Endothelial Facilitation in Alzheimer's Disease. An Open Label Pilot Study of the Sequential and Cumulative Effects of Simvastatin, L-Arginine, and Sapropterin (Kuvan) on Cerebral Blood Flow and Cognitive Function in Patients With Alzheimer's Disease.
Phase: PHASE2
Conditions: Alzheimer's Disease
Sponsor: University of Massachusetts, Worcester

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Title: Endothelial Facilitation in Alzheimer’s Disease; An open-label pilot 
study of the sequential and cumulative effects of Simvastatin, L-Arginine, 
and Sapropterin (Kuvan) on cerebral blood flow and cognitive function in 
patients with Alzheimer’s Disease 
 
NCT01439555 
 
Revised: June 11, 2017 
 
 

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Revised: June 11, 2017 
 
INSTRUCTIONS: 
1) 
Title 
Endothelial Facilitation in Alzheimer’s Disease; An open-label pilot 
study of the sequential and cumulative effects of Simvastatin, L-Arginine, 
and Sapropterin (Kuvan) on cerebral blood flow and cognitive function in 
patients with Alzheimer’s Disease. 
 
2) 
IRB Review History* 
N/A 
3) 
Objectives* 
Purpose and hypothesis:  The purpose of this study is to determine whether 
treatment of subjects who have mild Alzheimer’s disease or Mild Cognitive 
Impairment (MCI), using a combination of drugs that increase endothelial nitric 
oxide synthase (eNOS), can increase cerebral blood flow, and improve cognitive 
function. 
 
Alzheimer’s Disease (AD) is a degenerative disorder of unknown etiology, 
characterized by progressive dementia, and hallmark pathology at postmortem of 
senile plaques and neurofibrillary tangles in the brain. It may be caused by rare 
(3%) dominant genetic mutations (APP, Presenilin 1 and 2), occurring as an 
Early Onset Dominantly Inherited (EODI) form; but more commonly occurs as 
Late Onset Sporadic AD (LOSAD), which is sporadic, but may be associated with 
more common genetic risk factors (APOEe4). Age is by far the most important 
risk factor, however; and vascular risk factors (diabetes, hypertension, 
dyslipidemia) are strongly related to the incidence of AD. While much research 
has been devoted to the “amyloid hypothesis,” that beta amyloid (Aβ) formation is 
the underlying cause of AD, it remains uncertain whether the Aβ  is actually the 
cause of AD, or a secondary consequence, and a “marker” as AD develops. Aβ is 
found in brains during normal aging; and clinical trials of drugs that block the 
formation of Aβ, or remove it, have not produced a benefit; nor has the amount of 
brain Aβ - determined during life, or at post-mortem - been shown to relate to the 
severity of dementia.  
 
Decreased cerebral blood flow is characteristic of AD; and we and others 
have shown that brain microvascular endothelium is scanty and poorly stained 
immunohistochemically. We and others have shown that statin drugs reduce the 
incidence of AD in individuals treated with statins, independent of cholesterol 
levels. The microvascular endothelium is known to be a paracrine organ with 
important trophic secretory activity, critical to maintaining the normal function and 
growth of cells, including neurons, and the healthy maintenance of organs. 
Microvascular capillaries lie in direct proximity to every one of the hundred billion 
neurons in the brain, and we hypothesize that their endothelial trophic secretions, 
as well as blood supply to neurons, are critical to the survival and function of the 
brain.  

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The hypothesis being tested is that improving brain microvascular 
endothelial function will help to maintain the normal, healthy function of the brain, 
and avoid atrophic changes with advancing age that often result in cognitive 
decline and eventually may cause Alzheimer’s dementia. We propose continued 
study of an open label clinical trial consisting of a series of synergistic treatments 
that are known to improve endothelial function. The treatments will be used in 
subjects with early AD and MCI. 
 
Three drugs – all FDA approved – improve endothelial eNOS in a 
synergistic, interactive manner- simvastatin, L-Arginine, and sapropterin (Kuvan). 
As a surrogate measure of microvascular endothelial function, and efficacy of the 
treatment, we will measure cerebral blood flow (CBF) using MRI-based arterial 
spin labeling, and contrast perfusion imaging techniques; and will assess 
cognitive function, which should either improve (although more slowly), or 
evidence a decreased rate of cognitive decline over time, compared with the 
usual progression of AD.  
 
4) 
Background* 
 
At present, the etiology of LOSAD remains unknown (1-4). Characterized 
by gradual-onset, progressive dementia, its hallmark cerebral pathology is 
defined by neuritic plaques containing fragmented neuritic 
particles and β−amyloid (Aβ), and by neurofibrillary tangles (NFT), containing 
paired helical filaments comprised of hyperphosphorylated tau protein. Loss of 
synapses (5-7) and neurons (5, 7), and increasing cortical atrophy (8) underlie 
the declining cognitive function. These changes often, but not always, begin in 
the medial temporal lobe structures, including the entorhinal cortex and the 
hippocampal areas. While this pathology is indistinguishable from that seen in 
the rare, EODI AD, which appears to be caused by mutations of genes related 
to the formation of Aβ (3, 9) (as well as to Notch1 activation (9)), it is not clear 
whether Aβ, or its precursor protein (APP), have a primary causal role in the 
development of neural degeneration and dementia in EODI AD. The relation of 
amyloid to LOSAD is even less clear. As one indication of this uncertainty, 
therapeutic efforts to remove amyloid in humans (e.g., by immunologic means), 
or to interfere with its production by blockade of the key beta and gamma 
secretases that cleave Aβ from its parent protein –APP-, have so far been 
ineffective in modifying AD (10, 11); nor is the amount of Aβ imaged by PET 
scanning with Pittsburgh Compound B (C-PIB) clearly related to cognitive 
impairment (12). Despite the evidence that Aβ dimers can be toxic to synapses 
(13), there is increasing doubt regarding the hypothesized principal role of Aβ as 
the fundamental etiology of sporadic AD, suggesting that the accumulation of 
amyloid may be a downstream effect (14), or a marker of the underlying 
degenerative process.  
 
 
What then are the probable mechanisms of development of AD? The 
strongest risk factor for LOSAD, which comprises more than 95% of AD, is, by 
far, advancing age (2). The risk of developing AD doubles every 5 years after 
age 65 (15), with almost 50% of individuals showing significant cognitive 

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impairment by age 85. The annual incidence of AD at 85 is 20-30 times greater 
than at 65 (16). Other identified risk factors include the presence of an 
apolipoprotein Eε4 allele; and importantly, a number of vascular risk factors, 
which include hypertension, diabetes, and dyslipidemia (17-20).  
In human studies, analyses performed with PET and SPECT scanning 
have shown decreased metabolism and CBF in patients with AD, particularly in 
the parietal regions, and involving frontal and temporal areas as well (21, 22). 
Microscopic examination of post-mortem AD brain with specific 
immunohistopathologic stains for microvascular endothelium (CD 31) reveals 
narrowed, tortuous microvessels with scanty, poorly-stained endothelium in 
affected AD cortical tissue. While the possibility exists that these vascular 
changes may be a consequence of altered brain structure, or of diminished 
functional demand, the consistent epidemiologic association of multiple vascular 
risk factors with the incidence of AD suggests that the vascular changes are a 
plausible causal factor, initiating or contributing to the pathogenesis and 
development of AD. 
One line of reasoning suggests that the failure of brain microvasculature 
may have an important role in the pathogenesis of AD. A number of studies 
support the concept that the microvascular endothelium in brain (and elsewhere) 
is a major paracrine tissue, secreting trophic factors that are critical in 
maintaining organ/tissue integrity (23-26). This concept, pioneered by Judah 
Folkman (27), underlies an important strategy in the therapy of cancers, in which 
tumor tissue deprived of adequate vasculature has been shown to shrink. 
Angiostatin agents, which block angiogenesis and the integrity and function of 
vascular endothelium, have been used to control the growth of a number of 
experimental and human cancers. Folkman also noted, however, that in 
experimental animals, transplanted normal tissue will not survive and grow when 
vascular function is blocked by angiostatin agents, and will undergo atrophy. 
Whether this is due to inadequate blood flow (the conduit function of blood 
vessels), or to the paracrine functions of endothelium, is not known. Factors 
secreted by endothelial cells in cell culture have been shown, for example, to be 
critical for the survival, growth and differentiation of neural stem cells, 
emphasizing the importance of these trophic influences in the maintenance and 
growth of normal neural tissue (26). 
Early in the course of AD – as an initial event – synaptic, axonal, then 
neuronal loss, with atrophy of brain in affected areas, takes place. While decline 
of many critical molecular housekeeping functions may contribute to this 
involutional atrophic change, which eventually evolves into major, widespread 
cortical atrophy, degeneration and dementia, we hypothesize that an important 
component initiating this degenerative cascade and atrophy is the loss of 
microvascular trophic and nutritional functions. The goal of the present 
therapeutic intervention, therefore, is the facilitation of optimal brain 
microvascular endothelial function. While direct monitoring of trophic functions of 
the endothelium is not practical, microvascular integrity and function can be 
assessed by measuring changes in CBF; the paracrine and microvascular flow 

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functions are parallel, related functions. Assessing cognitive function should also 
provide information on the important beneficial effects on brain function.  
 
Endothelial Targets: 
Endothelial function can be facilitated by increasing eNOS activity, and by 
reducing endothelin-1.  
Endothelial nitric oxide synthase, or Type 3 nitric oxide synthase, synthesizes NO 
from L-arginine, which then facilitates vascular relaxation via cGMP. eNOS 
activity can be increased by the administration of HMGCoA reductase inhibitors 
(statins), which are widely used to reduce cholesterol synthesis by blocking the 
mevalonate pathway. Statins have pleiotropic effects, however, which are known 
to reduce the risk of vascular events well beyond the reduction of total 
cholesterol, or of LDL. The effects of statins on eNOS (28, 29), and on 
endothelin-1 (30), as well as their anti-inflammatory effects, are believed to be 
instrumental in its efficacy.  
Production of NO can be enhanced by the administration of its precursor 
amino acid, L-arginine (31). The synthesis of NO also requires a critical cofactor, 
tetrahydrobiopterin (BH4; sapropterin; Kuvan) (32). Thus, the opportunity to 
enhance brain eNOS activity by the stepwise addition of statins, L-Arginine and 
BH4 (Kuvan) could be utilized to counteract age-, environmental- and genetic 
factors impairing cerebral microvascular function, and enhancing the trophic and 
nutritional influences of microvascular function in the brain. 
 
The goal of this therapeutic study is the stepwise enhancement of eNOS 
activity in order to improve microvascular endothelial function in the brains of 
subjects with early stages of AD and MCI.  
 
Investigator’s background related to Alzheimer’s disease 
 
 
David Drachman has been involved in research on memory, the brain and 
Alzheimer’s Disease for most of his long career in academic Neurology. His work 
on herpes simplex encephalitis confirmed the critical role of the hippocampal 
complex in memory (34), and initiated his interest in the cognitive deficits of 
aging. His seminal work demonstrating the role of the cholinergic system in 
memory, and the observation that cholinergic blockade with scopolamine in 
young subjects reproduced cognitive deficits found in aging and dementia (35, 
36), resulted in the development of 3 of the 4 drugs (the anticholinesterases) 
currently approved for the treatment of AD. He co-authored the NINCDS-ADRDA 
criteria for AD (37) – which is the most-cited Neurologic reference in the medical 
literature. His laboratory first demonstrated the loss of synapses in AD (6), and 
he was a collaborator in the studies that first demonstrated the genetic basis of 
Familial AD (38). He served as Chairman of the Medical and Scientific Advisory 
Board of the National Alzheimer Association, and was a member of the FDA 
panel on neurological drugs for four years. He participated in clinical trials of 
Aricept, Namenda, Lipitor and other drugs for the treatment of Alzheimer’s 
Disease. He has developed a screening test for dementia (39), and for the 
behavioral disorders occurring with Alzheimer’s Disease (40). He was the senior 

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author on a seminal study of the role of statins in preventing dementia and AD 
(41). Over the years, he has written extensively on the etiology and mechanism 
of Alzheimer’s Disease (2, 42-46).  
 
Dr. David Drachman was the mentor for Dr. Elizabeth DeGrush during 
their shared time at UMASS in the neurology department.  Unfortunately he has 
since passed away, prior to completion of the study.  Prior to his death, he chose 
to assign her the Primary Investigator role for the continuation of the study.  
 
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Alzheimer's disease. Expert Rev Neurother 2008;8:743-750. 
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Profenno LA, Faraone SV. Diabetes and overweight associate with non-
APOE4 genotype in an Alzheimer's disease population. Am J Med Genet B 
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Reitz C, Tang MX, Manly J, Mayeux R, Luchsinger JA. Hypertension and 
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Herholz K, Carter SF, Jones M. Positron emission tomography imaging in 
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O'Brien JT. Role of imaging techniques in the diagnosis of dementia. Br J 
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progenitor cells stimulate cerebrovascular production of prostacyclin by paracrine 
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ischemic limb blood flow in diabetic microangiopathy via eNOS/NO upregulation 
but not via PDGF-BB expression. Am J Physiol Heart Circ Physiol 
2008;294:H2785-2791. 
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Enomoto S, Sata M, Fukuda D, Nakamura K, Nagai R. Rosuvastatin 
prevents endothelial cell death and reduces atherosclerotic lesion formation in 
ApoE-deficient mice. Biomed Pharmacother 2009;63:19-26. 
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Strey CH, Young JM, Lainchbury JH, et al. Short-term statin treatment 
improves endothelial function and neurohormonal imbalance in 
normocholesterolaemic patients with non-ischaemic heart failure. Heart 
2006;92:1603-1609. 
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and tetrahydrobiopterin protects against ischemia/reperfusion-induced 

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endothelial dysfunction in patients with type 2 diabetes mellitus and coronary 
artery disease. Atherosclerosis 2008. 
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Katusic ZS, d'Uscio LV, Nath KA. Vascular protection by 
tetrahydrobiopterin: progress and therapeutic prospects. Trends Pharmacol Sci 
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Pfister LA, Tureen JH, Shaw S, et al. Endothelin inhibition improves 
cerebral blood flow and is neuroprotective in pneumococcal meningitis. Ann 
Neurol 2000;47:329-335. 
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Drachman DA, Adams RD. Herpes simplex and acute inclusion-body 
encephalitis. Arch Neurol 1962;7:45-63. 
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Drachman DA, Leavitt J. Human memory and the cholinergic system. A 
relationship to aging? Arch Neurol 1974;30:113-121. 
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Drachman DA. Memory and cognitive function in man: does the 
cholinergic system have a specific role? Neurology 1977;27:783-790. 
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McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. 
Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work 
Group under the auspices of Department of Health and Human Services Task 
Force on Alzheimer's Disease. Neurology 1984;34:939-944. 
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St George-Hyslop PH, Tanzi RE, Polinsky RJ, et al. The genetic defect 
causing familial Alzheimer's disease maps on chromosome 21. Science 
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Drachman DA, Swearer JM, Kane K, Osgood D, O'Toole C, Moonis M. 
The cognitive assessment screening test (CAST) for dementia. J Geriatr 
Psychiatry Neurol 1996;9:200-208. 
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Drachman DA, Swearer JM, O'Donnell BF, Mitchell AL, Maloon A. The 
Caretaker Obstreperous-Behavior Rating Assessment (COBRA) Scale. J Am 
Geriatr Soc 1992;40:463-470. 
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Jick H, Zornberg GL, Jick SS, Seshadri S, Drachman DA. Statins and the 
risk of dementia. Lancet 2000;356:1627-1631. 
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Drachman DA, Leber P. Treatment of Alzheimer's disease -- searching for 
a breakthrough, settling for less. N Engl J Med 1997;336:1245-1247. 
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Drachman DA. Rethinking Alzheimer's disease: the role of age-related 
changes. Curr Neurol Neurosci Rep 2007;7:265-268. 
45. 
Drachman DA. Commentary on "a roadmap for the prevention of 
dementia: the inaugural Leon Thal Symposium." Prevention of dementia: 
roadmap or maintenance manual? Alzheimers Dement 2008;4:169-170. 
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Drachman DA. The treatment of Alzheimer's disease: where have we 
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134. 
 
Preliminary Data 
 

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Ten subjects have completed the 6 month treatment program. From preliminary 
analysis of the first two subjects in the study, MRI-based arterial spin labeling 
and gadolinium perfusion studies reveal a significant degree of increase in CBF 
from baseline to the conclusion of the 6month period. The psychometric studies 
reveal moderate improvement in psychometric test performance, and subjective 
measures of cognition and performance of activities of daily living (CDR; CIBIC 
Plus) indicated by the experimental subjects, their spouses, and family members 
reflect evidence of improvement.  The remainder of the data have yet to be 
analyzed. There were no adverse events attributable to the medications used.  
 
5) 
Inclusion and Exclusion Criteria* 
Inclusion Criteria: Subjects must have mild AD and MCI; age between 55-
85; Mini Mental State Exam (MMSE) between 15-26; a caregiver who can 
provide information, and bring patient to the sessions; no known allergies to any 
of the medications to be used; normal renal function; willingness of patient and 
spouse/responsible caregiver to participate. 
 
 Exclusion Criteria: Significant Psychiatric disorder; stroke; current use of 
any of the test medications (e.g., statin, L-Arginine, Kuvan); phenylketonuria 
(PKU) ; elevated serum phenylalanine level (>10 mg/dL); allergy to any of the 
medications; current active malignancy; renal insufficiency (elevated creatinine 
above 1.3mg/dl); abnormal liver function (ALT or AST 2x normal); other serious 
disease including coronary insufficiency or congestive heart failure, carotid 
stenosis greater than 50%, active peptic ulcer, urinary tract or other active 
infection, cancer (except skin cancer, or 5 years inactive breast or prostate 
cancer) etc.; pregnancy; or inability to come to UMass for follow-up. Subjects 
may continue to take anticholinesterase drugs for AD (Aricept, Exelon, 
Razadyne) and/or Namenda, if they have been on the drug(s) for at least 3 
months. Subjects on levodopa and male subjects taking drugs for erectile 
dysfunction (Viagra, Cialis, Levitra) are cautioned regarding hypotension. 
 
Adults unable to consent: All of the subjects have some cognitive 
impairment, but most will be able to provide informed consent. Regardless, we 
require that a responsible family member also responds regarding the patient’s 
inclusion in the study, after appropriate information and the consent form have 
been presented. 
No children or adolescents; no pregnant women; and no prisoners are to be 
considered for inclusion in this study of late-onset Alzheimer’s disease. 
 
6) 
Study-Wide Number of Subjects* 
N/A 
7) 
Study-Wide Recruitment Methods* 
This is a single center study at UMass Medical School, and recruitment is 
under the control of the PI. 
 

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Subjects will be recruited from 6 sources: 
1) UMass Neurology Clinic patients seen for early dementia and/or their legally-
responsible caregivers, may be asked if they would be interested in participating 
in the study 
2) An advertisement (see attached) will be sent to Daycare centers and Senior 
centers in the Worcester vicinity 
3) The Massachusetts/New Hampshire Alzheimer Association has been notified 
of the availability of the study, and asked to publicize it. 
4) Word of mouth among patients in the Neurology Clinic at UMass and affiliated 
hospitals, and physicians will continue to be used to publicize the availability of 
the study. 
5) Newspaper advertisements in local newspapers in the Worcester vicinity will 
indicate the availability of the study. 
6) The trial is listed in clinicaltrials.gov, and family members or patients can 
respond to that listing 
 
8) 
Study Timelines* 
 
• Each subject will be enrolled for 4 months after baseline testing. In the 
case that significant improvement is noted, this may be extended for 
compassionate use. In the case that any significant adverse effects are 
observed, the study will be terminated before the end of the 4-month 
interval. 
• We anticipate that it will require between 2 and 3 years to enroll all ten 
subjects 
• The primary analyses should be completed by June, 2015 
 
9) 
Study Endpoints* 
 
The primary endpoint of the study is the increase of CBF resulting from the 
combination of 3 experimental drugs, comparing the CBF at the end of the study 
with the baseline determination. Since this is a pilot study, global CBF and focal 
CBF over several critical areas (e.g., hippocampus; parietal lobes, frontal lobes) 
will be compared. The arterial spin labeling CBF and the Gadolinium-based 
perfusion CBF will both be examined for this purpose. 
The secondary endpoint will be the performance of the subjects on the 
psychometric tests done at each return visit and at the end of the 4- month study, 
in comparison with their performance at baseline. This includes the MMSE; 
Alzheimer’s Disease Assessment Scale - Cognitive (ADAS-Cog); Cognitive 
Assessment Screening Test (CAST); the Clinical Dementia Rating (CDR/sum of 
boxes); and the Clinician Interview-Based Impression of Change plus caregiver 
input (CIBIC plus).  
 
The safety endpoints include any significant adverse symptoms; abnormal 
observations on physical examination that occur during the study; and any 

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significant adverse changes in the laboratory studies done at monthly and end-
of-study testing (CBC, metabolic profile, lipid profile, CPK, UA; EKG). 
 
10) Procedures Involved* 
 
1) Baseline evaluation: 
 
a) Neurological Examination; general physical examination; CAST. 
 
b) Laboratory studies: CBC/differential, ESR; metabolic profile, CRP; lipid 
profile, CPK; FTI/TSH, antithyroid Ab’s; RPR; B12 level; HbA1C; ANA; PT/INR; 
urinalysis. 
 
c) Imaging:  MRI brain, MRA brain and neck These studies will be done at 
a single session in the MRI suite. The MRI and MRA are done without moving 
the patient by using different settings on the MRI scanner. The MRA requires the 
intravenous injection of Gadolinium, as described. Subjects who are 
claustrophobic may be given 0.5- 1.0 mg. Klonopin, a tranquillizer, to prevent 
anxiety during the scanning procedure. ,  
d) Cerebral blood flow (CBF). is done in the advanced MRI facility, before 
drug treatments on subjects who have no exclusion criteria, and choose to 
proceed in the study. Klonopin 0.5-1.0 mg may be given to prevent anxiety 
before the scan. 
 
e) Psychometric testing- MMSE; ADAS Cog; CDR/sum of boxes; CAST 
    
f) ECG 
 
 
Abbreviations: All the following are blood tests: CBC- Complete Blood 
Count; ESR- Erythrocyte Sedimentation Rate; CRP- C-Reactive protein; CPK- 
Creatine Phosphokinase; FTI- Free Thyroxine Index; TSH- Thyroid Stimulating 
Hormone; Antithyroid Ab’s- Antithyroid Antibodies; RPR- Rapid Plasma Reagin; 
B12-  Vitamin B12; HbA1C-  Hemoglobin component A1C (to which glucose is 
bound); ANA- Anti-Nuclear Antibodies; PT/INR-  Prothrombin Time/ International 
Normalized Ratio (for blood clotting). 
 
The following is a cardiac test: EKG - Electrocardiogram 
 
The following are imaging studies: MRI- Magnetic Resonance Imaging 
(of brain); MRA-  Magnetic Resonance Angiography; CBF- Cerebral Blood Flow 
 
The following are psychological tests: MMSE; ADAS-Cog; CAST. 
 
Drug name: BH4 – Sapropterin or Kuvan 
 
  
2) Drug administration: 
 
a) Week 0 
a. Simvastatin 40 mg/day, at bedtime, for 30 days; continue; and 
add:  
b) Week 4 
a. L-Arginine 2.0 gm TID and HS for 30 days; continue; and add: 
c) Week 8-16 
a. Sapropterin (Kuvan; BH4) 20 mg/kg/day for 60 days;  
 

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  Following taking of each drug, the following tests will be done. The next 
medication will be given to the patient/caregiver at this testing session, and they 
will be notified within 2 days (i.e., after the laboratory results are available) to 
begin taking the next drug if all laboratory tests are within acceptable normal 
limits. 
i. 
Interview of caregiver and patient re adverse effects: 
Dizziness, headache, confusion, sleep disturbance, rash, 
cardiac symptoms, respiratory symptoms, GI symptoms, urinary 
symptoms; other (per informant) 
ii. 
Laboratory studies: CBC, metabolic profile, lipid profile, CPK, UA,  
iii. 
Cognitive function, memory (caregiver, patient) MMSE; CIBIC Plus 
(Clinician Interview-Based Impression of Change, Plus Caregiver 
information)  
iv. 
Cerebral blood flow imaging study  
 
3) At Week 16 (end of study) 
a) Interview of caregiver and patient re adverse effects as above; 
b) Laboratory studies: CBC, metabolic profile, lipid profile, CPK, UA; EKG 
c) Cognitive function, memory (caregiver, patient) 
a. MMSE; ADAS Cog; CDR/sum of boxes; CIBIC Plus 
d) Cerebral blood flow imaging study 
e) Electrocardiogram 
f) after completion of the 4- month study, subjects will have the choice of 
continuing to take the three study medications, or may opt to taper and 
discontinue them over 8-day periods for each drug, as described 
above (tetrahydrobiopterin first, L-Arginine second, simvastatin third). 
For subjects who choose to continue the drugs, they will be provided at 
no charge to the subjects until the last enrolled subject has completed 
the study, and will be tapered as described above. Subjects who 
choose to continue the medications will be followed at 3-month 
intervals in the Neurology Clinic at UMass, with appropriate studies to 
monitor safety, including a comprehensive metabolic profile, CPK, ESR 
and complete blood count. Note that since the drugs are FDA 
approved for other indications, they could be given “off-label.” 
Procedures to lessen probability/magnitude of risks:  
a) Patients are examined at baseline, and excluded if they have 
any significant medical or psychiatric disorder. Patients with 
cancer, renal insufficiency, stroke, myocardial infarction, 
phenylketonuria, abnormal liver function, coronary insufficiency, 
congestive heart failure, or intolerance to any of the drugs to be 
used are excluded. 
b) All subjects must have a responsible caregiver available to 
observe them on a daily basis, and report any untoward 
changes in function to the PI or other investigator. 

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Page 13 of 24 
Revised: June 11, 2017 
c) Baseline and repeated inquiry about medical problems, physical 
examination, and repetition of laboratory studies at each return 
visit to observe any adverse effects of drugs, or changes in 
medical status, are carried out.  
Drugs and devices used in the research; purpose of their use; regulatory 
approval status 
Three FDA-approved drugs are used, sequentially and 
cumulatively, for the purpose of increasing cerebral blood flow by 
facilitating brain endothelial nitric oxide synthase (eNOS). The drugs are: 
simvastatin; L-Arginine; and sapropterin (tetrahydrobiopterin). In addition, 
patients who have significant claustrophobia if in the MRI scanner may 
receive a small oral dose (0.5 to 1.0 mg.) of clonazepam. 
 
Data Collection 
Data regarding baseline physical and laboratory status, and the 
same data on each return visit will be collected and recorded in each 
subject’s file.  
Cerebral blood flow data will be collected from each evaluation.  
Data regarding cognitive testing will be collected for each visit. 
The formal follow-up of subjects is 4 months (120 days), during 
which the data, as described, are collected and recorded. Subjects are 
returned to their primary care physicians and managing neurologists. They 
are asked to return two months after conclusion of the formal study for 
brief neurological evaluation (not a part of the study); and may continue to 
be followed afterwards in the Neurology outpatient clinic at UMass at their 
choice 
11) Data and Specimen Banking* 
No blood, spinal fluid or other specimens are stored for subjects in 
this study.  
Data are stored electronically on a secure, HIPPA compliant 
UMASS server.  Any paper copies of data or patient information are kept 
in a locked cabinet in a locked room. Data are available to the PI and 
other investigators involved in the study. Relevant medical information 
may be made available to the subjects’ personal physicians in case of any 
adverse effects, either related to the use of the medications used in the 
study, or significant coincidental medical events observed during the 
course of the study. All data are secure; HIPAA rules apply to all medical 
information.  
Data presented or published regarding the results of the study will 
be de-identified as to individual origin and subjects included. 
 

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12) Data Management* 
Power analysis: This is a pilot study involving ten subjects, and data 
are being collected for preliminary assessment of the potential benefits of 
the treatment, for consideration of conducting a larger scale study. As a 
result, no power analysis is planned for this pilot study. 
Data analysis: The CBF and psychometric data obtained for each 
individual subject at baseline will be compared with any changes observed 
in comparable data obtained at each subsequent assessment (one month, 
two months, four months). The data will be analyzed to determine change: 
improvement, stability or decline; and to assess statistical significance of 
magnitude of change with addition of each added drug (and the conjoint 
administration of all three drugs) during the four-month course of the 
study.  
Security:  Data are stored electronically on a secure, HIPPA compliant 
UMASS server.  Any paper copies of data or patient information are kept in a 
locked cabinet in a locked room.. All investigators must pass the CITI 
examination. Access to the data is restricted to the investigators who handle the 
data, which are confidential. As this is a pilot study, and treatment is not blinded, 
subjects will be identified by their individual names and UMass medical record 
numbers for the qualified investigators in the study. All reports will use sequential 
coded numerical designations for subjects. 
Data storage: Data will be stored for the duration of the study, and 5 
additional years. Each investigator is responsible for transmission of the data 
collected by her/him; i.e., psychometric data by the investigator administering the 
test; cerebral blood flow by the imager, and the data analyst recording and 
analyzing the data, etc.  
Collected data include all medical, clinical laboratory, psychometric, 
imaging and cerebral blood flow data. All these data are maintainedelectronically 
on a secure, HIPPA compliant UMASS server.. In addition, routine laboratory 
data (blood studies, urine, EKG) will be entered in the UMass Allscripts record in 
order to be available to the subjects’ primary care physicians. 
 
13) Provisions to Monitor the Data to Ensure the Safety of Subjects* 
 
All clinical and clinical laboratory data are collected and recorded at 
baseline and at each visit (4 weeks, 8 weeks, 16 weeks).  All the data are 
reviewed by the PI for each subject following each visit. Report forms noting the 
results of the tests are available for each visit. In addition, each subject’s family 
member has a direct telephone number to notify the PI of any adverse event, 
whether related or not to the medications.  
 
 
All adverse events related to the study drugs are reported to the UMass 
IRB, and the FDA. All KUVAN™ serious adverse events, whether or not 
considered drug-related, will be reported and documented on Form FDA 3500 A 

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Page 15 of 24 
Revised: June 11, 2017 
(MedWatch Form) and forwarded directly to BioMarin Pharmaceutical Inc. Drug 
Safety Department within 24 hours (Contact information on file). This includes 
serious, related, labeled (expected) and serious, related, unlabeled (unexpected) 
adverse experiences. 
 
14) Withdrawal of Subjects* 
Subjects may be withdrawn without their consent under the following 
circumstances: 
l. The investigator decides that continuing in the study would be harmful to them.  
2. They need treatment not allowed on this study.  
 
 
 
 
 
3. They fail to keep your appointments or take the medications as instructed.  
4. They become pregnant.  
5. The study is canceled by the investigators or the UMMS Institutional Review 
Board.  
The subject/caregiver is asked to come to the University of Massachusetts 
Medical Center to meet with the PI. Laboratory studies, as scheduled for the final 
visit, will be carried out to assess the absence of any significant adverse effects. 
In the case that any significant adverse effects occur, the study will be terminated 
before the end of the 4-month interval by tapering the doses of the drug causing 
the adverse effect over an 8-day interval. This will be done by giving ¾ of the 
maximum dose for 2 days; then ½ the max. dose for 2 days; ¼ the max dose for 
2 days; then 1/8 the max dose for 2 days, then discontinuing it. If the subject is 
on all 3 drugs, tetrahydrobiopterin will be tapered first; L-Arginine second; then 
simvastatin last. If only one or two of the drugs have been given, they will be 
tapered as described. In case of any severe adverse effects, the affecting drug 
may be discontinued immediately, as needed. 
If the subject declines a final visit, the telephone contact with the 
responsible caregiver may comprise the final encounter. 
 
15) Risks to Subjects* 
Risks are primarily related to the drugs used in the study: 
 
Simvastatin can produce elevation of liver function tests in approximately 
1% of patients, and myalgia in about 1-2%, with elevated creatine phosphokinase 
(CPK) in less than 2%. Rarely, rhabdomyolysis (muscle breakdown) may occur, 
evidenced by muscle pain, weakness and elevated CPK. Additional uncommon 
side effects include GI irritation, constipation, skin rash, allergic reactions, or 
hematologic reactions, headache, upper respiratory infection, renal failure and 
tendon rupture. 
 
L-arginine is an amino acid normally present in the diet. It is not a 
prescription item, and is sold OTC. Most adverse effects occur only with 
parenteral injection of L-Arginine in large doses. Adverse effects are uncommon, 
and can include GI symptoms, including stomach discomfort, diarrhea, nausea, 
vomiting, bloating and abdominal cramps; renal toxicity, including elevated BUN 
and creatinine levels; cutaneous flushing; hypotension; endocrine effects 

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Page 16 of 24 
Revised: June 11, 2017 
including release of growth hormone, insulin, glucagon and prolactin; numbness 
and headache.  
 
Sapropterin (BH4; Kuvan) is a synthetic preparation of the dihydrochloride 
salt of naturally occurring tetrahydrobiopterin (6R-BH4 or BH4). It can produce 
gastrointestinal side effects, including nausea (4%), abdominal pain (5%), 
diarrhea (8%) and vomiting (8%); headache (15%); and upper respiratory 
symptoms –nasal discharge (11%), pain in throat (10%), and upper respiratory 
infection (12-17%). Gastritis, spinal cord injury, streptococcal infection, testicular 
cancer and urinary tract infection have occurred with Kuvan treatment, but were 
considered not caused by BH4. 
No specific information is available on the conjoint risks of use of the three 
drugs in this study. 
 
Other risks are claustrophobia when in the MRI scanner; and the 
possibility of further renal toxicity from gadolinium administration in patients who 
have pre-administration renal insufficiency (who are excluded). Adverse effects 
related to gadolinium contrast injection, which occur in less than 1% of patients 
without renal disease, can include transient headache, nausea,and taste 
perversion; and extremely rarely, an anaphylactic reaction. Subjects with 
claustrophobia may be given 0.5 – 1.0 mg Klonopin orally. This may cause 
drowsiness, slowing of heart rate, or rarely an allergic reaction. 
 
Blood Draw 
Blood samples will be taken by inserting a needle into a vein in the arm 
and withdrawing a sample of blood. It is fairly common for a harmless “black and 
blue” mark to appear at the site of the vein puncture. Occasionally, patients 
become dizzy as a consequence of having blood drawn and rarely someone may 
faint; infection at the puncture site is a rare complication.. 
 
Electrocardiogram 
The risks include skin irritation and a rash from wearing or removing the 
patches that stick to the subject’s skin or from the gel that is used with them. 
 
Loss of Confidentiality 
The patient’s personal information could be lost or exposed. This is very 
unlikely; the study personnel will do everything possible to assure that the 
information is protected. 
 
 
Questions regarding cardiac, respiratory, upper and lower GI, urinary 
symptoms, joint or muscle pains will be sought from the patient and caregiver at 
every visit. Complete blood count, metabolic profile and urinalysis will be 
obtained each month. The electrocardiogram procedure has no risk for the 
subject. Any change in heart rate, rhythm, or cardiac integrity occurring during 
the study will be evaluated at the end of the study by an electrocardiogram. 
 

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Page 17 of 24 
Revised: June 11, 2017 
 
The hepatotoxicity of simvastatin will be minimized by obtaining baseline 
liver function tests (LFT’s) , and excluding subjects with abnormal liver function 
(AST or ALT 2x normal). In addition, LFTs will be obtained every month prior to 
starting the next cumulative drug treatment. CPK levels will be obtained monthly. 
 
 
Subjects who experience claustrophobia will be prepared for the scanning 
experience with Klonopin, 0.5 mg orally one hour before the study; repeated one 
half hour before the study if necessary.  Patients with renal insufficiency will be 
excluded from participation in the study to avoid potential renal toxicity with 
gadolinium contrast medium. 
 
If subjects or their caregivers withdraw from the study for any reason, they will be 
asked to return as above. If the subject is unable to tolerate one of the three 
drugs, they may continue in the study with those drugs that are tolerated, with the 
collection of data as if they had remained fully involved. 
 
16) Potential Benefits to Subjects* 
 
AD is a progressive dementing disorder, regarded as one of the most 
catastrophic conditions that can affect elderly individuals. At present there are no 
treatments that have been shown to alter the course of the condition, although 
several drugs can ameliorate the severity of the dementia to a moderate degree. 
The present study regimen is intended to modify the presumptive underlying 
cause of the AD- i.e., impaired microvascular function. The treatment is given for 
4 months; it is not known whether this modulation of cerebral microvascular 
endothelial function can slow the progress of the disease, or for what period any 
beneficial effect may persist. The opportunity to slow, reduce or arrest the 
progression of AD, however, could be of significant benefit to subjects.  
 
17) Vulnerable Populations* 
 
 
All subjects included in this study are assumed to have some degree of 
cognitive impairment, since they have mild or moderate Alzheimer’s Disease. As 
a result, all subjects are required to have a responsible caregiver give consent to 
the study, in addition to the subject her/himself. In addition, the caregiver must 
have daily contact with the experimental subject, and will have telephone access 
to the PI to report any adverse events, whether related to the drugs involved, or 
otherwise not involved. Subjects will be particularly closely monitored because of 
their cognitive impairment, and will be withdrawn if they appear unduly 
distressed. 
 
 
Risks to subjects are considered to be minimal since the drugs being used 
are well-known, FDA approved, and have minimal risks. Subjects, and their 
responsible caregivers give assent for the study.  
 
18) Multi-Site Research* 
N/A 

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Page 18 of 24 
Revised: June 11, 2017 
 
19) 
Community-Based Participatory Research* 
N/A 
 
20) Sharing of Results with Subjects* 
 
Study results are available to be shared with the subjects and/or 
responsible caregivers after the conclusion of their participation (4 months), when 
the data have been analyzed. Those subjects, or responsible family members, 
are informed that they may inquire regarding changes in cognitive function and 
cerebral blood flow. They are also notified during the course of the study of any 
abnormal findings on their testing following each visit. 
 
 
The subjects’ primary care physicians are kept informed regarding any 
abnormal laboratory or clinical findings; any adverse events; and any 
improvement in the subjects’ performance or cerebral blood flow. The information 
is conveyed immediately, in the case of an adverse event, by e-mail, telephone, 
or (for internal physicians at UMass) via the electronic medical record system. 
Communication with the primary care physicians is maintained as needed 
throughout the 4 months of the study. 
 
 
As noted, since this is an unblinded pilot study, routine laboratory data are 
recorded in the Allscripts electronic medical record to be available to the 
subjects’ primary care physicians. 
 
21) Setting 
 
All studies described are carried out in the facilities of the University of 
Massachusetts Memorial Medical Center and Medical School. Clinical 
examinations and psychometric testing are done in the Neurology Clinic on Level 
A of UMass Memorial Medical Center, University Campus. Imaging studies are 
carried out in the University of Massachusetts Medical School Advanced MRI 
facility in the A-level of the medical school, using the 3-Tesla Siemens MRI 
scanner. 
 
As noted above, subjects are recruited from any of 6 sites: UMass 
Neurology Clinic patients seen for early dementia and/or their legally-responsible 
caregivers, may be asked if they would be interested in participating in the study; 
an advertisement (see attached) will be sent to Daycare centers and Senior 
centers in the Worcester vicinity; the Massachusetts/New Hampshire Alzheimer 
Association has been notified of the availability of the study, and asked to 
publicize it; word of mouth among patients in the Neurology Clinic at UMass and 
affiliated hospitals, and physicians will continue to be used to publicize the 
availability of the study; newspaper advertisements in local newspapers in the 
Worcester vicinity will indicate the availability of the study; the trial is listed in 
clinicaltrials.gov, and family members or patients can respond to that listing. 
 
 
The study is carried out entirely at UMass Memorial Medical Center and 
Medical School, and follows the regulatory rules and conditions of UMass; no 
other outside organizations are involved. 

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Page 19 of 24 
Revised: June 11, 2017 
 
22) Resources Available 
Principal Investigator 
The PI is a resident physician training in neurology and psychiatry at 
UMASS.  She will devote approximately 20% time to this study. Each 
subject’s visit requires approximately 4 hours of face-to-face time with the 
subject and family. Additional time is devoted to scheduling; data 
collection, recording and analysis; communication with subjects and family 
members; writing abstracts and manuscripts; and coordination of the 
study. The PI is responsible for all aspects of the study, while under 
supervision of the faculty advisor. 
 
The change of the PI was informed to all current and former study 
participants via phone calls by the PI herself. 
Faculty Advisor 
The faculty advisor will be Dr. Nils Henninger, M.D. Dr. Henninger is 
an Assistant Professor of Neurology and Psychiatry at UMASS.  He is a 
vascular neurologist who is well published with a strong research interest 
in traumatic brain injury and ischemic stroke.  He is available for clinical 
concerns, data analysis, abstract and manuscript writing and editing.  He 
is responsible for overseeing the progress of the study in a supervisory 
role. 
 
Staff 
Clinical Trials Coordinator. Arranging visits; obtaining drug; managing 
specimens; maintain documents; adverse event monitoring and reporting; 
IRB communications and continuing review, communication with subjects, 
performance of the MMSE, and other psychometric tests or research 
procedures as trained. 
Sub-Investigators: sub-investigators will include neurologists, imaging 
specialists, neuropsychologists and radiologists. Each sub-investigator will 
be a MD, DO or PhD. Experience and specific training in conducting 
neuropsychological testing; patient examination; assisting with 
arrangements for MRI scanning; consent subjects; take medical history; 
conduct physical examination. Involvement in writing, presentation of data. 
May be in residency/fellowship training, or faculty level. Carrying out 
arterial spin labeling and perfusion imaging studies in MRI setting. Analyze 
imaging data to determine global and focal cerebral blood flow. 
Collaborate with imaging, cerebral blood flow studies. 
In addition, we will share coded, anonymous data with external 
collaborators.  We will advise collaborators to obtain any approvals 
required by their home institution prior to analyzing the data.  We will 

INVESTIGATOR STUDY PLAN - REQUIRED 
 
 
Page 20 of 24 
Revised: June 11, 2017 
never break the code for these individuals or try to re-identify subjects, 
and the use is limited to this research project.  Data will be transmitted by 
DVD (password protected when possible) or by secure email or by a 
UMMS IT approved means. 
 
 
Facilities available 
The University of Massachusetts-Memorial Medical Center is 
available for any medical problems that may arise in the course of the 
study. The UMass Memorial hematology and chemistry laboratories are 
involved in the processing of specimens for routine following of subjects.  
Communication. 
Personnel involved in the study are individually informed regarding 
the subject involvement and scheduling for procedures. Meetings of the 
involved staff are conducted at 3-6 month intervals as necessary to inform 
all members of updates, subjects, responsibilities, data. 
 
23) Prior Approvals 
All personnel involved with the MRI-based scanning must be 
trained/retrained annually in safety measures related to the use of the MRI 
scanning machine. 
All personnel must be trained with, and pass, the CITI website 
program for clinical trials investigators; retraining is biennial. 
IBC approval is not needed for this study because the study only 
deals with routine blood labs processed in the UMMHC clinical lab. 
 
24) Recruitment Methods 
Subjects with AD comprise approximately 10% of all individuals over 
the age of 65, with the frequency increasing exponentially with greater 
age.  Recruitment, however, requires that the subjects are interested in 
being involved in a clinical trial; do not have any exclusionary illnesses, 
and are not currently taking a statin drug. Many patients with AD are seen 
annually in the UMass Neurology Clinic, and may be eligible for inclusion if 
they meet criteria and are interested. Other individuals contact the 
investigator as a result of word-of-mouth, online awareness of the study 
from the “clinicaltrials.gov” website, the MA/NH Alzheimer Association, 
and physicians seeking trials for their patients with AD.  
Subjects are screened by a clinical evaluation done by the PI. When 
necessary to ascertain the diagnosis, usual diagnostic tests (standard of 
care) including a PET scan, a lumbar puncture with analysis of spinal fluid 

INVESTIGATOR STUDY PLAN - REQUIRED 
 
 
Page 21 of 24 
Revised: June 11, 2017 
for beta amyloid and phospho-tau protein, detailed psychometric 
evaluation or PET scan with Florbetapir for presence of beta amyloid may 
be used to assure accurate diagnosis prior to offering entry into the study. 
Medical records provided by other physicians or neurologists who have 
evaluated the subject for AD may be requested under HIPAA rules.  
Telephone interviews may be used for preliminary screening to 
ascertain any inclusionary or exclusionary conditions. 
Methods of recruitment are described in (7) above. No payment is 
given to subjects. 
25) Local Number of Subjects 
Ten subjects are planned to be included in this pilot study. All 
subjects are local. 
 
26) Confidentiality  
This is described in (11, 12 and 13) above. Data are kept in a locked 
cabinet in a locked room. Only the investigators have access to all the 
data.  
 
27) Provisions to Protect the Privacy Interests of Subjects (HIPAA) 
Subjects are evaluated and have contact only with the included 
investigators, except for (1) scheduling of visits; and 2) drawing of blood in 
the laboratory by phlebotomists. 
Subjects will be evaluated and have contact exclusively with trained 
members of the research team/investigators, who have been sensitized to 
the issue of Alzheimer’s disease. They are assured of the confidentiality 
and security of the information obtained.  
HIPAA releases are obtained from the subjects and their responsible 
caregivers. Subjects and caregivers sign releases for information obtained 
from other physicians who care for them, or who have relevant records 
regarding their care.  
28) Compensation for Research-Related Injury 
The University of Massachusetts does not provide funds for the 
treatment of research-related injury. If the subject is injured as a result of 
participation in the study, treatment will be provided. The subject or his/her 
insurance carrier will be expected to pay the costs of this treatment. No 
additional financial compensation for injury or lost wages is available. 
 
29) Economic Burden to Subjects 
 

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Page 22 of 24 
Revised: June 11, 2017 
The subjects are not responsible for any expenses related to this 
study other than personal travel. Subjects entered in this study will have 
insurance-related payments to ascertain their baseline neurological and 
medical status, as would every patient seen in the Dementia and 
Cognitive disorders clinic at UMass. Once the subjects have undergone 
the baseline medical/neurological evaluation, and have been accepted 
into the study, however, all additional expenses related to the study will be 
paid for by the study funding. If an unrelated medical problem should 
develop during the course of the study, this will be paid for by the patient’s 
own insurance.  
30) Consent Process 
Consent will be obtained both verbally and in writing. The consent 
process is carried out with the subject and caregiver, together with the 
investigator, in an examining room setting in the Neurology clinic. Subjects 
and caregivers will be provided a written description of the study, including 
the number of visits, laboratory tests to be obtained, time involved, and 
possible risks and benefits. This will be discussed with the potential 
subjects in the presence of the responsible family member/caregiver. They 
will be given unlimited time to consider their decision to be enrolled or not, 
either while in the Clinic, or after considering the trial at home; all 
questions are answered. They will be informed (if patients at UMMC) that 
no change in care for their general or neurological problems will occur 
whether they decide to enroll in the study or not. Although some of the 
subjects will not be totally capable of comprehension of all aspects of the 
study, the extent of their understanding will be evaluated.  
All subjects undergo clinical neurological evaluation, including 
detailed cognitive evaluation, and psychometric testing as described. This 
provides the information needed to assess the capacity of subjects to 
assent to the trial. 
In addition, subjects whose cognitive ability is marginally impaired 
(e.g., MMSE scores of 15 -26) will be recruited. They should all be able to 
provide some degree of assent; but as noted, in all cases assent will also 
be required from the subject’s responsible caregiver as well. 
No non-English-speaking subjects will be included in the study 
because of difficulties in evaluating their cognitive performance on 
standard English tests, No children, adolescents or pregnant women will 
be enrolled in the study. 
 
For the relation to cognitively-impaired adults, see (17) 
 
Dr. DeGrush will notify existing subjects of the ongoing collection of 
research data during the time period that each subject is on the study drug 
combination, and for up to 1 year post discontinuation of the study drug.  

INVESTIGATOR STUDY PLAN - REQUIRED 
 
 
Page 23 of 24 
Revised: June 11, 2017 
will happen via a letter to subjects with a HIPAA authorization (no 
signature required). Subjects will be invited to contact the PI with any 
questions and many are still in clinical follow-up and will be notified in 
person as well.  
 
 
31) Process to Document Consent in Writing 
Formal consent will be obtained both verbally and in writing from the 
subjects and from their responsible caregiver. If capable, the subject will 
sign and personally date the written informed consent. 
 
32) Drugs or Devices 
The three drugs used in this study are stored in the research 
pharmacy in the ACC building at UMass. They will be obtained for 
appropriate visits from the research pharmacists. 
 
i. The drugs are lawfully marketed in the United States.  
ii. The research is not intended to be reported to the FDA in support 
of a new indication for the drugs, nor to support a significant change in 
labeling of the drugs.  
iii. The research is not intended to support a significant change in 
advertising of the products. 
iv. The research does not involve a route of administration or dosage 
level or use of a patient population or other factor that significantly 
increases the risks (of decreases the acceptability of the risks) associated 
with the use of the drug products. 
v. The research is conducted in compliance with the marketing 
limitations described in 21 CFR 312.7. 
 

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Applicable to: 
FDA Regulation 
IND Studies 
IDE studies 
Abbreviated 
IDE studies 
21 CFR 11 
X 
X 
 
21 CFR 54 
X 
X 
 
21 CFR 210 
X 
 
 
21 CFR 211 
X 
 
 
21 CFR 312 
X 
 
 
21 CFR 812 
 
X 
X 
21 CFR 820 
 
X