, if necessary, will be handled on an ad-hoc basis with prior approval from the funding sponsor. 
 
Visit 1  
$20 
Visit 2  
$20 
Visit 3  
$20 
Visit 4A 
$20 
Visit 4B 
$20 
Visit 5  
$125 
Visit 6 
$10 
Visit 7 
$20 
Visit 8 
$20 
Visit 9 
$20 
Visit 10A 
$20 
Visit 10B 
$20 
Visit 11 
$125 
Visit 12 
$10 
Manual Payment (unscheduled visit, lab visit, or AE) $50 
 
13.    Publication Plan 
The Institution or respective designees may present or publish the results of a scientific investigation 
involving this Study in accordance with International Committee of Medical Journal Editors (ICMJE). The 
Sponsor Investigator, funding agency, or PI initiating the study will collaborate to determine who has 
publication rights for authorship upon review and approval of proposed manuscripts. 

HSC 20190766H 
 
Page 26 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
 
14.   References 
 
1. Centers for Disease Control and Prevention. “National Diabetes Fact Sheet: estimates and general 
information on diabetes and prediabetes in the US, www.cdc.gov/diabetes/pubs/pdf/ndfs_2019.pdf 
2. ADA. 2008 Economic costs of diabetes in the US in 2007. Diabetes Care 31:596-615 
3. DCCT Research Group. 1993 The effect of intensive treatment of diabetes on the development and 
progression of long-term complications in insulin-dependent diabetes mellitus.  NEJM 329:977-986 
4. UKPDS Group.  1998 Intensive blood-glucose control with sulphonylureas or insulin compared with 
conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 352:837-853 
5. UK Prospective Diabetes Study.  1998   Effect of intensive blood-glucose control with metformin on 
complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 352:854-865 
6. Stratton IM, Adler AI, Neil HAW, et al.  2000 Association of glycaemia with macrovascular and 
microvascular complications of type 2 diabetes.  BMJ 321:405-412 
7. Holman RR, Paul SK, Bethel MA, et al.  2008 10-year follow-up of intensive glucose control in type 2 
diabetes.  NEJM 359:1577-89 
8. DeFronzo RA.  2009  Banting Lecture. From the triumvirate to the ominous octet:  a new paradigm for the 
treatment of type 2 diabetes.  Diabetes 58:773-795 
9. DeFronzo RA. 1997 Pathogenesis of type 2 diabetes: metabolic and molecular implications for identifying 
diabetes genes.  Diabetes Rev 4:177-269 
10. DeFronzo RA.  1988  Lilly Lecture.  The triumvirate:  beta cell, muscle, liver.  Diabetes 37:667-687. 
11. Merovci A, Solis-Herrera C, Daniele G et al.  Dapagliflozin improves muscle insulin sensitivity but 
enhances endogenous glucose production. J Clin Invest. 2014;124(2):509–514,    
12. Abdul-Ghani M, Del Prato S, Chilton R, DeFronzo RA: SGLT2 Inhibitors and Cardiovascular Risk: Lessons 
Learned From the EMPA-REG OUTCOME Study. Diabetes Care 39:717-725, 2016. 
13. Abdul-Ghani M, DeFronzo RA, Del Prato S, Chilton R, Singh R, Ryder REJ. Cardiovascular disease and 
T2DM:  Has the dawn of a new era arrived?  Diabetes Care (in press). 
14. Ryder REJ, DeFronzo RA. Diabetes medications with cardiovascular protection – what now after 
LEADER? – could metformin, pioglitazone, empagliflozin and liraglutide complement each other to save 
lives? Br J Diabetes 16-18, 2016. 
15. Cherney DZ, Perkins BA, Soleymanlou N, Har R, Fagan N, Johansen OE, Woerle HJ, von Eynatten M, 
Broedl UC: The effect of empagliflozin on arterial stiffness and heart rate variability in subjects with 
uncomplicated type 1 diabetes mellitus. Cardiovasc Diabetol 13:28, 2014. 
16. Zinman B, et al. Empagliflozin, CV outcomes in type 2 diabetes.  N Engl J Med.  2015; 373: 2117– 2128.   
17. Neal B, et al. Canagliflozin and CV events in type 2 diabetes.  N Engl J Med.  2017; 377: 644– 657 
18. ACE/AACE. Consensus statement on the comprehensive type 2 diabetes management algorithm. 2019 
executive summary. Endocrin Prac 2019;25:69-100 
19. López-Otín C, Blasco MA, Partridge L, Serrano M, Kroemer G. The hallmarks of aging. Cell. 
2013;153(6):1194-217. 
20. Bonnet F, Scheen AJ. Effects of SGLT2 inhibitors on systemic and tissue low-grade inflammation: the 
potential contribution to diabetes complications and CVD.  Diabetes & Metabolism 2018;44:457-464 
21. Garvey TW, et al. Effects of canagliflozin versus glimepiride on adiokines and inflammatory biomarkers in 
type 2 diabetes. Metabolism 2018; 85:32-37 
22. Ishibashi Y, et al.Tofogliflozin, a highly selective inhibitor of SGLT2 blocks proinflammatory and 
proapoptotic effect of glucose overload on proximal tubular cells partly by suppressing oxidative stress 
generation. Horm Metab Res 2016 48:191-195 
23. Fleming TH, et al.  A. Reactive metabolites and AGE/RAGE mediated cellular dysfunction affect the aging 
process-amini-review. Gerontology 201;57:435-443 
24. Beisswenger PJ, et al.  Oxoaldehyde metabolism and diabetic complications. BiochemSoc Trans 2003; 31: 
1358–1363 

HSC 20190766H 
 
Page 27 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
25. Daniele G, Xiong J, Solis-Herrera C, et al. Dapagliflozin enhances fat oxidation and ketone production in 
patients with type 2 diabetes. Diabetes Care 2016;39:2036-2041 
26. Terami N, et al. Long-term treatment with the sodium glucose cotransporter 2 inhibitor, dapagliflozin, 
ameliorates glucose homeostasis and diabetic nephropathy in db/db mice. Plos One 2014;9(6):e100777 
27. Ojima A, et al. Empagliflozin, an inhibitor of sodium-glucose cotransporter 2 exerts anti-inflammatory and 
antifibrotic effects on experimental diabetic nephropathy. Horm Metab Res 2015; 47: 686–692 
28. Osorio H, et al. Sodium-glucose cotransporter inhibition prevents oxidative stress in the kidney of diabetic 
rats Oxid Cell Med Longev 2012; Article 542042; doi:10.1155/2012/542042)   
29. Bays H,et al.Canagliflozin in overweight and obese subjects without DM. Obesity 2014;22:1042-1049 
30. Hubert HB, et al. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of 
participants in the Framinghamd Heart Study. Circulation 1983;67:968-977 
31. DeFronzo RA. From the triumvirate to the ominous octet: a new paradigm for the treatment of type 2 
diabetes mellitus. Diabetes 2009;773-795 
32. Ma Y, et al. Obesity and risk of colorectal cancer PLoS One 2013; 8(1):e53916 
33. Suk S-H, et al. Abdominal obesity and risk of ischemic stroke. Stroke 2003;34:1586-1592 
34. Li L, et al. Obesity is an independent risk factor for non-alcoholic fatty liver disease: evidence from a meta-
analysi of 21 cohort studies. Obes Rev 2016;17:510-519 
35. Lundkvist P, Pereira MJ, Katsogiannos P, Sjöström CD, Johnsson E, Eriksson JW. Dapagliflozin once daily 
plus exenatide once weekly in obese adults without diabetes: Sustained reductions in body weight, 
glycaemia 
and 
blood 
pressure 
over 
1 year. Diabetes 
Obes 
Metab. 
2017;19(9):1276–1288. 
doi:10.1111/dom.12954 
36. McMurray JJV et al. The Dapagliflozin and Prevention of Adverse-outcomes in Heart Failure (DAPA-HF) 
trial: baseline characteristics. Eur J Heart Fail. 2019 Jul 15. doi: 10.1002/ejhf.1548 
37. Abdul-Ghani M., Al Jobori H., Daniele G. Inhibition of renal sodium-glucose co-transport with empagliflozin 
lowers fasting plasma glucose and improves beta cell function in subjects with impaired fasting 
glucose. Diabetes. 2017 Sep;66(9):2495-2502. doi: 10.2337/db17-0055. 
38. Defronzo RA. Glucose intolerance and aging: evidence for tissue insensitivity to insulin. Diabetes. 
1979;28(12):1095-101. PubMed PMID: 510806. 
39. Chavez AO, Coletta DK, Kamath S, Cromack DT, Monroy A, Folli F, et al. Retinol-binding protein 4 is 
associated with impaired glucose tolerance but not with whole body or hepatic insulin resistance in 
Mexican Americans. Am J Physiol Endocrinol Metab. 2009;296(4):E758-64. Epub 2009/02/05. doi: 
90737.2008 [pii]10.1152/ajpendo.90737.2008. PubMed PMID: 19190263. 
40. Tantiwong P, Shanmugasundaram K, Monroy A, Ghosh S, Li M, DeFronzo RA, et al. NF-kappaB activity in 
muscle from obese and type 2 diabetic subjects under basal and exercise-stimulated conditions. Am J 
Physiol 
Endocrinol 
Metab. 
2010;299(5):E794-801. 
Epub 
2010/08/27. 
doi: 
ajpendo.00776.2009 
[pii]10.1152/ajpendo.00776.2009. PubMed PMID: 20739506. 
41. Pesta D, et al.  Similar qualitative and quantitative changes in mitochondrial respiration following strength 
and endurance training in normoxia Am J Physiol Regul Integr Physiol. 2011 Oct; 301(4): R1078-87. 
42. Tchkonia T, Morbeck DE, Von Zglinicki T, et al. Fat tissue, aging, and cellular senescence. Aging Cell. 
2010;9(5):667-84. 
43. Fletcher, G.F., et al., Exercise standards for testing and training: a scientific statement from the American 
Heart Association. Circulation, 2013. 128(8): p. 873-934. 
 
 
 
 
 
 
 

HSC 20190766H 
 
Page 28 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
 
15.   Attachments 
A. Dapagliflozin Full Prescribing Information Handout 
 

HSC 20190766H 
 
Page 29 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
SUMMARY OF PROTOCOL CHANGES 
Date 
Version 
Section 
Before 
After 
09/10/19 
1.0 
All 
 
IRB submission version 
 
11/07/19 
1.1 
Section 5.6 
 
Section 8.5 
 
 
Section 8.5.2 
Unblinding of Study 
Drug 
Unblinding Procedures 
 
 
Unblinding verbiage 
Renamed “Handling of 
Study Drug”  
Renamed “Safety 
Procedures” 
 
Removed unblinding 
verbiage 
11/08/19 - 11/15/19 
1.2 
Section 5 and 
throughout 
 
 
Throughout document 
 
 
Section 6, Study 
Procedures and Visits 
Research Pharmacy or 
Pharmacy verbiage 
 
 
STX VA clinical site 
 
 
Redundancies in visit 
language 
Replace with Research 
Drug Manager or 
management unit; 
added FDA required 
language for labeling 
 
Replace with UT MARC 
site 
 
Streamlined verbiage 
and added fibroscan and 
MRS/MRI at RII 
 
12/05/19 
1.2.1 dated 11-15-19 
Cover page 
 
 
SAE Reporting 
Administrative update 
needed 
 
Empty cells on pg. 17 
Updated IRB# and 
versioning 
 
Removed empty cells 
12/18/19 
1.3 
CTO changes 
 
Approved Stips met - 
new study by IRB  
03/20/20 
2.0 
Cover sheet 
Study Summary  
Eligibility Criteria 
Stopping Rules 
Section of Visits 
Needed Updates               
Study duration 
Safety lab ranges 
Needs to be added 
Separate Visits 4 and 10 
into 4A-B and 10A-B 
Versioning updated 
Treatment phase v total 
Exclusionary lab ranges  
Added rules 
Relax physical 
performance burden 
05/26/20 
2.1 
Study Summary 
 
 
 
Exclusion Criteria 
 
 
 
 
Required updates. 
 
 
 
Required updates 
 
 
 
 
Study site, exclusion 
criteria & statistical 
methodology updated 
 
Blood donation in prior 2 
months & h/o frequent 
UTI added; renal failure 
clarified 
 

HSC 20190766H 
 
Page 30 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
Section 3.4 (Potential 
risks to Subject Safety) 
 
 
Section 5.6.3 
(Dispensing of Study 
Drug 
 
Section 6.1. (Study 
Visits) 
 
 
 
 
 
 
 
 
Section 6.3 (Analyses) 
 
Section 7 (Statistical 
Methods) 
 
 
 
 
 
 
Section 8 (Reporting 
AEs & UPs) 
 
9.3.4 (Telehealth Visits) 
Required updates 
 
 
 
 
Required updates 
 
 
 
Required updates & 
clarification 
 
 
 
 
 
 
 
 
Required clarification 
 
 
ANOVA 
 
 
 
 
 
Required clarification 
 
 
 
Required updates 
Risks for dapagliflozin 
updated; added potential 
risks of home visits;  
 
Added dispensed at 
home visit, by mail or 
curbside delivery 
 
Text added to clarify 
muscle biopsy 
procedure at Visit 5; 
added home & video 
telehealth visits; added 
BICRC study site; CPET 
made optional; urine 
HCG removed 
 
Blood/plasma volume 
clarified 
 
ANCOVA will be used 
for comparisons 
between groups; the 
study will only use data 
from pts. who complete 
the study 
 
 
Added clarification for 
reporting SAEs 
 
 
Telehealth visits 
description added 
07/22/20 
2.2 
Study Summary;Study 
Design;  4.1 Inclusion 
Criteria; 6.1.8 
 
3.3, Study Endpoints 
 
 
 
6.1, Study Visits 
 
 
6.1.1; Visit Schedule 
Summary 
Required update 
 
 
 
Matsuda index using 
OGTT 
 
 
Required update 
 
 
Required update 
Removed OGTT  
 
 
 
HOMA-IR index using 
fasting insulin & glucose 
 
 
Added Bluetooth scale 
 
Removed OGTT, added 
insulin & FFA 
08/11/20 
2.3 
Inclusion Criteria 
 
 
3.2, General Design 
BMI 30-37 
 
 
Correction 
BMI 30-38 (>29.5 will be 
rounded up) 
 
Study treatment period 
and total study duration 
corrected. 
08/31/20 
2.3.1 
3.4, Potential Risks to 
Subject Safety 
Blood Withdrawal 
Added risks of 
venipuncture by 
needlestick w/o catheter 
10/16/20 
2.3.2 
4.3 Subject 
Recruitment & 
Screening 
will screen up to 40 
potentially eligible 
candidates 
will screen up to 100 
potentially eligible 
candidates 
10/29/20 
2.4 
6.1 Study Visits; 6.2 
Visit Summary 
Schedule 
Required update 
Due to availability of 
DXA and MRI 
scanners.Visits 2&3 

HSC 20190766H 
 
Page 31 
Version: 2.4_10-29-2020 
19-766H, Solis-Herrera, Form BB, 10-30-20, AMD.doc 
 
CONFIDENTIAL 
will be performed 
interchangeably, as 
well as Visits 8&9, 
Visit windows, also, 
expanded to +/- 2 
weeks.