Safety/Tolerability and Effects on Cognitive Impairment, Impaired Cerebral Cortical Metabolism and Oxidative Stress of R(+)Pramipexole Administered to Subjects With Early Alzheimer's Disease
Phase: PHASE2
Conditions: Alzheimer's Disease
Sponsor: Virginia Commonwealth University

 
 
Title: Safety and Tolerability Study of R(+)Pramipexole in Alzheimer’s Disease 
 
NCT #: NCT01388478 
 
Document date: 02/18/2011 
 
Document Type: Protocol and Statistical Analysis Plan 
 
 
 

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
1	  
Safety and Tolerability Study of R(+)Pramipexole in Alzheimer’s Disease 
 
BACKGROUND AND SIGNIFICANCE: 
The looming problem 
Dementia due to Alzheimer’s disease (AD) type pathology currently afflicts 3.5-5 million 
Americans, with resulting annual costs for medical and hospice care and lost wages of caregivers 
estimated to be 150-200 billion dollars. Because the major risk for developing AD is aging, and given 
the projected 2 to 2.5-fold increase in the age-vulnerable population as the “baby boomer” generation 
ages, projected expenditures for AD care in 15-20 years could equal the baseline Department of 
Defense budget. In addition to the immense personal tragedies inflicted by AD, the looming medical 
and socioeconomic disaster posed by this one condition of brain aging should stimulate massive efforts 
to both understand its pathophysiology and develop disease trajectory-altering therapies. 
What are the roadblocks limiting disease-altering AD therapy development? 
 
The vast majority of AD (~95%) occurs sporadically without clear autosomal genetic cause. 
While certain genes such as APOE4 increase risk of acquiring AD, they certainly are not causal. Genes 
felt to be causal for genetic (familial) AD that represents ~5% of the AD population involve either one of 
multiple known mutations of amyloid precursor protein (APP) or mutations in one of the two known 
presenilin genes (PS1 or PS2). Because cells expressing APP only or with PS mutations (but not PS 
mutations alone) overproduce 40-42 amino acid long peptide fragments of APP, known as beta amyloid 
1-40 or 1-42, because AD brains characteristically accumulate beta amyloid as visible plaques, and in 
light of the in vitro neurotoxicity of beta amyloids (esp the 1-42 peptide), a causal theory known as the 
“beta amyloid cascade hypothesis” was advanced ~15 years ago and has dominated AD investigations 
and experimental therapeutics. Arguments for and against this hypothesis have been both many and at 
times stridently debated. Opponents argue that this hypothesis has now been tested in humans with 
several different types of beta amyloid lowering therapies and found to be deficient. Proponents argue 
that the theory either has not yet had the proper testing in humans, and/or that the toxic species are low 
molecular weight soluble oligomeric forms of beta amyloid (as opposed to insoluble plaques). 
Therapies that either reduce beta amyloid production (beta- or gamma-secretase inhibitors) or remove 
accumulated beta amyloid (immunotherapies) continue to be developed and enter testing in humans 
with AD. As a result, the amyloid cascade hypothesis will “get its day in court”, but there is clearly a 
substantial risk of failure in pursuing solely this single therapeutic avenue. 
 
In addition to whatever conceptual barriers that have arisen as a result of the dominance of the 
amyloid cascade hypothesis (some have compared its vocal proponents to a “scientific cartel”), a more 
vexing problem relates to defining other “targets”. Traditional pharma drug development has relied upon 
defining specific molecular targets, developing and screening multiple candidates against that target, 
and selecting the most efficacious/least toxic for potential development to use in humans. For a 
complex and likely heterogeneous disease such as AD, the identities of the targets causal for disease 
progression are not clear. A major premise of this application is that the molecular target approach for 
altering neurodegenerative diseases is too limiting and likely to fail. That has been the case so far in 
Parkinson’s disease [3], the second most prevalent neurodegenerative disease of adults. Rather, the 
approach taken in this application is to try and define consistent abnormalities in systems biologic 
processes that are defective in AD, then apply therapies that correct these abnormal biological 
processes. This proposal advances a process-altering, not a molecular target-driven approach. 
Elevated oxidative stress appears early in AD and can drive increased beta amyloid accumulation 
 
Most eukaryotic life on earth lives in atmospheric oxygen and is dependent on oxidative 
decarboxylation of fuels and reduction of oxygen to water by mitochondrial respiration to produce 
storage energy (ATP). Highly differentiated, non-mitotic cells such as neurons are energy intensive, 
very dependent on mitochondrial respiration, and as a consequence must inactivate relatively large 
amounts of reactive oxygen species (ROS) such as superoxide anion and its diffusible dismutation 
product hydrogen peroxide. When ROS production rates exceed inactivation rates, a state of “oxidative 
stress” exists, wherein proteins, lipids and nucleic acids are oxidatively damaged. Because most ROS 
normally arise from the small inefficiency of mitochondrial respiration, mitochondrial components 

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
2	  
particularly experience oxidative stress damage. Paradoxically, oxidative damage to mitochondrial 
DNA, RNA and respiratory proteins appears to increase further the inefficiency of respiration, driving up 
ROS production rates. This leads to a downward spiral over time in mitochondrial respiration due to 
oxidative damage, formulated as the “mitochondrial hypothesis of aging”, at least as applied to energy-
intensive, non-mitotic tissues such as brain, heart, retina and muscle.  
 
Relative oxidative stress in brain tissue can be monitored in living subjects by assay of certain 
oxidized small lipid molecules known as F2-isoprostanes/neuroprostanes [4,5,6,7,8]. In deceased 
subjects, brain tissues can be assayed for the same molecules, as well as oxidized proteins, other 
lipids and nucleic acids. For subjects with mild cognitive impairment (MCI), a pre-AD state for a certain 
fraction, elevated oxidative stress markers are present in spinal fluid and brain tissues 
[4,5,9,10,11,12,13,14,15,16,17,18,19]. For mice expressing familial AD genes, brain oxidative stress is 
elevated long before beta amyloid accumulation begins [6]. For AD brains, elevated oxidative stress 
could be responsible for appearance of elevated beta amyloid peptides, as expression of beta 
secretase enzyme (necessary for cleaving the N-terminal part of beta amyloid from APP) is increased 
by oxidative stress, and activity of insulin degrading enzyme (neprilysin), which degrades beta amyloid 
peptide, is decreased by oxidative stress [20,21,22,23,24]. 
mtDNA in sporadic AD can contribute to oxidative stress and increased beta amyloid production 
 
Human mitochondria have multiple copies of their own small (~16.6 kbase) circular, maternally 
inherited DNA that codes for 13 essential respiratory proteins. Human brain mtDNA accumulates point 
mutations and oxidative damage with aging. Individual brain neurons also experience clonal expansion 
of mtDNA’s containing sizeable (5-7 kbase) deletions that cannot produce essential respiratory 
proteins. As a result, age-related damage to brain neuronal mtDNA, leading to increased oxidative 
stress, is an attractive hypothesis for risk of developing neurodegenerative conditions such as AD. 
 
In our previous studies we have tested the hypothesis that AD patients harbor pathogenic 
mtDNA’s by creating cybrid cells that selectively express mtDNA against constant nuclear genetic and 
neuronal cell culture backgrounds [25]. We found that compared to cybrid cells made from age-
matched non-AD controls, cybrids from AD subjects had increased oxidative stress, impaired 
mitochondrial functions and secreted increased beta amyloid peptides [15,25,26]. While not providing 
insight into the specifics of mtDNA abnormalities, and not proving causality of mtDNA to initiate AD 
pathogenesis, our cybrid studies implicated mtDNA-driven oxidative stress as a likely contributor to 
beta amyloid overproduction in AD. 
 
If abnormal mtDNA’s produce impaired respiration and increased oxidative stress in AD brain 
neurons as our cybrid studies suggest is possible, and if such increased oxidative stress further 
damages mitochondrial components and increases beta amyloid production, then reduction of 
mitochondrial oxidative stress should exert a disease-slowing effect in AD. This benefit, if present, 
would neither support nor refute the amyloid cascade hypothesis, since oxidative stress by itself is 
damaging to neuronal integrity. However, there is also no a priori reason to reject the possibility of 
multiple interacting drivers of neurodegeneration. To return to the initial argument advanced, what this 
application proposes is development of approaches to reduce mitochondrially generated oxidative 
stress as a systems biological problem in AD, rather than target a specific macromolecule. 
What about regional vulnerability? 
 
A consistent, defining characteristic of adult neurodegenerative diseases is regional 
vulnerability, meaning that selected neuronal populations degenerate at increased rates relative to 
other neurons. For AD, loss of hippocampal and nucleus basalis neurons is greatest, followed by 
certain cortical neuronal populations. For PD, nigral dopamine and other brainstem aminergic neurons 
are most vulnerable. How can this be?  
 
The honest answer is that causes of regional vulnerability are both intriguing and remain 
elusive. Altering their mechanisms may offer great therapeutic benefits. Yet, rational experiments to 
alter pathogenic mechanisms can proceed in the absence of knowing how regional vulnerability occurs. 
In the case of AD and PD, overlapping of clinical phenotypes and pathologies with disease progression 
implicates similar disease mechanisms, at least in some subjects. 
 

R(+) pramipexole in Alzheimer’s Disease  
James P. Bennett, Jr. M.D., Ph.D.-Sponsor
2/18/2011 
$"
SPECIFIC AIMS 
The primary aim of this protocol is to test the safety and tolerability of R-Pramipexole in humans 
with probable AD.  We will also explore changes in oxidative stress and brain metabolic consequences 
as a “proof of concept” exploratory aim.   
Primary Aim: Assess the safety and tolerability of R-Pramipexole in probable AD.  Twenty 
subjects with probable AD will initiate treatment with 100 mg/day of R(+) pramipexole for one month. If 
tolerated, the subjects will increase to 200 mg/day for one month and then 300 mg/day for the next 4 
months. Participants will be contacted by phone every two weeks to determine any adverse events.   
They will also be examined by a physician, have their vital signs measured and have routine safety 
blood labs performed every two months.  
Exploratory Aim: Assess the effect of R-Pramipexole on oxidative stress and brain metabolic 
consequences.  Prior to initiation of R(+)PPX dosing, we will obtain plasma and spinal fluid for 
oxidative stress markers and obtain brain glucose metabolism PET scans (2FDG PET). During the last 
month of 300 mg/day dosing, obtain plasma and spinal fluid samples and repeat 2FDG PET scan.  
PRELIMINARY DATA 
R(+)pramipexole is a mitochondrially concentrated antioxidant 
Pramipexole (PPX) is a benzothiazole synthesized in the 1980’s as an apomorphine analogue 
[27]. The stereospecific synthesis yielded S(-)PPX (Figure 1), which possessed potent and full agonist 
actions at the D2 family of brain dopamine receptors. S(-)PPX was developed for clinical use in humans 
and was approved in 1997 by the FDA as Mirapex, for treatment of Parkinson’s disease symptoms 
due to nigrostriatal dopamine deficiency. 
PPX synthesis also yielded the R(+) PPX enantiomer (Figure 1), which was subsequently 
shown to possess very weak potency at D2 receptors. However, both R(+) and S(-) PPX are present at 
physiological pH as lipophilic, doubly charged cations, a property that predicted to the sponsor that they 
would be concentrated into mitochondria. Because PPX also possessed a favorable reduction potential 
that predicted it would inactivate all common ROS and reactive nitrogen species (RNS), R(+)PPX had 
potential as a mitochondrially concentrated ROS/RNS scavenger that should be tolerated in very high 
doses because of its weak potency at D2 receptors. 
R(+)PPX is concentrated into mitochondria (Figure 2) and scavenges mitochondrial superoxide 
(Figure 3). 
 
 
	
%&'()&('*+",-"%./0"123"
4.50"6'1786*9,:*;"<'',="6,82&+"
&,"1+>77*&'8)")1'?,2;"
	
@6&1A*",-"B$CD"EEF"82&,"78&,)G,23'81;"
H8&,)G,23'81".),2&',:I",6*2")8'):*+J"?1'+0J"=*'*":>+*3"
.K'8&,2/F"!LLI!M".NON0I",6*2"&'812P:*+0J"+,28)1&*3"
N8P,',(+:>".%HEI"-8::*3"&'812P:*+0",'"(2),(6:*3"=8&G"QRRE"
.!"SHI"-8::*3")8'):*+0"123"6'*82)(?1&*3"-,'"#;T"782"82"
71:1&*O6>'(N1&*U),2&18282P".#;TOT"7H0"82)(?1&8,2"?(--*'"
.1::"L;#"7PO7:0;"@6&1A*"=1+"+&1'&*3"?>"1338&8,2",-"BVCD"EEF"
.$"SR8O7:0"123"&*'7821&*3"1&"&G*"8238)1&*3"&87*;"Q',7"Q8P"#"
,- B!D
	
"EEF"38'*)&:>"+)1N*2P*+"+(6*',983*"128,2".W#X/0"&G(+"
'*3()82P"78&,)G,23'81:"G>3',P*2"6*',983*"6',3()&8,2"82"
8+,:1&*3"78&,)G,23'81;"KY<EZ"H2%W[".%W[#0"787*&8)I"
K4W\WFZ"=1&*'"+,:(?:*"N8&1782"];""^,&*"&G1&"EEF"1&"!"(H"8+"
719871::>"6,&*2&"1&"+)1N*2P82P"+(6*',983*"J"8+"7,'*"6,&*2&"
&G12"KY<EJ"123"8+"+:8PG&:>":*++"6,&*2&"&G12"G8PG":*N*:+",-"
K4W\WF".(26(?:8+G*3"31&1"-',7"Y,*''G82P*'/_2P*:G*87"
+G1'*3"=8&G"`EY"82"N83*,),2-*'*2)*0

R(+) pramipexole in Alzheimer’s Disease  
James P. Bennett, Jr. M.D., Ph.D.-Sponsor
2/18/2011 
a"
R(+)PPX is also concentrated into brain >6-fold from plasma (Figure 4) and achieves steady state 
plasma levels of > 1 µM in humans dosed with 300 mg/day. (Figure 5) 
 
 
R(+)PPX can safely be administered to humans up to 300 mg/day and slows progression of ALS 
Based on the preclinical pharmacology of R(+)PPX and his prediction that it would be tolerated 
in much higher doses than S(-)PPX (limited to 4.5-6 mg/day), the sponsor(Bennett) obtained a 
physician-sponsor IND from the FDA to administer R(+)PPX to humans with ALS. Dosing began in 
spring, 2004. With private funding, the sponsor carried out a series of small Phase 1-2 studies in ALS 
subjects, culminating in a dose escalation study to 300 mg/day carried out in 2006-07. In each study, 
the sponsor obtained data showing a slowing of disease progression in ALS, but the numbers were too 
small and the studies were all comparative dose, open label that did not allow definitive statements 
about efficacy [2] 
In 2006 R(+)PPX was licensed to Knopp Neurosciences that began its own commercial 
development of R(+)PPX. In Dec, 2009 Knopp announced its very positive Phase 2b results from a 
placebo-controlled trial in early ALS subjects 
(http://www.knoppneurosciences.com/index.php?section=news&subsection=news&id=60) 
In the case of ALSFRS-R, the number of treatment failures, defined as the loss of 6 points or greater 
in ALSFRS-R scores from baseline, totaled 9 subjects (or 33%), in the placebo group; 8 subjects 
(35%), in the 50 mg/day group, 4 subjects (15%) in the 150 mg/day group, and 2 subjects (8%) in the 
300 mg/day group (p=0.014). 
   In the case of pulmonary function, the number of treatment failures, defined as a reduction in forced 
vital capacity of 20% or greater from baseline, totaled 8 subjects (30%) in the placebo group, 3 subjects 
(13%) in the 50 mg group, 3 subjects (12%) in the 150 mg group, and 1 subject (4%) in the 300 mg 
group (p=0.028). 
Both the PI and Knopp have observed excellent safety records of R(+)PPX. The sponsor has 
searched for evidence of suppression of serum prolactin, as a consequence of in vivo D2 dopamine 
receptor activity, in ALS patients undergoing dose escalation with R(+)PPX. He found no evidence of 
suppression of prolactin levels (Figure 6). This suggests that at a daily dose of 300 mg/day, his 
preparation of R(+)PPX has no detectable activity at central D2 dopamine receptors and should be well 
tolerated by subjects with mild dementia. 
 
 
 
 
 
 
	
Y'182"1))(7(:1&8,2",-"%./0"EEF".bEEFc0"123"
4.50"EEF".b%^[c0"1-&*'"a"31>+",-"#LL"7POAPO31>"82&1A*"
82"78)*;"Q',7"B!D"
"
	;"%&*13>"+&1&*"
&',(PG"6:1+71":*N*:+"82"<
+(?d*)&+"3,+*3"=8&G"N1'>
4.50EEF"318:>"7P;"e*23*
123"=&".AP0"+G,=2"82"
:*P*23;"Q',7"B#D"
tolerated by subjects with m
	
"\1)A",-"*--*)&",-"4.50EEF",'1:"3,+82P",2"+*'(7"
6',:1)&82":*N*:+;"%G,=2"1'*"318:>"4.50EEF"3,+*+"3('82P"&G*"
3,+*"*+)1:1&8,2"+&(3>",-"f"<\%"+(?d*)&+"123"&G*"7*12"5O/"
%]H",-"&G*8'"+*'(7"6',:1)&82":*N*:+;"<^Wg<"383"2,&"'*N*1:"
12>"*--*)&",-"EEF"3,+*",2"6',:1)&82;"KG*'*"=1+"2,"
+8P28-8)12&"38--*'*2)*"?*&=**2"+*'(7"6',:1)&82":*N*:+"1&"L"
123"$LL"7PO31>"EEF;".h12PJ"i*::*'"123"Y*22*&&J"
(26(?:8+G*30"

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
5	  
 
Thus, at this point in time R(+)PPX has been administered to ~170 subjects, ~50 of whom have taken 
300 mg/day for 6-9 months. R(+)PPX has an excellent safety record with no drug-related serious 
adverse events reported. It has excellent preclinical data supporting brain and mitochondrial 
concentration and ROS scavenging. Its clinical use in humans with the devastating disease ALS 
demonstrated efficacy in slowing disease progression in a placebo-controlled trial. It is entering 
definitive Phase 3 efficacy testing in ALS and is ready to be tested in probable AD in this trial.  
While the sponsor (Bennett) and Knopp Neurosciences maintain a collegial relationship, each 
has his/its own IND, R(+)PPX supply, and independently pursues clinical testing of R(+)PPX. Knopp is 
presently completely focused on pursuing Phase 3 testing of R(+)PPX in ALS. The sponsor of this 
proposal has amended his IND to pursue testing of R(+)PPX in AD and PD subjects. The sponsor 
declares a financial interest in the uses of R(+)PPX in degenerative illnesses. 
 
AD subjects show early increases in brain oxidative stress and reductions in cortical energy metabolism 
 
In recent years several groups have argued persuasively that mitochondrial dysfunction and 
increased oxidative stress are early deficits in humans with AD and transgenic mice expressing familial 
AD genes. It is not necessary to repeat the details of these arguments here; the reader is referred to 
specific reviews for details [9,10,11,12,13,14,28,29,30].  
 
One of the very recent reviews of this subject [10] is particularly passionate in its arguments and 
summarizes most forcefully the basic argument. Bonda, et al [10] argue that increased beta amyloid 
production occurs as part of an antioxidant response to early oxidative stress. This beta amyloid 
response paradoxically turns into its own neurodegenerative stimulus, stimulating increased oxidative 
stress in its own right.  This positive feed-forward “vicious” neurodegenerative cycle is well established 
by the time clinical symptoms appear and may become increasingly difficult to overcome as the disease 
progresses. Bonda, et al, and others, argue for early initiation of effective antioxidant therapy, at the 
earliest sign of cognitive impairment. 
 
Under normal dietary (non-fasting) circumstances, most brain energy is formed from glucose 
metabolism. Rates of accumulation of deoxyglucose provide measure of regional brain glucose 
metabolic rates, which reflect cytosolic glycolysis and ultimately pyruvate metabolism in mitochondria. 
Robust cerebral cortical glucose metabolism is reduced in MCI subjects in a pattern that recapitulates 
more severe metabolic reductions once AD is clinically established.  
 
Recent advances in understanding the utility of cerebral glucose metabolism, studied with FDG-
PET, to discriminate MCI from AD and follow progression of AD have begun to appear as a result of the 
Alzheimer’s Disease Neuroimaging Initiative (ADNI).  The results of a very recently reported study 
using statistical brain mapping of FDG-PET scans in MCI and early/probable AD subjects [31] are 
shown in Figure 7. The authors found multiple cortical areas of decline in both MCI and early AD 
subjects. Notably, they calculated that 66 AD subjects will be required in each treatment arm of a 
randomized clinical trial to detect with 80% power at p=0.05 a 25% change in decline of FDG 
accumulation over a 12 month period.  
 
Figure	  7.	  Statistical	  brain	  maps	  of	  the	  spared	  (non-­‐
declining)	  regions	  of	  interest	  (ROI’s)	  (in	  the	  blue	  color	  
scale)	  and	  the	  ROI’s	  where	  over	  twelve-­‐months	  there	  wa
a	  decline	  in	  brain	  glucose	  metabolism	  (in	  the	  red-­‐to-­‐yello
color	  scale).	  Shown	  in	  A	  are	  probable	  AD	  patients	  and	  B	  
MCI	  patient	  groups.	  The	  brain	  maps	  were	  generated	  usin
baseline	  and	  follow-­‐up	  images	  acquired	  in	  the	  each	  patie
group's	  training	  set.	  	  Note	  anatomic	  similarity	  of	  involve
brain	  regions	  between	  the	  AD	  and	  MCI	  groups	  and	  the	  
overall	  more	  extensive	  involvement	  of	  regions	  that	  
declined	  over	  12	  months	  in	  the	  AD	  compared	  to	  MCI	  
group.	  

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
6	  
Available antioxidants have not been helpful 
As recently reviewed by Dumont, et al, [12] several trials of antioxidants have been carried out in AD 
subjects. Compounds showing some positive activity in transgenic mouse models but generally failing 
in human subjects included vitamin E, idebenone (CoenzymeQ10 analogue) cloquinol, curcumin and 
dimebon. One possibility for failure of these compounds in humans, in addition to kinetic issues, is that 
none are predicted to accumulate into brain mitochondria. If one is testing the hypothesis that 
mitochondrially generated ROS are driving elevated oxidative stress damage in AD, then brain and 
mitochondrial concentration of the ROS scavenger are critical. R(+)PPX satisfies these criteria (see 
Figures 2 and 4 above). 
 
EXPERIMENTAL DESIGN AND METHODS 
General 
This is a safety and tolerability study of R(+)PPX in subjects with probable AD. R(+)PPX is an 
orally active, brain and mitochondrially concentrated free radical scavenger that has shown excellent 
safety and tolerability in Phase 1 and 2 studies in >100 ALS subjects. Its lack of in vivo D2 dopamine 
receptor activity (based on not lowering serum prolactin) at daily doses up to 300 mg/day contrasts with 
the potent dopamine receptor-limiting dosing of S(-)PPX (Mirapex) at 4.5-6.0 mg/day. Pharmacokinetic 
studies carried out by the PI show that daily R(+)PPX doses of 300 mg/day frequently yield steady-
state trough plasma PPX levels >1 µM, which predict highly neuroprotective brain PPX levels of >6 µM 
[2].  
R(+)PPX slows the progression of disability and decline of respiratory capacity in early ALS 
subjects (Knopp Phase 2b, Phase 3 pending).  The scientific rationale for the current proposed study in 
probable AD is that oxidative stress is an early abnormality in human AD and transgenic animal models 
of familial AD. Increased brain oxidative stress is likely causal for AD pathogenesis and can stimulate 
net production of beta amyloid by increasing beta amyloid synthesis (beta secretase expression) and 
inhibiting beta amyloid degradation (neprilysin activity). The sponsor’s group has shown that mtDNA 
from AD subjects expressed in a cybrid model can drive increased oxidative stress and beta amyloid 
production, which is reduced by PPX. The current study will not define how oxidative stress is 
increased in AD brain, rather it will correct that problem by treatment with a well tolerated and novel 
mitochondrial antioxidant.  
The sponsor has extensive experience testing R(+)PPX in ALS and has an active physician-
sponsor IND that has been amended to allow testing of R(+)PPX in AD subjects (see DSMB charter in 
appendix for more information).  Because of conflicts of interest, the sponsor will not be involved at all 
in recruitment, treatment or evaluation of AD subjects; that will occur at Kansas University Medical 
Center (KUMC), with Dr. Jeff Burns as the Principal Investigator. James Bennett, Jr.,MD, PhD will 
function as Sponsor in this study but will have no direct involvement in clinical care. 
The primary goal of the study is to establish the safety and tolerability of the study medication in 
individuals with AD. Exploratory variables involve changes in brain and peripheral oxidative stress 
assayed by isoprostane levels in spinal fluid and serum, respectively, change in cognitive function and 
improvement in brain glucose metabolism assayed by FDG-PET scan. The goal of the present study is 
to establish that up to 300 mg/day of R(+)PPX is tolerated by subjects with probable AD, lowers 
oxidative stress and may show a trend of improving brain glucose metabolism.  
 
Subject selection and recruitment 
 
Subjects with probable AD will be identified and recruited through the Memory Disorders Clinic 
at the University of Kansas Medical Center (KUMC). This clinic is under the direction of Dr. Jeff Burns, 
an accomplished AD clinical investigator.  
KU Alzheimer and Memory Program 
The KU AMP, directed by Dr. Burns, has been an active and rapidly expanding research group at 
KUMC since 2004.  In this short time, the AMP has developed the infrastructure and expertise for the 
identification, recruitment, and characterization of nondemented and probable AD research participants, 
established a history of successful collaborations, attracted both new and experienced investigators 

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
7	  
into the field of AD research, and has established an early track record of scientific productivity primarily 
along a programmatic theme of the role of metabolic dysfunction in AD and aging.  These efforts have 
led to recent funding for two R01s assessing the neurobiological effects of exercise in older adults with 
and without AD.   
Additionally, the AMP also supports clinical trial activities through the AD Clinical Trial Unit, initiated 
and directed by Dr. Burns.  The Clinical Trial Unit staff includes three clinicians (Burns, Anderson, and 
Anne Arthur, ARNP), a director of research (Anita Macan), and a research nurse (Cherie Parker).  Pat 
Laubinger provides oversight and planning for the Clinical Trial Unit through her role as the 
administrative director of the AMP. 
 
Alzheimer and Memory Clinic  
Dr. Burns directs the Alzheimer and Memory Clinic, the major referral clinic for the area and the 
state of Kansas and the clinical study site for this application.  The clinic evaluates more than 600 
patients annually, 300 of which are new evaluations, and is staffed by four clinicians (Burns, Anderson, 
Swerdlow, and Arthur) in addition to a multidisciplinary team (social worker, pharmacist, 
psychometrician, and a nurse).  AMP research evaluations are not conducted in the clinic.  Rather, 
patients interested in research who appear to meet criteria for entry are referred to the AMP for 
enrollment into specific studies.   
Clinic Database:  Patients evaluated in the clinic are asked to provide consent to be contacted in 
the future for possible consideration of research studies.  Additionally, consent is provided to store 
health information in a database.  The database contains information regarding patient diagnosis, 
medications, medical history, and basic cognitive performance data (MMSE and memory testing [logical 
memory]).  The information collected was chosen to provide basic information regarding common 
inclusion and exclusion criteria to best target potential recruitment into our ongoing investigational 
studies and clinical trials.   
Since initiating the database in September 2004, information on a total of 945 unique patients has 
been entered into our database.  Of these, 486 were diagnosed with AD (mean age 74.7 years, MMSE 
19.8, and logical memory II 1.5) and 112 were diagnosed with MCI (mean age 72.5, MMSE = 26.8, 
logical memory II = 5.1).  Forty patients included in the database have a diagnosis of dementia with 
Lewy bodies and 25 with frontotemporal dementia.  The use of the database has been helpful in 
identifying participants for recruitment into research studies.  Patients identified as potentially meeting 
enrollment into the UDS Registry or clinical trials are flagged in the database and referred to our 
recruitment coordinator for contact and further screening.  The database has been an effective and 
efficient way to recruit participants from our active clinic population.   
 
Alzheimer’s Disease:  Individuals with AD meet NINDS-ADRDA criteria for possible of probable AD and 
have a score of 14 - 26 inclusive on the MMSE.  NINDS-ADRDA criteria are operationalized as 1) 
memory impairment, 2) the gradual onset and progression of impairment in memory and in at least one 
other cognitive domain (as demonstrated by clinical history and neuropsychological testing) and 3) the 
absence of clinical or laboratory evidence of other disorders that could account for memory or cognitive 
decline or if a second disorder is present it is not considered the primary cause of dementia.   
 
VCU laboratory site 
 
The physician-sponsor is a faculty member at Virginia Commonwealth University and has no 
relationship with Dr. Burns or KUMC. Because the /sponsor has a financial interest in the commercial 
development of R(+)PPX, it is critical that he have no relationship with Dr. Burns/KUMC and have no 
influence on subject recruitment or study execution. However, the sponsor will provide analytical 
services for this application. Serum and spinal fluid specimens will be analyzed blinded as to subject 
identity and time in study. The sponsor has available facilities for LC-MS analysis of PPX and 
isoprostane levels.  

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
8	  
	  
	  
Inclusion and Exclusion Criteria at Entry  
Inclusion Criteria 
Exclusion criteria  
• Informed consent provided by the participant or the 
participant’s legally acceptable representative 
• Age 55 years or older 
• Diagnosis of Probable AD according to the National 
Institute of Neurological and Communicative 
Disorders and Stroke-Alzheimer’s Disease and 
Related Disorders Association (NINCDS-ADRDA)   
• Community dwelling with a caregiver able and 
willing to accompany the participant on all visits, if 
necessary.  Caregiver must visit with the subject>5 
times a week and accompany participant to study 
visits. 
• Rosen Modified Hachinski score of 4 or less  
• MMSE score of 14-26 inclusive 
• Stable doses of medications for at least 30 days 
prior to screening.   
• Reliable person to administer study drug to the 
participant twice a day for the duration of the study 
• Imaging study (CT or MRI) of the brain compatible 
with AD or age-related changes after onset of 
memory problems (absence of significant 
abnormalities that may explain cognitive decline 
(such as, multiple lacunar infarcts or a single prior 
infarct > 1 cm3, micro-hemorrhages or evidence of 
a prior hemorrhage > 1 cm3, evidence of cerebral 
contusion encephalomalacia, aneurysm, vascular 
malformation, or space-occupying lesion such as 
an arachnoid cyst or brain tumor) 
• Adequate visual and auditory abilities to perform all 
aspects of the cognitive and functional 
assessments 
• Significant neurological disease, other than AD, that may affect 
cognition 
• Current clinically-significant systemic illness that is likely to result 
in deterioration of the patient’s condition or affect the patient’s 
safety during the study   
• History of clinically-evident stroke 
• Clinically-significant infection within the last 30 days 
• Myocardial infarction or symptoms of active coronary artery 
disease (e.g., angina) in the last two-years. 
• Uncontrolled hypertension within the last 6 months 
• History of cancer within the last 5 years (except non-metastatic 
basal or squamous cell carcinoma) 
• History of drug or alcohol abuse as defined by DSM-IV criteria 
within the last 2 years   
• Insulin-dependent diabetes mellitus  
• Clinically significant depression (Geriatric Depression Scale score 
>5). 
• History of kidney disease or renal insufficiency (serum creatinine 
level >1.5)  
 
 
Treatment protocol 
Overview (see calendar of events below): After providing signed informed consent, participants 
will undergo a screening visit to assess study participant eligibility.  Neuropsychological testing (ADAS-
Cog) will be performed at baseline and every two months (visits 2, 3, 4, and End of Study (EOS)). A 
lumbar puncture and blood draw (for isoprostane analysis) and fluoro-deoxy-glucose positron emission 
tomography (FDG-PET) will be performed at baseline and after 6 months of treatment to serve as 
exploratory “proof of concept” measures to explore the effect of R-Pramipexole on key biological 
targets.  Safety visits with laboratory testing and physical assessments will occur every two months. 
Follow up phone calls to the participants and their study partner will be conducted every two weeks 
during treatment to assess for possible adverse events. 
 
Screening Visit:  A screening visit will occur in the GCRC and last approximately 2 hours.  
Participants will be accompanied by a study partner and provide informed consent.  Demographics, 
medical history, and medications will be collected by a study coordinator.  The study coordinator will 
administer the mini-mental status exam, Geriatric Depression Scale and Hachinski Ischemic Scale.  
Vital signs will be assessed (height, weight, blood pressure, respiratory rate, temperature) and non-
fasting blood and urine will be collected for routine safety labs including a chemistry panel (sodium, 
potassium, chloride, CO2, BUN, glucose, calcium, total protein, total bilirubin, albumin, alkaline 
phosphatase, AST and ALT), hematology panel (complete blood count including differential), and a 
microscopic urinalysis.   A study clinician will perform a physical and neurological exam and review the 
inclusion / exclusion criteria and AD diagnostic criteria to determine study participant eligibility.   

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
9	  
Baseline Assessments:  Baseline assessments will occur within four weeks of the screening 
visit and will consist of two or three visits to KUMC: 1) Cognitive testing at the KU Alzheimer and 
Memory Program (<1 hour), 2) FDG PET scanning in the radiology department (1.5 hours), and 3) 
GCRC visit for a blood draw and lumbar puncture (2 hours).   
Cognitive Testing:  A study psychometrician will perform a standard battery of cognitive tests on 
all participants utilizing the Alzheimer’s Disease Assessment Scale – Cognitive subscale (ADAS-Cog).  
The ADAS-Cog is composed of 11 subtests of memory and language and is frequently used for clinical 
trials.   
Positron Emission Tomography (PET) Scans:  Fluoro-deoxy-glucose (FDG) PET imaging will be 
performed on all participants at baseline and after treatment for 6 months.  Participants will be asked to 
fast for at least four hours prior to the scanning session.  The participant’s blood glucose will be 
checked prior to scanning and must be < 180 mg/dL.  After the injection of 5 mCi of tracer, subjects will 
sit in a quiet, dimly lit room for 30 minutes after which they are placed in the scanner.  Procedures will 
be identical to those used extensively by this group in the Alzheimer’s Disease Neuroimaging Initiative.   
Lumbar Puncture:  Participants will arrive in the GCRC in the early morning after an overnight 
fast for blood and CSF collection.  Fasting blood (14 cc) will be drawn for isoprostane analysis.  Dr. 
Burns will perform all lumbar punctures.  Lidocaine will be used for topical anesthesia and an 
atraumatic 24 gauge Sprotte needle will be inserted for CSF collection at the L3/4 or L4/5 interspace.  2 
cc of fluid will be discarded and 2 cc sent to the local laboratory for routine cell counts, protein, and 
glucose.  Ten milliliters of blood will be collected and spun. The serum sample will be sent to the 
protocol investigator for isoprostane analyses.  After completion of the procedure, participants will be 
remain in the GCRC;  have breakfast; and rest for about 30-45 minutes before being discharged home 
with post lumbar puncture instructions. A phone call to the participant 24 hours after the lumbar 
puncture will be performed to assess for any problems following this procedure.  The FDG Pet Scan 
and the lumbar puncture must be completed on two different days at least 24 hours apart.	  	  
Safety Visits:  Participants will have in-person safety assessments (1.5 hours) in the GCRC 
every 8 weeks.  Vital signs and weight will be measured; concurrent medications and adverse events 
will be assessed. A physical and neurological examination will be performed by a study clinician.  A 
targeted symptom checklist will be reviewed with the participant and study partner at each visit to 
assess occurrence of adverse events including those most associated with the use of pramipexole 
(Mirapex, see table 1 of appendix).  Blood and urine will be collected for safety labs.   Study drug will be 
dispensed at safety visits i.e. visits 1, 2, and 3.  Cognitive testing (ADAS-Cog) will be administered at 
each safety visit.     
Study Drug Administration: R(+)PPX is provided by the sponsor to the KUMC investigational 
pharmacy as the water soluble dihydrochloride salt, in the form of powder manufactured under GMP 
conditions by Quality Chemical Laboratories, the supplier of drug for all of Dr. Bennett’s studies. The 
investigational pharmacy prepares a water solution at 10 mg/ml. This solution has been tested by the  
sponsor and is stable at 4 degrees for at least two months.  
 
Treatment is initiated after the Baseline visit at 100mg a day (50 mg bid in morning and early 
evening) for 1 month. If tolerated, dosing will increase to 200mg a day (100 mg bid) for a second one-
month interval. If at the end of four months of being on study drug, the participant is not experiencing 
side effects the study drug will be increased to 300mg a day (150 mg bid) where it will remain for the 
next 4 months.   Subjects will be seen every two months for safety assessments prior to any dose 
escalation and will also be contacted every two weeks by phone (see below). If a participant 
experiences mild, non-serious adverse events possibly due to the study drug, the study clinician will 
determine the causality and make a decision whether to continue the study medication and at what 
dosage. If study drug is discontinued temporarily (>10 days), it will be titrated to the target dose with 
dose increases no more frequent than once a month.   
            Drug Accountability:  Participants in the study will return any unused drug and study drug 
containers at each of the safety visits. Study partners will be asked to account for any missed dosages 
of the study drug and the reason for missing the dosing. Participants are encouraged to maintain 100 
percent compliance with dosing. The study partner and the participant will be advised of their 

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
10
compliance at each safety visit before the study drug is dispensed and means and measures to 
increase compliance will be initiated. All unused study drug and containers will be returned to the 
investigational pharmacy for disposal. 
Phone Calls:  Participants and their study partner will be contacted by the study coordinator 
every two weeks by phone after starting to take the study medication to review concurrent medications 
and adverse events.   
            End-of-Treatment Assessments (Visit 5):  Final outcome assessments will be completed 
during week 24 visit/ Visit 4 and consist of identical procedures to the baseline assessments (see 
above):  1) Cognitive testing at the KU Alzheimer and Memory Program (1 hour), 2) FDG PET scanning 
in the radiology department (1.5 hours), and 3) GCRC visit for a blood draw and lumbar puncture (2 
hours).  In addition the participant will have a physical/ neurological examination, safety laboratory 
sampling, vital signs, concurrent medications and adverse events. The participant will return all 
remaining study drug and containers at this visit. No additional medication will be dispensed. 
 
End-of-Study Visit:  Participants will return two weeks after completing the R(+)PPX treatment 
for a final physical and neurological exam and review of adverse events.   
 
 
Data analysis 
Primary Aim: Safety 
 
Subject safety is the primary variable and item of greatest concern in this study. The extensive 
dosing experience with R(+)PPX in ALS subjects, many of whom have mild dementia, combined with 
its lack of detectable D2 dopamine receptor activity in vivo at 300 mg/day dosing, support its safety in 
probable AD subjects. Safety and tolerability will be evaluated by frequent contact with subjects and 
caregivers and lab safety studies every two months.  The frequency and severity of adverse events will 
be examined and their potential causal relationship to the study drug (as determined by the study 
physician) will be assessed (the adverse events related to Mirapex [pramipexole] are listed in table 1 of 
appendix).  This information will be used to guide dose selection and inform a more definitive safety 
and efficacy study.  Additionally, cognitive performance data will be acquired every two months to 
assess the cognitive trajectory to explore possible dose-related changes in cognitive decline over the 6 
months of intervention.  
 
Exploratory Aims 
Oxidative stress 
 
Isoprostanes are stable oxidative products of polyunsaturated fatty acids. Oxidative stress will 
be evaluated by following serum isoprostane levels over the course of dose escalation and by assaying 
csf isoprostane before and after R(+)PPX. A very sensitive LC-MS assay will be used. Serum and CSF 
PPX levels will also be assayed by LC-MS.  To assess change in isoprostane levels with treatment, we 
will compare baseline (pre-treatment) and 6-month (post-treatment) isoprostane levels using a paired t-
test.  We hypothesize that isoprostane levels will be reduced after 6 months of R(+)PPX treatment.    
 
2-FDG PET 
 
Changes in cerebral glucose metabolism as a proxy for mitochondrial respiration will be 
assayed at baseline and after a period of several months dosing with R(+)PPX at 300 mg/day. Multiple 
regions will be compared, with particular attention paid to hippocampus. The statistical mapping 
approach described by Chen, et al [31] will be used. Regional FDG uptake will be compared pre- and 
post-PPX dosing. Correlations will also be sought with assays of oxidative stress reduction, to see if 
greater reductions in brain oxidative stress (reflected by reductions in isoprostane levels) are reflected 
in elevations in cortical 2-FDG. 
 
Conclusions 
 
An abundance of compelling evidence supports the early appearance of oxidative stress as a 
pathogenic event in AD. Oxidative stress is elevated in brains of persons with pre-AD condition of MCI 
and in transgenic mice expressing familial AD genes prior to the amyloidosis seen in these models. Our 

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
11
studies in the mitochondrial transgenic cybrid model of AD supports mtDNA as a contributor to AD 
oxidative stress and beta amyloid production. In toto, reduction of oxidative stress early in the course of 
AD should reduce the trajectory of neurodegeneration. 
 
The sponsor studied S(-) and R(+) PPX in his laboratory beginning in 1997 and has clinically 
tested R(+) pramipexole in ALS subjects under a physician-sponsor IND since 2004. R(+)PPX is now 
commercially licensed and under separate development for treating ALS by Knopp Neurosciences. 
R(+)PPX is a brain and mitochondrially concentrated antioxidant that can be safely administered to 
humans at daily doses up to 300 mg/day and has no detectable DA receptor activity in vivo. At this 
dose many subjects achieved trough steady-state PPX levels of >1 µM, predicting brain levels of >6 µM 
that are clearly in the ROS scavenging and neuroprotective levels. R(+)PPX at 300 mg/day 
substantially improves the course of ALS in short-term studies and will enter Phase 3 testing later this 
year. 
 
The present application seeks to introduce R(+)PPX treatment to subjects with early AD. In this 
protocol the subjects will undergo careful dose escalation from 100 mg/day to 300 mg/day R(+)PPX 
over 4 months. Subjects will have regular serum, combined with baseline and late treatment spinal fluid 
samples, assayed for isoprostanes as measures of oxidative stress. Serum and spinal fluid will also be 
assayed for [PPX]. As a measure of cerebral metabolism, brain 2-FDG PET scans will be obtained at 
baseline and after several months of dosing with 300 mg/day R(+)PPX. 
 
The goal of the present study is to determine if R(+)PPX can be administered in high doses to 
probable AD subjects, and if so, whether oxidative stress is reduced and cerebral metabolism is 
increased. Hopefully the results from this study will justify the cost of a larger early efficacy study in 
probable AD.  
 
Data Management 
The KU Alzheimer and Memory Program currently uses an electronic database system, called 
REDCap (Research Electronic Data Capture), for much of its data management needs. REDCap was 
developed by Vanderbilt University, with collaboration from a consortium of institutional partners, for 
electronic collection and management of research and clinical trial data. This secure system is hosted 
by the Center for Research Methods and Data Analysis (CRMDA) at the University of Kansas 
Lawrence (KU-L) campus.  The CRMDA hosts a KU-L Information Technology-controlled, HIPAA-
certified REDCap database server on which project data will be stored. The REDCap system provides 
secure, web-based applications that have an intuitive interface for users to enter data and real time 
validation rules (with automated data type and range checks) at the time of entry. These systems offer 
easy data manipulation with audit trails and an automated export mechanism to common statistical 
packages (SPSS, SAS, Stata, R/S-Plus). REDCap was developed specifically around HIPAA-Security 
guidelines and all web-based information transmission is encrypted. REDCap is used at many 
institutions and currently supports > 170 academic/non-profit consortium partners on six continents and 
13,000 research end-users (www.project-redcap.org).  Brad Amstein, a member of the Alzheimer and 
Memory Program at KUMC, is responsible for working with the CRMDA and the REDCap system to 
design the database, its forms, the data entry process, and reports related to adverse events and 
pertinent safety data for this research study.   
 
Data Safety and Monitoring Plan  
All adverse events (AE’s) will be  reported to the PI and sponsor in a timely fashion. The study 
coordinator will enter the AE data from the source documentation into REDCap within 5 business days 
from receipt of the initial call to report the AE.  Any serious adverse event will be reported to the PI and 
sponsor immediately and then to the General Clinical Research Center and the Human Subject’s 
Committee according to reporting guidelines. 
 
A Data Safety and Monitoring Board (DSMB, see DSMB charter attached below) will meet quarterly to 
review AE’s and the overall safety of the ongoing trial.  The DSMB is composed of three experienced 
clinicians: Maral Mouradian, MD from the Robert Wood Johnson Medical School, Un Kang, MD from 

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
12
the University of Chicago, and Fred Wooten, MD from the University of Virginia. Dr. Mouradian will be 
the acting Chairman.  
 
The DSMB will have access to de-identified participant medical records and other study-related 
records. The investigator agrees to cooperate with the monitor (s) to ensure that any problems detected 
in the course of these monitoring visits are resolved. Personal contact between the DSMB and the 
investigator will be maintained throughout the clinical trial to assure that the investigator is fulfilling his 
obligations and the facilities used in the clinical trial remain acceptable. 
 
The DSMB will perform a quarterly review of lab safety data, results of physical/ neurological 
assessments and subject adverse event/SAE reports. The DSMB can advise and recommend 
temporary or permanent withdrawal of a subject or that the entire study be placed on hold or 
terminated.  
 
All grade 2 and above AE’s according to CTCAE v3.0 will be reviewed by the DSMB members 
quarterly.  To facilitate this review, a list of each AE grade 2 or higher (by CTCAE v3.0) will be 
generated from REDCap.   Each AE listed will include the grade, the type of event, and the potential 
relationship of the AE to the study intervention.  The PI will be notified within 24 hours by the study 
coordinator of all AE’s grade 3 or higher.   Should a study participant experience an AE in any category 
rated 3 or greater according to CTCAE v3.0, that individual will be removed from the study immediately.  
Should three or more subjects (15% of target enrollment) have AE’s in any category that is grade 3 or 
higher according to CTCAE v3.0 that are possibly or probably related to study intervention, the study 
will be terminated.   

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
13
 
 
* Height done only at screening 
** Isoprostane analysis- CSF and plasma 
 
Schedule of Study Procedures and Assessments 
 
 
 
Week # 
-4 
-2 
0 
2 
4 
6 
8 
10 
12 
14 
16 
18 
20 
22 
24 
26 
Visit Name 
Scr 
B 
1 
P/C 
P/C 
P/C 
2 
P/C 
P/C 
P/C 
3 
P/C 
P/C 
P/C 
4 
EOS 
  
	  	  
  
	  	  
	  	  
	  	  
	  	  
	  	  
	  	  
	  	  
	  	  
	  	  
	  	  
	  	  
	  	  
  
	  	  
Informed Consent 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
NINDS-ADRDA  
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Hachinski Ischemic Scale 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Geriatric Depression Scale 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
MMSE 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Demographics 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Medical History 
X 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Medication History 
X 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Body height/ weight * 
X 
  
X 
  
 
  
X 
  
 
  
X 
  
  
  
X 
X  
Vital Signs 
X 
  
X 
  
 
  
X 
  
 
  
X 
  
 
  
X 
X  
Baseline Sx Checklist 
X 
  
X 
  
 
  
X 
  
 
  
X 
  
  
  
X 
X  
Physical/Neuro Exam 
X 
  
  
  
 
  
X 
  
 
  
X 
  
  
  
X 
X  
Safety labs 
X 
  
  
  
  
  
X 
  
 
  
X 
  
  
  
X 
X  
Inclusion/ Exclusion 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
ADAS-Cog 
  
X 
  
  
  
  
 X 
  
  
  
 X 
  
  
  
X  
 
FDG PET scan-brain 
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
X  
  
Lumbar puncture 
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
X  
  
Isoprostane analysis ** 
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
X  
  
Dispense Study Drug 
  
  
X 
  
  
  
X 
  
  
  
X 
  
  
  
 
  
Drug Accountability 
  
  
  
  
X  
  
X 
  
  
  
X 
  
  
  
X 
  
Concurrent Medications 
  
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events 
  
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Scr: Screen; B: Baseline; P/C: Phone Call follow-up; EOS: End of Study; MMSE: Mini Mental Status Exam; NINDS-ADRDA: National Institute of  
Neurological Disorders  and Stroke - Alzheimer's Disease and Related Disorders Association criteria for AD;  
ADAS-Cog: Alzheimer's Disease Assessment Scale - Cognitive subscale;   
FDG-PET: Fluoro-deoxyglucose Positron Emission Tomography;  
 
 
 

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
14
 
References 
1.	  Danzeisen	  R,	  Schwalenstoecker	  B,	  Gillardon	  F,	  Buerger	  E,	  Krzykalla	  V,	  et	  al.	  (2006)	  Targeted	  antioxidative	  and	  neuroprotective	  
properties	  of	  the	  dopamine	  agonist	  pramipexole	  and	  its	  nondopaminergic	  enantiomer	  SND919CL2x	  [(+)2-­‐amino-­‐4,5,6,7-­‐
tetrahydro-­‐6-­‐Lpropylamino-­‐benzathiazole	  dihydrochloride].	  J	  Pharmacol	  Exp	  Ther	  316:	  189-­‐199.	  
2.	  Wang	  H,	  Larriviere	  KS,	  Keller	  KE,	  Ware	  KA,	  Burns	  TM,	  et	  al.	  (2008)	  R+	  pramipexole	  as	  a	  mitochondrially	  focused	  
neuroprotectant:	  initial	  early	  phase	  studies	  in	  ALS.	  Amyotroph	  Lateral	  Scler	  9:	  50-­‐58.	  
3.	  Waldmeier	  P,	  Bozyczko-­‐Coyne	  D,	  Williams	  M,	  Vaught	  JL	  (2006)	  Recent	  clinical	  failures	  in	  Parkinson's	  disease	  with	  apoptosis	  
inhibitors	  underline	  the	  need	  for	  a	  paradigm	  shift	  in	  drug	  discovery	  for	  neurodegenerative	  diseases.	  Biochem	  Pharmacol	  
72:	  1197-­‐1206.	  
4.	  Casadesus	  G,	  Smith	  MA,	  Basu	  S,	  Hua	  J,	  Capobianco	  DE,	  et	  al.	  (2007)	  Increased	  isoprostane	  and	  prostaglandin	  are	  prominent	  in	  
neurons	  in	  Alzheimer	  disease.	  Mol	  Neurodegener	  2:	  2.	  
5.	  Pratico	  D,	  Clark	  CM,	  Liun	  F,	  Rokach	  J,	  Lee	  VY,	  et	  al.	  (2002)	  Increase	  of	  brain	  oxidative	  stress	  in	  mild	  cognitive	  impairment:	  a	  
possible	  predictor	  of	  Alzheimer	  disease.	  Arch	  Neurol	  59:	  972-­‐976.	  
6.	  Pratico	  D,	  Uryu	  K,	  Leight	  S,	  Trojanoswki	  JQ,	  Lee	  VM	  (2001)	  Increased	  lipid	  peroxidation	  precedes	  amyloid	  plaque	  formation	  in	  
an	  animal	  model	  of	  Alzheimer	  amyloidosis.	  J	  Neurosci	  21:	  4183-­‐4187.	  
7.	  Saenger	  AK,	  Laha	  TJ,	  Edenfield	  MJ,	  Sadrzadeh	  SM	  (2007)	  Quantification	  of	  urinary	  8-­‐iso-­‐PGF2alpha	  using	  liquid	  
chromatography-­‐tandem	  mass	  spectrometry	  and	  association	  with	  elevated	  troponin	  levels.	  Clin	  Biochem	  40:	  1297-­‐1304.	  
8.	  Song	  F,	  Poljak	  A,	  Smythe	  GA,	  Sachdev	  P	  (2009)	  Plasma	  biomarkers	  for	  mild	  cognitive	  impairment	  and	  Alzheimer's	  disease.	  
Brain	  Res	  Rev	  61:	  69-­‐80.	  
9.	  Beal	  MF	  (2005)	  Oxidative	  damage	  as	  an	  early	  marker	  of	  Alzheimer's	  disease	  and	  mild	  cognitive	  impairment.	  Neurobiol	  Aging	  
26:	  585-­‐586.	  
10.	  Bonda	  DJ,	  Wang	  X,	  Perry	  G,	  Nunomura	  A,	  Tabaton	  M,	  et	  al.	  (2010)	  Oxidative	  stress	  in	  Alzheimer	  disease:	  A	  possibility	  for	  
prevention.	  Neuropharmacology.	  
11.	  Butterfield	  DA,	  Drake	  J,	  Pocernich	  C,	  Castegna	  A	  (2001)	  Evidence	  of	  oxidative	  damage	  in	  Alzheimer's	  disease	  brain:	  central	  
role	  for	  amyloid	  beta-­‐peptide.	  Trends	  Mol	  Med	  7:	  548-­‐554.	  
12.	  Dumont	  M,	  Lin	  MT,	  Beal	  MF	  (2010)	  Mitochondria	  and	  antioxidant	  targeted	  therapeutic	  strategies	  for	  Alzheimer's	  disease.	  J	  
Alzheimers	  Dis	  20	  Suppl	  2:	  S633-­‐643.	  
13.	  Gackowski	  D,	  Rozalski	  R,	  Siomek	  A,	  Dziaman	  T,	  Nicpon	  K,	  et	  al.	  (2008)	  Oxidative	  stress	  and	  oxidative	  DNA	  damage	  is	  
characteristic	  for	  mixed	  Alzheimer	  disease/vascular	  dementia.	  J	  Neurol	  Sci	  266:	  57-­‐62.	  
14.	  Guglielmotto	  M,	  Giliberto	  L,	  Tamagno	  E,	  Tabaton	  M	  (2010)	  Oxidative	  stress	  mediates	  the	  pathogenic	  effect	  of	  different	  
Alzheimer's	  disease	  risk	  factors.	  Front	  Aging	  Neurosci	  2:	  3.	  
15.	  Khan	  SM,	  Cassarino	  DS,	  Abramova	  NN,	  Keeney	  PM,	  Borland	  MK,	  et	  al.	  (2000)	  Alzheimer's	  disease	  cybrids	  replicate	  beta-­‐
amyloid	  abnormalities	  through	  cell	  death	  pathways.	  Ann	  Neurol	  48:	  148-­‐155.	  
16.	  Lovell	  MA,	  Markesbery	  WR	  (2007)	  Oxidative	  DNA	  damage	  in	  mild	  cognitive	  impairment	  and	  late-­‐stage	  Alzheimer's	  disease.	  
Nucleic	  Acids	  Res	  35:	  7497-­‐7504.	  
17.	  Nunomura	  A,	  Perry	  G,	  Aliev	  G,	  Hirai	  K,	  Takeda	  A,	  et	  al.	  (2001)	  Oxidative	  damage	  is	  the	  earliest	  event	  in	  Alzheimer	  disease.	  J	  
Neuropathol	  Exp	  Neurol	  60:	  759-­‐767.	  
18.	  Onyango	  IG,	  Bennett	  JP,	  Jr.,	  Tuttle	  JB	  (2005)	  Endogenous	  oxidative	  stress	  in	  sporadic	  Alzheimer's	  disease	  neuronal	  cybrids	  
reduces	  viability	  by	  increasing	  apoptosis	  through	  pro-­‐death	  signaling	  pathways	  and	  is	  mimicked	  by	  oxidant	  exposure	  of	  
control	  cybrids.	  Neurobiol	  Dis	  19:	  312-­‐322.	  
19.	  Perry	  G,	  Nunomura	  A,	  Hirai	  K,	  Zhu	  X,	  Perez	  M,	  et	  al.	  (2002)	  Is	  oxidative	  damage	  the	  fundamental	  pathogenic	  mechanism	  of	  
Alzheimer's	  and	  other	  neurodegenerative	  diseases?	  Free	  Radic	  Biol	  Med	  33:	  1475-­‐1479.	  
20.	  Nalivaeva	  NN,	  Fisk	  LR,	  Belyaev	  ND,	  Turner	  AJ	  (2008)	  Amyloid-­‐degrading	  enzymes	  as	  therapeutic	  targets	  in	  Alzheimer's	  
disease.	  Curr	  Alzheimer	  Res	  5:	  212-­‐224.	  
21.	  Quiroz-­‐Baez	  R,	  Rojas	  E,	  Arias	  C	  (2009)	  Oxidative	  stress	  promotes	  JNK-­‐dependent	  amyloidogenic	  processing	  of	  normally	  
expressed	  human	  APP	  by	  differential	  modification	  of	  alpha-­‐,	  beta-­‐	  and	  gamma-­‐secretase	  expression.	  Neurochem	  Int	  55:	  
662-­‐670.	  
22.	  Tamagno	  E,	  Guglielmotto	  M,	  Aragno	  M,	  Borghi	  R,	  Autelli	  R,	  et	  al.	  (2008)	  Oxidative	  stress	  activates	  a	  positive	  feedback	  between	  
the	  gamma-­‐	  and	  beta-­‐secretase	  cleavages	  of	  the	  beta-­‐amyloid	  precursor	  protein.	  J	  Neurochem	  104:	  683-­‐695.	  
23.	  El-­‐Amouri	  SS,	  Zhu	  H,	  Yu	  J,	  Marr	  R,	  Verma	  IM,	  et	  al.	  (2008)	  Neprilysin:	  an	  enzyme	  candidate	  to	  slow	  the	  progression	  of	  
Alzheimer's	  disease.	  Am	  J	  Pathol	  172:	  1342-­‐1354.	  
24.	  Fisk	  L,	  Nalivaeva	  NN,	  Boyle	  JP,	  Peers	  CS,	  Turner	  AJ	  (2007)	  Effects	  of	  hypoxia	  and	  oxidative	  stress	  on	  expression	  of	  neprilysin	  in	  
human	  neuroblastoma	  cells	  and	  rat	  cortical	  neurones	  and	  astrocytes.	  Neurochem	  Res	  32:	  1741-­‐1748.	  

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
15
25.	  Swerdlow	  RH,	  Parks	  JK,	  Cassarino	  DS,	  Maguire	  DJ,	  Maguire	  RS,	  et	  al.	  (1997)	  Cybrids	  in	  Alzheimer's	  disease:	  a	  cellular	  model	  of	  
the	  disease?	  Neurology	  49:	  918-­‐925.	  
26.	  Trimmer	  PA,	  Keeney	  PM,	  Borland	  MK,	  Simon	  FA,	  Almeida	  J,	  et	  al.	  (2004)	  Mitochondrial	  abnormalities	  in	  cybrid	  cell	  models	  of	  
sporadic	  Alzheimer's	  disease	  worsen	  with	  passage	  in	  culture.	  Neurobiol	  Dis	  15:	  29-­‐39.	  
27.	  Schneider	  CS,	  Mierau	  J	  (1987)	  Dopamine	  autoreceptor	  agonists:	  resolution	  and	  pharmacological	  activity	  of	  2,6-­‐
diaminotetrahydrobenzothiazole	  and	  an	  aminothiazole	  analogue	  of	  apomorphine.	  J	  Med	  Chem	  30:	  494-­‐498.	  
28.	  Burchell	  VS,	  Gandhi	  S,	  Deas	  E,	  Wood	  NW,	  Abramov	  AY,	  et	  al.	  (2010)	  Targeting	  mitochondrial	  dysfunction	  in	  
neurodegenerative	  disease:	  Part	  II.	  Expert	  Opin	  Ther	  Targets	  14:	  497-­‐511.	  
29.	  Burchell	  VS,	  Gandhi	  S,	  Deas	  E,	  Wood	  NW,	  Abramov	  AY,	  et	  al.	  (2010)	  Targeting	  mitochondrial	  dysfunction	  in	  
neurodegenerative	  disease:	  Part	  I.	  Expert	  Opin	  Ther	  Targets	  14:	  369-­‐385.	  
30.	  Muller	  WE,	  Eckert	  A,	  Kurz	  C,	  Eckert	  GP,	  Leuner	  K	  (2010)	  Mitochondrial	  dysfunction:	  common	  final	  pathway	  in	  brain	  aging	  and	  
Alzheimer's	  disease-­‐-­‐therapeutic	  aspects.	  Mol	  Neurobiol	  41:	  159-­‐171.	  
31.	  Chen	  K,	  Langbaum	  JB,	  Fleisher	  AS,	  Ayutyanont	  N,	  Reschke	  C,	  et	  al.	  Twelve-­‐month	  metabolic	  declines	  in	  probable	  Alzheimer's	  
disease	  and	  amnestic	  mild	  cognitive	  impairment	  assessed	  using	  an	  empirically	  pre-­‐defined	  statistical	  region-­‐of-­‐interest:	  
findings	  from	  the	  Alzheimer's	  Disease	  Neuroimaging	  Initiative.	  Neuroimage	  51:	  654-­‐664.	  
	  
 
 
 
 
Appendix:   
1. Table of Treament-Emergent Adverse Events from Mirapex 
2. Data Safety and Monitoring Board (DSMB) Charter

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
16
 
Table 1: Treatment-Emergent Adverse-Event* Incidence in Double-Blind, Placebo-Controlled Trials in 
Early Parkinson's Disease (Events ≥ 1% of Patients Treated with MIRAPEX tablets and Numerically More 
Frequent than in the Placebo Group) 
Body System/    
Adverse Event         
      MIRAPEX  
         N=388 
          Placebo  
           N=235 
Body as a Whole  
  Asthenia 
14 
12 
  General edema 
5 
3 
  Malaise 
2 
1 
  Reaction unevaluable 
2 
1 
  Fever 
1 
0 
Digestive System  
  Nausea 
28 
18 
  Constipation 
14 
6 
  Anorexia 
4 
2 
  Dysphagia 
2 
0 
Metabolic & Nutritional System  
  Peripheral edema 
5 
4 
  Decreased weight 
2 
0 
Nervous System  
  Dizziness 
25 
24 
  Somnolence 
22 
9 
  Insomnia 
17 
12 
  Hallucinations 
9 
3 
  Confusion 
4 
1 
  Amnesia 
4 
2 
  Hypesthesia 
3 
1 
  Dystonia 
2 
1 
  Akathisia 
2 
0 
  Thinking abnormalities 
2 
0 
  Decreased libido 
1 
0 
  Myoclonus 
1 
0 
Special Senses  
  Vision abnormalities 
3 
0 
Urogenital System  
  Impotence 
2 
1 

R(+) pramipexole in Alzheimer’s Disease  
 
James P. Bennett, Jr. M.D., Ph.D.-Sponsor 
2/18/2011 
17
*Patients may have reported multiple adverse experiences during the 
study or at discontinuation; thus, patients may be included in more 
than one category.  
 
Source: Mirapex (pramipexole) package insert 
	  
IND	  60,948.	  	  
R(+)	  Pramipexole	  Treatment	  of	  Alzheimer’s	  or	  Parkinson’s	  Disease.	  
Data	  Safety	  and	  Monitoring	  Board	  (DSMB)	  Charter	  
	  
Purpose:	  The	  Sponsor	  (James	  P.	  Bennett,	  Jr.	  M.D.,	  Ph.D.)	  obtained	  IND	  60,948	  for	  use	  of	  the	  experimental	  
neuroprotective	  drug	  R(+)	  pramipexole	  dihydrochloride	  (PPX)	  to	  treat	  patients	  with	  amyotrophic	  lateral	  
sclerosis	  (ALS).	  The	  IND	  was	  removed	  from	  clinical	  hold	  at	  the	  end	  of	  2002,	  and	  Phase	  I	  studies	  were	  
initiated	  by	  the	  Sponsor	  in	  March,	  2004,	  followed	  by	  Phase	  II	  studies	  in	  2005.	  In	  2006	  the	  license	  for	  testing	  
of	  R(+)PPX	  was	  acquired	  by	  Knopp	  Neurosciences	  (now	  Knopp	  Biosciences).	  Knopp	  obtained	  its	  own	  
commercial	  IND	  and	  carried	  out	  Phase	  I/II	  studies.	  Following	  the	  completion	  of	  a	  successful	  Phase	  IIB	  study	  
in	  2009,	  the	  license	  for	  Phase	  III	  clinical	  testing	  in	  ALS	  was	  acquired	  from	  Knopp	  by	  Biogen-­‐Idec	  in	  August,	  
2010.	  
	  
The	  Sponsor	  of	  IND	  60,948	  has	  retained	  an	  active	  physician-­‐sponsor	  IND	  and	  in	  2006-­‐2007	  amended	  his	  
IND	  to	  carry	  out	  studies	  of	  R(+)PPX	  in	  patients	  with	  Alzheimer’s	  disease	  (AD)	  and	  Parkinson’s	  disease	  (PD).	  
This	  DSMB	  is	  chartered	  to	  monitor	  safety	  and	  tolerability	  of	  R(+)PPX	  in	  AD	  or	  PD	  patients.	  No	  protocols	  
involving	  efficacy	  of	  slowing	  disease	  progression	  are	  currently	  being	  considered.	  Should	  such	  efficacy	  
studies	  be	  proposed,	  this	  Charter	  will	  be	  amended.	  
	  
Composition:	  This	  DSMB	  will	  consist	  of	  at	  least	  three	  neurologist-­‐physicians	  who	  have	  experience	  with	  
experimental	  therapeutics	  in	  humans.	  	  One	  member	  will	  function	  as	  Chair,	  based	  on	  mutual	  agreement	  of	  
the	  members.	  Participation	  on	  this	  DSMB	  is	  voluntary,	  follows	  solicitation	  by	  the	  Sponsor	  and	  is	  
compensated	  at	  an	  annual	  rate	  of	  $2,000	  per	  annum.	  	  
	  
DSMB	  review	  of	  clinical	  studies:	  Members	  of	  the	  DSMB	  will	  receive	  by	  electronic	  means	  all	  of	  the	  safety	  
laboratory	  and	  clinical	  data	  on	  each	  participant.	  The	  DSMB	  members	  will	  also	  receive	  all	  Adverse	  Event	  (AE)	  
and	  Serious	  Adverse	  Event	  (SAE)	  reports	  generated	  during	  the	  study.	  It	  is	  anticipated	  that	  such	  data	  
submissions	  will	  occur	  on	  a	  monthly	  basis.	  The	  DSMB	  will	  meet	  quarterly.	  These	  meeting	  can	  occur	  
electronically	  or	  by	  telephone	  conference,	  depending	  on	  the	  wishes	  of	  the	  DSMB	  members.	  SAE	  reports	  will	  
be	  provided	  by	  the	  Sponsor	  to	  the	  DSMB	  based	  on	  FDA	  regulations.	  All	  SAE’s	  are	  reported	  within	  72	  hours,	  
and	  all	  deaths,	  expected	  or	  unexpected,	  are	  reported	  within	  24	  hours.	  
	  
The	  DSMB	  will	  provide	  to	  the	  Sponsor	  its	  advice	  regarding	  any	  safety/tolerability	  issues	  that	  arise.	  This	  
advice	  can	  include	  recommendation	  that	  a	  particular	  subject	  be	  temporarily	  or	  permanently	  withdrawn	  
from	  the	  study	  or	  that	  the	  entire	  study	  be	  placed	  on	  hold	  or	  terminated.	  	  
	  
DSMB	  Reports:	  The	  advice	  provided	  to	  the	  Sponsor	  by	  the	  DSMB,	  and	  Sponsor’s	  responses,	  will	  become	  part	  
of	  the	  IND	  record	  and	  will	  be	  filed	  by	  the	  Sponsor	  with	  the	  Sponsor’s	  IND	  annual	  reports.