Long Term Nitric Oxide Bioavailability on Vascular Health in Chronic Obstructive Pulmonary Disease
Phase: PHASE2
Conditions: Chronic Obstructive Pulmonary Disease (COPD)
Sponsor: Augusta University

 
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Protocol Title: Long Term Nitric Oxide Bioavailability on Vascular Health in 
Chronic Obstructive Pulmonary Disease (COPD-LT) 
Principal Investigator: Ryan A. Harris, PhD, CES, FACSM 
1. Objectives 
Researchers have found a link between chronic obstructive pulmonary disease (COPD) and heart 
disease; however, a link is all they have found.  In a previously funded grant, using a double blind, 
randomized experimental design, we explored the effect of an acute dose of Kuvan or an 
antioxidant cocktail (1000mg of vitamin C, 600IU of vitamin E, and 600mg alpha-lipoic acid) on 
vascular health in patients with COPD.  Consequently, we found in separate experiments, that a 
single dose of both antioxidants and Kuvan transiently improves vascular health in patients with 
COPD.  The current project is an attempt to expand on our previous findings and explore the effects 
of sub-chronic use of antioxidants and Kuvan on sustaining the improvements in vascular health in 
COPD.     
 
 
 
 
 
 
 
 
 
 
 
 

 
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2. Background 
 
Chronic obstructive pulmonary disease (COPD) affects up to 14 million people and is among the top five 
leading causes of death worldwide. Although COPD is a disease of the lungs, recent evidence indicates 
that COPD is associated with multiple systemic consequences including vascular endothelial dysfunction. 
Recently, it has been suggested that more patients with COPD die from cardiovascular disease and 
coronary heart disease than of direct pulmonary complications. Examination of the mechanisms that 
contribute to a reduction nitric oxide (NO) bioavailability resulting in vascular endothelial dysfunction in 
patients with COPD are important as endothelial dysfunction has been indicated to be an independent 
predictor of future atherosclerotic cardiovascular disease and events. 
 
NO Bioavailability and Vascular Function. Evidence indicates that a reduction in concentrations of NO, 
a hallmark of proatherogenic states, facilitates atherosclerosis. The flow-mediated dilation (FMD) 
technique, which represents a fundamental assay of NO bioavailability, has provided means to evaluate 
vascular endothelial function noninvasively and has been shown to correlate with invasive testing of 
coronary artery endothelial function. 
 
Vascular Endothelial Function in COPD. The NO dependent mechanism for vasodilation 
is considered the most vital endothelial mediated function because of its antiatherogenic property. 
Moreover, endothelial dysfunction has been proposed as the earliest identifiable event in the process of 
atherosclerosis. In fact, recent evidence indicates that endothelial dysfunction is associated with an 
increased risk for CVD in several different clinical populations and can even be considered a predictor of 
COPD. To our knowledge, there is limited data describing in vivo vascular endothelial function in patients 
with COPD. With respective limitations, each study reports an impaired FMD in patients with COPD 
which appears to be associated with the degree of airway obstruction; however, examining the role of NO 
bioavailability in contributing to endothelial dysfunction in patients with COPD and the molecular 
mechanisms involved have yet to be determined. 
 
Tetrahydrobiopterin (BH4) in COPD. Tetrahydrobiopterin(BH4) is an essential cofactor required for NO 
production through the “coupling” with nitric oxide synthase (NOS). Accordingly, the uncoupling eNOS 
has been indicated to contribute to vascular oxidative stress and endothelial dysfunction in animal models. 
In fact, an improvement in FMD has been observed in current smokers following BH4 supplementation. 
Additionally, recent evidence indicates the essential role of BH4 in regulating pulmonary vascular 
homeostasis. Moreover, a recent review addressed the role of BH4 in regulating vascular endothelial 
function and potential therapeutic implications of BH4 in various clinical populations, which included 
chronic smokers; however, no studies have investigated the contributing role of BH4 in “recoupling” 
eNOS and increasing NO bioavailability in patients with COPD. The proposed novel investigation aims to 
identify if decreased BH4 levels are contributing to the reduction in NO bioavailability and vascular 
endothelial dysfunction in COPD. If so, these findings may provide support for the use of BH4 
supplementation to provide a salutary effect on vascular endothelial function in COPD. 
 
Oxidative Stress and COPD.  A shift in the antioxidant/free radical balance in favour of free radicals is 
termed oxidative stress.  Superoxide anion (O2-) and other free radicals are highly energized molecular 
species, structurally distinct in that they contain one or more unpaired electrons in their atomic orbital 33.  
Although low concentrations of free radicals appear to have important roles in cell signaling, an excess of 
free radicals can cause a wide spectrum of cellular damage, including lipid peroxidation, alteration of 

 
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intracellular redox state, inactivation of enzymes, and damage to DNA.  Unsurprisingly, elevated oxidative 
stress has been observed in smokers34-36 and in COPD24, 37.  Since the initial observation that O2- and other 
free radicals inactivate nitric oxide38, which plays a fundamental role in regulating endothelial function, it 
seems logical that the elevated oxidative stress observed in COPD would contribute to endothelial 
dysfunction.  One method to reduce oxidative stress is through a reduction in superoxide anion (O2-), 
which would limit the degradation of NO, thus increasing its bioavailability.  Antioxidant supplementation 
has been utilized as a means to reduce oxygen free radicals and increase NO bioavailability in several 
clinical populations39-41. 
 
 
 
3. Inclusion and Exclusion Criteria 
List the inclusion/exclusion criteria: 
 Inclusion 
o 24 patients with medically diagnosed COPD 
o 24 apparently healthy controls  
 Exclusion 
o FEV1/FVC >0.7 (normal lung function in patients only) 
o Clinical diagnosis of heart disease or diabetes 
o Vasoactive medications (i.e. nitrates, beta-blockers, Viagra etc.) 
o uncontrolled high blood pressure 
o high blood pressure in your lungs 
o thyroid problems 
o Fluid in the lungs 
o Sleep apnea 
o Anemia 
o Raynaud’s Phenomenon 
o GI bleeding 
o Gangrene of the digits 
o History of low platelets or coagulopathies 
o Phenylketonuria (PKU) 
o Pregnant 
o Lactation 
o Any allergy to Kuvan 
 
4. Number of Subjects/Records/Samples Collected 
A maximum of 48 volunteers will be needed for this entire research study.  For patients, there are 2 
protocols which each consist of 6 visits each.  We would like to recruit 12 patients with COPD that will be 
asked to complete the Kuvan protocol and an additional 12 patients that will be asked to complete the 
Antioxidant protocol.  Apparently healthy controls (n=24) will be asked to only complete visit one.  
      
 

 
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5. Recruitment Methods 
Patients with COPD will be recruited from the Pulmonary and Critical care medicine unit, family medicine, 
internal medicine, and local outreach clinics associated with Georgia Regents University.  We will also use 
I2B2 to pull up inclusion and or exclusion criteria for potential participants as well as power chart to gather 
contact information; for this purpose a Waiver of Consent, Waiver of HIPAA Authorization along with the 
telephone screening forms that will be used to contact potential participants will be approved by the 
designated IRB before patient recruitment takes place.  The main source of control subject recruitment will 
be the parents of the subjects enrolled in other studies here at the Georgia Prevention Institute (GPI). The 
GPI sees approximately 10,000 subject visits per year (both children and adults). 
Click here to enter text. 
 
6. Procedures Involved 
Body Composition. The subjects body fat, bone, and lean tissue will be measured at the beginning of the 
study with a low level x-ray machine called dual-energy x-ray absorptiometry (DXA) for short.  These 
tests give the subjects body about 4 extra days worth of the type of background radiation that everyone 
receives every year from the environment.  The subject will be asked to lie still on a table with their eyes 
closed while a mechanical arm moves above their body measuring their body composition. Body Mass 
Index (BMI) will also be calculated using measurements of the subject’s height and weight.  Waist to Hip 
Ratio (WHR) will be measured using a vinyl tape measuring around their waist and hips.     
 
Pulmonary Function Test. All volunteers will perform a lung function test to measure how well their lungs 
work.  This involves taking a deep breath and then blowing into a tube as hard as they can, until they 
cannot blow any further.  We will also measure how well the air crosses through the lungs by having each 
participant breathe a mixture of gasses (10% He, 21% O2, 0.3% CO, and balance N2) and having them 
hold their breath for 10 seconds.  Following the baseline lung function test, it is possible that the volunteer 
will be excluded from the study if their lung function does not meet the criteria above. 
 
Blood Samples. Blood samples will be taken from a vein in your arm by a certified technician before and 
after each protocol.  For each experimental visit, a total of about 40 ml of blood (~ 2-3 tablespoons) will be 
taken. This amount is less than 1/10 of the amount that is withdrawn during a normal blood donation (500 
ml or 15 fluid ounces).  We will use this blood to test for blood fat (cholesterol) and the concentration of 
certain hormones, and to determine the level of harmful chemicals found in the blood.  You may only 
drink water after dinner the night before this test.   
 
Muscle Function Test. For this test, the subject will lie on their back.  We will place a cuff around their 
upper thigh and place an oxygen measuring device and four electrodes on the middle of their thigh muscle. 
These electrodes will be used to stimulate their thigh using a commercial electrical stimulation unit.  The 
stimulation will be set so that the muscles contract strongly, but we will adjust the stimulation to a level 
that the subject can tolerate.  We will perform two measurement trials, each consisting of a short (15 
second) electrical stimulation period followed by a series of 15 short cuff inflations to block the blood flow 
to the leg.  There will be a 2-5 minute rest period between trials. 
Arterial Stiffness Evaluation (PWV). A device will be used to measure how fast the participant’s blood 
travels.  This test is called pulse wave velocity or PWV.  How fast the subject’s blood travels is also a 
measure of how stiff their arteries are.  Stiff blood vessels/arteries are linked to heart disease. To start the 

 
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test, participants will be asked to lie still in a resting position for about 20 minutes. The research assistant 
will place white patches called electrode sensors on their body.  A pen-like device is gently applied on the 
carotid artery (neck) and then the femoral artery (groin) and the radial artery (wrist) to record how fast 
their blood flows between each of the points. 
Arterial Function (FMD). This test looks at how artery expands with changes in blood flow and is used to 
characterize the health of the subject’s arteries. The subject will lie on their back for 20 minutes to rest.  
We will then measure the function of the artery by scanning an artery in the arm.  Following baseline 
measurements, a blood pressure cuff placed around the subjects forearm will be inflated to 250 mm Hg to 
stop blood flow for 5 minutes.  Blood flow and velocity and arterial diameters will be recorded for 2 
minutes following the release of the cuff. 
Ankle Brachial Index (ABI). This test is done by measuring the blood pressure in both the arm and the 
lower leg (ankle) while the subject is lying down.  We will use this test to screen for peripheral vascular 
disease.   
Six-Minute Walk Test (6MWT).  This test measures the distance that a patient can quickly walk on a flat, 
hard surface in a period of 6 minutes.  A line, 30 m in length, will be drawn out in tape with cones at each 
end of the line to mark the turnaround points.   
Skin Blood Flow. The laser imaging camera is a special camera that shines a low energy laser light on the 
surface of the skin to measure blood flow.  The FLPI makes graphs, photos, and movies of skin blood 
flow.  There are no known risks associated with the laser imaging camera.  The small skin probes can hurt 
the eye if you stare into the light for a long time; however, we do not turn on the laser until the probes are 
taped to a surface of the skin.    
Iontophoresis. Acetylcholine, sodium nitropruside and L-NAME are vasoactive substances that will be 
used to increase and decrease skin blood flow. The amount of drug delivered is based on the amount of 
current being delivered.  Using this technique with such a low level current, there should be no drug that 
enters the body.  Although the current being used is very small (less than 200mA), participants may feel 
mild skin irritation on the hand or the forearm where the chambers are placed. 
Local Heating. We measure the temperature of the skin under the ring holders.  The skin will feel very 
warm but should not hurt.  The heating of the water will make the skin of the arm red under the holders 
like when the subjects takes a hot bath.  The redness will not last more than a few hours.  Some people 
may be more sensitive to the heating than others and therefore if the arm gets too hot, we will reduce or 
stop the heating. 
 
In this study there will be 5 experimental visits following the preliminary visit each being four weeks 
apart. For the Kuvan (BH4) protocol, depending on the randomized group the subject is in they will 
receive either 5 mg, 10 mg, or 20 mg per kg of treatment.   
Tentative Schedule of Events:  
*Note subject may or may not be asked to perform all procedures during each testing day depending on 

 
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time and availability. Also, some preliminary day measures may not be completed on the preliminary day 
and may be completed some other time during the course of the study.* 
Preliminary Day 
 Consent 
 ABI 
 IMT 
 DXA Scan 
 Pulmonary Function Test 
 6 min Walk Test 
Experimental Testing Days 
 Continued consent 
 PWV 
 FMD 
 Skin Blood Flow/Local Heating 
 Blood Draw 
 Pulmonary Function Test 
Risk Assessment 
 
All procedures in this study have been routinely performed in research studies in the past and are of low 
risk to participants. 
 
Venous Blood Draw.  Potential risks related with taking a blood sample are few but include slight bruising, 
pain, a temporary feeling of faintness, and phlebitis. Rarely, there may be a small blood clot or infection at 
the site of the needle puncture.  All blood draws will be performed by a research team member or a nurse 
who is certified in drawing blood; in either case sterile techniques will be used. 
 
Pulmonary Function Test. There are no known risks associated with this test. 
 
Muscle Function Test. Electrical stimulation of the muscles may be uncomfortable and could be painful.  If 
the muscle stimulation is too painful, we will adjust the stimulation to a level that the subject can tolerate.  
The study does not require the stimulation to be painful for the study to be successful.  Because the 
stimulator “exercises” the muscle, the muscle may be sore for a few days following the protocol.  
 
Body Composition. The DXA will expose the subject to a minimal amount of radiation. The DXA scan 
will expose the participants body to about 3 mrem per scan. Everyone receives a small amount of 
unavoidable background radiation from the natural environment each year. The radiation dose from the 
DXA scan is equal to less than three to four extra days' worth of natural background radiation. Radiation at 
significantly higher levels is known to cause cancer; however, the amount of radiation in this study is very 
low and is not expected to cause bodily injury during the subject’s lifetime. The radiation dose discussed 

 
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here is what the participant will receive from this DXA study only. Radiation dose from multiple 
exposures is cumulative. Our radiation devices are monitored regularly for continued performance and 
approved for testing. The subjects will be asked if they are receiving additional x-ray exposure from other 
sources during the consenting process.  
 
Pregnancy.  Radiation at large doses is known to have an effect on a developing fetus. Although radiation 
doses from these studies are extremely small, if the subject is a premenopausal female a urine pregnancy 
test will be conducted to rule out pregnancy.  
 
Arterial Health and Stiffness. The risks associated with the flow-mediated dilation, pulse-wave velocity, 
and intima media thickness tests are minimal, if not none. Potential risks include redness of the skin, 
bruising, numbness, pain, tingling of the fingers and discomfort while the cuff is inflated.  The risks 
associated with the lubricant gel are skin irritation and possible break out of rash.   
Kuvan.  The potential risks associated with Kuvan are headache, diarrhea, abdominal pain, vomiting, upper 
respiratory tract infection, and nausea.  These risks are the most commonly reported in approximately 4% 
of patients chronically treated with Kuvan.   
Antioxidant Cocktail.  (1000mg of vitamin C, 600IU of vitamin E, and 600mg alpha-lipoic acid) There are 
no known risks associated with taking the antioxidant cocktail. 
 
Skin Blood Flow:  The laser imaging camera is a special camera that shines a low energy laser light on the 
surface of the skin to measure blood flow.  The FLPI makes graphs, photos, and movies of skin blood 
flow.  The subject will be able to see a harmless red light on their skin. There are no known risks 
associated with the laser imaging camera.  The small skin probes can hurt the eyes if the subjects stare into 
the light for a long time.  We do not turn on the laser until the probes are taped to a surface of the arm.    
 
Iontophoresis:  Acetylcholine, sodium nitropruside and L-NAME are vasoactive substances that will be 
used to increase and decrease skin blood flow. The amount of drug delivered is based on the amount of 
current being delivered.  Using this technique with such a low level current, there should be no drug that 
enters the body.  Although the current being used is very small (less than 200mA), the subject may feel 
mild skin irritation on the hand or the forearm where the chambers are placed. 
 
Six-Minute Walk Test: Potential risk related to this test are few but include chest pain, shortness of breath, 
leg cramps, staggering, sweating, and pale skin color in the face.  Every effort will be made to minimize 
these risks.  A staff member who is certified in basic life support will be present at all times.  We will have 
a chair available throughout the test if the patient needs to take a break.  Oxygen will also be readily 
available. 
 
Local Heating:  We measure the temperature of the subject’s skin under the ring holders.  The skin will 
feel very warm but should not hurt.  The heating of the water will make the skin of the subjects arm under 
the holders red like when taking a hot bath.  The redness will not last more than a few hours.  Some people 
may be more sensitive to the heating than others.  If the subjects arm feels too hot, the subject has been 
instructed to tell us, and we will reduce or stop the heating. 
 

 
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Visits Required: 
There are six visits required for all COPD subjects for this study, a preliminary visit, and 5 
experimental day visits (baseline, 4 weeks, 8 weeks, 12 weeks, and a follow up visit on week 16). 
Control subjects will need to only complete one experimental day visit.  
Subjects may participate in both protocols but they do not have to. If they do wish to participate in 
both protocols, they must wait at least 4 weeks in between protocols. 
Click here to enter text. 
 
 
7. Data and Specimen Management 
a. Describe the data analysis plan, including any statistical procedures: 
The proposed investigation is an open-label dose response investigation.  More 
importantly, this investigation is a pilot project that is based on the transient findings of our 
previous funded American Heart Association grant. Nonetheless, for the Kuvan protocol 
we will employ a 3 x 5 (dose x time) mixed factorial ANOVA with the repeated factor 
being time.  For the Antioxidant protocol we will employ a Repeated measures ANOVA.  
For both protocols we will run planned comparisons of the treatment response to the 
control data to determine the effects of the treatment relative to the baseline value of the 
control.  In an attempt to reduce the family wise error rate, planned comparisons will also 
be made for the interaction between baseline and 12 weeks for each dose with comparisons 
made with the withdraw period.  
 
☐  N/A       
 
b. When applicable, provide a power analysis: 
The power and sample sizes could not be determined from the acute intervention 
study.   
☐  N/A       
c. Describe how data and specimens will be handled: 
☐  N/A       
i. 
What information will be included in that data or associated with the specimens? 
All specimens will be collected with deidentified information. Specifically, the ID, 
date, specimen type (i.e. serum or plasma), and analyte to be measured will be 
included on the tube label. 
ii. 
Where and how data and/or specimens will be stored? 
       Data are stored in subject folders, specimens are stored de-identified in -80 freezers 
 
iii. 
How long will the data and/or specimens be stored? 
Until analyzed 

 
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iv. 
Who will have access to the data or specimens? 
All investigators who are on the protocol 
v. 
Who is responsible for receipt or transmission of the data and/or specimens? 
Dr Harris 
vi. 
How will data and/or specimens be transported? 
According to biosafety procedures 
 
 
8. Provisions to Monitor the Data to Ensure the Safety of Subjects 
This study involves no more than minimal risk study and this section is not required. ☐ N/A 
 
The plan might include establishing a data monitoring committee and a plan for reporting data 
monitoring committee findings to the IRB and the sponsor. 
a. Describe the plan to periodically evaluate the data collected regarding both harms and 
benefits to determine whether subjects remain safe. 
Subjects will be monitored the entire time they are in the LIVEP lab. The PI and study team 
will evaluate the safety for each participant by changes in BP and HR before, during and 
after treatment.   
b. Describe what data are reviewed, including safety data, untoward events, and efficacy data. 
During consenting we ask what drugs they are currently taking and we also ask on every 
visit if there have been any changes to the drugs. We will frequently monitor BP, and HR to 
determine how the treatment is affecting them.   
c. Describe how the safety information will be collected (e.g., with case report forms, at study 
visits, by telephone calls with participants). 
     Data is consistently collected during their visits which will monitor how their body is reacting to the 
drug or cocktail treatment.    
d. Describe the frequency of data collection, including when safety data collection starts. 
This done with every visit, subjects BP, and HR are consistently monitored during the 
duration of their visit 
e. Describe who will review the data. 
The PI will review the data on a daily basis.  Because Biomarin is the manufacture of 
Kuvan and is providing the drug for this study, the researchers may also disclose 
information to BioMarin Pharmaceutical Inc.  
f. Describe the frequency or periodicity of review of cumulative data. 
    This will be evaluated during each visit.  

 
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g. Describe any conditions that trigger an immediate suspension of the research. 
 If the PI thinks that the study is causing harm to the participant they will withdraw that subject 
from the study.   
 
9. Withdrawal of Subjects                                                                     ☐ N/A       
In the event that participating in the study might be harmful to the subject’s health and 
well-being, we will end their study participation.  In addition, if we feel that the 
participants are not adhering to the treatment we have the right to end their study 
participation.  At any time, the subjects also have the right to stop participating in the 
study.  
☐  N/A       
For any reason the subjects ask to withdraw from the study they will be paid an 
hourly rate of $10.00 an hour.  
 
☐  N/A       
 
☐  N/A       
 
10. Risks to Subjects 
All procedures in this study have been routinely performed in research studies in the past and are of low 
risk to participants. 
 
Venous Blood Draw.  Potential risks related with taking a blood sample are few but include slight bruising, 
pain, a temporary feeling of faintness, and phlebitis. Rarely, there may be a small blood clot or infection at 
the site of the needle puncture.  All blood draws will be performed by a research team member or a nurse 
who is certified in drawing blood; in either case sterile techniques will be used. 
 
Pulmonary Function Test. There are no known risks associated with this test. 
 
Muscle Function Test. Electrical stimulation of the muscles may be uncomfortable and could be painful.  If 
the muscle stimulation is too painful, we will adjust the stimulation to a level that the subject can tolerate.  
The study does not require the stimulation to be painful for the study to be successful.  Because the 
stimulator “exercises” the muscle, the muscle may be sore for a few days following the protocol.  
 
Body Composition. The DXA will expose the subject to a minimal amount of radiation. The 1 DXA scan 
will expose the subjects’ body to about 1.5 mrem radiation dose. Everyone receives a small amount of 
unavoidable background radiation from the natural environment each year. The radiation dose from the 
DXA scan is equal to less than 2 extra days' worth of natural background radiation. Radiation at 
significantly higher levels is known to cause cancer; however, the amount of radiation in this study is very 

 
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low and is not expected to cause bodily injury during your lifetime. The radiation dose discussed here is 
what you will receive from this DXA study only. Radiation dose from multiple exposures is cumulative. 
Our radiation devices are monitored regularly for continued performance and approved for testing. The 
subjects will be asked if they are receiving additional x-ray exposure from other sources during the 
consenting process.  
 
Pregnancy.  Radiation at large doses is known to have an effect on a developing fetus. Although radiation 
doses from these studies are extremely small, if the subject is a premenopausal female a urine pregnancy 
test will be conducted to rule out pregnancy.  
 
Arterial Health and Stiffness. The risks associated with the flow-mediated dilation, pulse-wave velocity, 
and intima media thickness tests are minimal, if not none. Potential risks include redness of the skin, 
bruising, numbness, pain, tingling of the fingers and discomfort while the cuff is inflated.  The risks 
associated with the lubricant gel are skin irritation and possible break out of rash.   
Kuvan.  Kuvan is FDA approved for the use in phenylketonuria (PKU).  Although Kuvan has not been 
approved for the use in COPD, it is generally well tolerated. The potential reported risks associated with 
Kuvan use in PKU are headache, diarrhea, abdominal pain, vomiting, upper respiratory tract infection, and 
nausea.  These risks are the most commonly reported in at least 4% of patients chronically treated with 
Kuvan.   
Antioxidant Cocktail.  There are no known risks associated with taking the antioxidant cocktail. 
 
Skin Blood Flow:  The laser imaging camera is a special camera that shines a low energy laser light on the 
surface of the skin to measure blood flow.  The FLPI makes graphs, photos, and movies of skin blood 
flow.  They subject be able to see a harmless red light on their skin.  There are no known risks associated 
with the laser imaging camera.  The small skin probes can hurt the subject’s eye if they stare into the light 
for a long time.  We do not turn on the laser until the probes are taped to a surface of the arm. 
 
Iontophoresis:  Acetylcholine, sodium nitropruside and L-NAME are vasoactive substances that will be 
used to increase and decrease skin blood flow. The amount of drug delivered is based on the amount of 
current being delivered.  Using this technique with such a low level current, there should be no drug that 
enters the body.  Although the current being used is very small (less than 200mA), you may feel mild skin 
irritation on the hand or the forearm where the chambers are placed. 
 
Local Heating:  We measure the temperature of the subject’s skin under the ring holders.  The skin will 
feel very warm but should not hurt.  The heating of the water will make the skin of the subjects arm under 
the holders red like when taking a hot bath.  The redness will not last more than a few hours.  Some people 
may be more sensitive to the heating than others.  If the subjects arm feels too hot, the subject has been 
instructed to tell us, and we will reduce or stop the heating. 
Adverse Events 
According to the ICH definition, an adverse event (AE) is any untoward medical occurrence in a patient or 
clinical investigation subject administered a pharmaceutical product, and that does not necessarily have a causal 
relationship with this treatment.  An AE can therefore be any unfavorable and unintended sign (including an 

 
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abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal 
(investigational) product, whether or not considered related to the investigational product. 
This definition includes intercurrent illnesses or injuries that represent an exacerbation (increase in frequency, 
severity, or specificity) of pre-existing conditions.  Whenever possible, it is preferable to record a diagnosis as 
the AE term rather than a series of terms relating to a diagnosis.  
Adverse event information will be collected in an ongoing fashion through patient reporting AEs to their 
physician or health care provider.  Seriousness and relatedness will be assessed by the treating physician, with 
appropriate reporting. 
A designated primary contact person based at the treatment center will be responsible for the collection and 
reporting of AEs for patients participating in the program.   
Serious Adverse Events 
A serious adverse event (SAE) is defined as any AE that: 
 
Results in death 
 
Is life threatening, that is, places the subject at immediate risk of death from the event as it occurred. 
This definition does not include a reaction that, had it occurred in a more severe form, might have 
caused death 
 
Requires in-patient hospitalization or prolongation of an existing in-patient hospitalization. Admission 
of a subject to the hospital as an in-patient as a result of an AE, even if the subject is released on the 
same day, qualifies as hospitalization 
 
Results in persistent or significant disability or incapacity. An event qualifies as resulting in a persistent 
or significant disability or incapacity if it involves a substantial disruption of the subject’s ability to 
carry out usual life functions.  This definition is not intended to include experiences of relatively minor 
or temporary medical significance. 
 
Is a congenital anomaly or birth defect, an AE that occurs in the child or fetus of a subject exposed to 
the product prior to conception or during pregnancy 
 
Important medical event that does not meet any of the above criteria, but may jeopardize the subject or 
require medical or surgical intervention to prevent one of the outcomes listed above. 
More than one of the above criteria may apply to any specific event. 
 
Pregnancy  
 
Pregnancy in a subject being treated with the product should be reported immediately (within 24 hours of 
becoming aware of the pregnancy) to BioMarin Pharmacovigilance by using the FDA 3500A (MedWatch 
Form).  Every effort should be made to follow the patient through resolution of the pregnancy (termination or 
delivery) and report the resolution of the FDA 3500A (MedWatch Form) to BioMarin Pharmacovigilance. 
 
SAE and Pregnancy Reporting 
In Investigator IND studies,  
KUVAN™ serious, related, unlabelled, (unexpected) adverse events will be reported to the FDA as required by 
21 CFR 312.32 by the Investigator/Sponsor. These reports may be filed utilizing the Form FDA 3500A 
(MedWatch form).  The Investigator/Sponsor will provide BioMarin Pharmacovigilance, with a copy of this 
report. 
 
All serious adverse events (SAEs) and pregnancy reports whether or not considered drug-related should be 
reported to BioMarin Pharmacovigilance (contact information below) within 24 hours of receipt by the 
investigator/sponsor  by using the FDA 3500A (MedWatch Form).  

 
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For Comparator Drugs / Secondary Suspects (Concomitant Medications), all serious adverse experiences will 
be forwarded to the product manufacturer. 
 
For Comparator Drugs / Secondary Suspects (Concomitant Medications), all serious adverse experiences will 
be forwarded to the product manufacturer. 
 
Clinicians should not wait to collect additional information that fully documents the event before notifying 
BioMarin’s Pharmacovigilance Department of an SAE or pregnancy.  BioMarin may be required to report 
certain SAEs to regulatory authorities within 7 calendar days of being notified about the event; therefore it is 
important that clinicians submit additional information requested by BioMarin Pharmacovigilance as soon as it 
becomes available.   
Reporting of SAEs to the IRB will be done in compliance with the standard operating procedures and policies 
of the IRB and with applicable regulatory requirements.   
Contact information for BioMarin’s Pharmacovigilance Department is as follows: 
BioMarin Pharmaceutical Inc. 
105 Digital Drive 
Novato, CA  94949 
Phone: (415) 506-6179 
Fax: 
(415) 532-3144 
Email: drugsafety@bmrn.com 
 
Product Complaints Reporting 
 
A product complaint (“Complaint”) is any direct, written, electronic, or oral communication of 
dissatisfaction that alleges deficiencies related to the identity, quality, durability, labeling, purity, stability, 
appearance, effectiveness, safety, and/or design of a drug  product after it is released for distribution.  
 
Complaints that simultaneously fall under Adverse Event definitions under this Protocol need only be 
reported via the Adverse Event reporting procedure set forth in this Protocol.   
 
Investigator or designee (Reporter) shall capture the following Complaint information as relates to Kuvan 
used under this Protocol: 
 
• 
Date complaint received 
• 
Product Name and Lot Number 
• 
Indicate if the product is available for return to BioMarin for investigation  
• 
Quantity Affected 
• 
Detailed Description of complaint 
• 
Study Protocol Number 
• 
Investigator Name 

 
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• 
Site Contact 
• 
Site Number 
• 
Subject Number  
• 
Name and contact information of the person who is reporting the complaint as well as name and 
contact information of the complainant.  The reporter will be contacted by BioMarin Product 
Complaint Quality Assurance Department.  
Investigator or designee (Reporter) will use his or her best efforts to report Complaints to BioMarin within 
five days of learning of the Complaint.  
Investigator or designee will submit the complaint information by email at productcomplaint@bmrn.com 
or by fax at 415-523-1457. 
 
 
There are no costs for participating in the study; however, the subjects will be responsible 
for the costs of transportation to the Georgia Prevention Institute for clinic visits.  
There is no cost for the medications/supplements used during the study or for any of the 
procedures and tests required for this study. The cost of the lab draws during the study will 
be covered by the study investigators 
☐  N/A       
a. If applicable, describe risks to others who are not subjects. 
 
X  N/A       
 

 
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11.  Potential Benefits to Subjects 
COPD is the 3rd leading cause of death in the US.  Participation in this study will advance our knowledge 
and understanding of the link between heart and lung disease and contribute to the treatment and 
prevention of COPD.  Although there is no direct benefit to the participant, access to the results and 
information on 1) cholesterol values, 2) skeletal muscle function test, and 3) functional and structural 
measurements of the health of the participants arteries will be available.  They may also choose whether 
they receive the results of these assessments; however, if the participant choose to receive the results, Dr. 
Harris or another qualified research member will explain the results to the participant in detail.  
 
 
12.  Confidentiality 
To minimize the risk of the subject confidentiality, no testing material will be linked to the name, SSN, 
medical record number, or any other identifiable markers. Instead, each participant will be assigned a 
random identification number (ID). Those unique ID numbers will be used in the data file. A list of 
participants’ names and their ID numbers is kept in a separate file and only the Principal Investigator and 
collaborating investigators named on the informed consent document will have access to this file. E-mail 
addresses and phone numbers are not shared with outside parties.  
 
13.  Consent Process 
On the preliminary visit when subjects first arrive they will be undergo the informed consent process.   The 
RA will go over everything that will be involved in the study in detail.  If the subject understands they will 
be asked to initial each page after the RA has explained that page of the document to them. The RA will 
answer any questions the subject may have during the consent process.  In addition, when finished going 
through the ICD, the RA will ask the subject again if  he/she has any questions and will get confirmation 
that the subject still wants to participate in the study. If the subject agrees they will sign the document on 
the last page followed by the RA’s signature indicating the subject understands everything.  Dr Harris will 
confirm that the subjects understand the study and are still willing to participate.  Dr Harris will also 
answer any questions that the subjects might have.  All subjects will be aware that they have the right to 
stop the test at any time.   
 
 
14.  Compensation for Research-Related Injury                      
This section is not required when research involves no more than Minimal Risk to subjects.☐ N/A 
Because of Georgia Regents University policy, the institution is not able to offer financial compensation 
should the subject be injured as a result of participating in this research.  However, the subject is not 
precluded from seeking to collect compensation for injury related to malpractice, fault, or blame on the 
part of those involved in the research, including the institution.  Each risk described has been considered 
and all safety precautions have been put in place to protect the subject. The subjects are aware if they have 
any questions or concerns during the study they will need contact us immediately. 

 
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15.  Resources Available                                                                        ☐  N/A       
The study doctor, Dr. Caralee Forseen, will be on hand to work with patients if a medical consequence 
occurs as a result of the research. Patients will also be directed to the GRU clinics or ER if necessary. If the 
issue is psychosocial, then patients will be directed to the GRU Psychology department to talk to one of the 
licensed and trained psychologists on staff. 
All research staff are required to sign by their duties associated with each study that they understand and 
know how to carry out their duties in any event. These documents can be found in the HAC binders in the 
office of the PI.   
.