Short Term Effects of Leptin Withdrawal or Initiation in Lipodystrophy Independent of Energy Intake
Phase: PHASE2
Conditions: Lipodystrophy
Sponsor: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

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Short-term Effects of Leptin Withdrawal or Initiation in Lipodystrophy 
Independent of Energy Intake 
 
Principal Investigator:  
 
*Rebecca J. Brown, M.D., M.H.Sc. 
  
Associate Investigators:  
 
*Phillip Gorden, M.D. 
*Elaine Cochran, M.S.N., C.R.N.P. 
Kong Y. Chen, Ph.D., MSCI 
Kevin Hall, Ph.D. 
*Megan Startzell, R.N., M.P.H. 
Ranganath Muniyappa, M.D. 
Amber Courville, Ph.D., R.D. 
Ahmed Gharib, M.D. 
Marc Reitman, M.D., Ph.D.  
Christopher Koh, M.D. 
James Reynolds, M.D. (NIH/CC) 
 
Non-NIH Collaborators: 
Andrea Ramirez, M.D., M.S. (Vanderbilt University School of Medicine) 
Ravinder J. Singh, M.D, Ph.D. (Mayo Clinic, Rochester, MN) 
 
 
 
 
Elizabeth Parks, Ph.D (University of Missouri School of Medicine) 
 
 
 
 
Elif Oral, M.D. (Metabolism, Endocrinology, and Diabetes at the University of 
 Michigan) 
 
 
 
 
Abhimanyu Garg, M.D. (University of Texas Southwestern) 
 
 
 
 
Stephen O’Rahilly, M.D. (Univ. of Cambridge, Metabolic Research Labs, UK) 
 
 
 
 
Robert Semple, M.D. (Univ of Cambridge, UK) 
 
 
 
 
David Savage, M.D. (Univ. of Cambridge, UK) 
 
 
 
 
Morey Haymond, M.D. (Baylor College of Medicine) 
 
 
 
 
Shaji K. Chacko, Ph.D. (Baylor College of Medicine) 
 
Non-Investigator Research Staff:           Michelle Michelle Ashmus, BSN, RN 
 
 
 
 
*indicates those who may obtain informed consent 
 
 
 
Protocol Overview 
Protocol Title:  
Short-term Effects of Leptin Withdrawal or Initiation in 
Lipodystrophy Independent of Energy Intake 
Abbreviated Title:  
Leptin Independent of Energy Intake 
IRB:  
NIDDK/NIAMS  
Research Type:  
Phase II Clinical Trial 
Multi-site Collaboration:  
No 
Intramural Collaboration: 
No 
Ionizing Radiation Use:  
(X-rays, e.g., CT; radioisotope, e.g. PET; 
etc.) 
Research Indicated 
Investigational New Drug/Device:  
Yes 
Patient Self-Referral Allowed:  
Yes  
List Protocol On Web:  
Yes  
Is tissue being collected for research 
purposes:  
Yes 
 

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Conflict of Interest  
The protocol involves no drugs/devices/products that may lead to payments and/or royalties to be paid to the 
investigators or the NIH. 
   
The investigators have no equity, consultative, or other financial relationship with a non-NIH source related to 
this protocol which might be considered a conflict of interest.  
 
Time Frame 
Start Date:  
11/1/2012 
End Date:  
12/31/2019 

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Table of Contents 
 
Precis – Abstract _______________________________________________ 4 
Study Objectives ________________________________________________ 5 
Introduction __________________________________________________ 5 
Subject Eligibility Assessment and Enrollment _____________________________ 7 
Study Design and Statistical Analysis __________________________________ 8 
Design ___________________________________________________________ 8 
Randomization______________________________________________________ 9 
Outcome Measures ___________________________________________________ 9 
Statistical Considerations _________________________________________ 10 
Sample Size Justification ______________________________________________ 10 
Statistical Methods for Data Analysis ______________________________________ 12 
Study Implementation ___________________________________________ 13 
Medications _______________________________________________________ 13 
Study Procedures ___________________________________________________ 16 
Follow-up ________________________________________________________ 22 
Human Subject Protection ________________________________________ 22 
Data and Safety Monitoring Plan _________________________________________ 22 
Adverse Events ____________________________________________________ 23 
Rationale for Subject Selection __________________________________________ 26 
Risks/Benefits Analysis including Considerations of Alternatives to Participation _________ 27 
Financial Compensation ______________________________________________ 32 
Consent/Assent Procedures ____________________________________________ 32 
Research Use, Storage and Disposition of Human Subjects’ Samples and Data ___________ 33 
Appendices __________________________________________________ 35 
Appendix A:  Sample Patient Calendars ____________________________________ 35 
Appendix B:  Investigator Qualifications and Roles ____________________________ 378 
     Appendix C: Myalept Package Insert ……………………………………………………………………………………………… 39 
     Appendix D: Waiver of Consent……………………………………………………………………………………………………… 41 
References ________________________________________________ 403 
 

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Precis – Abstract 
 
Background 
Leptin is an adipocyte-derived hormone that can be thought of as a signal from adipose tissue to the rest of the 
body conveying information about long-term nutritional status.  Patients with lipodystrophy have leptin 
deficiency secondary to lack of adipose tissue, and thus represent a natural model for studying the effects of 
leptin deficiency and replacement in humans.  Leptin replacement in lipodystrophy ameliorates metabolic and 
endocrine abnormalities, including reducing food intake, improving insulin resistance and diabetes, reducing 
ectopic lipid, and normalizing reproduction.  The reduction in energy intake induced by leptin replacement is 
likely responsible for part of the improvements observed in glucose and lipid metabolism.  The clinical effects of 
leptin that are independent of changes in energy intake, and the mechanisms underlying these effects, have been 
poorly explored in humans. 
 
Aim 
The primary aim of this study is to determine the energy intake-independent effects of leptin on energy 
metabolism in lipodystrophic subjects.  The major aspects of energy metabolism to be studied are: 
1. Lipid metabolism, including fasting lipids, lipolysis and fatty acid turnover, and ectopic lipid storage. 
2. Glucose metabolism, including fasting glucose, endogenous glucose production, and insulin sensitivity 
3. Energy expenditure, including total and resting energy expenditure, skeletal muscle work efficiency, and 
spontaneous physical activity 
 
In addition, the effects of leptin on endocrine and autonomic function will be examined, including effects on the 
thyroid, gonadal, and adrenal axes, as well as blood pressure, body temperature, and heart rate variability. 
 
Methods 
This is a non-randomized, parallel group study.  Two groups of patients aged 14 to 70 years with lipodystrophy 
will be studied: leptin naïve and leptin treated. Minors will only be included in the leptin naive arm. All subjects 
will be stabilized on a weight maintenance diet for 5 days (Period 1).  After this, leptin will be withdrawn from 
leptin treated subjects, and leptin will be initiated in leptin naïve subjects for a period of 14 days (Period 2).  The 
same isocaloric diet will be continued throughout both Periods, permitting study of leptin’s effects independent 
of energy intake.   
 
All subjects will undergo metabolic testing on admission, at the end of Period 1, and throughout Period 2, to 
generate a detailed short-term time course of the effects of leptin initiation or withdrawal. At the end of Period 2, 
leptin will be continued in the leptin naïve subjects, and restarted in the leptin treated subjects.  Repeat metabolic 
testing will be performed 6 months (ideally 5-9 months but may be extended to 12 months in foreign subjects) 
after leptin initiation in the leptin-naïve cohort to generate information on leptin’s long-term effects. 
 
 

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Study Objectives 
 
The primary aim of this study is to determine the energy intake-independent effects of leptin on energy 
metabolism in lipodystrophic subjects.   
 
The null hypothesis is that, when caloric intake is fixed, leptin has no effects on energy metabolism. 
 
The alternative hypothesis is that, when caloric intake is fixed, leptin does have measureable effects on energy 
metabolism. 
 
The major aspects of energy metabolism to be studied are: 
1. Lipid metabolism, including fasting lipids, lipolysis and fatty acid turnover, and ectopic lipid storage. 
2. Glucose metabolism, including fasting glucose, endogenous glucose production, and insulin sensitivity 
3. Energy expenditure, including total and resting energy expenditure, skeletal muscle work efficiency, and 
spontaneous physical activity 
 
In addition, the effects of leptin on endocrine and autonomic function will be examined, including effects on the 
thyroid, gonadal, and adrenal axes, as well as blood pressure, body temperature, and heart rate. 
 
 
Introduction 
Leptin 
Leptin is an adipocyte-derived hormone that can be thought of as a signal from adipose tissue to the rest of the 
body conveying information about long-term nutritional status.  In particular, low leptin levels serve as a signal 
of inadequate nutritional stores.  Rodents and humans with leptin deficiency due to mutations of the leptin gene 
or its receptor exhibit many of the same physiological changes observed in starvation, including hyperphagia, 
infertility, decreased immune function, and, in rodents, decreased energy expenditure; these abnormalities can be 
reversed with leptin replacement1-10.  Due to the constant “starvation signal” from leptin deficiency, both rodents 
and humans with congenital leptin deficiency exhibit extreme obesity, which can be greatly ameliorated with 
exogenous administration of leptin4-7,9.  One mechanism by which body weight is reduced after leptin 
replacement is via appetite reduction, with spontaneous reductions in food intake of ~50% in both rodents6,9 and 
humans5.  In rodents, there is also evidence that leptin replacement decreases body weight by increasing energy 
expenditure.  Although leptin-induced alterations in energy expenditure are likely to be much more important in 
rodents than in humans due to differences in small versus large animal biology, there is limited evidence of an 
effect in humans. In weight-reduced healthy humans, leptin replacement to pre-weight-loss levels appears to 
increase energy expenditure11,12.  Similarly, in patients with congenital leptin deficiency, leptin treatment appears 
to prevent the typical weight-loss induced fall in energy expenditure5,13. 
 
In addition to its roles in regulating body weight, immune function, and reproduction, leptin is important for 
normal glucose and lipid metabolism5,7,9,14,15. Leptin replacement in deficiency states improves glucose and lipid 
metabolism, including reversal of insulin resistance and diabetes7,9,14,16,17, and reduction in hepatic and circulating 
triglycerides7,14,15. The physiologic and molecular mechanisms by which leptin alters insulin and lipid 
metabolism have been explored in rodent models, and to a much lesser extent in humans.  One major effect of 
leptin is reduction of hepatic gluconeogenesis, which appears to be mediated via the central nervous system 
through effects on the vagus nerve18.  Leptin-induced decreases in lipogenic enzymes, including stearoyl-
coenzyme A desaturase 1, fatty acid synthase, and HMG CoA reductase have been found in liver and adipose 
tissue in rodents15,19.  Recently, insulin-like growth factor binding protein 2 (IGFBP2) has been proposed as a 
major mediator of leptin’s antidiabetic effects, with IGFBP2 overexpression reversing diabetes in leptin-deficient 
animals.  In addition, leptin may have effects on glycemia independent of improvements in insulin sensitivity, 

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via overlapping post-receptor signaling pathways between insulin and leptin, including phosphatidylinositol 3-
kinase20. 
 
Leptin also has effects on other organ systems, including bone.  In rodent models, leptin deficiency is associated 
with decreased cortical bone in the vertebrae and limbs, and increased trabecular bone in the vertebrae.  These 
effects are reversed with leptin administration; hence, leptin replacement results in overall increased bone 
mineral density21.  This effect has not been well-studied in humans.   
 
Leptin in lipodystrophy 
Lipodystrophies, in which there is partial or complete absence of adipose tissue (and hence, adipokines such as 
leptin), represent another model for understanding the actions of leptin in a state of deficiency and replacement.  
Unlike patients with congenital leptin deficiency, patients with lipodystrophy are non-obese, but have more 
extreme manifestations of the metabolic syndrome due to factors such as ectopic lipid storage22,23.  Leptin 
replacement in lipodystrophy reduces food intake24,25 and ameliorates most metabolic abnormalities, including 
insulin resistance25-27 and diabetes26,28,29, hypertriglyceridemia27-29, and hepatic steatosis25,30. Based on data 
derived largely from studies conducted in the intramural research program of the NIDDK, the FDA approved 
metreleptin (recombinant methionyl leptin) for the treatment of generalized lipodystrophy in February, 2014; 
however, leptin remains an experimental therapy in other forms of lipodystrophy, including partial 
lipodystrophy. 
 
Limited information is available about the time course of leptin’s effects in lipodystrophy.  In seven patients with 
generalized lipodystrophy, declines in glucose and triglyceride levels reached statistical significance by 7 days 
after leptin initiation31.  In these subjects, non-significant increases in insulin sensitivity (measured using the 
hyperinsulinemic, euglycemic clamp) were seen one month after starting leptin, and significant increases after 2 
months.   
 
More detailed mechanistic studies of leptin’s effects on glucose and lipid metabolism after 3-8 months have been 
performed on three patients with lipodystrophy (one acquired generalized and two congenital generalized)25.  
Using stable isotope infusions in combination with the hyperinsulinemic, euglycemic clamp, these subjects in the 
leptin deficient state were shown to have elevated hepatic glucose production and severe hepatic insulin 
resistance compared to healthy controls.  After leptin replacement for 3-8 months, hepatic insulin resistance 
decreased to nearly that of controls, and insulin-stimulated glucose disposal doubled.  These changes were 
associated with an 86% reduction in hepatic triglyceride content and a 33% reduction in muscle triglyceride, 
suggesting that reduction in ectopic lipid may have contributed to the improvements in insulin sensitivity.  Non-
significant decreases in glycerol turnover were also observed following leptin treatment, suggesting that leptin 
increased lipolysis in any existing adipose tissue or within ectopic lipid stores.  In a single subject, a 30% 
reduction in muscle fatty acyl CoA levels was observed after leptin replacement, offering support for the 
hypothesis that these compounds contribute to insulin resistance by interfering with insulin receptor substrate-1 
(IRS-1) tyrosine phosphorylation, a key step in the insulin signaling cascade.  In summary, leptin appears to 
improve plasma glucose and triglycerides within 1 week, while improvements in insulin sensitivity may be 
detectable by one month, with continued improvement thereafter, and changes in ectopic lipid storage may not 
be detectable for several months after leptin initiation. 
 
The effect of leptin on lipid metabolism has also been examined in a randomized, controlled trial of leptin for 4 
months in 17 men with HIV associated lipodystrophy32.  In this trial, the authors did not find any effects of leptin 
treatment on lipid metabolism, including fasting triglycerides, rates of lipolysis, and fatty acid oxidation.  This 
suggests that there may be differences in the effect of leptin on lipid metabolism in HIV patients versus the non-
HIV infected population studied at NIH.  These differences may be related to the severity of the phenotype 
(typically milder in HIV) or to the doses of leptin used in the HIV study (0.02-0.04 mg/kg/day, which is 25-50% 
of the lowest doses used in NIH studies). 
 

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Energy intake independent effects of leptin 
In lipodystrophy, as in other models of leptin deficiency, leptin replacement causes a reduction in spontaneous 
food intake by approximately 50% 24,25.  It is likely that reduced energy intake is at least partially responsible for 
observed changes in glucose and lipid metabolism in lipodystrophic patients, as caloric restriction or fasting has 
long been known to improve glycemia control in patients with diabetes. Prior to the development of insulin, 
starvation followed by severe carbohydrate restriction was state of the art treatment for diabetes33.  Marked 
improvement in blood glucose with less severe caloric restriction (330 – 1800 kcal per day for 3-21 days) has 
been shown by multiple researchers since that time 34-41.  Two studies in this group 36,41 demonstrated an 
approximately 50% rise in insulin sensitivity, suggesting that improvements in insulin sensitivity may be a major 
mechanism underlying lower blood glucose levels following caloric restriction. 
 
In rodent models of leptin deficiency, pair-feeding studies have been performed to assess the energy intake-
independent effects of leptin replacement.  Leptin effects in rodents that have been shown to be at least partly 
independent of energy intake include increased energy expenditure15, increased body temperature9, decreased 
insulin resistance9,14,16-18, and decreased blood glucose9,14,16,17.  In contrast, leptin’s effects on triglycerides and 
free fatty acids in rodents were not independent of energy intake15.   
 
In humans, the energy intake-independent effects of leptin have been assessed in only two studies.  A single 
patient with acquired, generalized lipodystrophy was studied while taking leptin, and during leptin withdrawal, 
while maintaining constant energy intake29.  In this patient, blood glucose did not change during leptin 
withdrawal, a rise in serum insulin (indicative of worsening insulin resistance) was seen after four days, and a 
rise in triglycerides after seven days.  Although based on a single subject, these data suggest that leptin’s effects 
on both insulin resistance and lipids may be partly independent of energy intake in humans.  Liebel’s group 
studied the energy intake-independent effects of leptin in ten healthy subjects following 10% weight loss, a 
model of relative leptin deficiency11.  Subjects in the weight-reduced state were studied before and after five 
weeks of leptin replacement to pre-weight-loss levels, while maintaining constant energy intake.  Leptin 
replacement resulted in an increase in energy expenditure to pre-weight-loss levels that appeared to be due to 
changes in skeletal muscle work efficiency, thyroid hormones, and catecholamines.  Because these subjects did 
not have abnormalities of glucose or lipid metabolism, the energy intake-independent effects of leptin on these 
parameters were not examined. 
 
 
Subject Eligibility Assessment and Enrollment 
Inclusion Criteria 
1. Age 14-70 years (children under age 18 will only be enrolled in the leptin-naïve arm of the study 
[Inclusion criterion 3b, below) 
2. Clinically-significant lipodystrophy as summarized below: 
a. Lipodystrophy identified by the study physician during physical examination as an absence of 
fat outside the range of normal variation. 
b. Circulating leptin levels < 12.0 ng/mL in females and < 8.0 ng/mL in males 
c. Presence of at least one of the following metabolic abnormalities: 
i. Diabetes as defined by the 2007 American Diabetes Association criteria: 
1. Fasting plasma glucose ≥ 126 mg/dL, or 
2. 2-hour plasma glucose ≥ 200 mg/dL following a 75 gram 91.75 gm/kg) oral 
glucose load, or 
3. Diabetic symptoms with a random plasma glucose ≥ 200 mg/dL. 
ii. Fasting insulin >30 µU/mL 
iii. Fasting hypertriglyceridemia >200 mg/dL  
 
3. Either: 

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a. Leptin naïve, with plans to initiate leptin treatment during the current study.  For the purpose of 
this study, “leptin naïve” will be defined as having received no exogenous leptin in the 4 months 
prior to study participation.  Thus, subjects who previously received leptin therapy, 
discontinued, and wish to restart are eligible. 
Or 
b. Leptin treated, meaning the subject has taken a stable dose of exogenous leptin for a minimum 
of 4 months prior to study entry (adults over age 18, only) 
 
Exclusion Criteria 
In leptin treated subjects only, the following exclusion criteria apply: 
1. Poorly controlled diabetes at study entry (hemoglobin A1c ≥ 9%). 
2. Poorly controlled hypertriglyceridemia at study entry (serum triglycerides > 800 mg/dL). 
3. Extreme hypertriglyceridemia prior to leptin (preleptin triglycerides greater than 2000 mg/dL). 
4. History of chronic or recurrent acute pancreatitis (>1 episode), or a single episode of pancreatitis while 
receiving leptin treatment. 
5. Lipase greater than the upper limit of normal (491 units/L) at study entry. 
6. Known presence of neutralizing antibodies to leptin. 
 
In all subjects (leptin treated and leptin naïve), the following exclusion criteria apply: 
7. Known HIV infection or HIV-associated lipodystrophy. 
8. History of diabetic ketoacidosis. 
9. Active inflammatory disease (e.g. dermatomyositis). 
10. Change in diabetes or lipid-lowering medications within the past 6 weeks. 
11. Estimated glomerular filtration rate < 30 mL/minute. 
12. Current or recent (past 2 weeks) use of systemic glucocorticoids. 
13. Inadequately controlled hypothyroidism (TSH < 0.4 or >4 mcIU/L) or change in thyroid medication in 
the past 8 weeks. 
14. Pregnancy or breast-feeding. 
15. Psychiatric disorder impeding competence or compliance. 
16. Any medical condition or medication that will increase risk to the subject (e.g. ischemic heart disease, 
decompensated liver disease) or that will interfere with interpretation of study data (e.g. Cushing’s 
syndrome). 
17. Current alcohol or substance abuse. 
18. Subjects who have a known hypersensitivity to E. coli derived proteins. 
19. Subjects with acquired lipodystrophy and a hematologic abnormality such as neutropenia and/or 
lymphadenopathy. 
 
 
Study Design and Statistical Analysis 
 
Design 
 
This is a prospective, non-randomized, study.  Two groups of subjects will be studied.  In the leptin naïve group, 
subjects with lipodystrophy who have not received leptin therapy in the past 4 months will be studied first in the 
leptin deficient state (Period 1), and second during the first 14 days of leptin initiation (Period 2).  In the leptin 
treated group, subjects with lipodystrophy who have been receiving stable doses of leptin for a minimum of 4 
months will be studied first in the leptin replete state (Period 1), and then during a 14 day period of leptin 
withdrawal (Period 2).  Throughout both periods, subjects will consume an isocaloric diet (described in detail 
under Study Implementation, below), thus controlling for any effects of leptin on energy intake.  Measurement of 
metabolic and endocrine parameters will be performed on admission, at the end of Periods 1 and 2, and at 

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intermediate time points during Period 2.  Subjects in the leptin naïve group will be restudied 6 months (range, 5-
9 months) after starting leptin.  At that time, options for continued treatment with leptin will be discussed and/or 
facilitated (see Long-term follow up, below).  Given budgetary constraints, foreign subjects will be given the 
option to return in 12 months and will be asked to have lab work completed locally 3-6 months after starting 
leptin. 
 
 
Randomization 
Although the optimal method to study the time course of leptin’s effects would be a randomized, double-blinded, 
placebo controlled, cross-over study, such a study design is not feasible in this population.  Lipodystrophy is an 
extremely rare disease, reported in only about 1000 patients worldwide42.  The NIH study of leptin treatment in 
lipodystrophy currently follows approximately 65 active patients.  A randomized, cross-over design would 
require a subset of these patients to undergo multiple visits to NIH of approximately 16 days, separated by wash-
out periods of approximately 4 months.  Subjects newly starting on leptin could not be enrolled, as leptin could 
not be ethically withheld during the washout period.  The likelihood of enrolling a sufficient number of subjects 
to complete such a study is very low.  Therefore, we have chosen a more feasible study design in which the 
effects of short-term leptin initiation and withdrawal can be examined in a non-randomized fashion.   
 
Outcome Measures 
The primary aim of this study is to determine the energy intake-independent effects of leptin on energy 
metabolism in lipodystrophic subjects.  Important aspects of energy metabolism to be studied include glucose 
metabolism, lipid metabolism, and energy expenditure.  For each of these three aspects of energy metabolism, 
we will measure a primary, secondary, and one or more exploratory outcomes, as follows: 
 
Glucose Metabolism 
• 
Primary outcome: Total body insulin sensitivity (measured as glucose disposal rate during a 
hyperinsulinemic, euglycemic clamp) 
• 
Secondary outcomes: 
o Hepatic insulin sensitivity (measured as suppression of endogenous glucose production during a 
hyperinsulinemic, euglycemic clamp) 
o Fasting plasma glucose 
o Fasting C-peptide 
• 
Exploratory outcomes: 
o Insulin-like growth factor binding protein 2 (IGFBP2) and other novel mediators of leptin action 
on glycemia 
 
Lipid Metabolism 
• 
Primary outcome: Rate of lipolysis (measured using stable isotope tracers) 
• 
Secondary outcomes: 
o Fasting plasma triglycerides 
• 
Exploratory outcomes: 
o Rate of fatty acid turnover (measured using stable isotope tracers) 
o Liver triglyceride (measured using MRI and MRS) 
o Muscle triglyceride (measured using MRS)  
 
Energy Expenditure 
• 
Primary outcome: Total 24 hour energy expenditure (measured using indirect calorimetry in the 
metabolic chamber)  
• 
Secondary outcomes: 
o Resting energy expenditure (measured using indirect calorimetry with a hood) 

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o Skeletal muscle work efficiency (measured as the exercise-induced incremental change in 
energy expenditure above resting energy expenditure) 
• 
Exploratory variables: 
o Spontaneous physical activity (measure using portable accelerometers) 
o Thyroid function 
o Urine and plasma catecholamines 
o Cardiac autonomic nervous system tone (measured using heart rate variability analysis) 
 
Additional outcomes include the following: 
Thermal regulation 
• 
Core versus peripheral body temperature 
• 
Thermal comfort (measured using visual analog scales) 
Endocrine 
• 
LH pulsatility analysis 
Other 
• 
Blood pressure (measured using 24 hour ambulatory monitoring) 
• 
Hunger and satiety (measured using visual analog scales) 
• 
Markers of bone turnover (-CTX and P1NP) will be measured to look for potential effects of leptin 
on bone formation and resorption. 
 
Statistical Considerations 
Sample Size Justification 
This is an exploratory study of the energy-intake independent effects of leptin initiation and withdrawal in 
lipodystrophy.  Preliminary data are not available to generate estimates of power for each outcome to be tested.  
The primary comparisons to be tested for each outcome of interest are results at the end of Period 1 versus the 
end of Period 2, analyzed separately for each group of subjects (leptin-naïve versus leptin treated).  Thus, sample 
size calculations are based on paired, before and after, comparisons within each group of subjects.  The data and 
references used for power calculations are shown in the table, below.  Data in the table using the 10% weight 
loss model are given as percent change from pre-weight loss values, while data from lipodystrophy patients are 
given as absolute differences between leptin treated and untreated states.  All calculations assumed a sample size 
of 10 and an alpha of 0.05, without correction for multiple comparisons.  Because the standard deviations (SDs) 
of differences between on and off leptin conditions were not reported in publications, the SDs of the difference 
(used to calculate power for paired comparisons) was estimated in two ways:  First, the SDs of differences are 
calculated by assuming that the SDs of on and off leptin reported in the literature are independent (Power 1 in the 
table). Second, a “worst-case scenario” was assumed that the SDs on and off leptin in the literature are perfectly 
positively correlated (Power 2 in the table). The first scenario is the commonly used method, while the second 
case is the most conservative calculation.   
 
Outcome 
Model 
Duration 
of leptin 
Off-leptin 
mean (SD) 
On-leptin 
mean (SD) 
Power 
1 
Power 
2 
Total energy expenditure11 (%   in 
kcal/day) 
10% wt loss 
5 wk 
-22% (15.8) 
-6% (4.7) 
0.92 
0.79 
Skeletal muscle work efficiency11 (% 
  in kcal/min expended during 
exercise vs. at rest) 
10% wt loss 
5 wk 
20% (12.6) 
3% (2.5) 
0.99 
0.97 
Resting energy expenditure24 
lipodystrophy 
4 mo 
35.5 (8.2) 
33.6 (6.7) 
0.14 
0.11 
T311 (% ) 
10% wt loss 
5 wk 
-9% (6.3) 
3% (3.2) 
0.99 
0.99 

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T343 (nmol/L) 
lipodystrophy 
4 mo 
124 (37) 
114 (26) 
0.18 
0.13 
T411 (% ) 
10% wt loss 
5 wk 
-7% (7.9) 
-1% (1.3) 
0.77 
0.66 
fT443 (pmol/L) 
lipodystrophy 
4 mo 
1.05 (0.15) 
1.03 (0.15) 
0.09 
0.08 
TSH43 (U/mL) 
lipodystrophy 
4 mo 
1.37 (0.37) 
1.24 (1.1) 
0.10 
0.09 
Norepinephrine11 (% ) 
10% wt loss 
5 wk 
-12% (15.8) 
-7% (12.6) 
0.19 
0.14 
Epinephrine11 (% ) 
10% wt loss 
5 wk 
-40% (35) 
28% (47) 
0.98 
0.83 
Sympathetic nervous system tone11 
(%  in mean ECG R-R interval after 
atropine + esmolol vs. atropine alone) 
10% wt loss 
5 wk 
-25% (22.1) 
1% (1.6) 
0.98 
0.97 
Liver volume24 (cm3) 
lipodystrophy 
4 mo 
3055 (1051) 
2433 (763) 
0.45 
0.29 
Total body insulin sensitivity31 
(glucose infusion rate during clamp, 
mg*kg-1*min-1) 
lipodystrophy 
1 mo 
2.5 (0.79) 
3.7 (1.1) 
0.87 
0.63 
Total body insulin sensitivity25 
(glucose infusion rate during clamp, 
mg*kg-1*min-1) 
lipodystrophy 
4 mo 
1.2 (0.35) 
5.4 (1.6) 
1 
1 
Hepatic insulin sensitivity25 (% 
suppression of endogenous glucose 
production during clamp) 
lipodystrophy 
4 mo 
40 (10.4) 
82 (8.7) 
1 
1 
Fasting glucose31 (mg/dL) 
lipodystrophy 
7 d 
172 (20) 
120 (12) 
1 
0.99 
Fasting triglycerides31 (mg/dL) 
lipodystrophy 
7 d 
700 (272) 
260 (98) 
0.99 
0.98 
Fasting triglycerides31 (mg/dL) 
lipodystrophy 
14 d 
700 (272) 
110 (38) 
1 
0.99 
Rate of lipolysis25 (glycerol turnover, 
mol*kg fat mass-1*min-1 
lipodystrophy 
4 mo 
78 (36) 
25 (7) 
0.99 
0.99 
 
Based on these calculations, a sample size of 10 subjects in each group (leptin-naïve and leptin-treated) will 
provide greater than 80% power (in most cases greater than 95%) for the following primary and secondary 
outcomes: 
Glucose Metabolism 
1. Total body insulin sensitivity 
2. Hepatic insulin sensitivity  
3. Fasting plasma glucose 
Lipid Metabolism 
1. Rate of lipolysis 
2. Fasting triglycerides 
Energy Expenditure 
1. Total energy expenditure 
2. Skeletal muscle work efficiency 
 
Exploratory outcomes for which we anticipate greater than 80% power include epinephrine and sympathetic 
nervous system tone.  Discrepant data exist for the effects of leptin on thyroid function (specifically, T3) based 
on the model used (lipodystrophy versus 10% weight loss), and this study should help to clarify whether this 
effect does or does not exist in lipodystrophy.  We do not anticipate observing significant changes in resting 
energy expenditure; however, because this procedure is minimal risk, we feel that it will be important to 
document negative results for this outcome.  Certain outcome measures, such as liver triglyceride (for which 
liver size was a proxy in the table, above), and insulin sensitivity, appear to progressively change over time with 
leptin replacement.  For these outcomes, a 2 week intervention may be insufficient to observe statistically 
significant results.  For other outcome measures, such as intramyocellular triglyceride, preliminary data on the 
short-term effects of leptin are not available, but effects, if present, are unlikely to be detectable by two weeks. 

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Therefore, in addition to obtaining data after 2 weeks of leptin withdrawal or initiation, we will restudy subjects 
in the leptin-naïve group 6 months (range is 5-9 months) after leptin initiation to look for changes that may not 
be detectable by 2 weeks. 
 
Because some subjects may not complete the study, or may not have interpretable data for each outcome, we 
plan to enroll up to 20 subjects in each group in order to have 10 completers per group. 
 
Statistical Methods for Data Analysis 
Data will be analyzed separately for the leptin naïve and leptin treated subjects.  This is done because the effects 
of leptin withdrawal after long-term treatment are likely to be different from the effects of leptin initiation after 
long-term deficiency. 
 
Analysis of Primary Outcomes 
Measurements in each of the primary outcomes will be analyzed using the paired t-test (for normally distributed 
variables) or Wilcoxon paired test (for skewed variables) to test if there is any significant difference between the 
two study periods (on and off leptin) for each group (leptin naïve and leptin treated), respectively. In addition, 
mixed models incorporating baseline (pre-diet) parameters as covariates will be used to adjust for any effects of 
the inpatient, metabolic diet, independent of leptin’s effects.  For variables with more than 2 measurements 
during Period 2, repeated measure linear models (Mixed model or GLM) will be used to study the time effect, 
using pooled data from the 2 periods. Potential covariates to be explored in the model include: Age, sex, race, 
percent body fat, lean mass, body weight, type of lipodystrophy, and endogenous leptin level.  To account for 
any deviation from the isocaloric protocol diet, actual caloric intake will be included as a covariate in mixed 
model analyses. 
 
Additional correlations between variables within and between each of the major outcome categories (glucose 
metabolism, lipid metabolism, and energy expenditure) will be analyzed using either Pearson’s correlation or 
simple linear regressions. These include the following: 
1. Association between change in total body insulin sensitivity and changes in hepatic insulin sensitivity, 
fasting plasma glucose, and C-peptide  
2. Association between change in rate of lipolysis, and changes in fasting triglycerides and fatty acid 
turnover 
3. Association between insulin sensitivity and ectopic lipid stores, and rates of lipolysis and fatty acid 
turnover 
4. Association between change in total energy expenditure and changes in resting energy expenditure, 
skeletal muscle work efficiency, spontaneous physical activity, thyroid function, catecholamines, and 
cardiac autonomic nervous system tone. 
 
Analysis of Secondary and Exploratory Outcomes 
Methods for analysis of secondary outcomes will be similar to those for primary outcomes. In addition, we will 
perform analysis to study the following associations between categories of outcome measures: 
1. Association between the Ectopic Lipid measurements with Glucose and Lipid measurements 
2. Association between the Endocrine measurements with Energy Expenditure measurements 
 
Analysis of long-term data 
Additional follow up data will be obtained and analyzed 6 to 12 months after leptin initiation for the leptin naïve 
patients.  Long-term follow-up measurements for this group will be compared with the baseline using paired 
comparisons. Time-dependent effects will also be investigated using repeated measures analysis. The analysis 
methods to be used are similar to those used in the primary outcome analyses. 
 
By Group Comparisons 

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Although most of the analyses will be performed separately for leptin naïve vs. leptin treated patients due to the 
consideration stated previously, exploratory analyses will be carried out to compare the two study groups.  These 
analyses include: 
1. Comparison of outcomes and baseline characteristics by group will be performed using t-test or rank 
test, depending on the distribution of measurement compared 
2. Model analysis using general linear models will be performed by including group as a factor 
 
Study Implementation 
Subjects will be admitted to the Metabolic Research Unit in the NIH Clinical Center.  They will remain as 
inpatients throughout the 19 day duration of the short-term portion of the study.  After admission, they will 
undergo a history and physical examination, and baseline labs will be obtained.  Baseline phenotyping will 
include measurement of resting energy expenditure, hemoglobin A1c, and fasting lipid panel, glucose, insulin, 
and C-peptide. Fasting triglycerides and hemoglobin A1c will be used to assess subject eligibility in the leptin 
treated group.  Additional labs used to assess subject eligibility in all subjects include electrolytes, BUN, 
creatinine, CBC, and a pregnancy test for female patients of reproductive potential. Height, weight, blood 
pressure, resting pulse, temperature, and anthropometric data (e.g. skin fold measurements, waist circumference, 
etc.) will be obtained. Additionally, the clinical testing that was formerly included in 02-DK-0022 will be done:  
ECHO, OGTT, liver/abdominal and pelvic ultrasounds. 
 
Diet 
 
After baseline phenotyping, subjects will be placed on a low fat (20±5% protein, 25% fat, 55±5% carbohydrate), 
weight maintenance diet from the metabolic research kitchen.  Total caloric requirements will be estimated by 
the research dietitian.  Due to the low proportion of body fat in people with lipodystrophy, all male and female 
subjects’ energy needs will be estimated using the Mifflin St. Joer equation for males with an activity factor of 
1.3. Upon admission, resting energy expenditure will be measured and dietary energy will be adjusted as needed. 
The diet may be adjusted during the first few days, but will be continued for the remainder of the study without 
change.   
 
In the leptin naïve group, appetite is expected to decrease following leptin initiation during Period 2, although the 
early time course of this effect is not known.  Subjects will be encouraged to eat all food presented to them by 
the metabolic kitchen in order to maintain the isocaloric nature of the diet throughout both periods.  However, if 
they are unable to consume all food, the uneaten portion will be returned to the metabolic kitchen and weighed to 
document the extent of deviation from the isocaloric diet.  Analogously, in the leptin-treated group, subjects may 
feel hungry after leptin withdrawal, but will only be permitted to eat the food provided by the metabolic kitchen. 
 
In prior studies of leptin replacement in lipodystrophy, subjects had a mean weight loss of only 2.8 kg (4.6% of 
initial body weight) after 4 months of leptin replacement.  Hence, changes in body weight during the course of 
the 3 week inpatient portion of this study are not expected to be clinically significant.  Because each subject will 
be compared with him/herself in the leptin deficient versus leptin replaced state, maintaining constant 
(isocaloric) food intake during both conditions will allow assessment of the energy-intake independent effects of 
leptin. 
 
Medications 
Leptin Treatment 
Any subject starting leptin on this study will get it through NIH under IND, regardless of whether or not they fit 
in an FDA approved category.  After the follow-up visits, subjects who are eligible will be transitioned to 
commercial drug supply through their physician.  Subjects undergoing leptin withdrawal may receive leptin 
under IND or FDA approved commercial drug, depending on the timing of their study participation. 
 
Details of leptin administration and dosing for the subjects who are leptin treated are as follows:  

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Formulation, storage conditions/stability, and drug reconstitution are detailed in the package insert (Appendix 
C).  For patients receiving metreleptin through the NIH Pharmacy, the following additional conditions will 
apply: 
 
Storage Conditions and Stability: 
The study drug must be stored in a secure location under controlled conditions at the study site or pharmacy 
before dispensing to subjects.  Metreleptin must be stored at 2-8o C prior to reconstitution.  It is recommended 
that the refrigerator be connected to a back-up power source, and a temperature alert system.  Aegerion 
Pharmaceuticals must be notified if any test material is exposed to excessive or uncontrolled temperatures; 
possible replacement of the affected material will be considered.  Study staff must be instructed in proper storage 
of the study drug.   
 
Storage Temperature Monitoring: 
Records of the storage conditions should be maintained throughout the study by either a continuous temperature 
recording system, a regularly maintained temperature alarm system or by regular visual inspection of a calibrated 
thermometer placed inside the refrigeration unit.  
 
Expiration Dating: 
As per standard practice for experimental biologic pharmaceuticals, Aegerion Pharmaceuticals will conduct 
periodic stability assays to monitor product stability and determine appropriate expiration dating of the study 
drug.  The appropriate Aegerion Pharmaceuticals representative shall communicate this information to the 
investigator. 
 
Availability 
Metreleptin is being supplied by Aegerion Pharmaceuticals.   
 
Initial Drug Shipment and Re-Supply 
A signed and completed Drug Request Form must be emailed, at least 5 days prior to the expected delivery date, 
to Aegerion Supply Chain for approval and processing at Orders.GAP@aegerion.com.  At the end of the study, 
and after full accountability is performed on study drug or site closure, study drug destruction will occur at NIH. 
 
Supply of Drug 
The study test drug will be shipped to the investigator's institution and should be checked for amount and 
condition of the drug received.  This data will be entered into the proof of receipt letter.  The proof of receipt 
letter should be faxed to the appropriate Aegerion Pharmaceuticals representative at the number indicated on the 
letter and the original retained in the pharmacy files. 
 
Side effects: 
Side effects of metreleptin observed in all clinical studies, including in patients with generalized or partial 
lipodystrophy, are detailed in the package insert (Appendix C) 
 
Dosing of metreleptin: 
Leptin treated subjects: Leptin treated subjects take leptin as once or twice daily subcutaneous injections, at 
doses between 0.06 and 0.24 mg per kg per day.  The total daily dose and dosing interval is determined by both 
clinical response and the total volume of medication to be delivered.  During Period 1, the leptin treated group 
will continue their previous dose of leptin (≤ 0.24 mg/kg/day), and injections will be given at approximately 8 
am, and 8 pm (for patients on twice daily dosing).   
 

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Leptin naïve subjects: For leptin naïve patients, leptin will be initiated at a dose of 5 mg twice daily in subjects 
weighing at least 50 kg.  This dose is equivalent to 0.14 mg/kg/day for a 70 kg individual.  For subjects weighing 
less than 50 kg, leptin will be initiated at a dose of 0.15 mg/kg/day, divided twice daily.  For comparison 
purposes, a typical starting dose of leptin given to lipodystrophy patients who were previously enrolled in 
protocol 02-DK-0022 is 0.08-0.1 mg/kg/day, and the range of doses used in these patients is between 0.06 and 
0.24 mg/kg/day.  Thus, the starting dose of leptin used in this study is slightly higher than that which was 
typically used in protocol 02-DK-0022, but well within the typical dose range.  This higher starting dose was 
chosen to maximize the probability of observing effects from leptin within the short, 2 week duration of this 
study.  We do not anticipate a significantly increased risk of adverse events related to this higher starting dose 
(see Risks). The first dose of leptin will be given at approximately 8 am on the first day of Period 2 (Day 0).  
Dosing will continue unchanged throughout Period 2.  At discharge, leptin doses may be adjusted based on 
individual patient responses, and future dose adjustments will be conducted as outlined below. 
 
Dose escalation: 
The dose of metreleptin will be increased beyond 5 mg twice daily (or 0.15 mg/kg/day in patient under 50 kg) 
only if there is a clear decline in metabolic status without alternative explanations for the metabolic change (such 
as an infection, noncompliance or dietary indiscretion).  It is important to note this because of the wide range of 
variation in the clinical presentation of these patients, it is impossible to define pre-determined thresholds of 
metabolic parameters that would appropriately guide dose modifications.  Instead, the PI will use best clinical 
judgment to make dose modifications based on the constellation of metabolic and clinical data available for each 
patient.  Dose escalations will be capped such that the total dose administered will not exceed 0.24 mg/kg/day for 
any patient without seeking prior permission from the FDA, the NIDDK/ NIAMS IRB and Aegerion 
Pharmaceuticals, the manufacturer of Metreleptin.  If subjects do not tolerate a higher dose level, they can 
continue the study at the next lowest tolerated dose.  Based on previous clinical experience with Metreleptin, 
tolerance to Metreleptin at doses between 0.12-0.24 mg/kg/day is not expected to be an issue.  
 
Dose reduction: 
The dose of metreleptin will be decreased if a subject experiences excessive weight loss (BMI below the normal 
range for age and sex, or a lesser degree of weight loss that is distressing to the patient).  Doses will also be 
decreased if a subject experiences injection site reactions that cannot be controlled with antihistamines and/or 
analgesics. 
 
 
Leptin Withdrawal 
For leptin treated subjects, the last dose of leptin will be given on the final day of Period 1 (Day -1) at either 8 
am or 8 pm, depending on whether the subject receives once or twice daily dosing.  No leptin will be given 
during Period 2 (Days 0-13).  Leptin will be resumed on the morning of Day 14 at the previous dose.  In patients 
who were treated with leptin under protocol 02-DK-0022, we typically recommend tapering of leptin over a 1 
week period in patients who stop leptin treatment in an outpatient setting.  In contrast, in this protocol, leptin will 
be stopped without a taper under inpatient observation.  The risks of stopping leptin are discussed under Risks. 
 
Pre-study Medications 
With the exception of insulin (discussed below) subjects will continue their pre-admission medications 
throughout the study.  This includes oral hypoglycemic agents, lipid-lowering medications, and other 
medications either related or unrelated to lipodystrophy and its complications. 
 
Glucose Management 
Leptin naïve subjects: Leptin naïve subjects who take insulin or insulin secretagogues may be at risk of 
hypoglycemia after leptin initiation due to improvements in insulin sensitivity.  Bedside blood glucose 
monitoring will be performed prior to meals and at bedtime (or more frequently if clinically indicated) in diabetic 

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subjects.  Adjustments in insulin doses will be made on an as-needed basis to maintain blood glucose within a 
target range of 100-180 mg/dL. 
 
Leptin treated subjects: Bedside blood glucose monitoring will be performed prior to meals and at bedtime (or 
more frequently if clinically indicated) in all subjects in this group.  In leptin-treated subjects who take insulin, 
home insulin doses will be continued throughout the study.  We anticipate that subjects in the leptin treated 
group (regardless of whether they require insulin at home) may have worsened insulin sensitivity during leptin 
withdrawal, and hence, may experience hyperglycemia.  As changes in blood glucose are a major outcome of 
this study, insulin will not be started, nor will home insulin doses be increased, unless a subject has fasting blood 
glucoses greater than 300 mg/dL, non-fasting glucose > 500, or a 200 mg/dL increase from baseline in either 
fasting or non-fasting glucose. Unlike patients with type 1 diabetes, patients with lipodystrophy are at extremely 
low risk of developing diabetic ketoacidosis; hence, the risks associated with short-term hyperglycemia are 
minimal (see Risks). 
 
Standardized Exercise 
In order to maintain physical fitness during the three week hospitalization, sedentary subjects will engage in 30 
minutes of walking on a treadmill each day (during both Periods 1 and 2) at a mild to moderate self-selected 
pace.  In subjects who habitually exercise, the duration and intensity of exercise will be increased to be 
consistent with their typical exercise routine. 
 
Study Procedures 
Subjects will undergo metabolic and endocrine testing at the end of Period 1 and at the end of Period 2.  Certain 
tests will also be performed at earlier time points during Period 2, in order to clarify the time course of leptin 
initiation and withdrawal on these outcomes.  Explanations for the timing of these tests are provided in the 
detailed test descriptions.  A summary of the test schedule is in the table, below.  Tests associated with Period 1 
and the follow-up are highlighted in gray.  The exact timing of each test may vary slightly due to practical 
scheduling issues.  A sample patient calendar is given in Appendix A. 

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Period 1 
Period 2 
 Study Day 
-
5 
-
4  
-3  -2  -1  0  
1  
2  3  4  
5  
6  
7  
8  
9  10  11  12  13  14  
Metabolic 
Chamber  
 
 
 
 
x  
 
 
 
 
 
 
 
x  
 
 
 
 
 
x  
 
24 hr urine 
 
 
 
 
x 
 
 
 
 
 
 
 
x 
 
 
 
 
 
x 
 
DEXA 
 
 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
Skin temperature  
 
 
x 
 
x  
 
 
 
 
 
x     
 
 
 
 
x 
 
x 
 
Exercise test 
 
 
x 
 
 
 
 
 
 
 
x 
 
 
 
 
 
x 
 
 
 
Resting Energy 
Expenditure 
x 
 
 
x  
 
 
x 
 
 
 
x 
 
 
 
x 
 
 
x  
 
 
Blood pressure 
monitoring  
 
 
 
x 
x 
x  
x 
 
 
 
 
 
 
 
 
 
 
x 
x 
 
Heart rate 
monitoring 
 
 
 
x 
x 
x 
x 
 
 
 
 
 
 
 
 
 
 
x 
x 
 
Euglycemic    
Clamp  
 
 
 
x  
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
 
 
Glucose & lipid 
turnover 
 
 
 
x  
 
 
 
 
 
 
 
x  
 
 
 
 
 
x  
 
 
LH pulsatility 
 
 
x  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x  
 
 
MRI/MRS 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
x 
 
 
 
Fasting research 
blood tests  
x 
 
 
 
x  
x  
 
x   
x  
 
x  
 
x  
 
x  
 
x  
x 
 
Safety labs 
x 
 
 
 
x  
x  
 
x   
x  
 
x  
 
x  
 
x  
 
x  
x 
 
Actigraphy  
 
 
x  
x 
x  
x  
x  
x  x  x  
x  
x  
x  
x  
x  x  
x  
x 
x  
 
Vital signs  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Anthropometrics 
x 
 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
Bedside glucose 
monitoring 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Pregnancy test 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
 
 
 
Echocardiogram 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ultrasounds 
x 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
OGTT 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Long-term follow-up 
Certain effects of leptin may not be detectable, or may be submaximal, within the 2-week intervention period in 
this study.  These include changes in liver steatosis and insulin sensitivity.  For this reason, we wish to study the 
longer-term (6 months) effects of leptin in subjects participating in this study.  Therefore, we plan to restudy 
subjects in the leptin naïve group and bring them in for follow-up 6 months (range, 5-9 months) after starting 
leptin.  Given budgetary and logistical issues, foreign patients may be seen for follow-up 12 months after 
initiating leptin therapy.  We will ask them to obtain lab work locally and send us the results.  It will not be 
possible to maintain an isocaloric diet for 6 months after leptin initiation in the free-living environment.  

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Therefore, long-term follow-up data on leptin’s effects will not help to answer questions about the energy intake 
independent effects of leptin.  Nonetheless, these data will provide valuable additional information about the 
time course of leptin’s actions in lipodystrophy.  Testing during the follow-up visits will mimic that performed 
during Period 1. 
 
Metabolic Testing 
1. Exercise testing: Testing will be performed at the end of Period 1, in the middle and end of Period 2, and 
during the long-term follow-up visit for subjects in the leptin-naïve group.  Skeletal muscle work 
efficiency will be measured as the increment in energy expenditure above resting energy expenditure 
during exercise, with lower incremental increase in energy expenditure corresponding to greater muscle 
work efficiency.  This test will be conducted on a cycle ergometer.  Following a 10 minute warm-up 
period, subjects will pedal at 60 rpm with the resistance adjusted to generate 10W of power for 4 
minutes.  The resistance will then be increased such that the power generated is 25W for 4 minutes, then 
50W for 4 minutes.  Breath-by-breath oxygen consumption and carbon dioxide production will be 
collected and averaged every 30 seconds using a metabolic cart (ParvoMedics TrueOne2400, Sandy 
UT).  Heart rate will be monitored by electrocardiograph.   
 
2. Free-living physical activity (actigraphy) will be quantified minute-by-minute using small, portable 
pager-type and watch accelerometers at the subjects’ hip and wrist. Overall physical activity levels, daily 
changes, amount of time spent in sedentary, moderate, vigorous intensity categories and activity-
associated energy expenditures will be extracted [35]. Actigraphy will be conducted continuously 
throughout the study, beginning on Day -5, and ending on Day 14, and during the long-term follow-up 
visit for subjects in the leptin-naïve group 
 
3. Resting Metabolic Rate (RMR):  The RMR will be measured upon awakening before breakfast after a 
minimum 8 hour fast, in a resting supine position using the standard technique of the Clinical Center. 
This is done using a microprocessor-controlled indirect calorimetry device (ParvoMedics TrueOne2400, 
Sandy UT) that measures oxygen consumption and carbon dioxide production.  The procedure involves 
positioning a canopy over the patient’s head that allows the patient to exchange gas with an open-circuit 
design. The recording should be for at least 20 minutes after achieving a steady curve. This measurement 
is done under conditions of minimal physical activity. The amount of carbon dioxide generated and 
oxygen consumed by the patient is determined by calorimeter. RMR measurements will be obtained after 
admission to assist with estimation of caloric requirements, once at the end of Period 1, and 
approximately every 4 days during Period 2 in order to look for any time-course effects of leptin 
initiation of withdrawal. RMR will also be measured during the long-term follow-up visit for subjects in 
the leptin-naïve group 
 
4. DEXA scan for total body composition:  Measurements of fat-free mass will be obtained and used to 
normalize energy expenditure measurements. Measurements will be obtained at the end of Period 1 and 
the end of Period 2, and during the long-term follow-up visit for subjects in the leptin-naïve group, 
immediately after leaving the metabolic chamber.  A DEXA scan (iDXA, GE Healthcare, Madison WI) 
will be performed to determine total and regional body fat and lean soft tissue masses, bone mineral 
content and density. DEXA produces photons at two different energy levels, 40 and 70 KeV. The 
photons pass through tissues and attenuate at rates related to elemental composition. Bone mineral, with 
highly attenuating calcium and phosphorous, is readily distinguished from soft tissues. The different 
elemental profiles of fat and bone-mineral free lean components allows for the analysis of soft tissue fat 
content, so that bone mineral, fat, and bone mineral fat-free lean components may be resolved.  
 
5. Blood pressure monitoring:  Blood pressure will be monitored every 30 minutes using an automated 
ambulatory blood pressure monitor.  Because leptin’s effects on blood pressure have been reported to be 
rapid and transient following leptin initiation (Sadaf Farooqi, unpublished observations), testing will be 

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focused on the 48 hours immediately before and after leptin initiation and withdrawal.  An additional 48 
hours of monitoring will be performed at the end of Period 2, and during the long-term follow-up visit 
for subjects in the leptin-naïve group, to look for longer term effects. 
 
6. Heart rate variability: Heart rate will be measured and recorded using a portable ECG Holter monitor, 
which will be downloaded and analyzed for heart-rate variability using power spectrum 
analyses.  Testing will be performed in conjunction with blood pressure monitoring. 
 
7. Visual Analog Scales (hunger, thermal regulation): Patients will be given a questionnaire to determine 
their level of thermal comfort and hunger using visual analog scales (VAS), as shown in Appendix III.  
The hunger VAS question has been characterized previously, and is digitized exactly onto an iPad app 44.  
Testing does not require supervision, and will be performed on a daily basis after lunch. 
 
8. Skin temperature: Wireless probes (iButtons, Maxim Inc., Sunnyvale,CA) will record skin temperature 
with data reported each minute.  The positions of the skin sensors at five sites (deltoid, hand, pectoralis 
major, anterior thigh, and shin) will be according to the ISO standards45.  Skin temperature monitoring 
will be performed prior to, during, and for one hour following each exercise test, as well as throughout 
each stay in the metabolic chamber. 
  
9. Metabolic chamber: The room calorimeter is a specially constructed room designed to assess the 
metabolism of human subjects.  Designed as a walk-in “pull” calorimeter, it is an open circuit unit that 
draws conditioned room air into the room calorimeter at the same flow rate as it is extracted into the gas 
analysis system42.   Each of the three rooms is equipped with toilet and sink with privacy screen, 
treadmill, bed, desk, and computer with access to television and other forms of entertainment.  In 
addition to the detailed measurements using portable activity monitors, a general physical activity level 
is also measured continuously through a wall mounted monitoring device (microwave sensor).  Food and 
fresh water is passed through an air-lock drawer system. In this rapid- response room calorimeter, the 
sleeping energy expenditure, diet induced thermogenesis43 and the specific energy costs of prescribed 
non-intense physical activity types44 will be assessed. A recent study of our first room calorimeter 
showed better than ±85 kcal/day (95% Confidence Interval) reproducibility in total energy expenditure 
in 10 healthy normal subjects (total energy expenditure ranged from 1551 to 3559 kcal/day), and ±0.023 
in average and sleeping RQ. Compared to the literature, this is the most precise system to date. 
Continuous nursing supervision with telemetry cardiac monitoring is a standard procedure to enhance 
patient safety46-48.  Subjects will wear standardized clothing while in the metabolic chamber in order to 
increase uniformity in measurements of skin temperature and thermal comfort.  Subjects will have a 30 
minute treadmill walking period in the chamber in order to bring out any effects of altered skeletal 
muscle work efficiency on total energy expenditure.  Subjects will stay in the metabolic chamber at the 
end of Period 1, in the middle and end of Period 2, and during the follow-up visit for subjects in the 
leptin-naïve group. 
 
10. Glucose and Lipid Turnover: Stable isotope tracers will be used to measure glucose and lipid turnover.  
Endogenous glucose production will be measured using steady-state infusion of [6,6-2H2] glucose tracer.  
The fractional rate of gluconeogenesis will be measured using steady-state oral dosing of deuterated 
water (2H2O) 49. The rate of lipolysis will be measured using steady-state infusion of deuterium-labeled 
2H5-glycerol, and the fatty acid turnover rate will be measured using steady-state infusion of [U-13C16] 
palmitate.  Subjects will fast after 8 pm.  A total of 3 grams per kg lean body mass of 2H2O will be given 
in four divided doses every two hours at 9 pm, 11 pm, 1 am, and 3 am in order to enrich the subject’s 
body water pool to approximately 0.5% 2H2O.  Beginning at ~5 am,  a primed [6,6-2H2]glucose infusion 
will be given for 3 hours, after which blood samples to measure isotope enrichment will be measured 
over a period of 30 minutes at steady state.  Two hours after the [6,6-2H2]glucose infusion begins, a 
primed 2H5-glycerol infusion, and unprimed [U-13C16] palmitate infusion will be given for one hour, and 

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isotope enrichment will be measured over a period of 30 minutes at steady state.  Tracer studies will be 
performed at the end of Period 1, in the middle and end of Period 2, and during the follow-up visit for 
subjects in the leptin-naïve group.  To assess the effects of hyperinsulinemia on glucose turnover, the 
glucose tracer infusion will be continued during the euglycemic, hyperinsulinemic clamp study, below, 
with blood samples for tracer enrichment obtained during the steady-state period of the clamp. 
 
11. Euglycemic Hyperinsulinemic Clamp:  This is the gold-standard test to measure insulin sensitivity.  For 
insulin treated subjects, an overnight insulin drip may be given beginning at 6 pm the night prior to the 
clamp to maintain euglycemia.  After an 8-hour fast, insulin will be infused at a dose of 120 
mcU/m2*minute.  This dose is designed to suppress endogenous glucose production and near-maximally 
stimulate glucose uptake in this group of very insulin resistant subjects.  For a small number of subjects 
with extreme insulin resistance (requiring more than 200 units of insulin per day), higher doses of insulin 
may be used during the clamp study to create a state of hyperinsulinemia above the subject’s baseline 
state.  20% dextrose enriched with 2.5% [6,6-2H2] glucose tracer will be infused at a variable rate to 
maintain blood glucose at approximately 90 mg/dL.  If subjects remain hyperglycemic without dextrose 
infusion after 1 hour of insulin infusion (by which time maximum insulin effect is expected), the clamp 
will be considered “failed” and will be prematurely terminated. During the insulin infusion, blood 
samples (0.5 mL) will be obtained every 5 minutes to measure blood glucose at the bedside.  At steady 
state, the rate of dextrose infusion provides an estimate of insulin-stimulated glucose disposal.  
Additional samples will be drawn to measure the glucose and lipid tracers (described above), insulin, and 
other hormone levels.  Due to the blood volumes and inconvenience of this test to participants, it will be 
performed once at the end of Period 1, once at the end of Period 2, and during the follow-up visit for 
subjects in the leptin-naïve group.  If technical problems occur with a clamp study (e.g. IV failure or 
failure to attain steady-state glucose and insulin levels), the clamp may be repeated if blood volume 
limits permit. 
 
12. Fasting research blood tests:  Fasting glucose, insulin, C-peptide, markers of insulin action (e.g. 
IGFBP2), lipid panel, free fatty acids, and high-sensitivity C-reactive protein will be measured every 
other day. Markers of bone turnover ( -CTX and P1NP) will be obtained twice at the end of Period 1, 
twice at the end of Period 2, and during the follow-up visit for subjects in the leptin-naïve group. 
Additional blood samples will be stored for future analysis of leptin and inflammatory markers. as well 
as used to measure circulating RNA and DNA during periods in which patients do or do not receive 
leptin, to determine the effects of leptin on circulating nucleic acids and pharmacoepigenomics of leptin 
therapy. 
 
13. Biochemical evaluation:   A baseline biochemical evaluation, which includes:  electrolytes, BUN, 
creatinine, LDH, CPK, SGOT, SGPT, bilirubin, alkaline phosphatase, calcium, magnesium, albumin, 
protein, iron, and transferrin, will be conducted during Period 1 and at follow-up.   
 
14. Magnetic Resonance Imaging (MRI) and Magnetic Resonance Spectroscopy (MRS):  Hepatic, muscle 
and central body fat will be measured by magnetic resonance imaging (MRI) and magnetic resonance 
spectroscopy (MRS). MR studies will be performed at the end of Period 1, at the end of Period 2, and 
during the follow-up visit for subjects in the leptin-naïve group.  Studies are performed on a 3T MRI 
scanner using phased-array coils. B0 shim parameters are optimized with a breath hold B0 mapping 
method (1). Navigator gated T2 weighted (T2w) and breath-hold T1 weighted (T1w) images in coronal 
and axial orientations are used to prescribe a 20x20x20 mm3 spectroscopy volume in an area with high 
signal to noise ratio, free of obvious fatty structures or blood vessels. After additional manual shimming, 
and optimization of transmit power and WS RF level 32 signals are averaged with a minimum repetition 
time (TR) of 3s and 35 ms echo time (TE) with WET water suppression (WS) followed by 4 signals 
averaged with WS RF power set to zero. Spectral data are fitted with AMARES (2) using a model of 
four resonances for the lipid signals on the WS spectra.  Additionally, the apparent T2’s of the summed 

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lipid CH2 and CH3 resonances lipid and the T2 of water are measured with five quick expiration breath 
hold non-WS spectra averaging two signals each at TR 3s and TE 24, 36, 48, 96 and 144 ms. These T2 
values are used to correct the water and total lipid signals for signal decay in the 35 ms echo delay. Fat 
fraction is then calculated as from the T2 corrected signals Swater and Slipid as: fat fraction = 
 Slipid/(Swater+Slipid). Visceral and subcutaneous fat measurements will be obtained using standard T1 
Spin Echo technique which presents fat as a bright signal that can be segmented for area and volume 
measurements. 
 
15. 24 hour urine studies:  Urine will be collected during each stay in the metabolic chamber (at the end of 
Period 1, in the middle and end of Period 2, and during the follow-up visit for subjects in the leptin-naïve 
group).  Samples will be analyzed for nitrogen excretion to assess macronutrient oxidation, as well as 
excretion of glucose, protein and minerals.  
 
16. Oral glucose tolerance test:   After a 12-hour fast preceding the test, subjects will be given 75 gram 
(1.75gm/kg in pediatric patients less than 40kg) oral glucose solution. Venous glucose, plasma insulin 
and free fatty acid levels (3 cc blood to be drawn at each draw) will be obtained from blood samples 
drawn at -10, 0, 30, 60, 90, 120 and 180 minutes during the oral glucose tolerance test. 
 
Endocrine Evaluation 
1. LH pulsatility will be assessed using overnight sampling.  Blood will be sampled from an indwelling IV 
catheter every 10 minutes between 11 pm and 7 am. Arithmetic mean levels for LH will be calculated. 
Analysis of pulsatile secretion of LH will be determined using a modification of the Santin and 
Bardin Method50, which requires a 20% increase from nadir to peak LH concentrations for pulse 
detection. LH pulse frequency will be determined by calculating the number of LH pulses during the 
sampling interval. LH pulse amplitude will be calculated from the difference between the nadir and 
peak hormone levels. Due to the blood volume requirements of this test, it will be performed once at the 
end of Period 1, once at the end of Period 2, and during the follow-up visit for subjects in the leptin-
naïve group. 
 
2. Thyroid function will be assessed as serum levels of total and free thyroxine, triiodothyroinine (T3), and 
thyroid stimulating hormone (TSH).  Thyroid function tests will be performed at the end of Period 1, in 
the middle and end of Period 2, and during the follow-up visit for subjects in the leptin-naïve group. 
 
3. Catecholamines: Plasma and 24 hour urine catecholamines will be measured to assess effects of leptin on 
adrenal medullary function. Testing will be performed at the end of Period 1, in the middle and end of 
Period 2, and during the follow-up visit for subjects in the leptin-naïve group. 
 
Safety Labs 
1. Amylase and lipase will be drawn approximately every other day in the leptin withdrawal group at the 
time of the Fasting Research Blood draws. 
2. Pancreatic elastase will be measured in stool samples approximately every other day (depending on 
when subjects are able to provide stool samples). 
3. Urine or serum pregnancy testing will be obtained on female subjects with reproductive potential after 
admission, and will be repeated prior to radiation exposure (for DEXA scans) as needed.  If the study 
participant is a minor, and she is found to have a positive pregnancy test, we will inform her.  If the 
patient grants us permission to do so, we will discuss this with her parent(s) so that they can help their 
daughter make good medical decisions.  
4. Immunogenicity testing:  As a post marketing requirement, blood will be drawn at baseline and at the 6 
month follow-up visit for measurement of neutralizing antibodies to leptin.   
 

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Imaging Studies 
1. Ultrasound of pelvis:  This will be performed on female patients to evaluate the effects of 
hyperinsulinism and hyperandrogenism on the ovaries.  The ovarian volumes, number of cysts and cyst-
volumes will be recorded. 
2. Echocardiogram:  This will be performed to evaluate the presence of cardiomyopathy or heart failure 
before starting leptin.  In the NIDDK long term leptin study those with generalized lipodystrophy 
frequently had signs of hypertrophic cardiomyopathy.   
3. Ultrasound of abdomen or liver:  This will be performed to evaluate size and echogenicity of the liver 
and other abdominal organs before starting leptin and at follow-up. 
4. Ultrasound of thyroid:  This will be performed at Baseline on all enrolled patients with insulin 
resistance to screen for possible papillary thyroid carcinoma (PTC) since this patient population may be 
at a higher risk of developing PTC.  The testing may also uncover information for future analysis.   
5. Other imaging studies as clinically indicated: 
a. Long bone X-rays to evaluate osseous lesions and to provide further definition as to the natural 
history of such lesions.   
 
Follow-up 
Post-Study Treatment 
Subjects newly starting leptin who decide not to complete the entire 19 days of the study will be given the option 
to continue leptin ad to come back for follow-up and evaluation in six months.   
 
Patients who have generalized lipodystrophy and who reside within the US may continue leptin treatment as an 
FDA-approved drug through their home endocrinologist.  These patients may also continue to receive care at 
NIH via protocol 76-DK-0006 (Studies of Molecular Genetics of Insulin Secretion, Insulin Action, and Diabetes 
Mellitus).  However, leptin drug supply will not be offered through this study.  
 
Patients who have partial lipodystrophy are not eligible to receive leptin treatment as an FDA-approved drug.  In 
addition, patients with generalized lipodystrophy who do not live in the US cannot obtain FDA-approved drug 
despite being on-label indication.  After completing 6 months of leptin treatment in this study, these patients will 
have the following options: 
1. Taper leptin over 1 week and discontinue the drug 
2. Receive leptin through other clinical trials (at NIH or elsewhere) if such trials are available 
3. Receive leptin through a compassionate use IND 
 
These choices will be discussed with patients and study staff will assist with decision-making, based on drug 
availability and the patient’s clinical improvement (or lack thereof) with leptin therapy.  Regardless of the option 
chosen, partial lipodystrophy patients and non-US generalized lipodystrophy patients may also continue to 
receive care at NIH via protocol 76-DK-0006. 
 
Post-Study Obligations 
There are no anticipated post-study obligations. 
 
Human Subject Protection 
 
Data and Safety Monitoring Plan 
The collection, monitoring and analysis of adverse events will be the responsibility of the Principal Investigator 
and the investigative team.  Serious adverse events will be reported to the NIDDK/NIAMS  IRB per NIH 
guidelines (below).  Overall accrual and adverse event information will be reported to the NIDDK/NIAMS IRB 
annually. 
 

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As required by FDA 21 CFR 312.50 (and NIH OHSRP’s SOP 23), trial procedures will be subject to review 
and/or monitoring visits to ensure compliance with the protocol and applicable regulatory requirements with the 
NIDDK quality assurance program plan.  Audit and/or monitoring visits results will be reported to the Principal 
Investigator/Sponsor for further reporting to the FDA consistent with applicable regulations.   The specific 
monitoring plan will be developed with the Principal Investigator and frequency of monitoring visits determined 
by such factors as study enrollment, data collection status and regulatory obligations.  Study documents and 
pertinent hospital or clinical records will be reviewed to verify that the conduct of the study is consistent with the 
protocol plan. 
 
Adverse Events, Protocol Deviations, and Unanticipated Problems 
Adverse events, protocol deviations, unanticipated problems (UP), serious adverse events (SAEs), sponsor and 
serious, are defined as described in NIH HRPP SOP 16 (“Reporting Requirements for Unanticipated Problems, 
Adverse Events and Protocol Deviations.”). All adverse events occurring during the study, including those 
observed by or reported to the research team, will be recorded and summarized at the time of annual review. 
Serious unanticipated problems and serious protocol deviations, will be reported to the NIDDK/ NIAMS IRB 
and CD as soon as possible but not more than 7 days after the PI first learns of the event. Not serious 
unanticipated problems will be reported to the NIDDK/ NIAMS IRB and CD as soon as possible but not more 
than 14 days after the PI first learns of the event.  
 
Non-serious protocol deviations will only be reported to the NIDDK/ NIAMS IRB (within 14 days after the PI 
first learns of the event) if they represent a departure from NIH policies for the conduct of human subjects 
research, adversely affect the health care of the subject(s) or compromise the interpretation or integrity of the 
research.  Non-serious protocol deviations that result from normal subject scheduling variations or technical 
issues associated with sampling that does not impact the health of the subject or the interpretation of the study 
data will not be reported. 
 
 
Adverse Events  
 
An Adverse Event (AE) is defined as any new untoward medical occurrence or worsening of a preexisting 
medical condition in a clinical investigation subject administered an investigational (medicinal) product and that 
does not necessarily have a causal relationship with this treatment. An AE can therefore be any unfavorable and 
unintended sign (such as an abnormal laboratory finding), symptom, or disease temporally associated with the 
use of investigational product, whether or not considered related to the investigational product. 
 
The causal relationship to study drug is determined by a physician and should be used to assess all adverse 
events (AE). The casual relationship can be one of the following: 
 
Related: There is a reasonable causal relationship between study drug administration and the AE. 
 
Not related: There is not a reasonable causal relationship between study drug administration and the AE.  
 
The term "reasonable causal relationship" means there is evidence to suggest a causal relationship.  
Adverse events can be spontaneously reported or elicited during open-ended questioning, examination, or 
evaluation of a subject. (In order to prevent reporting bias, subjects should not be questioned regarding the 
specific occurrence of one or more AEs.) 
 
Non-Serious Adverse Event Collection and Reporting 
The collection of non-serious AE information should begin once a subject’s written consent to participate in the 
study has been obtained.  Any significant worsening noted during interim or final physical examinations, 

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electrocardiogram, x-ray filming, any other potential safety assessment required or not required by protocol 
should also be recorded as a non-serious or serious AE, as appropriate, and reported accordingly. 
 
Non-serious AEs should be followed to resolution or stabilization, or reported as SAEs if they become serious 
(see Section “Serious Adverse Events Reporting & Collection”). Follow-up is also required for non-serious AEs 
that cause interruption or discontinuation of study drug and for those present at the end of study treatment as 
appropriate.  
 
Laboratory Test Result Abnormalities 
The following laboratory test result abnormalities should be captured on the non-serious AE CRF page or SAE 
Report Form as appropriate: 
1. Any laboratory test result that is clinically significant or meets the definition of an SAE  
2. Any laboratory test result abnormality that required the subject to have study drug discontinued or 
interrupted 
3. Any laboratory test result abnormality that required the subject to receive specific corrective therapy. 
It is expected that wherever possible, the clinical rather than laboratory term would be used by the reporting 
investigator (eg, anemia versus low hemoglobin value). 
All identified non-serious AEs must be recorded and described on the non-serious AE page of the case report 
forms (CRF). Completion of supplemental CRFs may be requested for AEs and/or laboratory abnormalities that 
are reported/identified during the course of the study. 
 
Serious Adverse events  
A Serious adverse event is defined as one of the following (in accordance with FDA 21 CFR312.32 and the NIH 
intramural guidance for principal investigators on reporting adverse events) 
• 
death from any cause, 
• 
life threatening event, i.e., an event that places the subject, in the view of the investigator, at 
immediate risk of death from the event as it occurred. 
• 
any event that requires or prolongs in-patient hospitalization 
• 
any event that results in persistent or significant disability/incapacity  
• 
any congenital anomaly/birth defect diagnosed in a  child of a subject who participated in this study. 
• 
other medically important events that in the opinion of the investigator may jeopardize the subject or 
may require intervention to prevent one of the other outcomes listed in the definition above. 
Examples of such events include, but are not limited to, intensive treatment in an emergency room or 
at home for allergic bronchospasm; blood dyscrasias or convulsions that do not result in 
hospitalization.) 
 
Suspected transmission of an infectious agent (eg, pathogenic or nonpathogenic) via the study drug is an SAE. 
Although pregnancy, overdose, cancer, and potential drug induced liver injury (DILI) are not always serious by 
regulatory definition, these events will be handled as SAEs (per Aegerion Pharmaceuticals request via United 
Biosource Corporation, the CRO contracted by Aegerion to perform Pharmacovigilance activities on their 
behalf). 
 
NOTE:  
The following hospitalizations are not considered SAEs:  
− 
a visit to the emergency room or other hospital department < 24 hours, that does not result in admission 
(unless considered an important medical or life-threatening event) 
− 
elective surgery, planned prior to signing consent 
− 
admissions as per protocol for a planned medical/surgical procedure 

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− 
routine health assessment requiring admission for baseline/trending of health status (eg, routine 
colonoscopy) 
− 
medical/surgical admission other than to remedy ill health and planned prior to entry into the study. 
Appropriate documentation is required in these cases 
− 
admission encountered for another life circumstance that carries no bearing on health status and requires 
no medical/surgical intervention (eg, lack of housing, economic inadequacy, caregiver respite, family 
circumstances, administrative reason). 
 
Pregnancy 
 
All pre-menopausal women included in the study will be asked to use an effective method of contraception. If 
necessary, a gynecology consultation will be obtained to assist the patients to choose an appropriate method of 
contraception.  
 
Should a patient become pregnant while taking metreleptin, metreleptin may be continued during pregnancy 
under the following circumstances: 
1. The investigators feel that metreleptin withdrawal would constitute a harm to mother and fetus. 
2. The patient understands that the effects of metreleptin in pregnancy are unknown, and wishes to 
continue. 
3. The patient receives prenatal care from a high-risk obstetrician experienced in managing diabetes during 
pregnancy. Management of diabetes must be the primary responsibility of the patient’s local health care 
providers, although the NIH study team will provide advice as appropriate regarding metreleptin use and 
use of concentrated insulin (U-500) if necessary. 
4. The patient and her local health care team agree to remain in close contact with the NIH study team and 
respond to requests for clinical information needed to document the course of pregnancy and its 
outcome.  
 
Should a patient become pregnant while on study, per 45 CFR 46.204, (1) no inducements, monetary or 
otherwise, will be offered to terminate a pregnancy, (2) individuals engaged in research will not be involved in 
any decisions as to timing, method, or procedures used to terminate a pregnancy, and (3) individuals engaged in 
the research will have no part in determining viability of a neonate. 
 
The investigator must immediately notify the Aegerion Pharmaceuticals (or designee) Medical Monitor of this 
event and complete and forward a Pregnancy Surveillance Form to United Biosource Corporation (UBC) (or 
designee) within 7 business days via email to AegerionPV@UBC.com and Francine.Galibert@UBC.com.  
 
Follow-up information regarding the course of the pregnancy, including perinatal and neonatal outcome and, 
where applicable, offspring information must be reported on the Pregnancy Surveillance Form.  Any pregnancy 
that occurs in a female partner of a male study participant should be reported to the sponsor. Information on this 
pregnancy will be collected on the Pregnancy Surveillance Form. 
 
Overdose 
An overdose is defined as the accidental or intentional administration of any dose of a product that is considered 
both excessive and medically important. All occurrences of overdose must be reported as an SAE. 
 
Serious Adverse Event Collection and Reporting 
Following the subject’s written consent to participate in the study, all SAEs, whether related or not related to 
study drug, must be collected, including those thought to be associated with protocol-specified procedures. All 
SAEs must be collected that occur within 30 days of discontinuation of dosing. The investigator should report 

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any SAE that occurs after these time periods and that is believed to be related to study drug or protocol-specified 
procedure.  
 
An SAE report should be completed for any event where doubt exists regarding its seriousness.  
If the investigator believes that an SAE is not related to study drug, but is potentially related to the conditions of 
the study (such as withdrawal of previous therapy or a complication of a study procedure), the relationship 
should be specified in the narrative section of the SAE Report Form. 
 
SAEs, whether related or not related to study drug, (including pregnancies) must be reported to Aegerion 
Pharmaceuticals on an SAE Report Form or similar form (e.g. CIOMS, MedWatch) and submitted as soon as 
possible but not more than 7 calendar days in the event of a death or a life-threatening event or in 15 calendar 
days for all other SAEs.  SAE reports within 7 calendar days are to be transmitted via email: 
SAE Email Address:  AegerionPV@UBC.com and Francine.Galibert@ubc.com   
If only limited information is initially available, follow-up reports are required. (Note: Follow-up SAE reports 
should include the same investigator term(s) initially reported).  If an ongoing SAE changes in its intensity or 
relationship to study drug or if new information becomes available, a follow-up SAE report should be sent to the 
Aegerion Pharmaceuticals (or designee) using the same procedure used for transmitting the initial SAE report.   
All SAEs should be followed to resolution or stabilization. 
 
Per NIH HRPP SOP 16, all serious adverse events will be reported to the NIDDK/NIAMS IRB at the time of 
annual review.  The PI will report all deaths (that are not Unanticipated Problems) to the NIDDK CD and 
NIDDK/NIAMS IRB as soon as possible, but not more than 7 days after the PI first learns of the event, unless 
otherwise specified by the NIDDK CD and documented in the protocol. 
 
Deaths 
Per NIH HRPP SOP 16, the PI will report all deaths (that are not Unanticipated Problems) to the NIDDK 
Clinical Director and the NIDDK/NIAMS IRB as soon as possible, but not more than 7 days after the PI first 
learns of the event, unless otherwise specified by the NIDDK CD and documented in the protocol. 
 
Rationale for Subject Selection 
Subjects eligible for this study include mature adolescents and non-elderly adults with lipodystrophy. All 
subtypes of lipodystrophy (i.e. generalized, partial, acquired, and congenital) will be eligible.  Although 
restricting the study to one or two lipodystrophy subtypes (such as the most severe forms: acquired and 
congenital generalized) would likely give greater homogeneity in the patient population, such restrictions would 
dramatically decrease feasibility in this extremely rare condition.  Because each subject will be compared to 
him/herself in this within-subjects design, the effects of inter-subject heterogeneity will be less important. 
 
For leptin-treated patients who are withdrawing from leptin, this study is of greater than minimal risk, and 
without prospect of direct benefit to subjects, but likely to yield generalizable knowledge about the subjects’ 
condition, e.g. lipodystrophy.  For those in the leptin naïve arm of the study, there is a prospect of direct benefit. 
Based on these criteria, mature adolescents ages 14-17 years will be permitted to participate in the leptin-naïve 
arm of the study.  Even though there is the potential for clinical benefit, younger children and adults who are 
unable to give informed consent are unlikely to possess the emotional maturity to participate in such a complex 
and time-consuming study.  Because the risk of pancreatitis with leptin withdrawal represents greater than a 
minor increment over minimal risk, children will not be enrolled in the leptin withdrawal arm of the study.  As 
we gain more experience in risks of leptin withdrawal in adults, we may request NIDDK/NIAMS IRB 
permission to include children in this arm in the future.    Adults over age 70 years are excluded in order to 
decrease inhomogeneity related to an aging population.  Because there is no prospect for direct benefit, adults 
who are unable to give informed consent will not be eligible. 
 

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Withdrawal Criteria 
1. Withdrawal of consent.  A subject wishes to withdraw from the study as stated in the informed consent 
(all subjects reserve the right to withdraw from the study without prejudice). 
2. Adverse event.  A subject experiences an adverse event that in the investigator’s opinion necessitates 
withdrawal from the study.  Specific examples of adverse events that would result in withdrawal are: 
a) Pancreatitis during the leptin withdrawal period in the leptin treated group.  Pancreatitis is a 
clinical diagnosis, and will be suspected in the presence of moderate to severe abdominal pain 
accompanied by nausea and/or vomiting.  If pancreatitis is suspected, amylase and lipase levels 
will be drawn, and GI consultation obtained.  However, even if amylase and lipase levels are 
normal, in the presence of typical signs and symptoms of pancreatitis, leptin will be restarted. 
b) Diabetic ketoacidosis during the leptin withdrawal period in the leptin treated group 
3. Investigator decision.  An investigator feels it is in the subject's best interest to terminate participation. 
The detailed reasoning behind this decision will be documented. 
4. Protocol violation.  Includes subject noncompliance, pregnancy, study entry criterion violation, or start 
of an unacceptable concomitant medication. 
 
Subjects in the leptin treated group, who undergo leptin withdrawal during this study, will be immediately 
restarted on leptin if they withdraw from the study for one of the above reasons. 
 
Risks/Benefits Analysis including Considerations of Alternatives to Participation 
 
Benefits 
1. Leptin Initiation: Leptin naïve subjects enrolled in this study will initiate leptin treatment under this 
treatment protocol.  Since the patients included in this protocol have metabolic abnormalities, they have 
some likelihood of considerable clinical benefit from this trial. The potential benefits of leptin in 
lipodystrophy are discussed in detail in protocol 02-DK-0022.  In brief, leptin has been shown to cause 
short-term improvements (within 14 days, the duration of the current protocol) in blood glucose and 
triglyceride levels31.  Long-term benefits (over 3 years) of leptin in lipodystrophy have been 
demonstrated under protocol 02-DK-0022, and include decreased hemoglobin A1c, triglycerides, ALT 
and AST51. Given the clear benefits, in February 2014 the FDA approved leptin (Myalept) for treatment 
of individuals with generalized lipodystrophy.  A review of the data obtained in 02-DK-0022 showed 
that leptin also leads to clinically important improvements in patients who have partial lipodystrophy 
with significant metabolic disease.   
 
2. Leptin Withdrawal: Subjects undergoing leptin withdrawal as part of this study will not have any real or 
potential personal medical benefit accruing from study participation.  However, they will contribute to 
important research that has the potential to improve medical treatment of lipodystrophy patients in the 
future. 
 
Risks/Discomforts 
1. General:  Some patients may find the time needed to complete the research studies an inconvenience in 
their routine lives. 
 
2. Leptin Initiation: Leptin naïve subjects enrolled in this study will initiate leptin treatment under this 
treatment protocol.  The risks of leptin are discussed in detail in the drug package insert (Appendix C).  
In brief, adverse effects of leptin include mild to moderate injection site reactions, headache, temporary 
flu-like symptoms, and the development of non-neutralizing antibodies that do not interfere with clinical 
efficacy. Three subjects who were enrolled in 02-DK-0022 developed antibodies that may block the 
effects of leptin.  All three subjects had congenital generalized lipodystrophy.  Two of these subjects had 
episodes of sepsis after the development of neutralizing antibodies (multiple episodes in one patient and 
a single, unverified episode in the other patient).  Both patients had risk factors for sepsis including 

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cirrhosis with portal hypertension, and severe periodontal disease.  It is unknown if these sepsis episodes 
were related to the presence of neutralizing antibodies.  The subject with multiple sepsis episodes was 
withdrawn from leptin in order to improve quality of life, as her life expectancy is limited.  She did not 
experience worsening of metabolic status after leptin withdrawal, suggesting a possible loss of efficacy 
of leptin replacement in conjunction with her neutralizing antibodies.  The second patient has been lost 
to follow-up and no further clinical information is available.  The third patient has not had sepsis.  This 
patient requires the maximum dose of leptin (0.24 mg/kg/day) to maintain good metabolic control, 
suggesting a possible partial loss of efficacy associated with neutralizing antibodies. At this point the 
clinical effects of this type of blocking antibody are not established.  In patients who make very little 
leptin, such as those with generalized lipodystrophy, a blocking antibody might make the injected leptin 
medication ineffective, and health status would return to where it was before starting leptin treatment.  
As immunodeficiency has been reported in patients who make no leptin (congenital leptin deficiency), 
sepsis might be related to neutralizing antibodies.  In patients who make more leptin, such as those with 
partial lipodystrophy, a blocking antibody might not only make the injected leptin medication 
ineffective, it might also block the leptin the body makes, resulting in worse health status than before 
starting leptin treatment.  In this study, leptin will be initiated at a slightly higher dose (0.14-0.15 
mg/kg/day) than the typical starting dose of leptin given in protocol 02-DK-0022 (0.08-0.1 mg/kg/day).  
This higher dose will be used to more rapidly observe leptin’s biological effects within the short, 2 week 
duration of this study.  The dose of 0.14-0.15 mg/kg/day is well within the dose ranges that were used to 
treat lipodystrophy patients enrolled in  protocol 02-DK-0022 (up to 0.24 mg/kg/day) and, based on our 
experience, is not likely to increase the risk of leptin related adverse events. 
 
3. Leptin Withdrawal: In the current protocol, we anticipate worsening of metabolic parameters, 
particularly blood glucose and triglycerides, during leptin withdrawal. Risks associated with short-term 
worsening of blood glucose and triglycerides are discussed below. 
a. Hyperglycemia:  Leptin withdrawal for 2 weeks may increase blood glucose in many patients.  
To reduce this risk, patients will be continued on their home antihyperglycemic regimens, 
including oral medications and/or insulin.  In addition, only patients with good to fair diabetes 
control (hemoglobin A1c < 9%) will be enrolled.  Unlike patients with type 1 diabetes, patients 
with lipodystrophy are at extremely low risk for ketoacidosis in the context of hyperglycemia, as 
diabetes in lipodystrophy is typically due to insulin resistance rather than insulin deficiency.  
Subjects with a history of diabetic ketoacidosis will be excluded.  Because blood glucose is an 
important endpoint, we will not initiate insulin, or increase insulin doses, in the case of mild 
hyperglycemia.  However, for safety reasons, we will initiate or increase insulin if a subject has 
fasting blood glucoses greater than 300 mg/dL, non-fasting glucose >500 mg/dL, or a 200 
mg/dL increase from baseline in either fasting or non-fasting glucose. A two-week period of 
hyperglycemia will not significantly impact the risk of long-term diabetes-related complications.  
Acute hyperglycemia may be associated with mild patient discomfort due to polydipsia, 
polyuria, blurred vision, or non-specific malaise associated with sensing a high blood sugar. 
a. Hypertriglyceridemia: Leptin withdrawal for 2 weeks may increase blood triglycerides in many 
patients.  To reduce this risk, patients will be continued on their home lipid-lowering regimens 
(e.g. statins or fibrates).  In addition, only patients with fair triglyceride control (serum 
triglycerides < 800 mg/dL) will be enrolled.  The main risk of short-term hypertriglyeridemia is 
acute pancreatitis.  Pancreatitis is discussed in more detail, below.  
b. Pancreatitis: There have been 3 serious adverse events associated with short-term leptin 
withdrawal in the course of the 12 years (approximately 500 patient-years) that leptin treatment 
has been given to lipodystrophy patients at NIH.  Each of these SAEs is described below: 
i. 
NIH-1:  This is the first lipodystrophy patient treated with leptin, and with the most 
severe lipid abnormality, possibly due to the copresence of another lipid disorder 
coupled with lipodystrophy.  This subject had triglycerides greater than 30,000 mg/dL 
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plasmapheresis.  In this subject, inpatient leptin withdrawal for 10 days during a 1900 
kcal/day diet led to a rise in triglycerides from 400 to 800 mg/dL.  Leptin was restarted 
after 10 days due to the development of nausea, vomiting, and abdominal pain consistent 
with acute pancreatitis (but without elevated amylase or lipase).  Leptin was then 
restarted, and the patient recovered uneventfully.  Of note, ~10 years after this SAE, the 
patient was diagnosed with superior mesenteric artery syndrome, and her symptoms of 
episodic abdominal pain, nausea, and vomiting have substantially improved since this 
was surgically treated.  Thus, this patient’s symptoms during leptin withdrawal on a 
controlled diet may not have represented true pancreatitis. 
ii. 
NIH-25:  This was a 15 year old patient with congenital, generalized lipodystrophy with 
no known history of pancreatitis.  The patient was admitted to an outside hospital with 
acute pancreatitis following a period of poor compliance with leptin therapy (taking 4-5 
of 14 prescribed doses per week).  Leptin was not given in the hospital.  On hospital day 
3, the patient suffered a cardiac arrest and died.  The cause of death was listed as shock 
from pancreatitis. 
iii. 
NIH-38:  This 36 year-old patient with partial lipodystrophy and a history of recurrent 
pancreatitis was admitted to an outside hospital for dehydration related to colitis.  
Amylase and lipase were normal on admission.  The outside hospital did not administer 
leptin, and after 2-3 days of leptin withdrawal, the patient developed elevated amylase 
and lipase consistent with acute pancreatitis. Leptin was restarted, and the patient 
recovered without incident. 
Because of the risk of pancreatitis with leptin withdrawal, our group has recommended that 
patients discontinuing leptin in the outpatient setting (in the absence of physician supervision) 
gradually taper the dose over one week.  In this study, in order to more rapidly test the effects of 
leptin withdrawal, we plan to discontinue leptin without tapering.  Leptin has been discontinued 
in at least 25 other lipodystrophy patients, either based on patient decision (e.g. non-compliance 
or personal choice) or joint patient-investigator decision.  In half of these patients, leptin was 
tapered over 1 week, and in the other half it was stopped without a taper. None of these patients 
had any serious adverse event resulting from acute leptin withdrawal, although long-term 
(months to years) worsening of metabolic parameters (A1c, triglycerides, ALT/AST) and other 
adverse events related to the natural history of lipodystrophy were observed.  Based on these 
observations, we estimate that the risk of pancreatitis during short-term leptin withdrawal is low, 
but non-zero.  The following measures are being taken to minimize the risk of pancreatitis to 
patients undergoing leptin withdrawal in this study: 
i. 
Subjects at increased risk of pancreatitis are excluded, as follows: 
a. Triglycerides over 2000 mg/dL at initiation of leptin treatment.  This will 
exclude patients with extreme hypertriglyceridemia at baseline, who would be more 
likely to rebound to high levels with leptin withdrawal, regardless of their current 
triglyceride control or history of pancreatitis. 
b. Prior history of more than one episode of pancreatitis, or 1 or more episodes of 
pancreatitis after starting leptin. Even in the presence of a known risk factor such 
as hypertriglyceridemia, having recurrent pancreatitis (more than one episode) 
suggests that a patient may be at intrinsically greater risk of pancreatitis.  We have 
therefore chosen a very conservative cutoff of more than one prior episode.  This 
will permit enrollment of subjects who have had a single, isolated episode of 
pancreatitis prior to starting leptin.  Subjects who have had pancreatitis while 
receiving leptin are presumed to be at greater risk with leptin withdrawal, and will 
not be enrolled. Unfortunately, a careful literature review reveals no data to more 
precisely quantify the risk of future pancreatitis based on past pancreatitis.  The 
spectrum between acute, recurrent acute, and chronic pancreatitis is poorly 
understood, but even in patients with a risk factor such as hypertriglyceridemia, 

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additional “hits” (such as genetic modifiers) may be necessary to trigger recurrent or 
chronic pancreatitis52.   
c. Current triglycerides over 800 mg/dL.  Our gastroenterology consultants felt that 
a patient’s risk of pancreatitis is more likely to be related to their pre-leptin 
triglycerides and their past history of pancreatitis, rather than their current 
triglyceride level.  The level of hypertriglyceridemia that is likely to occur after 
leptin withdrawal in a patient with triglycerides of 800 at the onset of the study is 
not known. In a single patient, the effect of 10 days of leptin withdrawal on 
triglycerides during a controlled diet was measured.  In this patient (NIH-1), 
triglycerides rose from 400 to 800 mg/dL.  If this response is typical, we would 
anticipate that, in a patient enrolled with triglycerides of 800 mg/dL, the triglyceride 
level might increase to 1200 mg/dL after leptin withdrawal, which is just above the 
threshold of risk for pancreatitis.  However, it is important to note that pancreatitis is 
a rare complication of hypertriglyceridemia, even when serum triglycerides are 
elevated above 1000 mg/dL.  The risk of subjects reaching this degree of 
triglyceride elevation will be reduced by only enrolling those with triglycerides 
<800 mg/dL, as well as keeping subjects on a fat and carbohydrate controlled diet 
during leptin withdrawal.   
d. Current lipase > 491 units/L (the upper limit of normal in the NIH assay).  
While both amylase and lipase are often used clinically in the assessment of 
pancreatitis, amylase is a non-specific test that may be elevated for other reasons.  
Subjects with elevated lipase at study entry will be considered to have laboratory 
findings consistent with pancreatitis, and will be excluded. 
ii. 
The key element that will minimize risk to subjects is that leptin withdrawal will be 
performed under close inpatient observation with a controlled diet that should help 
maintain lower blood glucose and triglycerides. Clinical and laboratory monitoring of 
subjects for pancreatitis will be performed throughout the period of leptin withdrawal, as 
follows 
a. Safety labs will be monitored approximately every other day (when research labs are 
obtained.  These will include amylase, lipase, and stool pancreatic elastase.  
Elevated lipase (greater than the upper limit of normal, 491 units/L) will be a 
withdrawal criterion. Elevated amylase will be used only as a supportive criterion.  
Stool pancreatic elastase will be measured primarily for research purposes, as a 
marker of pancreatic exocrine function. Although triglycerides will be measured 
along with these labs, isolated elevation of triglycerides, without signs or symptoms 
of pancreatitis or elevated lipase, will not be a withdrawal criterion. 
b. If pancreatitis is clinically suspected (either based on signs/symptoms consisting of 
moderate to severe abdominal pain with nausea or vomiting, or based on lipase), the 
following will take place: 
i. Amylase and lipase levels will be drawn 
ii. GI consultation will be obtained  
c. If a diagnosis of pancreatitis is likely or confirmed based on labs and/or GI 
consultation, the following additional actions will be taken 
i. Appropriate treatment will be initiated based on GI recommendations (usually, 
NPO and pain medications) 
ii. Leptin will be restarted immediately 
iii. The patient will be withdrawn from the study 
iv. The IRB will be notified per guidelines for SAEs 
 
4. Blood Sampling:  Peripheral blood draws (venipuncture) performed during this study for research will 
not exceed 10.5 mL/kg, or 550 mL (whichever is smaller) per 8-week period for adults.   For pediatric 

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patients, blood draws will not exceed 5 mL/kg in a single day, or 9.5 mL/kg or 550 mL (whichever is 
smaller) per 8 week period.  Patients may experience some discomfort at the site of the needle entry, and 
there is a risk of bruising at the site.  There is a remote risk of fainting or local infection. 
 
5. Oral Glucose Tolerance Test:  Patients will be required to drink a very sweet glucose containing 
beverage.  This may be associated with mild nausea or distaste.  Due to serial blood draws, an 
intravenous line will be placed, with attendant risks of discomfort and possible skin infection. 
 
6. Euglycemic Hyperinsulinemic Clamp Study: In order to assess insulin sensitivity, patients will receive 
an intravenous infusion of insulin and – via a second intravenous access – increasing amounts of glucose 
to maintain euglycemia.  Insertion of the necessary intravenous lines may cause the above-mentioned 
discomfort and a possible skin infection.  Insulin infusion can induce hypoglycemia and hypokalemia.  
Either event is very unlikely, since patients undergo frequent blood glucose measurements and are 
constantly observed for the presence of hypoglycemic symptoms by an experienced nurse and/or 
physician.  However, in order to prevent complications, two patent, well-functioning intravenous lines 
are required during this procedure.  
 
7. Glucose and Lipid Turnover: The stable isotopes C is not associated with any toxicity at the doses used 
in these studies 53.  Deuterium at the doses given may cause temporary dizziness.  This risk will be 
minimized by dividing the 2H2O dose into four aliquots, and by giving the doses at night while subjects 
lie in bed.  If subjects need to get out of bed (e.g. to use the bathroom) the patient will first sit upright in 
bed for a few minutes prior to standing, and a nurse will be available to supervise and assist.  Palmitate 
must be complexed to albumin prior to delivery, and thus carries the risks associated with use of human 
blood products.  To minimize exposure to human albumin, uniformly labeled 13C16 palmitate will be 
used, permitting use of the minimum possible dose of this tracer. 
 
8. Resting Energy Expenditure:  There are no significant risks associated with measurement of resting 
energy expenditure.  Some patients may feel uncomfortable from lying still with a plastic hood over the 
head for approximately 30 minutes. 
 
9. Actigraphy, heart rate variability, blood pressure monitoring, and skin temperature: There are no 
significant risks associated with actigraphy, or monitoring of heart rate, blood pressure, or skin 
temperature.  Some patients may find it an inconvenience to wear the devices. 
 
10. DEXA Scan:  The effective radiation dose with total body DEXA scanning is 0.00001 rem.  This is 
equivalent to average daily background radiation from natural sources, and is not thought to increase 
lifetime cancer risk.  Subjects in this study will have up to three DEXA scans (total radiation dose 
0.00003 rem) per year. 
 
11. Magnetic Resonance Imaging (MRI) and Magnetic Resonance Spectroscopy (MRS):  While MR 
scanning is thought to be safe, the procedure may cause anxiety in some patients since current equipment 
used at the Clinical Center uses a closed tube. Adult patients will be offered sedatives such as Valium if 
they express worry about being in a closed space. Conscious sedation will not be employed on 
adolescents to perform any of these tests. Parental support will be sought if adolescents find it hard to 
stay immobile for the duration of the studies. No intravenous contrast will be used in these studies. 
 
12. 24 hour urine collection:  Urine collection may be slightly inconvenient for subjects; however, there is 
no health risk. 
 

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13. Metabolic Chamber: Some inconvenience can reasonably be expected as a result of spending an 
extensive time (24 hours) in the live-in room calorimeter.  However, the risk to subjects' health is 
minimal. 
 
14. Ultrasounds:  The pelvic ultrasound may be uncomfortable due to pressure on a full bladder but there are 
no risks. 
 
15. Echocardiogram:  The echocardiogram may be inconvenient but there are no risks to the subject’s health.   
 
Alternatives to participation 
Participation in clinical trials is completely voluntary.  Refusal to participate will not affect a subject's ability to 
participate in other studies of leptin and lipodystrophy at NIH or elsewhere. 
 
Financial Compensation 
All subjects will receive financial compensation for their time per Clinical Center guidelines for on-site visits, 
and additional compensation will be provided for specific procedures based on inconvenience units, as follows: 
 
 
 
 
 
Short-term (3 week) 
study 
Long-term follow-up 
visit 
Procedure 
Inconvenience 
Units 
Compensation 
Occurrence 
Total 
Occurrence 
Total 
Inpatient per 
diem 
n/a 
$40 
20 
$800 
4 
$160 
Metabolic 
Chamber  
5 
$50 
3 
$150 
1 
$50 
DEXA 
1 
$10 
2 
$20 
1 
$10 
Exercise test 
1 
$10 
3 
$30 
1 
$10 
Euglycemic    
Clamp  
5 
$50 
2 
$100 
1 
$50 
Tracer studies 
2 
$20 
3 
$60 
1 
$20 
LH pulsatility 
3 
$30 
2 
$60 
1 
$30 
MRI/MRS 
3 
$30 
2 
$60 
1 
$30 
Total 
$1280  
 
$410 
 
Consent/Assent Procedures 
Written consent/assent will be obtained from each subject after detailed explanations of the planned 
procedures by the principal or an associated investigator in language understandable to the subject. The 
consent process will take place prior to any study procedures.  Sufficient time and opportunity will be 
given for discussion of the research as well as to answer any questions the subject may have, taking 
care to minimize or eliminate the perception of coercion or undue influence.  The participant and the 
investigator will sign the current IRB-approved informed consent document.  A copy of the consent 
will be given to the subject for future reference and the consenting process will be documented in the 
electronic medical record (CRIS).   
 
Given the prospect of direct benefit for minor subject participants, only one parent/guardian or LAR 
will need to give written informed consent prior to any screening visits, study procedures or treatments. 
The Principal Investigator or other designated qualified protocol investigators will explain the study in 

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language understandable to the parent/guardian or LAR. If appropriate, the investigator will also 
explain the study to the minor who is of a younger age and level of understanding.  Sufficient time and 
opportunity will be given for discussion of the research as well as to answer any questions they may 
have, taking care to minimize or eliminate the perception of coercion or undue influence. A witness 
will also sign the consent document to attest only to the validity of the signature of the parent/guardian 
or LAR, not the validity or quality of the consent. If appropriate, the investigator will have the minor 
will provide assent, and if possible, will sign the current IRB approved assent document. The 
investigator will sign the assent as well. A copy of the consent and assent will be given to the minor 
and his/her parent/guardian or LAR for future reference. The signed documents will be sent to the 
Medical Records Department for placement in the subject's permanent CC medical record. The consent 
process will additionally be documented in the electronic medical record (CRIS)  
For patients currently enrolled on the protocol, that are turning of legal age (i.e. 18 years of age) and 
who are able to provide consent, we plan to follow the procedures outlined in NIH SOP 14D and the 
same procedures described above in order for the patient to continue receiving study drug without 
interruption.  
We do not plan or anticipate the enrollment of non-English speaking subjects. However, they are not 
excluded from participation either. If there is unexpected enrollment of a research participant for which 
there is no translated extant IRB-approved consent document, the Principal Investigator and/or those 
authorized to obtain informed consent will use the short form consent process as described in MAS 
Policy M77-2, NIH SOP 12, 45 CFR 46.117 (b), and 21 CFR 50.27 (b).  The summary that will be used 
is the English version of the extant IRB-approved consent document. We request prospective IRB 
approval of the use of the short form consent process for up to a maximum of 5 requests (either for 
individual participants or families of participants) in a given language, and will notify the IRB at the 
time of continuing review of the frequency of the use of the short form. Should we reach the threshold 
of 5 subjects and/or families speaking a single language, we will request an additional use of the short 
form from the IRB and will notify the Board that we plan to have any consent documents frequently 
used with that population translated into the language(s) they speak. 
Subjects have the right to withdraw participation from this protocol at any time. 
 
Research Use, Storage and Disposition of Human Subjects’ Samples and Data 
For future reference and potential use, we will store all samples (blood or fluids) in our locked freezers for an 
unlimited period of time. Samples will be labeled with coded identifiers linked to patient identity only via a 
secured database. Research records and data with personal identifiers will be stored in our locked offices, the 
medical record department, and the electronic study database. This material will additionally be protected by 
medical record and computer access procedures.  Access to records and data associated with personal 
information will be restricted to the Principal Investigator, Co-Investigators, study support staff, and database 
support staff. 
 
Stored samples and/or data may be sent to outside collaborating laboratories, or shared with other NIH 
collaborating investigators, to study questions related to lipodystrophy or its complications (including, for 
example: glucose metabolism, diabetes, obesity, weight, appetite, steatohepatitis, and lipid metabolism). Samples 
may be sent to outside commercial laboratories for analysis.  Samples and data sent to outside laboratories and 
collaborators for analysis and/or testing will contain only coded numbers, without personal identifiers. Tech 
Transfer agreements will be completed before the exchange of samples and/or data with outside collaborators. 
 

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Subjects may request that unused samples be removed from our freezers and returned to the subject, or be 
destroyed.  If no such request is made, we will keep samples until they are completely used or no longer of 
scientific value, at which time they will be destroyed. We do not plan to destroy personal medical information or 
stored data. The Principal Investigator will report loss or destruction of data or samples to the NIDDK/NIAMS 
IRB.  
 
Material Transfer Agreement/Collaboration(s): 
Collaboration has been established with Dr. Morey W. Haymond, a board-certified pediatric endocrinologist and 
Professor of Pediatrics and Medicine at Baylor College of Medicine.  Our direct site contact will be Shaji 
Chacko, Ph.D.   The purpose of the collaboration is to assist in the conduct of the clinical studies determining the 
rates of glucose production and gluconeogenesis in subjects with a variety of forms and severity of 
lipodystrophy. This will include the review of the protocol design, potentially the analysis of coded human 
subject samples, review of the coded data derived and interpretation of the results. 
 
Collaboration has been established with Dr. Ravinder J. Singh at the Mayo Clinic in Rochester, Minnesota.  The 
purpose of the collaboration is to assess whether steroid synthesis and metabolism is altered in patients with 
lipodystrophy and effected by metreleptin treatment. This collaboration will involve transfer of coded human 
plasma and urine samples (not data), review of the coded data derived, and interpretation of the results. 
 
Collaboration has been established with Dr. Elizabeth Parks at the University of Missouri School of Medicine.  
The purpose of the collaboration is to measure rates of de novo lipogenesis during periods in which patients do 
or do not receive leptin, using stable isotope tracer techniques.  This will involve transfer of coded human frozen 
plasma, and/or isolated triglyceride-rich particles derived from frozen plasma, review of the coded data derived 
and interpretation of the results. 
 
Collaboration has been established with Professor Stephen O’Rahilly in Cambridge, England.  Our direct 
physician contacts are Dr. Robert Semple and Dr. David Savage.  The purpose of this collaboration is to share 
coded de-identified clinical data collected from subjects enrolled under this protocol at NIH.  The Laboratory at 
Cambridge University will use the coded data, including laboratory, anthropometric, imaging and demographic 
data, to characterize the phenotype of patients affected by suspected mutations of the insulin receptor or 
lipodystrophy and to study the association between phenotypes and causative genetic mutations, in order to 
better understand the pathogenesis and natural history of these diseases, improve the diagnosis, and predict and 
assess response to treatment.  
 
Collaboration has been established with Elif Oral, MD at the University of Michigan in Ann Arbor.  Dr. Elif 
Oral, is a former NIDDK investigator, and familiar with our patient population.  The purpose of this 
collaboration is to improve the diagnosis of patients with lipodystrophy by characterizing their phenotype 
compared to control subjects, and to determine biomarkers which may predict response to treatment. To reach 
these goals, Dr. Oral will be provided coded de-identified blood samples (serum, plasma) and coded de-
identified clinical data to analyze body composition and additional clinical data (including laboratory, 
anthropometric, imaging and demographic data) from study participants enrolled at NIH under this protocol.    
 
Collaboration has been established with Abhimanyu Garg, MD at the University of Texas Southwestern.  This 
collaborator is a former associate investigator of our original leptin protocol, and is a world’s expert on 
syndromes of lipodystrophy.  The purpose of this agreement is to transfer coded de-identified metabolic and 
clinical data, including laboratory, anthropometric, imaging and demographic data, to characterize the phenotype 
of patients affected by lipodystrophy and to study the association between phenotypes and causative genetic 
mutations, in order to better understand the pathogenesis and natural history of this disease, improve the 
diagnosis, and predict and assess response to treatment.  

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Appendices 
Appendix A:  Sample Patient Calendars 
Short-term portion of study (leptin naïve and leptin treated subjects) 
Period 1 
  
  
  
  
Period 2 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Study 
Day 
-6 
-5 
-4 
-3 
-2 
-1 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
Time 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
6:00 
  
Fasting 
labs 
  
  
LH sampling 
Fasting 
labs 
Chambe
r 
  
Fasting 
labs 
  
Fasting 
labs 
  
Fasting 
labs 
  
Chambe
r 
  
Fasting 
labs 
  
Fasting 
labs 
LH 
samplin
g 
Chamber 
6:30 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
7:00 
  
REE 
  
  
  
Start 24 
hr urine 
Stop 24 
hr urine 
REE 
  
  
  
REE 
  
Start 24 
hr urine 
Stop 24 
hr urine 
REE 
  
  
Stop 24 
hr urine 
Fasting 
labs/ 
Start 24 
hr urine 
Stop 24 
hr urine 
7:30 
 Oral 
Glucose 
toleranc
e Test 
  
  
  
  
  
  
  
  
  
Start tracers 
Start 
skin 
temp 
DEXA 
  
  
  
  
  
Start 
tracers 
  
  
  
  
  
Start 
tracers 
Start 
skin 
temp 
DEXA 
8:00 
Start diet 
  
  
REE 
Chambe
r 
Fasting 
labs 
  
  
  
  
  
  
Chambe
r 
Fasting 
labs 
  
  
  
REE 
Chambe
r 
Stop 
Actigrap
h 
8:30 
  
  
  
  
VAS 
(fasting) 
Stop 
skin 
temp 
  
  
  
  
  
  
VAS 
(fasting) 
  
  
  
  
  
VAS 
(fasting) 
Stop skin 
temp 
9:00 
Start 
Actigrap
h 
 Pelvic 
Ultrasound 
  
  
  
Start BP 
monitor 
  
  
  
  
  
  
  
  
  
  
  
  
  
Dis-
charge 
9:30 
  
  
  
  
  
  
Stop BP 
monito
r 
  
  
  
  
  
  
  
  
  
  
  
  
  
10:00 
  
 Abdominal 
ultrasound 
Exercise test 
  
  
  
  
  
  
  
Exercis
e test 
  
  
  
  
  
Exercis
e test 
  
  
  
10:30 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
11:00 
  
  
  
Skin temp 
monitor 
  
  
  
  
  
  
  
Skin 
temp 
monito
r 
  
  
  
  
  
Skin 
temp 
monito
r 
  
  
  
12:00 
  
  
  
  
Clamp 
  
  
  
  
  
  
  
  
  
  
  
  
  
Clamp 
  
  
13:00 
Admit 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-lunch) 
  
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
VAS (p-
lunch) 
  
VAS (p-
lunch) 
  
14:00 
  
  
  
MRI 
  
  
  
  
  
  
  
  
  
  
  
  
  
MRI 
  
  
  
15:00 
  
  
 Thyroid 
ultrasound 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
16:00 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
17:00 
  
  
  
  
Start BP 
monitor 
  
  
  
  
  
  
  
  
  
  
  
  
  
Start BP 
monitor 
  
  
18:00 
  
  
  
  
  
Stop BP 
monitor 
  
  
  
  
  
  
  
  
  
  
  
  
  
Stop BP 
monitor 
  
19:00 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
20:00 
Exercise 
Exercise 
Exercise 
Exercise 
Exercise 
Exercise 
Exercise 
Exercis
e 
Exercis
e 
Exercis
e 
Exercis
e 
Exercis
e 
Exercis
e 
Exercise 
Exercise 
Exercis
e 
Exercis
e 
Exercis
e 
Exercise 
Exercise 
  
23:00 
  
  
  
8 hr LH 
sampling 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
8 hr LH 
samplin
g 
  
  

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Appendix A:  Sample Patient Calendars 
 
Long-term follow-up (leptin naïve subjects, only) 
  
Study Day 
0 
1 
2 
3 
4 
5 
Time 
  
  
  
  
  
  
5:00 
  
  
  
Start tracers 
  
  
6:00 
  
Fasting labs 
LH sampling 
  
  
Chamber 
6:30 
  
  
  
  
  
  
7:00 
  
OGTT 
REE 
  
Start 24 hr urine 
Stop 24 hr urine 
7:30 
  
(NPO) 
  
  
Start skin temp 
DEXA 
8:00 
  
  
  
  
Chamber 
  
8:30 
  
  
  
  
  
Stop skin temp 
9:00 
  
  
Start Actigraph 
  
  
  
9:30 
  
  
Skin temp monitor 
Clamp 
  
Stop Actigraph 
10:00 
  
  
Exercise test 
  
  
  
10:30 
  
  
  
  
  
  
11:00 
  
  
Skin temp monitor 
  
  
Discharge 
12:00 
  
  
  
  
  
13:00 
Admit 
  
  
  
  
14:00 
  
  
MRI 
  
  
15:00 
  
  
  
  
  
16:00 
  
  
Start HR monitor 
Stop HR monitor 
  
  
17:00 
  
  
  
Start BP monitor 
Stop BP monitor 
  
18:00 
  
  
  
  
  
  
19:00 
  
  
  
  
  
  
20:00 
  
  
  
  
  
  
23:00 
  
8 hr LH sampling 
  
  
  
  

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Appendix B:  Investigator Qualifications and Roles 
 
Rebecca J. Brown, M.D., M.H.Sc. is a board certified pediatric endocrinologist, and an Assistant 
Clinical Investigator of the Diabetes Endocrinology, and Obesity Branch. Dr. Brown has six years of 
experience conducting clinical studies in children adults with diabetes, and has a Master’s degree in 
Clinical Research. She is the Principal Investigator of this study, and is responsible for the study design, 
implementation, and interpretation. 
 
Kong Chen, Ph.D.  is the director of the Human Metabolism and Body Weight Regulation Core, and a 
Clinical Investigator of the Diabetes Endocrinology, and Obesity Branch.  Dr. Chen’s role in this project 
will be to assist Dr. Brown with the measurements and data interpretation of energy expenditure, body 
composition, exercise efficiency, body temperature, and physical activity.  
 
Elaine K. Cochran, M.S.N., CRNP, is a nurse practitioner in the Diabetes, Endocrinology and Obesity 
Branch, and is lead associate investigator of the ongoing study of leptin treatment in lipodystrophy 
patients.  She is an expert in the administration of leptin to patients with lipodystrophy.  Her role in this 
project will be to assist in clinical management and education of patients, as well as assist in measurement 
of insulin sensitivity using the euglycemic hyperinsulinemic clamp studies. 
 
Amber Courville, PhD, RD, CSSD. is a registered dietitian working for the NIH Clinical Center.  Dr. 
Courville’s role in this project will be to assess subjects energy needs and coordinate the provision of a 
controlled metabolic research diet to the subjects during the study. 
 
Ahmed Gharib, M.D., is a board certified radiologist and clinical research in NIDDK.  Dr. Gharib’s role 
in this study will be to assist Dr. Brown with the measurement and interpretation of liver and muscle 
triglyceride. 
 
Phillip Gorden, M.D. is a board certified endocrinologist, Senior Investigator in the Diabetes, 
Endocrinology and Obesity Branch, and Director Emeritus of the NIDDK.  He has over four decades of 
experience conducting clinical studies in patients with rare disorders of extreme insulin resistance, and is 
Principal Investigator of the ongoing study of leptin treatment in lipodystrophy patients.  His role in this 
project will be to work with Dr. Brown on study strategy, design, and interpretation.   
 
Kevin Hall, Ph.D., is a researcher in the Laboratory of Biological Modeling in NIDDK.  His research 
focuses on using mathematical modeling to quantitatively integrate metabolism data with body weight 
and composition data.  Dr. Hall’s role in this project will be to assist Dr. Brown with the measurements 
and data interpretation of energy expenditure and body composition.  
 
Morey W. Haymond, M.D. is a board-certified pediatric endocrinologist and Professor of Pediatrics and 
Medicine at Baylor College of Medicine. Dr. Haymond’s role in this project will be to assist Dr. Rebecca 
Brown in the conduct of the clinical studies determining the rates of glucose production and 
gluconeogenesis in subjects with a variety of forms and severity of lipodystrophy. This will include the 
review of the protocol design, potentially the analysis of subject samples, review of the data derived and 
interpretation of the results. 
 
Megan Mattingly, RN, MPH is a research nurse in the Diabetes, Endocrinology and Obesity Branch.  
Ms. Mattingly’s role in this project will be to assist Dr. Brown with the coordination of patient visits, 
patient education and communication, as well as assist in measurement of insulin sensitivity using the 
euglycemic hperinsulinemic clamp studies. 

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Ranganath Muniyappa MD, PhD.  is a board-certified Endocrinologist and a Staff Clinician at DEOB, 
NIDDK, NIH. Dr. Muniyappa’s role in this project will be to assist Dr. Brown with the assessment of 
insulin sensitivity/resistance using the euglycemic hyperinsulinemic clamp studies. 
 
Marc Reitman MD PhD.  is trained in internal medicine and endocrinology and metabolism and is 
currently a senior investigator and branch chief in intramural NIDDK.  Dr. Reitman is an expert in leptin 
physiology and clinical trials.  His role in this project will be to work with Dr. Brown on study strategy, 
design, and interpretation.   
 
Andrea Ramirez, M.D. M.S., is an Assistant Professor of Medicine in the Division of Diabetes, 
Endocrinology and Metabolism, with the Department of Medicine at Vanderbilt University School of 
Medicine in Nashville, TN.  Dr. Ramirez earned her M.D. at Duke University and trained in Internal 
Medicine and Clinical Pharmacology at Vanderbilt University.  She also earned her Masters of Science in 
Clinical Investigation at Vanderbilt University.  Dr. Ramirez trained in Endocrinology, Diabetes, and 
Metabolism at the National Institutes of Health and is certified by the American Board of Internal 
Medicine in Internal Medicine and Endocrinology, Diabetes, and Metabolism.  She has participated in 
multiple clinical protocols related to endocrinologic disease and studies the genetics of diabetes.  Dr. 
Ramirez's role in this project will be to assist Dr. Rebecca Brown in determining the effects of leptin on 
circulating nucleic acids and pharmacoepigenomics of leptin therapy. 
 
Ravinder J. Singh, M.D., Ph.D., is a consultant Laboratory Medicine and Pathology at the Mayo Clinic 
located in Rochester, Minnesota.  Dr. Singh’s role in this project is to assist Dr. Rebecca Brown in the 
conduct of clinical studies by assessing whether steroid synthesis and metabolism is altered in patients 
with lipodystrophy and effected by metreleptin treatment.  Dr. Singh will perform different measurements 
that he has developed using mass spectrometry using coded human plasma and urine samples, collected 
from the study subjects enrolled at NIH. 
 
Elizabeth Parks, Ph.D., is a professor of nutrition and exercise physiology at the University of Missouri 
School of Medicine.  Dr. Parks’ role in this project is to assist Dr. Rebecca Brown in the conduct of the 
clinical studies by examining the effects of leptin in patients with lipodystrophy on glucose and lipid 
metabolism and energy expenditure, independent of food intake.   Dr. Parks plans to measure rates of de 
novo lipogenesis during periods in which patients do or do not receive leptin, using stable isotope tracer 
techniques. 
 
James Reynolds, M.D., is board-certified in endocrinology and nuclear medicine and a Scientist 
Emeritus at the National Institutes of Health and special volunteer in Radiology and Imaging Sciences 
Department. He is a Certified Clinical Densitometrist (ISCD) with 25 years’ experience in bone 
densitometry and body composition studies. He will be assisting Dr. Rebecca Brown in providing data 
and analysis of whole body densitometry scans on patients with Lipodystrophy. 

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Appendix C:   Myalept Package Insert  
 
 
package 
insert_myalept_acces

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Appendix D:  Waiver of Consent 
 
PURPOSE 
The purpose of this project is to understand more about the health problems experienced by people with 
lipodystrophy, so that we can understand how treatments such as leptin may improve or prevent those 
health problems.  If we can show that patients who have not received leptin treatment have worse health 
problems than those who have received leptin treatment, this may eventually lead to wider availability of 
leptin treatment.   
 
This project has four objectives: 
• 
To describe the demographic and clinical characteristics of patients with generalized and partial 
lipodystrophy. 
• 
To describe the severity of metabolic complications (e.g. hyperlipidemia, diabetes, 
steatohepatitis) of lipodystrophy and assess the association of disease severity markers (i.e., 
elevated glucose, triglycerides, low leptin levels) with survival. 
• 
To characterize the burden (e.g., pain, organ damage, hyperphagia, school/work productivity) of 
lipodystrophy and assess the impact of disease severity markers (i.e., elevated glucose, 
triglycerides, low leptin levels) 
• 
To assess the potential benefit of leptin replacement therapy on all of the above.  
 
DATA COLLECTION 
Aegerion Pharmaceuticals, the current owner of leptin, through Analysis Group, Inc. would like to 
perform a one-time data abstraction from NIH to further understand the benefits of leptin.   
 
The data sources that will be used by Analysis Group are: 
1. Manual review of NIH medical records 
2. Electronic download of NIH medical record data using BTRIS 
3. Research records (not contained in CRIS or BTRIS) from the approved protocols covered by this 
consent waiver 
4. Direct queries to investigators 
 
Subjects whose data are abstracted for this project, will not be contacted about results pertaining to this 
amendment without prior approval by the IRB. 
 
Below are the key variables to be abstracted:   
 
• 
Demographics 
• 
Diagnosis  
• 
Anthropometric measurements (e.g., neck, waist, hip, arm circumferences; % fat, BMI) 
• 
Family history 
• 
Metabolic and lipid profile 
o Lab values (e.g., HbA1c, triglycerides) 
o Presence of diabetes or insulin resistance  
• 
Liver profile 
o Lab values (including biopsy)  

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o Diagnoses of liver diseases 
o Liver transplant (new or historical) 
• 
Kidney profile 
o Lab values (including biopsy) 
o Kidney transplant (new or historical) 
• 
Pancreas profile  
o Diagnoses of pancreatic diseases 
• 
Heart disease 
o Diagnoses of heart diseases 
o Heart transplant (new or historical) 
• 
Medication use 
o Insulin 
o Metformin 
o Other diabetes medications 
o Triglycerides medications 
o Other lipid lowering medications 
o Antihypertensive medications 
• 
Comorbidities (e.g., diabetes, hypertriglyceridemia, surgical history, malignancy, etc.) 
• 
Visit information (including withdrawal from the study) 
• 
Adverse events and associated resource utilization (e.g., emergency room visits, hospitalization, 
mortality and cause)  
• 
Reproductive history 
• 
Quality of life: 
o Hyperphagia history 
o Social/work productivity (as documented in Social History in medical records) 
o Pain/fatigue history  
o Psychological distress (e.g. related to physical appearance) 
 
PROTECTION OF SUBJECT CONFIDENTIALITY 
 The Analysis Group, Inc. has had all the relevant training to extract and review data.  They are required to 
perform their services in accordance with HIPAA and other state/federal/privacy laws.   The Analysis Group 
staff will receive NIH medical records system training.  It is necessary for staff from Analysis Group to have 
access to PII while they are physically at NIH, because of the amount of effort that would be required by 
NIH staff to manually redact all PII from all patient medical records. All the data that leaves the NIH would 
be entered onto electronic case report forms (e-CRFs) housed in an electronic data base and would be 
completely de-identified.  Each patient’s data will be associated only with their study ID number.  Only NIH 
research staff involved in these studies will be able to connect the study ID number to the patient’s identity.  
No patient samples of any kind (e.g. blood, urine, DNA) will leave the NIH as part of this study. If data is 
lost or destroyed, we will report this to the NIDDK/NIAMS IRB. 
 
CONSENT/ASSENT PROCEDURES 
Because the informed consent documents for this study did not specifically address this use of data, we 
have requested a waiver of informed consent. 
All subjects agreed to participate in the study designed to test the safety and effectiveness of long-term 
leptin replacement.  All patients started in 02-DK-0022 or 13-DK-0057.  Additionally, most of the 
patients were also co-enrolled in 76-DK-0006 in which they consented to participate in studies the 
purpose of which was to understand the natural history of insulin resistance and lipodystrophy.  Because 

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the purpose of the current project is identical to that expressed in the past consents, the rights and welfare 
of the patients are not altered.   
The original and current consent for this protocol states, “Your stored samples and/or data may be sent to 
outside collaborating laboratories or shared with other NIH collaborating investigators. We will use these 
samples and data to study questions related to lipodystrophy and its complications (such as diabetes, 
lipids, and liver disease). Samples (blood or fluids) and data shared with collaborators or sent to 
commercial laboratories for research purposes will be labeled only with coded numbers, without personal 
identifiers.”  
 
We would like to request a waiver of informed consent to proceed with this project.   
 
NIH SOP Number 12 addresses the requirements for waiving the consent process.  We wrote our response to 
each of the four points below.   
 
12.10 WAIVING OR ALTERING ELEMENTS OF INFORMED CONSENT UNDER 45 CFR 46  
 
A. Circumstances in which the IRB may waive or alter elements of the informed consent procedure 
or waive the requirements to obtain informed consent: An NIH IRB may approve a consent 
procedure that does not include, or which alters some, or all, of the elements of informed 
consent set forth in 45 CFR 46.116(ab), or waive the requirements to obtain informed consent, 
provided the IRB finds and documents in the IRB meeting minutes:  
1. The research involves no more than minimal risk to the subjects.  
Response:    Extracting the data from this protocol would involve no more than minimal risk to the 
subjects involved.  The data will be de-identified and the team extracting the data is expected to perform 
their services per HIPPA and other relevant federal/state privacy laws.   
2. The waiver or alteration will not adversely affect the rights and welfare of the subjects.  
Response:    Extracting the data from this protocol would not adversely affect the rights and welfare of 
the subjects.  All subjects consented to participate in studies of which the purpose was to understand the 
natural history of insulin resistance and lipodystrophy as well as the efficacy of leptin over the long term.  
All subjects consented to share their data with other collaborating investigators as long as their data was 
de-identified.  Because the purpose of the current project is identical to that expressed in the consents the 
rights and welfare of the patients are not altered.   
3. The research could not practicably be carried out without the waiver or alteration, and  
Response:  Currently there are 28 patients enrolled in this protocol from across the United States, Canada 
and Argentina.  They are on a one to two year visit cycle and re-consenting patients could not be 
completed in a timely manner.  
4. Whenever appropriate, the subjects must be provided with additional pertinent information after 
participation (see 45 CFR 46.116(d), link also in References  
 
Response:  We do not think that this is relevant to this project.   

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