A Randomized Open-label Trial of Deprescribing Proton Pump Inhibitors to Reduce the Risk of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt Creation
Phase: PHASE1
Conditions: Hepatic Encephalopathy
Sponsor: Duke University

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A randomized open-label trial of deprescribing proton pump inhibitors to reduce the risk 
of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation 
 
Protocol Identifying Number: Pro00108517 
Principal Investigator: James Ronald, MD PhD 
Funded by: Duke Radiology Putman Seed Fund 
Draft Number: v.1.0 
March 29, 2021 
 
 

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Table of Contents 
List of Abbreviations……………………………………………………………………………………… 
Statement of Compliance……………………………………………………………………………….. 
Protocol Summary……………………………………………………………………………………….. 
Schematic of Study Design……………………………………………………………………………… 
1 
Key Roles…………………………………………………………………………….…………… 
2 
Introduction: Background Information and Scientific Rationale………………..……………. 
 
2.1 
Background Information…………………………………………………..…………….. 
 
2.2  
Rationale…………………………………………………………………..……………… 
 
2.3 
Potential Risks and Benefits…………………………………………..………………... 
 
 
2.3.1 Known Potential Risks………………………………………..………………… 
 
 
2.3.2 Known Potential Benefits…………………………………..…………………… 
3 
Objectives and Purpose…………………………………………………….……………………. 
4 
Study Design and Endpoints……………………………………………….……………………. 
 
4.1 
Description of the Study Design………………………………….…………………….. 
 
4.2 
Study Endpoints………………………………………………….………………………. 
4.2.1 Primary Endpoint…………………………….………………………………….. 
4.2.2 Secondary Endpoints…………………………………..……………………….. 
4.2.3 Exploratory Endpoints…...……………………………………………………… 
5 
Study Enrollment and Withdrawal………………………………………………………………. 
 
5.1 
Participant Inclusion Criteria……………………………………………………………. 
 
5.2 
Participant Exclusion Criteria…………………………………………………………… 
 
5.3 
Strategies for Recruitment and Retention…………………………………………….. 
 
5.4 
Participant Withdrawal or Termination………………………………………………… 
 
 
5.4.1 Reasons for Withdrawal or Termination………………………………………. 
 
 
5.4.2 Handling of Participant Withdrawals or Termination………………………… 

3 
 
 
5.5 
Premature Termination or Suspension of Study……………………………………… 
6 
Study Agent……………………………………………………………………………………….. 
7 
Study Procedures and Schedule………………………………………………………………... 
 
7.1 
Study Procedures/Evaluations…………………………………………………………. 
 
 
7.1.1 Study Specific Procedures……………………………………………………... 
7.1.2 Standard of Care Study Procedures...………………………………………… 
 
7.2 
Laboratory Procedures/Evaluations……………………………………………………. 
 
 
7.2.1 Clinical Laboratory Evaluations………………………………………………... 
 
 
7.2.2 Other Assays or Procedures…………………………………………………… 
 
 
7.2.3 Specimen Preparation, Handling, and Storage………………………………. 
 
 
7.2.4 Specimen Shipment…………………………………………………………….. 
 
7.3 
Study Schedule…………………………………………………………………………... 
 
7.4 
Justification for Sensitive Procedures………………………………………………….. 
 
7.5 
Concomitant Medications, Treatments, and Procedures……………………………. 
 
 
7.5.1 Precautionary Medications, Treatments, and Procedures………………….. 
 
7.6 
Prohibited Medications, Treatments, and Procedures……………………………….. 
 
7.7 
Prophylactic Medications, Treatments, and Procedures…………………………….. 
 
7.8 
Rescue Medications, Treatments, and Procedures………………………………….. 
 
7.9 
Participant Access to Study Intervention at Study Closure………………………….. 
8 
Assessment of Safety…………………………………………………………………………….. 
 
8.1 
Specification of Safety Parameters…………………………………………………….. 
 
 
8.1.1 Definition of Adverse Events (AE)……………………………………………... 
 
 
8.1.2 Definition of Serious Adverse Events (SAE)…………………………………. 
 
 
8.1.3 Definition of Unanticipated Problems (UP)…………………………………… 
 
8.2 
Classification of an Adverse Event…………………………………………………….. 
 
 
8.2.1 Severity of Event………………………………………………………………… 

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8.2.2 Relationship to Study Intervention.……………………………………………. 
 
 
8.2.3 Expectedness……………………………………………………………………. 
 
8.3 
Time Period and Frequency for Event Assessment and Follow-Up………………... 
 
8.4 
Reporting Procedures…………………………………………………………………… 
 
 
8.4.1 Adverse Event Reporting………………………………………………………. 
 
 
8.4.2 Serious Adverse Event Reporting……………………………………………... 
 
 
8.4.3 Unanticipated Problem Reporting……………………………………………... 
 
 
8.4.4 Events of Special Interest………………………………………………………. 
 
 
8.4.5 Reporting of Pregnancy………………………………………………………… 
 
8.5 
Study Halting Rules……………………………………………………………………… 
 
8.6 
Safety Oversight………………………………………………………………………….. 
9 
Clinical Monitoring………………………………………………………………………………… 
10 
Statistical Considerations………………………………………………………………………… 
 
10.1 
Statistical and Analytical Plans…………………………………………………………. 
 
10.2 
Statistical Hypotheses…………………………………………………………………… 
 
10.3 
Analysis Datasets………………………………………………………………………… 
 
10.4 
Description of Statistical Methods……………………………………………………… 
 
 
10.4.1 General Approach……………………………………………………………….. 
 
 
10.4.2 Analysis of the Primary Endpoint…………...…………………………………. 
 
 
10.4.3 Analysis of the Secondary and Exploratory Endpoints…………...…………. 
 
 
10.4.4 Safety Analyses………………………………………………………………….. 
 
 
10.4.5 Adherence and Retention Analyses…………………………………………… 
 
 
10.4.6 Baseline Descriptive Statistics…………………………………………………. 
 
 
10.4.7 Planned Interim Analyses………………………………………………………. 
 
 
10.4.8 Additional Sub-Group Analyses……………………………………………….. 
 
 
10.4.9 Multiple Comparison/Multiplicity……………………………………………….. 

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10.4.10 Tabulation of Individual Response Data…………………………………….. 
 
 
10.4.11 Exploratory Analyses…………………………………………………………... 
 
10.5 
Sample Size………………………………………………………………………………. 
 
10.6 
Measures to Minimize Bias……………………………………………………………… 
10.6.1 Enrollment/ Randomization/ Masking Procedures…………………………… 
10.6.2 Evaluation of Success of Blinding................................................................ 
10.6.3 Breaking the Study Blind/Participant Code…………………………………… 
11 
Source Documents and Access to Source Data/Documents………………………………… 
12 
Quality Assurance and Quality Control…………………………………………………………. 
13 
Ethics/Protection of Human Subjects…………………………………………………………… 
13.1 
Ethical Standard………………………………………………………………………….. 
13.2 
Institutional Review Board………………………………………………………………. 
13.3 
Informed Consent Process……………………………………………………………… 
13.3.1 Consent/Assent and Other Documents Provided to Participants…............. 
13.3.2 Consent Procedures and Documentation…………………………………….. 
13.4 
Participant and Data Confidentiality……………………………………………………. 
13.4.1 Research Use of Stored Human Samples, Specimens or Data……………. 
13.5 
Future Use of Stored Specimens………………………………………………………. 
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Data Handling and Record Keeping……………………………………………………………. 
14.1 
Data Collection and Management Responsibilities…………………………………... 
14.2 
Study Records Retention………………………………………………………………... 
14.3 
Protocol Deviations………………………………………………………………………. 
14.4 
Publication and Data Sharing Policy…………………………………………………… 
15 
Study Administration……………………………………………………………………………… 
 
15.1 
Study Leadership………………………………………………………………………… 
16 
Conflict of Interest Policy………………………………………………………………………… 

6 
 
17 
Literature References……………………………………………………………………………. 

7 
 
List of Abbreviations 
AE 
 
Adverse Event 
CFR 
 
Code of Federal Regulations 
CRC 
 
Clinical Research Coordinator 
CLDQ  
Chronic Liver Disease Questionnaire 
CRF 
 
Case Report Form 
GERD  
Gastroesophageal Reflux Disease 
GI 
 
Gastrointestinal 
HE 
 
Hepatic Encephalopathy 
HIPAA  
Health Insurance Portability and Accountability Act 
ICH 
 
International Conference on Harmonization 
IR 
 
Interventional Radiology 
IRB 
 
Institutional Review Board 
ITT 
 
Intention-to-Treat 
MHE  
Minimal Hepatic Encephalopathy 
PACE  
Protected Analytics Computing Environment 
PHES  
Psychometric Hepatic Encephalopathy Score 
PI 
 
Principal Investigator 
PPI 
 
Proton Pump Inhibitor 
QOL 
 
Quality of Life 
QOLRAD 
Quality of Life in Reflux and Dyspepsia 
SAE 
 
Serious Adverse Event 
TIPS  
Transjugular Intrahepatic Portosystemic Shunt 
UP 
 
Unanticipated Problem 
 

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Statement of Compliance 
The trial will be conducted in accordance with the International Conference on Harmonization 
(ICH), the Code of Federal Regulations on the Protection of Human Subjects (45 CFR Part 46), 
and the Putman Seed Fund Terms of Award. The Principal Investigator will assure that no 
deviation from, or changes to the protocol will take place without prior agreement from the 
sponsor and documented approval from the Institutional Review Board (IRB), 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 Training. 
I agree to ensure that all staff members involved in the conduct of this study are informed about 
their obligations in meeting the above commitments. 
Principal Investigator (PI): 
 
Print/Type Name 
 
Signed: 
 
 
 
Date:  
 
 
 

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Protocol Summary 
Title: A randomized open-label trial of deprescribing proton pump inhibitors to reduce the risk of 
hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation. 
Precis: A total of 40 patients taking proton pump inhibitors (PPIs) who undergo transjugular 
intrahepatic portosystemic shunt (TIPS) creation as part of routine clinical care will be 
randomized in 1:1 fashion to either continue or discontinue their PPIs to determine whether 
these commonly used gastric acid suppressing agents increase risk of post-TIPS hepatic 
encephalopathy (HE). Patients will be assessed for symptoms of minimal HE (MHE), using the 
established psychometric hepatic encephalopathy score (PHES) battery of tests. MHE 
assessment will be conducted at two timepoints: at baseline prior to randomization and TIPS 
creation and approximately 4 weeks after randomization and TIPS creation. Stool samples will 
also be collected at both timepoints to allow characterization of the gastrointestinal (GI) tract 
microbiome using 16S rRNA sequencing. The pre to post-TIPS change in PHES scores will be 
compared between patients randomized to continue versus discontinue their PPIs. Quality of life 
(QOL) will also be assessed. Changes in the GI tract microbiome will be analyzed to determine 
whether this represents a potential biological mechanism linking PPI use with post-TIPS HE. 
Objectives: The primary objective is to determine whether discontinuation of PPIs reduces the 
risk of post-TIPS HE. Additional secondary objectives will include a comparison of cirrhosis-
specific and gastroesophageal reflux disease-specific QOL in the PPI continuation and 
discontinuation groups. An exploratory objective is to determine whether PPI induced changes 
in the GI tract microbiome represent a potential biological mechanism mediating PPI-induced 
risk of post-TIPS HE.  
Endpoints: Change in PHES pre to post-TIPS by intention-to-treat (ITT) (primary endpoint). Per-
protocol change in PHES; change in Chronic Liver Disease Questionnaire (CLDQ) and Quality 
of Life in Reflux and Dyspepsia (QOLRAD) scores pre to post-TIPS (secondary endpoints). 
Mediation analysis of GI tract bacterial taxon abundances as a potential link between PPI use 
and post-TIPS HE (exploratory endpoint). 
Population: 40 male and female Duke University Hospital patients over the age of 18 taking 
PPIs and undergoing TIPS placement as part of routine clinical care 
Phase: 2 
Number of Sites Enrolling Participants: 1 
Description of Study Intervention: Patients will be randomized to receive instructions to stop 
their existing PPI therapy (experimental/discontinuation/deprescribing arm) or to receive no 
specific instructions regarding PPI therapy (control/continuation arm) 
Study Duration: Approximately 24 months 
Participant Duration: Approximately 6-8 weeks 
 
 

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Schematic of Study Design 
 

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1 
Key Roles 
Principal Investigator: 
James Ronald, M.D. Ph.D. 
Duke University Medical Center 
2301 Erwin Road 
Durham, NC 27710 
Email: james.ronald@duke.edu 
Phone: 919-684-7299 
 
Lead Clinical Research Coordinator: 
Latonia Strader, C.R.C. 
Duke University Medical Center 
2301 Erwin Road 
Durham, NC 27710 
Email: latonia.strader@duke.edu 
Phone: 919-684-7810 
 
 

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2 
Introduction: Background Information and Scientific Rationale 
2.1 
Background Information 
Transjugular intrahepatic portosystemic shunt (TIPS) creation is an important minimally invasive 
procedure for treatment of complications resulting from cirrhosis and portal hypertension (1). 
Despite the beneficial effects of TIPS on ascites, gastrointestinal (GI) variceal bleeding risk, and 
in certain settings survival (2, 3), development of hepatic encephalopathy (HE) after TIPS can 
limit use of this procedure. HE is the most common complication of TIPS, occurring in 30% to 
60% of patients (4). Medical therapy for HE, though effective, can be expensive (5) and cause 
unpleasant side effects (6). Thus, in patients who experience post-TIPS HE, the reduction in 
quality of life (QOL) can negate other beneficial effects of TIPS (7, 8). Furthermore, the cost of 
HE related care is substantial, estimated at $5,370-$50,120 per patient per year (9). Therefore, 
additional strategies to reduce the risk of post-TIPS HE are needed. 
Recent retrospective studies have shown an association between proton pump inhibitor (PPI) 
use and HE in cirrhotic patients (10-20). Meta-analyses have supported a small but significantly 
increased risk of HE among cirrhotic patients taking PPIs, with pooled odds ratios ranging from 
1.50 to 2.58 (21-24). Among these studies, two focused exclusively on TIPS patients and 
described a more robust effect size in this high risk population with a greater than 3 fold 
increased risk of post-TIPS HE among PPI users (19, 20). In an independent, unpublished 
dataset of 86 TIPS patients, we have further replicated the dose dependent association 
between PPI use and post-TIPS HE (Figure 1). 
 
Figure 1: Patient timelines after TIPS showing intervals of PPI use and episodes of HE (left 
panel). Incidence rate ratios showing statistically significantly increased rates of post-TIPS HE 
with PPI use (middle panel) and with increasing PPI dosages (right panel). 
Biological mechanisms to account for the association between PPI use and HE remain 
unknown, but a potential pathway involves alterations in the GI tract microbiome. Randomized 
placebo controlled studies have demonstrated that PPI use leads to distinct changes in the 
microbiome (25). These changes, characterized by colonization of the lower GI tract by oral 
flora not destroyed in a more alkaline stomach, appear to be reversible upon discontinuation of 
PPIs (25, 26). Separate observational studies have characterized the differences in GI flora 

13 
 
between cirrhotic patients with HE versus those without HE (27). In patients with HE, reduced 
levels of Lachnospiraceae, Ruminococcaceae, and Clostridiales and increased 
Enterobacteriaceae and Streptococcaeae closely mirror the changes caused by PPI use (25, 
27). Thus, given the concordant changes in the lower GI tract microbiome seen with PPI use 
and in patients with HE, these bacterial taxa could play a role in mediating HE. However, other 
mechanisms, such as a simple effect of pH, are also plausible. Lactulose, long established as 
an effective treatment for HE, is a colonic acidifying agent (28). In a reduced pH environment in 
the colon, ammonia is protonated to the less well absorbed ammonium ion, which is thus 
excreted (28). By raising luminal pH, PPIs may counteract this process. 
PPIs are among the most commonly used medications, but a Cochrane review has reported 
that 25% to 70% of patients may be prescribed a PPI inappropriately (29). Among TIPS 
patients, 60% to 75% take PPIs (19, 20). While short courses of PPIs are indicated for ulcer 
disease (30, 31) and possibly for prevention of esophageal variceal band ligation ulcers (32), 
PPIs do not appear in practice guidelines for prevention and management of portal hypertensive 
bleeding in cirrhotic patients (33). Thus, discontinuation of inessential PPI therapy in cirrhotic 
patients undergoing TIPS creation may be a simple and cost effective intervention to reduce the 
risk of post-TIPS HE. 
Since the link between PPI use and HE is based solely on retrospective, observational data and 
because biological mechanisms remain unexplored, this protocol proposes a prospective, 
randomized study design to more definitively support or refute a role for PPI use as a risk factor 
for HE. Such a study design would more clearly determine whether discontinuation of PPI 
therapy can reduce the risk of post-TIPS HE and may also provide mechanistic insights into the 
interplay between upper GI tract pH, the GI tract microbiome, and HE. 
2.2 
Rationale 
Rationale for a randomized trial 
The rationale for this proposed prospective, randomized deprescribing trial is that currently 
available retrospective data implicating PPI use in post-TIPS HE are inadequate to justify 
discontinuation of PPIs. This is based on three considerations. First and foremost, retrospective 
data are unable to support causal conclusions. Therefore, the observation that TIPS patients 
taking PPIs experience higher rates of post-TIPS does not imply that discontinuation of PPIs 
would reduce rates of HE in these patients. Second, a Cochrane review of randomized PPI 
deprescribing trials described increased rates of gastroesophageal reflux disease (GERD) 
symptoms in patients who stopped their PPIs (29). Therefore, even if PPI use is causally linked 
to increased risk of post-TIPS HE, the harmful effects from worsening GERD in patients 
discontinuing PPIs may outweigh the beneficial reduction in post-TIPS HE. Third, retrospective 
observational studies provide few insights into biological mechanisms. Therefore, even if 
discontinuation of PPIs was known to be beneficial, this narrow strategy would fail to advance 
the understanding of physiologic connections between upper GI tract pH, the GI tract 
microbiome, and HE. 
Rationale for microbiome analysis 

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In addition to better establishing causality and better assessing the potential benefits and risks 
of deprescribing PPIs to prevent HE, the proposed prospective, randomized study design will 
allow further analyses to dissect the role of the GI tract microbiome in HE. The proposed study 
seeks to further evaluate the role of the GI tract microbiome via statistical mediation analysis as 
illustrated in Figure 2 (34). Scenario A depicts a direct effect of PPIs on HE. Scenario B depicts 
simple mediation. The microbiome is considered a mediator if (1) PPIs are causally related to 
HE (i.e. c ≠ 0 in scenario A), (2) PPIs are causally related to microbiome change (i.e. a ≠ 0 in 
scenario B), and (3) the microbiome significantly predicts HE after controlling for PPI use (i.e. b 
≠ 0 in scenario B). Complete mediation is said to occur if c’ = 0 (i.e. the impact of PPI use on HE 
is driven entirely through changes in 
the microbiome), whereas partial 
mediation is said to occur if c’ ≠ 0 
(i.e. PPIs affect the risk of HE both 
through the microbiome but also 
through other unexplained 
mechanisms, such as a direct effect 
of pH). Formal statistical methods 
for quantifying such relationships in 
mediation analysis have been 
described (34). 
Figure 2: Arrows demonstrate 
directionality of hypothesized causal 
chains linking PPI use, the 
microbiome, and post-TIPS HE.  
Rationale for a deprescribing trial 
This protocol proposes a randomized deprescribing study design, whereby patients who are 
already taking PPIs are randomized continue or discontinue their PPI. Because currently 
available retrospective data suggest PPIs may increase risk of HE, it would be potentially 
unethical to administer PPIs to patients not already on these agents. In contrast, a deprescribing 
trial, where patients are randomized to continue or discontinue a potentially ineffective or 
harmful medication, can be considered in such circumstances (35). Such deprescribing trials 
are well accepted in the field of geriatrics to combat polypharmacy and reduce pill burden, and 
PPIs have been the focus of multiple deprescribing trials (29). 
Rationale for studying TIPS patients 
This study focuses on deprescribing PPIs in the subset of cirrhotic patients undergoing TIPS 
creation. While a PPI deprescribing trial could be considered in cirrhotic patients in general or in 
other patient subsets, HE represents an acute clinical problem in TIPS patients and prevention 
and management of HE in this group remains a challenge (36). Retrospective studies have 
shown greater than 3 fold higher rates of HE associated with PPI use among TIPS patients (19, 
20), compared with 1.50 to 2.58 fold higher rates among cirrhotic patients in general (21-24). 

15 
 
Therefore, TIPS patients may be more likely to enjoy benefits related to reduction in HE that 
outweigh the risks of worsening GERD symptoms. 
2.3 
Potential Risks and Benefits 
2.3.1 Known Potential Risks 
Adverse reactions to abrupt discontinuation of PPIs have been characterized in a deprescribing 
trial conducted in 164 patients age 65 and older with a history of acute grade I-III esophagitis 
(37): 
● GERD: heartburn (54.8% in discontinuation arm vs 8.3% in PPI continuation arm), acid 
regurgitation (41.9% vs 12.5%) 
● Esophagitis documented by endoscopy: 69.6% vs 20.4% 
● Other rare adverse events (AEs) occurring in both arms: glossitis, headache, diarrhea, 
cardiac arrhythmia, urticaria, abdominal pain, impotence, dysuria, leukopenia, pruritus, 
dizziness  
 
Patients with gastric or duodenal ulcers, grade IV esophagitis (deep ulcer or esophagitis with 
complications) were excluded from this study. No ulcers, complications from esophagitis, or 
cases of grade IV esophagitis were reported in the discontinuation arm.  
 
2.3.2 Known Potential Benefits 
Potential benefits of PPI discontinuation include reduction in post-TIPS HE symptoms and 
decreased pill burden. 
 
3 
Objectives and Purpose 
 
Primary objective: To determine whether discontinuation of PPIs in patients undergoing TIPS 
creation reduces the risk of post-TIPS HE, as assessed by psychometric hepatic 
encephalopathy score (PHES) tests of minimal hepatic encephalopathy (MHE). 
Secondary objectives: To determine whether discontinuation of PPIs impacts chronic liver 
disease or GERD related QOL, as assessed by the Chronic Liver Disease Questionnaire 
(CLDQ) and Quality of Life in Reflux and Dyspepsia (QOLRAD) surveys. 
Exploratory objectives: To perform mediation analysis to determine whether the relationship 
between PPI use and post-TIPS HE is driven by changes in the GI tract microbiome, 
characterized through 16S rRNA sequencing of stool samples. 
4 
Study Design and Endpoints 
4.1 
Description of the Study Design 

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The proposed study is a single center randomized, open-label, deprescribing trial of PPI users 
undergoing TIPS creation. The study will involve two arms: the experimental/PPI discontinuation 
arm will be instructed to stop taking their PPIs prior to TIPS creation and the control/PPI 
continuation arm will receive no special instructions regarding their preexisting PPI medication. 
Patients will be assessed for MHE using the PHES test battery and for QOL using the CLDQ 
and QOLRAD surveys prior to randomization, and approximately 6-8 weeks later after TIPS 
creation. Stool samples will be collected at both time points. After the second and final 
assessment approximately 4 weeks after TIPS creation patients will have completed the study.  
4.2 
Study Endpoints 
4.2.1 Primary Endpoint 
The primary endpoint of this study will be an intention-to-treat (ITT) analysis of the change in 
PHES pre versus post-TIPS, compared between the PPI continuation and discontinuation arms. 
4.2.2 Secondary Endpoints 
Secondary endpoints of the study will include a per-protocol analysis of the change in PHES pre 
versus post-TIPS in the PPI continuation versus discontinuation arm; an ITT analysis of the 
change in CLDQ and QOLRAD scores pre versus post-TIPS in the PPI continuation versus 
discontinuation arms; episodes of overt HE, defined as a West-Haven score greater than or 
equal to 2 (e.g. gross disorientation, drowsiness, asterixis, and inappropriate behavior), on-
demand use of histamine H2 blockers or PPIs due to GERD symptoms, and AEs. 
4.2.3 Exploratory Endpoints 
As an exploratory endpoint, the GI tract microbiome will be characterized by 16S rRNA 
sequencing of stool samples at both time points. The change in bacterial taxon abundances pre 
versus post-TIPS will be estimated in each patient. Statistical mediation analysis will be used to 
explore whether PPI use impacts the risk of HE through changes in the GI tract microbiome 
(Figure 2). 
5 
Study Enrollment and Withdrawal 
5.1 
Participant Inclusion Criteria 
In order to be eligible to participate in this study, an individual must meet all of the following 
criteria: 
● Undergoing TIPS creation as part of routine clinical care 
● On PPIs therapy (at least 20 mg omeprazole equivalent daily) 
● Provision of signed and dated informed consent form by participant or legal 
representative 
● Stated willingness to comply with all study procedures and availability for the duration of 
the study 
● Male or female, age greater or equal to 18 
 

17 
 
Women and members of minority groups and their subpopulations will be offered the 
opportunity to participate in the study in accordance with the NIH Policy on Inclusion of Women 
and Minorities as Participants in Research Involving Human Subjects. The following PPI doses 
are considered equivalent: omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg, 
esomeprazole 20 mg, and dexlansoprazole 30 mg (38, 39). 
5.2 
Participant Exclusion Criteria 
An individual who meets any of the following criteria will be excluded from participation in this 
study: 
● Grade IV esophagitis or gastric or duodenal ulcer 
● Recent endoscopic esophageal variceal band ligation necessitating PPI therapy for 
prevention of banding ulcer 
● Zollinger-Ellison syndrome 
● Active Helicobacter pylori infection 
● Pregnancy 
5.3 
Strategies for Recruitment and Retention 
Potential patients will be identified by the Interventional Radiology (IR) clinical team at the time 
of referral for TIPS creation. At the time of referral for TIPS, patients will be screened for 
eligibility and exclusion criteria. Potential study candidates will be contacted by the IR team and 
the study will be described to the patient by the treating IR physician. Patients who are 
potentially interested in participating will then have the opportunity to undergo a formal written 
informed consent discussion at the time of the pre-TIPS IR clinic visit. No compensation will be 
provided for study participation.  
5.4 
Participant Withdrawal or Termination 
5.4.1 Reasons for Withdrawal or Termination 
An investigator may terminate participation in the study if: 
● Any clinical AE, laboratory abnormality, or other medical condition or situation occurs 
such that continued participation in the study would not be in the best interest of the 
participant 
● The participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation. 
5.4.2 Handling of Participant Withdrawals or Termination 
Patients who withdraw consent prior to randomization will not have undergone any study related 
intervention. Therefore, replacement of these participants will be permitted. Any patients who 
undergo randomization and withdraw prior to completion of the study will be analyzed according 
to the principle of ITT. 
5.5 
Premature Termination or Suspension of Study 

18 
 
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. If the study is prematurely terminated or suspended, the PI will promptly 
inform the IRB and will provide the reason(s) for the termination or suspension. 
Circumstances that may warrant termination or suspension include, but are not limited to: 
● Determination of unexpected, significant, or unacceptable risk to participants 
● Demonstration of efficacy that would warrant stopping 
● Insufficient compliance to protocol requirements 
● Data that are not sufficiently complete and/or evaluable 
● Determination of futility 
Study may resume once concerns about safety, protocol compliance, data quality are 
addressed and satisfy the IRB. 
6 
Study Agent 
Patients will be randomized to receive instructions to stop their existing PPI therapy 
(experimental/discontinuation/deprescribing arm) or to receive no specific instructions regarding 
PPI therapy (control/continuation arm). Therefore, considerations related to storage, handling, 
formulation, and labeling of study agent are not applicable. 
7 
Study Procedures and Schedule 
7.1 
Study Procedures/Evaluations 
7.1.1 Study Specific Procedures 
The following will study specific procedures will occur: 
● Prior to randomization, all patients will undergo assessment of MHE, using the 
established PHES battery of pencil-and-paper tests (Figure 3), QOL assessments using 
the CLDQ and QOLRAD surveys, and will be provided with return-by-mail at home stool 
collection kits 
● Patients will be randomized to either receive instructions to immediately discontinue their 
PPI, or to receive no specific instructions regarding their PPI 
● Patients in the PPI discontinuation arm will receive intermittent phone call reminders 
encouraging them to refrain from PPI use, to attempt lifestyle interventions to counteract 
GERD symptoms (e.g. smoking cessation, avoiding late evening meals, and head-of-
the-bed elevation) (40), and to use on-demand over-the-counter histamine H2 blocker 
therapy for intolerable GERD symptoms 
● Approximately 4 weeks following TIPS creation, all patients will undergo reassessment 
of MHE and QOL and will be provided with return-by-mail at home stool collection kits 
● At the completion of the study, all patients will be invited to resume or discontinue PPI 
therapy at their discretion and upon discussion with their primary care, gastroenterology, 
and IR physicians  

19 
 
 
Figure 3: PHES tests from (41). 
7.1.2 Standard of Care Study Procedures 
The following occur as standard of care for all patients undergoing TIPS creation: 
● After receiving a referral TIPS creation, the treating IR physician reviews the patient’s 
electronic medical records including history, medications, allergies, physical examination 
and imaging findings, and laboratory tests to evaluate the patient’s candidacy for the 
procedure 
● All patients referred for TIPS creation undergo a pre procedure consultation with the 
treating IR physician 
● All TIPS procedures are performed under general anesthesia. Portal vein access is 
achieved using intracardiac echocardiography/intravascular ultrasound guidance. 
Controlled expansion covered Viatorr covered stent grafts are deployed and dilated to 
achieve a target reduction in the portosystemic pressure gradient of 50% or <12 mm Hg 
for varices and <8 mm Hg for ascites (1). Patients are admitted to the hospital following 
TIPS creation for post procedure observation.  
● Patients undergo routine follow up with the IR clinical team approximately 4 weeks after 
TIPS creation. 
7.2 
Laboratory Procedures/Evaluations 
7.2.1 Clinical Laboratory Evaluations 
Routine clinical laboratory evaluation prior to TIPS procedure includes assessment of a 
complete metabolic panel, complete blood count, and coagulation studies (prothrombin 
time/international normalized ratio). These laboratory evaluations are performed as part of 
standard of care for patients undergoing TIPS creation. No study specific clinical laboratory 
assessments are proposed. 

20 
 
7.2.2 Other Assays or Procedures 
Microbiome analyses from stool samples will be performed by Duke University core facilities 
according to established protocols. DNA extraction will be performed using the Qiagen 
PowerSoilPro DNA Kit. Polymerase chain reaction amplification of the V4 variable region of the 
16S rRNA gene will be performed following the Earth Microbiome Project protocol 
(http://www.earthmicrobiome.org/). DNA sequencing will be performed by the Duke Sequencing 
and Genomic Technologies shared resource on an Illumina MiSeq instrument. Sequence data 
will be analyzed by the Genomic Analysis & Bioinformatics Core.  
7.2.3 Specimen Preparation, Handling, and Storage 
Patients will be provided with commercially available at home stool DNA Genotek OMNIgene-
GUT collection kits (https://www.dnagenotek.com/US/products/collection-microbiome/omnigene-
gut-kit/OMR-200.100.html). Patient friendly instructions for use of this kit are available from the 
manufacturer and will be further explained to study participants by the CRC. Briefly, at home 
after stooling, patients use a small spatula provided in the kit to obtain a stool sample which is 
placed in a stabilizing collection tube. The tube is then placed in a bio-specimen bag. Fecal 
samples collected with the OMNIgene-GUT kit can be stored at room temperature for up to 60 
days.   
7.2.3 Specimen Shipment 
Patients will be supplied with a prepaid 2-way mailers shipping box with peelable adhesive strip 
for sample return. Custom labels are created for traceability.  
7.3 
Study Schedule 
7.3.1 Screening 
Patients referred to IR for TIPS creation are screened for procedure candidacy by the treating 
IR physician. At this time screening for study eligibility will also be performed. Patients deemed 
eligible for the study will be contacted by the IR clinical team to confirm ongoing PPI use and to 
introduce them to the study prior to the routine pre-TIPS IR clinic visit. Patients potentially 
interested in study participation will then be referred to the study team CRC. The CRC will then 
formally screen the patient for eligibility based on a review of the electronic medical record. In 
accordance with IRB and HIPAA regulations, no PHI will be recorded during this screening 
evaluation. 
7.3.2 Enrollment/Baseline 
At the time of the routine pre-TIPS IR clinic visit, patients who remain potentially interested in 
participating in the study will meet with the study team CRC and informed written consent will be 
obtained from subjects who elect to participate. Baseline MHE assessment via the PHES tests 
and QOL surveys will then be administered and home stool collection kits will be provided. 
7.3.3 Follow-Up 

21 
 
After enrollment and baseline assessments, open-label randomization will be performed. 
Patients randomized to the PPI discontinuation arm will be contacted via telephone and 
instructed to discontinue their PPI. These patients will receive a reminder telephone call 
approximately 1 week later. All patients will then undergo the TIPS procedure per routine 
standard of care. While inpatient after the TIPS procedure and 2 weeks later by telephone, 
patients in the PPI discontinuation arm will again be reminded to abstain from PPI use. Adverse 
events occurring within 30 days of TIPS creation will be recorded, in accordance with Society of 
Interventional Radiology guidelines (42). 
7.3.4 Final Study Visit 
The final study visit will occur at the routine 4 week post-TIPS follow up IR clinic visit. Final 
assessments of MHE and QOL will occur and the final home stool collection kits will be 
provided.  
7.3.5 Early Termination Visit 
Not applicable. 
7.3.6 Unscheduled Visit 
Unscheduled visits related to complications from the TIPS procedure may occur as needed, per 
routine standard of care. 
7.3.7 Schedule of Events Table 
Procedures Referra
l for 
TIPS 
(~Day -
14) 
Pre-
TIPS 
IR 
clinic 
visit 
(Day 
0) 
Post-
clinic 
phon
e call 
(Day 
1) 
PPI 
remind
er 
phone 
call 
(~Day 
7) 
TIPS 
perform
ed 
(~Day 
14) 
In 
person 
PPI 
remind
er  
(Day 
15) 
PPI 
reminde
r phone 
call 
 (~Day 
28) 
Post-TIPS 
IR clinic 
visit (~Day 
42) 
Screening 
by IR 
clinical 
team 
X 
 
 
 
 
 
 
 
Informed 
written 
consent 
 
X 
 
 
 
 
 
 
MHE 
assessmen
t  
 
X 
 
 
 
 
 
X 
QOL 
assessmen
t 
 
X 
 
 
 
 
 
X 
Stool 
sample 
 
X 
 
 
 
 
 
X 

22 
 
collection 
kit provided 
Randomiza
tion 
 
 
X 
 
 
 
 
 
Reminder 
to refrain 
from PPI 
use 
 
 
 
X 
 
X 
X 
 
TIPS 
procedure 
 
 
 
 
X 
 
 
 
 
7.4 
Justification for Sensitive Procedures 
Not applicable. 
7.5 
Concomitant Medications, Treatments, and Procedures 
All concomitant standard of care medications for post-TIPS HE (e.g. lactulose, rifaximin) 
deemed necessary by gastroenterology and IR physicians will be permitted. Use of such 
medications will be documented on case report forms (CRFs). 
For GERD symptoms related to discontinuation of PPIs, patients will be encouraged to 
undertake lifestyle interventions (e.g. smoking cessation, avoiding late evening meals, and 
head-of-the-bed elevation) (40). If lifestyle interventions are inadequate to control GERD 
symptoms, patients may use on-demand over-the-counter histamine H2 blocker therapy. On-
demand use of PPIs will be discouraged but permitted for refractory, intolerable GERD 
symptoms. Use of on-demand pharmacological agents will be recorded on the CRFs. 
7.5.1 Precautionary Medications, Treatments, and Procedures 
Not applicable. 
7.6 
Prohibited Medications, Treatments, and Procedures 
Not applicable. 
7.7 
Prophylactic Medications, Treatments, and Procedures 
Not applicable. 
7.8 
Rescue Medications, Treatments, and Procedures 
Not applicable. 
7.9 
Participant Access to Study Intervention at Study Closure 
After completion of the study patients will be informed that they may resume or discontinue their 
PPI based on their own preferences and in consultation with their primary care, 
gastroenterology, and IR physicians.  

23 
 
8 
Assessment of Safety 
8.1 
Specification of Safety Parameters 
Safety parameters included as secondary endpoints include episodes of overt HE and drug 
related AEs (see Section 4.2). 
8.1.1 Definition of Adverse Events (AE) 
Adverse event means any untoward medical occurrence associated with the use of an 
intervention in humans, whether or not considered intervention-related (21 CFR 312.32 (a)). 
8.1.2 Definition of Serious Adverse Events (SAE) 
An AE or suspected adverse reaction is considered “serious” if, in the view of the investigator, it 
results in any of the following outcomes: death, a life-threatening adverse event, prolongation of 
hospitalization, or a persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions. Important medical events that may not result in death, be life-
threatening, or result in prolongation of hospitalization may be considered serious when, based 
upon appropriate medical judgement, they may jeopardize the patient or subject and may 
require medical or surgical intervention to prevent on of the outcomes listed in this definition. 
Examples of such medical events include development of grade IV esophagitis, gastric or 
duodenal ulcers, or West-Haven grade 4 HE (e.g. comatose, unresponsive to pain, decorticate 
or decerebrate posturing). 
8.1.3 Definition of Unanticipated Problems (UP) 
Unanticipated problems involving risks to participants or others 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 study documents, such as the IRB-approved 
research protocol and informed consent document; and (b) the characteristics of the 
participant populations 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 
● Suggest that the research places participants or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously known 
or recognized 
8.2 
Classification of an Adverse Event (AE) 
8.2.1 Severity of Event 
Adverse events will be graded according to the following guidelines to describe severity: 

24 
 
● Mild – Events require minimal or no treatment and do not interfere with the participant’s 
daily activities. 
● Moderate – Events result in a low level of inconvenience or concern with the therapeutic 
measures. Moderate events may cause some interference with functioning. 
● Severe – Events interrupt a participant’s usual daily activity and may require systemic 
drug therapy or other treatment. Severe events are usually potentially life-threatening or 
incapacitating. 
8.2.2 Relationship to Study Intervention 
For all collected AEs, the clinician who examines and evaluates the participant will determine 
the AE’s causality based on temporal relationship and his/her clinical judgement. The degree of 
certainty about causality will be graded using the categories below: 
● Definitely Related – There is clear evidence to suggest a causal relationship, and other 
possible contributing factors can be ruled out. The clinical event occurs in a plausible 
time relationship to the study intervention and cannot be explained by concurrent 
disease or other medications. 
● Probably Related – There is evidence to suggest a causal relationship, and the influence 
of other factors is unlikely. The clinical event occurs within a reasonable time after the 
study intervention, is unlikely to be attributed to concurrent disease or other medications. 
● Possibly Related – There is some evidence to suggest a causal relationship (e.g. the 
event occurred within a reasonable time after the study intervention). However, other 
factors may have contributed to the event (e.g. the participant’s clinical condition or other 
concomitant events). Although an AE may rate only as “possibly related” soon after 
discovery, it can be flagged as requiring more information and later be upgraded to 
“probably related” or “definitely related” as appropriate. 
● Unlikely to be Related – A clinical event whose temporal relationship to the study 
intervention makes a causal relationship improbable (e.g. the event did not occur within 
a reasonable time after the study intervention) and in which other medications or 
underlying disease provides plausible explanations (e.g. the participant’s clinical 
condition or other concomitant treatments). 
● Not Related – The AE is completely independent of study intervention, and/or evidence 
exists that the event is definitely related to another etiology. There must be an 
alternative, definitive etiology documented by the clinician. 
8.2.3 Expectedness 
The PI James Ronald, MD PhD will be responsible for determining whether an AE is expected 
or unexpected. An AE will be considered unexpected if the nature, severity, or frequency of the 
event is not consistent with the risk information previously described for the study intervention. 
8.3 
Time Period and Frequency for Event Assessment and Follow-Up 
The occurrence of an AE or SAE may come to the attention of study personnel during the study 
or during routine clinical monitoring following completion of the study. All AEs not meeting the 

25 
 
criteria for SAEs will be captured on the CRF. Information to be collected includes event 
description, time of onset, clinician’s assessment of severity, relationship to the study 
intervention (assessed only by those with the training and authority to make a diagnosis), and 
time of resolution/stabilization of the event. All AEs occurring while on study must be 
documented appropriately regardless of relationship. All AEs will be followed to adequate 
resolution. 
Any medical condition that is present at the time that the participant is screened will be 
considered as baseline and not reported as an AE. However, if the study participant’s condition 
deteriorates at any time during the study, it will be recorded as an AE. UPs will be recorded in 
the data collection system throughout the study. 
Changes in the severity of an AE will be documented to allow an assessment of the duration of 
the event at each level of severity to be performed. AEs characterized as intermittent require 
documentation of onset and duration of each episode. 
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. Events will be followed for outcome information until resolution or 
stabilization. 
8.4 
Reporting Procedures 
8.4.1 Adverse Event Reporting 
For any problem or AE requiring prompt reporting to the IRB but not meeting criteria for a SAE, 
within ten business days of the investigator becoming aware of the event, study personnel will 
send to the IRB a Safety Event submission in the eIRB. 
8.4.2 Serious Adverse Event Reporting 
The study clinician will complete a SAE Form within the following timelines: 
● Immediately (within 24 hours) upon learning of an unanticipated study-related death, 
study personnel will notify the IRB via e-mail or fax by providing a brief summary of the 
event. Then, within 1 week (five business days), study personnel will send to the IRB a 
Safety Event submission in the eIRB. 
● For a reportable SAE, study personnel will notify the IRB within five business days of the 
investigator becoming aware of the event. Study personnel will send a Safety Event 
submission in the eIRB. 
All SAEs will be followed until satisfactory resolution or until the investigator deems the event to 
be chronic or the adherence to be stable. Other supporting documentation of the event may be 
requested by the IRB and should be provided as soon as possible. 
8.4.3 Unanticipated Problem Reporting 

26 
 
Incidents or events that meet the criteria for UPs require the creation and completion of an UP 
report form. The PI will report UPs to the IRB. The UP report will include the following 
information: 
Protocol identifying information: protocol title and number, PI’s name, and the IRB project 
number; 
● A detailed description of the event, incident, experience, or outcome; 
● An explanation of the basis for determining that the event, incident, experience, or 
outcome represents an UP; 
● A description of any changes to the protocol or other corrective actions that have been 
taken or are proposed in response to the UP. 
To satisfy the requirement for prompt reporting, UPs will be reported using the following 
timeline: 
● UPs that are SAEs will be reported to the IRB within 1 week (5 business days) of the 
investigator becoming aware of the event. 
● Any other UP will be reported to the IRB within ten business days of the investigator 
becoming aware of the problem. 
8.4.4 Events of Special Interest 
Not applicable. 
8.4.5 Reporting of Pregnancy 
Not applicable. 
8.5 
Study Halting Rules 
The study intervention will be halted when three SAEs determined to be “definitely related” or 
“probably related” to PPI discontinuation are identified. 
8.6 
Safety Oversight 
Safety oversight will be under the direction of the PI who has appropriate expertise in TIPS 
procedures and in post procedure care. Safety oversight will occur continuously throughout the 
study. 
9 
Clinical Monitoring 
Study audits may be performed to ensure that the rights and well-being of human subjects are 
protected, that the reported trial data are accurate, complete, and verifiable, and that the 
conduct of the trial is in compliance with the currently approved protocol/amendment(s). Audits 
may be performed at any time at the discretion of the Duke University Health System IRB. 
10 
Statistical Considerations 

27 
 
10.1 
Statistical and Analytic Plans 
A separate statistical analysis plan will not be created. See below for detailed description of the 
statistical analysis plan. 
10.2 
Statistical Hypotheses 
 
Primary endpoint: The null hypothesis is that there is no difference between PPI continuation 
and discontinuation groups in the change in PHES pre versus post-TIPS. The alternative 
hypothesis is that there is a difference in the change in PHES pre versus post-TIPS in the PPI 
continuation and discontinuation groups: 
 
H0: µ+PPI = µ-PPI versus H1: µ+PPI ≠ µ-PPI 
 
Here µ+PPI represents the mean difference in PHES among patients in the PPI continuation arm, 
and µ-PPI represents the mean difference in PHES among patients in the PPI discontinuation 
arm.  
 
Secondary endpoints: 
 
Per-protocol evaluation of PPI deprescribing on post-TIPS HE: The null hypothesis is 
that there is no difference in the change in PHES among patients who adhered with PPI 
discontinuation instructions versus those who continued to use PPIs. 
 
ITT analysis of the change in CLDQ and QOLRAD scores: The null hypothesis is that 
there is no difference in the pre to post-TIPS change in CLDQ/QOLRAD scores among 
patients in the PPI discontinuation arm compared to patients in the PPI continuation arm. 
 
Episodes of overt HE: The null hypothesis is that there is no difference in the number of 
patients experiencing an episode of overt HE, defined as a West-Haven score greater 
than or equal to 2, in the PPI discontinuation arm compared to patients in the PPI 
continuation arm. 
 
On-demand requirement for acid suppression therapy: Descriptive statistics will be 
presented on the number of patients in the PPI discontinuation arm reporting on-demand 
use of histamine H2 blockers or PPIs. 
 
Adverse events: The null hypothesis is that there is no difference in the number of 
patients experiencing an AE in the PPI discontinuation arm compared to patients in the 
PPI continuation arm. 
 
Exploratory endpoints: 
For analyses exploring the role of the microbiome in mediating PPI induced post-TIPS HE, the 
null hypothesis is that b = 0 and that c = c’ (no mediation, see Figure 2). The alternative 
hypothesis is that b ≠ 0 and c’ < c (partial or complete mediation) (34). 
10.3 
Analysis Datasets 

28 
 
Analysis datasets will include all randomized patients (ITT analysis dataset) and patients who 
discontinued PPI therapy (defined as those who used on-demand histamine H2 blockers or 
PPIs less than twice weekly) versus those who continued PPIs therapy (defined as a daily dose 
of a least 20 mg omeprazole equivalent) (per-protocol analysis dataset). 
10.4 
Description of Statistical Methods 
10.4.1 General Approach 
● For descriptive statistics, such as patient demographics, means and ranges will be 
reported for continuous variables, whereas counts and percentages will be reported for 
categorical variables. 
● For inferential tests, differences in sample means will be assessed by two-sided 
unpaired T-tests, whereas differences in proportions will be assessed by two-sided 
Fisher’s exact tests. 
● For statistical mediation analysis, the non-parametric bootstrap method of Preacher and 
Hayes will be utilized (34).  
● For all inferential tests, a two-sided p-value less than 0.05 will be considered significant. 
10.4.2 Analysis of the Primary Endpoint 
For the primary outcome, statistical analysis will be conducted via a two-sided unpaired T-test of 
the hypothesis H0: µ+PPI = µ-PPI versus H1: µ+PPI ≠ µ-PPI. The estimate of µ+PPI, the mean difference 
in pre versus post-TIPS PHES in the PPI continuation arm, is derived from the sample mean: 
x̅ +PPI = 1/n ∑ (xpost-TIPS,i – xpre-TIPS,i) 
 
Here xpost-TIPS,i and xpre-TIPS,i are the PHES test scores 4 weeks after TIPS and 2 weeks before 
TIPS for ith subject in the PPI continuation arm. The estimate of µ-PPI is obtained in an identical 
fashion from patients in the PPI discontinuation arm. For the primary outcome analysis will be 
conducted according to the principle of ITT. 
 
10.4.3 Analysis of the Secondary and Exploratory Endpoints 
 
Per-protocol evaluation of PPI deprescribing on post-TIPS HE: Statistical analysis will be 
conducted via a two-sided unpaired T-test of the hypothesis H0: µ+PPI = µ-PPI versus H1: 
µ+PPI ≠ µ-PPI. Here µ+PPI and µ-PPI are the pre to post-TIPS change in PHES estimated 
from the sample means in the per-protocol dataset.  
 
ITT analysis of the change in CLDQ and QOLRAD scores: Statistical analysis will be 
conducted via a two-sided unpaired T-test of the hypothesis H0: µ+PPI = µ-PPI versus H1: 
µ+PPI ≠ µ-PPI. Here µ+PPI and µ-PPI are the pre to post-TIPS change in QOL scores on the 
respective surveys, estimated in the ITT dataset. 
 
Episodes of overt HE: Statistical analysis will be conducted via a two-sided Fisher’s 
exact test of the hypothesis H0: p+PPI = p-PPI versus H1: p+PPI ≠ p-PPI. Here p+PPI is the 
proportion of patients in the PPI continuation arm experiencing at least one episode of 

29 
 
greater than or equal to West-Haven grade 2 overt HE, and p-PPI is the corresponding 
proportion in the PPI discontinuation arm. 
 
On-demand requirement for acid suppression therapy: The proportion of patients in the 
PPI discontinuation arm needing on-demand histamine H2 blockers and PPIs will be 
reported. 
 
Adverse events: Statistical analysis will be conducted via a two-sided Fisher’s exact test 
of the hypothesis H0: p+PPI = p-PPI versus H1: p+PPI ≠ p-PPI. Here p+PPI is the proportion of 
patients in the PPI continuation arm experiencing at least AE, and p-PPI is the 
corresponding proportion in the PPI discontinuation arm. 
 
Exploratory analysis of the role of the GI tract microbiome in mediating PPI induced 
post-TIPS HE: Analysis will be conducted using statistical mediation analysis (34, 43). 
Criteria for assessing mediation are based on the following equations: 
Y = µ1 + c X + ε1 
Mj = µ2 + a X + ε2 
Y = µ3 + c’ X + b Mj + ε3 
Here Y is a vector where the ith element represents the pre to post-TIPS change in 
PHES for the ith patient. Mj is a vector describing the bacterial abundance for the jth taxon 
with the ith element representing the pre to post-TIPS change for the ith patient. X is an 
indicator vector where the ith element is 0 if the patient was randomized to the PPI 
discontinuation arm and 1 otherwise.  The µ and ε terms represent intercepts and error 
terms, respectively. Variable Mj is considered a mediator if the regression coefficients 
satisfy (1) c ≠ 0, (2) a ≠ 0, and (3) b ≠ 0. The non-parametric bootstrap test of Preacher 
and Hayes will be utilized to formally test these relationships (34). For microbiome 
studies, the mediating effects on HE are analyzed using relative abundances of bacterial 
taxa at the family and genus levels in a causal compositional mediation model (43). Due 
to the multiplicity of bacterial families and genera, the false discovery rate will be used 
for multiple testing correction (44). 
10.4.4 Safety Analyses 
Analyses of AEs will be performed as described above in Section 10.4.3. 
10.4.5 Adherence and Retention Analyses 
Analysis of on-demand acid suppression pharmacotherapy will be performed as described 
above in Section 10.4.3. No retention analyses are planned. 
10.4.6 Baseline Descriptive Statistics 
Baseline characteristics of the PPI continuation and discontinuation arms will be compared, 
including demographics, comorbidities, prior HE and anti-HE therapy, and TIPS procedure 
characteristics, using means and ranges for continuous variables and counts and percentages 
for categorical variables. Inferential tests to assess differences in baseline characteristics of the 

30 
 
groups will be performed using T-tests for continuous variables and Fisher’s exact tests for 
categorical variables. 
10.4.7 Planned Interim Analyses 
10.4.7.1 Safety Review 
As described above in Section 8.5 Study Halting Rules, if three SAEs related to PPI 
discontinuation are identified the study will be halted. 
10.4.7.2 Efficacy Review 
Not applicable. 
10.4.8 Additional Sub-Group Analysis 
Not applicable. 
10.4.9 Multiple Comparison/Multiplicity 
As described above in Section 10.4.3 the false discovery rate criteria of Benjamini and 
Hochberg (44) will be used for multiple testing correction in GI tract microbiome mediation 
analyses. 
10.4.10 Tabulation of Individual Response Data 
Not applicable. 
10.4.11 Exploratory Analyses 
Exploratory analyses related to the GI tract microbiome are described above in Section 10.4.3. 
These analyses are considered exploratory for the following reasons: 
 
To formally conclude mediation in the most rigorous sense, two additional criteria must 
be met in addition to those described above: (1) there can be no measurement error in 
the mediator variable Mj (2) Y cannot cause Mj. In this study measurement error is 
present in Mj, the change in abundance of the jth bacterial taxon pre to post-TIPS. In 
addition, the pre to post-TIPS change in PHES could potentially cause changes in the GI 
tract microbiome, for example in patients prescribed rifaximin therapy due to overt post-
TIPS HE. 
 
In mediation analysis, sample sizes of 50 patients are typically required to detect large 
effects, and medium size effects may require 100 patients (45). Therefore, the present 
study may lack power to detect medium size or small mediation effects. 
 
Because microbiome mediation analysis utilizes relative abundances of bacterial taxa at 
the family and genus levels (43) a multiple testing correction is required as described 
above. The necessity for multiple testing correction further reduces statistical power. 
10.5 
Sample Size 

31 
 
The target sample size is estimated to provide statistical power for the primary outcome, the pre 
to post-TIPS change in PHES compared between the PPI continuation and discontinuation 
groups. Compared to pre-TIPS, patients perform approximately 18%, 51%, 26%, and 48% 
worse post-TIPS on the number connection A/B, digit symbol, and block design tests, 
respectively (46). Assuming a similar degree of PHES worsening pre- versus post-TIPS among 
the PPI continuation arm, but that cessation of PPIs would improve HE such that test 
performance is unchanged in the discontinuation arm, the estimated power with 20 patients in 
each arm (40 patients total) would be 71% to 96%. The proposed sample size and study 
duration are commensurate with previous studies. For example, previous clinical trials of 
lactulose and rifaximin for minimal HE randomized 61 patients for 12 weeks (47) and 42 patients 
for 8 weeks (48). Approximately 30 patients undergo elective TIPS creation per year at Duke 
University Hospital, with approximately 60-75% of those taking PPIs. Thus, approximately 20 
patients per year are expected to be eligible for the study.  
10.6 
Measures to Minimize Bias 
10.6.1 Enrollment/Randomization/Masking Procedures 
Randomization codes will be generated and maintained by the PI. Randomization of subjects 
between the PPI continuation and discontinuation groups will be performed in a 1:1 fashion. The 
patient and treating IR physician will not be blinded (open-label design). The CRC performing 
MHE assessments via PHES tests and QOL assessments via the CLDQ and QOLRAD surveys 
will be blinded to patient assignment. 
10.6.2 Evaluation of Success of Blinding 
Not applicable. 
10.6.3 Breaking the Study Blind/Participant Code 
Not applicable. 
11 Source Documents and Access to Source Data/Documents 
Source data will include CRFs and the electronic medical record. CRFs will include Duke 
medical record number, a study subject identifier, PHES test results, QOL survey results, and 
patients’ reported use of on-demand histamine H2 blockers and PPIs. Raw source data and 
post-processed data from stool microbiome sequencing will be maintained in the Duke 
Protected Analytics Computing Environment (PACE).  
12 
Quality Assurance and Quality Control 
Quality control procedures will be implemented beginning with the data entry into CRFs. Any 
missing data or data anomalies will be reviewed by the PI and will be communicated to study 
members for clarification/resolution. The study team will provide direct access to all trial related 
source data/documents and reports for the purpose of monitoring and auditing by the IRB. 
13 
Ethics/Protection of Human Subjects 

32 
 
13.1 
Ethical Standard 
The investigator will ensure that this study is conducted in full conformity with Regulations for 
the Protection of Human Subjects of Research codified in 45 CFR Part 46, 21 CFR Part 50, 21 
CFR Part 56, and/or the ICH. 
13.2 
Institutional Review Board 
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 must be obtained before any participant is enrolled. 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 will be IRB approved; a determination will be made regarding 
whether previously consented participants need to be re-consented. 
13.3 
Informed Consent Process 
13.3.1 Consent/Assent and Other Informational Documents Provided to Participants 
Consent forms describing in detail the study intervention, study procedures, and risks are given 
to the participant and written documentation of informed consent is required prior to starting 
intervention/administering study product. The written informed consent form is submitted with 
this protocol to the IRB. 
13.3.2 Consent Procedures and Documentation 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in 
the study and continues throughout the individual’s study participation. Extensive discussion of 
risks and possible benefits of participation will be provided to the participants and their families. 
Consent forms will be IRB-approved and the participant will be asked to read and review the 
document. The investigator will explain the research study to the participant and answer any 
questions that may arise. All participants will receive a verbal explanation in terms suited to their 
comprehension of the purposes, procedures, and potential risks of the study and of their rights 
as research participants. Participants will have the opportunity to carefully review the written 
consent form and ask questions prior to signing. The participants should have the opportunity to 
discuss the study with their surrogates or think about it prior to agreeing to participate. The 
participant will sign the informed consent document prior to any procedures being done 
specifically for the study. The participants may withdraw consent at any time. A copy of the 
informed consent document will be given to the participants for their records. The rights and 
welfare of the participants will be protected by emphasizing to them that the quality of their 
medical care will not be adversely affected if they decline to participate in this study. 
13.4 
Participant and Data Confidentiality 
Participant confidentiality is strictly held in trust by the participating investigators and their staff. 
Therefore, the study protocol, documentation, data, and all other information generated will be 

33 
 
held in strict confidence. No information concerning the study or the data will be released to any 
unauthorized third party without prior written approval from the PI and IRB. 
Representatives of the IRB may inspect all documents and records required to be maintained by 
the investigator, including but not limited to, medical records (office, clinic, or hospital) and 
pharmacy records for the participants in this study. 
The study participant’s contact information will be securely stored for internal use during the 
study. At the end of the study, all records will continue to be kept in a secure location for as long 
a period as dictated by IRB and Institutional regulations. 
Study participant research data, which is for purposes of statistical analysis and scientific 
reporting, stored in locked file cabinets in the locked IR office suite and on a secured password 
protected computer in the PI’s locked office. 
13.4.1 Research Use of Stored Human Samples, Specimens or Data 
● Electronic data will be stored in PACE  
● Bacterial DNA isolated from stool samples will be stored in a -80C freezer in the locked 
IR laboratory of Dr. Charles Kim. 
 
13.5 
Future Use of Stored Specimens 
Future use of stored specimens will be require a separate application to the IRB for approval. 
14 
Data Handling and Record Keeping 
14.1 
Data Collection and Management Responsibilities 
Data collection is the responsibility of the study team and PI. The investigator is responsible for 
ensuring the accuracy, completeness, legibility, and timeliness of the data reported. 
All source documents will be completed in a neat, legible manner to ensure accurate 
interpretation of data. When making changes or corrections, the original entry will be crossed 
out with a single line, and initialed and dated. Erasing, overwriting, or correction fluid will not be 
permitted on original documents. 
Clinical data will be entered into the PI’s password protected computer in a locked office in the 
IR suite in Duke University Hospital. No data will be stored, transmitted, or shared with non-
study personnel, on non-secured or non-Duke University Health System computers.   
14.2 
Study Records Retention 
Study documents will be retained for a minimum of 6 years following completion of the study in 
accordance with IRB regulations. 
14.3 
Protocol Deviations 

34 
 
A protocol deviation is any noncompliance with the clinical trial protocol. The noncompliance 
may be either on the part of the participant, the investigator, or the study team. As a result of 
deviations, corrective actions are to be developed by the site and implemented promptly. 
These practices are consistent with ICH: 
● 4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3 
● 5.1 Quality Assurance and Quality Control, section 5.1.1 
● 5.20 Noncompliance, sections 5.20.1, and 5.20.2. 
It is the responsibility of the study team to use continuous vigilance to identify and report 
deviations within 10 working days of identification of the protocol deviation. Protocol deviations 
will be sent to the local IRB per their guidelines. 
14.4 
Publication and Data Sharing 
The International Committee of Medical Journal Editors (ICMJE) member journals have adopted 
a clinical trials registration policy as a condition for publication. In addition, in accordance of with 
Food and Drug Administration Amendments Act of 2007 which mandates that a "responsible 
party" (i.e., the PI) register and report results of certain "applicable clinical trials" (including trials 
of drugs and biologics: controlled, clinical investigations, other than Phase I investigations, of a 
product subject to FDA regulation), the trial will be registered with ClinicalTrials.gov and results 
reported. 
15 
Study Administration 
15.1 
Study Leadership 
The PI will govern the conduct of the study. The study will be subject to Duke University Health 
System IRB oversight. 
16 
Conflict of Interest Policy 
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed 
and managed. Furthermore, persons who have a perceived conflict of interest will be required to 
have such conflicts managed in a way that is appropriate to their participation in the trial. 
17 
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