Clinical trial NCT04608448
Conditions: Aging Epigenetics Inflammatory Mediators
Keywords: Epigenetic clock
Sponsor: The University of Texas Health Science Center at San Antonio
Start date: 2021-04-28; Completion date: 2022-04-15
Enrollment: 22 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Topical Rapamycin ointment will be applied to participant forearms to test whether epigenetic changes in the skin are elicited.

Detailed description:
Rapamycin 8% ointment will be applied topically to one of the participant's forearms and matching placebo to the opposite forearm daily for a total of 6 months. After consenting, screening and randomization of arms, the participants will be monitored at monthly visits until study completion.

Arms: arm 1: Ointment is applied to a color coded area on the subject forearm daily. arm 2: Placebo ointment is applied to a color coded area on the subject forearm daily.
Interventions: intervention 1: Rapamycin Topical Ointment intervention 2: Placebo
Intervention descriptions: intervention 1: 8% topical rapamycin ointment intervention 2: Petrolatum ointment containing no active ingredient

Protocol documents:
ICF_001.pdf: 
Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
20-720H, Kraig, Form D, 10-12-21, AMD.docx 
 
Page 1 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
 
 
 
Official Study Title:  
An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing inflammation 
and re-setting the epigenetic clock (Topical-RAPA) 
 
 
NCT number: NCT04608448 
 
IRB Approval Date: 10-12-2021 
 
Unique Protocol ID: HSC20200720H 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
20-720H, Kraig, Form D, 10-12-21, AMD.docx 
 
Page 2 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
Concise Summary 
 
Important Information  
This information gives you an overview of the research.  More information about these topics may be found in the 
pages that follow.  You may choose not to take part in the study or may choose to leave the study at any time.  
Deciding not to participate, or deciding to leave the study later, will not result in any penalty or loss of benefits to 
which you are entitled and will not affect your relationship with us. 
 
1. What problem is this study trying to solve? 
You are being asked to participate in a research study.  Scientists do research to answer important questions which 
might help change or improve the way we do things in the future.   
 
We know that cells in the body change the way they behave as we age, often causing inflammation that affects the 
cell’s ability to produce new healthy cells. Safely studying the anti-aging benefits of medications administered and 
absorbed into the body is a challenge in older human beings. Therefore, testing anti-aging medications in a small 
patch of skin with little to no absorption of the medicine into the body may be a better option. It may keep research 
participants safer and avoid serious risks to them.  
 
There are 2 goals of this research study: (1) to test whether age-associated changes in genes of skin cells (also 
known as the “epigenetic clock”) are stopped or reversed by topical treatment with an investigational 
ointment (sirolimus, RAPA); and, (2) to evaluate whether the RAPA ointment, when topically applied to the skin for 6 
months, is able to reverse changes in the immune system and inflammation that are thought to be associated with 
aging.  
 
For more information, please see the Why is this Study being Done section below.   
 
 
2. What will happen to me during the study and how is this different from continuing with usual care? 
What are all my options for treatment, including the pros and cons? 
The research study team plans to enroll people age 65 to 95 in general good health.  Study staff will schedule you 
for a total of eight (8) research visits. Visits will include informed consent and screening, physical exam and safety 
labs, dispensing and treatment with RAPA topical ointment, research labs (blood draws and skin samples), and 
monthly follow up. You will use the topical study drug on one arm and the placebo (just ointment without drug in it) 
on the other arm. After the treatment period, there is one last visit at the Research Unit where a researcher will 
perform the skin sampling procedure on your arms that causes minimal to no scarring and does not require a local 
anesthetic (numbing). 
 
For more information, please see the What will be done if you decide to be in the research section below.   
 
 
3. How much time will I spend on the study? 
The total duration of the study is 7-8 months. Most visits are monthly and will take less than an hour except the first 
(90 minutes) and last visits (up to 4 hours). 
 
 
4. Could taking part in the study help me and are there risks?  
We do not know if there will be any physical benefit from using the study medication. You will be compensated a 
small amount of money for your time and effort after each completed visit. Previous studies have shown the topical 
medicine is absorbed into the skin but not into the body, and therefore, we expect it to have few side effects other 
than mild to moderate localized redness, rash, or itching.  
 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
20-720H, Kraig, Form D, 10-12-21, AMD.docx 
 
Page 3 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
We want you to report immediately to the research team when any possible side effects or other medical symptoms 
occur while you are in the study whether or not they seem related to the study medicine. 
 
For more information, please see How could you or others benefit from your taking part in this study section 
below.   
 
For details and a list of risks you should know about, please see the What are the risks of participation in the 
research section below. 
 
 
5. What else should I consider before I make my decision? 
Other considerations you may have about participation include the importance and limitations of applying medication 
to your skin every day for 6 months, as well as the value of your time to comply with appointments and phone-
reporting about symptoms. Six (6) of the 8 visits will be conducted as home visits (or if you prefer, at an alternate 
site within 20 miles of the UTHSA) for your convenience. Only the first (Visit 0) and last visit (Visit 7) will be 
conducted in person at the Research Unit.  
 
We work hard to protect the confidentiality of your personal health information and your privacy. We promise not to 
share information without your permission.  However, if you choose an alternative site for your “home visits” that is 
in a public setting, we cannot guarantee privacy.  
 
Please review the rest of this document for additional details about these topics and other information you 
should know before making a decision about participating in this research. 
 
 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
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Page 4 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
Consent to be part of a Research Study 
To be conducted at  
University of Texas Health Science Center at San Antonio (UT Health San Antonio) 
 
Information about this form 
You may be eligible to take part in a research study.  This form gives you important information about the study.   
 
Please take time to review this information carefully.  You should talk to the researchers about the study and ask 
them any questions you have.  You may also wish to talk to others (for example, your friends, family, or a doctor) 
about your participation in this study.  If you decide to take part in the study, you will be asked to sign this form.  
Before you sign this form, be sure you understand what the study is about, including the risks and possible benefits 
to you. 
 
Please tell the researchers or study staff if you are taking part in another research study. 
 
Voluntary Participation - You do not have to participate if you don't want to.  You may also leave the study at any 
time.  If you leave the study before it is finished, there will be no penalty to you and you will not lose any benefits to 
which you are entitled.   
   
General Information – “Who is conducting this research?” 
 
Principal Investigator 
The Principal Investigator (PI) is the researcher directing this study; the PI is responsible for protecting your rights, 
safety and welfare as a participant in the research.  The PI for this study is Ellen Kraig, PhD, Professor at UT Health 
San Antonio in the Department of Cell Systems and Anatomy. 
 
Co-Principal Investigator  
The Co-Principal Investigator shares the principal investigator’s responsibilities for this study.  The Co-Principal 
Investigator for this study is Dean L. Kellogg, Jr, MD, PhD, Professor in the Department of Medicine-Division of 
Geriatrics, Gerontology and Palliative Medicine. 
 
Funding  
The National Institutes of Health/National Institute on Aging (NIH/NIA), a federal agency that promotes scientific 
research, is funding this study.  This organization is providing money to UT Health San Antonio so that the 
researchers can conduct the study. 
 
Purpose of this study – “Why is this study being done?” 
We know that cells in the body change the way they behave as we age; this often causes inflammation at the 
cellular level that affects the cell’s ability to produce new healthy cells. These changes are a normal part of aging. 
Researching the anti-aging benefits of medications administered and absorbed internally becomes a challenge for 
safety reasons in older human populations. Therefore, limiting the area being tested to a small patch of skin with 
little to no absorption of the medicine into the body systems is expected to help avoid serious risk to the participants. 
The researchers hope to learn two things: (1) if aging effects on skin cell genes (also known as the “epigenetic 
clock”) are improved by topical treatments with an investigational ointment (sirolimus, RAPA) and (2) to evaluate the 
safety and effectiveness of the RAPA ointment when topically applied to the skin for 6 months to test its effect on 
reversing inflammation or immune system responses that are thought to be associated with aging. We want to 
establish laboratory testing that will measure markers of healthy aging. 
 
Investigation Use of Drug  
This study involves the use of an investigational drug called Sirolimus® (rapamycin, RAPA).  “Investigational” means 
that the drug has been approved by the U.S. Food & Drug Administration (FDA) to be administered by mouth for 
other indications. RAPA has not been FDA-approved for topical use and is being used for research purposes in this 
study. 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
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Page 5 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
This study will help find out what effects, good and/or bad, topical RAPA ointment has on people who use it and on 
its effect on skin genes (DNA methylation). The safety of this drug in humans has been tested in prior research 
studies; however, some side effects may not yet be known.   
 
At Visit 7 at the end of the treatment period, we will obtain the skin sample and run lab tests on skin tissue and fluid 
from under the skin. To generate the specimens, we will use a device called a Negative Pressure instrument (NP-2 
or NP-4, Electronic Diversities, LLC) that has been used in other research studies to cause a skin blister. This 
method is non-invasive, carries little or no risk, and causes minimal discomfort.  
 
Using the device creates a suction effect causing the skin to develop a small blister less than ½-inch in diameter (up 
to 10 millimeters) and approximately ¼-inch in height (3-4 millimeters). This process involves a small chamber of the 
device strapped to the inside area of your forearm situated between the wrist and elbow. See more detailed 
information in Visit 7 and added discussion in the Section on Potential Risks. 
 
A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by U.S. Law. This Web 
site will not include information that can identify you. At most, the Web site will include a summary of the study and 
results. You can search this Web site at any time.  
 
Information about Study Participants – “Who is participating in this research?” 
 
You are being asked to be a participant in this study because you are between the ages of 65 and 95 and have 
been vaccinated for COVID-19 (or will have been vaccinated prior to the start of the study). In addition, you are a 
non-smoker in good general health without active infection or unstable disease or you are stable on treatment for 
existing medical conditions not taking medication(s) that would exclude you from participating.  
 
How many people are expected to take part in this study? This study will enroll up to 75 study participants to attain 
at least 40 completers. 
 
 
Information about Study Procedures – “What will be done if you decide to be in the research?” 
 
While you are taking part in this study, you will be asked to attend approximately eight (8) visits with the researchers 
or study staff. Visits 0 and 7 will be conducted at the UT Health San Antonio [either in the Medical Arts and 
Research Center (MARC) FORU on first floor or in the Cell Systems & Anatomy Department Research Unit in the 
UTHSA Basic Science Building on second floor]. Visits 1-6 will typically be conducted as home visits (or at an 
alternate site within 20 miles of the UTHSA, if the subject prefers), but two of these visits (#4 and #6) may be 
replaced with phone calls if you feel comfortable with the application procedure and there have been no problems.  
 
COVID-19 Screening (standard of care) 
• 
All participants will be pre-screened by telephone questionnaires before visits are scheduled. No COVID-19 
testing will be done by the research team during this study. If getting a test is indicated, we will refer you to 
your primary care physician for further instructions and care.  
• 
Upon entering the facility, you will be required to wear a mask. If you do not have a mask, one will be 
provided for you.  
• 
At each study visit, whether the visit is conducted in the Research Unit or in your home, the study staff will 
take your temperature and ask COVID-19 screening questions to document in the research record.  
• 
For your personal safety and the safety of study staff, these COVID-19 screening procedures will be 
repeated at each and every visit.  
• 
Study staff wear personal protective equipment (PPE), including masks, gloves and possibly a surgical gown 
depending on research activities for the visit. 
 
 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
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Informed Consent Process 
The process of explaining the study to you and all study-related activities is known as the informed consent process 
and is important to research ethics. We are required to obtain your voluntary consent with signatures before any 
information about you can be collected or stored for research purposes. After reviewing and signing this form, we 
will provide you a copy for reference. 
We will perform an assessment of your memory and thinking by drawing a clock (CLOX test) to ensure that the 
consent is valid. 
 
Screening - (Visit 0) 
After you sign this form, we will carry out exams, tests, and/or procedures as described below to find out if you can 
continue in the study; this is called screening. We may be able to use the results of exams, tests, and/or procedures 
you completed before enrolling in this study.  You will be told which results we will obtain, and which procedures will 
not have to be repeated.  Some of the procedures are described below as “standard care” and would be done even 
if you do not take part in this research study. You will be told which ones are for “research only”. 
 
Screening Procedures  
The following procedures will be performed to ensure you are eligible to participate. 
 
Medical history – Study staff will ask questions about your history of illnesses and surgeries and record any 
and all medications that you take currently or may have taken recently. You will also be asked about COVID-
19 vaccination as this is required for you to be eligible for study participation; the vaccine will not be provided 
as part of this study. 
 
Physical examination, including 
• 
Standard vital signs to measure your height, weight, heart rate (listen to your heart or take your 
pulse), blood pressure, and temperature 
• 
Tattoos or scars on the forearms will be examined to ensure that they will not interfere with drug 
application. 
• 
Physical exam similar to what you get when you visit your doctor for a routine checkup. 
• 
Electrocardiogram (ECG/EKG) – 12 sticky pads on your chest attached to wires connected to a 
machine that measures your heart function  
• 
Blood draw (safety labs for research eligibility) – Blood will be taken from a vein in your arm or hand 
to measure: 
o 
Complete blood count (CBC) to count the number of red blood cells and white blood cells  
o 
Blood chemistry (CMP) to check your liver function, measure the amount of sugar/ 
cholesterol in your blood (hemoglobin A1c and lipid panel), which will help us to determine 
your overall, general health   
o 
If you have had these tests in the last 60 days and we have access to the results, we can 
accept them for study purposes 
 
This visit will take approximately 60-90 minutes. Compensation for this visit is valued at $25.00 (see Participant 
Payment Section for more details). 
 
The results of the screening exams, tests, and/or procedures will be reviewed by study staff to determine whether 
you will be allowed to continue in the study.  If you are not allowed to continue in the study, the researcher will 
discuss the reasons with you.  
 
If safety lab reports show any values outside the normal range, the medical investigator will determine whether the 
difference is “clinically significant” or not and might choose to repeat a specific test(s) to confirm the results before 
determining eligibility. This could possibly require an additional or “interim” visit. 
 
 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
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Page 7 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
Assignment to Study Intervention 
When it is determined that you will be allowed to continue in the study, you will be provided study medication and 
you will act as your own “control” for the study. What this means is, you will apply the active study drug to the inner 
surface of one forearm and the “placebo” (inactive) ointment to the other forearm. 
 
• 
Topical RAPA – petrolatum ointment (like Vaseline®) with 8% RAPA in it 
• 
Placebo – similar ointment with no study drug in it 
 
Neither you nor the researchers will know which of your arms is receiving the study drug and which is getting 
placebo. This is called “double blinding.” In the event of an emergency, there is a way for the researcher to find out 
which you are receiving. 
 
Study Procedures - as a participant, you will undergo the following procedures: 
All visits are for research purposes.  
 
Visit 0 – consent and screening – detailed above and performed in the Research Unit 
 
Visits 1 through 6 – conducted as home visits (or if the subject prefers, at an alternate location within 20 miles of 
the UTHSA) that will occur monthly, with phone follow up in between home visits. Visits 4 and 6 may instead be 
conducted by phone if the individual participant has been fully compliant with no adverse events. At each home visit, 
the study staff will: 
• 
adhere to COVID-19 safety precautions (temperature, screening questions, masks, etc.) 
• 
if clinically indicated, listen to your heart and take your blood pressure  
• 
review your current health status and other medications 
• 
ask questions about any side effects or expected/unexpected symptoms you experienced since the previous 
visit (called Adverse Event review) 
• 
two weeks after home visit #1, you will receive a phone call to check on your adherence to daily study drug 
administration and to determine whether there have been any Adverse Events 
• 
schedule further research visits 
• 
prescribe and dispense study medication (Visits 1, 3, and 5)  
• 
review clear instructions verbally and in writing that explain how to apply the ointment 
• 
mark the skin area where medication is applied 
 
Study Medication 
At Visits 1, 3 and 5 we will deliver study medication. Using the Topi-Click® dispenser system, the container is 
shaped like a cylinder of stick deodorant and by turning it one time, the measured amount of medication is squeezed 
out for you to apply. See Risks section for more information about effects of the medication. 
 
Each container is color coded and labeled for which arm gets which medication. For the left arm (L), you will use the 
dispenser color coded in Leaf Green labeled “L”, and for the right arm (R) you will use the red-coded dispenser and 
labeled “R”. We plan to mark your arm with a permanent marker that is Red on the right and Green on the left where 
the medication should be applied. As mentioned earlier, only the pharmacist will know which dispenser has active 
medication in it. 
 
Dispensers should be stored at room temperature, not refrigerated or left in a hot car or direct sunlight. We will ask 
you to return all medication dispensers during the study, so we can weigh them and calculate how much medication 
was used from each. Please do not throw them away. 
 
Each home visit is estimated to take up to 60 minutes and will be compensated at a rate of $10 per home visit. If 
home visit 4 or 6 is replaced by a phone call, it will be compensated at the rate of $10/visit. Any interim phone calls 
(between monthly scheduled visits) will not be compensated. 
 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
20-720H, Kraig, Form D, 10-12-21, AMD.docx 
 
Page 8 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
Visit 7 – we will ask you to return to a Research Unit at the UT Health San Antonio to undergo post-treatment 
assessments, including: 
 
• 
COVID-19 precautions 
• 
Vital signs, medical history, medication review, and post-treatment physical exam (like in Visit 0) 
• 
Blood draw – Blood will be taken either by venipuncture or by a finger prick using single-use lancets. 
o 
RAPA level in blood 
 
• 
Skin tissue and fluid sampling by suction blister procedure  
o 
Will be performed by a licensed clinical provider trained to do the procedure. No local anesthetic 
(numbing medicine) is required. 
o 
Specimens will be collected from the inner surface each forearm; at the site of topical application. 
Both arms will undergo suction at the same time. 
 
Arm(s) will be comfortably positioned with inner side (ventral) facing up 
 
Skin area will be cleaned with a mild antiseptic or alcohol pad 
 
A suction chamber will be placed on each forearm and secured with straps to create a seal 
at the skin 
 
Negative pressure console is turned on and pressures increased slowly and gradually at 30-
minute intervals until a skin blister appears on each arm.  
 
The blister can take from 1 to 3 hours to form fully. The fully formed blister will be 
approximately ½-inch in diameter and ¼-inch in height.  
 
You may feel warmth and an itching sensation at the blister site during the suction 
procedure. 
 
The researcher uses a small gauge needle to withdraw blister fluid (interstitial fluid) from 
each blister and transfers collected fluid from each arm to a small storage tube 
 
Next the researcher uses surgical scissors or a small sharp scalpel (knife) and tweezers to 
remove the “roof” skin of each blister and prepares the sample for storage 
 
Each blister site is medicated with antibiotic ointment and covered with a small bandage. 
o 
You will rest approximately 15-30 minutes before being discharged to home. The study staff will give 
you instructions to keep the wound(s) clean and promote healing. 
o 
The procedure is reported to cause minimal scarring and little to no discomfort after the procedure.    
 
This visit will take approximately up to 4 hours and will be compensated at a rate of $200. 
 
 
 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
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UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
 
Visit Schedule of Activities 
 
Visit Number 
V0 
V1 
V2 
V3 
V4 
V5 
V6 
V7 
Month# 
 
0 
1 
2 
3 
4 
5 
6 
Goal 
Consent 
& Screen 
Pre-
drug 
RAPA/ 
Placebo 
RAPA/ 
Placebo 
RAPA/ 
Placebo 
RAPA/ 
Placebo 
RAPA/ 
Placebo 
RAPA/ 
Placebo 
COVID-19 screening 
X 
X 
X 
X 
X 
X 
X 
X 
Consent 
X 
 
 
 
 
 
 
 
CLOX test 
X 
 
 
 
 
 
 
 
Vital signs 
X 
 
 
 
 
 
 
X 
Medical History 
X 
 
 
 
 
 
 
 
Consent and 
medication review 
X 
X 
X 
X 
X 
X 
X 
X 
Physical Exam 
X 
 
 
 
 
 
 
X 
12-lead EKG 
X 
 
 
 
 
 
 
 
Safety Labs (fasting): 
 
 
 
 
 
 
 
 
 CBC,CMP,A1c, lipids 
X 
 
 
 
 
 
 
 
Study drug dispensed 
 
X 
 
X 
 
X 
 
 
Self-reported AE 
 
X 
X 
X 
X 
X 
X 
X 
RAPA level 
 
 
 
 
 
 
 
X 
Phone call to assess 
compliance and AEs 
 
2 wks 
later 
 
 
 
 
 
 
Suction Blister Proc. 
  Blister fluid 
 
 
 
 
 
 
 
X 
  Blister roof excision 
 
 
 
 
 
 
 
X 
 
Ending Participation Early  
 
Could your participation end early? There are several reasons why the researchers may need to end your 
participation in the study (early withdrawal).  Some reasons are: 
• 
The researcher believes that it is not in your best interest to stay in the study. 
• 
You become ineligible to participate. 
• 
Your condition changes and you need treatment that is not allowed while you are taking part in the study. 
• 
You do not follow instructions from the researchers. 
• 
The study is stopped. 
 
The researchers will discuss your options for medical care when your participation in this study ends. 
 
Future Use of Your Information or Biospecimens Collected as Part of Your Participation 
 
Identifiers may be removed and the de-identified information or biospecimens could be used for future research 
studies or distributed to another investigator for future research studies without additional informed consent from you 
or your legally authorized representative.  
 
Your collected skin specimens will be stored in a locked freezer located in the UTHSA laboratory and a portion will 
be sent to core facilities for analysis. When the study is complete, all remaining materials will be destroyed. 
Specimens in the lab or sent for analysis will be labeled with your subject number and sample site (left vs. right 
arm), as appropriate, but will not include any personal identifying information. Your biospecimens or data derived 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
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from your biospecimens, even if identifiers are removed, may be used for commercial profit and you would 
not share in this commercial profit. 
 
Risks – “What are the risks of participation in the research?” 
Risks from the research 
There are no known social, legal, or psychological risks.   
 
At the time of collection, all specimens and data are coded and stored such that so that there is no risk to the 
privacy of individuals or confidentiality of data.  Data are stored in electronic form behind institutional electronic 
firewalls and/or in physically secured laboratory facilities that are patrolled by armed police forces.  These 
procedures have adequately protected our data for decades and we believe that they will continue to be highly 
effective in the future. 
 
Risks from the specific research procedures (drug(s), interventions, or procedures) 
Everyone taking part in the study will be watched carefully for any side effects.  However, the study doctors don’t 
know all the side effects that may happen.  Be sure to tell your study doctor immediately, about any side effect that 
you have while taking part in the study. 
The following section will describe potential risks related to your participation in this research study.  You should talk 
to the study doctor about any side effects or other problems you have while taking part in the study.    
Risks and side effects related to the research include those which are: 
 
 
Study Medication (Topical RAPA) 
Less Likely, and not Serious 
In previous human studies cited by our investigators, topical administration did not produce systemic or serious 
reactions. Side effects from this study will usually go away soon after you stop using the RAPA medication.  In some 
cases, side effects can be long lasting or may never go away. 
In 100 people, approximately 1 to 5 may have: 
• 
Localized skin redness, mild rash or itching; resolves when medication is stopped 
• 
RAPA can cause mild to moderate redness or itching at the site of application. If a clinically significant rash 
develops, the study medication will be stopped, and participation will cease. 
 
Rare and Serious 
Approximately 1 in 1,000 people may have an allergic reaction. Persons with any allergy or sensitivity to RAPA will 
not be studied.  Participants will be instructed to notify the research team and get help right away if any of the 
symptoms of an allergic reaction occur.  
 
Serious allergic reactions related to the oral medication include: 
• 
Swelling of face, eyes, or mouth 
• 
trouble breathing or wheezing 
• 
throat tightness 
• 
chest pain or tightness 
• 
feeling dizzy or faint 
• 
rash or peeling of skin 
 
 
Blood draws (venipuncture) 
 
Likely, and not Serious 
In 100 people, approximately 5-10 may have: 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
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• 
Bleeding, bruising, or localized pain at the site of the blood draw 
• 
Bleeding will be seen as bruising (discoloration) at the place where the blood was obtained. The bruising 
usually goes away within 3 to 4 days, although sometimes it may take a week. The bruising is helped by 
using hot packs. 
 
Less Likely, some may be Serious 
There is a small risk, less than 1 in 100, of infection where your veins are punctured. Report to your study team any 
signs or symptoms of infection including localized warmth, redness, swelling or pain. 
 
Rare and Serious 
None 
 
 
Blood draws (finger prick) 
 
Likely, and not Serious 
In 100 people, approximately 5-10 may have: 
The specific risk associated with single use lancets and finger-stick devices is pain at the site of skin puncture. 
 
 
Suction blister procedure 
 
Likely, not Serious 
In 100 people, approximately 10-20 may have: 
• 
Localized itching at the blister site, during the suction process. Once the suction is removed, we expect the 
sensation to resolve spontaneously. 
 
Less Likely, some may be Serious 
In 100 people, approximately 5-10 may have: 
• 
Ruptured blister during the suction process, which could require a repeat process. This risk is minimized by 
closely monitoring the blister formation and reducing suction as needed. 
 
Rare and Serious 
In 100 people, less than 1 may develop an infection. 
• 
Blisters will usually heal on their own. The skin over the blister helps keep out infections. To minimize 
infection risk at suction blister sites, all subjects will have the sites treated with topical antibiotic ointment and 
covered with a band-aid or gauze.  They will be provided with antibiotic ointment and band-aids for use at 
home until the sites have healed. Make sure that there is no rubbing or friction on the blister site. 
• 
You should contact your health care provider if 
o 
The blister looks infected - if it is draining pus, or the area around the blister is red, swollen, warm, or 
very painful 
o 
You have a fever 
o 
You have health problems such as circulation problems 
 
We will tell you about any significant new findings which develop during the course of this research which may relate 
to your willingness to continue taking part.   
 
For more information about risks and side effects, ask one of the researchers or study staff. 
 
This study will/may include genetic testing to determine the pattern of DNA modifications in your skin cells. These 
patterns, called epigenetic profiles, change with age but cannot be used to identify you. 
 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
20-720H, Kraig, Form D, 10-12-21, AMD.docx 
 
Page 12 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
Are there Risks related to withdrawing from the study?  
If you decide to withdraw from this study early, please discuss your decision with the principal investigator.  The 
researcher may ask you to complete study withdrawal procedures at a final study visit.  This visit includes returning 
study medication dispensers and completing some parts of the final visit.  
Depending on final data collection, the visit may be done over the phone, at the home, or in the Research Unit. 
There is no risk to you if you do not complete the final withdrawal procedures and you can choose not to participate 
in them. 
 
Are there risks if you also participate in other research studies? 
Being in more than one research study at the same time may increase the risk to you.  It may also affect the results 
of the studies.  You should not take part in more than one study without approval from the researchers. 
 
 
What if a research-related injury occurs?  
The researchers have taken steps to minimize the known or expected risks.  However, you may still 
experience problems or side effects, even though the researchers are careful to avoid them.  In the event of a 
research-related injury or if you experience an adverse reaction, please immediately contact your study doctor.  
See the section “Contact Information” for phone numbers and additional information.  You may also need to tell 
your regular doctors. 
 
If you are injured or made sick from taking part in this research study, medical care will be provided. This care 
may be billed to you or your insurance. Depending on the circumstances, this care may be provided at no cost 
to you. We have no plans to give you money if you are injured. The investigator can provide you with more 
information. 
 
If you sign this form, you do not give up your right to seek additional compensation if you are harmed as a 
result of being in this study. 
 
 
Benefits – “How could you or others benefit from your taking part in this study?” 
There is no guarantee or promise that you will receive any benefit from this study.   
We hope the information learned from this study will benefit other people with similar conditions in the future. 
 
 
Payments – Will there be any payments for participation? 
The researchers will provide you with a MasterCard®.  Compensation will be automatically credited within three 
days of each study visit.  Your name, address and date of birth will be shared with a third-party solely for the 
purposes of compensation processing.  This information will only be used for the administration of the compensation 
(ClinCard) and will be kept strictly confidential.   
 
Visit 0, Consent/Screening 
25.00 
25.00 
Visit 1 – 6, Home (or alternate site) follow-up visits (V4 and/or 
V6 may be replaced by phone calls, in some cases) 
10.00 
60.00 
Visit 7, Post treatment testing 
200.00 
200.00 
Manual payment, Interim Visit 
Prorated at $15.00/hour 
 
      Total Compensation all visits 
 
     $    285.00 
 
In addition to the compensation on the card, you may elect to receive study-related messages (text and/or email). 
These messages will contain information confirming that money has been loaded onto your card. If desired, you 
may also receive reminder messages with information about your next appointment with researchers or study staff.   
 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
20-720H, Kraig, Form D, 10-12-21, AMD.docx 
 
Page 13 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
Please indicate your willingness to receive study-related messages: 
□ 
Yes, I would like to participate (please select the best method(s) for communication) 
o 
Cell Phone (text messages) 
o 
Email 
□ 
No, I choose not to participate 
 
Costs – Will taking part in this study cost anything? 
Ask the researchers if you have any questions about what it will cost you to take part in this study (for example bills, 
fees, or other costs related to the research). 
 
The sponsor will provide the study drug free of charge during this study.  At the end of your participation you must 
return all unused study drug to the researcher.   
 
 
Confidentiality – How will your records be kept confidential? 
 
Information we learn about you in this study will be handled in a confidential manner, within the limits of the 
law.  If we publish the results of the study in a scientific journal or book, we will not identify you.  The 
Institutional Review Board and other groups that have the responsibility of monitoring research may want to 
see study records which identify you as a subject in this study.   
 
Research policies require that private information about you be protected and this is especially true for your 
health information.  However, the law sometimes allows or requires others to see your information.  The 
information given below describes how your privacy and the confidentiality of your research records will be 
protected in this study. 
 
What is Protected Health Information (PHI)?   
Protected Health Information is information about a person’s health that includes information that could make it 
possible to figure out who it is.  According to the law, you have the right to decide who can see your protected 
health information.  If you choose to take part in this study, you will be giving your permission to the 
investigators and the research study staff (individuals carrying out the study) to see and use your health 
information for this research study.  In carrying out this research, the health information we will see and use 
about you will include: your medical history, medications, and health status (based on the blood work and 
screening tests we perform and the information you provide), and information that is created or collected during 
your participation in the study, and results of blood tests and laboratory assays performed with your skin 
samples. In addition, we will see demographic information like your age, sex, ethnicity, and race. Since we 
arrange for home visits, we will also have your address. We will get the health information by asking you and 
running basic blood tests.  
 
How will your PHI be shared?   
Because this is a research study, we will be unable keep your PHI completely confidential.  We may share your 
health information and your age (but not your name or other identifiers besides age) with people and groups 
involved in overseeing this research study including: 
• 
Dr. Horvath, a collaborator at UCLA who performs the analysis of the epigenetic clock, and the laboratory 
facilities both at the UTHSCSA (pharmacology core) and the University of Minnesota (genomics core) 
• 
Clinical Lab that runs standard blood analyses 
• 
Doyle’s Pharmacy (Houston) prepares the topical dispensers and retains the key to drug vs. placebo site 
• 
Collaborators at the UTHSCSA, including statisticians and bioinformaticians (Dr. W. Koek and Dr. H. Zare).  
• 
The DSMB, the data safety monitoring board of the Pepper Center at the UTHSCSA. This committee 
checks the study data on an ongoing basis to determine if it should be stopped for any reason. 
• 
The members of the local research team 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
20-720H, Kraig, Form D, 10-12-21, AMD.docx 
 
Page 14 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
• 
The Institutional Review Board and the Compliance Office of the University of Texas Health Science 
Center at San Antonio, and other groups that oversee how research studies are carried out.  
• 
The Food and Drug Administration (FDA) and other U.S. (National Institute on Aging, NIA) and international 
governmental regulatory agencies involved in overseeing drug research; this study has been designated 
“exempt” by the FDA. 
 
If you decide to participate in this study, you will be giving your permission for the groups named above, to 
collect, use and share your health information.  If you choose not to let these groups collect, use and share 
your health information as explained above, you will not be able to participate in the research study. 
Parts of your PHI (such as your age) may be photocopied and sent to a central location or it may be 
transmitted electronically, such as by e-mail or fax. The groups receiving your health information may not be 
obligated to keep it private.  They may pass information on to other groups or individuals not named here.   
 
This study includes genetic testing to determine the pattern of DNA modifications in your skin cells. These patterns, 
called epigenetic profiles, change with age but cannot be used to identify you. 
 
The Genetic Information Nondiscrimination Act (GINA) is a Federal law that will protect you in the following ways: 
• 
Health insurance companies and group plans may not request genetic information from this research; 
• 
Health insurance companies and group plans may not use your genetic information when making 
decisions regarding your eligibility or premium; 
• 
Employers with 15 or more employees may not use your genetic information when making a decision to 
hire, promote, or fire you or when setting the terms of your employment. 
 
GINA does not protect you against genetic discrimination by companies that sell life insurance, disability 
insurance, or long-term care insurance.  GINA also does not protect you against discrimination based on an 
already-diagnosed genetic condition or disease.  
 
 
How will your PHI be protected?   
In an effort to protect your privacy, the study staff will use code numbers, instead of your name, to identify your 
health information. Subject identifiers will be used on any photocopies of your study records, on any specimens 
collected (blood or skin samples), and any other study materials containing health information that are sent outside 
of the UTHSCSA for review or testing.  If the results of this study are reported in medical journals or at meetings, 
you will not be identified. 
 
Do you have to allow the use of your health information? 
You do not have to allow (authorize) the researchers and other groups to see and share your health information.  
If you choose not to let the researchers and other groups use your health information, there will be no penalties 
but you will not be allowed to participate in the study.   
After you enroll in this study, you may ask the researchers to stop using your health information at any time.  
However, you need to say this in writing and send your letter to Dr. Ellen Kraig, Department of Cell Systems and 
Anatomy, MC 7762, UTHSCSA, 7703 Floyd Curl Drive, San Antonio, TX, 78229.  If you tell the researchers to 
stop using your health information, your participation in the study will end and the study staff will stop collecting 
new health information from you and about you for this study.  However, the study staff will continue to use the 
health information collected up to the time they receive your letter asking them to stop. 
 
Can you ask to see the PHI that is collected about you for this study?   
The federal rules say that you can see the health information that we collect about you and use in this study.  
Contact the study staff if you have a need to review your PHI collected for this study. 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
20-720H, Kraig, Form D, 10-12-21, AMD.docx 
 
Page 15 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
 
You will only have access to your PHI until two years following the end of your participation in the study. Because 
of the type of research, you can only access your PHI when the study is done.  At that time, you have the right 
to see and copy the medical information we collect about you during the study, for as long as that information is 
kept by the study staff and other groups involved.   
 
How long will your PHI be used?   
Authorization to use your PHI will expire 5 years after the last subject completes the study or on 05/31/2027, 
whichever occurs first. 
 
 
By signing this form, you agree to let us use and disclose your health information for purposes of the study until 
05/31/2027. 
 
 
Contact Information – Whom can you contact if you have questions, concerns, comments or 
complaints? 
 
If you have questions now, feel free to ask us.  If you have additional questions, concerns, comments or complaints 
later or you wish to report a problem which may be related to this study please contact: 
 
Primary contact: 
 
Dean L. Kellogg, Jr, MD, PhD can be reached at 210-235-3681 (pager) or 210-788-6497 (mobile) during and after 
regular business hours. 
 
Note: To use the pager, you need to have a touch tone (push button) telephone.  Dial the pager number as you 
would any phone number.  When you hear 3 short high-pitched beeps, dial in the number where you want the doctor 
to call you back.  Push the # button, hang up and wait for the doctor to return your call. 
 
If primary is not available, contact 
Terry Q. Romo, FNP-BC can be reached at 210-617-5300 x14266 (can be reached during normal work hours) or 
(210) 834-7819.  
 
Dr. Ellen Kraig can be reached at 210-367-3171. 
 
The University of Texas Health Science Center committee that reviews research on human subjects (Institutional 
Review Board) will answer any questions about your rights as a research subject, and take any concerns, 
comments or complaints you may wish to offer.  You can contact the IRB by calling 210-567-8250, or by mail to IRB, 
UTHSCSA, Mail Code 7830, 7703 Floyd Curl Drive, San Antonio, TX  78229-3900. 
 
 


Title of Study: An innovative proof-of-concept approach to identify age-modulating drugs capable of reversing 
inflammation and re-setting the epigenetic clock (Topical RAPA) 
 
 
20-720H, Kraig, Form D, 10-12-21, AMD.docx 
 
Page 16 of 16 
UT Health San Antonio Research Consent and Authorization Documents (v Jan 19 2021) 
 
Research Consent & Authorization Signature Section 
If you agree to participate in this research and agree to the use of your protected health information in this research 
sign this section.  You will be given a signed copy of this form to keep.  You do not waive any of your legal rights by 
signing this form.   
 
SIGN THIS FORM ONLY IF THE STATEMENTS LISTED BELOW ARE TRUE 
• 
You have read the above information. 
• 
Your questions have been answered to your satisfaction about the research and about the collection, use and 
sharing of your protected health information.    
 
Adult Signature Section 
• 
You have voluntarily decided to take part in this research study. 
• 
You authorize the collection, use and sharing of your protected health information as described in this form. 
 
 
 
 
 
 
 
 
AM 
PM 
Printed Name of Subject 
 
 
 
Signature of Subject 
 
 
Date 
 
Time 
 
AM 
PM 
Printed Name of Witness 
 
 
Signature of Witness 
 
 
Date 
 
Time 
 
  Check if consent and authorization obtained from an individual who is unable to read and/or write but can 
otherwise communicate and/or comprehend English. Have witness initial below. 
Declaration of witness:  I was present for the entire consent process.  ________ ←(initials of witness) 
 
 
 
 
 
 
AM 
PM 
Printed Name of Person 
Obtaining Consent & 
Authorization 
 
Signature of Person Obtaining Consent 
& Authorization  
 
 
Date 
 
Time 
  Consent and authorization was obtained from this individual who is unable to read and/or write but can otherwise 
communicate and/or comprehend English.   The method used for communication with the subject was: 
______________________.   
The specific means by which the subject communicated agreement to participate was: 
____________________________________ 
 
 
  
 

Prot_SAP_002.pdf: 
20-720H, Kraig, Form BB, 08-17-21, AMD.docx 
 
Version 1.2 
Official Study Title: An innovative proof-of-concept approach to 
identify age-modulating drugs capable of reversing inflammation 
and re-setting the epigenetic clock (Topical-RAPA) 
 
 
NCT number: NCT04608448 
 
IRB Approval Date: 08-17-21 
 
Unique Protocol ID: HSC20200720H 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


20-720H, Kraig, Form BB, 08-17-21, AMD.docx 
Version 1.0 
 
An innovative proof-of-concept approach to identify age-modulating drugs 
capable of reversing inflammation and re-setting the epigenetic clock 
(Topical-RAPA) 
Study Chairman or Principal Investigator: 
Ellen Kraig, PhD 
University of Texas Health Science Center San Antonio 
Department of Cell Systems & Anatomy 
School of Medicine 
7703 Floyd Curl Drive, MC7762 
San Antonio, Texas 78229-3900 
210-367-3171 
 
kraig@uthscsa.edu 
 
 
Supported by: The National Institute on Aging 
 
Study Intervention Provided by: Grant Funds 
Sponsor of IND/IDE: 152906 Exempt per FDA 
Dean L Kellogg, Jr, MD, PhD 
UT Health Science Center 
Department of Medicine – Division of Geriatrics,  
Gerontology and Palliative Medicine 
7703 Floyd Curl, MC 7885 
San Antonio, TX 78229-3900 
210-617-5197 
kelloggd@uthscsa.edu 
 
Version 1.4  16 August 2021


Protocol Template, Version 3.0 
i 
TABLE OF CONTENTS 
TABLE OF CONTENTS .............................................................................................................. i 
Study Title .................................................................................................................................. iv 
Objectives .................................................................................................................................. iv 
Design and Outcomes ................................................................................................................ iv 
Interventions and Duration ........................................................................................................ iv 
Sample Size and Population....................................................................................................... iv 
STUDY TEAM ROSTER............................................................................................................. 5 
Principal Investigator:                Ellen Kraig, PhD ..................................................................... 5 
Co-Investigators:   Dean L. Kellogg, Jr, M.D., PH.D. ............................................................. 5 
1 
Study objectives ..................................................................................................................... 6 
1.1 
Primary Objective ........................................................................................................... 6 
1.2 
Secondary Objectives...................................................................................................... 6 
2 
BACKGROUND AND RATIONALE ................................................................................ 6 
2.1 
Background on Condition, Disease, or Other Primary Study Focus .............................. 6 
2.2 
Study Rationale ............................................................................................................... 7 
3 
STUDY DESIGN ................................................................................................................... 9 
4 
SELECTION AND ENROLLMENT OF PARTICIPANTS .......................................... 10 
4.1 
Inclusion Criteria .......................................................................................................... 10 
4.3 
Study Enrollment Procedures ....................................................................................... 11 
4.4 
Subject Recruitment and Retention .............................................................................. 12 
5 
STUDY INTERVENTION ................................................................................................. 12 
5.1 
Interventions, Administration, and Duration ................................................................ 12 
5.1.1.1 Rapamycin powder (from a supplier to Doyle’s pharmacy) ..................................... 13 
5.1.1.2 Petrolatum (Vaseline, vehicle only) .............................................................................. 14 
5.2 
Handling of Study Interventions ................................................................................... 15 
5.3 
Concomitant Interventions ............................................................................................ 15 
5.3.1 Allowed Interventions ............................................................................................... 15 
5.3.2 Prohibited Interventions ............................................................................................ 16 


20-720H, Kraig, Form BB, 08-17-21, AMD.docx 
 
Version 1.2   ii 
5.4 
Adherence Assessment ................................................................................................. 16 
6 
STUDY PROCEDURES .................................................................................................... 17 
6.1 
Schedule of Activities ................................................................................................... 17 
6.2 
Schedule of Evaluations ................................................................................................ 18 
7 
SAFETY ASSESSMENTS ................................................................................................. 20 
7.1 
Specification of Safety Parameters ............................................................................... 20 
7.2 
Adverse Events and Serious Adverse Events ............................................................... 21 
7.3 
Unanticipated Problems Involving Risk to Subjects or Others (UPIRSO)................... 21 
7.3.1 Adverse Event Reporting Period ........................................................................... 22 
7.3.2 Pre-existing Condition ............................................................................................ 22 
7.3.3 Abnormal Laboratory Values ................................................................................ 22 
7.3.4 Hospitalization, Prolonged Hospitalization or Surgery ...................................... 22 
7.4 
Recording of Adverse Events ....................................................................................... 22 
7.6 
 Reporting of Serious Adverse Events and Unanticipated Problems ............................ 23 
7.6.2 Investigator reporting: notifying the UTHSCSA IRB ............................................ 24 
Notifying the IRB and or FDA if SAE or UPIRSO .............................................................. 24 
7.7 
Medical Monitoring ...................................................................................................... 24 
7.8 
Investigator Reporting of Protocol Deviations/Violations ........................................... 24 
7.8.1 Deviations and violations may be identified in a number of ways including: ... 25 
7.8.2 Definitions of Protocol Deviations/Violations ....................................................... 25 
7.9 
Safety Monitoring ......................................................................................................... 25 
8 
INTERVENTION DISCONTINUATION........................................................................ 26 
9 
STATISTICAL CONSIDERATIONS .............................................................................. 26 
9.1 
General Design Issues ................................................................................................... 26 
9.2 
Sample Size and Randomization .................................................................................. 26 
9.2.1 Treatment Assignment Procedures ........................................................................... 27 
9.3 
Interim analyses and Stopping Rules ............................................................................ 27 
9.4 
Primary Objective ......................................................................................................... 27 
9.5 
Secondary Objectives.................................................................................................... 27 
9.6 
Data Analyses ............................................................................................................... 28 
10 DATA COLLECTION AND QUALITY ASSURANCE ................................................ 29 
10.1 
Data Integrity ................................................................................................................ 29 
10.2 
Data Management ......................................................................................................... 29 


20-720H, Kraig, Form BB, 08-17-21, AMD.docx 
 
Version 1.2   iii 
10.3 
Quality Assurance ......................................................................................................... 29 
10.3.1 
Training ............................................................................................................... 29 
10.3.2 
Quality Control Committee ............................................................................... 29 
10.3.3 
Study Monitoring Plan ....................................................................................... 29 
11 PARTICIPANT RIGHTS AND CONFIDENTIALITY ................................................. 30 
11.1 
Institutional Review Board (IRB) Review .................................................................... 30 
11.3 
Participant Confidentiality ............................................................................................ 30 
11.4 
Study Discontinuation ................................................................................................... 30 
12 ETHICAL CONSIDERATIONS ....................................................................................... 31 
13 COMMITTEES................................................................................................................... 31 
14 PUBLICATION OF RESEARCH FINDINGS ................................................................ 31 
15 REFERENCES .................................................................................................................... 32 
16 SUPPLEMENTS/APPENDICES ...................................................................................... 34 
 
 
 
 
 
 


20-720H, Kraig, Form BB, 08-17-21, AMD.docx 
 
Version 1.2   iv 
Study Title  
An innovative proof-of-concept approach to identify age-modulating drugs capable of 
reversing inflammation and re-setting the epigenetic clock (Topical-RAPA) 
Objectives  
AIM 1: Test whether epigenetic changes in skin are elicited by topical treatments with                  
RAPA 
AIM 2: Test whether baseline inflammation is affected by topical RAPA 
Design and Outcomes   
This is a double-blinded pilot treatment study, where each subject provides his/her own 
control to assess whether rapamycin will stop, slow, or reverse the “epigenetic clock” 
using DNA extracted from skin and the change in levels of inflammatory mediators 
measured in blister fluid in healthy subjects aged 65-95 years.  
Interventions and Duration  
Rapamycin 8% ointment will be applied topically, 0.25ml, to one of the participant’s 
forearms and matching placebo, 0.25ml, to the opposite forearm daily for a total of 6 
months. The total participant duration will include a consenting/screening visit (0) will 
last 60-90 minutes, followed by monthly visits (1-6) of up to 60 minutes, and followed by 
the final visit (7) of up to 4 hours. 
 
Sample Size and Population  
The study aims to recruit 75 subjects to ensure at least 40 completers, approximately half 
male and half female. 


20-720H, Kraig, Form BB, 08-17-21, AMD.docx 
 
Version 1.2   5 
STUDY TEAM ROSTER  
 
 
Principal Investigator:               Ellen Kraig, PhD 
 
University of Texas Health Science Center San Antonio 
 
Department of Cell Systems & Anatomy 
 
School of Medicine 
 
7703 Floyd Curl Drive, MC7762 
 
San Antonio, Texas 78229-3900 
210-367-3171 
 
kraig@uthscsa.edu  
 
Co-Principal Investigator:        Dean L. Kellogg, Jr, M.D, Ph.D. 
UT Health Science Center 
Department of Medicine – Division of Geriatrics, 
Gerontology and Palliative Medicine 
   7703 Floyd Curl, MC 7885 
   San Antonio, TX 78229-3900 
                                                     210-617-5197  
                                                     kellogg@uthscsa.edu 
 
  
 
SITES: 
UT Health San Antonio 
 


20-720H, Kraig, Form BB, 08-17-21, AMD.docx 
 
Version 1.2   6 
1 
STUDY OBJECTIVES 
1.1 Primary Objective 
Test whether epigenetic changes in skin are elicited by topical treatments with RAPA 
1.2 Secondary Objectives 
Test whether baseline inflammation is affected by topical RAPA 
 
2 
BACKGROUND AND RATIONALE  
2.1 Background on Condition, Disease, or Other Primary Study Focus 
The study is focused on the effects of mTOR antagonism specifically on elderly subjects. 
In order to identify drugs and/or interventions with the potential to delay the onset and progression 
of age-associated pathologies, preclinical studies have used animal models where extension of 
lifespan could be accurately assessed. Several outstanding candidate therapeutics have been 
identified over the last decade; these include mTOR inhibitors (like rapamycin), senolytic agents, 
acarbose, and others. However, translating anti-aging results from animal models into humans has 
been challenging. For example, measuring extension of lifespan would be impractical in humans, 
so it is necessary to identify and validate parameters that can serve as surrogate markers of healthy 
aging. Moreover, the efficacy of age-modulating drugs is often only demonstrable with older 
individuals where functional deficits are already evident. Thus, testing of potential anti-aging 
therapeutics should be done in a cohort of human subjects of an advanced age; issues of safe 
administration would be even more acute in this “at risk” population. To circumvent these 
limitations, we propose to develop and validate an innovative, minimally invasive, cost-effective 
assay in human subjects ranging from 65-95 years old. The putative anti-aging test drug will be 
applied topically to a discrete area of skin on the subject’s forearm while a “vehicle only” (control) 
is applied in parallel to the opposite arm. Thus, each subject will serve as his/her own control. The 
pharmacodynamic outcomes at the “test” and placebo sites will be compared in both males and 
females since the effects of age-modulating agents often differ between the sexes. Ascertaining 
the efficacy of topically-applied therapeutics requires robust biomarkers of aging that can be 
measured in skin, but will be generalizable to the intact organism. Towards this end, we have opted 
to use two independent parameters that are known to be modified with aging both locally (in 
individual tissues) and systemically: i) the DNA methylation pattern or “epigenetic clock” and  ii) 
biomarkers associated with inflammation. To validate the proposed technique, we have chosen a 
drug, rapamycin (RAPA), which has already been shown to modulate aging in rodents and which 
has been tested for safe systemic application in humans [1-4]. After a 6 month treatment phase, 
suction blisters will be generated at each site to allow collection of skin cells (blister flap) for use 
in the epigenomic analysis (Aim 1) and interstitial (blister) fluid for use in measuring cytokines 
and other inflammatory regulators (Aim 2). Once validated, our approach can be used to safely 
and efficiently screen the age-modulating potential of pharmacological agents in humans to 
identify those agents that warrant large, expensive human clinical trials with systemic agent 
administration. 
 
 


20-720H, Kraig, Form BB, 08-17-21, AMD.docx 
 
Version 1.2   7 
2.2 Study Rationale 
Demonstrating age modulating benefits of drugs in long-lived humans is challenging. Although 
there are outstanding animal models used to identify candidate interventions which extend 
lifespan [2, 3, 13], an efficient and cost-effective approach to test which of these drugs can be 
used safely and with efficacy in an older human cohort is not available. Thus, we propose to 
develop and validate an innovative, relatively safe, minimally invasive approach for the initial 
evaluation of the potential efficacy of purported age-modulating agents in humans prior to 
moving forward with a large, costly human clinical trial. Our scientific premise is that putative 
age-modulating agents can be pre-screened for beneficial effects through topical application to 
the skin of humans. In this way, the drug effects will be limited to the small test area with 
minimal or no systemic delivery, thereby avoiding serious risks to the human subjects. As 
summarized in Figure 1, potential agents can be applied to different ‘experimental’ skin sites in 
the same person with simultaneous application of ‘control’ placebo treatments on opposite 
forearms. This approach will allow each subject to serve as his/her own control. Age-modulating 
efficacy of the tested agent(s) can be assessed from skin samples obtained from the experimental 
treated and placebo control sites. Skin samples can be easily obtained with suction blister or 
small punch biopsy techniques for subsequent testing [14-17]. Ascertaining the age modulating 
efficacy from these samples will require robust biomarkers of aging that can be measured in skin, 
but will be generalizable to the intact organism. Towards this end, we have opted to use two 
parameters that are known to be modified with aging both locally (in individual tissues) and 
systemically: i) the DNA methylation pattern or “epigenetic clock” and ii) biomarkers associated 
with inflammation.   
To validate the proposed pre-screening approach, we have chosen to initially test a single agent, 
rapamycin (RAPA), an mTOR pathway antagonist. RAPA has been shown to prolong lifespan in 
rodents. Improvements in cognition, cardiovascular function, and certain aspects of immunity 
were also demonstrated in animal models [7, 18-23].  Based on these promising results, we 
undertook a pilot study of orally-delivered RAPA in older (aged 70-95 yrs) human subjects as a 
potential anti-aging therapeutic. As described in detail [1], short-term (2 months) RAPA 
treatment was relatively well tolerated in these older individuals. In addition, we and others have 
established that RAPA can be efficaciously delivered transdermally [24, 25]. As shown in Figure 
2A, easily detectable levels of the drug are obtained locally (in the skin at the application site) 
within 12 hours of application while there was no detectable level of RAPA in the blood even 
after 7 days of topical application of 8% RAPA. Moreover, as shown in Figure 2B, 7 days of 8% 
RAPA led to improved endothelium-dependent vasodilation in older, but not younger persons, 
demonstrating that this treatment exerted pharmacological effects. In an "N of 1" study, 8 months 
of topical 8% RAPA treatment decreased the size of keloids (Kellogg, data not shown). Topical 
RAPA has also been tested clinically and shown to be efficacious in the treatment of psoriasis 
and tuberous sclerosis [24, 26, 27]. Thus, mTOR inhibition with RAPA should be an excellent 
model for development and validation of the proposed pre-screening protocol. The ‘long-term’ 
significance is that, once validated, our approach can be used to safely and efficiently screen the 
age-modulating potential of pharmacological agents in humans, in vivo, in a relatively short 
amount of time in order to identify those agents that warrant large, expensive human clinical 
trials with systemic agent administration. 


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b) Innovation: 
We will develop a new pre-screening approach that can be safely used for translational studies in 
humans. The proposed protocol, employing topical application, should both enhance our 
understanding of underlying mechanisms affected by aging and identify the most promising age-
modulating pharmacological therapies for future clinical trials with systemic administration. A 
priority for translating the pharmacological manipulation of aging from animal models into 
humans, especially in the geriatric age group, is subject safety. Since these test interventions will 
be given to essentially healthy persons to treat aging (a normal life process) rather than to 
mitigate an overt disease process, taking age-modulating drugs must entail no additional risks 
over those inherent in normal aging.  Furthermore, successful agents must act to prolong 
healthspan or at least delay the onset of age-related pathologies. Ideally, age modulating agents 
would ‘reset’ the biological clock and slow or reverse the increase in baseline inflammation; 
thereby rejuvenating treated individuals. The innovation in this proposal derives from the choice 
of biomarkers to be followed to assess efficacy of topical treatment. First, we propose to use two 
independent measures of aging such that simultaneous effects on both outcomes would be highly 
significant. Second, the “epigenetic clock” defined by Dr. Steve Horvath (a collaborator on this 
project), is an innovative tool for estimating chronological age of cells based on the DNA 
methylation at 391 CpG motifs. This test has been previously validated for both skin cells and 
blood cells, suggesting that the results from topical administration will be directly translatable to 
systemic dosing. Third, to test for the effect of the topically applied drug on baseline 
inflammation, we will use a multiplex Luminex array to measure levels of 29 human cytokines 
(both pro and anti-inflammatory). In addition, ELISAs will be performed on three analytes 
known to play critical roles in regulating inflammation: IL-6 (interleukin-6), soluble ICAM-1, 
and RAGE (receptor for advanced glycation end products). Importantly, by using RAPA as the 
initial test compound, we will be able to directly compare the results with topical application to 
results from human clinical trials with oral administration. The future implications and potential 
uses deriving from this “high risk, potentially high reward” R21 are vast.  
c) Approach: 
Rationale. The NIA Interventions Testing Program (ITP) was developed to assess the potential of 
drugs to extend lifespan in mice and has identified several promising candidates, including 
aspirin, rapamycin (RAPA), 17αEstradiol, acarbose, NDGA (nordihydroguaiaretic acid), and 
Protadim [28] Additional putative age-modulating compounds have been identified through other 
approaches; these include senolytics, NAD precursors, and Sirtuin activators, among others [2]. 


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Although several of these agents have moved into human clinical trials, such efforts are limited 
due to: i) high costs; ii) the inability to use “lifespan” as an outcome measure in long-lived 
humans; and  iii) the reluctance to test drugs in an older “at risk” population. This last limitation 
is often circumvented either by using a younger subject cohort or by targeting individuals with 
serious illnesses; neither of these options is ideal. For example, some age-modulating drugs only 
show a treatment effect in older subjects where the loss of function with age changes the baseline 
allowing an effect to be detected (one such example is shown in Figure 2B where an effect of 
topical RAPA was seen only in older subjects). Similarly, studies of older subjects with cancer, 
autoimmunity, or another illness are compromised by associated co-morbidities and other drugs 
being taken to treat the primary illness. Thus, it is critically important to test putative age-
modulating drugs on an older human cohort that is otherwise clinically stable.   
The ‘gold standard’ for testing a drug for its ability to slow the ravages of aging would be a long-
term placebo-controlled human clinical trial where changes in lifespan and age-associated 
pathologies could be assessed. However, this is simply not feasible in humans and is even 
challenging in relatively long-lived non-human primate models. Thus, we propose to develop 
and validate an innovative, minimally invasive, safe, and cost-effective technique for initial 
translational testing of purported age-modulating agents in humans. Our approach utilizes topical 
application of the intervention being tested to the skin of consenting human subjects. In order to 
sample the treated skin regions, suction blisters will be generated as a source of skin cells 
(keratinocytes) and blister fluid to be used in determining efficacy of the putative anti-aging 
treatment. There are several significant advantages inherent in this new approach. Specifically, 
the topical administration of agents to small areas of skin in humans will obviate the greater risks 
of systemic drug administration. As the target area is relatively small, this approach will require 
significantly less drug than a systemic clinical trial at a much lower cost as well. Moreover, the 
risk to human participants will be minimized as the agent is only delivered into skin, not 
systemically. As our proposed approach is safer than systemic administration and less invasive, 
we anticipate that successful recruitment of volunteer subjects will be much easier which is 
particularly important when dealing with an older cohort. Lastly, multiple ‘experimental’ skin 
sites can be treated simultaneously such that each subject will serve as his/her own control, 
thereby increasing statistical power and validity of the trial.   
 
3 
STUDY DESIGN 
 
Overall study design.  
As shown diagrammatically in Figure 1, consenting subjects would apply the test compound to 
designated experimental and control sites on their forearms for the study period. As discussed 
below, we have opted for daily dosing over a 6-month period. At that point, suction blisters 


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would be generated at each of the sites; this will allow us to harvest both the skin flap and blister 
fluid. The efficacy of the potential age-modulating drug would then be assessed using two 
independent parameters: i) the potential to stop, slow, or reverse the “epigenetic clock” (Specific 
Aim 1) using DNA extracted from the skin and ii) changes in the levels of inflammatory 
mediators (Specific Aim 2) measured in the blister (interstitial) fluid. The topical approach to 
drug pre-screening is ideal for several reasons. First, skin is easily accessible and the applications 
can be handled by the subjects themselves. Second, human skin shows an invariant age-
dependent phenotype characterized by decreased epidermal thickness, changes in the 
vasculature, reduction in the number of melanocytes and dendritic (Langerhans) cells, and lower 
levels of specific collagen types. Third, it is relatively easy to access the treated skin and fluids 
therein using the already established suction blister protocol [15, 16]. Lastly, the cost associated 
with topical application is significantly lower than systemic dosing as one can obtain relatively 
high concentrations of the test agent when it’s being applied to a small area of skin; in this case, 
10 cm ²/site.   
 
4 
SELECTION AND ENROLLMENT OF PARTICIPANTS  
Participants will not be excluded based upon ethnicity or race. For the proposed studies, we will 
draw on the general population of San Antonio and surrounding area which is more than 50% 
Hispanic. We suspect that we will have approximately 50% (or slightly more) Hispanic subjects 
in our proposed study.  In our past studies, our volunteer population has been approximately 50% 
male and 50% female and we anticipate recruiting this equal sex distribution for the proposed 
trial.  All subjects will be in good health, non-smoking persons between the ages of 65 and 95.  
As outlined previously, all ethnicities, racial groups, and both sexes will be studied.  Subjects 
will be enrolled after confirmation of good health by history and physical exam, clinical 
laboratory tests (fasting glucose and lipid profile, metabolic profile, complete blood count, 
Hemoglobin A1C) and 12-lead ECG. The ethnicity of our past study populations generally 
reflected our local population: 47% Non-Hispanic White, 48% Hispanic, and 5% African 
American with an equal gender distribution.    
Vulnerable Populations:  No vulnerable populations will be involved in the proposed protocols. 
 
4.1 Inclusion Criteria  
Participants must meet all of the inclusion criteria to participate in this study: 
• 65-95 years of age. 
• Good health with all chronic diseases (hypertension, coronary artery disease, etc.) 
clinically stable. 
• Selected subjects will be in good health (Per the World Health Organization, good 
health will be defined as complete physical, mental, and social well-being and not 
merely the absence of disease or infirmity). 
• All diseases or infirmities will be clinically stable whether managed by 
medications or not. 
• CLOX score of 10 or greater 


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• Women will be postmenopausal 
• Postmenopausal women taking hormone replacement will be included if they 
have been on a stable dose for ≥6 months 
• Participants will have been vaccinated for COVID-19 prior to beginning the 
treatment course 
• Participants will live within 20 miles of the UTHSA to facilitate home visits (or 
may choose to meet in a mutually convenient location within 20 miles of the 
UTHSA for all home visits) 
4.2   Exclusion Criteria  
All candidates meeting any of the exclusion criteria at baseline will be excluded from 
study participation: 
• Diabetes. 
• History of skin ulcers or poor wound healing, or keloid formers. 
• Smoking (current or within 5 years). 
• Current liver disease (acute or chronic). 
• Treatment for anticoagulation (coumadin or novel oral anticoagulant). 
• Treatment with drugs known to affect cytochrome P450 3A (diltiazem, 
erythromycin, etc. - due to role in rapamycin metabolism). 
• Treatment with an immunosuppressant (prednisone, etc.) within the 6 months. 
• History of recent (within 6 months) Myocardial Infarction or active Coronary 
Disease. 
• Hypersensitivity to rapamycin or petrolatum (ointment vehicle). 
• Tattoo or scar tissue on the forearm in the application area. 
  
4.3 
Study Enrollment Procedures  
Healthy human volunteers of normal cognitive function capable of consenting will be consented 
as study participants. Since the effectiveness of some age-modifying drugs (i.e., RAPA) can 
become more evident with age (Fig. 1B), we will recruit test subjects ranging from 65 to 95 years 
old. Subjects will be non-smokers and will be instructed to continue taking any currently 
prescribed medications. Female subjects will be postmenopausal. All ethnicities and races will be 
included. Prior to initiating treatment, potential subjects will be screened for exclusions, 
including serious co-morbidities, by medical history, clinical labs, and physical examination 
including EKGs. Both male and female subjects will be recruited. This is critically important as 
the age-modulating drugs often show greater efficacy in one sex. For example, RAPA was 
shown to extend lifespan to a greater extent in female mice than in males while acarbose showed 
the reverse [4, 29]. Thus, our goal is to recruit 75 subjects to ensure that there will be 40 
“completers”, approximately half female and half male. Towards this end, we will use the 
Subject Recruitment Call Center established and operated by the Research Core-2 (RC2) of the 
San Antonio OAIC (Pepper Center; Dr. Kellogg, RC2 co-leader). This center has been 
spectacularly successful in meeting subject recruitment goals for clinical trials of age modulating 
agents and has registered over 1800 persons who are willing to participate in future human trials. 


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Other instruments for subject recruitment may also be used. These include:  i) the national online registry 
at https://www.researchmatch.org,  ii) UT Health's Find-A-Study webpage at 
https://vpr.uthscsa.edu/findastudy/;  and  iii) the Barshop Clinical Trials webpage at  
https://barshopinstitute.uthscsa.edu/clinical-trials/; iv) ads may be placed in the San Antonio Express 
News or other local periodicals read by the target population, and v) ads may be placed on Facebook 
and/or other social media sites.   
Once subjects have been appropriately consented and cleared for participation, each individual 
will be given two Topi-CLICK® containers of ointment and complete instructions on the 
application protocol. Initially, we will test 1 concentration of the drug with a “vehicle only” 
(negative control, petrolatum) applied to the opposite arm. Importantly, since each subject will 
serve as his/her own control, no separate placebo group will be needed.   
4.4 
Subject Recruitment and Retention 
Subject recruitment will take place through the Subject Recruitment Call Center established and 
operated by the San Antonio Claude D. Pepper Older Americans Independence Center (SA 
OAIC) Research Core-2 (RC2, Dr. Kellogg Core Co-Leader).  RC2 developed the "Call Center 
and Participant Registry" for efficient subject recruitment.  The public is made aware of the Call 
Center through advertisements placed by the SA OAIC in local newspapers, websites, social 
media, or other online resources, on broadcast media, and through local presentations to civic 
groups.  The Center has one primary phone line that receives phone calls from potential 
participants.  Potential subjects are asked for permission to enter demographic and preliminary 
clinical data that are subsequently entered into a REDCap based registry. The Call Center is 
active 24 hours a day, 7 days a week, and is the main point of entry for participants for aging 
studies such as the present proposal.  RC2 staff determine each caller's study suitability based on 
the caller’s interest, initial screening information, and study eligibility criteria (which can vary 
among ongoing studies).  This subject database currently has records of 1811 persons who are 
willing trial participants.  The REDCap database of potential subjects will be queried for the 
proposed trial as the major source of recruitment, significantly reducing costs for external 
advertising. Enrolled subjects will be seen at in-person monthly Visits 1-6 in their homes (or at 
an alternate convenient site) and contacted bi-weekly by the study team to facilitate retention and 
to confirm treatment compliance. Visits 4 and 6 may be conducted by phone with those subjects who 
have demonstrated their strict compliance to protocol (in Visits 2 and 3) and have experienced no adverse 
effects.  
5 
STUDY INTERVENTION  
5.1 Interventions, Administration, and Duration  
The selection of topical application of 8% RAPA in petrolatum is based on our preliminary data.  
Our preliminary data indicate that topical 8% RAPA ointment: 
a) produces local effects (reduced EC50 for endothelium-dependent vasodilator response to 
methacholine in older, but not younger, persons; it also led to keloid regression); 
b) produces detectable intradermal RAPA levels (as measured with intradermal microdialysis);  
c) is without local or systemic adverse reactions; and  


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d) this concentration of RAPA ointment produces no detectable systemic RAPA levels.  
These preliminary results support our view that this treatment is safe for use in older humans. 
 
 
To validate the proposed technique, RAPA was chosen as our initial test agent; it has been found 
to extend lifespan in laboratory animals [4], be transdermally deliverable with topical application 
(see [24] and Fig. 2), improve epigenetic aging signatures in mice [30, 31], and restore some 
physiological functions in animal models when systemically delivered [7, 18-23, 32]. Moreover, 
we and others have shown that RAPA can be used with relative safety in older humans, even 
with systemic delivery [1, 5, 6]. In preliminary feasibility studies, RAPA ointments (1% or 8%) 
were applied to forearm skin sites and RAPA delivery into the skin interstitial space was 
assessed by placing an intradermal microdialysis probe at each site and then measuring the drug 
levels attained in the collected interstitial fluid by HPLC-mass spec. As shown in Figure 2A, 
significant RAPA levels (11.5±4.0 ng/ml) were seen with a 7 day course of the 8% RAPA 
ointment; while a 1% dose yielded much lower values. Simultaneous blood sampling after 1 
week of 8% RAPA dosing showed undetectable RAPA in the serum; thus, the treatment should 
be efficacious locally without having systemic consequences.   
    
5.1.1 Compounded Investigational Product 
 
5.1.1.1 Rapamycin powder (from a supplier to Doyle’s pharmacy) 
Molecular formula: C51H79NO13 
Synonyms: Rapamune, sirolimus 
PubChem Substance ID 57654583 
CAS No. 53123-88-9 
An FDA-approved macrocyclic triene antibiotic forms a complex with FKBP12 that binds to and 
inhibits the molecular target of rapamycin (mTOR). Rapamycin (RAPA) is a potent 
immunosuppressant and has anticancer activity. 


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i) Mechanism of Action 
The RAPA oral formulation developed by Pfizer (RAPAMUNE, sirolimus) inhibits T 
lymphocyte activation and proliferation that occurs in response to antigenic and cytokine 
(Interleukin [IL]-2, IL-4, and IL-15) stimulation by a mechanism that is distinct from that of 
other immuno-modulators.  In cells, sirolimus binds to the immunophilin, FK Binding Protein-12 
(FKBP-12). The sirolimus: FKBP-12 complex has no effect on calcineurin activity. This 
complex binds to and inhibits the activation of the mammalian Target Of Rapamycin (mTOR), a 
key regulatory kinase. This inhibition suppresses cytokine-driven T-cell proliferation, inhibiting 
the progression from the G1 to the S phase of the cell cycle. Dosage forms and strengths include: 
oral solution (60mg/60mL in amber glass bottle) and oral tablets (0.5, 1, and 2mg). 
ii) Safety 
From oral administration, serious allergic reactions identified by the manufacturer include: 
• swelling of face, eyes, or mouth 
• trouble breathing or wheezing 
• throat tightness 
• chest pain or tightness 
• feeling dizzy or faint 
• 
rash or peeling of skin 
In previous human studies cited earlier in this protocol, topical administration did not produce 
systemic or serious reactions. Potential Risks due to topical RAPA include local skin rash or 
irritation; the drug does not reach detectable levels systemically. Participants will be instructed to 
notify the research team and get help right away if any of the above symptoms of an allergic 
reaction occur. 
iii) Storage 
The powder is packaged in a glass bottle with instructions to keep container tightly closed in a 
dry and well-ventilated place. 
5.1.1.2 Petrolatum (Vaseline, vehicle only) 
i) Mechanism of Action 
Petrolatum is a pale yellow to yellow-colored, translucent, soft unctuous mass. It is odorless, 
tasteless, and not more than slightly fluorescent by daylight, even when melted. Petrolatum is an 
inert material with few incompatibilities. 
ii) Safety 
Petrolatum is mainly used in topical pharmaceutical formulations and is generally considered to 
be a nonirritant and nontoxic material. Animal studies, in mice, have shown petrolatum to be 
nontoxic and non-carcinogenic. Although petrolatum is generally nonirritant in humans 
following topical application, rare instances of allergic hypersensitivity reactions have been 
reported, as have cases of acne, in susceptible individuals following repeated use on facial skin. 
However, given the widespread use of petrolatum in topical products, there are few reports of 
irritant reactions. The allergic components of petrolatum appear to be polycyclic aromatic 
hydrocarbons present as impurities. The quantities of these materials found in petrolatum vary 
depending upon the source and degree of refining. Hypersensitivity appears to occur less with 
white petrolatum and it is often the preferred material for use in cosmetics and pharmaceuticals. 


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iii) Storage 
Petrolatum is an inherently stable material owing to the unreactive nature of its hydrocarbon 
components; most stability problems occur because of the presence of small quantities of 
impurities. On exposure to light, these impurities may be oxidized to discolor the petrolatum and 
produce an undesirable odor. Petrolatum should not be heated for extended periods above the 
temperature necessary to achieve complete fluidity (approximately 70°C/158°F). When heated 
to decomposition it emits acrid smoke and irritating fumes. 
Petrolatum may be sterilized by dry heat. Petrolatum should be stored in a well-closed container, 
protected from light, in a cool, dry place. 
iv) Regulatory Status 
GRAS listed. Accepted for use in certain food applications in many countries worldwide. 
Included in the FDA Inactive Ingredients Database (ophthalmic preparations; oral capsules and 
tablets; otic, topical, and transdermal preparations). 
5.1.2 Packaging 
Drug and placebo will be supplied by the compounding pharmacy in a metered dispenser called 
the Topi-CLICK® container. The opaque Topi-CLICK® dispenses 0.25 mL of ointment, 
protects the product from light exposure, and serves to conceal any subtle differences between 
placebo and investigational product. 
Drug will be labeled as an investigational drug as required by law: 
“Caution: New Drug — Limited by Federal (or United States) law to investigational use.”  
 
5.2 Handling of Study Interventions  
The 8% rapamycin and vehicle-only ointments will be compounded and purchased from Doyle’s 
Professional Pharmacy who have experience compounding rapamycin for topical application in 
human clinical trials.  All the rapamycin ointment and the placebo (petrolatum only) ointment 
will be provided to participants in Topi-CLICK® containers, a pump bottle for use in clinical 
trials that dispense 0.25ml per depression of the pump actuator.  Potency studies show that the 
8% rapamycin in petrolatum retains 96.8% potency after 60 days when stored at room 
temperature.  Dr. Kellogg holds a current IND (#144448) for topical rapamycin ointment used in 
another trial. The FDA determined that the current study of topical rapamycin was "exempt."   
Study drug will be shipped to and stored in a Research Pharmacy and dispensed to participants 
by the research pharmacy pharmacist. The study team will maintain records of drug 
accountability. 
NOTE: RAPA 8% ointment retains 96.8% potency after 60 days at room temperature, as 
documented in IND 144448 under Dr. Kellogg. 
 
5.3 Concomitant Interventions 
5.3.1 Allowed Interventions 
• 
For female postmenopausal participants, hormone replacement therapy use is 
permitted if the subject has been on a stable dose for at least 6 months. 


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5.3.2  Prohibited Interventions 
• Systemic steroid or immunosuppressant therapy 
• Body lotions, astringents, or other skin applications including cosmetics and 
especially sunscreen to the targeted skin area(s) 
• Other antifungal, antibiotic, or topical preparations 
 
5.3.3 Drug interactions 
In previous human studies cited earlier in this protocol, topical administration did not produce 
systemic or serious reactions. Participants will be instructed to notify the research team and get 
help right away if any of the above symptoms of an allergic reaction occur. 
Drug interactions with systemic use include: Inducers of CYP3A4 and P-gp may decrease 
sirolimus concentrations whereas inhibitors of CYP3A4 and P-gp may increase sirolimus 
concentrations. Avoid concomitant use of sirolimus with strong inducers (e.g., rifampin, 
rifabutin) and strong inhibitors (e.g., ketoconazole, voriconazole, itraconazole, erythromycin, 
telithromycin, clarithromycin) of CYP3A4 and P-gp. Avoiding consumption of grapefruit juice 
is also cited. 
 
5.4 Adherence Assessment  
Subjects will be contacted monthly either in person or by phone (Visits 2-7) to verify compliance. In 
addition, subjects will be called approximately 14 days after Visit 1 to ensure that they have been 
following the application directions and have no questions or potential adverse events. Subjects also 
receive a drug diary to help record administrations and any notable effects, which supports reporting 
the participant’s experiences at phone follow-ups and clinic visits. 
Each Topi-CLICK® container will be weighed before being given out and at collection (after 2 
months) to quantify compliance. 
 
 
 
 
 
 
 
 
 
 


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6 
STUDY PROCEDURES 
6.1 
Schedule of Activities 
 
VISIT # (Month #) 
V0 
V1 (0) 
V2 (1) 
V3 (2) 
V4 (3) 
V5 (4) 
V6 (5) 
V7 (6) 
Visit goal 
Consent/ 
Screen 
Pre-
drug 
RAPA/ 
Placebo 
RAPA/ 
Placebo 
RAPA/ 
Placebo 
RAPA/ 
Placebo 
RAPA/ 
Placebo 
RAPA/ 
Placebo 
SCREENING PROCEDURES 
Consent & 
CLOX1=10+ 
X 
 
 
 
 
 
 
 
RAPA/CONTROL OINTMENTS 
60 day supplies of 
study drug 
 
X 
 
X 
 
X 
 
 
SAFETY / ADVERSE EVENTS / METABOLIC 9  
Physical Exam 
X 
 
 
 
 
 
 
X 
ECG/EKG 
X 
 
 
 
 
 
 
 
Self-Reported AEs 
 
 
X 
X 
X 
X 
X 
X 
CBC  
X 
 
 
 
 
 
 
 
Metabolic profile, 
fasting blood, 
sugar/lipids, HbA1c 
X 
 
 
 
 
 
 
 
RAPA blood levels 
 
 
 
 
 
 
 
X 
SUCTION BLISTER COLLECTIONS 
Blister fluid collection 
for inflammatory 
mediators 
 
 
 
 
 
 
 
X 
Blister roof collection 
for DNA methylation  
analysis 
 
 
 
 
 
 
 
X 


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6.2 Schedule of Evaluations  
6.2.1 Visit 0 (60 to 90 minutes) 
 6.2.1.1 Consenting Procedure 
Before any screening procedure is performed, informed consent must be obtained. Eligible 
subjects will be asked to come to the research area to review and sign the consent form. Staff 
conducting the consent process adhere to local standard operating procedure (SOP) for consent 
administration. When scheduling consent appointments, staff will ask participants to arrive 
fasting. 
Participants will be asked at each visit whether they would like to continue participation in this 
study.  
 
6.2.1.2 Screening /Baseline 
Following consent and signature, participants will undergo minimal cognitive screen using the 
CLOX1 test to ensure consent is valid. The CLOX test is a clinical tool widely used in screening 
for cognitive disorders and dementia, which involves a clock drawing task designed to elicit 
executive impairment and discriminate it from non-executive failure.   Study staff will: 
•  Obtain vital signs, height and weight, lab work (fasting) to ensure safety and rule out 
systemic infection (complete blood count [CBC], comprehensive metabolic panel [CMP], 
lipid panel, HbA1C content) 
• Electrocardiogram (ECG/EKG)  
•  Document medical history, concomitant medication review, physical examination, and  
•  Perform evaluation of eligibility criteria listed in Sections 4.1 – 4.2 above. 
 
Additional baseline activities and data collection to include: 
• Current and recent medications within past 6 months 
• Verification of application sites of study drug, RAPA/placebo 
 
6.2.2 Visit 1 (Less than 60 minutes) 
• Verify participant is still willing to participate in study 
• Explain how to apply medication and possible side effects to monitor.  
Use of the study drug 
Each ointment will be applied to a 10 cm² area of skin on the forearm with randomization 
among subjects of which side (left vs. right) receives RAPA vs. placebo to eliminate any 
positional bias. Importantly, each subject will be his/her own control. To permit double-
blinding while avoiding treatment confusion, dispensers will be color coded and subjects 
will have the skin sites similarly colored using surgical markers. The initial application 
will be done for subject education; thereafter, the subjects will apply the compounds daily 
and refresh the pen outlines as needed. Fresh Topi-CLICK® containers will be given to 
each subject on a bi-monthly basis.  


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After ointment application, subjects will cover the site with hypo-allergenic bandage   to 
prevent ointment removal or soiling of clothing. Subjects will be instructed to avoid 
cross-contamination between forearm sites by washing hands between applications and 
using new disposable finger cots (glove-like, but cover only the finger) with each application. 
Subjects will be contacted/visited monthly to verify compliance. Topi-CLICK® containers 
will be weighed before they are given to participants and at collection (after two months) 
to quantify compliance and the amounts used. 
• Dispense study drug, two color coded Topi-CLICK® containers.  
• 
Phone calls will be made to follow up with subjects regarding adherence or AEs approximately 
14 days after Visit 1.  
 
6.2.3 Visit 2 (Less than 60 minutes) 
• Verify participant is still willing to participate in study 
 
6.2.4 Visit 3-6 (Each less than 60 minutes) 
• Verify participant is still willing to participate in study 
• Study drug will be dispensed at Visit #3 and #5 (60-day supply) 
• 
For subjects who have demonstrated outstanding compliance and have experienced no adverse 
events, Visits 4 and/or 6 may be replaced by phone calls. 
 
6.2.5 Visit 7 (up to 4 hours)  
• Verify participant is still willing to participate in study 
• Physical exam 
• Self-reported AEs 
• Rapamycin blood levels 
• Suction blister fluid collection 
• Suction blister skin flap collection 
Process for induction of a suction blister 
Blisters are induced at the sites of rapamycin/placebo administration on the subjects by means of 
a negative pressure cutaneous suction method.  The Negative Pressure Instrument System is a 
commercially available self-contained instrument package that combines all the necessary 
elements to successfully create suction blisters on a patient's skin. The blisters are created 
through the use of suction chambers that are attached to the patient's skin. The instrument 
console contains the power source, vacuum pump, temperature controls and all related controls 
to operate multiple suction chambers. The suction chambers are connected to the console by a 
flexible connection. Each of the chambers is controlled by a preset temperature control to 
provide an optimal skin warming temperature. Both chambers share an adjustable common 
vacuum source that affects all chambers equally. 
1) Assemble the suction device. 
2) Disinfect the orifice plate and the skin of the volunteer using alcohol swabs. 


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3) Attach the suction device within the treatment area on each forearm, by loosely securing 
the chamber with the provided straps. The chamber will adhere to the skin and maintain 
its position once negative pressure is applied. 
4) Turn the suction device on and adjust the pressure to -20kPa (150mmHg) 
5) After 30 minutes, increase the negative pressure to -25kPa (187.5 mm Hg), and then to -
30kPa (225 mmHg) after 60 minutes. Keep the pressure at -30kPa (225 mm Hg) until a 
blister is fully formed. The blister induction phase ranges from 60-180 minutes. 
6) Once the blister is fully formed, release the pressure, and carefully remove the suction 
chamber whilst maintaining integrity of the blister. 
7) Note the time taken for blister induction. 
 
Harvesting the suction blister fluid and blister roof 
1) Using a sterile 1-3 ml syringe with a 23G-26G needle, insert the needle into the 
top/lateral side of the blister roof and slowly aspirate the fluid, avoiding touching the 
floor of the cavity. Withdraw as much fluid as possible, and transfer to a sterile 
microfuge tube. 
2) Remove the blister roof using a sterile scalpel or sterile surgical scissors and store at -
80°C for subsequent nucleic acid isolation. 
3) Apply an antibiotic ointment (such as Neosporin) and a band aid to the blister, as long as 
the subject does not have any allergic reaction to the antibiotic ointment. The blister 
should heal within a week, no anesthesia is required for this procedure. 
 
7 
SAFETY ASSESSMENTS  
Participant safety will be monitored once an individual is enrolled in the study. Dr. Kellogg will 
be responsible for ensuring the first-hand monitoring of the data and safety of study participants 
on a monthly basis. He will be assisted by other members of the study staff. 
7.1 Specification of Safety Parameters 
Protection against risk is paramount in our research and in the operation of our laboratory. The 
risks of the proposed studies are extremely small.  This is by design and reflects the history and 
philosophy of the laboratory.  All of our proposed studies are reviewed and approved by our IRB 
prior to any studies in the clinic or laboratory.  All volunteers will be in good health, as 
documented by a medical history and physical examination performed by overseeing clinical 
staff. Volunteers will be queried using minimally invasive methods.  Antibiotic ointment and 
gauze are used to cover and protect the area of suction blister formation.  In the unlikely event of 
an adverse effect, appropriate medical procedures will be undertaken.  There are no known 
social, legal, or psychological risks.  At the time of collection, all data will be de-identified and 
stored that way so that there is no risk to the privacy of individuals or confidentiality of data.  
Data are stored in electronic form behind institutional electronic firewalls, or in physically 
secured laboratory facilities that are patrolled by armed police forces.  These procedures have 
adequately protected our data for decades and we believe that they will continue to be highly 
effective in the future.  To minimize infection risk at suction blister sites, all subjects will have 


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the sites treated with topical antibiotic ointment and covered with a bandage or gauze.  They will 
be provided with antibiotic ointment and bandages for use at home until the sites have healed.  
Any participants with an allergy to RAPA and persons with such sensitivity are excluded. Risks 
are minimized by the monitoring procedures we use, the selection of methods, and by the 
monitoring of adverse events and by using minimally invasive harvesting techniques for fluid 
aspiration and blister roof excision. 
7.2 Adverse Events and Serious Adverse Events  
Adverse Event (AE): In general, AE is used very broadly and encompasses physical and 
psychological harms and includes:   
 
 
Any untoward or unfavorable medical occurrence in a human subject, including any abnormal 
sign (for example, abnormal physical exam or laboratory finding), symptom, or disease, 
temporally associated with the subject’s participation in the research, whether or not it is 
considered related to the subject’s participation in the research. 
 
Intercurrent illnesses or injuries should be regarded as adverse events.  Abnormal results of diagnostic 
procedures are considered to be adverse events if the abnormality: 
• 
results in study withdrawal 
• 
is associated with a serious adverse event 
• 
is associated with clinical signs or symptoms 
• 
leads to additional treatment or to further diagnostic tests 
• 
is considered by the investigator to be of clinical significance 
Serious Adverse Event (SAE): Any adverse event that: 
• 
Results in death 
• 
Is life threatening, or places the participant at immediate risk of death from the event 
as it occurred 
• 
Requires or prolongs hospitalization 
• 
Causes persistent or significant disability or incapacity 
• 
Results in congenital anomalies or birth defects 
• 
Is another condition which investigators judge to represent significant hazards 
 
7.3 
Unanticipated Problems Involving Risk to Subjects or Others (UPIRSO) 
Any incident, experience, or outcome that meets all of the following criteria:  
• 
Unexpected in nature, severity, or frequency (i.e. not described in study-related documents such 
as the IRB-approved protocol or consent form, the investigators brochure, etc.) 
• 
Related or possibly related to participation in the research (i.e. possibly related means there is a 
reasonable possibility that the incident experience, or outcome may have been caused by the procedures 
involved in the research) 
• 
Suggests that the research places subjects or others at greater risk of harm (including physical, 
psychological, economic, or social harm). 
 


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7.3.1 Adverse Event Reporting Period 
The study period during which adverse events must be reported is normally defined as the period 
from the initiation of any study procedures to the end of the study treatment follow-up. For this 
study, the study treatment follow-up is defined as 30 days following the last administration of 
study treatment. 
7.3.2 Pre-existing Condition 
A preexisting condition is one that is present at the start of the study. A pre-existing condition should be 
recorded as an adverse event if the frequency, intensity, or the character of the condition worsens during 
the study period. 
 
At screening, any clinically significant abnormality should be recorded as a preexisting condition. At the 
end of the study, any new clinically significant findings/abnormalities that meet the definition of an 
adverse event must also be recorded and documented as an adverse event. 
7.3.3 Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an adverse event if any one of the following 
conditions is met:  
• 
The laboratory abnormality is not otherwise refuted by a repeat test to confirm the abnormality 
• 
The abnormality suggests a disease and/or organ toxicity 
The abnormality is of a clinically significant degree requiring active management; e.g. change of dose, 
discontinuation of the drug, more frequent follow-up assessments, further diagnostic investigation, etc. 
 
7.3.4 Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be documented and 
reported as a SAE unless specifically instructed otherwise in this protocol. Any condition responsible for 
surgery should be documented as an AE if the condition meets the criteria for and adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an AE in the 
following circumstances: 
• 
Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures for a 
preexisting condition (e.g., colonoscopy, SCI annual evaluation, respite care).  
• 
Surgery should not be reported as an outcome of an adverse event if the purpose of the surgery was 
elective or diagnostic and the outcome was uneventful. 
• 
Hospitalization or prolonged hospitalization required to allow efficacy measurement for the study. 
• 
Hospitalization or prolonged hospitalization for therapy of the target disease of the study, unless it 
is a worsening or increase in frequency of hospital admissions as judged by the clinical investigator. 
 
7.4 
Recording of Adverse Events 
At each contact with the subject, the investigator or study staff will seek information about adverse events 
by specific questioning and, if appropriate, by examination.  Information on all AEs will be recorded 
immediately in the source documentation. Site staff will record AEs using the appropriate data collection 
form in REDCap, which will be exported as an AE Log (See Section 9.3) for periodic review, at least 
monthly and ad hoc, depending on severity and expected/unexpected nature of the event. 
 


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The clinical course of each event will be followed until resolution, stabilization, or until it has been 
determined that the study treatment or participation is not the cause. SAEs that are still ongoing at the end 
of the study period will be followed up to determine the final outcome. Any SAE that occurs after the study 
period and is considered to be possibly related to the study treatment or study participation will be recorded 
and reported per Institutional policy and according to FDA requirements. 
7.6 
 Reporting of Serious Adverse Events and Unanticipated Problems 
 
SAEs and UPIRSOs will be reported per local IRB policy and procedure. 
 
Each subject is evaluated for any adverse events (AE). Any event that is reported to either the 
principal investigator or designated research staff by either the subject or medical staff caring for 
the subject and which meets the criteria will be documented. Any AE reported as serious will 
necessitate an adverse event report, which will be submitted to the IRB and to the Pepper Center 
DSMB.   
Unanticipated risks to subjects or others (UPIRSO) that are a result of study participation are 
promptly reported to the IRB and, if deemed appropriate, to the Pepper Center DSMB. The 
report will include a description of the event, when and how it was reported, as well as any 
official chart records or documentation to corroborate the event or the reporting of the event. All 
adverse events will be graded as mild, moderate, or severe. All adverse events will be 
summarized annually and submitted to the IRB. Any action resulting in a temporary or 
permanent suspension of this study (e.g. local site IRB actions) will be reported to FDA or drug 
manufacturer per IRB stipulations.   
7.6.1 Investigator Reporting: notifying DSMB 
Any study-related SAE-UPIRSO, must be reported to the Principal Investigator by telephone 
within 24 hours of the event. To report such events, a Serious Adverse Event (SAE) form must 
be completed and submitted within 24 hours.  The investigator will keep a copy of this SAE form 
on file at the study site.   
 
Report SAEs by email and facsimile to: 
 
Dean L. Kellogg, Jr, MD, PhD 
Professor, Medicine-Geriatrics 
Email: kelloggd@uthscsa.edu 
210-617-5132 fax      210-235-3681 page
 
 
Within the following 48 hours, the Principal Investigator provides further information on the 
SAE or the UPIRSO in the form of a written narrative. This should include a copy of the 
completed SAE form, and any other diagnostic information that will assist the understanding of 
the event.  
 
 
 


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7.6.2 Investigator reporting: notifying the UTHSCSA IRB 
 
Notifying the IRB and or FDA if SAE or UPIRSO 
 
• Within 7 calendar days 
Any study event that is: 
– associated with the use of the study drug 
– unexpected,  
– fatal or life-threatening, and  
 
• Within 15 calendar days 
Any study event that is: 
– associated with the use of the study drug, 
– unexpected, and 
– serious, but not fatal or life-threatening 
-or- 
– a previous adverse event that was not initially deemed reportable but is later found to fit 
the criteria for reporting (reporting within 15 calendar days from when event was 
deemed reportable). 
Any finding from tests in laboratory animals that:  
– suggests a significant risk for human subjects including reports of mutagenicity, 
teratogenicity, or carcinogenicity. 
 
Additional reporting requirements 
 
Post marketing surveillance and adverse events may be submitted on FDA Form 3500A or in a 
narrative format. The contact information for submitting safety reports is noted below: 
 
Food and Drug Administration 
Center for Drug Evaluation and Research 
Division of Dermatology and Dental Products (DDDP) 
5901-B Ammendale Road 
Beltsville, MD 20705-1266 
Phone: (301) 796-2290 
Fax: (301) 796-9712  
 
7.7 
Medical Monitoring 
The Investigator and or Co-PI will review the safety and progress of this study on a monthly 
basis or when needed if SAE or SAE-UPIRSO occurs.   
7.8 Investigator Reporting of Protocol Deviations/Violations 
Departures during the conduct of a research study constitute a protocol deviation, violation or 
exception and as such must be reported to the UTHSCSA IRB. 
 


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Tracking and reporting of protocol deviations and violations to the IRB is the responsibility of 
the PI. To determine whether deviations or violations require prompt reporting or other action, 
refer to the IRB document entitled “Decision Tree – Evaluating Departures” on the IRB website. 
Failure to report departures from the protocol according to IRB policy may constitute possible 
non-compliance, which will require a Prompt Report Form and possible FDA reporting by IRB. 
 
7.8.1 
Deviations and violations may be identified in a number of ways including:  
• 
A report by an individual can be made directly to the IRB Office.  
• 
The IRB may learn of event through its continuing review of ongoing research.  
• 
Compliance reviews (audits) conducted by the Office of Regulatory Affairs and 
Compliance or one of the HSC affiliated institutional compliance offices.  
• 
A report by an individual can be made directly to the Office of Regulatory Affairs 
and Compliance (Hotline) or one of the HSC affiliated institutional compliance 
offices.  
• 
A report by another committee, department, institution, or official.  
• 
An audit or report from the study sponsor or sponsor’s monitoring entity. 
 
7.8.2 
Definitions of Protocol Deviations/Violations  
• 
Protocol deviations – such as out of window visit, missed lab, usually recognized 
after the fact, etc. 
• 
Protocol violations – enrolling an ineligible participant, using wrong consent version, 
willful act of not following protocol 
• 
Emergency 
violations 
Refer 
to 
UTHSCSA 
IRB 
Policy 
website: 
https://research.uthscsa.edu/irb/policy/deviations for more information 
  
7.9 Safety Monitoring 
Data Safety Monitoring Plan (DSMP):  Our studies are designed to explore both the responses 
to topical RAPA on DNA methylation (the Skin Epigenetic Clock) and the altered mechanisms 
involved in inflammation.  Dr. Kellogg will be responsible for ensuring the first-hand 
monitoring of the data and safety of study participants on a weekly and monthly basis. He will 
be assisted by other members of the study staff. A REDCap database will be designed to include 
an inclusion/exclusion checklist that is reviewed and signed by Dr. Kellogg for each subject 
enrolled before study medications are ordered by the investigators.  
 
The San Antonio Claude D. Pepper Older Americans Independence Center Data Safety 
Monitoring Board (DSMB) will be responsible for reviewing clinical trial data from the 
proposed study on an ongoing basis to ensure the safety of study subjects. This DSMB was 
created by the SA OAIC under the auspices of the SA OAIC Research Core 2 (RC2) to ensure 
subject safety and data integrity for studies involving older persons Board members are 
independent, with no vested interest in this study. The DSMB will assign a staff member to 
conduct quarterly assessments for data quality control/assurance on collected data, which is 
reviewed on an annual basis by the Pepper Center Regulatory Coordinator and PI at the time of 


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preparing continuing review documentation for IRB submission.  This study will be reviewed 
by the Pepper Center (DSMB) at least annually. The Pepper Center DSMB meets 3-4 times a 
year, by teleconference call, to review study progress and participants’ safety. 
8 
INTERVENTION DISCONTINUATION  
Should a subject develop a rash during study intervention, RAPA medication will be stopped and 
their participation will cease. 
In the unlikely event that a study-related death or SAE occurs, the decision to stop the trial, 
either temporarily or permanently, will be the collaborative responsibility of the Pepper Center 
DSMB and the Principal Investigators. 
9 
STATISTICAL CONSIDERATIONS  
9.1 General Design Issues  
The intent of this pilot project is to validate the novel approach of examining age-modulating 
effects of pharmacological agents in humans, in vivo, through local transdermal drug application 
thus avoiding the risks of systemic drug administration.  We propose to study at least 40 older 
persons, age 65-95.  We will study at least 20 women and 20 men.  The test agent for the project 
will be 8% rapamycin (RAPA) ointment with petrolatum-only ointment as a control agent.  
Ointment treatments will be for 6 months.  The duration derives in part from our unpublished 
observation that 8 months of topical 8% RAPA ointment caused significant regression of an 
established keloid in a 63 year old person.  At present, there are no other in vivo data relevant to 
power analyses for our proposed project; however, recently published in vitro work by our 
collaborator, Dr. Horvath, suggests that our approach may be viable in vivo.  In that study, 
Horvath and colleagues examined the in vitro effects of rapamycin on keratinocytes obtained 
from 3 different persons and found that rapamycin retarded keratinocyte aging independently 
from its effects on replicative senescence, proliferation rate or frequency, and differentiation 
(Horvath, Lu et al. 2019).  They also found that rapamycin inhibited cellular senescence, as well 
as epigenetic aging.  Our proposed trial will recapitulate the foregoing in vitro keratinocyte study 
design with substitution of in vivo treatment of keratinocytes in humans, in lieu of in vitro cell 
culture approach. Instead of samples from 3 different persons, we will study 50 different persons, 
half women and half men.  Our study uses a "within-subject" design where each person will be 
his/her own control and thus increase statistical power.  In our pilot trial, we are interested in 
precise estimates of feasibility and acceptability, as well as outcome variability that will aid in 
the planning of future sufficiently powered efficacy trials.  
  
9.2 Sample Size and Randomization 
A sample size of 40 persons with experimental (RAPA) and control samples from each person 
will allow us to be relatively precise in our conclusions regarding feasibility outcomes.  


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9.2.1 Treatment Assignment Procedures 
Participants are both the active comparator and control arm for the study with one forearm 
assigned as the active site and the other the control site. Randomization codes will be assigned to 
each subject for active study drug and placebo. Each participant receives color-coded Topi-
CLICK® containers of the study drug, which will be assigned to the same color-coded patch on 
the corresponding forearm. 
  
9.3 Interim analyses and Stopping Rules 
The Sponsor, Dr. Kellogg, has the authority to stop patient participation, suspend accrual or stop 
the study in its entirety at any time for safety. (in particular any rash or skin reaction will stop 
that subject's experiment.)  Dr. Kellogg will report all events (internal / external) to the 
UTHSCSA Pepper Center DSMB and IRB per the UPIRSO reporting criteria.  UPIRSOs being 
submitted promptly and non-UPIRSOs reported at minimum annually.    
As described above, if an individual event or accumulation of events should occur that warrant 
stopping the study, this will be done by Dr. Kellogg and DSMB.  Dr. Kellogg and DSMB will 
review safety summary reports and they will be reported to the IRB with progress reports or 
more promptly if they meet UPIRSO criteria. 
  
9.4 Primary Objective 
Test whether epigenetic changes in skin are elicited by topical treatments with RAPA 
 
Methylation of cytosine residues in DNA, particularly when found in CpG islands, is often 
associated with silencing of downstream genes. Dr. Horvath, a collaborator on this project, has 
identified a set of 391 DNA methylation marks that change with aging and can be used to assess 
the age of an individual [34, 35]. His novel “epigenetic clock” has been used to predict “time to 
death” and parameters of healthy aging. To determine the effects of topical RAPA on the 
epigenetic clock, DNA will be extracted from the blister skin flaps (keratinocytes) taken after 
treatment from the two sites on each subject using Qiagen DNeasy kits. The genomic DNA will 
be sent to the University of Minnesota Genomics Center for analysis on Infinium Methylation 
EPIC arrays. The data will be analyzed by Dr. Horvath; he will compare the profiles seen with 
RAPA to the profiles seen at the placebo site for each individual focusing on the methylation 
marks that comprise the aging clock. 
 
9.5 Secondary Objectives 
Test whether baseline inflammation is affected by topical RAPA  
 
In order to examine the effect of topical RAPA (or any future test drug) on the inflammatory 
milieu in skin, Luminex-based assays will be performed on the interstitial fluid collected from 
suction blisters at the end of the 6 month treatment period. These allow simultaneous 


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measurement of ≥29 different human cytokines/chemokines from as little as 30µl. It is 
anticipated that pro-inflammatory cytokines (i.e., IL-12, IL-6, TNF-α) would be elevated in this 
older population, so a decrease in their levels upon treatment with RAPA (but not the vehicle) 
would support an anti-aging potential. Since inflammation underlies many age-associated 
pathologies, this finding would have broad implications. For this reason, we will also perform 
sensitive ELISAs for three analytes known to play a functional role in regulating age-associated 
inflammatory phenotypes. These will include: i) interleukin-6 (IL-6); although present in the 
Luminex panel, IL-6 detection often requires a more sensitive ELISA [1]; ii) sICAM-1 (soluble 
intercellular adhesion molecule-1, a biomarker of vascular endothelial cell activation/damage) 
[36] and iii) RAGE (receptor for advanced glycation end products) [37, 38]. Validated ELISA 
kits are commercially available for these three analytes and have been tested by us with sera 
from the subjects in the pilot human trial of oral RAPA (Fig. 4). Sufficient blister fluid will be 
recovered in order to perform all of the tests outlined including: i) RAPA levels by HPLC-mass 
spec; ii) Luminex multiplex cytokine arrays; and iii) ELISAs for IL-6, RAGE, and sICAM-1. 
Remaining fluid will be aliquoted and frozen at -20°C. 
9.6 Data Analyses 
As pilot studies are preparatory investigations that provide specific information necessary for 
planning subsequent definitive trials. A major purpose of the present proposal is to perfect the 
study design, measures, procedures, recruitment criteria, and operational strategies for use in 
larger and/or longer subsequent trials with rapamycin and/or other purported anti-aging agents. 
 Our project will provide the means to evaluate the technical aspects of our novel approach of 
testing topical treatments with simultaneous untreated controls within individual subjects.  This 
pilot project will serve as a platform to generate preliminary data and foster new methodological 
development. Our pilot 'proof of concept' study is designed so that the information gained can be 
put to optimal use in future studies that build on scientific evidence of the efficacy and reduced 
costs of our approach.  
Our proposed 'proof of concept' trial will contribute to the development and design of future 
(larger and/or longer) studies by: 
– 
Refining the research hypotheses 
– 
Identifying barriers to successful study completion 
– 
Evaluating acceptability of methods and instruments to participants 
– 
Estimating the time required for study participation 
– 
Providing estimates of missing data and dropout 
– 
Estimating rates and variability in outcomes for future studies 
– 
Testing mechanistic efficacy/ ‘proof of concept’ for future trials 
Regarding analyses of inflammatory mediators:  
Assay results will be analyzed by 2 factor ANOVA (RAPA vs Placebo as within factor and sex 
as second factor); power calculations based on our prior studies with systemically administered 


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rapamycin indicate that N=9 may be needed for those inflammatory mediators we previously 
found to decrease significantly with systemic RAPA (ICAM-1 and RAGE).  Calculations 
indicate that as many as 141 samples may be needed for others (IL-6) that we have not found to 
differ significantly with systemic RAPA. These estimates are based on unpaired comparisons 
between subjects who received systemic RAPA or placebo for 8 weeks. The design for the 
proposed trial permits each subject to serve as his/her own control and thus should reduce these 
estimates. 
 
10 
DATA COLLECTION AND QUALITY ASSURANCE 
10.1 Data Integrity 
Data integrity will be assessed by review of the written/computer (REDCap) documents used to 
record all collected data on a weekly basis. The representational faithfulness (composed of four 
essential qualities or core attributes: completeness, currency/timeliness, accuracy/correctness and 
validity/authorization data) of all data to the true state of the measurement that the information 
represents will be the responsibility of Dr. Kraig, Dr. Kellogg and study coordinator. 
 
10.2 Data Management  
Data integrity will be assessed by review of the written/computer documents used to record all 
collected data on a weekly basis. The representational faithfulness (composed of four essential 
qualities or core attributes: completeness, currency/timeliness, accuracy/correctness and 
validity/authorization data) of all data to the true state of the measurement that the information 
represents will be the responsibility of the Principal Investigators and the study coordinator. 
10.3 Quality Assurance  
10.3.1 
Training 
All study personnel interacting with human subjects or with access to PHI will 
complete all human subjects training to include Good Clinical Practice training.  
 
10.3.2 Quality Control Committee  
 We will use the Regulatory Office and Data Safety Monitoring Board operated by 
RC2 to ensure subject safety and that all regulatory aspects of human trials are met. 
   
10.3.3 Study Monitoring Plan 
 The Principal Investigators will ensure that the designated regulatory coordinator or 
other quality assurance reviewer is given access to all the above noted study-related 
documents and study related facilities (e.g. pharmacy, diagnostic laboratory, etc.), and 
has adequate space to conduct study monitoring visits as assigned. 
 
10.3.4 Monitoring and Auditing 
The Principal Investigators will permit study-related monitoring, audits, and 
inspections by the IRB, the funding sponsor, the OAIC Pepper Center Data Safety 


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and Monitoring Board (DSMB), government regulatory bodies, and University 
compliance groups of all study related documents (e.g. source documents, regulatory 
documents, data collection instruments, study data etc.). The investigators will 
ensure the capability for inspections of applicable study-related facilities (e.g. 
pharmacy, diagnostic laboratory, etc.). 
Participation as an investigator in this study implies acceptance of potential 
inspection by government regulatory authorities and applicable University 
compliance and quality assurance offices. 
11 
PARTICIPANT RIGHTS AND CONFIDENTIALITY  
11.1 Institutional Review Board (IRB) Review 
This protocol and the informed consent document and any subsequent modifications will be 
reviewed and approved by the IRB responsible for oversight of the study. The IRB responsible 
for review of this study will be the University of Texas Health Science Center San Antonio 
Institutional Review Board (UTHSA IRB). 
11.2 Informed Consent Forms 
Consent forms will be IRB approved and the participant will be asked to read and review the 
document. The investigator will explain the research study to the participant and answer any 
questions that may arise. A verbal explanation will be provided in terms suited to the 
participant’s comprehension of the purposes, procedures, and potential risks of the study and of 
their rights as research participants.  Participants will be informed that participation is voluntary 
and that they may withdraw from the study at any time, without prejudice, and that the quality of 
their medical care will not be adversely affected if they decline to participate in this study. 
Participants will have the opportunity to carefully review the written consent form and ask 
questions prior to signing. The participants will be given a copy of the ICF so that they may 
discuss the study with their family or surrogates or think about it prior to agreeing to participate. 
The informed consent process will be conducted and documented in the source document 
(including the date), and the form signed, before the participant undergoes any study-specific 
procedures. A copy of the signed informed consent document will be given to the participants for 
their records.  
11.3 Participant Confidentiality  
Any data, specimens, forms, reports, video recordings, and other records that leave the site will 
be identified only by a participant identification number (Participant ID, PID) to maintain 
confidentiality.  All records will be kept in a locked file cabinet.  All computer entry and 
networking programs will be done using PIDs only. Information will not be released without 
written permission of the participant, except as necessary for monitoring by IRB, the FDA, the 
NIA, and the OHRP. 
11.4 Study Discontinuation  
The study may be discontinued at any time by the IRB, the NIA, the OHRP, the FDA, or other 
government agencies as part of their duties to ensure that research participants are protected.  


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12 
ETHICAL CONSIDERATIONS 
 This study is to be conducted according to US and international standards of Good Clinical 
Practice (FDA Title 21 part 312) applicable government regulations and Institutional research 
policies and procedures. 
This protocol and any amendments will be submitted to the Institutional Review Board (IRB), in 
agreement with local legal prescriptions, for formal approval of the study conduct. The decision 
of the IRB concerning the conduct of the study will be made in writing to the investigator and a 
copy of this decision will be provided to the funding sponsor before commencement of this 
study.   
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in this 
study.  
 
13 
COMMITTEES 
 The San Antonio Claude D. Pepper Older Americans Independence Center Data Safety 
Monitoring Board (DSMB) will be responsible for reviewing clinical trial data from the 
proposed study on an ongoing basis to ensure the safety of study subjects and validity and 
integrity of the data.   
14 
PUBLICATION OF RESEARCH FINDINGS 
Publication authorship will be determined by the relative contributions of the PIs. It is likely that 
the first paper from this work will demonstrate validity of the topical age-modulating assay using 
rapamycin as the test drug. In this case, as in our previous paper (1), Dr. Kraig would likely 
handle much of the bench data analysis and would be first author, while Dr. Kellogg would have 
overseen all clinical aspects and comprehensive data analysis, so he would be the appropriate 
senior author. However, if the epigenomic data were used more extensively in a second paper, 
then Dr. Horvath might be first and the two PIs would have shared senior authorship. We make it 
a priority to discuss authorship openly before writing the paper(s).     
 
Dissemination Plan 
This trial has been registered in ClinicalTrials.gov; Identifier NCT04608448.  All consent 
documents for the trial will include a specific statement concerning ClinicalTrials.gov. Results 
will be submitted to ClinicalTrials.gov as required.  UT Health San Antonio has an internal 
policy that ensures that clinical trials registration and results reporting occur in compliance with 
policy requirements. Open access publication of results will also be made as significant results 
are obtained. 


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REFERENCES 
1. Kraig, E., L. Linehan, H. Liang, T. Romo, Q. Liu, Y. Wu, A. Benevides, T. Curiel, M. 
Javors, N. Musi, L. Chiodo, W. Koek, J. Gelfond and D. Kellogg, Jr., A randomized control trial 
to establish the feasibility and safety of rapamycin treatment in an older human cohort: immuno-
logical, physical performance, and cognitive effects. Exp. Gerontology, 2018. 105:53-69. 
2. Campisi, J., P. Kapahi, G.J. Lithgow, S. Melov, J.C. Newman and E. Verdin, From 
discoveries in ageing research to therapeutics for healthy ageing. Nature, 2019. 571:183–192 
3. Nadon, N., R. Strong, R. Miller, J. Nelson, M. Javors, Z. Sharp, J. Peralba and D. Harrison, 
Design of aging intervention studies: the NIA interventions testing program. Aging, 2008. 
30:187–199. 
4. Harrison, D.E., R. Strong, Z.D. Sharp, J.D. Nelson, C.M. Astle, K. Flurkey, N.L. Nadon, 
J.E. Wilkinson, K. Frenkel, C.S. Carter, M. Pahor, M.J. Javors, E. Fernandez and R.A. Miller, 
Rapamycin fed late in life extends lifespan in genetically heterogeneous mice. Nature, 2009. 
460:392-395. 
5. Mannick, J.B., G.D. Giudice, M. Lattanzi, N.M. Valiante, J. Praestgaard, B. Huang, M.A. 
Lonetto, H.T. Maecker, J. Kovarik, S. Carson, D.J. Glass and L.B. Klickstein, mTOR inhibition 
improves immune function in the elderly. Science Translational Medicine, 2014. 6:1-5. 
6. Mannick, J.B., M. Morris, H.-U.P. Hockey, G. Roma, M. Beibel, K. Kulmatycki, M. 
Watkins, T. Shavlakadze, W. Zhou, D. Quinn, D.J. Glass and L.B. Klickstein, TORC1 inhibition 
enhances immune function and reduces infections in the elderly. Science Translational Medicine, 
2018. 6:1-10. 
7. Lesniewski, L.A., D.R. Seals, A.E. Walker, G.D. Henson, M.W. Blimline, D.W. Trott, G.C. 
Bosshardt, T.J. LaRocca, B.R. Lawson, M.C. Zigler and A.J. Donato, Dietary rapamycin 
supplementation reverses age-related vascular dysfunction and oxidative stress, while 
modulating nutrient-sensing, cell cycle, and senescence pathways. Aging Cell, 2017. 16:17-26. 
8. Horvath, S., A.T. Lu, H. Cohen and K. Raj, Rapamycin retards epigenetic ageing of 
keratinocytes independently of its effects on replicative senescence, proliferation and 
differentiation. Aging, 2019. 11(10):3238-3249. 
9. Horvath, S., J. Oshima, G.M. Martin, A.T. Lu, A. Quach, H. Cohen, S. Felton, M. 
Matsuyama, D. Lowe, S. Kabacik, J.G. Wilson, A.P. Reiner, A. Maierhofer, J. Flunkert, A. Aviv, 
L. Hou, A. A.Baccarelli, Y. Li, J.D. Stewart, E.A. Whitsel, L. Ferrucci, S. Matsuyama and K. 
Raj, Epigenetic clock for skin and blood cells applied to Hutchinson Gilford Progeria Syndrome 
and ex vivo studies. Aging, 2018. 10:1758-1775. 
10. Horvath, S. and K. Raj, DNA methylation-based biomarkers and the epigenetic clock theory 
of ageing. Nature Reviews Genetics, 2018. 19:371–384. 
11. Franceschi, C. and J. Campisi, Chronic Inflammation (Inflammaging) and Its Potential 
Contribution to Age-Associated Diseases. J Gerontol A Biol Sci Med Sci, 2014. 69:S4–S9. 
12. Pilling, L., R. Joehanes, D. Melzer, L.W. Harries, W. Henley, J. Dupuis, H. Lin, M. 
Mitchell, D. Hernandez, S.X. Ying, K.L. Lunetta, E.J. Benjamin, A. Singleton, D. Levy, P. 
Munson, J.M. Murabito and L. Ferrucci, Gene expression markers of age related inflammation in 
two human cohorts. Experimental Gerontol., 2015. 70:37-45. 
13. Mitchell, S.J., M. Scheibye-Knudsen, D.L. Longo and R.d. Cabo, Animal Models of Aging 
Research: Implications for Human Aging and Age-Related Diseases . Ann. Rev. Anim. Biosci., 
2015. 3:283–303. 


20-720H, Kraig, Form BB, 08-17-21, AMD.docx 
 
Version 1.2   33 
14. Clark, K.E., H. Lopez, B.A. Abdi, S.G. Guerra, X. Shiwen, K. Khan, O. Etomi, G.R. Martin, 
D.J. Abraham, C.P. Denton and R.J. Stratton, Multiplex cytokine analysis of dermal interstitial 
blister fluid defines local disease mechanisms in systemic sclerosis. Arthritis Res. Ther., 2015. 
17(1):73-84. 
15. Herfst, M.J. and H.v. Rees, Suction Blister Fluid as a Model for Interstitial Fluid in Rats. 
Arch. Dermatol. Res., 1978. 263:325-334. 
16. Holm, L.L., M. Vukmanovic-Stejic, T. Blauenfeldt, T. Benfield, P. Andersen, A.N. Akbar 
and M. Ruhwald, A Suction Blister Protocol to Study Human T-cell Recall Responses In Vivo. 
In Vivo. J. Vis. Exp. , 2018. 138:e57554.  
17. Mandal, A., A. Boopathy, L. Lam, K. Moynihan, M. Welch, N. Bennett, M. Turvey, N. 
Thai, J. Van, J. Love, P. Hammond and D. Irvine, Cell and fluid sampling microneedle patches 
for monitoring skin-resident immunity. Sci. Transl. Med., 2018. 10:eaar2227. 
18. Araki, K., A. Turner, V. Shaffer, S. Gangappa, S. Keller, M. Bachmann, C. Larsen and R. 
Ahmed, mTOR regulates memory CD8 T-cell differentiation. Nature, 2009. 460:108-111. 
19. Chen, C., Y. Liu, Y. Liu and P. Zheng, Mammalian target of rapamycin activation underlies 
HSC defects in autoimmune disease and inflammation in mice Journal of Clin Invest, 2010. 
120:4091-4101. 
20. Lin, A.-L., W. Zheng, J.J. Halloran, R.R. Burbank, S.A. Hussong, M.J. Hart, M. Javors, Y.-
Y.I. Shih, E. Muir, R.S. Fonseca, R. Strong, A.G. Richardson, J.D. Lechleiter, P.T. Fox and V. 
Galvan, Chronic rapamycin restores brain vascular integrity and function through NO synthase 
activation and improves memory in symptomatic mice modeling Alzheimer’s disease. J. 
Cerebral Blood Flow & Metab., 2013. 33:1412-1421. 
21. Li, J., S. Kim, J. Blenis, Rapamycin: one drug, many effects. Cell Metab, 2014. 19:373-379. 
22. Majumder, S., A. Caccamo, D.X. Medina, A.D. Benavides, M.A. Javors, E. Kraig, R. 
Strong, A. Richardson and S. Oddo, Lifelong rapamycin administration ameliorates age-
dependent cognitive deficits by reducing IL-1beta and enhancing NMDA signaling. Aging Cell, 
2012. 11(2):326-335. 
23. Urfer, S.R., T.L. Kaeberlein, S. Mailheau, P.J. Bergman, K.E. Creevy, D.E.L. Promislow 
and M. Kaeberlein, A randomized controlled trial to establish effects of short-term rapamycin 
treatment in 24 middle-aged companion dogs. GeroScience, 2017. 39(2):117–127. 
24. Koenig, M.K., C.S. Bell, A.A. Hebert, J. Roberson, J.A. Samuels, J.M. Slopis, R. Patti Tate 
and H. Northrup, Efficacy and Safety of Topical Rapamycin in Patients With Facial 
Angiofibromas Secondary to Tuberous Sclerosis Complex. JAMA Dermatol., 2018. 154(7):773-
780. 
25. Leducq, S., B. Giraudeau, E. Tavernier and A. Maruani, Topical use of mammalian target of 
rapamycin inhibitors in dermatology: A systematic review with meta-analysis. Am Acad 
Dermatol., 2019. 80:735-742. 
26. Haemel, A.K., A.L. O'Brien and J.M. Teng, Topical Rapamycin. Arch. Dermatol., 2010. 
146(7):715-718. 
27. Ormerod, A.D., S.A.A. Shah, P. Copeland, G. Omar and A. Winfield, Treatment of psoriasis 
with topical sirolimus: preclinical development and a randomized, double-blind trial. Br. J. 
Dermatology, 2005. 152:758-764. 
28. Nadon, N.L., R. Strong, R.A. Miller and D.E. Harrison, NIA Interventions Testing Program: 
Investigating Putative Aging Intervention Agents in a Genetically Heterogeneous Mouse Model. 
EBioMedicine, 2017. 21:3–4. 
29. Harrison, D.E., R. Strong, D.B. Allison, B.N. Ames, C.M. Astle, H. Atamna, E. Fernandez, 


20-720H, Kraig, Form BB, 08-17-21, AMD.docx 
 
Version 1.2   34 
K. Flurkey, M.A. Javors, N.L. Nadon, J.F. Nelson, S. Pletcher, J.W. Simpkins and D. Smith, 
Acarbose, 17-a-estradiol, and nordihydroguaiaretic acid extend mouse lifespan preferentially in 
males. Aging Cell, 2014. 13:273–282. 
30. Cole, J.J., N.A. Robertson, M.I. Rather, J.P. Thomson, T. McBryan, D. Sproul, T. Wang, C. 
Brock, W. Clark, T. Ideker, R.R. Meehan, R.A. Miller, H.M. Brown-Borg and P.D. Adams, 
Diverse interventions that extend mouse lifespan suppress shared age-associated epigenetic 
changes at critical gene regulatory regions. Genome Biology, 2017. 17:58-73. 
31. Wang, T., B. Tsui, J.F. Kreisberg, N.A. Robertson, A.M. Gross, M.K. Yu, H. Carter, H.M. 
Brown-Borg, P.D. Adams and T. Ideker, Epigenetic aging signatures in mice livers are slowed 
by dwarfism, calorie restriction and rapamycin treatment. Genome Biology, 2017. 18:57-67. 
32. Donato, A.J., D.R. Machin and L.A. Lesniewski, Mechanisms of Dysfunction in the Aging 
Vasculature and Role in Age-Related Disease. Circ. Res., 2018. 123:825-848. 
33. Fahy, G.M., R.T. Brooke, J.P. Watson, Z. Good, S.S. Vasanawala, H. Maecker, M.D. 
Leipold, D.T.S. Lin, M.S. Kobor and S. Horvath, Reversal of epigenetic aging and 
immunosenescent trends in humans. Aging Cell, 2019. 00:e13028-13040. 
34. Chen, B., R. Marioni, E. Colicino, M. Peters, C. Ward-Caviness, P. Tsai, N. Roetker, A. 
Just, E. Demerath, W. Guan, J. Bressler, M. Fornage, S. Studenski, A. Vandiver, A. Moore, T. 
Tanaka, D. Kiel, L. Liang, P. Vokonas, J. Schwartz, K. Lunetta, J. Murabito, S. Bandinelli, D. 
Hernandez, D. Melzer, M. Nalls, L. Pilling, T. Price, A. Singleton, C. Gieger, R. Holle, A. 
Kretschmer, F. Kronenberg, S. Kunze, J. Linseisen, C. Meisinger, W. Rathmann, M. 
Waldenberger, P. Visscher, S. Shah, N. Wray, A. McRae, O. Franco, A. Hofman, A. 
Uitterlinden, r.D. Abshe, T. Assimes, M. Levine, A. Lu, P. Tsao, L. Hou, J. Manson, C. Carty, A. 
LaCroix, A. Reiner, T. Spector, A. Feinberg, D. Levy, A. Baccarelli, J. van Meurs, J. Bell, A. 
Peters, I. Deary, J. Pankow, L. Ferrucci, and S. Horvath, DNA methylation-based measures of 
biological age: meta-analysis predicting time to death. Aging, 2016. 28:1844-1865. 
35. Horvath, S., DNA methylation age of human tissues and cell types. Genome Biology 
14:R115, 2013. 14:R115-134. 
36. Witkowska, A.M., Soluble ICAM-1: A marker of vascular inflammation and lifestyle. 
Cytokine, 2005. 31:127-134. 
37. Prakash, J., G. Pichchadze, S. Trofimov and G. Livshits, Age and genetic determinants of 
variation of circulating levels of the receptor for advanced glycation end products (RAGE) in the 
general human population. Mech Ageing Dev., 2015. 145:18-25. 
38. Ramasamy, R., S.F. Yan and A.M. Schmidt, RAGE: therapeutic target and biomarker of the 
inflammatory response—the evidence mounts. J. Leukocyte Biol., 2009. 86:505-511. 
39. Tchkonia, T., Y. Zhu, J. van Deursen, J. Campisi and J. Kirkland, Cellular senescence and 
the senescent secretory phenotype: therapeutic opportunities. J Clin Invest., 2013. 123:966-972. 
40. Bubna, A., Metformin - For the dermatologist. Indian J Pharmacol., 2016. 48:4-10. 
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SUPPLEMENTS/APPENDICES