The Effect of SGLT2 Inhibition on Adipose Tissue Inflammation and Endothelial Function Pilot
Phase: PHASE1
Conditions: Obesity, Pre-diabetes
Sponsor: Vanderbilt University Medical Center

The Effect of SGLT2 Inhibition on Adipose Inflammation and Endothelial Function 
05/25/2021
NCT # NCT04907214  

7/12/22  
 
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The Effect of SGLT2 Inhibition on Adipose Inflammation and 
Endothelial Function  
 
Mona Mashayekhi, MD, PhD 
Division of Diabetes, Endocrinology, and Metabolism 
Vanderbilt University Medical Center 
Nashville, TN 37221 
615-208-5037 
mona.mashayekhi@vumc.org 
 
 
Co-Investigators: 
Curtis L. Gabriel, MD, PhD 
Division of Gastroenterology, Hepatology and Nutrition 
Department of Medicine 
Vanderbilt University Medical Center 
Nashville, TN 37221 
curtis.l.gabriel@vumc.org 
 
Wayne J. English, MD 
Division of General Surgery 
Department of Surgery 
Vanderbilt University Medical Center 
Nashville, TN 37221 
wayne.english@vumc.org 
 
Matthew D. Spann, MD 
Division of General Surgery 
Department of Surgery 
Vanderbilt University Medical Center 
Nashville, TN 37221 
matthew.d.spann@vumc.org 
 
 

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Table of Contents: 
 
Study Schema 
1.0 
Background 
2.0 
Rationale and Specific Aims 
3.0 
Animal Studies and Previous Human Studies 
4.0 
Inclusion/Exclusion Criteria 
5.0 
Enrollment/Randomization 
6.0 
Study Procedures 
7.0 
Risks of Investigational Agents/Devices (side effects) 
8.0 
Reporting of Adverse Events or Unanticipated Problems involving Risk to 
Participants or Others 
9.0 
Study Withdrawal/Discontinuation 
10.0 
Statistical Considerations 
11.0 
Privacy/Confidentiality Issues 
12.0 
Follow-up and Record Retention 
 
 

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1.0 
Background 
Obesity is on the rise globally and is linked to cardiometabolic disease and inflammation. 
Obesity is a major risk factor for cardiovascular disease (CVD) and type 2 diabetes, with odds 
ratio for a pooled cardiometabolic outcome of 4.5 for class I obesity (body mass index (BMI) 
30.0-34.9 kg/m2) and 14.5 for class II/III obesity (BMI ≥35.0 kg/m2).1 Obesity is also associated 
with chronic systemic and adipose tissue (AT) inflammation.2-4 Inflammation has been linked 
with atherosclerosis and CVD development in a multi-factorial process involving endothelial cell 
activation, expression of adhesion molecules and recruitment of monocytes into the 
vasculature.5 Differentiation of these cells into macrophages and foam cells propagates the local 
inflammatory response and leads to development and progression of atherosclerotic plaques.6 
Thus, low-grade inflammation is thought to be a critical link between obesity and CVD 
development.7 
Macrophages and T cells are important in maintaining AT homeostasis and are 
dysregulated in obesity, contributing to systemic inflammation. A change from lean to 
obese AT is accompanied by a change in macrophage profile from homeostatic interleukin (IL)-
10-producing to inflammatory IL-6 and tumor necrosis factor (TNF) α-producing phenotype.2 
Furthermore, lean AT is characterized by anti-inflammatory IL-10-producing invariant natural 
killer T cells (iNKTs), IL-5-and IL-13-producing type 2 innate lymphoid cells (ILC2s), gamma-
delta T cells (γδT), and regulatory T cells (Tregs). With obesity, there is hypoxia associated with 
adipocyte hypertrophy and decreased blood supply leading to infiltration of pro-inflammatory 
CD8+ T cells, a decrease in iNKT, ILC2, and Tregs, and an increase in pro-inflammatory 
interferon (IFN)γ- and IL-17-producing T-helper (Th) 1 and Th17 cells.2,8 These changes not 
only affect local adipose inflammation, but contribute to adipocyte dysfunction, impaired lipid 
storage and handling, and systemic inflammation and metabolic disorders,9 representing a rich 
potential target for interventions.  
Importantly, while AT immune populations have been extensively characterized in obese 
animals, there are critical differences in AT immune cells in humans that require further 
investigation. For example, while AT macrophages in mice can be broadly classified into pro-
inflammatory M1 and homeostatic M2 phenotypes based on markers such as CD11c and 
CD206, in humans there are mixed inflammatory phenotypes with markers of both M1 and M2 
that require further investigation.10 Furthermore, cryopreserved samples from human clinical 
studies cannot be assessed for macrophage phenotypes by flow cytometry in the way that T 
cells can, as macrophages do not survive the process. Thus, microscopy on tissues with intact 
architecture is needed to evaluate human AT macrophages as proposed in this study (Aim 1b).  
Adipose depots contribute differentially to cardiometabolic disease in obesity. Visceral 
adipose tissue (VAT) that lines abdominal organs is approximately 10% of the fat in the human 
body, and VAT accumulation is a major risk factor for CVD and type 2 diabetes.11 Subcutaneous 
adipose tissue (SAT) that is beneath the skin is approximately 85% of the fat in the body. While 
some studies have demonstrated independent contributions of both VAT and SAT to insulin 
resistance,12 others have shown more significant contribution of VAT.13-15 In addition, there is 
indirect evidence that preferential accumulation of SAT during weight gain is associated with 
improved metabolic parameters, acting as a “metabolically safe” depot for excess fat 
deposition.9,16 While both VAT and SAT likely contribute to chronic inflammation of obesity, 
many of the cellular inflammatory features of obesity are more pronounced in VAT, including 
accumulation of pro-inflammatory macrophages,17-19 Th1 and Th17 cells.20 Studying VAT poses 
a special challenge in humans, as it is only accessible during abdominal surgery. SAT is more 
easily accessible either by biopsy or liposuction. Our study allows investigation of the 
inflammatory milieu in both VAT and SAT in relation to endothelial function, enabling us to better 
assess the contribution of each adipose depot to surrogate markers of CVD.  

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Current therapies to modulate inflammation in CVD leave a significant residual risk. 
Previous attempts to target inflammation in CVD have had mixed success.21 A randomized 
controlled trial (RCT) of colchicine in patients with stable coronary disease found a 67% 
reduction of cardiovascular (CV) events.22 Positive results were also reported with 
hydroxychloroquine in patients with rheumatoid arthritis,23 while methotrexate had mixed 
results.24,25 Finally, IL-1β antibody treatment in those with a prior myocardial infarction and high-
sensitivity C-reactive protein (hsCRP) above 2mg/L resulted in 15% reduction in CV events.26 
However, treatment with these drugs is associated with increased adverse events including 
infections and liver injury, and none are currently standard-of-care in the management of obese 
individuals at risk for or with established CVD. Thus, there remains a significant need for 
specific, targeted drugs that will reverse obesity-associated inflammation and prevent adverse 
cardiometabolic outcomes.  
SGLT2 inhibitors lower blood sugar and reduce major adverse CV outcomes. Sodium 
glucose co-transporter 2 (SGLT2) is a membrane protein found largely in the kidneys that is 
responsible for re-absorption of 90-97% of filtered glucose. SGLT2 inhibitors cause glucose 
excretion in the urine, reduce hemoglobin A1c (HbA1c) and induce weight loss of 2-3 kilograms 
(kg).27 In the EMPA-REG OUTCOME study, the SGLT2 inhibitor empagliflozin significantly 
decreased major adverse cardiovascular events (MACE) in diabetic patients with established 
CVD.28 Subsequent large CV outcome trials (CANVAS, DECLARE-TIMI 58, and CREDENCE) 
have now established a class effect for SGLT2 inhibitors in secondary prevention for MACE and 
primary and secondary prevention for heart failure and chronic kidney disease.29-33 Both the 
American Diabetes Association and American Heart Association (AHA) guidelines now 
recommend consideration of an SGLT2 inhibitor in those at risk for CVD.34,35  
SGLT2 inhibitors’ mechanism(s) of CV benefit are unclear. Trials testing strict glucose control or 
similar degrees of weight loss have failed to show equivalent CV benefits, suggesting SGLT2 
inhibition has independent effects on CV health. In addition, in the DAPA-HF study, patients with 
heart failure benefited from SGLT2 inhibition regardless of the presence or absence of diabetes, 
with decreased worsening heart failure or death from CV causes.32 Thus, given that weight loss 
or glucose control has not demonstrated the same CV benefit as the SGLT2 inhibitors, and that 
SGLT2 inhibition has demonstrated benefits in non-diabetics, one can hypothesize that the 
improved CV outcomes with these drugs is not due to decreasing blood glucose or weight loss 
alone. It has been proposed that SGLT2 inhibitors may improve CV outcomes by having an anti-
inflammatory function as discussed below.36  
SGLT2 inhibitors have been shown to improve indices of NAFLD. Non-alcoholic fatty liver 
disease (NAFLD) is a spectrum of diseases that ranges from simple steatosis to non-alcoholic 
steatohepatitis (NASH), an inflammatory condition characterized by elevation of liver enzymes 
and the development of hepatic fibrosis. Obesity and insulin resistance are major risk factors for 
development of NAFLD, and those with NAFLD have increased prevalence of comorbid 
CVD.37,38 There are currently no FDA-approved, NAFLD-specific treatments available. SGLT2 
inhibitor treatment has been shown to be associated with improvement in liver function in 
diabetic patients through an unknown mechanism.39,40 It is possible that this effect is mediated 
by the inflammatory milieu of the subcutaneous adipose tissue.  
 
 

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of diabetics decreased hsCRP, which correlated with improvements in insulin resistance.45 Of 
note, while some of the anti-inflammatory effects of SGLT2 may be modulated by weight loss 
especially in longer-term studies, it is unlikely that the small degree of weight loss of 2-3kg is 
sufficient to explain all the anti-inflammatory findings. In a study by Magkos et al., a careful 
evaluation of systemic and AT inflammation was performed after increasing degrees of weight 
loss in obese participants. This group found no improvement in inflammation after 5-11% weight 
loss, with trends in improvement starting to appear at 16% weight loss although not statistically 
significant.46 To date, no human studies have evaluated the effect of SGLT2 inhibition on the AT 
immune environment.  
SGLT2 inhibitors improve endothelial function and decrease progression of 
atherosclerosis in animals and may improve endothelial function in humans. SGLT2 
inhibitors decrease plaque burden and improve insulin resistance in ApoE knockout mice.47-49 
These animals also have improved inflammation as demonstrated by decreased pro-
inflammatory M1 macrophages in AT, and decreased circulating hsCRP, TNFα, IL-6 and 
monocyte chemoattractant protein (MCP)-1.47 In addition, endothelial function is improved in 
diabetic ApoE knockout mice after eight weeks of empagliflozin as measured by vascular 
response to acetylcholine.50 
The data in humans is less clear and complicated by study design and population differences. 
Several trials without comparator arms have shown an improvement in flow-mediated dilation 
(FMD) after 6-12 months of SGLT2 inhibitor therapy.51,52 FMD is a measure of endothelial 
function and surrogate marker of CVD. In a RCT of empagliflozin in type 2 diabetes, 
improvement in arterial stiffness was correlated with change in hsCRP after 6 weeks,53 
suggesting a link to inflammation. In contrast, a randomized open-label trial of patients with type 
2 diabetes and hypertension treated for four weeks with the SGLT2 inhibitor dapagliflozin or 
hydrochlorothiazide failed to find an improvement in FMD.54 In a blinded RCT, 12 weeks of 
treatment with dapagliflozin did not improve FMD as compared to placebo in patients with type 2 
diabetes and ischemic heart disease.55 Finally, Solini et al. evaluated the effect of acute 
treatment with dapagliflozin and showed that FMD improved after 2 days of treatment as 
compared with hydrochlorothiazide, with the caveat that this was not a randomized study 
design.56 Thus, while animal and human studies suggest an improvement in endothelial function 
with SGLT2 inhibitor therapy is likely, a randomized, double-blinded, controlled trial as proposed 
here will clarify the controversies in the literature, and simultaneous measurement of 
inflammation will assess the association between these factors during SGLT2 inhibition. 
SGLT2 inhibition is associated with improvements in NAFLD in humans and animals 
through unknown mechanisms. Several small clinical trials have shown that SGLT2 inhibitors 
improve indices of NAFLD, including reductions in hepatic steatosis and inflammation. An RCT 
of 50 diabetic patients showed that empagliflozin reduced liver fat and alanine transaminase 
(ALT) compared to untreated controls.57 Another RCT of 32 diabetic patients showed that 
luseogliflozin reduced hepatic fat relative to metformin, and despite higher visceral fat area.58 
Equal improvements in hepatic steatosis and ALT were observed in both arms of an RCT 
comparing ipragliflozin to pioglitazone.59 Similar results were shown in other single-arm clinical 
trials of SGLT2 inhibitors.60,61 A study in a mouse model of NAFLD showed reduced liver fat and 
liver inflammation in mice treated with canafligozin, and these improvements were associated 
with AT inflammation.62 The mechanisms by which SGLT2 inhibitors improve NAFLD have not 
been adequately explored in humans.  
 
 
 

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4.0 
Inclusion/Exclusion Criteria 
 
Phase 1: 
Inclusion criteria: 
1. Age 18 to 70 years old 
2. Impaired glucose tolerance (two-hour plasma glucose 140-199 mg/dL) or impaired 
fasting glucose (100-125mg/dL) or HbA1c 5.7-6.4% 
3. BMI ≥ 30 kg/M2 
4. The ability to provide informed consent  
Exclusion criteria:  
Criteria Related to Medical Diagnoses/Conditions/Treatments: 
1. Diabetes type 1 or type 2, as defined by a fasting plasma glucose of 126 mg/dL or 
greater, a two-hour plasma glucose of 200 mg/dL or greater, HbA1c ≥6.5%, or the use of 
anti-diabetic medication  
2. Pregnancy or breast-feeding. Women of child-bearing potential will be required to have 
undergone tubal ligation or to be using an oral contraceptive or barrier methods of birth 
control 
3. Cardiovascular disease such as myocardial infarction within six months prior to 
enrollment, presence of angina pectoris, significant arrhythmia, congestive heart failure 
(left ventricular hypertrophy acceptable), deep vein thrombosis, pulmonary embolism, 
second or third degree heart block, mitral valve stenosis, aortic stenosis or hypertrophic 
cardiomyopathy  
4. Presence of implanted cardiac defibrillator or pacemaker 
5. History of serious neurologic disease such as cerebral hemorrhage, stroke, or transient 
ischemic attack  
6. History of pancreatitis or pancreatic surgery 
7. History or presence of immunological or hematological disorders  
8. Clinically significant gastrointestinal impairment that could interfere with drug absorption  
9. History of advanced liver disease with cirrhosis 
10. Individuals with an eGFR<45 mL/min/1.73 m2, where eGFR is determined by the four-
variable Modification of Diet in Renal Disease (MDRD) equation, where serum creatinine 
is expressed in mg/dL and age in years: eGFR (mL/min/1.73m2)=186 • Scr-1.154 • age-
0.203 • (0.742 if female) 
11. Treatment with chronic systemic glucocorticoid therapy (more than 7 consecutive days in 
1 month) 
12. Treatment with anticoagulants  
13. Any underlying or acute disease requiring regular medication which could possibly pose 
a threat to the subject or make implementation of the protocol or interpretation of the 
study results difficult 
14. History of alcohol abuse (>14 per week for men and >7 per week for women) or illicit 
drug use 
15. Treatment with any investigational drug in the one month preceding the study 
16. Previous randomization in this trial  
17. Mental conditions rendering a subject unable to understand the nature, scope and 
possible consequences of the study  
18. Inability to comply with the protocol in the opinion of the principal investigator, e.g., 
uncooperative attitude, inability to return for follow-up visits, and unlikelihood of 
completing the study 

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studies.54,55 We expect that SGLT2 inhibition will improve FMD as measured in Aim 2, and that 
the relative change in AT inflammation will be associated with improvements in endothelial 
function.  
SGLT2 inhibition attenuates the development of hepatic steatosis and inflammation in a mouse 
model of NAFLD in spite of the accumulation of epididymal fat mass.62 These changes were 
associated with reduced expression of inflammatory genes in the epididymal fat pad. Multiple 
small clinical trials have also shown that SGLT2 inhibitors improve hepatic steatosis and 
markers of liver inflammation.39,40 We hypothesize that this is partly mediated by SGLT2-specific 
effects on adipose tissue, but this has not been adequately tested in humans. We expect that 
SGLT2 inhibition will improve NAFLD indices and TE-CAP imaging as measured in Aim 3, and 
that the relative change in AT inflammation will be associated with improvements in hepatic 
steatosis. 
Methods: 
Oral Glucose Tolerance Test: After an overnight fast, subjects will be given 75-g glucose by 
mouth. We will draw blood at 0, 30, 60, 90, and 120 min after administration of glucose for 
measurement of plasma glucose, insulin, and C-peptide.  
Vascular endothelial function (FMD): Measurement of endothelium-dependent and endothelium-
independent vasodilation will be performed using methods employed in multiple prior studies by 
our research team.67-70 Brachial artery diameter is measured using B-mode ultrasonography, 
and a simultaneous electrocardiographic signal is recorded and images are digitally acquired at 
end-diastole, synchronized to the R wave on the electrocardiogram. To assess endothelium-
dependent vasodilation, brachial artery diameter is measured under basal conditions and during 
reactive hyperemia. After a rest period, endothelium-independent vasodilation will be assessed 
by imaging the brachial artery under basal conditions and following the administration of 
sublingual nitroglycerin (0.4 mg). Acquisition and analysis of the stored images will be 
performed using software designed for this purpose by Medical Imaging Applications. The 
vessel wall lumen interface will be determined by derivative-based edge detection following 
identification of the region of the anterior and posterior walls by the investigator. The maximum 
diameter of the vessel will be determined and the percent change in diameter calculated. We 
have found that this technique yields an inter-observer variability of 0.05±0.16% and intra-
observer variability of 0±0.15%. 
Subcutaneous adipose harvest by liposuction: SAT will be obtained from the periumbilical area 
using a Tulip CellFriendlyTM GEMS closed syringe system for lipoaspiration. Approximately 5-10 
g of tissue is removed (~5.5-11 cc at a specific gravity of 0.918 for human fat). Immune cell 
extraction from the stromal vascular fraction will be performed using a gentleMACSTM 
Dissociator from Miltenyi Biotec followed by incubation with collagenase, mononuclear cell 
separation with Ficoll-Paque and cryopreservation for flow cytometry/sorting.  
PBMC harvest: PBMCs will be obtained through the peripheral IV into 3 EDTA tubes for total of 
60 milliliters, and transported at room temperature to the lab for processing. Cells will then be 
passed through a Ficoll-Paque barrier, washed with PBS, and stored in DMSO in a liquid 
nitrogen freezer for later analysis. 
Endothelial cell harvest: Endothelial cell harvest will be performed by passing a 0.018” sterile 
J- wire (Arrow International, PA) back and forth two to six cm beyond the tip of a venous catheter 
placed in a cubital vein. Approximately 1000-1500 ECs can be isolated after four passes of the 
wire. Cell viability is >90% with >90% staining positive for expected EC markers (nitric oxide 
synthase, vWF) without contamination by leukocytes or smooth muscle cells. 
TE-CAP: Liver elastography will be assessed using the FibroScan system by Echosens. All 

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scans will be performed at the Vanderbilt Digestive Diseases Clinic or the Clinical Research 
Center by one experienced, certified FibroScan technician. Participants will need to fast at least 
4 hours before the procedure. The participant’s abdomen will be exposed and will be placed 
supine with his or her right arm resting above his or her head during the procedure. A water-
soluble gel will be applied to the participant’s abdomen and a FibroScan probe will be placed 
over the intercostal space over the liver. Final results will be expressed as the median of 10 
successful measurements. Success will be defined as 10 captures with an interquartile range 
lower than 30% of the median kPa (fibrosis) and dB/m (steatosis). Patients with significant 
fibrosis defined as >8.0 kPa will be offered referral to a hepatologist for further evaluation. 
 
Laboratory Analyses: 
Clinical assays will be run in Vanderbilt CLIA-approved laboratories. Blood drawn for research 
assays will be centrifuged immediately at 4oC for 20 min, and plasma or serum will be divided 
into at least two aliquots, labeled, logged and stored separately at -80oC until sampling. 
Genotyping: DNA will be extracted from whole blood using the AutoPure LS extraction system 
(Qiagen, Valencia, CA, USA). Samples will be stored for future exploratory analyses. 
 
7.0 
Risks 
 
1. Insertion of venous catheters may cause bleeding, bruising, or infection. 
2. Frequent blood draws can cause anemia. 
3. During measurement of flow-mediated vasodilation, the administration of sublingual 
nitroglycerin can cause low blood pressure. Nitroglycerin may also cause severe 
headache. Patients will be monitored for this and the effects of nitroglycerin are 
transient. Patients will be asked to refrain from taking a PDE5 inhibitor at least one-week 
before the study day. 
4. Spending study days at the CRC can be inconvenient for subjects. 
5. Harvesting adipose tissue could cause pain, bleeding, or infection. We will use local 
lidocaine injection to numb the area and sterile technique. 
6. Harvesting endothelial cells from veins could cause pain, bleeding or infection, primarily 
from intravenous placement, as well as damage to the vein. We will use local lidocaine 
injection to numb the area and use sterile technique. We utilize a wire that has a soft 
rounded end to reduce any risk. We will utilize superficial veins. We will allow at least 
four weeks before repeating the procedure in the same vein.  
7. Pruritus or skin irritation may result from the vibration of the TE-CAP probe or the water-
soluble ultrasound gel needed for the procedure. 
8. Rare cases of ketoacidosis have been reported in postmarketing surveillance but only in 
those with type 1 or type 2 diabetes. We are studying an obese population with pre-
diabetes that is unlikely to develop this condition. We will advise patients to contact us 
immediately if they develop symptoms of nausea, vomiting, abdominal pain, malaise or 
shortness of breath so they can be evaluated. We will exclude those at increased risk for 
ketoacidosis including pancreatic insulin deficiency from any cause, caloric restriction 
and alcohol abuse.  
9. Empagliflozin causes intravascular volume contraction. We will screen patients for risk of 
symptomatic hypotension, which is more likely in presence of renal impairment, elderly, 
patients with low systolic blood pressure, and those on diuretics. Adverse reactions 
related to volume depletion occur in 0.3% of those on placebo and 0.3% of those on 
empagliflozin in pooled studies.  

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10. Empagliflozin can cause renal impairment from volume contraction, and there are 
postmarketing reports of acute kidney injury.  
11. Empagliflozin can increase incidence of urinary tract infections (17% on empagliflozin 
versus 16.6% on placebo in females, and 4.1% on empagliflozin versus 3.2% on 
placebo in males). We will exclude those with history of recurrent UTIs.  
12. Rare cases of urosepsis and pyelonephritis have been reported in post-marketing 
analysis. 
13. Empagliflozin increases the risk for genital mycotic infections, especially in those with 
history of chronic or recurrent infections. In females the rate is 6.4% in empagliflozin as 
compared with 1.5% in placebo, and in males 1.6% with empagliflozin as compared with 
0.4% in placebo. We will exclude uncircumcised men or men with history of balanitis, 
and women with history of severe vulvovaginitis or recurrent vulvovaginitis (>3) per year. 
14. Empagliflozin causes an increase in urination (0.8% in empagliflozin versus 0.4% in 
placebo) and increase in thirst.  
15. Necrotizing fasciitis of the perineum has been identified in post-marketing surveillance in 
patient with diabetes.  
16. Hypoglycemia can be observed with concomitant use of insulin and insulin 
secretagogues. We will study non-diabetic patients who are not on any medications.  
17. Empagliflozin can increase LDL-C.  
18. There may be unknown or unanticipated adverse effects.  
 
 
8.0 
Reporting of Adverse Events or Unanticipated Problems involving Risk to 
Participants or Others 
 
A Data and Safety Monitoring Committee (DSMC) will provide objective review of human safety 
and data quality. Committee members will be Dr. C. Michael Stein, Adriana Hung, and Tebeb 
Gebretsadik. Dr. Stein will chair the committee. All members hold a primary appointment outside 
the Division of Diabetes, Endocrinology and Metabolism. 
The DSMC will also receive quarterly reports of enrollment, protocol adherence, data quality, 
and adverse events (AE)s. The DSMC will review all serious AEs (SAEs), suspected 
unexpected serious adverse reactions (SUSARS), and serious adverse drug reactions 
(SADRs). Any SAE, SUSAR, or SADR will be reported to the DSMC, IRB, and FDA, if 
appropriate, as soon as possible, but not more than 7 days from the investigator’s notification of 
the event. Any pregnancy occurring during the trial would be reported similarly.  
Subjects will be questioned about AEs at each study visit. Any untoward medical event will be 
classified as an AE, regardless of its causal relationship with the study. Relationship to a study 
medication will be assessed as probably, possible or unlikely based on the United States 
Package Insert for the drug. An AE will be classified as serious if it a) results in death, b) is life-
threatening, c) requires inpatient hospitalization or prolongation of existing hospitalization, d) 
results in persistent or significant disability or incapacity, e) is a congenital anomaly or birth 
defect. Suspicion of transmission of infectious agents will also be considered an SAE. The 
DSMC may choose to become unblinded; however, it is expected that such unblinding would 
not occur without reasonable concern related either to patient safety or to data validity. 
Non-serious AEs and instances of noncompliance with the protocol will be reported at  
the time of annual review. 
 

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13.0 
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