A Phased Clinical Trial of a Dietary Supplement Kava: Biomarker Changes and Anxiolytic Effects Phase 2: Kava Biomarker
Phase: PHASE2
Conditions: Pharmacokinetics
Sponsor: University of Florida

A Phased Clinical Trial of a Dietary Supplement Kava: Biomarker Changes and Anxiolytic Effects Phase 
2: Kava Biomarker 
Version 7
Protocol PAR-18-829  
04Oct2022
NIH-FDA Clinical Trial Protocol Template – v5.0 2021-04-21 
1
 A Phased Clinical Trial of a Dietary Supplement Kava: 
Biomarker Changes and Anxiolytic Effects Phase 2: Kava 
Biomarker 
Unique Protocol Identification Number: PAR-18-829  
National Clinical Trial (NCT) Identified Number: NCT03843502 
Principal Investigator: Chengguo Xing, Carol Mathews 
IND/IDE Sponsor:  
Funded by: NCCIH 
Version Number: 7 
04Oct2022 
 
 
Summary of Changes from Previous Version: 
 
Affected 
Section(s) 
Summary of Revisions Made 
Rationale 
5.2 
Change in exclusion criteria to 
remove language that excludes those 
who are taking psychotropic 
medication to include them as long as 
they have been on a stable dose for 6 
weeks at the baseline visit 
During screening for the study many 
have been excluded who were on stable 
medication for anxiety. However, we 
are finding that they were still 
experiencing high levels of anxiety. 
This change will help to evaluate Kava 
as an adjunct therapy and does not 
affect the aims of the study or cause 
additional risk to study participants. 
 
 
 
 
 
 
 
Table of Contents 
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A Phased Clinical Trial of a Dietary Supplement Kava: Biomarker Changes and Anxiolytic Effects Phase 
2: Kava Biomarker 
Version 7
Protocol PAR-18-829  
04Oct2022
NIH-FDA Clinical Trial Protocol Template – v5.0 2021-04-21 
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STATEMENT OF COMPLIANCE 
Provide a statement that the trial will be conducted in compliance with the protocol, International 
Council on Harmonisation Good Clinical Practice (ICH GCP) and applicable state, local and federal 
regulatory requirements. Each engaged institution must have a current Federal-Wide Assurance (FWA) 
issued by the Office for Human Research Protections (OHRP) and must provide this protocol and the 
associated informed consent documents and recruitment materials for review and approval by an 
appropriate Institutional Review Board (IRB) or Ethics Committee (EC) registered with OHRP. Any 
amendments to the protocol or consent materials must also be approved before implementation. Select 
one of the two statements below. If the study is an intramural NIH study, use the second statement 
below: 
1. The trial will be carried out in accordance with International Council on Harmonisation Good 
Clinical Practice (ICH GCP) and the following: 
o 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR Part 
46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812). 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training. 
OR 
2. The trial will be conducted in accordance with International Council on Harmonisation Good 
Clinical Practice (ICH GCP), applicable United States (US) Code of Federal Regulations (CFR), and 
the [specify NIH Institute or Center (IC) [ Terms and Conditions of Award. The Principal 
Investigator will assure that no deviation from, or changes to the protocol will take place 
without prior agreement from the funding agency and documented approval from the 
Institutional Review Board (IRB), and the Investigational New Drug (IND) or Investigational 
Device Exemption (IDE) sponsor, if applicable, except where necessary to eliminate an 
immediate hazard(s) to the trial participants. All personnel involved in the conduct of this study 
have completed Human Subjects Protection and ICH GCP Training. 
For either option above, the following paragraph would be included: 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the IRB for review and approval. Approval of both the protocol and the consent 
form(s) must be obtained before any participant is consented. Any amendment to the protocol 
will require review and approval by the IRB before the changes are implemented to the study. 
All changes to the consent form(s) will be IRB approved; a determination will be made regarding 
whether a new consent needs to be obtained from participants who provided consent, using a 
previously approved consent form. 

A Phased Clinical Trial of a Dietary Supplement Kava: Biomarker Changes and Anxiolytic Effects Phase 
2: Kava Biomarker 
Version 7
Protocol PAR-18-829  
04Oct2022
NIH-FDA Clinical Trial Protocol Template – v5.0 2021-04-21 
3
1 PROTOCOL SUMMARY 
1.1 SYNOPSIS 
  
Title: 
A Phased Clinical Trial of a Dietary Supplement Kava: Biomarker Changes and Anxiolytic 
Effects  
Study 
Description: 
This study will examine the utility of plasma and urinary based biomarkers for the anxiolytic 
properties of kava, a natural dietary supplement. We will conduct a one week, double blind, 
randomized placebo controlled trial of kava, dosed at three 75 mg capsules per day, vs 
placebo, in adults with generalized anxiety disorder. Clinical measures of anxiety, blood, and 
urine will be obtained. Biomarkers of interest include PRKACA, cortisol, urinary TCE, and NA-
5HT. CYP2D6 testing will be conducted at the screening visit to examine, at the end of the 
study, whether kava metabolism through this enzyme affects the biomarker responses. 
Participants will be assessed pre- and post-treatment. They will also be followed for 12 
weeks after the end of treatment to identify any potential rare adverse events, particularly 
liver toxicity, that appear in a delayed fashion. 
Objectives: 
Primary Objective: 
To evaluate the effect of a one week 
flavokavain A/B-free kava trial in GAD 
patients on biomarker and anxiety scale 
changes, and the relationships between these 
measures, in a double-blind RCT. 
 
Endpoints: 
Primary Endpoint: 
Plasma PRKACA, cortisol, urinary TCE, urinary NA-5HT 
and cortisol levels 
Secondary Endpoints: 
Compliance determined by missed doses and increased 
dihydromyricetin (DHM) levels 
Study 
Population: 
We will screen 30 subjects in order to randomize 26 adults with GAD ages 18-50 for entry 
into the study, with at least 20 of them completing the study. There are no restrictions on 
ethnicity, social background, or gender. Subjects will only be accepted into the study if they 
are free of any history of significant medical illness as determined by history taking, physical 
examination, and routine laboratory tests. Female subjects of child-bearing potential will be 
given a pregnancy test. 

A Phased Clinical Trial of a Dietary Supplement Kava: Biomarker Changes and Anxiolytic Effects Phase 
2: Kava Biomarker 
Version 7
Protocol PAR-18-829  
04Oct2022
NIH-FDA Clinical Trial Protocol Template – v5.0 2021-04-21 
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Phase: 
2 
Description of 
Sites/Facilities 
Enrolling 
Participants: 
The University of Florida Clinical Research Center will be used to enroll participants and 
conduct research procedures. This facility is designed for clinical research. 
Description of 
Study 
Intervention: 
Bottles of flavokavain AB-free kava (75 mg kavalactones/capsule) with the same lot number 
will be directly purchased from Thorne Research Inc. This product will be used because of its 
lack of flavokavains A and B (<0.2 mg/capsule) and consistent content of total kavalactones. 
Participants will take either three 75 mg capsule of kava or three placebo capsule per day for 
one week. 
Study 
Duration: 
65 weeks 
Participant 
Duration: 
13 weeks 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

A Phased Clinical Trial of a Dietary Supplement Kava: Biomarker Changes and Anxiolytic Effects Phase 
2: Kava Biomarker 
Version 7
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1.2 SCHEMA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screening
Week/Day (-35 to -1)
•Obtain informed consent
•Obtained demographic information
•Screen potential participants by inclusion and exclusion criteria
•Obtain medical and psychiatric history, document
•Concomitant medication review
•Height, weight, and vital signs
•Lab testing (comprehensive metabolic panel (CMP, PT/INR, direct and indirect bilirubin)
•Urine Pregnancy test (for women of child bearing potential)
•Urine Drug Screen
•Adverse event review and evaluation
•CYP2D6 testing
•Psychiatric evaluaion including mood, anxiety, sleep, and suicidality rating scales ( M.I.N.I., 
MADRS, ISI, C-SSRS, and CGI-S)
•Complete Case Report Forms (CRFs)
Baseline assessments/Study intervention
Visit 1 /Day 1
•Administer study medication
•Concomitant medication review
•Urine pregnancy test (for women of child bearing potential)
•Urine drug screen
•Adverse event review and evaluation
•Biomarker assays (PRKACA, cortisol, c-AMP, and NA-5HT)
•Randomize
•Complete Case Report Forms (CRFs)
Visit 2/Week 1
•Concomitant medication review
•Lab testing (CMP, PT/INR)
•Adverse event review and evaluation
•Biomarker assays (PRKACA, cortisol, c-AMP, and NA-5HT)
•Psychiatric evaluaion including mood, anxiety, sleep, and suicidality rating scales (MADRS, 
ISI, C-SSRS, CGI-S, and HAM-A)
•Complete Case Report Forms (CRFs)
Visit 3/Week 4
•Concomitant medication review
•Lab testing (CMP)
•Adverse event review and evaluation
•Complete Case Report Forms (CRFs)
Visit 4/Week 8
•Concomitant medication review
•Lab testing (CMP)
•Adverse event review and evaluation
•Complete Case Report Forms (CRFs)
Final assessments
Visit 5/Week 12
•Concomitant medication review
•Lab testing (CMP, PT/INR)
•Adverse event review and evaluation
•Complete Case Report Forms (CRFs)

A Phased Clinical Trial of a Dietary Supplement Kava: Biomarker Changes and Anxiolytic Effects Phase 
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Version 7
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1.3 SCHEDULE OF ACTIVITIES (SOA) 
  
Procedures 
Phone Screen 
Screening 
Day -35 to -1 
Baseline 
Visit 1, Day 1 
Week 1 
Study Visit 2  
Day 7  +/-1 day 
Week 4 
Study Visit 3 
Day 28 +/- 1 day 
Week 8 
Study Visit 4 
Day 56 +/-1 day 
Week 12/Final Visit 
Study Visit 5 
Day 84 +/-1 day 
Informed consent 
 
X 
 
 
 
 
 
Demographics 
 
X 
 
 
 
 
 
Inclusion/exclusion review 
X 
X 
 
 
 
 
 
Medical and psychiatric 
history 
X 
X 
 
 
 
 
 
Administer study intervention 
 
 
X 
 
 
 
 
Concomitant medication 
review 
X 
X 
X 
X 
X 
X 
X 
Height and weight 
 
X 
 
 
 
 
 
Vital signs 
 
X 
 
 
 
 
 
Comprehensive Metabolic 
Panel 
 
X 
 
X 
X 
X 
X 
PT/INR 
 
X 
 
X 
 
 
X 
Direct and Indirect Bilirubin 
 
X 
 
 
 
 
 
Urine pregnancy test a 
 
X 
X 
 
 
 
 
Urine drug screen  
 
X 
X 
 
 
 
 
Adverse event review and 
evaluation 
 
X 
X 
X 
X 
X 
X 
Biomarker assays b 
 
 
X 
X 
 
 
 
CYP2D6 testing 
 
X 
 
 
 
 
 
M.I.N.I 
 
X 
 
 
 
 
 
MADRS, ISI, C-SSRS, and 
CGI-S 
 
X 
 
X 
 
 
 
HAM-A 
X 
 
 
X 
 
 
 
Randomize 
 
 
X 
 
 
 
 
Complete Case Report Forms 
(CRFs) 
 
X 
X 
X 
X 
X 
X 
 
 
 
a: 
For women of child bearing potential 
b: 
PRKACA, cortisol, urinary TCE, and NA-5HT     
 
 
 

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2 INTRODUCTION 
2.1 STUDY RATIONALE 
To validate PRKACA reduction (primary outcome), cortisol, urinary TCE, and NA-5HT reductions 
(secondary outcomes) as biomarkers for kava-induced anxiolysis in GAD. 
 
2.2 BACKGROUND 
There is a critical need for new anxiolytics with novel mechanisms for GAD treatment. GAD is a common, 
chronic, and impairing psychiatric disorder that affects more than 16 million American adults annually 
(1). Evidence-based treatments for GAD include selective serotonin reuptake inhibitors (SSRIs), 
serotonin norepinephrine reuptake inhibitors (SNRI’s), serotonin type 1A partial agonists, and 
benzodiazepines (BZD) (47). Unfortunately, many patients with GAD report only a partial response with 
these treatments or cannot tolerate their side effects. These patients continue to suffer with high levels 
of anxiety and impairment throughout their lives. BZDs are of particular concern because they often 
become the only treatment option for patients with GAD but carry a risk of chemical dependency, 
tolerance to the therapeutic effects, cognitive impairment, and in the long term, dementia and even 
death (3). Specifically, there is an unmet clinical need for new anxiolytics with a mechanism different 
from BZDs and free of the associated adverse effects (4). Kava is a promising candidate as a 
mechanistically novel anxiolytic. Kava is derived from Piper methysticum, a shrub that grows in the 
South Pacific islands. Extracts from the roots of this shrub (kava) are traditionally consumed as a daily 
beverage to help people relax, socialize, and improve sleep quality. Kava was used to treat anxiety in 
Europe in the 1990s (7-13). Clinical studies have shown that kava is effective for anxiolysis across a 
variety of patient groups (7-13). A recent meta-analysis of four randomized placebo-controlled trials that 
examined kava use for GAD favored improvement of anxiety symptoms with kava over placebo, 
although the results were not statistically significant (standardized mean difference = -0.99, CI -2.12 to 
0.14) (14, 15). Importantly, current studies demonstrate no signs of addiction or withdrawal from kava, a 
clear advantage over the BZDs (23). These results not only suggest that kava is a promising candidate for 
treatment of GAD, but also clearly indicate that more research is needed to confirm its utility. The 
mechanisms behind kava’s anxiolytic activity are far from established. Several targets have been 
proposed based on biochemical or cellular results at human irrelevant concentrations without in vivo 
validation, including GABAA (17-19), dopamine receptors (18), opioid receptors (18), histamine receptors 
(18), MAO-B (20), or ion channels (21). A few in vivo studies indicate that kava’s anxiolytic effect is not 
mediated through GABAA (24, 25), consistent with its lack of addiction or withdrawal in clinic. Given that 
most of currently available treatments for GAD work via serotonin reuptake or GABAA, this study has the 
potential to identify an anxiolytic with a unique mechanism of action. Kava use as a dietary supplement 
is increasing. Kava has long been available as a dietary supplement in the US market with a resurgence 
recently – the amount of kava exported from Vanuatu, Fiji and Tonga (the major kava producing 
countries) increased by ~25% annually between 2008 – 2013 and the U.S.A. is a major destination of 
kava export (30). Quality control and standardization, however, are lacking – we have analyzed the 
composition of 25 commercial kava products by LC-MS/MS. The abundance of the major kavalactones 

A Phased Clinical Trial of a Dietary Supplement Kava: Biomarker Changes and Anxiolytic Effects Phase 
2: Kava Biomarker 
Version 7
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varied by 10 – 30 fold (30) despite the fact that these kavalactones have been recommended for 
standardization (48). These products therefore likely vary significantly in their anxiolytic efficacies. The 
abundance of the hepatotoxic compounds, flavokavains A and B (32), varies even more (30), such that 
some products may impose higher risk of hepatotoxicity than others. Rigorous research therefore is 
needed to characterize kava’s pharmacology in conjunction with accurate characterization of its 
chemical compositions, essential to maximize kava’s benefit and to minimize its potential adverse risk. 
Kava is safe for use in clinical populations, especially when properly prepared. Kava was banned for 
clinical use in Europe from 2001 – 2014 because of concerns about potential hepatotoxicity (26). 
However, the purported incidence rate of kava-induced hepatotoxicity is extremely low (0.3 – 1 cases 
per one million daily doses) (48-56), much lower than BZD-based anxiolytics (57, 58). In addition, the 
WHO found that kava-related hepatotoxicity was likely due to quality problems, adulteration of the root 
with other parts of the plant, use of ethanol- rather than water-based extraction, and in some cases, 
interactions between kava and other drugs/herb preparations or chronic alcohol use (5, 49, 50, 59). As a 
result of these assessments, the ban on kava use was lifted in 2014, and kava is again available for use in 
Europe (26). We have closely monitored the safety of kava and its ingredients in all of our studies. We 
detected no signs of hepatotoxicity when kava was evaluated alone, even at elevated dosages and 
extended exposures (27-29, 32, 36, 60, 61). This was further supported by the results of our recent 
study, demonstrating that kava was safe unless co-administered with acetaminophen, due to 
flavokavains A and B (32), two lipophilic chemicals low in aqueous extracts (30). This finding suggests 
that the already low rate of potential hepatotoxicity with kava can be further mitigated by the use of 
preparations that have low (or no) levels of flavokavains A and B, and by excluding patients who are 
taking medications known to have potential hepatotoxicity. The risk of observing an instance of 
hepatotoxicity according to the WHO is less than 0.03% in the R61 phase and less than 0.9% in the R33 
phase of this study; this risk is further mitigated by our use of flavokavain A/B-free kava. 
2.3 RISK/BENEFIT ASSESSMENT 
2.3.1 KNOWN POTENTIAL RISKS 
  
The risks of participating in this project include those incurred during the administration of rating scales, 
blood drawing, and the administration of study medication (kava). Drawing blood requires venipuncture 
and is associated with the momentary discomfort of the needle stick. The risks of venipuncture include 
discomfort at the site of puncture, possible bruising and swelling around the puncture site, rarely an 
infection and uncommonly faintness. The amount of blood collected at each time point is less than two 
tablespoons. Potential side effects from the administration of Kava include: excessive sedation if 
combined with alcohol, rare allergic reactions and rare liver toxicity. The frequency of liver injury in Kava 
is not known.  Based upon reported cases, liver injury due to kava is less than 1:1,000,000 daily doses, 
and is likely due to the presence of flavokavains A and B in the kava preparation.  A few cases of 
clinically apparent liver injury have been published in the literature.  One of the potential risks with kava 
is an acute liver injury with severe hepatitis ending in fulminant hepatic failure, requiring liver 
transplantation, or even leading to death. Preliminary data from a previous human study by our group 

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did not identify any adverse events due to the consumption of kava supplementation. In addition, we 
are using a kava preparation that has been rigorously tested for the removal of flavokavains A and B, 
which are thought to cause the rare cases of liver toxicity that have been observed. 
  
2.3.2 KNOWN POTENTIAL BENEFITS 
  
None 
2.3.3 ASSESSMENT OF POTENTIAL RISKS AND BENEFITS 
  
All study personnel are accustomed to maintaining and ensuring patient confidentiality in the course of 
their work. In addition, all study personnel are highly trained in research procedures and in issues 
regarding protection of participants’ rights and privacy. All members of the research team, including the 
PIs, coinvestigators, study coordinator, data collectors, research assistants, data manager, and all 
students associated with the project will complete UF-mandated human subject training prior to study 
commencement. Participants’ identities will be protected through the following measures: consent 
forms will be stored behind a locked door and in a locked filing cabinet accessible only by the PI, and all 
identifying information will be stored in a separate, secured location from data that is collected during 
the study. Access to locked files will be restricted to essential personnel only. In addition to consent and 
identification files that are secured, all data files will be coded in a manner that makes identification of 
the participants extremely unlikely. Indeed, participants will be given a numerical ID code to ensure that 
inadvertent or unauthorized identification does not occur. Data will receive additional layers of security 
because the whole building, floor, and office in which locked records are maintained have restricted, 
keyed access. The anonymous codes assigned to participants will be verified and maintained throughout 
the study, and codes with names will be provided only to meet federal guidelines applicable to the 
facility. Data will be entered into a REDCap data base developed for the project. REDCap (Research 
Electronic Data Capture) is a secure, HIPAA-aligned web-based application designed to support 
traditional case report form data capture. REDCap’s automated export procedure will be utilized to 
export data into a SAS data set for analysis. 
  
The study coordinator for the proposed project has 6 years of experience and will be trained in all study 
procedures. She will coordinate the screening of potential participants and will meet with Dr. Mathews 
weekly to discuss study progress. Dr. Firpi-Morell, a gastroenterologist with expertise in hepatology and 
liver transplantation, will be responsible for overseeing the medical safety monitoring for this trial. He 
has extensive experience as a medical monitor for national clinical trials of multiple medications. He will 
communicate with Dr. Mathews on a regular basis, and will also communicate any and all adverse 
events to the data safety monitoring board. He will interpret the results of the liver biochemistries (all 
results will be blinded to treatment condition) and will be responsible for referring participants to 
appropriate additional clinical evaluation and intervention if needed. 
  

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Effective screening will rule out active medical or psychiatric conditions, including supplement or 
medication use, chronic alcohol use, and evidence of pre-existing liver disease that may prevent 
someone from participating in the studies.   Once the subject enters the study, an experienced research 
team will closely follow him or her. The research team has developed considerable expertise in 
monitoring the safety of subjects participating in research studies. An experienced research psychiatrist 
and the hepatologist is available 24 hours a day, 7 days a week. If at any point in the procedures 
symptoms become distressing or dangerous, subjects will be withdrawn from the study and, if 
necessary, treatment instituted. 
This project will be conducted in compliance with research statutes outlined in the Health Insurance 
Portability and Accountability Act. Each participant will be assigned a unique identification number, and 
this number will be used to link all subsequent information collected. This file will be secured with 
password access, since it represents a direct link between the name and identification number of a 
participant. All paper files and data are kept in locked file cabinets to ensure confidentiality. The other 
procedures to ensure confidentiality follow the regulations and policies of the University of Florida and 
UF Health. Data file archival and back-up will be performed on a regular basis. The routine monitoring, 
maintenance, and quality control of the databases will be the responsibility of Dr. Mathews. 
  
Participant distress during evaluations: All evaluations have been designed to minimize burden on 
patients with respect to fatigue, stress and/or discomfort. Only trained individuals will administer study 
tests and questionnaires. These individuals will be trained to be sensitive to signs of patient fatigue, 
stress or discomfort. Breaks during testing will be scheduled, and can be initiated by the patient if they 
desire. Participants may choose whether or not to receive the results of their clinical interviews. 
Participants who are assessed as suffering from an untreated psychiatric disorder and choose to obtain 
the results of their interview will be offered referrals to treatment locally if they choose. Participants will 
be free to discontinue their participation at any time if they feel that it is causing unacceptable distress 
or discomfort. 
  
Loss of Confidentiality: All research material will be treated in a confidential manner, and only research 
staff will have access to the data. Confidentiality will be maintained by assigning identification numbers 
for all aspects of the project; all data entered into computer databases will use only this identifier. Data 
are kept in separate coded REDCap data sets and in locked cabinets in locked rooms at UF with access 
limited to a small number of study personnel. All clinical and other records have identifying names of 
participants and relatives removed. Electronic data will be password protected and stored in a database 
on a secure server that is also password protected, with no patient identifying information. No 
identifiable individual data are presented in scientific publications. Only research personnel will have 
access to this data. 
  
Risks of Treatments of Unknown Efficacy: Participants will be informed by the investigators and through 
the written consent that few studies exist for kava treatment, and kava for GAD in particular has not 
been adequately tested. 
  

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Emergence of Depressive or other Psychiatric Symptoms or Suicidality: The research team will receive 
training in the rapid assessment and management of distress or emergence of psychiatric symptoms 
that may arise during the PK protocol. If a participant’s status raises concern, Dr. Mathews will offer a 
clinical evaluation and, when appropriate, participation in the study will be discontinued, and the 
participant will be referred for treatment according to clinical indication (hospitalization, partial 
hospitalization, other psychosocial interventions, pharmacotherapy, etc.). If a participant’s psychiatric 
state worsens at any point such that they are no longer able to participate in the treatment, the 
participant will be withdrawn from the research protocol and referred for the appropriate treatment 
according to clinical indication. The same procedures apply to any participant who reports suicidal intent 
or plan or makes a suicide attempt at any point in the study. Dr. Mathews is a licensed psychiatrist and 
will provide clinical oversight over assessments of suicidal ideation and safety. 
  
Management of psychiatric emergencies: We believe that the risk of psychiatric emergencies occurring 
during the execution of this study is low, based on the pilot data and our findings of the patient 
population. However, should such an emergency arise (such as an acute decompensation, statement or 
demonstration of active suicidal ideation, violence, etc), we have procedures in place to ensure the 
safety of the participant and the staff. 
  
Liver function abnormalities: We will use a kava product that has removed the potentially liver toxic 
elements, flavokavain A and B, and has been rigorously tested for quality. However, we will nevertheless 
closely monitor serum liver biochemistries (AST, ALT, ALP, bilirubin (total, direct, and indirect) and 
albumin) at baseline, and at weeks 1, 4, 8 and 12. Although the timing of any potential liver toxicity with 
kava is not known, the timing of the few reported cases in the NIH liver tox database suggests that the 
onset of symptoms related to hepatotoxicity (including nausea, fatigue) is likely to be between 2 weeks 
and 12 weeks following initial ingestion. We will also encourage participants to contact the study team 
for any concerning symptoms that they may have for up to 6 months post-treatment to ensure that no 
delayed reactions, no matter how unlikely, are missed. We will carefully educate participants about 
symptoms to watch for throughout the study and following treatment. 
  
  
  
 
 

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3 OBJECTIVES AND ENDPOINTS 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR 
ENDPOINTS 
Primary 
To evaluate the effect of an 8-
week flavokavain A/B-free kava 
trial in GAD patients on 
biomarker and anxiety scale 
changes, and the relationships 
between these measures, in a 
double-blind RCT. 
• 
Plasma changes in PRKACA, 
cortisol, urinary TCE, and urinary 
NA-5HT and cortisol levels 
• 
Changes in HAM-A score pre to 
post treatment  
  
• 
Biomarkers of interest 
• 
Measure of anxiolysis  
  
Compliance 
• 
Liver function tests 
• 
Number of missed doses 
• 
Standard measures of 
liver function 
• 
Quantified measure of 
compliance  
Tertiary/Exploratory 
N/A 
N/A 
N/A 

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4 STUDY DESIGN 
4.1 OVERALL DESIGN 
Aim: To validate PRKACA reduction (primary outcome), cortisol, urinary TCE, and NA-5HT reductions 
(secondary outcomes) as biomarkers for kava-induced anxiolysis in GAD. 
  
Study design: We will recruit and screen potential participants until we are able to randomize and enroll 
26 individuals with GAD, with the expectation that 20 will complete the study (10 per arm) based on a 
conservative estimate of a 25% drop-out rate (the drop-out rate for our pilot study was 19%). We will 
build on our prior work with smokers by evaluating the utility of PRKACA as a biomarker for kava-
induced anxiolysis among individuals with GAD. A one week double-blinded randomized, parallel, 
placebo-controlled trial of kava in GAD patients will be conducted. To minimize the risk of adverse 
events, particularly liver dysfunction, we will use flavokavain A/B-free kava in this study. Participants will 
be randomized, stratified by sex, to one of two conditions—placebo dosed three times a day or 75 mg of 
kava dosed three times a day. All pills will be taken with meals. Potential adverse effects will be 
evaluated via serum liver biochemistries and assessment of clinical symptoms in all participants at 
baseline, post treatment (day 7) and every 4 weeks for 12 weeks following discontinuation of treatment. 
Blood and urine for biomarker assessments will be collected at baseline and post treatment (day 7). 
CYP2D6 testing will be conducted at the screening visit to examine, at the end of the study, whether 
kava metabolism through this enzyme affects the biomarker responses. 
  
 
 
4.2 SCIENTIFIC RATIONALE FOR STUDY DESIGN 
Exploring the potential of plasma PRKACA, and in an exploratory fashion of cortisol, urinary TCE and NA-
5HT, as surrogate biomarkers of kava’s anxiolytic potential. 
 
 
4.3 JUSTIFICATION FOR DOSE 
We have isolated the major chemicals in kava and determined their benefits (66) and risks (32) in vivo. 
With such knowledge, we screened twenty-five commercially available kava products and quantified the 
major beneficial kavalactones, including kavain, dihydrokavain, methysticin, and dihydromethysticin 
(DHM, the chemopreventive ingredient), and the hepatotoxic compounds – flavokavains A and B (30). 
We identified one dietary kava product from Gaia Herbs (Kava Root) for our pilot human trial that has a 
high DHM content and low flavokavain A and B content. To ensure consistency, we characterized the 
content of three batches of this product by HPLC and NMR. Each capsule contained 75 ± 3 mg of 
kavalactones (the anxiolytic ingredients), consistent with the labeled 75 mg kavalactone per capsule. 
Each capsule also contained ~20 mg DHM. With three capsules per day, the human daily dose of kava is 
within the proposed anxiolytic range (120-280 mg daily (14)); the amount of DHM would be comparable 

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to its in vivo chemopreventive dose. This kava product also contained minimal flavokavains A and B 
(<1.0 mg/capsule). 
 
 
4.4 END OF STUDY DEFINITION 
The study will come to an end when the data for 13 controls and 13 subjects with GAD has been 
collected and analyzed. 
 
 

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5 STUDY POPULATION 
5.1 INCLUSION CRITERIA 
1) Adults ages 18-50 who meet DSM-5 criteria for GAD as the primary psychiatric diagnosis. 2) No more 
than one failed therapeutic trial of an FDA approved medication for the treatment of GAD. 3) Score of 
>14 on the Hamilton Anxiety Rating Scale at screening.  4) At least a 4 (moderate) on the Clinical Global 
Impressions Severity Scale at screening. 5) Females of potential childbearing status must use adequate 
contraceptive precautions. 
5.2 EXCLUSION CRITERIA 
1) Any change in current SSRI, SNRI, or other non-benzo anxiolytic medication within 6 weeks of baseline 
visit. 2) Inability to refrain from acetaminophen, alcohol or other potentially hepatotoxic substances. 3) 
History of liver disease or current liver disease or clinically significant elevation in serum liver 
chemistries. 4) Unstable medical or neurological condition. 5) Positive urine drug screen for substances 
of abuse. 6) Active substance abuse/dependence. 7) Lifetime history of a psychotic disorder, bipolar 
disorder, PTSD or OCD. 8) Any significant risk for self-harm or suicidality as determined by the principal 
investigator or suicide attempt within the last 6 months. 9) Psychotherapy newly instituted during the 6 
weeks leading up to enrollment in the study. Subjects established in psychotherapy without change 
during the course of the study may participate. 10) Montgomery-Asberg Depression Rating Scale 
(MADRS) > 20 (moderate or severe depressive symptoms). 
5.3 LIFESTYLE CONSIDERATIONS 
This study will exclude any individual who is a current tobacco smoker and anyone who is not able to 
abstain from alcohol consumption for the duration of the study. 
5.4 SCREEN FAILURES 
Subjects who do not meet inclusion and/or meets criteria for any of the exclusion criteria will be 
deemed a screen fail. 
5.5 STRATEGIES FOR RECRUITMENT AND RETENTION 
Subjects will be recruited from the population of patients seen in clinics staffed by the UF Department of 
Psychiatry, through advertisements and referrals in the community. These advertisements will be in the 
form of flyers and newspaper ads. When study referrals are received, a member of the research team 
will make contact within 24 hours to conduct a pre-screening phone interview. The study will be 
described to the potential participant and a brief set of questions will be asked to determine eligibility in 
the trial. Those who meet the inclusion/exclusion criteria below and are interested in participation will 
then be scheduled for an in-person screening visit. At that screening visit the informed consent will be 
reviewed in detail and the participant will be given the opportunity to ask questions prior to signing. 
Participants who are eligible at both screening and baseline will be randomized to receive study drug 

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and given instructions on taking it. At the end of this visit the participant will be scheduled for the next 
study visit. 
  
Compliance will be insured via the following methods: 
• 
Close monitoring during participation 
• 
Weekly reminder phone calls to confirm study visits 
• 
24/7 access to study coordinator and study doctor during participation 
• 
Establishing appropriate rapport such that the participant feels cared about by the research team and is 
motivated to return. 
• 
Providing ease of access to the research facilities—participants will be given parking or bus vouchers to 
facilitate their visits. Visits will be scheduled to accommodate the participants’ schedules as much as 
possible within the limitations of the study parameters. 
  
Participants will be compensated $25 for each assessment visit, and for the long term follow-up visits. 
Money will be loaded onto a prepaid visa card remotely, and will be provided at two time points 1) the 
end of the treatment (or at the time that the participant drops out) and 2) at the end of the 12 week 
follow up. Providing compensation at these delayed time points rather than after every visit encourages 
participation in the assessment visits. Note that participants are not compensated for participating in 
treatment, rather they are compensated for participating in the research assessments. 
  
  
  
 
 

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6 STUDY INTERVENTION 
6.1 STUDY INTERVENTION(S) ADMINISTRATION 
6.1.1 STUDY INTERVENTION DESCRIPTION 
  
Bottles of flavokavain AB-free kava (75 mg kavalactones/capsule) with the same lot number will be 
directly purchased from Thorne Research Inc. This product will be used because of its lack of 
flavokavains A and B (<0.2 mg/capsule) and consistent content of total kavalactones. Participants will 
take either one 75 mg capsule of kava or one placebo capsule three times a day for one week. 
  
6.1.2 DOSING AND ADMINISTRATION 
  
Optimal dosing regimen to be determined in phase 1 (75 mg three times a day or 225 mg once a day). 
  
A trained study team member will retrieve the study supplements from IDS Pharmacy and deliver them 
to the participant at the UF Health Outpatient Psychiatry Clinic. Instructions will be 
provided in writing on supplement administration and storage of supplements. Participants will be asked 
to keep track of any missed doses. Unused supplements will be returned to IDS via the study personnel 
at the end of the trial and will be destroyed by IDS. 
  
 
 
6.2 PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY 
6.2.1 ACQUISITION AND ACCOUNTABILITY 
  
Participants will be randomized to receive kava or placebo and given bottles with the correct number of 
pills and instructions on how to take the medication. 
6.2.2 FORMULATION, APPEARANCE, PACKAGING, AND LABELING 
  
Bottles of flavokavain AB-free kava (75 mg kavalactones/capsule) with the same lot number will be 
directly purchased from Thorne Research Inc. This product will be used because of its lack of 
flavokavains A and B (<0.2 mg/capsule) and consistent content of total kavalactones. For ongoing quality 
control, three capsules from each bottle will be analyzed via our established method to ensure adequate 
and constant content of total kavalactones and no flavokavains A and B. The Investigational Drug Service 
(IDS) pharmacy will package the investigational kava. Supplies with the appropriate number of capsules 
for each subject will be prepared and bottled for administration. 
  

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6.2.3 PRODUCT STORAGE AND STABILITY 
  
Product will be stored according to manufacturer recommendations. All unused supplement will be 
returned to IDS via study personnel and destroyed by IDS. 
  
6.2.4 PREPARATION 
  
Bottles of flavokavain AB-free kava (75 mg kavalactones/capsule) with the same lot number will be 
directly purchased from Thorne Research Inc. This product will be used because of its lack of 
flavokavains A and B (<0.2 mg/capsule) and consistent content of total kavalactones. 
6.3 MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING 
Eligible study participants will be randomly assigned to one of two groups: kava supplement or placebo. 
The pharmacist will use a computerized program SAS PROC PLAN procedure to generate the 
randomization scheme. Sequentially numbered, sealed, opaque envelopes containing group assignment 
(kava supplement or placebo) will be prepared by the pharmacist and numbered for each group 1 to 20. 
When a participant meets criteria to be randomized the study coordinator will open the next 
(sequentially numbered) appropriate envelope for participant assignment. Because this is a double-
blinded study, neither the investigators nor the participants will know whether participants have 
received the kava supplement or placebo. The placebo supplement will be provided by identical 
capsules that contain methylcellulose, an inactive ingredient. The pharmacist will distribute identical 
capsules (kava and placebo); thus, no distinguishing characteristics will be present. The list of prepared 
supplements will be maintained by the pharmacist who will distribute the appropriate supplements for 
the next consented, eligible study participant. 
6.4 STUDY INTERVENTION COMPLIANCE 
Secondary Endpoint: Compliance will be measured as number of missed doses (self-reported) and 
defined by the detection of DHM at least 3 times above its limit of quantification via the LC-MS/MS 
methods at post-treatment in at least 80% of participants who complete the kava arm (e.g., 8/10). 
6.5 CONCOMITANT THERAPY 
6.5.1 RESCUE MEDICINE 
  
25 mg of Hydroxyzine every 6 hours 
 
 

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7 STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL 
7.1 DISCONTINUATION OF STUDY INTERVENTION 
This study will be stopped prior to its completion if: (1) the intervention is associated with adverse 
effects that call into question the safety of the intervention; (2) difficulty in study recruitment or 
retention will significantly impact the ability to evaluate the study endpoints; (3) any new information 
becomes available during the trial that necessitates stopping the trial; or (4) other situations occur that 
might warrant stopping the trial. If at any time during the study the participants are found to be at 
excessive risk, the study will be terminated. All key research personnel have completed the required 
human subjects training course. Key personnel include all individuals responsible for the design and 
conduct of the study. 
7.2 PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
Study subjects will be informed that they are welcome to withdrawal or discontinue the study at any 
time should they feel this is not their best interest, does not meet their time availability, or for any other 
reason they see fit. Subjects will be asked to speak with the study coordinator or the investigator to 
indicate their request for withdrawal and all study related activity will stop. 
7.3 LOST TO FOLLOW-UP 
NCCIH considers lost to follow-up as a research subject who was participating in the study at a certain 
point in time and subsequently missed two consecutive study visits and is unresponsive to study 
contact, or is no longer participating in study activities. The anticipated lost to follow-up rate for this 
study will be 20% of total enrollment (e.g., N=2). 
 
 

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8 STUDY ASSESSMENTS AND PROCEDURES 
8.1 EFFICACY ASSESSMENTS 
N/A 
8.2 SAFETY AND OTHER ASSESSMENTS 
Built upon our understanding of kava’s hepatotoxic risk, a flavokavain A/B-free kava dietary supplement 
will be used in this trial, which is expected to reduce/eliminate kava’s potential hepatotoxic risk. We will 
exclude individuals with elevated risk for hepatotoxicity, and will closely monitor liver function and 
other potential adverse events during and for 12 weeks following treatment. 
8.3 ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS 
8.3.1 DEFINITION OF ADVERSE EVENTS (AE) 
  
An adverse event (AE) is any untoward medical occurrence in a subject during participation in the clinical 
study or with use of the experimental agent being studied. An adverse finding can include a sign, 
symptom, abnormal assessment (laboratory test value), or any combination of these regardless of 
relationship to participation in the study. 
8.3.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE) 
  
A serious adverse event (SAE) is one that meets one or more of the following criteria: 
• 
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 or incapacity 
• 
Results in a congenital anomaly or birth defect 
• 
An important medical event that may not result in death, be life threatening, or require hospitalization 
may be considered an SAE when, based upon appropriate medical judgment, the event may jeopardize 
the subject and may require medical or surgical intervention to prevent one of the outcomes listed in this 
definition. 
8.3.3 CLASSIFICATION OF AN ADVERSE EVENT 
  
 Any undesirable and unintended (although not necessarily unexpected) effect occurring as a result of 
interventions, interactions, or collection of identifiable private information in research. In medical 
research, any untoward physical or psychological occurrence in research, including abnormal laboratory 

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finding, symptom, or disease temporally associated with the use of (although not necessarily related to) 
a medical treatment or procedure. Adverse events involving drugs are also referred to as adverse drug 
experiences. The PI will review and access for any adverse event classification in this study. 
8.3.3.1 SEVERITY OF EVENT 
  
The following scale will be used to grade adverse events: 
1. Mild: no intervention required; no impact on activities of daily living (ADL) 
2. Moderate: minimal, local, or non-invasive intervention indicated; moderate impact on ADL 
3. Severe: significant symptoms requiring invasive intervention; subject seeks medical attention, needs 
major assistance with ADL 
8.3.3.2 RELATIONSHIP TO STUDY INTERVENTION 
  
To assess relationship of an event to study intervention, the following guidelines are used: 
1. Related (Possible, Probable, Definite) 
1. The event is known to occur with the study intervention. 
2. There is a temporal relationship between the intervention and event onset. 
3. The event abates when the intervention is discontinued. 
4. The event reappears upon a re-challenge with the intervention. 
2. Not Related (Unlikely, Not Related) 
1. There is no temporal relationship between the intervention and event onset. 
2. An alternate etiology has been established. 
8.3.3.3 EXPECTEDNESS 
  
The Study PI and Independent Monitoring Committee will be responsible for determining whether an 
SAE is expected or unexpected. An adverse event will be considered unexpected if the nature, severity, 
or frequency of the event is not consistent with the risk information previously described for the 
intervention. 
8.3.4 TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP 
  
Unanticipated problems will be recorded in the data collection system throughout the study. 
The PI will record all reportable events with start dates occurring any time after informed consent is 
obtained until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day of study participation. At 

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each study visit, the investigator will inquire about the occurrence of AE/SAEs since the last visit. Events 
will be followed for outcome information until resolution or stabilization. 
8.3.5 ADVERSE EVENT REPORTING 
  
AEs documented during the course of the trial will be reported to NCCIH on an annual basis by way of 
inclusion in the annual report and in the annual AE summary which will be provided to NCCIH and to the 
Independent Monitors. The Independent Safety Monitor(s) Report will state that all AEs have been 
reviewed. 
8.3.6 SERIOUS ADVERSE EVENT REPORTING 
  
SAEs that are unanticipated, serious, and possibly related to the study intervention will be reported to 
the Independent Monitors(s), IRB, FDA, and NCCIH in accordance with requirements. For the IND: 
• 
7-day IND Safety Report (unexpected fatal or life-threatening AEs related to the intervention); a copy of 
the report sent to the FDA will be submitted to the NCCIH Program Officer and Independent Safety 
Monitor(s) within 24 hours of FDA notification. 
• 
15-day IND Safety Report (any other serious and unexpected AE related to the intervention); a copy of the 
report submitted to the FDA will be submitted to the NCCIH Program Officer and Independent Safety 
Monitor(s) within 24 hours of FDA notification. 
All other AEs documented during the course of the trial will be reported to NCCIH on an annual basis by 
way of inclusion in the annual report and in the annual AE summary which will be provided to NCCIH 
and to the Independent Monitors. The Independent Safety Monitor(s) Report will state that all AEs have 
been reviewed 
8.3.7 REPORTING EVENTS TO PARTICIPANTS 
  
 In the case of abnormal lab values (liver functions), the PI will address these findings with the study 
subjects and provide the subject with a copy of the result for their current physician. 
8.3.8 EVENTS OF SPECIAL INTEREST 
  
None 
8.3.9 REPORTING OF PREGNANCY 
  
All individuals of child bearing age range will be required to provide a urine sample for pregnancy testing 
at the screening  visit. If they are determined to be pregnant they will be excluded from the study. 
 
 

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8.4 UNANTICIPATED PROBLEMS 
8.4.1 DEFINITION OF UNANTICIPATED PROBLEMS (UP) 
  
The Office for Human Research Protections (OHRP) considers unanticipated problems involving risks to 
subjects or others to include, in general, any incident, experience, or outcome that meets all of the 
following criteria: 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that are 
described in the protocol-related documents, such as the IRB-approved research protocol and informed 
consent document; and (b) the characteristics of the subject population being studied; 
• 
Related or possibly related to participation in the research (“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); and 
• 
Suggests that the research places subjects or others at a greater risk of harm (including physical, 
psychological, economic, or social harm) than was previously known or recognized. 
8.4.2 UNANTICIPATED PROBLEM REPORTING 
  
Incidents or events that meet the OHRP criteria for unanticipated problems require the creation and 
completion of an unanticipated problem report form. OHRP recommends that investigators include the 
following information when reporting an adverse event, or any other incident, experience, or outcome 
as an unanticipated problem to the IRB: 
• 
Appropriate identifying information for the research protocol, such as the title, investigator’s name, and 
the IRB project number; 
• 
A detailed description of the adverse event, incident, experience, or outcome; 
• 
An explanation of the basis for determining that the adverse event, incident, experience, or outcome 
represents an unanticipated problem; 
• 
A description of any changes to the protocol or other corrective actions that have been taken or are 
proposed in response to the unanticipated problem. 
To satisfy the requirement for prompt reporting, unanticipated problems will be reported using the 
following timeline: 
• 
Unanticipated problems that are serious adverse events will be reported to the IRB, Independent Safety 
Monitor(s), and NCCIH within 7 days of the investigator becoming aware of the event. 
• 
Any other unanticipated problem will be reported to the IRB, Independent Safety Monitor(s), and NCCIH 
within 14 days of the investigator becoming aware of the problem. 

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All unanticipated problems should be reported to appropriate institutional officials (as required by an 
institution’s written reporting procedures), the supporting agency head (or designee), and OHRP within 
one month of the IRB’s receipt of the report of the problem from the investigator. 
8.4.3 REPORTING UNANTICIPATED PROBLEMS TO PARTICIPANTS 
  
During this study we will follow the NIH and UF IRB guidelines on reporting unanticipated problems to 
study participants. 
 

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9 STATISTICAL CONSIDERATIONS 
9.1 STATISTICAL HYPOTHESES 
• 
Primary Efficacy Endpoint(s): 
o 
Mean PRKACA reduction will be 30% higher in kava group than placebo group 
o 
Mean  PRKACA and HAM-A score reductions in placebo group will be correlated by at least 0.3  
• 
Secondary Efficacy Endpoint(s): 
o 
Measurable DHM levels will be detected in 8/10 participants in kava arm  
9.2 SAMPLE SIZE DETERMINATION 
We will recruit and screen potential participants until we are able to randomize and enroll 26 individuals 
with GAD, with the expectation that 20 will complete the study (10 per arm) based on a 75% success 
rate (the retention rate for our pilot study was 81%).  Of particular interest is determining the utility of 
measuring changes in PRKACA as a marker of kava-induced anxiolysis. To provide context, the effect size 
seen in our pilot work was .794 (Cohen’s f) for PRKACA reductions on kava from baseline. Based on the 
proposed design, with 10 subjects per arm, we have 0.80 power to detect an effect size (Cohen’s f) of 
0.73 (82, 83). While this represents a large effect size, it is consistent with what was found in our pilot 
work. 
9.3 POPULATIONS FOR ANALYSES 
Individuals with GAD ages 18-50 
9.4 STATISTICAL ANALYSES 
9.4.1 GENERAL APPROACH 
  
In this aim, we will explore the effect of kava supplement on changes in PRKACA, cortisol, urinary TCE, 
and NA-5HT. Separate 2 x 2 (Condition (Placebo / Kava) x Time (Baseline and Post-treatment, within 
condition) generalized linear mixed models (GLMM) will be analyzed for (a) PRKACA, (b) cortisol, urinary 
TCE, and NA-5HT outcomes. Of primary interest is exploring effect sizes for the interaction effect 
(difference in slopes) for those outcomes over weeks 0 (baseline) to 1 under placebo and kava 
conditions. Simple main effects will provide information about the within-subjects slope for each 
condition. GLMM analyses allow for missing data for an intent-to-treat approach, and can accommodate 
measurement of study subjects at different time points during the study, incorporate time varying 
covariates, flexible covariance structures, and a variety of dependent variable distributions (including 
counts and dichotomous) (85, 86). The statistical model will contain main effects for condition and time 
and the condition by time interaction. Of primary interest is the treatment by time interaction effect, as 
that will reflect the effect of the kava intervention. 

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9.4.2 ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S) 
  
See above 
9.4.3 ANALYSIS OF THE SECONDARY ENDPOINT(S) 
  
No analysis needed- endpoint is simple measurement.  
9.4.4 SAFETY ANALYSES 
  
First, we will rigorously analyze the kava product prior to use to ensure its consistent quality with no 
flavokavains A and B. Second, we have implemented stringent exclusion criteria and will provide 
education to the enrolled subjects to minimize potential drug-herb interactions. Third, we will monitor 
participants throughout the study and for 12 weeks following the end of treatment to ensure that any 
potential acute or delayed adverse effects are identified and addressed. Serum liver chemistries (AST, 
ALT, ALP, bilirubin (total, direct, and indirect) and albumin, Prothrombin Time and International 
Normalized Ratio) will be drawn at baseline, post treatment, and every 4 weeks following treatment up 
to 12 weeks. The adverse events checklist will be completed at each of these visits as well. 
9.4.5 BASELINE DESCRIPTIVE STATISTICS 
  
Gender, age, baseline HAM-A scores, education, race, and baseline biomarker levels.  
9.4.6 PLANNED INTERIM ANALYSES 
  
None 
9.4.7 SUB-GROUP ANALYSES 
  
None 
9.4.8 TABULATION OF INDIVIDUAL PARTICIPANT DATA 
  
N/A 
9.4.9 EXPLORATORY ANALYSES 
  
N/A 
 
 

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10 SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS 
10.1 REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
10.1.1 INFORMED CONSENT PROCESS 
  
Informed consent is a process that is initiated prior to the individual agreeing to participate in the study 
and continues throughout study participation. Extensive discussion of risks and possible benefits of 
study participation will be provided to subjects and their families, if applicable. A consent form 
describing in detail the study procedures and risks will be given to the subject. Consent forms will be 
IRB-approved, and the subject is required to read and review the document or have the document read 
to him or her. The investigator or designee will explain the research study to the subject and answer any 
questions that may arise. The subject will sign the informed consent document prior to any study-
related assessments or procedures. Subjects will be given the opportunity to discuss the study with their 
surrogates or think about it prior to agreeing to participate. They may withdraw consent at any time 
throughout the course of the study. A copy of the signed informed consent document will be given to 
subjects for their records. The rights and welfare of the subjects will be protected by emphasizing to 
them that the quality of their clinical care will not be adversely affected if they decline to participate in 
this study. The consent process will be documented in the clinical or research record. To complete the 
informed consent process at the end of study participation, study staff will inform the subject when 
his/her participation has come to an end and will document the discussion in the study record. 
10.1.1.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED TO 
PARTICIPANTS 
  
All consented subjects will be provided a copy of their fully executed informed consent document. 
10.1.1.2 CONSENT PROCEDURES AND DOCUMENTATION 
  
Each subject will review the informed consent document with the study coordinator and will be 
provided time to ask and receive answers to any questions. The name of the person obtaining consent 
will be documented along with date and time consent was obtained. 
10.1.2 STUDY DISCONTINUATION AND CLOSURE 
  
This study will be stopped prior to its completion if: (1) the intervention is associated with adverse 
effects that call into question the safety of the intervention; (2) difficulty in study recruitment or 
retention will significantly impact the ability to evaluate the study endpoints; (3) any new information 
becomes available during the trial that necessitates stopping the trial; or (4) other situations occur that 
might warrant stopping the trial.” 
  

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If at any time during the study the participants are found to be at excessive risk, the study will be 
terminated. All key research personnel have completed the required human subjects training course. 
Key personnel include all individuals responsible for the design and conduct of the study. 
10.1.3 CONFIDENTIALITY AND PRIVACY 
  
Subject confidentiality is strictly held in trust by the investigators, study staff, and the sponsor(s) and 
their agents. This confidentiality is extended to cover testing of biological samples and genetic tests in 
addition to any study information relating to subjects. The study protocol, documentation, data, and all 
other information generated will be held in strict confidence. No information concerning the study or 
the data will be released to any unauthorized third party without prior written approval of the sponsor. 
The study monitor or other authorized representatives of the sponsor may inspect all study documents 
and records required to be maintained by the investigator, including but not limited to, medical records 
(office, clinic, or hospital) for the study subjects. The clinical study site will permit access to such records. 
All research material will be treated in a confidential manner, and only research staff will have access to 
the data. Confidentiality will be maintained by assigning identification numbers for all aspects of the 
project; all data entered into computer databases will use only this identifier. Data are kept in separate 
coded REDCap data sets and in locked cabinets in locked rooms at UF with access limited to a small 
number of study personnel. All clinical and other records have identifying names of participants and 
relatives removed. Electronic data will be password protected and stored in a database on a secure 
server that is also password protected, with no patient identifying information. No identifiable individual 
data are presented in scientific publications. Only research personnel will have access to this data. 
10.1.4 FUTURE USE OF STORED SPECIMENS AND DATA 
  
These data may be combined with those of future large RCTs. The data may also be disseminated in the 
format of seminar, abstract, peer-reviewed manuscript, and other forms. The remaining samples may be 
used for appropriate research upon approval, including the discovery of additional biomarkers. 
10.1.5 KEY ROLES AND STUDY GOVERNANCE 
Principal Investigator 
Medical Monitor 
Chengguo Xing 
Roberto Firpi 
Carol Mathews 
  
  
  
  
  
  
  
 
10.1.6 SAFETY OVERSIGHT 
  
The Data and Safety Monitoring Plan for this project will also include monitoring by an independent 
Data Safety Monitoring Board (DSMB), consisting of an anxiety disorders expert (Dr. Carr), a hepatologist 

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(Dr. Morelli), a statistician (Dr. Wu), and a pharmacologist (Dr. Law). These individuals will have no 
affiliation to the proposed study. The DSMB will review any serious adverse event that is reported within 
48 hours. They will also convene annually and at the end of the study to review all adverse events. 
Adverse events that are serious and unexpected will be immediately reported to the IRB, NIH, and FDA 
(if warranted). Non-serious unanticipated problems shall be described in annual reports to the IRB and 
NIH. The DSMB will review the adverse events and discuss any concerns regarding them with the 
Principal Investigators. 
  
Study progress and safety will be reviewed monthly (and more frequently if needed). Progress reports, 
including patient recruitment, retention/attrition, and AEs will be provided to the Independent 
Monitor(s) semi-annually. An Annual Report will be compiled and will include a list and summary of AEs. 
In addition, the Annual Report will address (1) whether AE rates are consistent with pre-study 
assumptions; (2) reason for dropouts from the study; (3) whether all participants met entry criteria; (4) 
whether continuation of the study is justified on the basis that additional data are needed to accomplish 
the stated aims of the study; and (5) conditions whereby the study might be terminated prematurely. 
The Annual Report will be sent to the Independent Monitor(s) and will be forwarded to the IRB and 
NCCIH, FDA, and sponsoring industry collaborator. The IRB and other applicable recipients will review 
progress of this study on an annual basis. 
10.1.7 CLINICAL MONITORING 
  
The study team will generate Study Reports for the Independent Monitor and will provide information 
on the following study parameters: liver function, serious adverse events, and biomarker data. 
  
Study Report tables will be generated only from aggregate (not by group assignment) baseline and 
aggregate safety data for the study population. 
  
10.1.8 QUALITY ASSURANCE AND QUALITY CONTROL 
  
The site SC will ensure that all study personnel have completed all required institution-specific and 
protocol-specific trainings and that these trainings are documented appropriately on the Training Log. 
The site SC will also ensure that new personnel are appropriately documented on the Delegation of 
Responsibilities Log (DOR). While training should be completed and documented in real time, the Lead 
SC will verify that all training is current and appropriately documented. All study staff will complete CITI 
or NIH Human Subjects training prior to commencement of study. The investigators are responsible for 
ensuring the accuracy, completeness, legibility, and timeliness of the data reported. All source 
documents should be completed in a neat, legible manner to ensure accurate interpretation of data. The 
investigators will maintain adequate case histories of study subjects, including accurate case report 
forms (CRFs), and source documentation. All data will be entered into a REDCap (Research Electronic 
Data Capture) database developed for this project. REDCap is a secure, HIPAA-compliant web-based 
application designed to support traditional case report form data capture. Data will be exported into a 

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SAS data set for analysis. Data integrity will be evaluated using descriptive statistics (e.g., means, 
standard deviations, frequencies, percent, range) appropriate for measurement levels. Checks for 
implausible or out-of-range values, distributional forms, and missingness will be performed. Data 
transformations (e.g., Box-Cox family of transforms) and/or cross product terms will be incorporated, if 
required, based on evaluation of tenability of statistical model assumptions and model fit to the data. All 
analyses will be conducted using SAS version 9.4 or later. 
10.1.9.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES 
  
Data collection and accurate documentation are the responsibility of the study staff under the 
supervision of the investigator. All source documents and laboratory reports must be reviewed by the 
study team and data entry staff, who will ensure that they are accurate and complete. Unanticipated 
problems and adverse events must be reviewed by the investigator or designee. 
10.1.9.2 STUDY RECORDS RETENTION 
  
During this study we will follow NIH, UF IRB, and FDA regulations on study record retention. Should the 
retention durations differ, we will recognize the longer duration for record retention. 
10.1.10 PROTOCOL DEVIATIONS 
  
All protocol deviation reporting will follow NIH and UF IRB guidelines. 
10.1.11 PUBLICATION AND DATA SHARING POLICY 
  
Sharing of data generated by this project is an essential part of our proposed activities and will be 
carried out in several different ways. We will publish the results of our work in appropriate psychiatric 
and pharmacological journals. After the publication of the results of the study, clinical data (without 
identifiers) will be made available to other investigators, if requested. As required by the IRB at UF, 
participants in our study have the option to choose whether or not they agree to allow their data to be 
shared with other investigators. In our experience, the vast majority of participants agree to have their 
information shared with other investigators who are interested in studying neuropsychiatric disorders. 
We also welcome collaboration with others to further explore kava’s clinical potential, its active 
ingredient(s) and detailed mechanism of action. 
  
Our plan includes the following: 
• 
Presentations at scientific meetings 
o 
From the projects, it is expected that approximately two to three presentations at scientific 
meetings would be appropriate in the field of anxiety, biomarker or pharmacokinetics. 
• 
Peer-reviewed publications 

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o 
The research results will be prepared for peer-reviewed publication. It is expected that the 
results from the proposed studies will be the basis for 2 – 4 manuscripts in the R61 phase, 
including 1) pharmacokinetic characterization of kava and its major ingredients; 2) biomarker 
changes in response to kava treatment and other clinical results. 
• 
Protocol sharing 
o 
We agree to share our experimental protocols and data with other researchers who are PIs and 
co-PIs of NIH grants. The sharing can be arranged through the following approaches: 1) on-line 
data base with a password that can be released to other researchers through the discussion with 
the program director; and 2) teleconference with other researchers through the arrangement of 
the program director. 
• 
Department websites 
o 
Both multi-PI’s department maintain departmental websites that have “News” section and 
websites for individual faculty. The general clinical trial information will be posted both at the 
“News” site and the multi-PI’s individual faculty website that further detailed information may be 
requested from the multi-PI. 
• 
Clinicaltrials.gov 
o 
The trial will be registered at clinicaltrials.gov and will be updated as the trial proceeds. 
10.1.12 CONFLICT OF INTEREST POLICY 
  
During this study we will follow the NIH policy pertaining to any current or possible conflicts of interest. 
10.2 ADDITIONAL CONSIDERATIONS 
None 
10.3 ABBREVIATIONS 
AE 
Adverse Event 
ANCOVA Analysis of Covariance 
CFR 
Code of Federal Regulations 
CLIA 
Clinical Laboratory Improvement Amendments 
CMP 
Clinical Monitoring Plan 
COC 
Certificate of Confidentiality 
CONSORT Consolidated Standards of Reporting Trials 
CRF 
Case Report Form 
DCC 
Data Coordinating Center 
DHHS 
Department of Health and Human Services 
DSMB 
Data Safety Monitoring Board 
DRE 
Disease-Related Event 

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EC 
Ethics Committee 
eCRF 
Electronic Case Report Forms 
FDA 
Food and Drug Administration 
FDAAA 
Food and Drug Administration Amendments Act of 2007 
FFR 
Federal Financial Report 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practices 
GMP 
Good Manufacturing Practices 
GWAS 
Genome-Wide Association Studies 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
ICH 
International Conference on Harmonisation 
ICMJE 
International Committee of Medical Journal Editors 
IDE 
Investigational Device Exemption 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISM 
Independent Safety Monitor 
ISO 
International Organization for Standardization 
ITT 
Intention-To-Treat 
LSMEANS Least-squares Means 
MedDRA Medical Dictionary for Regulatory Activities 
MOP 
Manual of Procedures 
MSDS 
Material Safety Data Sheet 
NCT 
National Clinical Trial 
NIH 
National Institutes of Health 
NIH IC 
NIH Institute or Center 
OHRP 
Office for Human Research Protections 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SMC 
Safety Monitoring Committee 
SOA 
Schedule of Activities 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
UP 
Unanticipated Problem 
US 
United States 
 
 

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10.4 PROTOCOL AMENDMENT HISTORY 
Version 
Date 
Description of Change  
Brief Rationale 
 3 
 03/02/2021 
 Added CYP2D6 testing to the 
study description and schedule of 
activities. 
 This was already included 
in other sections, but we 
wanted to make sure it was 
included in every relevant 
section. 
 4 
 03/30/2021 
Corrected the discrepancies 
between the schema and SOA. 
There should be no 
discrepancies so that 
everyone is on the same 
page.  
 5 
04/21/2021 
Corrected exclusion/inclusion 
criteria to reflect that we are 
doing the HAM-A during 
screening and not at baseline. 
Also corrected overall design to 
reflect that participants will be 
coming in for their week one visit 
on day 7, not day 8. 
There is no point in doing 
the HAM-A at baseline if we 
already completed it during 
the screening process. 
Participants will be coming 
in on day 7 because the 
sample for pharmacokinetic 
testing must be taken on the 
last day of their medication 
dosing. 
 6 
 3/31/2022 
Change in MADRS exclusionary 
criteria to reflect correct scoring 
of mild, moderate, and severe 
classification.  
 Previous scoring was not 
consistent with the scales 
scoring guidelines for mild, 
moderate, and severe 
symptoms of depression. 
Exclusion was changes to 
>20 to only exclude 
moderate and severe cases of 
depression as mild does not 
indicate need for exclusion 
in this study. 
 7 
10/4/2022 
Change in exclusion criteria to 
remove language that excludes 
those who are taking 
psychotropic medication to 
include them as long as they have 
been on a stable dose for 6 weeks 
at the baseline visit 
During screening for the 
study many have been 
excluded who were on stable 
medication for anxiety. 
However, we are finding that 
they were still experiencing 
high levels of anxiety. This 
change will help to evaluate 
Kava as an adjunct therapy 
and does not affect the aims 
of the study or cause 
additional risk to study 
participants. 

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11 REFERENCES