Treatment of Fragile-X Associated Tremor/Ataxia Syndrome (FXTAS) With Allopregnanolone
Phase: PHASE2
Conditions: Fragile X-associated Tremor/Ataxia Syndrome
Sponsor: Randi J. Hagerman, MD

Study Protocol and Statistical Analysis Plan
NCT02603926
Treatment of Fragile-X Associated Tremor/Ataxia Syndrome (FXTAS) With Allopregnanolone
Original document date: 05-NOV-2015
(Updated to include required title page and detailed statistical analysis plan 13-NOV-2018)

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Protocol Title: Treatment of Fragile X-associated Tremor/Ataxia 
Syndrome (FXTAS) with Allopregnanolone 
 
1) Author of Protocol 
UC Davis Researcher, Randi Hagerman, MD 
Medical Director, MIND Institute 
 
2) IRB Review History 
None 
 
3) Objectives 
The overall purpose of this study is to examine the safety and efficacy of 
Allopregnanolone as a possible treatment for FXTAS. 
Aim 1. To evaluate the effect of allopregnanolone for improving cognitive deficits, 
specifically memory problems, seen in premutation carriers aged 50-85 years who have 
neurological problems and FXTAS.  
We hypothesize that:  
A. Cognitive measures of working memory will improve with allopregnanolone 
treatment. 
B. Hippocampal activation during an associative memory recall task will increase on 
allopregnanolone. 
C. ERP word repetition effect amplitudes, which measure verbal learning and 
memory processes, will improve with allopregnanolone treatment. 
Aim 2. To evaluate the benefits of allopregnanolone on neurological symptoms, 
specifically on scores of tremor and ataxia (CATSYS tremor and sway measures) in 
premutation carriers with FXTAS.  
 
We hypothesize that neurological symptoms, specifically tremor and ataxia as 
measured by the CATSYS, will improve after 12 weeks of treatment. 
Aim 3. To assess changes in structural MRI variables that may reflect neurogenesis 
and neuroprotection in those treated with allopregnanolone. 
 
We hypothesize that improvements will be seen in structural brain measurements 
with allopregnanolone treatment, including increased hippocampal volume due to 
increased neurogenesis; better white matter integrity evidenced by higher fractional 
anisotropy (FA), mean length, and tract volume; and lower mean diffusivity (MD), 
particularly in limbic and motor-related fiber tracts, which have shown a correlation with 
FXTAS severity (cerebellar peduncles, cingulum and corpus callosum). 
 
 
4) Background 
Fragile X-associated tremor/ataxia syndrome (FXTAS) is a late-adult–onset 
neurodegenerative disorder that affects, with age- and gender-specific penetrance, 

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carriers of premutation alleles (55-200 CGG repeats) of the fragile X mental retardation 
1 (FMR1) gene. Defining clinical features of FXTAS include progressive kinetic tremor, 
gait ataxia, executive function and memory deficits, peripheral neuropathy, and 
parkinsonism; with associated, variable features, such as cognitive decline into 
dementia, and psychiatric problems, including depression, and dysautonomia (Berry-
Kravis et al., 2007; Hagerman et al., 2001; Jacquemont et al., 2003; Tassone and 
Berry-Kravis, 2010). 
For many individuals with the premutation, neurological and memory problems, 
executive function deficits, and neuropathy and psychiatric symptoms, particularly 
anxiety, can develop well before the onset of tremor and ataxia, the cardinal features of 
FXTAS (Bourgeois et al., 2009; Bourgeois et al., 2011; Coffey et al., 2008; Grigsby et 
al., 2008; Hagerman et al., 2007; Soontarapornchai et al., 2008). Neuroimaging in 
FXTAS reveals white matter disease of both the cerebellum and cerebrum (Brunberg et 
al., 2002; Cohen et al., 2006; Hashimoto et al., 2011; Loesch et al., 2008); atrophy of 
the brain stem, cerebellum and cerebrum (Adams et al., 2007; Adams et al., 2010; 
Hashimoto et al., 2011); spongiosis in the white matter; and intranuclear inclusions in 
neurons and astrocytes throughout the CNS and PNS (Greco et al., 2006; Hashimoto et 
al., 2011; Hunsaker et al., 2011). 
This grant proposes to assess the safety and efficacy of allopregnanolone as a new 
treatment for adults with both the premutation and neurological problems, including 
FXTAS. Allopregnanolone is a naturally occurring neurosteroid and positive modulator 
of GABAA receptors that can stimulate neurogenesis in the hippocampus (Brinton, 
2013), reverse hippocampal-dependent learning and memory problems (Singh et al., 
2011), and confer neuroprotection by both reducing the expression of the proapoptotic 
protein caspase 3 (Djebaili et al., 2005; Djebaili et al., 2004) and inhibiting the 
mitochondrial permeability transition pore, a  key process in the intrinsic pathway of 
apoptosis-induced loss of neurons (Sayeed et al., 2009). Our preliminary data 
demonstrate abnormal network bursting activity in hippocampal neurons cultured from 
premutation mice. Such persistent bursting is a plausible mechanism for the 
neurodegeneration that leads to the neurological symptoms in FXTAS. We have further 
demonstrated that allopregnanolone, by potentiating GABAA-receptor signaling, 
eliminates the abnormal bursting, providing a mechanism for neuroprotection (Palop et 
al., 2007). Given that allopregnanolone can prevent neuronal loss and also stimulate the 
generation of new neurons from neural stem and progenitor cells, allopregnanolone 
may counteract the development of neurological disability in FXTAS. Allopregnanolone 
is an endogenous metabolite of progesterone that lacks hormonal activity and is 
expected to be safe for chronic treatment; this drug is being studied in Alzheimer’s 
disease by Dr. Roberta Brinton at the University of Southern California (USC). 
Allopregnanolone has also demonstrated increased neurogenesis in animal studies 
after a single administration, however; greater improvements were found after weekly 
administration (As reviewed by Irwin and Brinton, 2014). Considering that pulse 
administration of allopregnanolone correlated with increased neurogenesis, these 
researchers hypothesize that this may have resulted due to the neurobiological system 
being allowed to return to homeostasis. We therefore hypothesize that through 
stimulation of neurogenesis, which confers neuroprotection, and GABAA-receptor–
positive modulatory effects, weekly administration of allopregnanolone to premutation 

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carriers with early FXTAS will lead to improvement in working memory deficits and other 
neurological symptoms. In addition, we hypothesize that there will be a reduction in 
functional and volumetric-imaging changes 
 
5) Inclusion and Exclusion Criteria: 
Inclusion Criteria 
• premutation carrier status (55 to 200 CGG repeats in FMR1),  
• men and women>50 and <85 years of age 
• FXTAS including an intention tremor and/or ataxia and/or deficits on the BDS-
2 demonstrating executive function deficits. The absolute presence of clinical 
tremor and ataxia is not essential because subclinical tremor or ataxia can be 
detected on the CATSYS, as described below, in carriers.  
 Exclusion Criteria 
• other genetic problems in addition to the premutation 
• a history of significant brain trauma 
• significant substance abuse 
• inability to follow the protocol 
• liver or kidney disease 
• heart failure 
• active cancer 
• other serious systemic disease 
• current use of phenytoin.  
 
6) Number of Subjects: We will enroll 15 subjects 
 
7) Recruitment Methods:  
Subjects will be recruited from Dr. Hagerman’s research database from FXTAS 
participants we have seen in previous research. 
 
We are requesting waiver of HIPAA for recruitment purposes only. The research team 
will identify potential subjects and access medical records to verify eligibility prior to the 
treating physician and research coordinator approaching the potential subject. Consent 
to participate and HIPAA Authorization to access additional information in the medical 
records will be obtained prior to enrollment into the study. The protected health 
information will not be reused or disclosed to outside persons or entities. 
  
The review of subjects' medical records is for limited information and only to determine 
eligibility. The data are derived from clinically indicated procedures and there is minimal 
risk to the subjects' status, employment, or insurability. Only research personnel will 
access medical records via EMR, and all personnel are required to use the “Quick 
Disclosure” function in EMR to document review. Without an initial review of the medical 

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record for screening purposes, it would not be possible to identify potential subjects and 
confirm their applicability for study participation.  
  
Once eligibility is confirmed, subjects will be approached to obtain their 
authorization to access and use their health information for the research. 
 

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8) Compensation to the Subjects: None 
 
9) Study Timelines 
Subjects will participate in –14 visits over 4 months. It is estimated that enrollment will 
occur over the course of one year.  
 
10) Study Endpoints 
 
Primary endpoints 
Our primary endpoint includes cognitive measures of working memory, specifically the 
CVLT2 (California Verbal Learning Test2), at the end of 12 weeks compared with 
baseline. We expect to see a 20% improvement on this primary endpoint by 12 weeks. 
 
Secondary endpoints 
 
Cognitive Measures: Improvements of 20% on the Behavioral Dyscontrol Scale (BDS-
2); Integrated Visual and Auditory Continuous Performance Test (IVA CPT); CANTAB 
Battery; COWAT; Frontal Systems Behavioral Task. 
 
Electrophysiological Measures: Improvement of 20% on the word learning N400 
amplitude and P300 amplitude in the oddball paradigm on the ERP and eye-tracking 
measures. 
 
Emotional Battery: Improvement of 20% in the scores on the SCL90 and Beck Anxiety 
Inventory. Resolution of depression or anxiety on the SCID. 
 
MRI measures: Improvement of the size of the hippocampal volume due to increased 
neurogenesis will be assessed. Improvements of 5% of total volume would be 
considered significant. Improvement in the white matter integrity with higher fractional 
anisotropy (FA), mean length, and tract volume, and lower mean diffusivity (MD), 
particularly in limbic and motor-related fiber tracts (cerebellar peduncles, cingulum and 
corpus callosum), will be assessed after 12 weeks. 
 
Motor/Balance Measures: Improvement of 15% on scores of tremor and/or balance as 
measured by the CATSYS tremor and sway assessments and the FXTAS rating scale 
(video protocol). 
 
11) Procedures Involved 
 
If exclusion/inclusion criteria are met then the subject will complete the following 
measures: 
 
Medical History, Physical, and Neurological Exam – Our medical history protocol, 
which we have used in our previous papers, is extensive and includes birth and 
development information, school history, health history, review of all systems, and 

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medication history(Riddle, Cheema et al. 1998, Leehey, Berry-Kravis et al. 2007, 
Coffey, Cook et al. 2008). We have added a detailed section regarding any neurological 
or related medical problems. Such components include: sensory deficits (numbness, 
tingling or pain in extremities, hearing loss), balance problems/ataxia, tremor of any 
kind, muscle pain, weakness, loss of stamina, any autonomic problems (orthostatic 
hypotension, hypertension, cardiac arrhythmias, pacemaker placement, impotence, 
urine or stool problems), visual changes, vertigo, reproductive problems (age of 
menarche, perimenopausal symptoms, age of menopause, PMS symptoms, regularity 
of periods), other endocrine problems (diabetes, thyroid dysfunction), autoimmune 
problems (lupus, arthritis, thyroid disease), and any previous medical or neurological 
diagnoses. We also take a detailed psychiatric history and document any use of 
medications, including psychotropic medications.  
 
All study subjects will receive a physical examination, which includes our assessment of 
typical fragile X features which are sometimes seen in carriers, as previously described 
in Riddle et al. (1998); growth parameters (height, weight and head circumference); 
heart rate and blood pressure; and a limited number of anthropometric features that are 
significantly influenced by FMRP in the pedigree analysis (Loesch, Huggins et al. 2003, 
Loesch, Huggins et al. 2004). We will also screen for hearing problems. Drs. Hagerman 
and/or Olichney will perform a detailed neurological examination that emphasizes the 
major motor features of FXTAS: tremor, cerebellar ataxia, neuropathy, and 
parkinsonism. 
 
Structured Video Protocol: Standardized testing for the neurological signs is 
videotaped, and the presence and severity of these signs are quantified with use of the 
FXTAS Rating Scale (Leehey, Berry-Kravis et al. 2011). This scale is a combination of 
items from three commonly used scales: the International Cooperative Ataxia Rating 
Scale (Trouillas, Takayanagi et al. 1997), the Unified Parkinson’s Disease Rating Scale 
(Fahn, Elton et al. 1987), and the Clinical Rating Scale for Tremor (CRST, Fahn, Tolosa 
et al. 1998). In addition, the tandem test from the Unified Huntington’s Disease Rating 
Scale (Huntington Study Group 1996) is included for quantitative tandem gait 
assessment. These assessments are needed to document the presence and severity of 
FXTAS symptoms. 
 
Eye-Tracking – With the Tobii eyetracker, we will document changes in pupillary 
diameter with exposure to light and dark stimuli, and we will document their eye 
movements in saccade, smooth pursuit, and anti-saccadic tasks.  
Saccade task: Saccades are fast, ballistic movements with both eyes towards a 
target. The participants are asked to follow a target with their eyes. The target jumps 
in a sequence of 10, 30 and 60 steps in the horizontal and vertical plane.  
Smooth pursuit task: The participants are asked to follow a moving target with their 
eyes. The target moves horizontally and vertically in a sinusoidal waveform with 
maximum amplitude of 20cm, at a frequency of 0.2 and 0.4 Hz.  
Anti-saccade task: The anti-saccade task requires the subjects to make a saccadic 
eye movement away from a target, rather than towards it. It is widely used in 
neuroscience research to prove insight into executive control in monkeys and 

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humans. The anti-saccade task requires the top-down inhibition of automatic pro-
saccade responses and the generation of voluntary anti-saccades. 
 
Laboratory Studies –Safety labs include the comprehensive metabolic panel 
(Chemistry 12 panel) and a complete blood count with differential.  
 
Molecular FMR1 testing will also be carried out with the initial blood draw. CGG-repeat 
size and methylation status will be determined by both Southern blot and PCR analysis, 
as previously described (Tassone, Pan et al. 2008, Filipovic-Sadic, Sah et al. 2010). 
FMR1-mRNA levels will also be measured by RT-PCR, as described by Tassone et al. 
(2000). 
 
Molecular outcome measures to be carried out by Dr. Paul Hagerman (Med: 
Biochemistry and Molecular Medicine, 4303 Tupper Hall, One Shields Ave, Davis, CA 
95616). We propose to follow at least three measures of cellular dysfunction as 
indicators both of the degree of dysfunction and of a therapeutic response. Specifically, 
we will measure levels of p53, phospho (g) H2AX, and protein nitrosylation (Ross-Inta, 
Omanska-Klusek et al. 2010, Napoli, Ross-Inta et al. 2011), since each of these three 
measures will reflect a global degree of dysfunction. We have implemented a time-
resolved (tr) FRET-based assay (Schutzius, Bleckmann et al. 2013) capability in the lab, 
which has replaced our ELISA method for quantifying FMRP. In each case, one of the 
antibodies directed against the protein of interest (e.g., p53) will be labeled with the 
Lanthanide donor, and a second antibody labeled with an allophycocyanin (APC) 
acceptor fluorophore (Perkin-Elmer). In the course of these measurements, which will 
be performed in 96 or 384-well format, we will also compare the same proteins in 
peripheral blood lymphocytes as well as fibroblasts, since the former represents a more 
convenient source for serial measurements throughout the treatment process. 
 
We will also utilize a number of outcome measures of mitochondrial function, including 
changes in ATP beta subunit (ATPB), the mitochondrial (Mn) superoxide dismutase 
(MnSOD), and nitrotyrosine load in ATPB as a measure of reactive nitrosyl species (a 
measure of oxidative stress) and they were abnormal in FXTAS so they will be utilized 
here as an outcome measure from blood. We also plan to utilize fluorescence-activated 
cell sorting (FacScan, MoFlo) using a range of fluorescent dyes that are specifically 
designed to measure mitochondrial membrane potential, a sensitive indicator of 
mitochondrial dysfunction. Our initial studies would involve measuring reduced 
mitochondrial membrane potential, using preparative flow cytometry (MoFlo) and 
fluorescent probes for reduction in mitochondrial membrane potential [e.g., JC-1, 
DilC1(5), or MitoTracker RedCMXRos] (Perry, Norman et al. 2011). We also plan to 
utilize the new Mito-ID® Oxygen and pH Sensors (Enzo) as an additional outcome 
measure. The primary outcome is a measure of mitochondrial function following the 
addition of allopregnanolone. 
 
Motor/Gait Measures – 
CATSYS Protocol 

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Our CATSYS protocol includes all four standardized measures of the neuromotor 
control (Despres, Lamoureux et al. 2000), amended protocols for the postural sway, and 
protocols for intention tremor as outlined in our previous publications (Aguilar, Sigford et 
al. 2008, Narcisa, Aguilar et al. 2011). Subjects are asked to hold the Tremor Pen as 
they would hold an ordinary pen, with the elbow joint bent at a right angle and free of 
body contact, and the pen positioned approximately 4 inches from the navel. For 
measuring resting tremor, subjects hold the pen for 24.6 seconds in each hand. For 
measuring intention tremor, subjects hold the Tremor Pen and tap the center of two 
circular stickers, approximately ½ inch in diameter, placed on opposite ends of the 
bottom portion of the computer monitor. The subjects are also asked to trace a line 
across the table using the Tremor pen. For measuring postural sway, subjects are 
asked to stand on a force plate with their feet standing approximately 3 inches apart, 
first with their eyes open and then with their eyes closed, for 60 s, and also for 32.5 s. 
From our preliminary data, we found that some of our older subjects were not able to 
stand on the force plate for the standardized 60 s, so we chose to also use the 32.5 s 
protocol that R. Letz employed in neurotoxicology studies (Gerr, Letz et al. 2000, Gerr, 
Letz et al. 2000, Letz and Gerr 2000, Frumkin, Letz et al. 2001, de la Paz, Philen et al. 
2003). 
Cognitive Ability 
Wechsler Scales of Intelligence: We will use the Wechsler Adult Intelligence Scale–
Fourth Edition (WAIS-IV; Wechsler 2009) for cognitive testing. 
Executive Function and Attention Battery 
Behavioral Dyscontrol Scale-2 (BDS): The BDS is a 9-item, 19-point scale adapted 
from the work of A.R. Luria (1966, 1980). The BDS has been validated as a measure of 
the ability to regulate purposeful, goal-directed activity and to engage in activities of 
daily living.(Kaye, Grigsby et al. 1990, Grigsby, Kaye et al. 1998, Grigsby, Kaye et al. 
2000, Grigsby, Kaye et al. 2002). In addition, the scale has been sensitive to 
involvement in premutation carriers (Loesch, Bui et al. 2003, Grigsby, Brega et al. 
2006). Although the BDS consists primarily of motor items, the nature of the items and 
the manner in which they are scored minimizes the effect of tremor on performance.  
Integrated Visual and Auditory Continuous Performance Test (IVA CPT): The IVA 
CPT (Sandford, Fine et al. 1995, Turner and Sandford 1995) is a computerized 
measure that assesses impulsivity, inattention, and hyperactivity. It is an integrated 13-
minute auditory and visual continuous performance test designed to assess two major 
factors: response control and attention control. The normative data consists of 1700 
typical individuals, ages 5 to 96 years. This test is sensitive to premutation involvement, 
and it reflects executive function involvement and clinical problems with attention and 
concentration.  
Letter Number Sequencing Test: This subtest of the WAIS-IV (Wechsler 2009) and 
WISC-IV (Wechsler 2003) was developed as a measure of working memory. Subjects 
are presented with mixed sequences of letters and numbers (e.g., 3-e-7-9-p) and are 
required to separate letters and numbers and repeat them in the proper sequence. The 
test has been shown to be a reliable and valid instrument (Wechsler 2009), which we 
have found sensitive to premutation involvement.  
Controlled Oral Word Association Test (COWAT): The COWAT is a subtest of the 
Neurosensory Center Comprehensive Examination for Aphasia. Most commonly 

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described as a measure of verbal fluency or cognitive flexibility, this test has been 
selected because it provides useful information concerning the ability to think actively in 
generating information, and it is strongly correlated with other measures of executive 
functioning. This test is sensitive to involvement in premutation carriers (Spreen and 
Strauss 1998). 
Frontal Systems Behavioral Scale (FrSBe): The FrSbe is a brief questionnaire with 
versions completed by both the subject and the spouse or caregiver. It is a good 
measure of executive function change over time following an illness or injury (Grace and 
Malloy 2001). 
 
Memory Function 
Wechsler Memory Scale – Fourth Edition (WMS-IV): The WMS-IV (Wechsler 2009) 
is an individually administered battery that focuses on domains of immediate, delayed, 
and working memory. Each of these domains is tested across two modalities, auditory 
and visual, and in two task formats, recall and recognition. The WMS-IV has been 
normed on individuals aged 16 to 90 years. This measure is very sensitive to FXTAS 
involvement and to premutation involvement in those without FXTAS, particularly in the 
phonological loop scores including the Digit Span, Letter-Number Sequencing, and the 
Verbal Paired Associates tasks. 
The Cambridge Neuropsychological Test Automated Battery (CANTAB): The 
CANTAB consists of a series of interrelated computerized non-verbal tests of memory, 
attention, and executive function. Especially for the assessment of cognitive 
dysfunction, the use of a computerized battery presents some methodological and 
practical advantages over traditional neuropsychological tests. The CANTAB has been 
standardized on a large population, aged 4 to 90 years old, in various research studies, 
and its validity has been established in a wide variety of clinical populations (Fray and 
Robbins 1996). Measures from the CANTAB are as follows: 
Motor Screening Test (MOT) is a short task designed to familiarize the subject with 
the touch-screen computer. This measure can identify any problems in vision, 
movement, or comprehension that could affect performance on the subsequent 
CANTAB subtests.  
Paired Associates Learning (PAL) assesses visual memory and new learning by 
using patterns that are difficult to verbalize. Performance on the PAL is dependent on 
the functional integrity of the temporal lobe, particularly the entorhinal cortex (Owen, 
Downes et al. 1990). The CANTAB PAL performance of patients with mild AD was 
impaired relative to both demographically-matched healthy controls (Sahakian, Morris et 
al. 1988) and to individuals with frontal variant fronto-temporal dementia (Lee, Rahman 
et al. 2003). Importantly, PAL was found to be relatively insensitive to major unipolar 
depression (only 7 percent of scores of patients with depression and AD fell within an 
overlapping range)(Swainson, Hodges et al. 2001), thus the assessment won’t be 
biased by an underlying mood disorder. 
One Touch Stockings of Cambridge (OTS) is a spatial planning test that gives a 
measure of frontal-lobe function. Performance on this subtest targets activation of a 
neural network known as the dorsolateral prefrontal cortex (Baker, Rogers et al. 1996), 
which is impaired in patients with frontal-lobe damage (Owen, Downes et al. 1990).  

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Spatial Working Memory (SWM) measures the ability to retain spatial information 
and manipulate it in working memory. It is a self-ordered task that also assesses 
heuristic strategy. Performance on this task is impaired by damage to the prefrontal 
cortex (Owen, Downes et al. 1990, Manes, Sahakian et al. 2002). In neuroimaging 
studies, SWM performance is associated with activations in the dorsolateral and mid-
ventrolateral prefrontal cortex (Owen, Doyon et al. 1996).  
Reaction Time (RT) is designed to assess vigilance and impulsivity. It measures 
motor- and mental-response speeds, as well as accuracy and tendency to respond 
prematurely. It also allows for a measure of anticipatory responding, preservative 
responding, and inter-trial variability in responding. Frontal and parietal lobe are 
measured by this subtest. Looking at both the movement time and the reaction time 
allows us to differentiate speeding or slowing of motor function from any speeding or 
slowing of cognitive function.  
Stop Signal Test (SST) assesses motor inhibition and impulsivity. Performance on 
this measure is associated with the integrity of the right inferior frontal gyrus (Aron, 
Dowson et al. 2003).  
Rapid Visual Processing (RVP) is a test of sustained attention. This task is similar to 
traditional continuous performance tasks. Performance on this measure has been 
shown to be associated with activation in a network brain structure, including the 
parietal and frontal lobes (Coull, Frith et al. 1996, Coull, Sahakian et al. 1996). 
Delayed Matching to Sample (DMS) assesses forced, choice-recognition memory for 
non-verbal patterns by testing both simultaneous matching and short-term visual 
memory. This test is primarily sensitive to damage in the medial temporal lobe area, 
with some input from the frontal lobes. 
 
Electrophysiological measures (ERP/EEG) 
EEG and ERPs consist primarily of summed post-synaptic excitatory and inhibitory 
neuronal potentials (Nunez and Srinivasan 2006), and provide a non-invasive and time-
sensitive measure of synaptic dysfunction in neurological disorders (e.g., Luck, 
Mathalon et al. 2011, Olichney, Yang et al. 2011). Our prior ERP study in FXTAS found 
marked attenuation of the N400 repetition effect (Olichney, Chan et al. 2010) – an 
established electrophysiological index of semantic priming and other verbal memory 
processes sensitive to amnestic mild cognitive impairment (MCI) and early AD 
(Olichney, Iragui et al. 2006, Olichney, Taylor et al. 2008, Kutas and Federmeier 2011). 
For the EEG/ERP, the subject wears a cap that has multiple sensors, which are 
attached to the scalp of the subject. Each scalp site is cleaned thoroughly, and then the 
sensor, a small sticker with some gel on it, is attached to the scalp.  
 Our ERP word repetition paradigm, which assesses language and memory, utilizes 
216 auditory category statements (e.g. a breakfast food); each statement is followed by 
a visual target word that either (50% probability) fits the category (e.g. pancake) or does 
not (e.g. a military title- 'quarter’; 50% probability of semantically incongruous targets). 
Subjects perform a simple semantic judgment task, in which they indicate by a verbal 
yes/no response if the target word fits the preceding category or not. No demands are 
made on declarative memory during the ERP recordings, and subjects with mild to 

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moderate dementia can generally perform the task well. These category-target pairs are 
repeated in a pseudo-random fashion that provides electrophysiological measures of 
implicit and explicit memory processes. One-third of the statements are presented only 
once. One-third of the statements are repeated twice, each repetition with a long lag 
(~120 s later), and one-third of the statements are repeated once with a short lag (1-4 
trials or ~10-40 s later). The experiment takes approximately 70 minutes.  
To assess attention and working memory, we propose to use a classic auditory 
P300 “oddball” paradigm, which utilizes either high (200 Hz) or low (133 Hz) auditory 
tones, with a dual response task. Our prior published studies of the P300 in FXTAS 
have shown the frontal P300 amplitude is reduced, and the degree of this reduction 
correlates well with executive dysfunction (Yang, Chan et al. 2013, Yang, Simon et al. 
2013). The subject indicates by button press (and reaction time data recorded) if the 
stimulus is the less frequent (probability = 25% of tones) target tone (i.e. specific ‘rare’ 
tone, low or high, which alternates across blocks), and also keeps a mental count of the 
number of target tones within each block. The auditory P300 experiment takes about 25 
minutes to complete (6 blocks lasting ~4 minutes each). 
Anxiety and Psychopathology 
Symptom Checklist-90–Revised (SCL-90-R): We will continue to use the SCL-90-R 
(Derogatis 1994) in adults, which has been productive in demonstrating emotional 
problems in carriers, both with and without FXTAS, that relate to molecular measures, 
particularly the FMR1 mRNA levels (Hessl, Tassone et al. 2005). The SCL-90-R is a 
standardized self-report measure of psychological symptoms (Hessl, Tassone et al. 
2005). There are 90 items with a 5-point rating scale, which has been normed on 
individuals aged 13 years and older.  
Beck Anxiety Inventory: To obtain a more detailed measure of anxiety, we will use 
the Beck Anxiety Inventory (Beck, Epstein et al. 1988) in all adults with the premutation 
and with controls. The Beck Anxiety Inventory is a 21-item self-report questionnaire that 
includes typical symptoms of anxiety during the past week, such as nervousness, 
inability to relax, and heart pounding or racing. It has high internal consistency 
(Cronbach’s alphas ranging from 0.90 to 0.94) and test-retest reliability over a one-week 
interval (0.67 to 0.93). It has demonstrated good convergence with other measures of 
anxiety in adults in both psychiatric and general populations. Moore et al. (Guy 1976, 
National Institute of Mental Health 1985) found that males with the premutation reported 
higher rates of anxiety on this measures than controls. 
Structure Clinical Interview for DSM-IV Axis 1 Disorders (SCID): The SCID (First, 
Spitzer et al. 1997) is a clinician administered, semi-structured interview covering a 
broad range of psychiatric diagnoses according to DSM-IV criteria. We and others have 
demonstrated significant emotional problems in carriers with and without FXTAS 
utilizing the SCID (Bourgeois, Coffey et al. 2009, Roberts, Bailey et al. 2009, Bourgeois, 
Seritan et al. 2011). We will use this measure to document anxiety and other psychiatric 
disorders in our subjects at baseline.  
Columbia-Suicide Severity Rating Scale (C-SSRS): The C-SSRS was designed to 
distinguish the domains of suicidal ideation and suicidal behavior. Four constructs are 
measured. The first is the severity of ideation, which is rated on a 5-point ordinal scale 
in which 1=wish to be dead, 2=nonspecific active suicidal thoughts, 3=suicidal thoughts 
with methods, 4=suicidal intent, and 5=suicidal intent with plan. The second is the 

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intensity of ideation subscale which comprises 5 items, each rated on a 5-point ordinal 
scale: frequency, duration, controllability, deterrents, and reason for ideation. The third 
is the behavior subscale, which is rated on a nominal scale that includes actual, 
aborted, and interrupted attempts; preparatory behavior; and nonsuicidal self-injurious 
behavior. And the fourth is the lethality subscale, which assesses actual attempts; 
actual lethality is rated on a 6-point ordinal scale, and if actual lethality is zero, potential 
lethality of attempts is rated on a 3-point ordinal scale. This scale will be carried out at 
baseline and at 3 months, 6 months. For the 5 who continue for one year this will be 
carried out at 3 month intervals until the end of the study.  In 2011 Posner and 
colleagues demonstrated that the C-SSRS had good convergent and divergent validity 
with other multi-informant suicidal ideation and behavioral scales and it is an optimal 
scale to use in clinical trials because it can document change in ideation and behavior 
over time.  
 
MRI Protocol: MR images will be acquired from a Siemens Trio 3T MRI scanner 
with a 32-channel head coil (Siemens Medical Solutions, Erlangen, Germany). DTI 
images with 30 gradient directions will be obtained using parallel imaging to reduce 
localized signal loss and shorten the length of image acquisition. The images will be 
acquired twice to increase signal-to-noise ratio and will be zero-filled to 256 × 256 pixels 
in plane by the scanner reconstruction software to increase image resolution. The DTI 
images will be acquired parallel to the AC-PC line in 68 axial slices of 2 mm slice 
thickness without gap. The GRAPPA acceleration factor will be set to 3. The FOV will 
be 240 mm, matrix 128x128, TR 7100ms, TE 72 ms, and flip angle 90°. The diffusion-
weighted images will be obtained at b-value of 800 s/mm² in 30 directions uniformly 
distributed in space along with four additional images with minimum diffusion weighting. 
The high-resolution, T1-weighted, 3D magnetization-prepared rapid gradient-echo 
(MPRAGE) images will be acquired for volumetric analysis along with other 
standardized structural images, including fluid-attenuated inversion recovery (FLAIR) 
MRI for lesion detection, and T2-weighted gradient-echo sequence (GRE) for 
hemorrhage. For the MPRAGE, the participants will be scanned in 208 sagittal slices of 
0.95 mm thickness (no gap) with FOV 243 mm, 256 × 256 matrix interpolated to 512 × 
512, TR of 2,500 ms, TE of 4.33 ms, and 7° flip angle. The FLAIR images will be 
acquired in 104 sagittal slices of 1.9 mm thickness (no gap) with FOV 243 mm, 512 × 
512 matrix, TR of 5,000 ms, TE of 455 ms, and inversion time 1,700 ms. The GRE 
sequence will be acquired in 48 axial slices of 3 mm thickness (no gap) with FOV 240 
mm, 384 × 384 matrix, TR of 4,000 ms, TE of 80 ms, and NEX 2. 
 
DTI measurements: We have previously shown that DTI measurements show high 
sensitivity to structural changes associated with the premutation (Wang, Johnston et al. 
2005, Hashimoto, Srivastava et al. 2011); we will thus continue using these methods to 
evaluate the improvement in white matter integrity as a consequence of treatment with 
allopregnanolone. The analysis will include all major tracts that can be reliably 
reconstructed under current image resolution, with a particular emphasis on limbic and 
motor-related fiber tracts (cingulum, middle and superior cerebellar peduncles, and the 
body of the corpus callosum; see Figure). From the reconstructed fiber tracts, tract-
based measurements will be obtained for quantifying the extent of change from baseline 

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to follow-up at one year. Measurements include the structural integrity measurements 
averaged over the extent of the tract, such as fractional anisotropy for measuring 
diffusion directionality, axial diffusivity for the amount of water diffusion along the 
predominant diffusion direction, radial diffusivity for the amount of diffusion 
perpendicular to the predominant diffusion direction, and volume-related 
measurements, such as mean length (i.e. the average length of the DTI streamlines 
reconstructed for a specific fiber tract) and tract volume (i.e. the number of voxels 
occupied by the reconstructed DTI streamlines). To detect more localized directionality 
and diffusivity changes not detectable by DTI tractography, a voxel-based analysis, 
tract-based spatial statistics (TBSS) will be performed at core white matter. The 
combination of these two leading DTI methods will maximize the chance of detecting 
potential drug-related structural changes in premutation carriers. 
 
Hippocampal measurements: Hippocampal volumes will be quantified by operator-
guided manual segmentation using Mayo BIR’s Analyze 8.5 and 9.0 (Robb 2001). 
These guidelines were developed from the anatomical analysis of post-mortem human 
brains using histological sections of tissue cut perpendicular to the hippocampal axis; 
they have been used previously by our group in this patient population (Koldewyn, 
Hessl et al. 2008). For a detailed description of this protocol see Schumann et al. 
(2004). Hippocampal volumes will also be corrected for total cerebral volume to account 
for overall individual differences in brain volume. 
 
 
 
Medication trial:  
If subjects qualify after screening measures, they will be invited to participate in the 
open trial of Allopregnanolone. The first 3 infusions and follow up observation will be 
performed at the UC Davis CTSC Clinical Research Center (CCRC). Infusion personnel 
will use the Richmond Agitation Sedation Scale (RASS) (Sessler et al., 2002; Ely et al., 
2003) to assess subjects before and during infusion. Subjects must obtain a RASS 
score of 0 (alert and calm) prior to infusion and the medication will be stopped if their 
RASS score falls below -1 (Drowsy) during infusion.  Subjects will all begin with 2.0 mg 
dosage. If tolerated, the next infusion will be 4.0 mg, and if that is tolerated, the next 
infusion will be 6.0 mg. Subject infusions will remain stable at the highest dosage 
tolerated for the remainder of the study. This means that study participants may be on 
different doses of the medication for the remainder of the trial.  These 9 (stable dose) 
infusions may also be administered at the Mount Sinai Beth Israel Phillips Ambulatory 
Infusion Center, as described below in item 19. 
The 2.0 mg, 4.0 mg, and 6.0 mg aliquots of the 0.5 mg/ml allopregnanolone in 6% 
sulfobutylether-β-cyclodextrin with 0.9% sodium chloride injection solution will be 
dispensed by the UC Davis Investigational Drug Pharmacy, or the Mount Sinai Beth Israel 
Phillips Research Pharmacy in single-use syringes. Syringes will be attached to the 
infusion pump for slow intravenous administration. Subjects will be observed for 2 hours 
after infusions at the center to assess side effects and tolerance. During this time, if the 
participant’s RASS score falls below -1, the dosage during the next visit will be lowered 
and the observation period may be extended as needed until the subject returns to their 

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baseline RASS score. Infusion personnel will adhere to the CTSC guidelines, or the 
Mount Sinai Beth Israel Phillips Ambulatory Infusion Center procedure manual, for the 
treatment of sedation.  In addition, subjects must be accompanied by someone who can 
drive them home from the CRCC infusion center or the Mount Sinai Beth Israel Phillips 
Ambulatory Infusion Center, and remain with them for at least 20 hours to monitor the 
subject for any adverse effects of the medication.  
 
To ensure consistency between sites, the UC Davis Investigational Drug Pharmacy will 
directly educate personnel at the Mount Sanai Beth Israel Research Pharmacy 
regarding the dispensing and storage of the study drug. 
 
The infusion personnel at the UC Davis CCRC infusion center, with Dr. Rogawski, will 
educate the infusion personnel at the Mount Sanai Beth Israel Phillips Ambulatory Infusion 
Center regarding the study procedures and the use of the RASS. 
 
Dr. Randi Hagerman will have monthly phone calls with Dr. Naomi Lubarr ensure procedures 
are consistent. In addition, Dr. Hagerman is available to Dr. Lubarr in the event of questions or 
concerns about the study. 
 
 
 
12) Data and Specimen Banking 
 
Each sample will be coded by a unique numerical identifier. 
There will be a up to a total of five blood draws throughout the study. The first blood 
draw will have a total volume of up to 45ml. The final blood draw will have a total 
volume of up to 30ml. Safety labs drawn before every escalating dose will have up to 8 
ml. Safety labs will be processed through the UCD Davis Pathology Laboratory. 
Remaining samples will be delivered to Dr. Tassone’s lab at the UC Davis MIND 
Institute’s Wet Lab for processing and storage. Samples will be kept until the end of the 
study, at which point they will be destroyed. Alternatively, on the study consent form, 
participants may indicate permission to allow for samples to be kept for a period of 15 
years after the end of the study.  
 
13) Data Management and Confidentiality 
 
The clinical study data will be entered into and stored in REDCap, which is managed by 
the Biomedical Informatics Program of the UC Davis Clinical and Translational Science 
Center. REDCap (Research Electronic Data Capture) data collection projects rely on a 
thorough study-specific data dictionary defined in an iterative self-documenting process 
by all members of the research team with planning assistance from the Biomedical 
Informatics Program. The iterative development and testing process results in a well-
planned data collection strategy for individual studies. The REDCap system provides 
secure, web-based applications that are flexible enough to be used for a variety of types 
of research, provide an intuitive interface for users to enter data and have real time 
validation rules (with automated data type and range checks) at the time of entry. These 

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systems offer easy data manipulation with audit trails for reporting, monitoring and 
querying patient records, and an automated export mechanism to common statistical 
packages (SPSS, SAS, Stata, R/S-Plus). REDCap servers are housed in a local data 
center at UC Davis Health System and all web-based information transmission is 
encrypted. REDCap was developed specifically around HIPAA-Security guidelines. For 
example, upon login, an approved username and password is required. REDCap has 
been disseminated for use locally at other institutions and currently supports 240+ 
academic/non-profit consortium partners on six continents and over 26,000 research 
end-users (www.project-redcap.org). All research personnel on this IRB protocol will have 
some type of access to this database. 
 
 
14) Provisions to Monitor the Data to Ensure the Safety of Subjects 
 
A Data Safety Monitoring Board (DSMB) will be established that includes two 
neurologists familiar with FXTAS, in addition to a statistician from UC Davis. All of the 
DSMB members will be independent of this study. The board will meet within the first 3 
months of initiating this study (after the first patient is dosed), and subsequently every 6 
months; it is also available to meet on an emergency basis as needed. Our statistician, 
Dr. Danh Nguyen, will prepare the data so that the DSMB can review the ongoing 
adverse events (AEs) of the study on allopregnanolone to assess if any significant 
problems are occurring with allopregnanolone, particularly serious adverse events 
(SAEs) which are also reported immediately to our IRB, NIH, and the FDA. The DSMB 
will send a summary report to Randi Hagerman (PI) and the sub-investigators Dr. 
Rogawski and Olichney. As the study continues there will also be outcome data that will 
be available from those who have completed the 12 weeks of the trial. The DSMB will 
make recommendations to the PI regarding whether the study should continue or stop 
depending on the AEs, including SAEs and the beneficial effects of the outcome data. 
The PI will abide by the recommendation of the DSMB regarding stopping the study. 
 
15) Withdrawal of Subjects 
 
 
If sedation occurs at the lowest dose of 2.0, then their dose will be cut in half at 
the subsequent visit. If this dose is not tolerated, then they will be removed from the 
study with safety labs obtained at the end of study visit. 
 
 
If a patient misses more than 3 doses they will be removed from the study, 
unless illness or an appropriate excuse is known. These subjects, as well as subjects 
who want to discontinue the study before visit 14, will be asked to come in for an end of 
study visit that will include safety labs and any of the outcome measures that are 
tolerated by the patient. If sedation develops in visits after the highest tolerated dose, 
then the dose can be de-escalated and they will move back to the previous dose that 
did not cause sedation.  

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16) Risks to Subjects 
 
This is a very comprehensive study, and subjects are asked to undergo a large 
number of tests and procedures.  There are side effects from all procedures as listed 
below. 
The amount of time dedicated to testing may make subjects tired.  We make an 
effort to spread the testing out over two days in order to make this easier, and subject 
are offered multiple breaks throughout the course of the testing day. 
Sometimes people feel nervous while taking the cognitive tests, or they get tired 
during the testing.  We take several breaks during the testing to help with fatigue.  The 
test administrators do what they can to reassure the subjects. 
Event Related Potentials may cause mild skin irritation at the sites where electrodes 
have been placed but these symptoms have always resolved within a few days.   
The blood draws are mildly painful but in our experience this has not been a problem 
in adults particularly aging adults who have experienced many blood tests prior to this 
research. We will clean the skin with alcohol before the blood draw and then apply 
pressure after the blood draw with a subsequent pressure bandage. We have never had 
problems with infection from our blood draws. Similarly, IV placement can be mildly 
painful, and there is a small risk of infection at the site.  
There are no known health risks associated with MRI. There is risk of injury for 
subjects with metal in or on the body; but we will carefully screen subjects as part of the 
standard protocol at the imaging center. It is also possible that individuals may 
experience claustrophobia during the MRI studies from being in the small tube. Subjects 
with a history of claustrophobia or significant anxiety can be given a mild sedative prior 
to the MRI to reduce these symptoms. 
 
Previous and currently ongoing clinical trials of allopregnanolone have not 
identified any significant risks. A clinical efficacy trial of allopregnanolone is being 
assessed in individuals with moderate to severe traumatic brain injury (TBI) under the 
direction of Dr. Michael Rogawski. The TBI study has enrolled 12 subjects, 6 of which 
have received allopregnanolone. In these subjects, no adverse events attributable to the 
drug product were reported. An additional 4 subjects received allopregnanolone 
intravenous solution in the treatment of status epilepticus under Emergency Use INDs. 
No adverse events attributable to the drug product were reported in these subjects. 
There are four other published reports of studies where allopregnanolone had been 
administered to groups of human subjects (As reviewed by Irwin and Brinton, 2014). In 
these reports, treatment emergent adverse events were mild and transient, and 
included nausea, mild sedation, fatigue, flushing, and anxiety. Given existing safety data 
in humans, we anticipate that mild, transitory sedation may be produced at the high 
dose levels of allopregnanolone in this protocol; some subjects may experience mild 
nausea, but we do not expect other adverse events. If nausea persists, we will go to the 
lower dose for the weekly infusions. 
All adverse events will be reported to the IRB annually along with the annual report 
and renewal request.  If the event is serious, it will be reported immediately, as is 
customary for all clinical trials. 
 

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17) Potential Benefits to Subjects 
Allopregnanolone has the potential to improve symptoms of FXTAS, such as executive 
function deficits and psychiatric symptoms, particularly the anxiety that is common in 
affected individuals. With the data in AD demonstrating benefit in Dr. Brinton’s studies, 
including neurogenesis in the mouse model, and because many with FXTAS also have 
AD, there may also be additional benefits for neurogenesis in the hippocampus in 
FXTAS. We hypothesize that FXTAS subjects treated with allopregnanolone will show 
slower neurological deterioration, improvements in memory and executive function, and 
improvements in brain processing on electrophysiological measures (event related 
potentials: ERP). 
 
18) Vulnerable Populations 
Not applicable. All subjects will be adults who are competent to consent. 
 
19) Multi-Site Research:  
After the stable dose has been reached over the first 3 infusions here at UC Davis, 
under the supervision of Dr Randi Hagerman MD, subjects may receive the remaining 9 
infusions under the supervision of Naomi Lubarr, MD at the Mount SInai Beth Israel 
Phillips Ambulatory Care Center. This is an outpatient clinical facility located at 10 Union 
Square East, NY, NY, 10003.  The Mount Sinai Beth Israel Phillips Ambulatory Infusion 
Center is on the 4th floor of this building.  It has 17 infusion chairs.  The infusion center 
nurses are trained and experienced in giving chemotherapy, monoclonal antibodies, 
transfusions, iron infusions, etc., and are well able to manage the procedural tasks 
required for infusions as well as infusion-related reactions.  The center has a policy and 
procedure manuals in place that address ambulatory infusions, hypersensitivity 
reactions, and anaphylactic reactions.  
Dr Lubarr’s outpatient office is located in the same building on the floor above the 
Infusion Center, in the Department of Neurology Suite.   

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20) The Phillips Ambulatory Care Center is located a short distance 
away from the inpatient hospital of Mount Sinai Beth Israel 
Medical Center, which is an 856-bed teaching hospital with an 
inpatient neurology floor, 2 designated neuro-critical care 
specialists, a neurology residency with 24 hour in-house 
neurology coverage, and a movement disorders fellowship.  
Community-Based Participatory Research: Not Applicable 
 
21) Sharing of Results with Subjects 
Experimental results will not routinely be shared with participants. If requested, an 
informal feedback session can be scheduled during the visit to provide this information. 
 
22) Setting 
Participants will be seen at the MIND Institute for screening, mid-point and end-point 
visits. Medication infusions will be at the CTSC Clinical Research Center (CCRC). This 
is a highly specialized patient unit that provides medical scientists with opportunities for 
careful study of disease.  
 
 
23) Resources Available 
We have the appropriate resources and personnel to conduct this research. Dr. 
Hagerman employs several full-time research personnel, including research 
coordinators and several faculty members have roles on this project, including 
psychologists, psychiatrists, and neurologists. We have completed many years of this 
project at UC Davis since 2001.  
 
24) Prior Approvals:  
This study was approved by the UC Davis Institutional Review Board on May 7, 2015. A 
modification to the protocol was approved on June 16, 2015. 
 
25) Provisions to Protect the Privacy Interests of Subjects 
All records associated with this study will be kept confidential and will be coded so that 
the subjects the data was obtained from are not directly identifiable with the data 
collected. The information obtained during this study will only be accessible by the 
researchers involved in this study. All records will be kept in a locked filling cabinet in a 
secured room. 
 
26) Compensation for Research-Related Injury 
It is important that you promptly tell the person in charge of the research if you 
believe that you have been injured because of taking part in this study. If you are 
injured as a result of being in this study, the University of California will provide 
necessary medical treatment. Depending on the circumstances, the costs of the 
treatment may be covered by University or the study sponsor or may be billed to 

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your insurance company just like other medical costs. The University and the 
study sponsor do not normally provide any other form of compensation for 
injury. For more information about compensation, you may call the IRB 
Administration at (916) 703-9151 or email at IRBAdmin@ucdmc.ucdavis.  
 
27) Economic Burden to Subjects 
Subjects will only be economically responsible for the costs due to traveling to and from 
the center, and other transportation costs while here. 
 
28) Consent Process 
The consent will conform to HRP-090. 
 
29) Process to Document Consent in Writing 
Written documentation of consent will follow guidelines as outlined in SOP, HRP-091 
 
30) Drugs or Devices 
A stock solution of allopregnanolone containing 2 mg/mL allopregnanolone in 
24% sulfobutylether-β-cyclodextrin  is stored frozen at the UC Davis Good 
Manufacturing Practices Laboratory (2921 Stockton Blvd, Sacramento CA 95817). 
The GMP facility will formulate the injection solution by dilution of the stock 
solution to 0.5 mg/ml allopregnanolone in 6% sulfobutylether-β-cyclodextrin with 
0.9% sodium chloride injection, USP. The stock and final solutions will be 
subjected to sterility and pyrogenicity testing, and testing for pH, osmolality, and 
particulates. The final product in 50 ml aliquots will be stored at 4 °C until used, 
but for no longer than one month, which is the current assured stability limit. The 
injection solution will be stored at and dispensed by the UC Davis Investigational 
Drug Pharmacy (2315 Stockton Blvd, Rm DT0762, Sacramento CA 95817). The 
aliquots of 2.0 mg, 4.0 mg, and 6.0 mg will be dispensed in a labeled syringe. The 
drug administration will be done by an infusion pump over the period of 30 
minutes. 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Statistical Analysis Plan
NCT02603926 
Treatment of Fragile-X Associated Tremor/Ataxia Syndrome (FXTAS) With Allopregnanolone
Prespecified Primary Outcome Analysis:
The prespecified primary outcome in this study is the California Verbal Learning Test II (CVLT2)  
Trial 1-5 Free Recall Total Raw Score. Mean and standard deviation for raw score at baseline/pre-treatment 
and at 14 weeks/post-treatment will be calculated, as well as the percentage of patients whose primary  
outcome measure showed improvement from baseline to follow-up.
Secondary Outcomes Analyses:
The prespecified secondary outcomes in this study include the Behavioral Dyscontrol Scale - 2  
(BDS-2) Total Score, the CATSYS Dot-to-Dot Tremor Intensity (CATSYS DTD TI), and the Hippocampal  
Volume as measured by structural MRI. Mean and standard deviation at baseline/pre-treatment and at 14  
weeks/post-treatment will be calculated for all secondary outcome measures, as well as the percentage of  
patients who showed improvement from baseline to follow-up on each measure.
Statistical Analysis:
All statistical analyses will be conducted in R 3.2.5 language and environment. One-sided paired t  
tests and Pearson correlation coefficients will also be utilized to assess for significance of changes in  
outcome measures, both primary and secondary. The threshold for statistical significance will be set at 0.05.