Gulf War Illness Inflammation Reduction Trial
Phase: PHASE2
Conditions: Chronic Inflammation, Chronic Pain, Fatigue, Cognitive Impairment
Sponsor: Minneapolis Veterans Affairs Medical Center

1 
 
Gulf War Illness Inflammation Reduction Trial 
Protocol: September 12, 2013 
 
Table of Contents:                 
 
 
 
 
      Page #                                                       
    
Project Narrative………….……………………….…….……….……...2-14 
  
 
Support….…………….………….……………………………….….….15-23 
 
Technical Abstract……….…….………….…………………………….24 
 
Lay Abstract………………………………….…………………….……25 
 
Statement of Work…….…….………….…....…………………………26-27 
 
 
 
Human Subjects Procedures...….………….………………….….……28-34 
 
 
 
Intervention………………………….………….……............................35-43 
 
Data Management ……….….………….……….…….…………….….44-46 
 
Surveys …………………………….……………….……………………47-62 
 
Impact…………………………….……………………………………….63 
 
Transition…………………………….….…………………………….…64-65 
 
IND/IDE…………………………….…………………………………….65-69 
 
 
 

2 
 
Project Narrative 
 
Background:  During Desert Shield and Desert Storm (August 2, 1990 to July 31, 1991) 696,841 United States military personnel 
were deployed to the Kuwaiti Theater of Operations. Today approximately one-third of those veterans are suffering from Gulf War 
Illness (GWI), an unexplained chronic multisymptom illness (1, 2).  
 
In 1995 the Department of Veterans Affairs (VA) initiated a retrospective cohort survey of 15,000 deployed and 15,000 non-deployed 
Gulf War era veterans (3).  A second study reexamined the health status of the veterans who participated in the 1995 baseline survey 
(4). This work identified the prevalence of multisymptom illnesses as the most significant difference between the deployed and non-
deployed veterans (36.5% vs. 11.7%, adjusted risk ratio = 3.05). Thus, GWI became the signature health-related outcome of the Gulf 
War.  
 
The underlying pathophysiology of GWI is not understood. Therefore, we performed a pilot study comparing blood samples from 
Gulf War veterans with and without multiple symptoms of pain, fatigue, and cognitive dysfunction. The objective of the study was to 
determine if there are quantifiable differences in blood that could be used to identify potential therapeutic targets for the treatment of 
GWI. The blood analysis included a complete blood count (CBC), plasma proteomics, platelet function studies, and the measurement 
of multiple coagulation parameters.  
 
The pilot study results provide strong evidence of chronic inflammation in veterans with GWI. This entirely new and provocative line 
of evidence presents an exciting opportunity to test an intervention that has the potential to both reduce symptoms and further define 
the pathophysiology of GWI. 
 
The goal of this proof-of-principal trial is to determine if reducing inflammation is an effective treatment for GWI. A successful trial 
with improved clinical outcomes and reduced biomarkers of inflammation would establish a new paradigm for the diagnosis and 
treatment of GWI. The testing of other therapeutic interventions designed to reduce inflammation and minimize toxicity could produce 
additional improvements in GWI treatment beyond those achieved in this trial.  The immediate and long-term positive consequences 
for the health and well-being of veterans with GWI would be significant. 
 
 
 
 

3 
 
Table 1. Plasma Protein Analysis: GWIpositive vs. GWInegative 
Analyte 
GWI 
Status 
n 
Mean ± SD 
Median 
Median 
Ratio 
P 
value* 
C-Reactive Protein (CRP), μg/ml 
+ 
57 
3.4 
± 
3.9 
2.1 
1.75 
0.032 
- 
27 
1.6 
± 
1.2 
1.2 
Leptin, ng/ml 
+ 
57 
10.9 
± 
8.0 
9.0 
1.67 
0.047 
- 
28 
8.7 
± 
10.2 
5.4 
Interleukin 1 beta (IL-1β), pg/ml 
+ 
14 
1.0 
± 
0.61 
0.83 
1.66 
0.022 
- 
11 
0.60 
± 
0.27 
0.50 
Brain-Derived Neurotrophic Factor (BDNF), 
ng/ml 
+ 
57 
1.5 
± 
0.92 
1.3 
1.59 
0.015 
- 
28 
1.4 
± 
1.6 
0.82 
Matrix Metalloproteinase-9  
(MMP-9), ng/ml 
+ 
57 
115 
± 
62.2 
103.0 
1.14 
0.034 
- 
28 
94.5 
± 
43.7 
90.5 
Matrix Metalloproteinase-2  
(MMP-2), μg/ml 
+ 
57 
2.3 
± 
0.59 
2.1 
0.88 
0.005 
- 
28 
2.7 
± 
0.74 
2.4 
Fatty Acid-Binding Protein, heart 
(FABP, heart), ng/ml 
+ 
53 
2.4 
± 
1.7 
1.8 
0.64 
0.020 
- 
25 
3.4 
± 
2.6 
2.8 
*Since the data summarized in this table were not normally distributed the Mann-Whitney rank sum test was employed. 
  
 
The pilot study was funded by research awards from the VA Office of Research and Development (ORD) and the Department of 
Defense (DoD) Congressionally Directed Medical Research Programs (CDMRP) Gulf War Illness Research Program (GWIRP). 
 
The CDC-10 survey instrument was used in the pilot study for symptoms assessment (5). Veterans with multiple symptoms were 
designated GWIpositive. All other subjects were designate GWInegative. Plasma levels of 90 proteins were quantified using Multi-Analyte 
Profiling (MAP) technology. Univariate analysis identified 7 statistically significant differences (p<0.05) between the two groups, 
Table 1. These data strongly suggest that chronic inflammation is present the majority of subjects with GWI. 
 

4 
 
The presence of C-reactive protein (CRP) in Table 1 is particularly 
noteworthy. The 
physiologic role of CRP is to initiate the complement cascade on the 
surface of damaged 
cells and invading microbes. CRP is also an acute-phase protein 
produced by the liver. 
Hepatocyte synthesis of CRP is regulated by Interleukin 6 (IL-6). 
Plasma CRP is stable 
and easy to measure. Furthermore, unlike IL-6, it is not subject to 
diurnal variations. 
Therefore, CRP is employed as a biomarker of IL-6-mediated 
inflammation (6). 
Linear regression analysis, Figure 1, revealed further evidence of a 
strong positive 
correlation (p=0.002) between plasma CRP and the number of GWI 
symptoms from the 
CDC-10. 
 
Chronic inflammation can trigger GWI-like symptoms:  
 
• Plasma CRP levels are frequently elevated in chronic inflammatory diseases such as rheumatoid arthritis (RA), multiple 
sclerosis (MS), and systemic lupus erythematosus (SLE). Increasing symptoms of pain, fatigue, and cognitive dysfunction 
often correlate with increasing CRP, and decreases in CRP are associated with corresponding decreases in symptoms (7-12).  
• It has been demonstrated that IL-6 produced in the periphery can induce microglial-mediated inflammation in the brain; and 
this activation of microglial cells is associated with fatigue, depression, sleep deprivation, hyperalgesia, and cognitive 
impairment (13). 
• Leptin is an adipokine that not only serves as a regulator of body weight and appetite, but also as an essential link between 
energy utilization and the immune system (14, 15).  Both IL-6 and leptin play central roles in the symptomology of the acute-
phase response to bacterial infections (16). Also, fatigue is associated with circulating leptin levels in irritable bowel syndrome 
(17). 
• 
Brain-Derived Neurotrophic Factor (BDNF) is a neurotrophin with functions related to the survival and proliferation of nerve 
cells and neuroinflammation. In addition, BDNF enhances inflammation-related pain (18, 19). Increases in blood levels of 
BDNF have been correlated with increased pain perception in both RA and fibromyalgia (18, 20).  
• Thus, the symptoms of pain, fatigue, and cognitive dysfunction experienced by GWIpositive veterans may be due in part to 
increased levels of CRP/IL-6, leptin, and BDNF.  
 
Interleukin 1 beta (IL-1β) was also identified in our pilot study as significantly higher in the GWIpositive group. IL-1β is a key pro-
inflammatory cytokine and a primary driver of the innate immune response. The strength of this observation is tempered by the fact 
that a majority of subjects in both groups had levels of the cytokine below the detectable limit of the assay.  
Figure 1. Plasma CRP vs. Symptoms Score
Symptoms Score
0
1
2
3
CRP, g/ml
0.1
1
10

5 
 
In the second phase of the proteomic analysis bivariate linear regression was used to look for associations between CRP and the other 
plasma proteins. Twelve statistically significant linear correlations with R values>0.30 and P values<0.01 were observed. We refer to 
this set of proteins as the CRP Proteome, Table 2.  The correlations with CRP suggest that IL-6-mediated inflammation plays some 
role in regulating the plasma levels of these proteins. Thus, some members of the proteome may be useful as biomarkers of a 
treatment-induced inflammation reduction. If the anticipated changes correlate with improved HRQOL and reduced symptoms, then 
this information may contribute to our understanding of GWI pathophysiology.  
 
Table 2. The CRP Proteome 
The presence of IL-6 in the proteome is not surprising given the coupling of 
IL-6 to CRP production.  The proteome also contains other ligands for cell-
surface receptors with important inflammation-related signaling functions, 
acute-phase proteins, complement and coagulation proteins, regulators of 
energy intake and utilization, etc. Their functions are consistent with a wound 
healing response involving activation of the coagulation and complement 
cascades, cell recruitment, extracellular matrix remodeling, and angiogenesis.  
Chronic inflammation is frequently accompanied by tissue destruction and 
repair, i.e., a state of chronic wound healing (21, 22). Therefore, the results 
presented in Table 2 support the conclusion that chronic inflammation is part 
of the underlying pathophysiology of GWI.  
 
A previous study observed evidence of platelet activation in a majority of 
GWIpositive subjects (23). Therefore, as part of our pilot study platelet functions 
were studied in GWIpositive and GWInegative subjects (24). Studies performed 
included platelet count, immature platelet fraction (IPF), plasma 
thrombopoietin (TPO), CRP, platelet aggregation and ATP secretion in 
response to six agonists, and spontaneous aggregation. Platelet counts and CRP were significantly elevated in GWIpositive compared to 
GWInegative subjects without elevation in IPF or TPO. Platelet aggregation did not differ between groups except for spontaneous 
aggregation that was significantly greater in GWIpositive subjects. Platelet ATP secretion was similar in the two groups except the 
response to a thrombin receptor activating peptide, 50 μM TRAP 6, was significantly greater in GWIpositive subjects. When platelet 
aggregation was analyzed in relation to CRP the response to a thromboxane receptor agonist, 0.5 μM U46619, was significantly 
greater in subjects whose CRP was ≥2 μg/ml. Therefore, GWIpositive subjects had elevated platelet counts, spontaneous aggregation, 
TRAP 6-induced secretion, and CRP, but no impairment of platelet function. The increased platelet counts and U46619-induced 
aggregation appear to be consequences of an underlying inflammatory state in GWI. 
Analyte (vs. CRP) 
R 
value 
P 
value 
Serum Amyloid P-Component  
0.594 
<.001 
Fibrinogen 
0.469 
<.001 
Leptin 
0.459 
<.001 
Plasminogen Activator Inhibitor 1 
0.433 
<.001 
Adiponectin 
0.359 
<.001 
Complement C3 
0.341 
<.001 
Insulin 
0.335 
<.001 
Apolipoprotein C-III 
0.322 
<.001 
Interleukin 6 
0.316 
0.007 
Thyroxine-Binding Globulin 
0.311 
<.001 
Interleukin-1 receptor antagonist  
0.310 
<.001 
EN-RAGE 
0.301 
<.001 

6 
 
 
Thrombin-antithrombin (TAT) is the inhibited end-product of thrombin generation and is rapidly cleared from the blood (t½ ~5min). 
Therefore, high levels of TAT indicate ongoing activation of the coagulation cascade. Median plasma TAT levels for the GWIpositive 
and GWInegative groups were 16.9 ng/ml and 8.9 ng/ml, respectively. The difference is statistically significant (p=0.006, Mann-Whitney 
rank sum test). Coagulation is an integral part of the innate immune response (25-27). Therefore, the activation of plasmatic 
coagulation in GWIpositive subjects is consistent with the chronic inflammation hypothesis.  
 
The plasma proteomics, platelet, and coagulation evidence presented above support the hypothesis that chronic inflammation is part of 
the underlying pathophysiology of GWI. Therefore, chronic inflammation was selected as the therapeutic target for this clinical trial. 
 
Objectives/Specific Aims/Hypotheses: The hypothesis on which this proposal is based is the following: Chronic inflammation is part 
of the underlying pathophysiology of GWI. Furthermore, products of inflammation contribute directly to GWI-associated symptoms 
of pain, fatigue, and cognitive dysfunction. Therefore, an intervention that reduces this inflammation may alleviate symptoms of the 
disorder and improve the health-related quality of life (HRQOL) of veterans with GWI. 
 
The primary objective of this proposed clinical trial is to determine if treatment with an anti-inflammatory drug improves HRQOL and 
reduces symptoms of veterans with GWI. This trial also provides a significant opportunity to advance scientific knowledge by testing 
the hypothesis that chronic inflammation is part of the underlying pathophysiology of GWI. Improved clinical outcomes combined 
with objective evidence of reduced proinflammatory biomarkers would confirm that chronic inflammation plays an important role in 
GWI.  
 
This clinical trial may contribute to the advancement of clinical practice.  A successful trial would validate the strategy of treating 
GWI-associated chronic inflammation. This new paradigm would change the standard of care by focusing on treatments that reduce 
inflammation. It is likely that other therapeutic interventions designed to reduce inflammation and minimize toxicity will emerge from 
this new perspective. These treatments for GWI could become part of a comprehensive patient-centered therapeutic program tailored 
to the specific needs of individual Gulf War veterans (28). 
 
Standardized self-report measures and proteomics will be used to evaluate treatment-related changes by performing the assessments at 
the beginning and the end of the treatment period and again eight weeks after the end of treatment. The specific aims to this study are 
the following: 
 
• Specific Aim 1: To measure the effects of the treatment on physical and mental functioning (Veterans Short Form 36-Item Health 
Survey).  

7 
 
• Specific Aim 2: To assess intervention-related changes in symptoms: pain (McGill Pain Questionnaire-Short Form), fatigue 
(Multidimensional Fatigue Inventory), and cognitive dysfunction (Cognitive Failures Questionnaire).  
• Specific Aim 3: To quantify changes in biomarkers of inflammation in response to the treatment (plasma proteomics). 
 
Study Design: This is a randomized, two-group, placebo-controlled, double-blind, clinical trial with the treatment group receiving a 
low dose (10mg qD) of delayed-release (DR)-prednisone for 8 weeks versus the placebo group receiving matching placebo for 8 
weeks. The study will determine if treating GWIpositive veterans for 8 weeks with DR-prednisone improves HRQOL, alleviates 
symptoms, and reduces inflammation parameters compared to GWIpositive veterans receiving placebo. Horizon Pharma, Inc., the 
developer of (DR)-prednisone (Rayos®), will supply the drug and the matching placebo for this study at no cost per the approved 
CRADA. 
 
Intervention Chronic inflammation has been identified as the therapeutic target. There is no direct evidence to guide the selection of 
the medication for this trial. Therefore, information relating to drug efficacy in established diseases with similar symptoms and 
biomarker profiles has been used to provide therapeutic guidance. 
 
Pain, fatigue, and cognitive dysfunction are the predominant symptoms of GWI. These symptoms also occur with high frequency in 
chronic inflammatory diseases such as RA, MS, Crohn’s disease, and SLE. For these diseases, increases in proinflammatory cytokines 
are often associated with increases in symptoms. Likewise, anti-inflammatory drugs that decrease proinflammatory cytokine levels 
have established efficacy for reducing symptoms and improving HRQOL (7-12). 
 
Four classes of anti-inflammatory drugs with established efficacy for the treatment of chronic inflammatory diseases were considered:  
 
• Biologic Response Modifiers (BRMs) 
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) 
• Disease-Modifying Anti-Rheumatic Drugs (DMARDs) 
• Glucocorticoids (GCs) 
There are no published studies in veterans with GWI utilizing drugs from any of these categories. Therefore, results of treatment of the 
aforementioned chronic inflammatory diseases were carefully reviewed to provide insight into the choice of a therapeutic modality. 
We first considered the mechanisms of action of the four drug classes. We then selected the mechanism with greatest likelihood of 
reducing GWI-associated inflammation. Following the selection of an appropriate mechanism, the available drugs were reviewed for 
potential efficacy and severity of side effects. 

8 
 
 
BRMs (e.g. etanercept, infliximab, rituxan)   target specific elements of the immune system. For example, the BRM etanercept is an 
inhibitor of tumor necrosis factor.  Since the information that would guide the choice of a BRM for this study is limited, there is a high 
likelihood of choosing incorrectly. Also, many BRMs have serious side effects, they are expensive, and the mode of delivery 
(injection) would likely reduce recruitment and compliance. Thus, BRMs were eliminated from further consideration. 
 
NSAIDs (e.g. aspirin, naproxen, indomethacin, piroxicam) are cyclooxygenase (COX) inhibitors. The COX enzymes, COX1 and 
COX2, catalyze essential reactions in prostaglandin (PG) synthetic pathways. PGs are oxygenated metabolites of arachidonic acid. 
They are rapidly generated in response to perturbations such as physical trauma and infection. PGs are important signaling molecules 
with a multitude of paracrine and autocrine functions. NSAIDs are used primarily to treat pain and fever. The analgesic and antipyretic 
effects of NSAIDs are primarily the result of decreased production of PGs.  
 
One argument against the use of NSAIDs is related to safety. The potential toxicity of NSAIDs at the doses that may be required to 
achieve anti-inflammatory effects is a concern. The FDA has imposed new labeling requirements for both prescription and over-the-
counter NSAIDs. The black box warnings highlight the potential for rare but serious cardiovascular events (COX 2) and 
gastrointestinal bleeding (COX 1) associated with their use. Another argument against the use of NSAIDs is the limited potential for 
efficacy.  The primary mechanism of action of NSAIDs is the suppression of proinflammatory PG production. This is a relatively 
narrow downstream target, and there is no direct evidence linking PGs to the symptoms of GWI. Therefore, NSAIDs were rejected. 
 
DMARDs (e.g. hydroxychloroquine, cyclosporine, methotrexate) are a category of otherwise unrelated drugs defined by their ability 
to suppress the immune system and reduce symptoms of rheumatic diseases. DMARDs are attractive with respect to their pleiotropic 
anti-inflammatory effects. However, DMARD immunosuppression is achieved by multiple mechanisms and in most cases the 
mechanism of action remains obscure. This lack of information regarding mechanism makes it difficult to judge the potential efficacy 
of DMARDs for treating GWI. In addition, the potential toxicity of these drugs is substantial. Therefore, DMARDs were rejected. 
 
GCs are steroid hormones made in the adrenal gland (cortisol, cortisone, etc.) as well as numerous synthetic derivatives 
(dexamethasone, prednisone, etc.). The mechanism of GC action begins with passage of the molecule across the plasma membrane, 
binding to the GC receptor (GCR) in the cytosol, and translocation of the complex into the nucleus. The GCR is a ubiquitous ligand-
activated transcription factor present in most cells from vertebrate animals. Changes in transcription are mediated by the binding of the 
GC-GCR complex to GC response elements in the suppressor or promoter sites of target genes. The multiple effects induced by this 
ligand-receptor interaction include stimulation of gluconeogenesis and immune system suppression (29). 
   
Some anti-inflammatory effects of GCs are achieved via the inhibition of proinflammatory transcription factors such as nuclear factor-
kappa B (NF-κB) and activator protein-1. In particular, the blockage of NF-κB activity may be a key to understanding the pleotropic 

9 
 
anti-inflammatory effect of GCs (30-32).  The suppression of NF-κB activity is achieved, at least in part, by the GC-GCR-induced 
synthesis of the NF-κB inhibitor (IκB). I-κB traps NF-κB in inactive cytoplasmic complexes resulting in the suppression of pro-
inflammatory gene expression.  
 
The efficacy of GCs as anti-inflammatory and immunosuppressive drugs is clearly established. Their pleiotropic effects on immune 
system functions make them attractive as potential treatments for the inflammation associated with GWI. Prednisone is an effective 
and widely prescribed synthetic GC. Its consideration for use in this trial has been enhanced by the evidence that a new formulation of 
the drug (Rayos®- delayed-release (DR)-prednisone) improves efficacy and safety.  
 
One of the limitations of prednisone treatment is related to the time of administration. Patients normally take the drug in the morning 
(~8 AM) which is not optimal with respect to achieving the anti-inflammatory effects. It has been demonstrated that prednisone 
chronotherapy, i.e., administration of the drug at the diurnal peak of proinflammatory cytokines levels (~2 AM), increases both 
efficacy and safety (33-37).  DR-prednisone is designed to optimize the time of delivery without requiring patients to wake in the 
middle of the night to take the medication. It is a tablet that releases the drug approximately 4h after ingestion. Therefore, DR-
prednisone can be taken at bedtime. 
 
The efficacy and safety of DR-prednisone chronotherapy have been established in recent clinical trials. In the CAPRA-1 trial DR-
prednisone was compare to immediate-release prednisone (average dose ~6mg qD) in the treatment of RA (38). The superiority of 
DR-prednisone was demonstrated after 12 weeks for the primary outcome (morning stiffness) and the reduction of IL-6, a key 
circadian proinflammatory cytokine. In the CAPRA-2 trial RA patients who were inadequate responders to DMARD therapy were 
randomized to either DR-prednisone (5 mg qD) or placebo in addition to existing therapy (39). After 12 weeks the subjects were 
assessed for signs and symptoms of RA. DR-prednisone was significantly better than placebo in 11 of 13 clinical measures and 2 of 3 
HRQOL assessments. Adverse event rates for the two arms of CAPRA 1 and CAPRA 2 were similar. In a longer term RA treatment 
study the effects on symptoms and the favorable safety profile of DR-prednisone persisted for 12 months, and no changes in 
hypothalamic-pituitary-adrenal axis function were detected (35). This experience provides confidence that significant toxicity will not 
be observed with the short-term administration of prednisone in the proposed trial. 
 
 
The clinical trial results presented above have established the efficacy and safety of DR-prednisone. Based on this evidence and the 
well-established pleiotropic anti-inflammatory effects of the drug, DR-prednisone has been chosen for the proposed trial. It is worthy 
of emphasis that a successful outcome of the clinical trial will provide support for additional study of anti-inflammatory agents, but it 
will not imply that prednisone would be the drug of choice for chronic management of GWI. Long-term toxicity of corticosteroid 
therapy may preclude its use; however, a positive outcome would justify further research. 
 

10 
 
Measurement of Study Variables The primary and secondary outcome measures, summarized in Table 3, were selected to examine 
the range of GWI-related symptomatology and biomarkers of inflammation. The self-report instruments will be administered and 
blood will be collected at the beginning and the end of the 8 week treatment period and at the end of the 8 week post-treatment period.  
 
The SF-36V is a modification of the well-established Medical Outcomes Study Short Form Health Survey (SF-36) for use with 
ambulatory Veterans Health Administration patients.  It surveys eight concepts of health: physical functioning, role limitations 
because of physical problems, bodily pain, general health perceptions, energy/vitality, social functioning, role limitations due to 
emotional problems and mental health (40-42).  From these concepts, two summary component scores are derived: a Physical 
Component Summary (PCS) and a Mental Component Summary (MCS).  Scores are standardized and range from 0 to 100, with a US 
population mean of 50 points and a SD of 10 points.  The PCS and the MCS have been demonstrated to have excellent psychometric 
properties (40, 41) and have been used extensively in GWI studies and throughout VA settings (5, 40-44). The subscale items largely 
address the diverse array of symptoms reported as a part of GWI. SF-36V PCS is a measure of HRQOL with respect to physical 
functioning and symptoms. 
 
Table 3.  Primary and Secondary Outcome Measures 
 
 
 
The primary 
outcome measure 
will be the presence 
or absence of a 
positive response 
on the SF-36V PCS 
following 
treatment. A 
positive response is 
defined as a 7-point 
or greater increase 
in the SF-36V PCS 
at 8 weeks versus 
the baseline score. 
This definition of a 
positive response to 
Primary 
Outcome 
Measure 
Secondary 
Outcome 
Measure 
Name of Measure 
Description 
x 
 
Veterans Short Form 36-Item 
Health Survey Physical Component 
Summary (SF-36V-PCS) 
HRQOL/ Physical Health Functioning 
 
x 
McGill Pain Questionnaire- Short 
Form (MPQ) 
Sensory pain, affective pain, pain now, 
and typical pain 
 
x 
Multidimensional Fatigue Inventory 
(MFI) 
General fatigue, physical fatigue, reduced 
activity, reduced motivation and mental 
fatigue 
 
x 
Cognitive Failures Questionnaire 
(CFQ) 
Self-report of cognitive symptoms, such 
as attention, concentration, and memory 
 
x 
Veterans Short Form 36-Item 
Health Survey Mental Component 
Summary (SF-36V-MCS) 
HRQOL/ Mental Health Functioning 
 
x 
HumanMAP®-v2.0/Antigens,  
hs-CRP assay,TAT ELISA 
Quantitative analysis of plasma biomarker 
levels 

11 
 
an intervention in veterans with GWI is based upon the psychometric properties of the SF-36V PCS and the distribution of scores 
observed in the population and comes from VA Cooperative Study Program (CSP) Study #470 (43, 44). Based on the results of the 
Veterans Health Study (40, 41), a 7 point change in the SF-36V PCS score is expected to represent an effect size of 0.75.   
 
Validated and standardized methods for the assessment of symptoms were selected due their wide use in GWI studies, sound 
psychometric properties, and demonstrated sensitivity to clinically meaningful changes in GWI symptoms following treatment:  
 
• The MPQ is a self-report survey which measures the quality of pain by asking patients to rate the intensity of 15 verbal 
descriptors of pain on a 0 to 3 rating scale with lower scores indicative of lower pain levels (45).  The scale yields subscale 
scores in the following domains: Sensory pain, affective pain, pain now, and typical pain.  The MPQ is a commonly used pain 
measure with considerable documentation of its reliability, sensitivity to change, and concurrent and predictive validity as a 
measure of pain quality and intensity (46).     
• The MFI is a 20-item self-report instrument designed to measure fatigue (47). The MFI covers the following dimensions: 
general fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue.  Scores on each dimension range 
from 4 to 20, with lower scores indicative of higher functioning.  The instrument has demonstrated good internal consistency, 
with an average Cronbach's alpha coefficient of 0.84.   
• The CFQ is a 25-item self-report measure designed to assess the frequency of failures in perception/attention (e.g. ``do you fail 
to notice signposts on the road?''), memory (e.g. ``do you forget appointments?'') and action (e.g. ``do you bump into people?'') 
(48). Patients are asked to indicate on a 5-point scale (0= never to 5=very often) how often they have experienced each 
cognitive failure in the past months. Studies have demonstrated the CFQ to have adequate internal consistency and test-retest 
reliability.   
• The MCS is one of two summary component scores derived from SF-36V (40-42). It is a clinically relevant measure that has 
been well-validated in the general population as well as a variety of disease states. The MCS measures changes in mental 
health-related functioning and has been used in other studies of GWI (5, 43, 44).  
Intervention-related changes in biomarkers of inflammation will also be assessed. At each study visit a blood sample will be drawn 
and fractionated. The platelet-free EDTA plasma samples will be stored at -80oC prior to assay. Biomarker levels will be determined 
at the beginning and the end of the 8 week treatment period and at the 16 week follow-up visit. Preparation and storage of the plasma 
samples will take place in Dr. Bach’s lab. Established immunoassay procedures utilizing MAP technology will be employed to 
quantify the concentrations of 85 plasma proteins (HumanMAP®-v2.0/Antigens). The assays will be performed on platelet-free 

12 
 
EDTA plasmas by Myriad RBM, Inc., Austin, TX. Myriad RBM validates all assays to clinical laboratory standards. The Myriad 
RBM laboratory is accredited by the College of American Pathologists. Its CLIA number is 45D1037483. 
Clinical laboratories generally use what is known as the high-sensitivity CRP (hs-CRP) assay to detect plasma CRP. The hs-CRP 
assay measures CRP using laser nephelometry. In our pilot study CRP levels were determined by the MAP assay described above. 
CRP levels will be measured by both methods in the proposed trial. The hs-CRP assays will be performed by the clinical laboratory of 
the Minneapolis VA Health Care System (MVAHCS). Using both procedures to determine plasma CRP levels will permit comparison 
with published data from the study of other inflammatory states.  
Plasma TAT levels will be quantified by enzyme-linked immunosorbent assay (ELISA) using the AssayMax Human TAT Complexes 
ELISA Kit from AssayPro®. The TAT ELISAs will be performed in Dr. Bach’s laboratory. All personal protective equipment 
appropriate for the handling of blood and blood products are used. Study personnel are trained in proper handling techniques for 
biohazards and hazardous chemicals.  
Other clinical laboratory tests will be performed in order to establish that certain exclusion criteria are not met. The tests will include a 
CBC, creatinine, blood glucose, hemoglobin A1C, and hs-CRP. Also, the CBC, hemoglobin A1C, blood glucose, and hs-CRP assay 
will be performed at each study visit. These tests will be will be conducted by the clinical laboratory of the MVAHCS. The laboratory 
has met all applicable standards for accreditation and is accredited by the College of American Pathologists. Its CLIA number is 
24D0988147. 
 
Recruitment methods The primary method for recruiting potential subjects will be an institutional review board (IRB)-approved 
recruitment letter sent to Gulf War veterans identified through registries and prior studies. Gulf War veterans who participated in our 
pilot study will be invited to participate in the trial.  Additional names of potential subjects will come from MVAHCS Gulf War 
Registry. This list currently includes 1,418 names. Any veteran deployed to the Gulf with an honorable discharge during Operation 
Desert Shield, Operation Desert Storm, and Operation Iraqi Freedom is eligible to have the Gulf War Physical and be included on this 
local registry. The addresses for the registrants are found in the Computerized Patient Record System (CPRS) of the MVAHCS. Some 
of the addresses in CPRS  will be no longer be current, as some people have moved since having the registry physical and have not 
updated their medical records with the facility, but the names and addresses Gulf War veterans are also available from other lists 
described below.  
 
Addresses of Gulf War veterans will also be obtained from lists generated by the DoD Data Manpower Data Center (DMDC) and the 
VA Decision Support Service (DSS). These lists, whose constituents overlap, have 4,371 and 1,871 names, respectively. The DMDC 
list is made up of US Armed Forces veterans who served in the Gulf War (1990-1991) with their most current DoD addresses located 
in Minnesota or Western Wisconsin within the VISN 23 boundary. The DSS list consists of addresses for Gulf War who have medical 
charts in the MVAHCS CPRS, live within 250 miles of the MVAHCS, and do not have a diagnosis of hepatitis, cancer, diabetes, 

13 
 
terminal illness, or condition that would prevent informed consent or survey completion, which would render them ineligible to 
participate in the study. In sum, we have access to names and addresses of more than 5,000 Gulf War veterans who are potentially 
eligible to participate in this study. 
 
Another method for reaching potential study subjects is a recently added feature of the MVAHCS in-house daily email newsletter. The 
newsletter now contains a posting section for active research studies. With IRB approval, the trial will be posted there. With veterans 
composing 26% of our MVAHCS workforce, this newsletter has the possibility of reaching many potential subjects. In addition, 
posters, fliers, and announcements in local media may also be used to further enhance recruitment. Contact with local Veterans’ 
Service Organizations (VSOs) and County Veteran Service Officers (CVSOs) and advertising for participation via their venues may 
also be employed.  
 
Human subject-to-group assignment process Block randomization will be used to assign participants to comparison groups. For each 
consecutive pair of enrolled subjects, one member will be assigned to the treatment condition, the other member to the placebo 
condition. The pseudo-random number generator in Microsoft Excel will be used to generate random numbers to permit the treatment 
assignment within each pair (block) of subjects. Treatment assignment codes will be generated and kept by the biostatistician. These 
codes will be stored on the secure VA Server behind VA firewalls.  
 
Case Definition of GWI Eligible participants for the proposed study are Gulf War veterans who were deployed in the Kuwaiti Theatre 
of Operations between August 2, 1990 and July 31, 1991 and who have GWI. The Kansas GWI case definition questionnaire will be 
administered as a screening tool in order to determine eligibility to participate in the study.   It has both exclusionary and inclusionary 
components. The Kansas GWI case definition was developed by Dr. Lea Steele from her population-based survey of over 2,000 
Kansas Gulf War veterans (49). It is a more comprehensive analysis of eligibility than the Fukuda case definition (CDC-10) employed 
in the pilot study (5). To be considered a “case” of GWI requires: 
 
• Veterans endorse moderately severe and/or multiple symptoms in at least 3 of 6 symptom domains: fatigue/sleep problems, 
pain symptoms, neurological/cognitive/mood symptoms, gastrointestinal symptoms, respiratory symptoms, and skin 
symptoms. 
• The symptoms first became a problem during or after the Gulf War. 

14 
 
Statistical Plan and Data Analysis: 
Power analysis The power calculation is based results from CSP #470 (Cognitive Behavioral Therapy and Aerobic Exercise for Gulf 
War Veterans’ Illnesses: A Randomized Controlled Trial) (44). The study population, GWIpositive Gulf War veterans, and the primary 
outcome measure, SF-36V PCS, are the same in CS #470 and this proposed trial.  
 
Based on an estimate of the variability of change in SF-36V PCS, i.e., variability associated with change in SF-36V PCS in response 
to a 3-month exercise intervention, we calculated that n=40 subjects per group will be needed to detect the difference between a 7-
point change in SF36V PCS in response to medication (versus no change in placebo response) with 80% power at the p=0.05 
significance level (nQuery Advisor v 7.0).  
 
A 7-point increase in the SF-36V PCS in GWIpositive veterans is believed to be clinically meaningful. The support for this assertion is 
presented in the design paper for CSP #470 (43). Based on the sample size estimate and a maximum projected attrition rate of 20%, a 
recruitment goal of 100 participants (50 per group) has been set for the Gulf War Illness Inflammation Reduction Trial.  
 
Data analysis The analysis of the data will first focus on the primary outcome measure of physical functioning (SF-36V PCS). Study 
subjects will be classified after the 8 week treatment phase as “improved/not improved” relative to baseline using the criteria of CSP 
#470 for a positive response of a 7-point or greater increase in the SF-36V PCS (43, 44). This outcome variable will be analyzed using 
logistic regression. Treatment condition will be the primary predictor variable in this model with age, gender, medications, complete 
blood count (CBC), body mass index, and baseline PCS included as adjustment covariates. 
 
The first round of data analysis will be followed by the analysis of differences in the outcome measures. The first group includes 
measures of symptoms and mental health-related functioning: MPQ, MFI, CFQ, and SF-36V MCS.  The second group includes the 
biomarkers of inflammation. Differences will be assessed using separate analyses of covariance.  Post-treatment scores will be the 
outcome variables. Baseline measurements of the same outcome variable will be included as an adjustment covariate along with age, 
gender, medications, CBC, and body mass index.  
 
An intent-to-treat analysis will be used for the primary and secondary outcome measures. Participants without calculable PCS scores 
at baseline will be excluded from the analysis. Participants who withdraw from the study or miss the final study visit will be classified 
as not improved. Missing values at the final assessment due to patient dropout will be set to equal baseline scores (last-observation-
carried-forward strategy).  Parallel analyses will be conducted on intent-to-treat (all patients) and per protocol (completers only) 
datasets. All outcome variables will be assessed for distributional normality.  Non-normally distributed data will be transformed, if 
possible, to achieve a normal distribution.  All primary and secondary outcome measures will be administered three times (0 weeks-8 
weeks-16 weeks). 
 
 

15 
 
Support 
 
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1. Research Advisory Committee on Gulf War Veterans’ Illnesses. Gulf War Illness and the Health of Gulf War Veterans: 
Scientific Findings and Recommendations. Washington, D.C.: U.S. Government Printing Office, November, 2008. 
2. Institute of Medicine of the National Academies Committee on Gulf War and Health. Gulf War and Health, Volume 8: Update 
of Health Effects of Serving in the Gulf War. Washington, DC: The National Academies Press. 2009. 
3.  Kang HK. Mahan CM. Lee KY. Magee CA. Murphy FM. Illnesses among United States veterans of the Gulf War: a 
population-based survey of 30,000 veterans. J Occup Environ Med. 2000; 42:491-501.  
4. Kang HK. Li B. Mahan CM. Eisen SA. Engel CC. Health of US Veterans of 1991 Gulf War: A Follow-Up Survey in 10 
Years. J Occup Environ Med. 2009; 51:401-410. 
5. Fukuda K. Nisenbaum R. Stewart G. et al. Chronic multisymptom illness affecting Air Force veterans of the Gulf War. 
JAMA. 1998; 280: 981-988.  
6. Yeh ETH. Willerson JT. Coming of age of C-reactive protein: using inflammation markers in cardiology. Circulation. 2003; 
107:370-372. 
7. Zhang JM. An J. Cytokines, Inflammation and Pain. Int Anesthesiol Clin. 2007; 45(2): 27–37. 
8. Davis MC. Zautra AJ. Younger J. et al. Chronic stress and the regulation of cellular markers of inflammation in rheumatoid 
arthritis: implications for fatigue. Brain Behave Immun. 2008; 22(1): 24-32. 
9. Roberts RO. Geda YE. Knopman DS. Et al. Association of C-reactive protein with mild cognitive impairment. Alsheimers 
Dement. 2009; 5(5): 398-405.  
10. Shucard JL. Gaines JJ. Ambrus J. Shucard DW. C-reactive protein and cognitive deficits in systemic lupus erythematosus. 
Cog Behav Neurol. 2007; 20(1): 31-37 
11. Vogelaar L van't Spijker A. van Tilburg AJP et al. Determinants of fatigue in Crohn's disease patients. European Journal of 
Gastroenterology & Hepatology. 2013;25:246-251.  
12. Solaro C. Uccelli MM. Management of pain in multiple sclerosis: a pharmacological approach. Nature Reviews Neurology. 
2011; 7(9):519-27.  
13. Dantzer R. Capuron L. Irwin MR. et al. Identification and treatment of symptoms associated with inflammation in medically 
ill patients. Psychoneuroendocrinology (2008); 33: 18–29. 
14. Li J. Li F. Zhao A. Inflammation and leptin. Drug Discovery Today. 2006; 3: 387-393. 
15. Carlton ED. Demas GE. French SS. Leptin, a neuroendocrine mediator of immune responses, inflammation, and sickness 
behaviors. Hormones and Behavior. 2012; 62: 272-279. 
16. Harden LM. du Plessis I. Poole S. Laburn HP. Interleukin-6 and leptin mediate lipopolysaccharide-induced fever and sickness 
behavior. Physiology & Behavior. 2006; 89: 146-155. 

16 
 
17. Piche T. Huet PM. Gelsi E. et al. Fatigue in irritable bowel syndrome: characterization and putative role of leptin. European J 
of Gastroenterology & Hepatology. 2007; 19: 237-243. 
18. Forsgren S. Grimsholm O.Dalen T. Dahlqvist SR. Measurements in the blood of BDNF for RA patients and in response to 
anti-TNF treatment help us to clarify the magnitude of centrally related pain and to explain the relief of this pain upon 
treatment. International Journal of Inflammation.2011; article ID 650685. 
19. Merighi A. Salio C. Grirri A. et al. BDNF as a pain modulator. Progress in Neurobiology. 2008; 85: 297-317. 
20. Haas L. Portela LVC. Bohmer AE. Oses JP. Lara DR. Increased plasma levels of brain derived neurotrophic factor (BDNF) in 
pataients with fibromyalgia. Neurochem. Res. 2010; 35: 830-834. 
21. Majno G. Chronic inflammation: links with angiogenesis and wound healing. Am J Path. 1998; 153, Issue (4): 1035–1039. 
22. Eming SA. Krieg T. Davidson JM. Inflammation in wound repair: molecular and cellular mechanisms. J Invest Dermatol. 
2007; 127(3): 514-25. 
23. Hannan KL. Berg DE. Baumzweiger W. Harrison HH. Berg LH. Ramirez R. Nichols D. Activation of the coagulation system 
in Gulf War Illness: a potential pathophysiologic link with chronic fatigue syndrome, a laboratory approach to diagnosis. 
Blood Coagulation and Fibrinolysis. 2000; 11: 673-678. 
24. Johnson GJ. Leis LA. Slater BCS. Bach RR. Elevated platelet count, CRP and thromboxane analog-induced platelet 
aggregation in subjects with Gulf War Veterans' Illnesses: evidence of a chronic inflammatory state? Blood Coagulation and 
Fibrinolysis (in press). 
25. Esmon,CT. Xu J. Lupu F. Innate immunity and coagulation. J Thromb Haemost. 2011; 9 (suppl 1):182-188. 
26. Levi M. van der Poll T. Buller HR. Bidirectional relations between inflammation and coagulation. Circulation. 2004; 
109:2698-2704. 
27. Esmon CT. The interactions between inflammation and coagulation. Brit J Haematol. 2005; 131:417-430. 
28. Institute of Medicine of the National Academies Committee on Gulf War and Health. Gulf War and Health, Volume 9: 
Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. 2013. 
29. Nicolaides NC. Galata Z. Kino T. Chrousos GP. Charmandari E. The human glucocorticoid receptor: molecular basis of biologic 
function. Steroids. 2010; 75: 1–12. 
30. Yamamoto Y. Gaynor RB. Therapeutic potential of inhibition of the NF-κB pathway in the treatment of inflammation and 
cancer. J Clin Invest. 2001; 107:135–142. 
31. De Bosscher K. Vanden Berghe W. Haegeman G.The interplay between the glucocorticoid receptor and nuclear factor-kappaB 
or activator protein-1: molecular mechanisms for gene repression. Endocr Rev. 2003; 24: 488–522. 
32. Rao NAS. McCalman MT. Moulos P. et al. Coactivation of GR and NFKB alters the repertoire of their binding sites and target 
genes. Genome Res. 2011; 21: 1404-1416. 

17 
 
33. Clarke L. Kirwan J. Efficacy, safety and mechanism of action of modified-release prednisone in rheumatoid arthritis. Ther 
Adv Musculoskel Dis. 2012; 4(3):159-166. 
34. Buttgereit F. Doering G. Schaeffler A. et al. Targeting pathophysiological rhythms: prednisonechronotherapy shows sustained 
efficacy in rheumatoid arthritis. Ann Rheum Dis. 2010; 69:1275–1280.  
35. Alten R, Doring G. Cutolo M. et al. Hypothalamus-pituitary-adrenal axis function in patients with rheumatoid arthritis treated 
with nighttime-release prednisone. J Rheumatol. 2010; 37:2025-2031.  
36. Kirwan J. Targeting the time of day for glucocorticoid delivery in rheumatoid arthritis. Int J Clin Rheum. 2011; 6: 273-279. 
37. Kirwan JR. Buttgerreit F. Symptom control with low-dose glucocorticoid therapy for rheumatoid arthritis. Rheumatology. 
2012; 51:iv14-iv20. 
38. Buttgereit F. Doering G. Schaeffler A. et al. Efficacy of modified-release versus standard prednisone to reduce duration of 
morning stiff ness of the joints in rheumatoid arthritis (CAPRA-1): a double-blind, randomized controlled trial. Lancet. 2008; 
371: 205–14. 
39. Buttgereit F. Mehta D. Kirwan J. Low-dose prednisone chronotherapy for rheumatoid arthritis: a randomized clinical trial 
(CAPRA-2). Ann Rheum Dis. 2013; 72(2):204-210. 
40. Kazis LE. Skinner K. Rogers W. Lee A. Ren XS. Miller D. Health Status and Outcomes of Veterans: Physical and Mental 
Component Summary Scores (SF-36V). Washington, DC, and Bedford, Mass: Office of Performance and Quality, Health 
Assessment Project, Center for Health Quality Outcomes and Economic Research, HSR&DService, and Veterans 
Administration; July 1998. 
41. Kazis LE, Miller DR, Clark J, et al. Health related quality of life in patients served by the Department of Veterans Affairs: 
results from the Veterans Health Study. Arch Intern Med. 1998; 158: 626-632. 
42. Kazis LE. Ren XS. Lee A. et al. Health status in VA patients: results from the Veterans Health Study using the Veterans SF-
36. Am J Med Qual. 1999; 14: 28-38. 
43. Donta ST. Clauw DJ. Engel CC. et al. Cognitive behavioral therapy and aerobic exercise for Gulf War veterans' illnesses: A 
randomized controlled trial. JAMA 2003; 289; 1396-1404. 
44. Guarino P Peduzzi P Donta ST. et al. A multicenter two by two factorial trial of cognitive behavorial therapy and aerobic 
exercise for Gulf War veterans’ illnessses: Design of a Veterans Affairs Cooperative Study (CSP #470). Controlled Clinical 
Trials. 2001; 22: 310-332. 
45. Melzack R. The short-form McGill Pain Questionnaire. Pain. 1987; 30: 191-197. 
46. Wilkie DJ. Savedra MC. Holzemer WL. Tesler MD. Paul SM. Use of the McGill Pain Questionnaire to measure pain: a meta-
analysis. Nurs Res. 1990; 39: 36–41. 

18 
 
47. Smets EM. Garssen B. Bonke B. De Haes JC. The Multidimensional Fatigue Inventory (MFI): psychometric qualities of an 
instrument to assess fatigue. J Psychosom Res. 1995; 39: 315-325. 
48. Broadbent DE. Cooper PF. FitzGerald P. Parkes KR. The cognitive failures questionnaire (CFQ) and its correlates. Br J Clin 
Psychol. 1982; 21: 1-16. 
49. Steele L. Prevalence and patterns of Gulf War iIllness in Kansas veterans: association of symptoms with characteristics of 
person, place, and time of military service. Am J Epidemiol. 2000; 152: 992-1002.  
 
 
 

19 
 
List of Abbreviations, Acronyms, and Symbols: 
BDNF  
 
Brain-Derived Neurotrophic Factor  
BRM  
 
Biologic Response Modifiers 
CBC  
 
Complete Blood Count 
CDC-10 
 
Centers for Disease Control 10 Question Symptoms Assessment 
CDMRP  
 
Congressionally Directed Medical Research Programs  
CFQ   
 
Cognitive Failures Questionnaire   
CITI 
 
 
Collaborative Institutional Training Initiative 
COX  
 
Cyclooxygenase 
CMI 
 
 
Chronic Multisymptom Illness 
CPRS   
 
Computerized Patient Record System  
CRP 
 
 
C-Reactive Protein 
CRADA 
 
Cooperative Research and Development Agreement 
CSP 
 
 
Cooperative Studies Program 
CVSO  
 
County Veteran Service Officer  
DMARD 
 
Disease-Modifying Anti-Rheumatic Drug  
DMDC  
 
Data Manpower Data Center   
DoD 
 
 
Department of Defense  
DR 
 
 
Delayed Release 
DRS   
 
Data Request System  
DSMB  
 
Data and Safety Monitoring Board  
DSS 
 
 
Decision Support Service 
ELISA  
 
Enzyme-Linked Immunosorbent Assay 
GC 
 
 
Glucocorticoid 
GCP  
 
Good Clinical Practices 
GCR  
 
Glucocorticoid Receptor  
GRECC 
 
Geriatric Research, Education & Clinical Center  
GWI   
 
Gulf War Illness 
GWIRP  
 
Gulf War Illness Research Program 
HIPAA 
 
Health Insurance Portability and Accountability Act 

20 
 
HRPO  
 
Human Research Protection Office 
HRQOL  
 
Health-Related Quality of Life 
hs-CRP 
 
high-sensitivity CRP 
IκB  
 
 
Nuclear Factor-kappa B Inhibitor 
IL-1β  
 
Interleukin 1 beta 
IL-6 
 
 
Interleukin 6 
IPF 
 
 
Immature Platelet Fraction  
IRB 
 
 
Institutional Review Board 
ISO 
 
 
Information Security Officer 
MAP  
 
Multi-Analyte Profiling 
MCS   
 
Mental Component Summary 
MFI   
 
Multidimensional Fatigue Inventory 
MPQ  
 
McGill Pain Questionnaire- Short Form 
MS 
 
 
Multiple Sclerosis 
MVAHCS 
 
Minneapolis VA Health Care System  
NDA  
 
Non-Disclosure Agreement 
NF-κB  
 
Nuclear Factor-kappa B 
NSAID  
 
Nonsteroidal Anti-Inflammatory Drug 
OHRP  
 
Office of Human Research Protections 
OIG   
 
Office of the Inspector General 
ORO  
 
Office of Research Oversight 
ORP  
 
Office of Research Protections 
ORD  
 
Office of Research and Development 
PCS   
 
Physical Component Summary 
PHI 
 
 
Protected Health Information 
PI 
 
 
Principal Investigator 
PO 
 
 
Privacy Officer 
RA 
 
 
Rheumatoid Arthritis 
RIPS  
 
Research Information Protection Subcommittee 
SDTU   
 
Special Diagnostic Treatment Unit  
SF-36V 
 
Veterans Short Form 36-Item Health Survey 
SLE 
 
 
Systemic Lupus Erythematosus 
TAT 
 
 
Thrombin-Antithrombin Complex 
TPO 
 
 
Thrombopoietin 

21 
 
TF 
 
 
Tissue Factor 
TRAP  
 
Thrombin Receptor Activating Peptide 
UDS  
 
Upload-Download System 
UPS 
 
 
United Parcel Service 
USAMRMC  
US Army Medical Research and Materiel Command 
VA  
 
 
Department of Veterans Affairs  
VHA  
 
Veterans Health Administration 
VSO  
 
Veterans’ Service Organization 
 
 

22 
 
 
Facilities, Existing Equipment, and Other Resources: The Minneapolis VAHCS is a large medical facility with excellent research 
space and resources. The VAHCS is only 10 minute by light rail connection from the main terminal of the Minneapolis/St. Paul 
International Airport. Dr. Bach's and Dr. Johnson’s laboratories are located in two adjacent rooms. Their main labs are 500 square feet 
each and Dr. Bach’s second lab directly across the hall is 250 square feet. 
The Research Service of the Minneapolis VAHCS provides the infrastructure necessary to 
carry out this research. The Special Diagnostic Testing Unit (SDTU) located in the MVAHCS is the location where the physical 
exams and blood draws will take place. A Registered Nurse will perform the blood draws in a quiet and private setting. The SDTU 
intake room will be the designated meeting room for the study visits.  
Staff members are in place to manage budgets, place orders, and meet all regulatory requirements. Research oversight is provided by 
the Research and Development Committee, the entity within Research Service overseeing two IRB committees, the subcommittee on 
research safety, and the subcommittee on animal care and use. In addition to laboratory space there are rooms in the research wing 
containing common equipment for use by all VA investigators and meeting rooms with the requisite audiovisual equipment for 
scientific presentations.  
The VISN23 Gulf War Registry at the Minneapolis VAHCS contains the names of approximately 1,400 veterans. This Gulf War 
Registry is one starting point for our recruitment of individuals to participate in this study.  
The Investigational Pharmacy at the MVAHCS will be the site for the management of the study drug. The Investigational Pharmacist 
will provide documentation of drug receipt, storage, dispensing, documentation of dispensing, monitoring expiration date of study 
drugs, documentation of study drug return, and study drug destruction.   
Equipment: Dr. Bach’s laboratory includes the following major equipment: Nuaire model NU-425-400 laminar flow hood, Napco 
model 5410 CO2 incubator, Dynatech Ultrawash II microtiter plate washer, Molecular Diagnostics SpectraMax M5 microtiter plate 
reader, Rainin Liquidator 96 manual benchtop pipetting system, Coag-A-Mate XM coagulation instruments (2), Savant Speed Vac, IEC 
Centra-CL2 centrifuges (4), Eppendorf model 5415C microfuges (2), Eppendorf model 5242 microfuge, Beckman Microfuge 11 (2), 
Nikon TMS inverted microscope, Beckman Coulter Ac●T diff 2TM hematology analyzers(2), Beckman Coulter Z2 cell and particle 
counter.  
There are two Dell desktop computers in the lab connected to the VA network. In addition to the standard Microsoft Office Suite 
package provided by VA, both computers have additional statistics, graphics, and curve fitting and statistics software and for data 
handling (SigmaPlot® 11). The laboratory also contains -20oC and -80oC freezers, a refrigerator/freezer combination, Dewar liquid 
N2 cell storage, a fume hood, Rainin manual and automatic pipettes, electrophoresis power supplies and equipment, analytical and top 
loading balances, pH meter, stirrers, water baths, temperature blocks, fraction collectors, etc. 
 Common Service equipment in Minneapolis VAHCS Research Service includes spectrofluorimeters, spectrophotometers, preparative 
and ultracentrifuges, confocal microscope, an imaging center, and walk-in cold rooms. 
 
 

23 
 
Intellectual Property: 
Background and Proprietary Information Elements relating to proprietary information and intellectual property are addressed in the 
CRADA. Horizon Pharma, Inc. has agreed to the terms of the CRADA. 
 
Intellectual and Material Property Plan The Principal Investigator, Dr. Ronald R. Bach is a full-time VA employee with an 
appointment as an Assistant Professor at the University of Minnesota. The VA and the University of Minnesota have a Cooperative 
Technology Administration Agreement (CTAA) which governs intellectual property rights where VA staff develop an invention and 
both VA and the University assert an interest in the invention VA and the University have experience using the CTAA when dual-
appointed personnel develop inventions. 
 
Commercialization Strategy Does not apply. 
 
Data and Research Resources Sharing Plan Data and research resources generated by this clinical trial will be 
made available to the research community and to the public at large. Data sharing will occur in a timely fashion. 
The expectation is that this will occur no later than the acceptance for publication of the main findings from the 
final dataset. The informed consent documents for this clinical trial will take the Data and Research Resources 
Sharing Plan into consideration and will address any potential risks for study subjects. 
Data sharing will be under the auspices of the PI. A data-sharing agreement that imposes appropriate limitations on user will be 
prepared. This agreement will ensure that the dataset will not be misused or misinterpreted.  Approvals for this agreement will be 
obtained from the MVAHCS IRB, Privacy Officer (PO), and Information Security Office (ISO) as well as the US Army Medical 
Research and Materiel Command (USAMRMC) Office of Research Protections (ORP), Human Research Protection Office (HRPO).  
Data sharing will be performed in accord with VA and USAMRMC policies and procedures.   
Central to the data sharing process is protection of study subject privacy. Shared data will contain no PHI. The 
agreement will specify the criteria for access to the de-identified data, conditions for research use, privacy and 
confidentiality standards to ensure data security at the recipient site, and prohibitions for manipulating data for 
the purposes of identifying subjects. The agreement will also contain elements safeguarding confidential and 
proprietary data, and third-party intellectual property.  
 
 
 

24 
 
Technical Abstract 
 
Background: Today approximately one-third of the U.S. military personnel who served in the 1990-1991 Gulf War are suffering from 
Gulf War Illness (GWI), an unexplained chronic multisymptom illness. The absence of information regarding the underlying 
pathophysiology of GWI has hindered efforts to develop effective treatments. Therefore, we performed a pilot study comparing blood 
samples from Gulf War veterans with and without multiple symptoms of pain, fatigue, and cognitive dysfunction. The goal of the pilot 
study was to identify a potential therapeutic target for the treatment of GWI. Proteomic analysis revealed a biomarker signature of 
innate immune system activation in veterans with GWI. Thus, chronic inflammation was identified as a potential therapeutic target. 
Objective/Hypothesis: The objective is to find an evidence-based treatment for GWI. This proposal is based on the hypothesis that 
chronic inflammation is part of the underlying pathophysiology of GWI. The elevated biomarkers of inflammation observed in veterans 
with GWI in our pilot study are associated with increased symptoms of pain, fatigue, and cognitive dysfunction in chronic inflammatory 
diseases. Therefore, an intervention that reduces this GWI-associated inflammation may alleviate some symptoms of the disorder and 
significantly improve the health-related quality of life (HRQOL) of veterans with GWI.  
Specific Aims: Standardized self-report measures and plasma proteomics will be used to evaluate treatment-related changes. The 
assessments will be performed at the beginning and the end of the eight week treatment period and again eight weeks after the end of 
treatment. The specific aims of this study are as follows: 
• Specific Aim 1: To measure the effects of the treatment on physical and mental functioning (Veterans Short Form 36-Item Health 
Survey).  
• Specific Aim 2: To assess intervention-related changes in symptoms: pain (McGill Pain Questionnaire-Short Form), fatigue 
(Multidimensional Fatigue Inventory), and cognitive dysfunction (Cognitive Failures Questionnaire).  
• Specific Aim 3: To quantify changes in biomarkers of inflammation in response to the treatment (plasma proteomics). 
Study Design: The proposed study is a randomized, two-group, double-blind, placebo-controlled clinical trial of delayed-release 
prednisone versus matching placebo. A total of 100 veterans with GWI will be enrolled in the trial. Prednisone was chosen as the 
study drug because of its well-established pleiotropic anti-inflammatory properties.  
Impact: A successful trial with improved clinical outcomes and reduced proinflammatory biomarkers would validate the hypothesis 
that chronic inflammation is part of the underlying pathophysiology of GWI. A new paradigm for the diagnosis and treatment of GWI 
would be established. The potential impact of this new paradigm on the health and well-being of veterans with GWI is significant.  
 
 

25 
 
Lay Abstract 
 
The goal of this clinical trial is to determine if reducing inflammation is an effective treatment for Gulf War Illness (GWI). In our pilot 
study blood samples from Gulf War veterans with and without GWI were compared.  There was strong evidence of chronic 
inflammation in veterans with GWI. Thus, chronic inflammation was identified as a potential target for treatment. 
Only veterans with GWI will be enrolled in this study. An established anti-inflammatory drug known as prednisone will be the 
medication. Prednisone is widely used for the treatment of certain chronic inflammatory diseases. A new form of the drug known as 
delayed-release prednisone will be used in this study. It is designed to release the medication into the blood stream at ~2 AM when 
prednisone is most effective at reducing inflammation. 
The dose of the drug and the length of the treatment were chosen to maximize the benefits of the treatment while minimizing the risks 
involved in taking the drug. Half the volunteers will take a pill containing the drug (treatment group) and half will take a pill that 
contains no medication (control group). The two pills will appear to be identical. Tests that measure quality of life, GWI symptoms, 
and inflammation will be performed three times during the study: at the beginning of the treatment period, at the end of the eight week 
treatment period, and eight weeks following the end of treatment. The trial will be completed in four years. 
This clinical trial presents the exciting opportunity to determine if treating inflammation in veterans with GWI reduces their symptoms 
and improves their quality of life. If the results of the trial are positive, then a new point of view regarding the diagnosis and treatment 
of GWI would be established.  
Using biomarkers of inflammation may improve diagnosis. Focusing on treatments designed to reduce inflammation and minimize 
toxicity could lead to additional improvements in the care of veterans with GWI. The impact of these changes on the health and well-
being of veterans with GWI would be significant. 
 
 

26 
 
Statement of Work  
September 12, 2013 
Proposed Start Date:  August 15, 2014  
 
 
Specific Aims:  
The first specific aim is to measure the effects of the treatment on physical and mental functioning (Veterans Short Form 36-Item Health 
Survey). The second specific aim is to assess intervention-related changes in symptoms: pain (McGill Pain Questionnaire-Short Form), 
fatigue (Multidimensional Fatigue Inventory), and cognitive dysfunction (Cognitive Failures Questionnaire). The third specific aim is 
to quantify changes in biomarkers of inflammation (plasma proteomics) in response to the treatment. 
 
Abbreviations: MVAHCS = Minneapolis Veterans Affairs Health Care System, GWV= Gulf War Veteran, GWI= Gulf War Illness 
HRQOL = Health-Related Quality of Life, RCT = Randomized Controlled Trial, MVMREF= Minnesota Veterans’ Medical Research 
and Education Foundation, HP= Horizon Pharma, SRS= Subcommittee for Research Safety, USAMRMC= U.S. Army Medical 
Research & Materiel Command, HRPO= Human Research Protection Office, CITI= Collaborative Institutional Training Initiative 
SDTU= Special Diagnostic Testing Unit, CRADA = Cooperative Research and Development Agreement, IRB = Institutional Review 
Board, DSMB= Data and Safety Monitoring Board ACR= Authorization to Conduct Research 
 
 
 

27 
 
 
 
Timeline 
(months) 
MVAHCS 
Major Task 1:Preparation for Initiation of Randomized Controlled Trial 
1-6 
 
1a.Coordinate with HP for nondisclosure agreements (NDAs) 
completed 
RRB 
1b. Submission and exemption of an Investigational New Drug (IND) application 
completed 
BCSS 
1c. Coordinate with HP for CRADA submission 
submitted 
RRB 
1d. Prepare Request for Waiver of Consent for Screening 
1-6 
BCSS 
1e. Prepare IRB Initial Application, including consent form, HIPAA & human subjects protocol 
1-3 
BCSS 
1f. Prepare SRS Safety Checklist and Hazard Assessment 
1-6 
BCSS 
1g. Design job descriptions, advertise, interview, and hire project related staff 
1-6 
RRB/GJJ 
1h. Create flow chart for all study steps, data collection and database requirements 
4-6 
BCSS 
1i. Complete Project Training = CITI, Chemical Safety, Information Safety and Security 
1-6 
RRB/GJJ/BCSS 
1j.Arrange for Memorandum of Understanding with VA Clinical Laboratory Service  
1-6 
RRB 
1k. Arrange for Blood Draws and Appointment Scheduling for Screening Physicals on SDTU 
1-6 
GJJ/BCSS 
1l. Set up documentation with MVMREF for Disbursement Authorization for Subject Payments 
1-6 
BCSS 
1m. Finalize arrangements with HP for delivery of study drug and placebo 
1-6 
BCSS 
1n. Meet with Research Pharmacist to set-up plan for study drug management 
1-6 
BCSS 
1o. Finalize Randomization plan with Study Statistician  
6 
BCSS/MK 
1p. Submit IRB approved ACR, Consent and HIPAA forms, Regulatory Documents to USAMRMC 
6 
RRB/BCSS 
Milestone Achieved: Treatment protocol, Research Pharmacy, Statistician and SDTU plans finalized 
6 
RRB/GJJ/HK 
Milestone Achieved: Local IRB, SRS approval 
6 
RRB/GJJ 
Milestone Achieved: at MVAHCS 
3 
RRB/GJJ 
Milestone Achieved: Authorization to Conduct Research granted at MVAHCS 
5 
RRB/GJJ 
Milestone Achieved: Regulatory and Administrative Approval at USAMRMC ORP and HPRO 
6 
RRB/GJJ 
Milestone Achieved: New research staff hired 
1-3 
RRB/GJJ 
Milestone Achieved: Research staff completes training 
1-6 
RRB/GJJ 

28 
 
 
Human Subjects Procedures 
 
 
Study Population: Gulf War veterans with Gulf War Illness (as defined by the Kansas case definition) are the focus of this study. All 
will be veterans of the first Gulf War (August 1, 1990 to July 31, 1991). The subjects, who may be males and females of all races and 
ethnic origins, are expected to be between 38 years and 70 years old. There are no targeted populations for this study. Vulnerable 
populations will not be targeted. There will be no children participating in the study. 
Inclusion/Exclusion Criteria: After the initial medication questions, the veteran will be asked to answer the Kansas Gulf War Illness 
(GWI) Case definition questionnaire. Waivers of Consent and HIPAA will have been requested and obtained from the IRB in order to 
screen using the Kansas GWI Case definition questionnaire. The Kansas GWI Case definition questionnaire includes both 
inclusionary and exclusionary conditions. Only those having “moderate/severe” scores in 3 out of 6 categories listed in the Kansas 
GWI Case definition will meet inclusion criteria.  In addition to the Kansas Criteria, subjects must also be willing to make several trips 
to the Minneapolis VAHCS for study visits and to take the study drug as directed. Subjects will be informed of the potential for drug 
interactions for medicines prescribed during the course of the study. Information regarding the use of the study drug will be given to 
each study subject (see Instructions for Study Medication attachment). Subject will be instructed to inform their personal physicians 
that they are participating in a research study involving treatment. Veterans, who are hypersensitive to any of the ingredients in 
prednisone, have active liver or kidney disease, untreated hypertension, diabetes or are pregnant or nursing, will not be permitted to 
participate. Additionally, those with inflammatory arthritis (RA, psoriatic arthritis, spondylitis, reactive arthritis, or IBD associated 
arthritis) will be excluded. Any other major inflammatory disease like active acute or chronic infections, ulcerative colitis, Crohn’s 
disease, inflammatory lung diseases, pericarditis, vasculitis, will all also be excluded. People meeting other inclusion criteria but with 
active infections could be rescreened when their infections clear. 
Veterans with diagnosed chronic conditions (e.g. Lupus, Stroke, Multiple Sclerosis, and fibromyalgia) that can produce symptoms, 
such as fatigue, cognitive impairment, and pain will be excluded based on the Kansas GWI Case definition questionnaire. Also, 
veterans who have conditions that might interfere with the ability to accurately report symptoms, such as severe psychiatric problems 
(e.g.  Schizophrenia, bipolar disorder, or alcohol/drug dependence requiring hospitalization), or administration of mind-altering 
substances such as tranquilizers, will be excluded. 
Inclusion of Women and Minorities in Study Subjects participating in this study may be males and females of all races and ethnic 
origins. 
Description of Recruitment Process: The primary method for recruiting potential subjects will be to send an IRB-approved 
recruitment letter to veterans listed on the Persian Gulf War Registry from the MVAHCS. This letter is carefully written at the 8th-
grade reading level, in order to accommodate a wide range of reading abilities. Following IRB-approval and the receipt of the 
Authorization to Conduct Research from the Research and Development Committee, the Study Coordinator will obtain the registry 
from the local registrar on behalf of the study and will prepare the mailing labels and envelopes. This list currently includes 1,418 

29 
 
names. Any veteran deployed to the Gulf with an honorable discharge during Operation Desert Shield, Operation Desert Storm, and 
Operation Iraqi Freedom is eligible to have the Gulf War Physical and be included on this local registry. The addresses for the 
registrants are found in the CPRS of the MVAHCS. Some of the addresses in CPRS  will be no longer be current, as some people have 
moved since having the registry physical and have not updated their medical records with the facility. Gulf War veterans’ names and 
addresses are also available from lists generated by the DMDC and the DSS. These lists will be generated following the placement of 
online requests using the following secure websites: https://www.dmdc.osd.mil/drs and 
http://vaww.visn23.med.va.gov/VISN23/Applications/Projects/ReportRequests/index.cfm.  
These lists, whose constituents overlap, have 4,371 and 1,871 names, respectively. The DMDC list is made up of US Armed Forces 
veterans who served in the First Gulf War (1990-1991) whose most current DoD addresses are located in Minnesota or Western 
Wisconsin within the VISN 23 boundary. Therefore, it is likely that the DMDC list may have a veteran’s actual current address. The 
DSS list consists of addresses for veterans of the Persian Gulf War (August 2, 1990 and July 31, 1991) who have medical charts in the 
MVAHCS CPRS, live within 250 miles of the Mpls VA, and do not have a diagnosis of hepatitis, cancer, or diabetes, which would 
exclude them from participating in the study. 
Because it is important to consider undue inducement in the enrollment of subjects into a study, subjects’ compensation will be limited 
to $100.00 per visit ($400.00 for the completed study). This amount is chosen because it will at least partially compensate the subject 
for missing at least a partial day of work. Because transportation to the VA would likely be outside their normal traveling distance for 
many subjects, especially those who would be traveling from outside the Twin Cities Metropolitan area, subjects will also be 
reimbursed for travel expenses at the rate of $0.415 per mile. In addition, subjects will be fasting when they arrive for each visit. 
Following each study visit, subjects will be encouraged to eat something before leaving the building. Subjects will be given a $10 food 
voucher for use in the MVAHCS cafeteria. 
We will be requesting approval for access to DMDC DRS for the purpose of conducting a clinical trial at the Minneapolis Veterans 
Affairs Health Care System. In order to receive approval for access, we must submit an IRB-approved protocol and Authorization to 
Conduct Research from the Research Service at the Minneapolis VA Health Care System. In addition to this, we will fill out the DRS 
required documentation accurately and completely. After the approval of these documents, the Principal Investigator/Study 
Coordinator of the proposed study, Gulf War Illness Inflammation Reduction Trial (Congressionally Directed Medical Research 
Programs (CDMRP) - Gulf War Illness Research Program- Clinical Trial W81XWH-13-GWIRP-CTA),  will be permitted to request 
access to a listing of Gulf War veterans' addresses for the purpose of conducting the above mentioned clinical study. 
Description of Informed Consent Process: Draft of Informed Consent provided at the end of this attachment. Because recruitment is 
being carried out using the local Persian Gulf War Registry, the research could not practicably be carried out without a waiver or 
alteration of consent for recruiting. A request for a waiver or alteration of consent for recruiting will be made.  Participation in the 
study will be initiated by an IRB-approved recruitment letter. When an interested veteran responds to the recruitment letter (by calling 
the included study hotline telephone number) he or she will be asked what medications are currently being taken.  
If the potential participant is taking a medication that would trigger exclusion, such as current oral corticosteroid or diabetic therapy, 
the coordinator will stop the interview and let the person know that participation in this study will not be permitted. Those taking 

30 
 
aspirin, ibuprofen, or other similar over-the-counter medications will not be excluded. Data on other drug use will be collected and 
presumably the randomization process will put users of other non-excluded medications equally into the two treatment groups. 
Once the veteran has met the pre-screening inclusion criteria, an initial appointment will be scheduled. Appointments will be 
conducted in the morning hours, initiated most often between the hours of 8:00am and 10:00am. At this appointment, the Study 
Coordinator will initiate the Informed Consent/HIPAA process.  This appointment includes the screening physical conducted by a VA 
physician and clinical laboratory blood tests. The process of obtaining Informed Consent is guided by Good Clinical Practices (GCP) 
and begins at the initial appointment. The potential study participant will meet the Study Coordinator in the SDTU Intake Room. In 
this quiet, private room, they will discuss the consent and HIPAA forms. A description of the study, the purpose of the study, the 
benefits and risks of participation, research subject’s rights, disclosure of protected health information and the subject’s right to 
confidentiality are among the items covered in the consenting process. If the subject would like to discuss the study with a family 
member or other accompanying person, he or she will be given the opportunity to do so at this time.  
Subjects who are unable to answer study questions, for any reason, will not be eligible to participate in the study. Any subject who 
meets any of the exclusionary criteria in the Kansas case definition will not be eligible to participate in the study. If a subject’s 
decision making capacity is questioned in any way, a modified Dysken tool will be used as an assessment tool to assess capacity.  
A potential study participant will have the opportunity to ask questions about the study and have questions answered by the Study 
Coordinator. The subject will be asked several open ended questions to assess the level of understanding just prior to signing the 
consent document. If further explanation and discussion of the study is necessary to improve the subject’s understanding of the study’s 
purpose and/or the subject’s involvement, it will be done at this time. If the veteran agrees to the content of the consent and HIPAA 
forms, he or she will voluntarily sign them. It will be stressed several times throughout the process that involvement in the study is 
strictly voluntary and the subject may withdraw at any time by notifying Dr. Bach or Dr. Johnson in writing. It will also be stressed 
that the records kept by the study team are not for clinical purposes, but rather for research purposes only and will not become part of 
their medical record. A witness to the signature will be present. Study subjects will receive a copy of the consent form. The consent 
forms will contain pertinent names and telephone numbers. Because informed consent is a process, rather than a onetime event, the 
study subject will be encouraged to ask questions as they arise throughout the course of the study. 
With the proper IRB authorizations for screening and/or recruitment and by virtue of being VA researchers, Dr. Bach and Dr. Johnson 
have access to the Gulf War registries and therefore access to the local Gulf War population. 
 Legally Authorized Representative and Assent There is no provision for obtaining consent via an individual’s Legally Authorized 
Representative. Inclusion will not be made by assent.  
Screening Procedures: Following the consenting process, the subject will have a screening appointment under the oversight of the 
Study Physician including a physical exam, Review of Systems, and blood tests. Subsequent visits will be formatted to provide an 
experience that will be predictable. By using the same appointment time and location, as often as possible, consistency of conditions 
will be met.  
Personal questions, including a list of current medications, will be asked on the screening questionnaire. Upon inclusion in the study, 
HRQOL will be measured by the SF-36V. A survey pertaining to fatigue, Multidimensional Fatigue Questionnaire, will also be 

31 
 
administered.  Pain will be assessed using the McGill Pain Questionnaire- Short Form. Cognition will be addressed using the 
Cognitive Failures Questionnaire. Subjects will answer the questions in a quiet and private room.  
Risks/Benefits Assessment: 
Foreseeable Risks Research risks to subjects include possible physical side effects from having blood drawn. They include faintness, 
inflammation of the vein, pain, bruising, or bleeding at the site of the puncture.  There is also a slight possibility of infection. There 
may be other unknown side effects that could occur. This risk is no greater than minimal risk. 
If the study subject meets inclusion criteria, additional blood samples will be obtained. These samples will be used for biomarker and 
safety analyses. The blood samples obtained from the study subjects will be strictly for purpose of the study and involve minimal risk. 
There is the slight possibility of psychological risk if answering the questions causes a subject to become uncomfortable. These 
questions pose minimal social and legal risk. 
Because the CPRS will be accessed for recruitment purposes and for the writing of Research Participant Progress Notes, there is a 
minimal risk that private personal information can be accessed for fraudulent purposes.  
There is the potential for economic harm that subjects may experience by participating in the study. There may be transportation costs 
to travel to the facility and possible lost wages due to time missed from work. To minimize potential economic harm, each subject will 
be compensated $100.00 for each visit relating to the study (3 total), and reimbursement for travel expenses ($0.415 per mile). 
Because the subject will be required to fast for the required blood tests, each subject will also receive a $10 food voucher at the end of 
each visit to the MVAHCS. 
There are physical risks involved with the administration of the study drug. Common adverse reactions to GCs include fluid retention, 
alteration in glucose tolerance, elevation in blood pressure, behavioral and mood changes, increased appetite and weight gain.   
Subjects will be informed of possible drug interactions and contraindications. Each subject will receive a medication information sheet 
listing important safety information, including drug interactions and contraindications, as well as side effects that may be of concern. 
Important telephone numbers are included in the consent documents and the study hotline is listed on the medication information 
sheet. 
Possible drug interactions include: 
• Anticoagulant agents: The study drug may enhance or diminish the effects of anticoagulant.  
• CYP 3A4 inducers and inhibitors:  These agents may respectively either increase or decrease clearance of GCs.   
• NSAIDs including aspirin and salicylates: The study drug may increase the risk of NSAID gastrointestinal side effects. 
Subjects will be instructed to take medications with food. To avoid additional NSAID side effects subjects will be advised to 
consider taking an over-the-counter proton pump inhibitor. 
 
The consent and HIPAA forms will be copied and sent to the IRB office. These copies will be the scanned into the subject’s CPRS 
record. A Research Participant Note will be written in the subject’s medical record and a flag created to notify other CPRS users that 
the subject is enrolled in an interventional study at the Minneapolis VA Health Care System. This flag will warn of participation in an 

32 
 
interventional study and act to warn of possible dual enrollment, thereby protecting the subject from experiencing the risks involved in 
participating in two studies concurrently.  
Risk Management and Emergency Response The subject will sign a HIPAA form giving the study staff permission to access his or 
her medical record.  All study staff realize the importance of keeping private personal information secure and are trained annually by 
the VA to minimize this risk. All VA sensitive research data for this protocol recorded on paper records, especially participant PHI, 
will be stored in locked file cabinets, in a locked lab, inside a security card controlled research wing of the hospital. It will be available 
and used only by approved study personnel. Before the investigators initiate the study, the privacy officer (PO) and information 
security officer (ISO) will work with the investigators to ensure the proposed research is in compliance with relevant privacy and 
confidentiality requirements, and information security requirements, respectively. They will make recommendations to the 
investigators of options available to correct any deficiencies. The PO and ISO review the proposed study protocol and any other 
relevant materials when they are submitted in the IRB application. During the course of the study, the PO and ISO will conduct 
assessments to ensure that all applicable local, VA and other Federal requirements for privacy and confidentiality, and for information 
security have been met.  
Because the MVAHCS Research Service is committed to protecting the integrity of the VA computer system and the security and 
privacy of data and PHI of study subjects, as well as that of employees, the Research Information Protection Subcommittee (RIPS) 
was formed. RIPS conducts annual audits of all Research areas to identify security and privacy vulnerabilities, assure the correction of 
these findings, educate the Research Staff in the principles of data and computer security, implement policy and procedures, and serve 
as a resource for researchers who have special data management needs. RIPS offers another layer of protection against risk for study 
subject data. To minimize risk, all VA sensitive research data for this protocol, including subject data and PHI, will be stored on a 
secure VA server behind the necessary VA firewalls. 
Because mailing lists will be generated using secure websites, the use of these private records will pose minimal risk to the subject.  
Data will be retrieved from the Data Request System (DRS) website for the DMDC report. The spreadsheets will be uploaded from 
the DRS secure website and will be linked to our DRS account through the Upload-Download System (UDS) and saved to a secure 
drive behind the firewall at the VAMHCS. The DSS report will be posted on the DSS secure drive and then moved onto a secure drive 
at the VAMHCS. 
Risk will be minimized by careful pre-screening of potential study subjects. Female subjects with child-bearing potential will agree to 
use acceptable, effective forms of contraception for the duration of the treatment portion of the study. Regular, careful monitoring of 
consented subjects is instituted to prevent or minimize potential risks.  Following informed consent, a panel of blood tests will be 
performed in order to check for possible undiagnosed liver disease, diabetes or other exclusions. Subjects with results not falling 
within accepted ranges will not be permitted to continue their participation in the study and will be withdrawn from participation. 
To minimize blood drawing risks, the blood will be drawn by skilled and experienced phlebotomists using accepted aseptic technique.  
To minimize economic risk the subjects will be compensated $100.00 per visit ($400.00 for the completed study). They will also be 
reimbursed for travel expenses at the rate of $0.415 per mile. The subjects will be fasting when they arrive for each visit. To 

33 
 
encourage them to break the fast before leaving the Medical Center, the study subjects will be given a $10 food voucher for use in the 
MVAHCS cafeteria. 
Subjects will be informed that if an adverse event occurs, depending on the severity of the effect, they need to inform the study 
coordinator, first seeking care from their own health care providers if the effect is severe. All adverse events will be monitored until 
stabilization or resolution occurs. Medical or professional intervention will be available, as necessary. Pertinent contact telephone 
numbers will be included in consent documentation and on the study medication information sheet. All serious adverse events, adverse 
events and unanticipated problems will be reported to the VA-IRB according to their current recommendations and regulations. 
Reports of aggregate safety data will be sent to the Data and Safety Monitoring Board (DSMB) on a quarterly basis. A DSMB 
composed of members who do not have a conflict of interest with the research project will be appointed. The DSMB will determine 
the frequency of its meetings, but these meetings will occur at least quarterly to coincide with the receipt of the quarterly report. A 
written report of the meeting will be forwarded to the PI, the IRB, and R&D Committee within 14 days of the each meeting.  
The DSMB will be composed of two physicians with relationships with the MVAHCS. One is a pulmonologist from the Primary Care 
Service with extensive clinical trial experience. The other recently retired MVAHCS physician was a psychiatrist from the Psychiatry 
Service with extensive expertise in psychometrics who also served as IRB committee chair. From the University of Minnesota 
Medical School, a Hematologist/Oncologist with extensive clinical research trial expertise will be appointed. All three appointees have 
extensive clinical expertise, as well as IRB and DSMB experience. The DMSB will determine the continued safety of research 
subjects based on the data submitted to the board. As the study progresses, aggregate safety data, including serious adverse events, 
adverse events and unanticipated problems, will be sent quarterly to the DSMB.  
Unanticipated problems involving risks to subjects or others will be reported to the MVAHCS IRB within 5 working days after the 
investigator becomes aware of the problem. The Unanticipated Problem Report form, located on the Research SharePoint website on 
the IRB Forms page, is used for this purpose. Any supporting documentation (de-identified) will be attached to the form. If the PI 
recognizes that the event/problem involves risk to subjects or others and a modification to the IRB consent and/or protocol is required, 
he will also submit revised copies of the consent and/or protocol, as well as a Full Committee Review Amendment form.  
Treatment assignment codes will be kept by the Biomedical Research Statistician, as well as the Research Pharmacist. This code will 
only be broken in the case of an adverse event when it is necessary for the Principal Investigators to know which treatment the patient 
is receiving before the participant can be treated or if someone not in the study uses the investigational agent.  For example, if a child 
in the participant’s household takes a study medication, the blind may be broken to determine treatment for the child. 
When it is necessary to break the blind, the researcher must notify the IRB. If the code is broken for a participant, this must be 
documented on the Adverse Event forms together with the reasons for breaking the code. The reason for breaking the code should also 
be written on the code document. The reason for premature un-blinding of the investigational product should be given, e.g. due to 
serious adverse event. 
The expected or unexpected, related or possibly related and serious or more prevalent than expected adverse event will be reported to 
the IRB no later than 5 working days after the investigator first learns of the event. An Internal Adverse Event form, located on the 

34 
 
Research SharePoint website on the IRB Forms page, must be completed and submitted to the IRB for each internal adverse event. 
The DMSB will determine the continued safety of research subjects based on the data submitted to the board. 
Emergency Care or Treatment for Adverse Event If a subject is injured or becomes ill as a result of participation in this research 
study, treatment will be available, including first aid, emergency treatment and follow-up care, as needed, through the VA Health Care 
System.  In the event a subject cannot reach a VA facility, the VA will consider payment for necessary medical care for any injury or 
illness directly related to participation in the research study. If a subject receives this type of medical care, he or she must contact the 
Research Investigator for this study. Contact information for the physicians associated with the study is located in the section of the 
consent entitled “Compensation for Any Injuries”. Subjects are instructed to immediately report any injuries resulting from 
participation in this study to Dr. Bach at (612) 467-4418 or Dr. Johnson at (612)467-4134 during the daytime hours.  If a VA 
physician needs to be contacted during the evenings or week-ends, subjects will be instructed to call the VA operator at (612) 725-
2000 and ask to have the Hematology physician-on-call paged.  Subjects will be told to tell the operator that they are a research study 
participants. Those not living in the Twin Cities metropolitan area will be instructed to call the toll-free number: 1-866-414-5058. 
Special Precautions Because subjects will be instructed to fast from midnight prior to their study appointments, vouchers for the VA 
Canteen Service will be provided to each subject following each study appointment. This will be done to encourage subjects to eat and 
drink something before leaving the building after their appointments.  
Subjects will also be instructed to take the study medicine with food each evening at bedtime, at approximately 10:00pm. 
Potential Benefits: This trial has the potential both in the short-term and in the long-term to improve the health and well-being of 
veterans with GWI. A successful trial with improved clinical outcomes and reduced biomarkers of inflammation would establish a 
new paradigm for the diagnosis and treatment of GWI. A change in clinical practice that focuses on inflammation could be 
implemented immediately. The testing of other therapeutic interventions designed to reduce inflammation and minimize toxicity could 
produce additional improvements in GWI treatment beyond those achieved in this trial.   
 
 
 
 
 
 

35 
 
Intervention 
Complete Name and Composition: RAYOS is a delayed-release prednisone tablet. It consists of a prednisone-containing core tablet 
in an inactive shell, which delays the onset of in vitro drug dissolution by approximately 4 hours. The active ingredient in RAYOS is 
prednisone, a corticosteroid. Prednisone is a synthetic adrenocortical steroid drug with predominantly corticosteroid properties. The 
molecular formula for prednisone is C21H26O5. The chemical name for prednisone is 17,21-dihydroxypregna-1,4-diene-3,11,20-trione.   
 
 
Prednisone is a white to practically white, odorless, crystalline powder and has a molecular weight of 358.43. Prednisone is very 
slightly soluble in water; slightly soluble in alcohol, chloroform, dioxane, and methanol. 
Each tablet contains 5 mg of prednisone, with the following inactive ingredients: dibasic calcium phosphate dihydrate, colloidal 
silicon dioxide, croscarmellose sodium, glycerol dibehenate, lactose monohydrate, magnesium stearate, povidone, yellow ferric oxide, 
and red ferric oxide.          
                                                            
Study Procedures:  
Screening Appointment with Physical Exam  (Week -1 or 0) Once the veteran has met the pre-screening inclusion criteria, an 
appointment will be made by the study team for the initial appointment, which will include a discussion of Informed Consent and 
HIPAA,  and a screening physical exam and blood tests. The process of obtaining Informed Consent is guided by Good Clinical 
Practices (GCP) and begins at the initial appointment. Study staff will have completed Collaborative Institutional Training Initiative 
coursework (CITI) for the protection of human research subjects and will follow best practices as described by the IRB of record. The 
potential study participant will meet the Study Coordinator in the SDTU Intake Room. In this quiet, private room, they will sit to 
discuss the consent and HIPAA forms. A description of the study, the purpose of the study, the benefits and risks of participation, 
research subject’s rights, disclosure of protected health information and the subject’s right to confidentiality are among the items 
covered in the consenting process.  
A potential study participant will have the opportunity to ask questions about the study and  have questions answered. He or she will 
be asked several open ended questions to assess the potential subject’s level of understanding. The questions will be related to the 
subject’s understanding of the study’s purpose, the side effects of the study medication, and what it means to receive a placebo. If the 
veteran agrees to the content of the consent and HIPAA forms, he or she will voluntarily sign them. A witness to the signature will be 
present. Study subjects will receive a copy of the consent form. Because informed consent is a process, rather than a onetime event, 
the study subject will be encouraged to ask questions that may arise throughout the course of the study. 
The signed consent and HIPAA forms will be copied and sent to the IRB office. These copies will be the scanned into the subject’s 
clinical record. The original will be retained in the subject’s study file in a locked cabinet in the locked laboratory.  A Research 
Participant Note will be written in the subject’s medical record and a flag created to notify other CPRS users that the subject is 
enrolled in an interventional study at the Minneapolis VA Health Care System. This flag will warn of participation in an interventional 

36 
 
study and act to warn of possible dual enrollment, thereby protecting the subject from experiencing the risks involved in participating 
in two studies concurrently.  
Following the signing of the consent and Health Insurance Portability and Accountability Act (HIPAA) forms, the subject will 
continue the evaluation process by filling out a detailed demographics questionnaire including details of location and duration of 
service during the First Gulf War, questions regarding exposures, tobacco and alcohol use.  At this first visit, considered to be the 
screening visit, participants will complete a structured clinical interview, a screening physical exam, and blood tests to rule out pre-
existing conditions that would preclude participation in the trial. The structured clinical interview is designed to obtain information 
regarding demographic variables and personal data, specifically age, gender, education level, ethnicity, marital status, employment 
status, service connection status, military branch, current and past mental and medical treatment, etc. There will also be a blood draw 
at this visit. 
In order to establish that certain exclusion criteria are not met, and to provide baseline data the following parameters will be checked: 
CBC, creatinine, blood glucose, hemoglobin A1C, hs-CRP.  To minimize blood drawing risks, the blood will be drawn by skilled and 
experienced phlebotomists using accepted aseptic technique. At the first, second and final study appointments blood samples will also 
be drawn for plasma proteomic analysis. A CBC will also be drawn at these appointments. The proteomic data and CBC data will 
serve as potential additional covariates to be used in making correlations during data analysis.  The study statistician will receive the 
individual, uniquely coded, MAP assay results directly from the outside laboratory and also from the in-house clinical laboratory, 
thereby preserving the blind. 
Those subjects who do not meet inclusion criteria following the screening physical will be notified via letter and thanked for their 
willingness to participate in the study. They will not be permitted to continue participating in the study.  In order to proceed to the 
active phase of the study, all eligible subjects will meet inclusion criteria, and have screening blood tests that are within acceptable 
ranges.  Consented subjects who have met inclusion criteria will be informed by phone call from the study staff. 
First Study Visit (Week 1): At this time, the first study visit will be scheduled and the subject will be block randomized to treatment 
or placebo groups by the Study Statistician. (Data on drug use will be collected and presumably the randomization process will put 
users of other non-excluded medications equally into the two treatment groups.) The appointment for the second (8 week) study visit 
also made at this time. It will be as close to 56 days after the first study visit as possible, keeping the variation between subjects to a 
minimum.  At the time of the 8 week visit, the appointment for the 16 week visit will be made.  The SDTU scheduler makes every 
effort to schedule appointments for the day and time requested, with excellent results.  
When the subject returns to the MVAHCS for the first study visit, the Study Coordinator will meet the subject at the SDTU Intake 
Room. The self-report instruments will be administered  by the coordinator and the subject given ample time to answer the questions. 
Following this, the blood draw for CBC and biomarkers will take place in the same room. Upon completing the blood draw, the Study 
Coordinator will walk with the subject to meet with the Research Pharmacist in the pharmacy. The Research Pharmacist will dispense 
study drug or placebo to consented and enrolled study subjects using a pre-determined randomization plan generated by the Study 
Statistician. This is done to ensure careful dispensing of the study drug and to see that the study is not compromised by revelation of 
treatment assignments. The Rayos® DR-prednisone tablet and placebo will be identical in appearance.  

37 
 
The Study Coordinator will make Early-study (Week 2) phone calls to the subjects. The purpose of the phone call will be to assess 
how each subject is progressing with the study, to answer any questions they might have, and to encourage maintenance of the 
treatment log.  
To facilitate the management of study drug or placebo administration, each study subject will receive an IRB-approved drug 
administration log. It will be much like a calendar on which a subject will record tablet self- administration. This log will be turned in 
at the conclusion of each subject’s participation in the active phase of the study. The log will both improve compliance (by making it 
easier to remember if a tablet has been taken on any given day) and demonstrate apparent compliance or lack thereof (by reflecting the 
subject’s record of tablet self-administration). 
Second Study Visit (as soon as possible after completing Week 8): At the second study visit, the Study Coordinator will once again 
meet the subject in the SDTU Intake Room. The subject will surrender any unused Study Drug which will be returned to the Research 
Pharmacist. The Pharmacist will dispose of the drug in a manner consistent with the VA pharmacy’s drug disposal policies. The self-
report instruments will be administered by the coordinator and the subject given ample time to answer the questions. Following this, 
the blood draw for glucose, hemoglobin A1C, CBC and biomarkers will take place in the same room.  At this point, the Study 
physician will conduct the Physical Exam and Review of Systems, followed by the blood draw. At this point the subject’s 
participation in the Treatment  Phase of the study will be concluded. A return appointment to occur 8 weeks later will be scheduled. 
Final Study Visit (16 weeks): The subject will return at 16 weeks for the final visit of the study. The subject will meet the coordinator 
in the SDTU Intake Room for a final round of the self-report measures intended to detect any change in symptoms and a blood draw 
for the analysis of biomarkers, glucose, hemoglobin A1C, and CBC. This will conclude the subject’s participation in the study. After 
this final study visit, there is no planned follow-up. 
Good Clinical Practice The conduct of the study will be done in accordance with the IRB-approved protocol and changes to the 
protocol will only be made with approval from the VA-IRB after submitting a request for amendment, as needed. All serious adverse 
events, adverse events and unanticipated problems will be reported to the VA-IRB according to their current recommendations and 
regulations. Reports of aggregate safety data will be sent to the DSMB on a quarterly basis.  Informed consent and HIPAA 
authorization will be obtained directly from the subject and documented in writing prior to the start of any study-related procedures, 
including screening tests and exams done solely to determine their eligibility for the study. Subjects, those taking the study drug and 
those taking placebo, will be informed that the drugs being used in the study are being used for investigational purposes. Adequate and 
accurate records will be maintained and will be made available for inspection, as required.  The delegation of responsibilities by the 
investigator will only be made to individuals who are appropriately qualified by training and experience. 
 
 
 
 
 
 
 

38 
 
Study Participation for Individual Subject 
 
Contact 
Approximate 
Duration 
Event 
Procedure 
Administered/  
Reviewed by 
Initial 
Contact 
15 minutes        Contact with Veteran 
Pre-Screening Phone Call, 
including Kansas Case 
Definition Questionnaire 
Study 
Coordinator 
Screening 
Visit 
(Week -1 
or -2) 
60 minutes 
Informed Consent 
Process 
Study Consent Form, HIPAA, 
Participant Information, 
including demographics 
Study 
Coordinator 
 
30 minutes 
Screening for 
Exclusion Criteria 
History, Physical Exam, and 
Review of Systems 
Physician 
15 minutes 
Screening for 
Exclusion Criteria 
Screening/ Baseline Blood Tests  Nursing Staff 
First 
Study 
Visit 
(Week 0) 
15 minutes 
Initiation of Active 
Phase 
SF-36V, McGill Pain 
Questionnaire-Short form, 
Multidimensional Fatigue 
Inventory, Cognitive Failures 
Questionnaire  
Research 
Assistant 
10 minutes 
Treatment 
Distribution 
Subject Receives Study Drug or 
Placebo 
Research 
Pharmacist 
15 minutes 
Collection of Blood 
Blood Draw for Biomarker 
Analysis and CBC, glucose, 
hemoglobin A1C 
Nursing Staff 
Early-
Study  
(Week  2) 
10 minutes 
Telephone Contact  
with Subject 
Phone call to assess study 
participation, check for possible 
toxicity, answer questions, and 
encourage maintenance of  
treatment log 
Study 
Coordinator 
Second 
Study 
Visit 
(Week 8) 
15 minutes 
Conclusion of Active 
Phase 
SF-36V, McGill Pain 
Questionnaire-Short Form, 
Multidimensional Fatigue 
Study 
Coordinator/ 
Research 
Assistant 

39 
 
Inventory, Cognitive Failures 
Questionnaire 
10 minutes 
Collection of Blood 
Blood Draw for Biomarker 
Analysis  and CBC, Glucose, 
and hemoglobin A1C 
Nursing Staff 
30 minutes 
Active Phase 
Completed 
Physical Exam and Review of 
Systems 
Physician 
Final 
Study 
Visit 
(Week 
16) 
15 minutes 
Evaluation of 
Possible Change in 
Symptoms 
SF-36V, McGill Pain 
Questionnaire-Short Form, 
Multidimensional Fatigue 
Inventory, Cognitive Failures 
Questionnaire 
Study 
Coordinator/ 
Research 
Assistant 
10 minutes 
Collection of Blood 
Blood Draw for Biomarker 
Analysis and CBC, Glucose, and 
hemoglobin A1C 
Nursing Staff 
 
 
 
 
 
 
Data Management 
 
Identifiers. Treatment assignment codes will be generated and kept by the Biomedical Research Statistician. These codes will be 
stored on the secure VA Server behind VA firewalls. These codes must be shared with the VA Research Pharmacist, who will prepare 
the medications. This code will only be broken in the case of an adverse event when it is necessary to know which treatment the 
patient is receiving before the participant can be treated or if someone not in the study uses the investigational agent. Plasma samples 
that are collected and stored prior to assay will be labeled with unique identifiers. The key that links the unique identifiers to the study 
subjects will be maintained by the study coordinator on a secure VA Server behind VA firewalls.  
Confidentiality. Before the investigators initiate the study, the PO and the ISO will work with the investigators to ensure the proposed 
research is in compliance with relevant privacy and confidentiality requirements, and information security requirements, respectively. 
They will make recommendations to the investigators of options available to correct any deficiencies. The PO and ISO review the 

40 
 
proposed study protocol and any other relevant materials when they are submitted in the IRB application. During the course of the 
study, the PO and ISO will conduct assessments to ensure that all applicable local, VA and other Federal requirements for privacy and 
confidentiality, and for information security have been met.  
 
The MVAHCS Research Service is committed to protecting the integrity of the VA computer system and the security and privacy of 
data and PHI of study subjects, as well as that of employees. Therefore, the Research Information Protection Subcommittee (RIPS) 
was formed. RIPS conducts annual audits of all Research areas to identify security and privacy vulnerabilities, assure the correction of 
these findings, educate the Research staff in the principles of data and computer security, implement policy and procedures, and serve 
as a resource for researchers who have special data management needs. RIPS offers another layer of protection against risk for study 
subject data.  
The study records will be available to and used by approved study personnel as needed for the conduct of the study. All study staff 
receive annual VA privacy and information security training. Federal agencies including, but not limited to, the Food and Drug 
Administration (FDA), the Office for Human Research Protections (OHRP), the VA Office of Research Oversight (ORO), the VA 
Office of the Inspector General (OIG), and representatives of USAMRMC may have access to the records. 
If sensitive information is collected in the conduct of this study for which there is a mandatory reporting requirement, then MVAHCS 
policies will be followed in the reporting of this information to state and local authorities. 
Disposition of data. All electronic VA sensitive research data for this protocol, including subject data and PHI, will be stored on a 
secure VA server behind the necessary VA firewalls. All hard copies of VA sensitive research data, especially participant PHI, will be 
stored in locked file cabinets, in a locked laboratory, inside a security card controlled research wing in Building 70 of the MVAHCS. 
Federal regulations for the destruction of federal records indicate that all study records generated during the course of VA research 
must be retained indefinitely.  
 
Sharing study results. Laboratory results from the screening visit will be made available to the subject and to his/her physician if 
requested by the subject. If persistent increases in blood glucose/hemoglobin A1C are detected during the treatment phase of the study 
the subject will be notified and advised to consult with his/her physician.  
 
Laboratory Evaluations: 
Specimens to be collected, schedule, and amount. The volume of blood collected for the purpose of screening will be ~12 ml. The 
study will begin within two weeks of the screening visit. The volume of blood collected at each study visit will be ~20 ml. There will 
be a total of three study visits occurring at 8 week intervals. The total amount of blood collect from each study subject will be ~72 ml 
 
Evaluations to be made. Blood tests performed for the purpose of screening will include a CBC, creatinine, blood glucose, 
hemoglobin A1C, and hs-CRP. Lab tests performed for each study visit will include a CBC, blood glucose, hemoglobin A1C, hs-CRP, 
TAT, and MAP plasma protein analysis (HumanMAP®-v2.0/Antigens). The screening assays are to establish that certain exclusion 

41 
 
criteria are not met. Tests associated with the study visits will quantify intervention-related effects on biomarkers of inflammation. 
The objective biomarker information is required to determine if DR-prednisone reduces chronic inflammation in veterans with GWI. 
The CBC results will be used as adjustment covariates in the data analysis. The CBC may also be used to evaluate the possibility of an 
intercurrent infection. For the purpose of subject safety blood glucose and hemoglobin A1C will be measured at each study visit.  
 
Storage. Preparation and storage of the plasma samples will take place in Dr. Bach’s laboratory in Building 70 of the MVAHCS. The 
platelet-free EDTA plasma samples will be stored in a locked ultralow freezer at -80oC prior to assay. Labeling of the samples with 
unique identifiers and maintaining the key will performed as described above (see Identifiers). Samples will be destroyed at the 
completion of the study after all protocol-defined analyses have been performed and abstracts, manuscripts, or primary publications 
already exists or are under review. Sample destruction will be performed according the VA policies and procedures.  
 
Labs performing evaluations and special precautions. Established immunoassay procedures utilizing MAP technology will be 
employed to quantify the concentrations plasma proteins (HumanMAP®-v2.0/Antigens). The assays will be performed on platelet-
free EDTA plasmas by Myriad RBM, Inc., Austin, TX. Coded sample will be sent to Myriad RBM on dry ice via the VA-approved 
overnight shipping service, United Parcel Service (UPS). Myriad RBM validates all assays to clinical laboratory standards. The 
Myriad RBM laboratory is accredited by the College of American Pathologists. Its CLIA number is 45D1037483. 
Lab tests performed for the purpose of screening will be conducted by the clinical laboratory of the MVAHCS. This lab will also 
perform the CBC, hemoglobin A1C, and hs-CRP assays at each study visit, The MVAHCS clinical laboratory has met all applicable 
standards for accreditation and is accredited by the College of American Pathologists. Its CLIA number is 24D0988147. 
Plasma TAT levels will be quantified by ELISA using the AssayMax Human TAT Complexes ELISA Kit from AssayPro®. The TAT 
ELISAs will be performed on previously frozen platelet-free EDTA plasmas in Dr. Bach’s laboratory. All personal protective 
equipment appropriate for the handling of blood and blood products are used. Study personnel are trained in proper handling 
techniques for biohazards and hazardous chemicals and in the shipping of specimens.  
 
 

42 
 
Surveys 
The primary and secondary outcome measures are summarized in Table 1. 
 
 
Table 1.  Primary and Secondary Outcome Measures 
 
 
The self-report instruments 
used to assess primary and 
secondary outcomes will be 
administered at the beginning 
and the end of the 8 week 
treatment period and at the end 
of the 8 week post-treatment 
period. These validated and 
standardized methods were 
employed in VA Cooperative 
Study Program (CSP) Study 
#470 (43, 44). In addition, the 
collection of a blood sample, 
plasma isolation, and storage 
of the plasma sample for 
proteomics analysis will be 
performed at each of study 
visits. 
 
The primary outcome measure 
will be the presence or 
absence of a positive response 
on the SF-36V PCS following treatment. A positive response is defined as a 7-point or greater increase in the SF-36V PCS at 8 weeks 
versus the baseline score. This definition of a positive response to an intervention in veterans with GWI is based upon the 
psychometric properties of the SF-36V PCS and the distribution of scores observed in the population and comes from VA Cooperative 
Primary 
Outcome 
Measure 
Secondary 
Outcome 
Measure 
Name of Measure 
Description 
x 
 
Veterans Short Form 36-
Item Health Survey 
Physical Component 
Summary (SF-36V-PCS) 
HRQOL/ Physical Health Functioning 
 
x 
McGill Pain 
Questionnaire- Short 
Form (MPQ) 
Sensory pain, affective pain, pain now, 
and typical pain 
 
x 
Multidimensional Fatigue 
Inventory (MFI) 
General fatigue, physical fatigue, reduced 
activity, reduced motivation and mental 
fatigue 
 
x 
Cognitive Failures 
Questionnaire (CFQ) 
Self-report of cognitive symptoms, such 
as attention, concentration, and memory 
 
x 
Veterans Short Form 36-
Item Health Survey 
Mental Component 
Summary (SF-36V-MCS) 
HRQOL/ Mental Health Functioning 
 
x 
HumanMAP®-
v2.0/Antigens,  
hs-CRP assay,TAT 
ELISA 
Quantitative analysis of plasma 
biomarker levels 

43 
 
Study Program (CSP) Study #470 (43, 44). Based on the results of the Veterans Health Study (40, 41), a 7 point change in the SF-36V 
PCS score is expected to represent an effect size of 0.75.   
 
Specialized rating scales and validation of the measurements. The SF-36V is a modification of the well-established Medical Outcomes 
Study Short Form Health Survey (SF-36) for use with ambulatory Veterans Health Administration patients.  It surveys eight concepts 
of health: physical functioning, role limitations because of physical problems, bodily pain, general health perceptions, energy/vitality, 
social functioning, role limitations due to emotional problems and mental health (40-42).  From these concepts, two summary 
component scores are derived: a Physical Component Summary (PCS) and a Mental Component Summary (MCS).  Scores are 
standardized and range from 0 to 100, with a US population mean of 50 points and a SD of 10 points.  The PCS and the MCS have 
been demonstrated to have excellent psychometric properties (40, 41) and have been used extensively in GWI studies and throughout 
VA settings (5, 40-44). The subscale items largely address the diverse array of symptoms reported as a part of GWI. SF-36V PCS is a 
measure of HRQOL with respect to physical functioning and symptoms. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

44 
 
 
 
 
 
 
McGill Pain Questionnaire-Short Form (MPQ). The MPQ is a self-report survey which measures the quality of pain by asking 
patients to rate the intensity of 15 verbal descriptors of pain on a 0 to 3 rating scale with lower scores indicative of lower pain levels 
(45).  The scale yields subscale scores in the following domains: Sensory pain, affective pain, pain now, and typical pain.  The MPQ is 
a commonly used pain measure with considerable documentation of its reliability, sensitivity to change, and concurrent and predictive 
validity as a measure of pain quality and intensity (46).     
 
 
 
 
 
 

45 
 
Multidimensional Fatigue Inventory (MFI).  The MFI is a 20-item self-report instrument designed to measure fatigue (47). The 
MFI covers the following dimensions: general fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue.  
Scores on each dimension range from 4 to 20, with lower scores indicative of higher functioning.  The instrument has demonstrated 
good internal consistency, with an average Cronbach's alpha coefficient of 0.84.   
 
 
 
Cognitive Failures Questionnaire (CFQ).  The CFQ is a 25-item self-report measure designed to assess the frequency of failures in 
perception/attention (e.g. ``do you fail to notice signposts on the road?''), memory (e.g. ``do you forget appointments?'') and action 
(e.g. ``do you bump into people?'') (48). Patients are asked to indicate on a 5-point scale (0= never to 5=very often) how often they 
have experienced each cognitive failure in the past months. Studies have demonstrated the CFQ to have adequate internal consistency 
and test-retest reliability.   
 
Impact 
Participants: Gulf War veterans with GWI (Kansas Case Definition) will be the participants in this proposed trial. The potential 
impacts of this trial on veterans with GWI include reduced symptoms and improved HRQOL. In addition, a successful trial will 
fundamentally change the way GWI is diagnosed and treated. 
Short-term impact: A successful trial with improved clinical outcomes and reduced inflammation would validate the hypothesis that 
chronic inflammation is part of the underlying pathophysiology of GWI. Thus, a new paradigm for diagnosis and treatment would be 
established. A change in clinical practice that focuses on inflammation could be implemented immediately. 
Long-term impact: The paradigm shift to GWI-associated chronic inflammation will have a long-term impact on GWI diagnosis and 
treatment. Testing other therapeutic interventions with the focus on reducing inflammation and minimizing toxicity could lead to new 
treatments for GWI. Biomarkers of inflammation may become objective measures of GWI. Thus, evidence-based methods for the 
diagnosis and treatment of GWI will continue to evolve and improve the HRQOL of veterans with GWI.  
 
 
 

46 
 
Transition 
This work will transition to the next phase after the successful completion of the GWIRP CTA. The details of the path that will be 
pursued will be determined by the specific results of the Gulf War Illness Inflammation Reduction Trial.   
 
Possibilities for future studies: 
• A multi-site trial of more targeted anti-inflammatory drugs for the treatment of GWI. The choice of the intervention(s) would 
be guided by the evidence from the current trial.  The biomarker evidence may reveal new details of the underlying chronic 
inflammatory state that will help to identify specific targets for the next phase intervention.  
• GWI biomarker studies. The objective is to develop biomarkers of inflammation as objective measures for the diagnosis of 
GWI and for the evaluation of treatment efficacy. This study will continue the work initiated in the pilot study and continued 
the Gulf War Illness Inflammation Reduction Trial. The relationship of GWI symptoms patterns with specific biomarker 
signatures will be a focus. This study would be a component of the next phase intervention trial. 
 
Potential sources of funding: 
• VA ORD 
• VA CSP 
• CDMRP GWIRP CTA 
• CDMRP GWIRP CTDA  
 
Additional sources of funding for the continuity of development and future studies will be explored. Collaborations such as those 
described in The VA/DoD Collaboration Guidebook for Healthcare Research will be considered.  
 
Milestones: 
• Obtain funding for continuity of development (year 3). 
• Successfully complete the Gulf War Illness Inflammation Reduction Trial (year 4). 
• Identify and develop next phase trial (year 4/5).  
• Obtain funding for next phase trial (year 5). 
• Initiate next phase trial (year 5/6). 
 
Issues of intellectual property and proprietary information, as addressed in Attachment 2 (Intellectual Property), CRADA, and NDA, 
will be similarly resolved in the next phase study.  
 

47 
 
The increased cost of a multi-site trial will require expanded sources of funding, as outlined above.  Schedule and sustainability are 
significant challenges for the next phase trial. Utilizing VA CSP infrastructure and resources is a potential solution to these issues. 
Manufacturability will be an important consideration in choosing the next phase intervention(s).  However, this is unlikely to be a 
significant barrier given the wide use of FDA approved anti-inflammatory drugs.