Safety and Tolerability of the Nutritional Supplement, Nicotinamide Riboside, in Systolic Heart Failure
Phase: PHASE1
Conditions: Heart Failure, Systolic
Sponsor: University of Washington

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Title page 
 
A randomized controlled trial to assess the safety and tolerability of the nutritional supplement, 
nicotinamide riboside, in systolic heart failure 
 
 
 
 
Test drug:   
 
 
 
 
Nicotinamide Riboside (NR) 
 
Study purpose: 
to assess the safety and tolerability of the 
nutritional supplement, nicotinamide 
riboside, in systolic heart failure 
 
Clinical Study phase: I/II 
Date: 2/17/2016 
 
Sponsor:  
Investigator initiated study funded by the 
NIH 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Confidential 
The information provided in this document is strictly confidential and is intended solely for the 
guidance of the clinical investigation. Reproduction or disclosure of this document - whether in 
part or in full - to parties not associated with the clinical investigation, or its use for any other 
purpose, without the prior written consent of the sponsor is not permitted. 
 
 
 
 
 

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Signature of principal investigators 
The signatories agree to the content of the final clinical study protocol as presented.  
 
Name: _______________________ 
Role: _______________________ 
 
 
 
Date: _______________________  
Signature: _______________________ 
 
 
 
 
 
 
Name: _______________________ 
Role: _______________________ 
 
 
 
Date: _______________________  
Signature: _______________________ 
 
 

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Table of Contents 
Title page ...................................................................................................................................................... 1 
Signature of principal investigators .......................................................................................................... 2 
Table of contents ......................................................................................................................................... 3 
1. Introduction ............................................................................................................................................ 4 
1.1 Background  .................................................................................................................................... 4 
1.2 Study rationale  .............................................................................................................................. 4 
1.3 Nicotinamide Riboside  ................................................................................................................. 4 
2 
Study Objectives ................................................................................................................................... 4 
3 
Study design .......................................................................................................................................... 4 
3.1 Design overview ............................................................................................................................. 4 
4 
Study Population................................................................................................................................... 5 
4.1 Eligibility ........................................................................................................................................... 5 
4.1.1 Inclusion criteria ................................................................................................................ 5 
4.1.2 Exclusion criteria ............................................................................................................... 5 
4.2 Discontinuation of subjects from study treatment  .................................................................... 6 
4.3 Subject identification...................................................................................................................... 6 
5 
Treatments............................................................................................................................................. 6 
6 
Procedures ............................................................................................................................................ 6 
6.1 Schedule of procedures ................................................................................................................ 7 
6.1.1 Visit 1 (Screening visit)..................................................................................................... 7 
6.1.2 Visit 2 (Randomization visit)  ........................................................................................... 8 
6.1.3 Follow-up visit 3 (week 2)  ............................................................................................... 8 
6.1.4 Follow-up visit 4 (week 4)  ............................................................................................... 8 
6.1.5 Follow-up telephone visit 5 (week 6) ............................................................................. 9 
6.1.6 Follow-up visit 6 (week 8)  ............................................................................................... 9 
6.1.7 Final Follow-up visit 7 (week 12) .................................................................................... 9 
6.1.8 End of washout telephone visit (30 days post Final Follow-up Visit)  ................... 10 
7 
Sources of Materials  ........................................................................................................................ 10 
8 
Potential Risks  .................................................................................................................................. 10 
9 
Adequate Protection Against Risk  ................................................................................................. 10 
10 Potential Benefits of Research to the Participant and Others  ................................................... 11 
11 Importance of the Knowledge to be Gained  ................................................................................. 11 
12 Data Safety Monitoring Board  ........................................................................................................ 11 
 
 
 
 
 

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1. Introduction 
1.1 Background 
Medical care of heart failure (HF) has been stagnant for the past 20 years; innovative 
therapy is urgently needed. A novel therapeutic target, mitochondrial dysfunction, has 
been implicated in multiple diseases, including heart failure. However, there currently is no 
specific treatment for mitochondrial dysfunction in human heart failure or any other 
disease. Mitochondria-based therapy development has been hampered both by limited 
understanding of how mitochondrial impairment causes cardiac dysfunction, and by a lack 
of interventions shown to improve mitochondrial function.  
 
1.2 Study rationale 
Recently, we demonstrated in a murine model, that impaired mitochondrial oxidative 
phosphorylation led to an increased myocardial NADH/NAD+ ratio and increased 
mitochondrial protein acetylation, without affecting mitochondrial ROS production or ATP 
synthesis. These changes rendered the heart susceptible to chronic stresses, which 
accelerated the development of heart failure. We observed a similar increase of 
NADH/NAD+ ratio and increase in protein acetylation in animal models of heart failure due 
to chronic pressure overload with no prior mitochondrial dysfunction. Supplying the NAD+ 
precursor, nicotinamide mononucleotide (NMN), to these mice normalized the 
NADH/NAD+ ratio, prevented increased mitochondrial protein acetylation and improved 
cardiac function. Though NMN is not orally bioavailable, we and others have shown that 
oral supplementation with nicotinamide riboside (NR), the precursor from which NMN is 
produced, also decreases (normalizes) tissue NADH/NAD+ ratio and improves 
mitochondrial function in mouse models. These animal model results suggest a 
conceptually innovative mechanism linking mitochondrial dysfunction to the development 
and progression of heart failure that is distinct from the existing hypotheses of oxidative 
stress and energy starvation. Thus, we hypothesize that oral supplementation with NR will 
increase NAD+ levels, thereby normalizing the NADH/NAD+ ratio caused by mitochondrial 
dysfunction during chronic stresses, and improve functional capacity and ventricular 
function in systolic heart failure.  
We therefore propose a safety and tolerability trial of the nutritional supplement, 
nicotinamide riboside (NR) in 30 participants with clinically-stable, systolic heart failure.  
 
1.3 Nicotinamide Riboside 
NR is a relative of niacin, but a closer relative of nicotinamide which, unlike niacin, does 
not induce flushing or pruritis and has no effect on lipid levels. NR does not induce insulin 
resistance or dysglycemia in mouse models. Thus, NR would potentially be cheap, safe, 
well-tolerated and readily available. The application is in response to the program 
announcement of “Nutrition and Diet in the Causation, Prevention, and Management of 
Heart Failure” as NR has recently been approved for human use as a health supplement.  
 
2. Study Objectives 
The Study has three objectives: 1) to determine the safety and tolerability of NR in patients 
with clinically-stable, systolic heart failure (LVEF <40%); 2) to determine whether, at the 
doses employed, NR has measureable effects on whole blood NAD+ levels; and 3) to 
explore the potential range of effects of NR supplementation on heart failure surrogate 
endpoints. 
 

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3. Study design 
3.1 Design Overview 
This study is a single-center, prospective, double-blind, 2:1 randomization to NR or 
placebo, safety and tolerability trial of placebo versus nicotinamide riboside (NR) in 
participants with clinically stable (NYHA functional class 1-IIIA) systolic heart failure (LVEF 
by echocardiography or radionuclide ventriculography <40%) due to non-ischemic or 
ischemic etiologies. 
 
4. Study Population 
4.1 Eligibility 
 4.1.1 Inclusion criteria 
• 
Men and women aged 18 and older with systolic heart failure (LVEF by 
standard 2D echocardiography or radionuclide ventriculography of <40%) 
deemed, in the clinical opinion of their treating cardiologist to be non-ischemic 
or ischemic in origin. 
• 
Clinically stable (no cardiac procedures or hospitalizations for hospitalizations 
for cardiac causes, including HF, ischemia or arrhythmia) within the previous 3 
months 
• 
Ability to undergo study procedures, including scheduled visits, blood draws and 
six-minute walk tests 
• 
Willingness/ability to provide informed consent 
 
 
 
4.1.2 Exclusion Criteria 
• 
Heart failure with preserved ejection fraction (LVEF >40%) 
• 
Heart failure due, in the opinion of their treating cardiologist, to etiologies other 
than non-ischemic or ischemic.  Examples of exclusionary heart failure 
etiologies include primary valvular disease, or infiltrative or inflammatory 
cardiomyopathies. 
• 
Cardiac surgery, percutaneous coronary intervention (PCI) or cardiac 
device implantation within the previous 3 months 
• 
Hospitalizations for cardiovascular causes, including heart failure, chest pain, 
stroke/TIA or arrhythmias within the previous 3 months 
• 
Inability to perform Study visits or procedures (e.g., physical inability to perform 
6MWT) 
• 
Unwillingness/inability to provide informed consent 
• 
ALT > x3 upper limit of normal, hepatic insufficiency or active liver disease 
• 
Recent history of acute gout 
• 
Chronic renal insufficiency with creatinine  2.5mg/dl 
• 
Pregnant (or likely to become pregnant) women 
• 
Significant co-morbidity likely to cause death in the 6 month follow-up period 
• 
Significant active history of substance abuse within the previous 5 years 
• 
Current participation in another long-term clinical trial 
• 
History of intolerance to NR precursor compounds, including niacin or 
nicotinamide 
 
 

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4.2 Discontinuation of subjects from study treatment 
This is a study of a nutritional supplement.  For those participants taking nicotinamide 
riboside, a warm flushing sensation may occur when first taking this supplement. We will 
monitor for skin rash, increased blood sugar, or cause mildly abnormal hepatic function.  In 
diabetic participants, it is possible that nicotinamide riboside may worsen glucose 
intolerance and necessitate an adjustment in medications for treatment of diabetes. We 
also will monitor for worsening in signs and symptoms of heart failure, by asking about 
worsening of dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, 
arrhythmia/palpitations or edema. We will monitor blood levels of B-type natriuretic peptide 
(BNP), serum electrolytes, BUN and creatinine at Study visits 1, 3, 4, 7 and visit 6 
according to the PI’s judgement. 
 
4.3 Subject identification 
Each subject will receive a unique study ID. Once assigned to a subject, the subject’s ID will 
not be re-used.  
 
5. Treatments 
Participants will be randomized to either NR at an initial dose of 250mg tablets or placebo 
two times per day. The NR dose then will be up-titrated weekly by 250mg/dose to a final 
dose of 1000mg two times per day at the end of Week 4. Participants will be continued on 
the 1000mg two times per day dose up to the final follow up visit (week 12).  If, at any step, 
a dose increase is not tolerated, the maximum previously-tolerated dose will be continued 
through to week 12. 
 
6. Procedures 
Every attempt should be made to complete the follow-up visits during the defined window 
periods. A final follow-up visit is required for all participants. In the rare cases a final follow-
up visit cannot occur within the 5-day timeframe following study end date, any attempt to 
contact must be recorded on a special contact form, until/unless appropriate information is 
obtained. 
Laboratory results: 
Participants will be blinded to the results of laboratory studies obtained as a part of this 
Study. 
Echocardiography results: 
Participants will be blinded to the results of echocardiograms obtained as a part of this 
Study.  

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6.1 Schedule of procedures 
  
6.1.1 Visit 1 (Screening visit) 
Prospective, eligible participants with documented systolic heart failure meeting study 
inclusion criteria will undergo a screening visit.  
 
The following procedures will be performed at the screening visit:  
 
o Demographic information, medical history (including NYHA class and most 
recent creatinine value), physical examination, current medical treatments 
o Minnesota Living with Heart Failure quality of life (MNQOL) score 
o Fasting blood draw: ONE 5mL pearl top tube (for BNP),TWO 3mL lavender top 
tubes (for CBC, HbA1C); ONE 4mL lime top tube [for uric acid, ALT, CK, 
Chemistry panel (electrolytes, glucose, blood urea nitrogen and creatinine)], ONE 
4mL gold SST tube (for insulin) ONE 2.7 mL “blue top” tube for whole blood NR 
and NAD+ levels and FOUR 4.5 mL GLASS blue top tubes (for mitochondrial 
function) 
o Urine pregnancy test at screening in women of child-bearing age 
o Six-minute walk test (6MWT) 
o Dispense placebo to take twice daily 
 
 
 

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6.1.2 Visit 2 (Randomization visit) 
After successful completion of the Screening visit, the participant will return for the 
Baseline Visit, at which participants would be randomized in a 2:1 allocation to receive 
blinded study medication with nicotinamide riboside or matching placebo. All participants 
who are randomized are irrevocably in the study, whether or not they are subsequently 
found to be eligible or actually receive the allocated treatment, and they should be 
followed until the study end date or death. Study drug administration should be initiated 
as soon as possible after treatment allocation. 
 
The following procedures will be performed at the randomization visit:  
 
o Update as needed demographic information, medical history, current medical 
treatments 
o Vital signs and weight 
o Randomization by investigational drug services. 
o BASELINE MNQOL score 
o BASELINE 6MWT 
o BASELINE echocardiography (TTE and TDI) This may also take place at 
screening if needed due to scheduling 
o Dispense blinded study medication: 
o 250mg PO BID or Placebo for one week 
o 500mg PO BID or Placebo for one week 
 
6.1.3 Follow-up visit 3 (week 2) 
The following procedures will be performed at the follow-up visits (Day 14±3): 
 
o Update as needed demographic information, medical history, current medical 
treatments 
o Vital signs and weight 
o MNQOL score 
o Fasting blood draw: ONE 5mL pearl top tube (for BNP),TWO 3mL lavender top 
tubes (for CBC, HbA1C); ONE 4mL lime top tube [for uric acid, ALT, CK, 
Chemistry panel (electrolytes, glucose, blood urea nitrogen and creatinine)], ONE 
4mL gold SST tube (for insulin), and ONE 2.7 mL “blue top” tube for whole blood 
NR and NAD+ levels 
o 6MWT 
o Record of adverse events, if any 
o Study drug adherence 
o Record of concomitant medications or interventions, if any 
o Dispense blinded study medication: 
o 750mg PO BID or Placebo for one week 
o 1000mg PO BID or placebo for one week 
 
6.1.4 Follow-up visit 4 (week 4) 
The following procedures will be performed at the follow-up visits (Day 28±3): 
 
o Update as needed demographic information, medical history, current medical 

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treatments 
o Vital signs and weight 
o MNQOL score 
o Fasting blood draw ONE 5mL pearl top tube (for BNP),TWO 3mL lavender top 
tubes (for CBC, HbA1C); ONE 4mL lime top tube [for uric acid, ALT, CK, 
Chemistry panel (electrolytes, glucose, blood urea nitrogen and creatinine)], ONE 
4mL gold SST tube (for insulin), and ONE 2.7 mL “blue top” tube for whole blood 
NR and NAD+ levels 
o Additional blood draw 3 hours after AM NR dose: ONE 2.7 mL “blue top” tube for 
whole blood peak NR and NAD+ levels 
o 6MWT 
o Record of adverse events, if any 
o Study drug adherence 
o Record of concomitant medications or interventions, if any 
o Dispense blinded study medication: 
o 1000mg PO BID or Placebo 
 
6.1.5 Follow-up telephone visit 5 (week 6) 
This visit will be conducted by study staff via telephone interview. The assessments 
include: 
 
o Record of concomitant medications or interventions, if any 
o Record of adverse events, if any 
 
6.1.6 Follow-up visit 6 (week 8) 
The following procedures will be performed at the follow-up visits (Day 56±5): 
o Update as needed demographic information, medical history, current medical 
treatments 
o Vital signs and weight 
o MNQOL score 
o * Fasting blood draw: ONE 5mL pearl top tube (for BNP),TWO 3mL lavender top 
tubes (for CBC, HbA1C); ONE 4mL lime top tube [for uric acid, ALT, CK, 
Chemistry panel (electrolytes, glucose, blood urea nitrogen and creatinine)], ONE 
4mL gold SST tube (for insulin), 
o 6MWT 
o Record of adverse events, if any 
o Study drug adherence 
o Record of concomitant medications or interventions, if any 
o Dispense blinded study medication: 
o 1000mg PO BID or Placebo 
 
 
Fasting blood draw optional in case of safety concerns 
 
6.1.7 Final Follow-up visit 7 (week 12) 
The following procedures will be performed at the final follow-up visit (Day 84 ± 5): 
o Update as needed demographic information, medical history, current medical 
treatments 
o Vital signs and weight 

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o MNQOL score 
o Fasting blood draw: ONE 5mL pearl top tube (for BNP),TWO 3mL lavender top 
tubes (for CBC, HbA1C); ONE 4mL lime top tube [for uric acid, ALT, CK, 
Chemistry panel (electrolytes, glucose, blood urea nitrogen and creatinine)], ONE 
4mL gold SST tube (for insulin),and ONE 2.7 mL “blue top” tube for whole blood 
NR and NAD+ levels and FOUR 4.5 mL GLASS blue top tubes (for mitochondrial 
function) 
o 6MWT 
o Echocardiography  
o Record of adverse events, if any 
o Study drug adherence 
o Record of concomitant medications or interventions, if any 
o Record of efficacy endpoints, if any 
 
6.1.8 End of washout telephone visit (30 days post Final Follow-up Visit) 
The washout visit will be conducted by study staff via telephone interview. Washout visit 
assessments include: 
 
o Record of concomitant medications or interventions, if any 
o Record of adverse events, if any 
 
7. Sources of Materials 
Data will be collected throughout the study from participants on their health status and 
concomitant medications. Clinical, demographic and laboratory values collected as a part 
of the Study will be stored in a multidimensional database at the UW Clinical 
Atherosclerosis Research Laboratory (CARL). All lab samples are identified by a study 
number only. The two echocardiograms will be recorded on MOD disks during the study. 
Individually identifiable data is recorded in individual study charts for each participant, and 
in a password-protected study database. Individually identifiable data will be accessible 
only to the study investigators. 
 
8. Potential Risks  
Participants may experience discomfort and bruising from blood draws. Rarely, an 
infection could develop.  
There are no known hazards to exposure of ultrasound waves, however some participants 
may experience discomfort at lying still.  
This is a study of a nutritional supplement. For those participants taking nicotinamide 
riboside, a warm flushing sensation may occur when first taking this supplement. We will 
monitor for skin rash, increased blood sugar, or cause mildly abnormal hepatic function. In 
diabetic participants, it is possible that nicotinamide riboside may worsen glucose 
intolerance and necessitate an adjustment in medications for treatment of diabetes. We 
also will monitor for worsening in signs and symptoms of heart failure, by asking about 
worsening of dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, 
arrhythmia/palpitations or edema. 
 
9. Adequate Protection Against Risk 
Recruitment and Informed Consent. Recruitment for this proposed study will be conducted 
according to the IRB policies at the University of Washington, as well as HIPAA policies. 

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Potential study participants will be identified under HIPAA waiver by chart review.  Their 
cardiologist will approve the approach before researcher contact.  Potential participants 
will be contacted by phone using the approved phone script, or seen in person if at the 
clinic. Only if the participant expresses any interest will we continue study recruitment.  
To the participants who are interested in the study, study staff will explain the study’s 
purpose and design and what would be required of participants. A series of questions will 
be asked to make sure the participant meets eligibility requirements. Then, the informed 
consent will be conducted by an investigator or a study coordinator. Participants will be 
encouraged to ask questions and to share the information with their regular doctor. A copy 
of this consent will be given to the participants; the original will be placed in the 
participant’s study chart.  
 
Protection Against Risks. All access to individually identified participant data is limited to 
the investigators who are directly involved in this research study, the clinical research staff 
of the Translational Research Unit during the subjects’ visits, and the UWMC Research 
Testing Service. Study charts and password-protected databases are confidential and are 
not released to outside parties except at the participant’s request. All blood samples for 
laboratory analysis outside UWMC are ONLY identified by a study number. The Study 
charts containing paper forms will be stored in the locked file cabinets in the research 
clinics or offices where they only can be accessed by the investigators. Each participant 
will receive a unique study number. The study number is linked to the participant’s 
personally-Identifiable information in the study database and used to perform data entry 
and linking.  
 
Notification of Participants and Their Physicians. Study participants and their primary care 
or vascular care physicians will be notified if there is clinical worsening of their heart 
failure. We will leave the further clinical follow-up and treatment plans to be made by the 
participants’ physicians. Participants will not be notified of the results of other laboratory 
studies performed specifically for this Study. 
 
10. Potential Benefits of Research to the Participant and Others 
Individual participants may benefit from this study by being on a nutritional supplement 
that has shown some promise in animal models of heart failure.  
 
11. Importance of the Knowledge to be Gained 
If the Study can demonstrate that nicotinamide riboside is safe and well-tolerated in 
participants with systolic heart failure, this will form the basis of a follow-on study to assess 
the efficacy of nicotinamide ribose on surrogate endpoints in heart failure, such as 
functional capacity and ejection fraction. Thus, the Study may provide information 
necessary to further explore the clinical utility of this nutritional supplement in the 
treatment of systolic heart failure, a large and growing population of high risk participants 
for whom treatment, at present, is less than adequate. 
 
12. Data Safety Monitoring Board 
A Data Safety Monitoring Board (DSMB) will be instituted for this Study in order to ensure 
its ongoing safety and to oversee the Interim Analyses. Recommendation for trial 
continuation will be guided by monitoring boundaries at interim analyses at which formal 
efficacy analysis is performed as well as safety evaluations at all safety data reviews. 
Safety review meetings will be held by the DSMB prior to Study initiation, at which time the 
DSMB will develop any formal “stopping rule(s)” for the Study. The DSMB will meet three 

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additional times: after completion of 10, 20 and 30 Study participants. Safety data will 
include pre-specified evaluation of parameters for blood glucose, myopathy, 
hepatotoxicity, renal function as well as signs/symptoms of heart failure, or other possible 
clinical side effects such as gout, as requested by the DSMB. Enrollment to the study will 
continue throughout the scheduled meetings of the DSMB. The three-member, Study 
DSMB Roster is provided below. 
 
o Jeffrey L. Probstfield, MD. (Chair) 
Director, Clinical Trials Service Unit and Professor of Medicine (Cardiology) 
University of Washington School of Medicine 
o W. Robb MacLellan, MD 
Professor of Medicine and Head, Division of Cardiology 
University of Washington 
o Kelley Branch, MD 
Deputy Director, Clinical Trials Service Unit and Assistant Professor of Medicine 
(Cardiology) 
University of Washington School of Medicine