Clinical trial NCT03744312
Conditions: Alzheimer Disease
Keywords: Inflammation PET scans
Sponsor: Columbia University
Start date: 2018-09-10; Completion date: 2022-07-20
Enrollment: 9 participants; Allocation: NON_RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This study is being done to learn about inflammation in the brain of those with Alzheimer's disease (AD). The purpose of this study is to determine if 11C-ER176 is able to accurately measure inflammation in patients with Alzheimer's disease. Both patients (with either mild cognitive impairment (MCI) or Alzheimer's disease) and healthy controls (participants without memory complaints or impairment) will be included in this study.

Detailed description:
Inflammation likely plays a role in the damage to the brain caused by Alzheimer's disease.

Accurately measuring inflammation in the brain could provide new information about the mechanisms that cause Alzheimer's disease, and could help identify new treatments that reduce inflammation. Positron emission tomography (PET) imaging is a type of brain scanning method that allows investigators to measure small molecules in the brain. ER176-PET was recently developed as an improved method for measuring brain inflammation. However, ER176-PET has not yet been used in patients with Alzheimer's disease. The investigators propose to use ER176-PET imaging in subjects with mild cognitive impairment (a very early stage of Alzheimer's disease) or mild Alzheimer's disease to compare the amount of inflammation with that seen in older control subjects. The investigators will first use a "gold standard" method of measuring ER176 in brain that requires sampling arterial blood during the scan. The investigators will compare these results to those obtained using novel methods that don't require blood sampling. The investigators hope to show that ER176 is a useful tool for measuring inflammation in Alzheimer's disease, and that the investigators can develop a way to obtain ER176 PET scans that don't require arterial blood sampling.

This study uses a special type of scan called a PET scan to take pictures of the brain. During the PET scan, a special dye is injected into the body. Two types of dye will be used in this study: Florbetaben and 11C-ER176. Florbetaben sticks to amyloid plaques, which are in the brain in Alzheimer's disease. Florbetaben has been approved by the Food and Drug Administration to help diagnose Alzheimer's disease. 11C-ER176 sticks to parts of the brain where there is inflammation. Past studies have shown that inflammation is present in the brains of patients with Alzheimer's disease.

Arms: arm 1: Alzheimer's disease (mild cognitive impairment or mild stage Alzheimer's disease dementia) arm 2: Healthy Controls
Interventions: intervention 1: 11C-ER176 intervention 2: Florbetaben
Intervention descriptions: intervention 1: 11C-ER176 sticks to parts of the brain where there is inflammation. Past studies have shown that inflammation is present in the brains of patients with Alzheimer's disease. The purpose of this study is to determine if 11C-ER176 is able to accurately measure inflammation in patients with Alzheimer's disease. intervention 2: Florbetaben sticks to amyloid plaques, which are in the brain in Alzheimer's disease.

Protocol documents:
Prot_SAP_000.pdf: 
IMAGING INFLAMMATION IN ALZHEIMER’S DISEASE WITH 
11C-ER176
Regulatory Sponsor: 
William Charles Kreisl, MD 
Taub Institute 
622 W. 168th St, PH 19, New York, NY 10032 
212-305-9194 
Funding Sponsor: 
Taub Institute 
622 W. 168th St, PH 19, New York, NY 10032 
212-305-9194 
Study Product: 
11C-ER176; 18F-Florbetaben 
Protocol Number: 
AAAR6570 
IND Number: 
139712 
Date: October 18, 2019 
Amended:   
Administrative Change: 
CONFIDENTIAL 
This document is confidential and the property of Columbia University Medical Center.  
No part of it may be transmitted, reproduced, published, or used by other persons without 
prior written authorization from the study sponsor. 
NCT03744312


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Table of Contents 
STUDY SUMMARY ................................................................................................................................................... 1 
1 
INTRODUCTION .............................................................................................................................................. 4 
1.1 
BACKGROUND .................................................................................................................................................. 4 
1.2 
INVESTIGATIONAL AGENT................................................................................................................................ 6 
1.3 
PRECLINICAL DATA ......................................................................................................................................... 6 
1.4 
CLINICAL DATA TO DATE ................................................................................................................................ 9 
1.5 
DOSE RATIONALE AND RISK/BENEFITS .......................................................................................................... 13 
2 
STUDY OBJECTIVES .................................................................................................................................... 13 
3 
STUDY DESIGN .............................................................................................................................................. 13 
3.1 
GENERAL DESIGN .......................................................................................................................................... 13 
3.2 
PRIMARY STUDY ENDPOINTS ......................................................................................................................... 16 
3.3 
SECONDARY STUDY ENDPOINTS .................................................................................................................... 16 
3.4 
PRIMARY SAFETY ENDPOINTS ........................................................................................................................ 17 
4 
SUBJECT SELECTION AND WITHDRAWAL.......................................................................................... 17 
4.1 
INCLUSION CRITERIA ..................................................................................................................................... 17 
4.2 
EXCLUSION CRITERIA .................................................................................................................................... 17 
4.3 
SUBJECT RECRUITMENT AND SCREENING ...................................................................................................... 17 
4.4 
EARLY WITHDRAWAL OF SUBJECTS ............................................................................................................... 18 
4.4.1 
When and How to Withdraw Subjects .................................................................................................. 18 
4.4.2 
Data Collection and Follow-up for Withdrawn Subjects ..................................................................... 19 
5 
STUDY DRUG ................................................................................................................................................. 19 
5.1 
DESCRIPTION ................................................................................................................................................. 19 
5.2 
TREATMENT REGIMEN ................................................................................................................................... 19 
5.3 
METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS ....................................................................... 19 
5.4 
PREPARATION AND ADMINISTRATION OF STUDY DRUG ................................................................................. 19 
5.5 
SUBJECT COMPLIANCE MONITORING ............................................................................................................. 19 
5.6 
PRIOR AND CONCOMITANT THERAPY ............................................................................................................ 19 
5.7 
PACKAGING.................................................................................................................................................... 19 
5.8 
BLINDING OF STUDY DRUG ............................................................................................................................ 19 
5.9 
RECEIVING, STORAGE, DISPENSING AND RETURN .......................................................................................... 20 
5.9.1 
Receipt of Drug Supplies ..................................................................................................................... 20 
5.9.2 
Storage ................................................................................................................................................. 20 
5.9.3 
Dispensing of Study Drug .................................................................................................................... 20 
5.9.4 
Return or Destruction of Study Drug ................................................................................................... 20 
6 
STUDY PROCEDURES .................................................................................................................................. 20 
7 
STATISTICAL PLAN ..................................................................................................................................... 23 
7.1 
SAMPLE SIZE DETERMINATION ...................................................................................................................... 23 
7.2 
STATISTICAL METHODS ................................................................................................................................. 23 
7.3 
SUBJECT POPULATION(S) FOR ANALYSIS ....................................................................................................... 23 
8 
SAFETY AND ADVERSE EVENTS ............................................................................................................. 23 
8.1 
DEFINITIONS .................................................................................................................................................. 23 
8.2 
RECORDING OF ADVERSE EVENTS ................................................................................................................. 25 
8.3 
REPORTING OF SERIOUS ADVERSE EVENTS.................................................................................................... 26 
8.3.1 
IRB Notification by Investigator .......................................................................................................... 26 
8.3.2 
FDA Notification by Investigator ......................................................................................................... 27 
8.4 
UNBLINDING PROCEDURES ............................................................................................................................ 27 
8.5 
STOPPING RULES ............................................................................................................................................ 27 
8.6 
MEDICAL MONITORING.................................................................................................................................. 27 


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9 
DATA HANDLING AND RECORD KEEPING .......................................................................................... 27 
9.1 
CONFIDENTIALITY .......................................................................................................................................... 27 
9.2 
SOURCE DOCUMENTS ..................................................................................................................................... 28 
9.3 
CASE REPORT FORMS..................................................................................................................................... 28 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ....................................................................... 28 
10.1 
STUDY MONITORING PLAN ....................................................................................................................... 28 
11 
ETHICAL CONSIDERATIONS .................................................................................................................... 28 
12 
STUDY FINANCES ......................................................................................................................................... 29 
12.1 
FUNDING SOURCE ..................................................................................................................................... 29 
12.2 
CONFLICT OF INTEREST ............................................................................................................................. 29 
12.3 
SUBJECT STIPENDS OR PAYMENTS ............................................................................................................ 29 
13 
PUBLICATION PLAN .................................................................................................................................... 29 
14 
REFERENCES ................................................................................................................................................. 29 


 
 
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List of Abbreviations 
 
 
 
PET 
Positron emission tomography 
11C-ER176 
O-methyl-11C](R)-N-sec-butyl-4-(2-chlorophenyl)-N-
methylquinazoline-2-carboxamide (a radioligand for inflammation) 
CSF 
Cerebrospinal fluid 
MRI 
Magnetic resonance imaging 
AD 
Alzheimer’s disease 
MCI 
Mild cognitive impairment 
EKG 
Electrocardiogram 
TSPO 
18 kDa translocator protein 
SNP 
Single nucleotide polymorphism 
AD 
Alzheimer’s disease 
SUVR 
Standardized uptake value ratio 
HAB 
High affinity binder 
MAB 
Mixed affinity binder 
LAB 
Low affinity binder 


Clinical Research Protocol Template 
 
page 1 
Version 4 
Study Summary 
Title 
Imaging inflammation in Alzheimer’s disease with 11C-ER176 
Short Title 
Imaging inflammation in Alzheimer’s disease with 11C-ER176 
Protocol Number 
Pending 
Phase 
II 
Methodology 
This is a single center PET study. 
 
After a screening period which includes brain MRI, neurological and 
neuropsychological examination, and determination of clinical and 
biomarker evidence of Alzheimer’s disease pathology (presence or 
absence of cognitive impairment and amyloid positivity on 18F-
florbetaben PET scan). Subjects will be diagnosed as Alzheimer’s 
disease (AD) or mild cognitive impairment (MCI) or cognitively 
normal. Subjects will then have one PET scan with 11C-ER176.  
Study Duration 
4 years 
Study Center(s) 
Taub Institute, CUMC  
Objectives 
The primary objective is to determine the ability of 11C-ER176 to detect 
increased TSPO (a marker of inflammation) in AD. 
Number of Subjects 
Up to 50 subjects will be screened and scanned with florbetaben (25 
subjects with MCI or AD and 25 controls. From the screened subjects, 
up to 30 subjects in total (15 with MCI or AD, 15 cognitively normal) 
will receive 11C-ER176 PET. 


 
 
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Diagnosis and Main 
Inclusion Criteria 
Inclusion criteria: 
1. Age 50 and older 
2. Meet criteria for either a) amnestic mild cognitive impairment 
(single or mixed domain) or Alzheimer’s disease, or b) have no 
cognitive impairment, based on history, exam, and 
neuropsychological testing.  
3. Subjects unable to provide informed consent must have a 
surrogate decision maker and be able to verbally assent to the 
study procedures. 
4. Written and oral fluency in English  
5. Able to participate in all scheduled evaluations and to complete 
all required tests and procedures. 
6. In the opinion of the investigator, the subject must be considered 
likely to comply with the study protocol and to have a high 
probability of completing the study. 
Exclusion criteria: 
1. Past or present history of certain brain disorders other than MCI 
or AD.   
2. Certain significant medical conditions, which make study 
procedures of the current study unsafe. Such serious medical 
conditions include uncontrolled epilepsy and multiple serious 
injuries.  
3. Contraindication to MRI scanning 
4. Conditions precluding entry into the scanners (e.g. morbid 
obesity, claustrophobia, etc.). 
5. Exposure to research related radiation in the past year that, when 
combined with this study, would place subjects above the 
allowable limits. 
6. Participation in the last year in a clinical trial for a disease 
modifying drug for AD. 
7. Inability to have a catheter in subject’s vein for the injection of 
radioligand.  
8. Inability to have blood drawn from subject’s veins.  
9. Taking anticoagulant medication (e.g., warfarin). 
 
Study Product, Dose, 
Route, Regimen 
18F-florbetaben, up to 8.1 mCi (300 MBq), IV, total of one injection. 
11C-ER176, up to 20 mCi (740 MBq), IV, total of one injection. 
Four control subjects will be used in test-retest study who will receive 
11C-ER176, up to 20 mCi (740 MBq), IV, total of two injections. 
Duration of 
administration 
A single dose of radioligand will be injected over 1 minute for the 18F-
florbetaben scan. A single dose of radioligand will be injected over 3 
minute for the 11C-ER176 scan. 
Reference therapy 
N/A 


 
 
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Statistical 
Methodology 
Comparing PET imaging among groups 
PET images will be analyzed using 1) the two-tissue kinetic model to 
calculate total distribution volume, corrected for free fraction of 
radioligand in plasma (VT/fP), and 2) the cerebellum as a pseudo-
reference region to calculate standardized uptake value ratios (SUVR). 
Effect size will be calculated for different regions as the difference in 
means (AD vs. controls) divided by the standard deviation.  
  
Secondary outcomes  
Coefficient of variation (%COV = standard deviation / mean) will be 
calculated for controls and patients with AD for both VT/fP and SUVR 
data. SUVR values will be calculated using cerebellum as reference 
regions. Additional reference regions will be explored. Correlation 
coefficients will be computed to look for correlation between 11C-
ER176 binding and clinical severity. We will also look for correlations 
between 11C-ER176 binding and atrophy, as determined using ROI 
volumes derived from MRI data. We will also calculate test-retest 
reproducibility for 11C-ER176 using data from the 4 controls who have 
two 11C-ER176 scans. 
  
Sample size determination  
This is a Phase 2 pilot study to determine feasibility and preliminary 
data for a larger study. Therefore, the proposed sample size is not 
necessarily expected to provide enough statistical power to see 
significant group differences. 
 


 
 
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1 Introduction 
This document is a protocol for a human research study. This study is to be conducted according 
to US and international standards of Good Clinical Practice (FDA Title 21 part 312 and 
International Conference on Harmonization guidelines), applicable government regulations and 
Institutional research policies and procedures.  
1.1 Background 
1.1.1. Background on Alzheimer’s disease 
While amyloid plaques are a pathological hallmark of Alzheimer’s disease (AD), whether 
β-amyloid is the causal agent of neurodegeneration in AD remains unclear. Evidence supporting 
the hypothesis that amyloid is a primary contributor to AD pathogenesis (the amyloid-first 
hypothesis) include the finding that genetic mutations responsible for inherited forms of AD 
cause increased amyloid production. Studies using positron emission tomography (PET) to 
measure amyloid plaque burden in vivo have demonstrated amyloid positivity before obvious 
atrophy or cognitive decline in healthy older controls. While tau positive neurofibrillary tangles 
represent the second hallmark of AD, tau mutations are seen in patients with variants of 
frontotemporal dementia, not AD. The propagation of tau pathology is thought to follow 
amyloidosis, suggesting amyloid in some way induces tau mediated degeneration. However, the 
link between amyloid and tau not clear as there are spatial and temporal distinctions. For 
example, bulk of amyloid burden in medial parietal cortex and frontal cortex early on, while tau 
burden begins in medial temporal cortex.  
 While β-amyloid has been shown to have direct neurotoxic effects in vitro, these effects 
are seen at concentrations of β-amyloid much higher than found in human brain[1].Therefore, 
amyloid may not confer significant direct toxicity. Rather, amyloid may induce secondary injury 
via activation of immune response. At physiologic concentrations, β-amyloid activates 
microglia[2], triggering a pro-inflammatory cascade as these resident neuroimmune cells attempt 
to clear β-amyloid from the brain[3]. This inflammatory response may be more toxic than β-
amyloid itself, as the resulting release of cytokines, activation of complement, and phagocytosis 
cause loss of neurons[4]. This inflammatory response may be the link between amyloid and tau, 
as inflammation can result in hyper-phosphorylation of tau, leading to the destabilization of tau 
filaments and aggregation of the neurofibrillary tangles that make up the second pathological 
hallmark of AD[5]. In turn, extracellular tau activates microglia[6], which could create a positive 
feedback loop of inflammation and tau pathology that propagates, independent of amyloid 
burden. The inflammation/tau relationship could also occur independently of the presence of 
amyloid. Indeed, autopsy findings of pre-tangle pathology occurring in midlife prior to 
amyloidosis[7] suggest that tauopathy may begin prior and independent to significant amyloid 
plaque deposition. Since amyloid burden correlates poorly with cognition[8], inflammation may 
be a more important mediator of neurodegeneration in AD. 
Measuring inflammation in vivo may also have an important role in determining prognosis 
and evaluating progression of disease in AD patients. Up to 30% of cognitively normal elders are 
amyloid positive on PET. Determining predictors of future cognitive decline among amyloid-
positive elders would allow us to distinguish incidental amyloid-positivity from that due to 
incipient Alzheimer’s disease in an elderly population. Furthermore, identifying the relative 
impact of inflammation on cognition may justify a more strategic approach for the development 
of anti-inflammatory therapeutics for AD. 


 
 
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1.1.2. Background on PET imaging of inflammation 
Inflammation can be quantified in vivo using PET imaging with radioligands that bind to 
the 18 kDa translocator protein (TSPO, formerly called the peripheral benzodiazepine receptor). 
Brain inflammation activates microglia and causes them to over-express TSPO[9]. Measurement 
of microglia activation, defined by the number of available TSPO binding sites, is used as a 
surrogate bio-marker of active brain inflammation[10].  PET imaging can quantify TSPO density 
in vivo using radioligands that cross the blood-brain barrier and bind to TSPO sites. 11C-(R)-PK 
11195, the prototypical TSPO radioligand, has been used to measure neuroinflammatory changes 
in several diseases, including Alzheimer’s disease[10] and 11C-(R)-PK 11195 binding has been 
shown to correlate with Mini-Mental State Examination score in patients with Alzheimer’s 
disease[11]. However, there have been conflicting reports about whether 11C-(R)-PK 11195 
binding is increased in Alzheimer’s disease or not[10, 12, 13]. Whether 11C-(R)-PK 11195 
binding is increased in MCI appears even less conclusive. For instance, [14] found a small 
increase in 11C-(R)-PK 11195 in PIB-positive patients with MCI relative to controls, but other 
studies found no increase in patients with MCI, even those who later progressed to dementia[12, 
13]. 
Limitations of 11C-(R)-PK 11195 have led to development of second generation TSPO 
radioligands. One such radioligand is PBR28, which has high in vitro affinity (~ 1 nM) for 
TSPO. In nonhuman primates, [11C]PBR28 has high brain uptake and fast washout[15], which 
allows reliable PET quantification. In addition, more than 80% of brain uptake is displaceable by 
nonradioactive TSPO ligands in nonhuman primates[15]. This means that over 80% of uptake is 
specifically bound to TSPO. [11C]PBR28 has high enough signal-to-noise ratio to localize 
inflammation to relatively small areas in humans with lacunar stroke[16]. Animal toxicology 
studies and early clinical PET studies have shown safety and tolerability of [11C]PBR28. In 
addition, the radiation exposure after injection of activity needed for reliable PET measurement 
(10-20 mCi) is well within limits for human research studies.  
The main limitation of 11C-PBR28, shared by all tested second generation TSPO 
radioligands, is differential affinity for the target protein[17]. This differential affinity is caused 
by the rs6971 polymorphism on the TSPO gene that causes a non-conservative amino acid 
substitution, resulting in three patterns of TSPO binding. Subjects without the polymorphism 
have high affinity binding for PBR28 and are referred to as high affinity binders (HABs). 
Homozygotes have low affinity binding and are referred to as low affinity binders (LABs). 
Heterozygotes express both high and low affinity TSPO and are referred to as mixed affinity 
binders (MABs). LABs are easily identified by PET due to negligible 11C-PBR28 binding in 
vivo; however, PET cannot easily resolve the difference between HABs and MABs, and MABs 
have, on average, 22% less total 11C-PBR28 binding than HABs[18]. Previous work from our 
laboratory demonstrated that correcting in vitro binding data for rs6971 genotype improves the 
ability of 3H-PBR28 to detect differences in TSPO density in schizophrenia and control brain 
tissue[18]. This strategy of TSPO genotype correction can be applied to PET imaging to remove 
confounding effects of differences in TSPO affinity. 
11C-ER176 is a novel TSPO radioligand that was developed because of its relative 
insensitivity to the rs6971 polymorphism. The ratio of binding affinity in HABs to that in LABs 
is only 1.3 to 1 for ER176, whereas the comparable ratio was 55 to 1 for PBR28 [19]. 11C-ER176 
also performed well as a PET radioligand for TSPO in monkey brain, showing more than 80% 
specific (i.e., displaceable) binding. Human blocking studies show that 11C-ER176 has higher 


 
 
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specific-to-nonspecific binding than both 11C-(R)-PK 11195 and 11C-PBR28 [20]. While there 
exists a small amount of in vivo sensitivity to the rs6971 polymorphism, 11C-ER176 binding can 
be stably quantified even in low affinity binders. 
  
1.1.3. Background of PET imaging of amyloid. 
 
While post-mortem examination is required to definitively demonstrate the presence of 
amyloid plaques in suspected cases of AD, PET imaging allows measurement of amyloid burden 
in vivo. 18F-florbetaben (FBB, formerly known as BAY94-9172) binds to fibrillar amyloid 
plaques in vivo[21]. FDA approved for commercial use to exclude AD. Dosimetry studies have 
shown that radiation exposure from this radioligand is similar to that from other 18F radioligand 
commonly used in human PET studies and clinical practice.  
1.2 Investigational Agent 
11C-PBR28 is a PET radioligand that binds to the 18 kDa translocator protein (TSPO), a 
marker of inflammation. 11C-PBR28 has previously been administered in humans.  
18F-Florbetaben (Neuraceq) has FDA approval for human use in evaluation of Alzheimer’s 
disease. We will use 18F-Florbetaben in this study for research purposes. 
Both radioligands will be administered in tracer doses. 11C-PBR28 will be administered at 
activity of up to 20 mCi per injection. 18F-Florbetaben will be administered at activity up to 8.1 
mCi per injection. 
1.3 Preclinical Data 
1.3.1. Preclinical Data for ER176 
1.3.1.1. Pharmacology of ER176 
Because TSPO is highly expressed in microglia and reactive astrocytes, it has been widely used 
over the last three decades as an in vivo biomarker to detect neuroinflammation using PET [9]. 
In recent years, a large number of clinical studies have been performed using new PET ligands, 
including [11C]PBR28, which has been used extensively by our group. Although these new PET 
ligands have higher levels of specific binding than the classic ligand [11C]PK 11195 [22], they 
are confounded by the fact that the binding affinity of most new ligands is affected by the rs6971 
polymorphism on the TSPO gene [17]. As noted above, this polymorphism determine whether 
human subjects are high- (HAB), mixed- (MAB), or low-affinity (LAB) binders. PET results 
may thus be affected by genotype in addition to pathological changes in TSPO density [23]. 
 
 
To cope with the confounding factor of polymorphism, a new ligand has been developed, 
[11C]ER176, with similarly high affinity for all three genotypes. Ki values of ER176 and [H-
3]PK 11195 measured in human leukocytes were 1.4 and 1.6 nM for HAB and LAB, 
respectively. ER176 also has lipophilicity of clog D = 3.80, which is appropriate for brain 
imaging. 
 
1.3.1.2. Animal toxicology for ER176 
SRI International conducted an extended acute toxicity study in rats. The results of this 
toxicity study have been provided by Dr. Robert Innis of NIMH and is publically available at 
https://pdsp.unc.edu/databases/snidd/IND/CER176.php. The executive summary is provided 
below. Please note that the toxicity study was designed around the assumption that the maximal 
mass dose would be 10 µg in a human subject. After receiving the report, and to be extra 
cautious, Dr. Innis’s group reduced the maximal mass dose to 5 µg for the first-in-human studies. 


 
 
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Thus, the report and Dr. Innis’s IND differ two-fold when referring to the projected human 
dose. For example, in the report, the actual dose of 22.0 µg/kg in a rat is referred to as 25X 
human equivalent dose (HED), whereas Dr. Innis’s IND refers to it as 50X HED. Under this 
present IND, we plan to use the same conservative mass dose limit of 5 µg per injection of 11C-
ER176. 
 
Executive Summary  
 
The objective of this study was to determine potential toxic effects and to identify 
potential target organs of toxicity, if possible, for the toxicity endpoints examined following a 
single intravenous (iv) bolus administration of ER176 given to Sprague Dawley rats. 
Additionally, the maximum tolerated dose (MTD) and no observed adverse effect level 
(NOAEL) of ER176 in rats may be established. Information from this study may be used to 
determine the suitability of the proposed human dose. 
 
Two groups of 10 male and 10 female rats were administered a single dose of either the 
vehicle control (Group 1) or ER176 at 88.1 µg/kg (528.6 µg/m2; 100 times the human dose; 
Group 2) on Day 1 by iv bolus injection into the tail vein. The vehicle was 10% ethanol and 90% 
saline. In Groups 1 and 2 five males and five females in each group were sacrificed on Day 3, 
while the remaining animals were sacrificed on Day 15. In-life evaluations of mortality, 
morbidity and clinical observations were conducted daily. Body weights were collected on 
Days 1, 3 and 15. Food consumption was evaluated twice weekly. Clinical pathology samples 
were collected on the day the animals were euthanized. All animals survived to their scheduled 
sacrifices. There were no test article–related effects seen in the animals treated with 88.1 µg/kg 
ER176 on body weights, food consumption, clinical pathology, gross necropsy, organ weights or 
histopathology, compared with the controls. However, slight ataxia was observed immediately 
post dose administration in 10 of 10 males and 6 of 10 females in the ER176 treated group. The 
effect was slight and transient, and the animals recovered quickly (within 2 hr post dose 
administration). All animals in the control group were normal. Due to this clinical finding and in 
an attempt to establish the NOAEL, additional animals were evaluated for clinical observations 
after consultation with the Sponsor.  
 
Three groups of 10 male and 10 female rats were administered ER176, by iv tail vein 
injection, at 22.0 µg/kg (132.5 µg/m2; 25 times the human dose; Group 3), 44.1 µg/kg (264.3 
µg/m2; 50 times the human dose; Group 4), or 88.1 µg/kg (528.6 µg/m2; 100 times the human 
dose; Group 5). In-life evaluations of mortality, morbidity and clinical observations were 
conducted daily for 3 days, and animals were sacrificed on Day 3. No test article–related effects 
were observed in the animals treated with 22.0 or 88.1 µg/kg of ER176 (Groups 3 and 5). 
However, a slight and transient ataxia was observed in one male rat immediately following 
dosing in the 44.1 µg/kg dose group (Group 4). It is not clear why animals in the high dose 
groups (100 times the human dose; 88.1 µg/kg) responded differently to ER176 in Groups 2 and 
5 in clinical observations immediately post dose administration. It may be due to animal-to-
animal variations in different shipments.  
 
In conclusion, a single dose of ER176 (22.0 µg/kg, 132.5 µg/m2; 25 times the projected 
human dose) administered intravenously was well tolerated in rats and produced no significant 
treatment–related effects. Animals in the 44.1 and 88.1 µg/kg treatment groups also tolerated the 
single dose administration, except a slight and transient ataxia was observed. The NOAEL is 
considered to be 22.0 µg/kg (132.5 µg/m2; 25 times the projected human dose). The MTD is 
considered to be greater than 88.1 µg/kg (528.6 µg/m2; 100 times the projected human dose). 


 
 
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Requested Mass Dose 
We request permission to inject a maximal mass dose of 5 µg, which is two-fold less than the 10 
µg that was considered the maximal dose for toxicity in the study described above. 
 
1.3.1.3. Monkey imaging studies with 11C-ER176 
Baseline and pre-blocked PET scans of [11C]ER176 were performed in two rhesus 
monkeys (a total of two baseline and two pre-blocked scans) and confirmed that [11C]ER176 has 
high levels of specific binding. In both monkeys, binding blockade was measured using brain 
activity. In addition, in one monkey, a more complete measurement of binding was performed by 
measuring total VT using metabolite-corrected arterial input function, i.e., [11C]ER176 levels in 
arterial plasma. For the pre-blocked scans, PK 11195 (5 mg/kg) was used as the blocking agent. 
In the baseline scans, the mass dose of ER176 was 0.111 µg/kg on average. The scans were 
performed under isoflurane anesthesia; blood pressure, heart rate, and ECG were monitored. 
These mass doses caused no changes in vital signs. 
Based on brain activity at late time points (60 - 120 minutes), 60% of brain activity in 
baseline scans was from specific binding (Fig. 2). However, these measurements did not take 
into account changes in blood data. VT measured with arterial input function and Logan plot was 
11 – 17 mL/cm3 in baseline and 1.6 – 2.5 mL/cm3 in pre-blocked scans. The complete 
measurements suggest that ~85% of activity of the baseline scan was specific binding. 
In the baseline and pre-blocked scans of one monkey described in section 8.2.2.1., 
[11C]ER176 levels were measured in arterial plasma. The pre-blocked scan showed about five 
times higher [11C]ER176 levels in arterial plasma. TSPO exists in several peripheral organs such 
as lungs, heart, and kidneys. Whole body imaging and arterial blood sampling were performed at 
the same time with another ligand ([11C]PBR28), and confirmed that [11C]PBR28 increases in 
arterial plasma were caused by binding blockade to TSPO in peripheral organs [24]. Therefore, 
increased [11C]ER176 levels in arterial plasma in the pre-blocked scan is consistent with the 
presence of specific binding to TSPO in peripheral organs. 
The arterial data from the two monkey scans showed fast clearance of [11C]ER176, the 
concentration of which decreased to a half of the peak within three minutes post-injection and to 
< 10% in 30 minutes. Clearance was 526 and 195 mL/min for the baseline and blocked scan, and 
the terminal half life by tri-exponential fitting was 24 and 49 minutes, respectively. 
 
1.3.2. Preclinical Data for 18F-florbetaben 
1.3.2.1. Pharmacology of 18F-florbetaben 
 
18F-florbetaben is a 18F-labeled stilbene derivative, which binds to β-amyloid plaques in 
the brain. The F-18 isotope produces a positron signal that is detected by a PET scanner. 3H 
florbetaben in vitro binding experiments reveal two binding sites (Kd of 16 nM and 135 nM) in 
frontal cortex homogenates from patients with AD. Binding of 18F-florbetaben to β-amyloid 
plaques in post-mortem brain sections from patients with AD using autoradiography correlates 
with both immunohistochemical and Bielschowsky silver stains. 18F-florbetaben does not bind to 
tau or α-synuclein in tissue from patients with AD. Neither Neuraceq nor non-radioactive 
florbetaben F-18 bind to AT8 positive tau deposits in brain tissue from patients with 
frontotemporal dementia (FTD), using autoradiography and immunohistochemistry, respectively. 
 
Following intravenous administration, 18F-florbetaben crosses the blood brain barrier and 
shows differential retention in brain regions that contain β-amyloid deposits. Differences in 


 
 
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signal intensity between brain regions showing specific and nonspecific 18F-florbetaben uptake 
form the basis for the image interpretation method. 
Results from the first in-human study of 18F-florbetaben are as follows (see Package 
Insert). Ten minutes after intravenous bolus injection of 300 MBq of 18F-florbetaben in human 
volunteers, approximately 6% of the injected radioactivity was distributed to the brain. 18F-
florbetaben plasma concentrations declined by approximately 75% at 20 minutes post injection, 
and by approximately 90% at 50 minutes. The F-18 in circulation during the 45- 130 minute 
imaging window was principally associated with polar metabolites of florbetaben. 18F-
florbetaben was 8.5% bound to plasma proteins and was eliminated from plasma primarily via 
the hepatobiliary route with a mean biological half-life of approximately 1 hour. In vitro studies 
show that metabolism of florbetaben is predominantly catalyzed by CYP2J2 and CYP4F2. At 12 
hours post-administration, approximately 30% of the injected radioactivity had been excreted in 
urine. Almost all F-18 radioactivity in urine was excreted as polar metabolites of 18F-florbetaben 
and only trace amounts of 18F-florbetaben were detected. In in vitro studies using human liver 
microsomes, florbetaben did not inhibit cytochrome P450 enzymes at concentrations present in 
vivo. 
 
1.3.2.2. Nonclinical Toxicology of florbetaben 
 
Animal studies have not been performed to evaluate the carcinogenic potential of 
florbetaben. Florbetaben did not demonstrate mutagenic potential in an in vitro bacterial 
mutation assay (Ames test) using five strains of Salmonella typhimurium and one strain of 
Escherichia coli or in an in vitro chromosomal aberration assay using human peripheral 
lymphocytes in the absence and presence of a metabolic activator. No study on impairment of 
male or female fertility and reproductive performance was conducted in animals. 
1.4 
Clinical Data to Date 
 
1.4.1. Human Experience with 11C-ER176 
1.4.1.1. Safety data for 11C-ER176 
Nine healthy volunteers had 11C-ER176 injected for whole-body PET scans (1 man and 2 
women; mean age ± SD, 30 ± 10 y) [20]. Eight separate healthy volunteers had 11C-ER176 
injected for brain PET imaging (1 man and 2 women; 32 ± 9 y old). 11C-ER176 was 
intravenously injected over 3 min. Specific activity was 121 ± 64 GBq/μmol at the time of 
injection.  
No adverse or clinically detectable pharmacologic effects were observed with 11C-ER176 
for any of the 17 subjects. No significant changes in vital signs or electrocardiograms were 
observed during the PET scan or in the results of laboratory tests repeated after the scan. 
 
1.4.1.2. Whole body imaging with 11C-ER176 in human subjects 
Nine healthy volunteers participated in the whole-body PET scans (1 man and 2 women 
each with HAB, MAB, and LAB status; mean age ± SD, 30 ± 10 y)[20]. TSPO affinity type was 
determined by in vitro receptor binding to TSPO on leukocyte membranes or genetic analysis. 
Time–activity curves were derived from volumes of interest for each source organ (i.e., brain, 
heart, lungs, liver, spleen, kidneys, and thyroid) delineated on the whole-body images using 
PMOD. For whole-body images, the measured radioactivity in each organ was converted to 
SUV. Regional SUV averaged from 60 to 120 min after injection (SUV60–120 min) was used to 


 
 
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measure radioligand uptake in each organ. This period was used because it better reflects 
receptor binding than the early period, which is strongly affected by blood flow. Differences in 
SUV60–120 min for each organ were compared between genotypes by Kruskal–Wallis testing. 
Whole-body imaging clearly showed that the in vivo binding of 11C-ER176 was sensitive 
to rs6971. Uptake for brain and lung was lower in LABs than in HABs at all time-points, with 
intermediate values for MABs. SUV60–120 min showed a significant difference between 
genotypes in heart (P < 0.05). The same tendency was observed in brain, lung, and spleen (Table 
1). 
 
Table 1. Organ Uptake of 11C-ER176 for Each Genotype[20] 
 
 
Residence times were calculated directly using the “Residence Times” model 
implemented in PMOD. Absorbed radiation doses were calculated by entering the residence 
times for each source organ into OLINDA/EXM, version 1.1, using the model for a 70-kg adult 
man. The residence time of organs was calculated for the 9 subjects. The effective dose was 4.1 
± 0.4 μSv/MBq, which is similar to that of other 11C-labeled radioligands. 
 
1.4.1.3. Brain imaging with 11C-ER176 in human subjects 
Eight separate healthy volunteers with either HAB, MAB, or LAB status had brain PET 
scans with 11C-ER176 (1 man and 2 women each for HAB and MAB status and 2 men with LAB 
status; 32 ± 9 y old) [20]. TSPO affinity type was determined by in vitro receptor binding to 
TSPO on leukocyte membranes or genetic analysis. The 3 HABs who participated in the brain 
PET scans received an oral dose of 90 mg of the TSPO agonist N-benzyl-N-ethyl-2-(7-methyl-8-
oxo-2-phenylpurin-9-yl)acetamide (XBD173) as a partial blockade about 1.75 h before the 
second injection of 11C-ER176.  
For brain images, total volume of distribution (VT), an index of receptor density that 
equals the ratio at equilibrium of the concentration of radioligand in tissue to that in plasma, was 
calculated with 1- and unconstrained 2-tissue compartment models (2TCM and 1TCM, 
respectively) using the radiometabolite-corrected plasma input function. To determine the 
minimal scan length for reliable measurements and also to indirectly assess whether 11C-ER176 


 
 
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radiometabolites enter the brain, the time stability of VT was examined by increasingly 
truncating the 90-min scan by 10-min increments to the shortest length of 0–50 min. 
A modification of the Lassen plot was used to estimate VND of 11C-ER176 in brain in 2 
ways: with an occupancy plot using the difference in VT at baseline and after partial blockade 
with XBD173 in HABs, and with a polymorphism plot using the difference in VT between 2 
genetic groups (i.e., between HABs and MABs, between HABs and LABs, and between MABs 
and LABs). 
Brain time–activity curves fitted better with 2TCM than 1TCM. The unconstrained 
2TCM fitting converged in brain time–activity curves from all regions, in all scans, and in all 
genotypes, both at baseline and after blockade with XBD173 in HABs (Fig. 4A). Compared with 
the 1TCM, the 2TCM showed lower mean Akaike information criterion scores (130 vs. 242) and 
higher mean model selection criterion scores (6.4 vs. 2.9). An F test also showed that the 
goodness of fit was significantly better with the 2TCM than with the 1TCM in all 154 fittings 
over a total of 11 scans, indicating the presence of significant amounts of both specific and 
nonspecific binding in human brain. The 2TCM identified VT well, with an average SE of 2.4% 
across brain regions. Regional VT values (mL·cm−3) were consistent with the known distribution 
of TSPO, showing high levels in the brain stem (4.3) and low levels in the putamen (3.2) at 
baseline for HABs. 
After receiving XBD173, all 3 HABs showed marked blocking effects, both in brain and 
in plasma. That is, receptor blockade decreased peak uptake in brain, increased washout, and 
decreased total uptake over the 90-min scan (Fig. 1A). In plasma, XBD173 significantly 
increased the concentration of 11C-ER176, consistent with its blocking the distribution of the 
radioligand to organs of the body (Fig. 1B) 
 
 
 
Fig. 1. Brain uptake and plasma radioactivity concentrations (conc) of 11C-ER176 in 
representative HAB at baseline (○) and after blockade with 90 mg of XBD173 (●). 
 
VT values were stable from 60 to 90 min and were well identified (SE < 10%) in all 3 
genotypes with the exception of 1 MAB and in the 3 HABs after blockade, which had low 
specific binding like that in LABs, indicating negligible accumulation of radiometabolites 
regardless of the genotype. 


 
 
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VT values were higher for HABs than for LABs in all regions of interest, with 
intermediate values for MABs. The whole-brain VT in HABs (3.3 ± 0.9 mL·cm−3) was about 
1.2-fold higher than that in MABs (2.9 ± 0.9 mL·cm−3) and about 2.2-fold higher than that in 
LABs (1.6 ± 0.5 mL·cm−3). VT for 11C-ER176 was well identified by the 2TCM in all 
genotypes. 
The receptor blocking study using XBD173 found that 11C-ER176 had adequately high 
BPND for all genotypes. The whole brain BPND—without correcting for fP—was 4.2 ± 1.3 and 1.4 
± 0.8 for HABs and LABs, respectively. The high BPND and good identifiability in all genotypes, 
including LABs, suggests that this new radioligand would likely have better sensitivity in 
detecting abnormalities in patients and that LABs may not need to be excluded as they are for 
11C-PBR28. 
In summary, although 11C-ER176 does not show sensitivity to the rs6971 SNP in vitro 
(see Section 8.1.1.), this radioligand does show a small degree of sensitivity to the SNP in vivo. 
This in vivo sensitivity is seen in both brain and peripheral organs (see Section 9.2.). However, 
the difference in binding between HABs and LABs is much lower for 11C-ER176 than for 11C-
PBR28. Importantly, VT and BPND may be reliably quantified in LABs with 11C-ER176.  
 
 
1.4.2. Human Experience with 18F-florbetaben 
 
Human brain studies with 18F-florbeteben have been performed (see Package Insert). The 
results are summarized as follows. 18F-florbetaben was evaluated in three single arm clinical 
studies (Study A-C) that examined images from adults with a range of cognitive function, 
including some end-of-life patients who had agreed to participate in a post-mortem brain 
donation program. Subjects underwent 18F-florbetaben injection and scan, then had images 
interpreted by independent readers masked to all clinical information. The Standard of Truth 
(SoT) was based on the histopathologic examination using Bielschowsky silver staining (BSS) of 
six brain regions assessed by a Pathology Consensus Panel masked to all clinical information 
(including PET scan results). 18F-florbetaben PET imaging results (negative or positive) 
corresponded to a histopathology derived plaque score based on the Consortium to Establish a 
Registry for Alzheimer’s Disease (CERAD) criteria using neuritic plaque counts. For the subject 
level SoT, if in any of the six regions β amyloid neuritic plaques were more than sparse, the 
subject was classified as positive; if in none of the regions the β-amyloid neuritic plaques were 
assessed as being more than sparse, the subject was classified as negative. 
 
Study A evaluated 18F-florbetaben PET images from 205 subjects and compared the 
results to postmortem truth standard assessments of brain β-amyloid neuritic plaque density in 
subjects who died during the study. The median age was 79 years (range 48 to 98 years) and 
52% of the subjects were male. By medical history 137 study participants had AD, 31 had other 
non-AD dementia, 5 had dementia with Lewy Bodies (DLB), and 32 had no clinical evidence of 
dementia. Interpretation of images from 82 autopsied subjects was compared to the subject level 
histopathology SoT. Three readers, after undergoing in-person tutoring, interpreted images using 
a clinically applicable image interpretation methodology. At autopsy, the subject level brain β 
amyloid neuritic plaque density category was: frequent (n = 31); moderate (n = 21); sparse (n = 
17); or none (n = 13).  
In Study B five independent, blinded readers underwent the Electronic Media Training in 
the clinically applicable image interpretation methodology and assessed images from the same 
82 end-of-life subjects who enrolled in Study A. The time interval between the 18F-florbetaben 


 
 
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scan and death was less than one year for 45 patients, between one and two years for 23 patients 
and more than two years for 14 patients.  
Study C evaluated the reliability and reproducibility of the clinically applicable image 
interpretation methodology using the Electronic Media Training; 461 images from previous 
clinical studies were included from subjects with a range of diagnoses. Five new readers assessed 
randomly provided images from subjects with a truth standard (54 subjects who underwent an 
autopsy) and without a truth standard (51 subjects with mild cognitive impairment, 182 subjects 
with AD, 35 subjects with other dementias, 5 subjects with Parkinson’s Disease and 188 healthy 
volunteers). Among the 461 subjects, the median age was 72 years (range 22 to 98), 197 were 
females, and 359 were Caucasian. Interreader agreement across all 5 readers had a kappa 
coefficient of 0.79 (95% CI 0.77, 0.83). The performance characteristics in 54 subjects with SoT 
were similar to those measured in Studies A and B. Additionally, intra-reader reproducibility was 
assessed from 46 images (10%); the percentage of intra- reader agreement for the 5 readers 
ranged from 91% to 98%. 
1.5 
Dose Rationale and Risk/Benefits 
Based on prior human experience and dosimetry data, we expect the proposed injected activity of 
11C-ER176 (up to 20 mCi) to be safe without expected toxicity. 18F-florbetaben is an FDA-
approved radiopharmaceutical used here for research purposes at injected activity recommended 
by the manufacturer (up to 8.1 mCi). 
2 
Study Objectives 
This is a proof-of-concept study to determine if 11C-ER176, a novel and improved radioligand 
for TSPO, detects increased TSPO density in patients with Alzheimer’s disease. 18F-florbetaben 
will be used to confirm Alzheimer’s disease pathophysiology in the patient group. We also seek 
to determine the test-retest reliability of 11C-ER176 in humans. 
 
We propose to inject 18F-florbetaben in 50 human subjects, each as a one-time dose, as part of 
the screening process. Twenty-five subjects will be cognitively normal. Twenty-five subjects 
will have either mild cognitive impairment or Alzheimer’s disease.  
 
From the screened subjects, we propose to inject 11C-ER176 in 30 human subjects, each as a one-
time dose, as part of the screening process. Fifteen subjects will be cognitively normal. Fifteen 
subjects will have either mild cognitive impairment or Alzheimer’s disease.  
 
In four of the control subjects, we will perform test-retest 11C-ER176 imaging. Each subject will 
have two injections of 11C-ER176 for the test-retest study. 
3 Study Design 
3.1 General Design 
 
3.1.1. Subject recruitment and screening procedures 
  
Men and women age 50 and older will be recruited from the Columbia Doctors Aging 
and Dementia clinic, the CUMC Alzheimer's Disease Research Center (ADRC), Dr. Davangere 
Devanand’s Questionable Dementia 2 (QD2) cohort, and the CUMC Washington Heights-


 
 
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Inwood Community Aging Project (known locally as WHICAP, R01 AG037212, PI Richard 
Mayeux). Participants may also co-enroll from the cognitive aging studies of Dr. Adam 
Brickman (protocol AAAO9758) and Dr. Yaakov Stern (protocols AAAI2752, AAAQ8249, and 
AAAQ8096), and from CUMC protocols AAAO1151, AAAQ7868, and AAAR4352 (PI = 
Kreisl). Participants may also self-refer as this study will be registered on clinicaltrials.gov. 
Informed consent will be obtained prior to study enrollment.  
 
For subjects with cognitive impairment, prior to obtaining informed consent, a licensed physician 
who is not listed as personnel on this protocol will determine whether the subjects has capacity to 
provide their own consent. If the subject lacks consent, a legally authorized representative will be 
required to provide consent for the subject. Only subjects who can provide an understanding of 
the study procedures, particularly of the risk of pain associated with the arterial catheter 
placement, by providing verbal assent, may be enrolled via the surrogate consent process. 
Subjects who are unable to provide meaningful assent will not be enrolled into the study. 
 
Up to 50 subjects will undergo screening including history, physical examination, routine 
laboratory studies, neuropsychological testing, brain MRI, and amyloid PET imaging.  
 
If any of the above screening procedures have been performed within one year of the 11C-
ER176 PET scan visit, then those procedures will not need to be repeated under this protocol. 
Rather the previously obtained results will be used.  
 
Subjects will be categorized as either amyloid-positive or amyloid-negative on PET. 
Subjects will be identified as either cognitively normal or cognitively impaired in consensus 
conference. Subjects must have Clinical Dementia Rating scale score of 0.5 or above and meet 
clinical criteria for either amnestic MCI (single or multiple-domain)[25] or Alzheimer’s 
disease[26] to be included in the cognitively impaired category. Of the screened subjects, only 
amyloid-positive patients and amyloid-negative controls will undergo 11C-ER176 PET. 
 
Subjects will have genetic analysis to determine the presence of the rs6971 (Ala147Thr) SNP on 
the TSPO gene.  
 
Target sample size for completers is 15 amyloid-positive patients and 15 amyloid-negative 
controls (30 subjects total). Our enrollment goal of 25 subjects per group will allow a 40% 
general screen failure/drop-out rate. Subjects who are coenrolled in other CUMC studies will not 
need to have brain MRI under this protocol if done within the last 12 months. Coenrolled 
subjects will not need to have 18F-florbetaben PET under this protocol if 1) they are controls and 
have had a negative 18F-florbetaben or other amyloid PET scan within the previous 12 months, or 
2) they are patients and have ever had a positive amyloid PET scan using any amyloid 
radioligand (18F-florbetaben, 18F-florbetapir, 18F-flutemetamol, or 11C-Pittsburgh Compound B).  
 
3.1.2 Neuropsychological testing 
The diagnosis of MCI or AD will be based on updated criteria[25, 26]. The 
neuropsychological test battery will include the following tests: the Mini-Mental State 
Examination, Selective Reminding Test, Benson Complex Figure Copy and Recall, MINT, 
Rosen Drawing Test, single word and sentence repetition from the NACC FTD module, 


 
 
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Geriatric Depression Scale (15 items), Trail Making Tests A and B, and Verbal Fluency (CFL, 
and Animals). Raw scores and demographically corrected T-scores (age, years of education, sex, 
and ethnicity) will be determined.  
 
3.1.3. Imaging procedures 
One brain MRI will be performed on each subject using a 3T scanner. Sequences 
performed will include 3D T1 (MPRAGE, 180 slice 1 mm resolution, 256 x 256 voxel count) for 
volumetric analysis and clinical sequences to exclude subjects with other intracranial pathology 
unrelated to AD. PET scans will take place on a Biograph mCT PET scanner (Siemens 
Healthcare) at the CUMC Kreitchman PET Center. Subjects will have one 18F-florbetaben 
(Neuraceq) PET scan (up to 8.1 mCi) to determine amyloid status[27]. Subjects will have one 
PET scan with 11C-ER176 (injected activity 10-20 mCi), except for 4 controls who will have two 
11C-ER176 scans for test-retest imaging. 11C-ER176 imaging will be performed with arterial 
sampling. 11C-ER176 will be synthesized by the CUMC PET Department Radiochemistry 
Laboratory. 18F-Florbetaben will be purchased from Piramal Imaging. Subjects will be informed 
if a clinically important abnormality is detected on PET imaging (e.g., brain tumor). 
 
Prior to 11C-ER176 PET imaging, one arterial catheter and one intravenous catheter will 
be placed. After a low-dose CT scan for attenuation correction, up to 20 mCi 11C-ER176 will be 
injected intravenously over 3 minutes. Emission scan will begin at the start of the radioligand 
infusion according to the following frame schedule: 30 seconds x 6, 1 minute x 3, 2 minutes x 2, 
and 5 minutes x 16 for total scan time of 90 min. During the emission scan, arterial samples will 
be drawn at 10 second intervals for the first 4 min using an automated blood sampler. Thereafter, 
manual arterial samples will be drawn at 6, 8, 10, 15, 20, 30, 40, 50, 60, 75, and 90 minutes. 
Alternatively, manually samples may be drawn at 15 sec intervals for the first 2.5 min, then at 3, 
4, 6, 8, 10, 15, 20, 30, 40, 50, 60, 75, and 90 minutes. Radioactivity in plasma will be quantified 
by a γ-counter and analyzed by reverse-phase chromatography to separate parent radioligand 
from radiometabolites[43] by the PET center radiometabolite laboratory. Free fraction of 11C-
PBR28 in plasma (fP) will be measured by ultrafiltration and normalized using a standard derived 
from pooled donor plasma[44]. Because one aim is to determine if 11C-ER176 may be useful in 
AD studies using simplified analysis, some subjects may have 11C-ER176 imaging without 
arterial catheterization . 
 
3.1.4 Image processing 
FreeSurfer (http://surfer.nmr.mgh.harvard.edu/), the MRI software package comprising a suite of 
automated tools for segmentation, reconstruction, and derivation of regional volumes and 
surface-based rendering, will be used for derivation of regions-of-interest (ROIs). Eleven ROIs 
will be extracted from the structural T1 image: entorhinal cortex, hippocampus, inferior temporal 
cortex, combined superior and middle temporal cortex, superior parietal lobule, inferior parietal 
lobule, precuneus, occipital cortex, prefrontal cortex, striatum, and thalamus. Age-adjusted 
hippocampal volumes will be used to define the presence or absence of neurodegeneration[28]. 
A single static 18F-florbetaben image acquired 50-70 min post-injection will be read by a trained 
investigator blinded to the subject’s diagnosis (Kreisl). A visual binary read (positive or 
negative) will be determined according to criteria established by Piramal imaging to stratify 
subjects as amyloid-positive or amyloid-negative.  


 
 
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11C-ER176 PET images will be analyzed using Freesurfer. ROIs will be applied to 
coregistered PET images to generate time-activity curves. The metabolite-corrected plasma 
activity curve will be used to estimate rate constants using the one- and two-tissue compartment 
models using PMOD software. The total distribution volume will be calculated from the 
resulting rate constants.  
 
3.1.5. Blood sampling and analysis 
Subjects will undergo venipuncture to collect 70 mL of blood. Collected blood will be used for 
screening laboratories, and for research tests. Research tests include determination of TSPO 
genotype, determined by SNP analysis using polymerase chain reaction with a pre-existing 
Taqman assay[17, 18, 29] in the Biomarkers Shared Resource of CUMC. Blood will also be 
collected for genetic and non-genetic tests related to inflammation (e.g., TREM2, use of 
peripheral blood mononuclear cells to create monocyte-derived microglia-like cells). Results 
from research tests will not be released to participants. Approximately 20 mL of blood sampled 
will be used for screening tests and approximately 50 mL of blood will be used for research 
tests.Blood samples will be stored prior to research use in a secure freezer. Stored samples will 
be labeled with subject ID number and no personal identifying information will be included on 
the stored sample label. Because the first eight participants to enter this study only had blood 
drawn for screening tests and TSPO genotyping, these subjects will be asked to return for another 
study visit to have 50 mL of blood drawn for research tests. Such returning participants will be 
re-consented prior to having the 50 mL blood draw. 
 
 
 
3.2 Primary Study Endpoints 
 
Because the drugs used in this study are radioligands given at tracer doses, there are no clinical 
endpoints of the study.  
 
Comparing PET imaging among groups 
PET images will be analyzed using 1) the two-tissue kinetic model to calculate total distribution 
volume, corrected for free fraction of radioligand in plasma (VT/fP), and 2) the cerebellum as a 
pseudo-reference region to calculate standardized uptake value ratios (SUVR). Effect size will be 
calculated for different regions as the difference in means (AD vs. controls) divided by the 
standard deviation.  
  
Secondary outcomes  
 
3.3 Secondary Study Endpoints 
Coefficient of variation (%COV = standard deviation / mean) will be calculated for controls and 
patients with AD for both VT/fP and SUVR data. SUVR values will be calculated using 
cerebellum as reference regions. Additional reference regions will be explored. Correlation 
coefficients will be computed to look for correlation between 11C-ER176 binding and clinical 
severity. We will also look for correlations between 11C-ER176 binding and atrophy, as 


 
 
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determined using ROI volumes derived from MRI data. We will also calculate test-retest 
reproducibility for 11C-ER176 using data from the 4 controls who have two 11C-ER176 scans. 
3.4 Primary Safety Endpoints 
N/A 
4 Subject Selection and Withdrawal 
4.1 Inclusion Criteria 
1. Age 50 and older 
2. Meet criteria for either a) amnestic mild cognitive impairment (single or mixed domain) 
or Alzheimer’s disease, or b) have no cognitive impairment, based on history, exam, and 
neuropsychological testing.  
3. Subjects unable to provide informed consent must have a surrogate decision maker 
4. Written and oral fluency in English  
5. Able to participate in all scheduled evaluations and to complete all required tests and 
procedures. 
6. In the opinion of the investigator, the subject must be considered likely to comply with 
the study protocol and to have a high probability of completing the study. 
 
4.2 Exclusion Criteria 
1. Past or present history of certain brain disorders other than MCI or AD.   
2. Certain significant medical conditions, which make study procedures of the current study 
unsafe. Such serious medical conditions include uncontrolled epilepsy and multiple 
serious injuries.  
3. Contraindication to MRI scanning 
4. Conditions precluding entry into the scanners (e.g. morbid obesity, claustrophobia, etc.). 
5. Exposure to research related radiation in the past year that, when combined with this 
study, would place subjects above the allowable limits. 
6. Participation in the last year in a clinical trial for a disease modifying drug for AD. 
7. Inability to have a catheter in subject’s vein for the injection of radioligand.  
8. Inability to have blood drawn from subject’s veins.  
9. Taking anticoagulant medication (e.g., warfarin). 
  
 
4.3 Subject Recruitment and Screening 
 
Men and women age 50 and older will be recruited from the Columbia Doctors Aging and 
Dementia clinic, the CUMC Alzheimer's Disease Research Center (ADRC), Dr. Davangere 
Devanand’s Questionable Dementia 2 (QD2) cohort, and the CUMC Washington Heights-
Inwood Community Aging Project (known locally as WHICAP, R01 AG037212, PI Richard 
Mayeux). Participants may also co-enroll from the cognitive aging studies of Dr. Adam 
Brickman (protocol AAAO9758) and Dr. Yaakov Stern (protocols AAAI2752, AAAQ8249, and 


 
 
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AAAQ8096), and from CUMC protocols AAAO1151, AAAQ7868, and AAAR4352 (PI = 
Kreisl). Participants may also self-refer as this study will be registered on clinicaltrials.gov.  
 
Informed consent will be obtained by a qualified investigator prior to study enrollment. 
Subjects will undergo screening including history, physical examination, routine laboratory 
studies, neuropsychological testing, brain MRI, and amyloid PET imaging to identify cohorts 
who are amyloid-positive with impairment (target n = 15) or amyloid-negative with normal 
cognition (n = 15). Approximately 40% of screened subjects are expected to fail screening 
procedures or withdraw from the study. We therefore plan to screen 50 subjects to ensure a total 
of 30 completers. Subjects who are co-enrolled in other CUMC studies will not need to have 
brain MRI or screening laboratories under this protocol if done within the last 12 months. Co-
enrolled subjects will not need to have 18F-florbetaben PET under this protocol if 1) they are 
controls and have had a negative 18F-florbetaben or other amyloid PET scan within the previous 
12 months, or 2) they are patients and have ever had a positive amyloid PET scan using any 
amyloid radioligand (18F-florbetaben, 18F-florbetapir, 18F-flutemetamol, or 11C-Pittsburgh 
Compound B).  
 
During screening, participants will be administered a neuropsychological test battery and a 
medical interview.  
If any of the above screening procedures have been performed within one year of the 11C-
ER176 PET scan visit, then those procedures will not need to be repeated under this protocol. 
Rather the previously obtained results will be used.  
The diagnosis of MCI or AD will be based on updated criteria[25, 26]. The 
neuropsychological test battery will include the following tests: the Mini-Mental State 
Examination, Selective Reminding Test, Benson Complex Figure Copy and Recall, MINT, 
Rosen Drawing Test, single word and sentence repetition from the NACC FTD module, 
Geriatric Depression Scale (15 items), Trail Making Tests A and B, and Verbal Fluency (CFL, 
and Animals). Raw scores and demographically corrected T-scores (age, years of education, sex, 
and ethnicity) will be determined.  
Subjects will be categorized by cognitive status, as impaired or unimpaired, based on a) 
history of cognitive impairment, b) neurological exam, c) neuropsychological testing, and d) a 
study team consensus diagnosis. 
 
 
4.4 Early Withdrawal of Subjects 
4.4.1 When and How to Withdraw Subjects 
Subjects will be withdrawn if they develop serious medical illness during the study, defined as an 
event determined to be grade 3 or higher, i.e., severe or life-threatening. The exception is a single 
event of syncope if felt by the PI to be vasovagal in etiology and related to catheter placement or 
venipuncture. Vasovagal syncope in response to blood drawing and IV placement is common 
and does not warrant study withdrawal if the subject’s loss of consciousness is brief (i.e., less 
than 5 minutes) and does not require further medical attention. 


 
 
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4.4.2 Data Collection and Follow-up for Withdrawn Subjects 
Data collected prior to withdrawal will be analyzed if possible. No data collection will take place 
after withdrawal in subjects who drop out of the study.  
5 Study Drug  
5.1 Description 
5.1.1. 11C-ER176 is a PET radioligand that binds to the 18 kDa translocator protein. 11C-ER176 
will be administered at tracer doses and is not expected to have a pharmacological effect. 
 
5.1.2. 18F-Florbeteben is a PET radioligand that binds to amyloid plaques. 18F-Florbetaben will 
be administered at tracer doses and is not expected to have a pharmacological effect. 
5.2 Treatment Regimen 
N/A 
5.3 Method for Assigning Subjects to Treatment Groups 
N/A 
5.4 Preparation and Administration of Study Drug 
11C-ER176 will be synthesized and administered by the CUMC PET Department. Injection will 
be administered at a target imaging dose of up to 20 mCi (740 MBq). 
 
18F-florbetaben will be synthesized by an off-site commercial manufacturer and delivered to the 
CUMC PET Department as a clear solution containing 18F-florbeteben (drug substance) 
formulated for intravenous bolus administration. 18F-florbetaben injection will be administered 
at a target imaging dose of up to 8.1 mCi (300 MBq).  
 
Calculation of activity to be injected will be performed by a qualified radiopharmacist in the 
CUMC PET department. 
5.5 Subject Compliance Monitoring 
N/A 
5.6 Prior and Concomitant Therapy 
Subjects will not be included in the study if they have participated in the last year in a clinical 
trial for a disease modifying drug for AD. 
 
5.7 Packaging 
N/A 
5.8 Blinding of Study Drug 
N/A 


 
 
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5.9 Receiving, Storage, Dispensing and Return 
5.9.1 Receipt of Drug Supplies 
Upon receipt of the of the study treatment supplies, the CUMC PET Center staff will 
perform an inventory and a drug receipt log will be filled out and signed by the person 
accepting the shipment.  Any damaged or unusable study drug in a given shipment (active 
drug or comparator) will be documented in the study files.  
5.9.2 Storage 
N/A 
5.9.3 Dispensing of Study Drug 
Both 11C-ER176 and 18F-florbetaben will be administered the same day of synthesis or 
delivery to the CUMC PET Department. 
5.9.4 Return or Destruction of Study Drug 
Any unused radiopharmaceutical will be on site and documented in the study files. 
6 Study Procedures 
 
This study will involve up to 5 outpatient visits. See schedule below. 
 
At the first screening visit, subjects will sign informed consent, undergo history and physical and 
neurological examination, neuropsychological testing, and have blood drawn and urine collected 
for routine safety laboratories and TSPO genotyping. Subjects who have previously had TSPO 
genotyping will not need to repeat this blood test regardless of when they were last genotyped for 
TSPO. Additional screening visits are required for brain MRI and 18F-florbetaben PET scan. 
Flexibility is allowed in screening procedures such that procedures may be performed in any 
order and may be performed on the same day if schedule allows for subject convenience. 
Subjects who already had brain MRI or safety laboratories performed under a different CUMC 
protocol do not need to have them repeated unless performed more than 12 months prior to 
inclusion in this study. Coenrolled subjects will not need to have 18F-florbetaben PET under this 
protocol if 1) they are controls and have had a negative 18F-florbetaben PET scan within the 
previous 12 months, or 2) they are patients and have ever had a positive amyloid PET scan using 
any amyloid radioligand (18F-florbetaben, 18F-florbetapir, 18F-flutemetamol, or 11C-Pittsburgh 
Compound B).  
 
 
 
Up to 3 screening visits are anticipated. However, additional visits may be necessary if certain 
tests must be scheduled on different days due to scheduling. 
 


 
 
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Screening procedures may be performed in any order and may be performed on the same day as 
the 11C-ER176 PET scan if schedule allows for subject convenience. Subjects who already had 
brain MRI or safety laboratories performed under a different CUMC protocol do not need to 
have them repeated unless performed more than 12 months prior to inclusion in this study. If any 
of the above screening procedures have been performed within one year of the 11C-ER176 PET 
scan visit, then those procedures will not need to be repeated under this protocol. Rather the 
previously obtained results will be used. The 11C-ER176 PET scan will be performed on a 
different day after screening procedures are completed. For the 4 subjects having test-retest 
imaging, two 11C-ER176 PET scans will be performed. These may be performed on the same 
day or on separate days. 
 
Subjects will have a total of 70 mL of venous blood drawn at time of screening to be used for 
screening laboratories, TSPO genotyping, and other research tests. Blood samples will be stored 
prior to research use in a secure freezer. Stored samples will be labeled with subject ID number 
and no personal identifying information will be included on the stored sample label. Results will 
not be released to participants. 


 
 
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Study Schedule 
Study Procedures 
Screen a 
Study b 
≤12 
months 
Visit 1 
(within 
12 
months 
of first 
screening 
visit) 
Visit 2 
(within 
12 
months 
of first 
screening 
visit) 
Informed consent 
X 
  
  
Medical/psychiatric history  
X 
  
  
Inclusion/exclusion criteria 
X 
Blood draw 
X 
  
  
Neuropsychological testing 
X 
  
  
MRI 
X 
  
  
18F-florbetaben PET scan 
X 
  
  
11C-ER176 PET  
  
X 
X c 
Laboratory determinations d  
X 
  
  
Neurological examination 
X 
  
  
Vital signs  
X 
  
  
Height and weight 
X 
X 
  
Adverse events e 
X 
X 
X 
a. Screening procedures may be performed in any order and may be performed on the same day 
if schedule allows for subject convenience Subjects who already had brain MRI or safety 
laboratories performed under a different CUMC protocol do not need to have them repeated 
unless performed more than 12 months prior to inclusion in this study. If any of the above 
screening procedures have been performed within one year of the 11C-ER176 PET scan visit, 
then those procedures will not need to be repeated under this protocol. Rather the previously 
obtained results will be used. Coenrolled subjects will not need to have 18F-florbetaben PET 
under this protocol if 1) they are controls and have had a negative 18F-florbetaben or other 
amyloid PET scan within the previous 12 months, or 2) they are patients and have ever had a 
positive amyloid PET scan using any amyloid radioligand (18F-florbetaben, 18F-florbetapir, 18F-
flutemetamol, or 11C-Pittsburgh Compound B). Up to 3 screening visits are anticipated. 
However, additional visits may be necessary if certain tests must be scheduled on different days 
due to scheduling. 
b. Study procedures must be completed within 12 months of MRI. Screening procedures may be 
performed on the same day as the 11C-ER176 PET scan for subject convenience if schedule 
allows. 
c. Four controls subjects will undergo 2 11C-ER176 PET scans, which may be performed on the 
same day or on different days. 
d. Laboratory determinations here include complete blood count, basic metabolic panel, liver 
functions tests, thyroid stimulating hormone, and urinalysis. 


 
 
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e. Adverse event reporting on Visit 2 to be performed after the 11C-ER176 PET scan is 
completed. Subject will be called by telephone 24 hours after both the 18F-florbetaben and 11C-
ER176 PET scans for follow up adverse event reporting. Follow up adverse event reporting for 
18F-florbetaben is not needed if the amyloid PET scan is performed under a separate protocol. 
 
7 Statistical Plan 
7.1 Sample Size Determination 
This is a Phase 2 pilot study to determine feasibility and preliminary data for a larger study. 
Therefore, the proposed sample size is not necessarily expected to provide enough statistical 
power to see significant group differences. 
7.2 Statistical Methods 
PET images will be analyzed using 1) the two-tissue kinetic model to calculate total distribution 
volume, corrected for free fraction of radioligand in plasma (VT/fP), and 2) the cerebellum as a 
pseudo-reference region to calculate standardized uptake value ratios (SUVR). Effect size will be 
calculated for different regions as the difference in means (AD vs. controls) divided by the 
standard deviation.  
 
We will also calculate test-retest reproducibility for 11C-ER176 using data from the 4 controls 
who have two 11C-ER176 scans. 
 
7.3 Subject Population(s) for Analysis 
Subjects will be elders age 50 and older with normal cognition, mild cognitive impairment, or 
AD. 
8 Safety and Adverse Events 
8.1 Definitions 
Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or 
worsens in severity during the course of the study.  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 
Adverse events are classified as serious or non-serious.  A serious adverse event is any AE 
that is:  


 
 
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• fatal 
• life-threatening 
• requires or prolongs hospital stay 
• results in persistent or significant disability or incapacity 
• a congenital anomaly or birth defect 
• an important medical event 
 
Important medical events are those that may not be immediately life threatening, but are 
clearly of major clinical significance.   They may jeopardize the subject, and may require 
intervention to prevent one of the other serious outcomes noted above.  For example, drug 
overdose or abuse, a seizure that did not result in in-patient hospitalization, or intensive 
treatment of bronchospasm in an emergency department would typically be considered 
serious.  
 
All adverse events that do not meet any of the criteria for serious should be regarded as 
non-serious adverse events.  
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 drug follow-up is defined as 24 hours following the last 
administration of study drug. Follow up adverse event reporting for 18F-florbetaben is not 
needed if this scan is performed under a separate protocol. 
Preexisting Condition 
A preexisting condition is one that is present at the start of the study.  A preexisting 
condition will be recorded as an adverse event if the frequency, intensity, or the character 
of the condition worsens during the study period. 
General Physical Examination Findings 
At screening, any clinically significant abnormality will 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 will also be recorded and documented as an 
adverse event.  
Post-study Adverse Event 
All unresolved adverse events will be followed by the investigator until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained.  At 
the last scheduled visit, the investigator will instruct each subject to report any subsequent 
event(s) that the subject, or the subject’s personal physician, believes might reasonably be 
related to participation in this study.  The investigator will notify IRB and FDA of any 
death or adverse event occurring at any time after a subject has discontinued or terminated 
study participation that may reasonably be related to this study.   
Abnormal Laboratory Values 
A clinical laboratory abnormality will 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 


 
 
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• The abnormality suggests a disease and/or organ toxicity 
• The abnormality is of a degree that requires active management; e.g. change of 
dose, discontinuation of the drug, more frequent follow-up assessments, further 
diagnostic investigation, etc. 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization will be 
documented and reported as a serious adverse event unless specifically instructed otherwise 
in this protocol.  Any condition responsible for surgery should be documented as an 
adverse event if the condition meets the criteria for and adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported 
as an adverse event in the following circumstances: 
• Hospitalization or prolonged hospitalization for diagnostic or elective surgical 
procedures for a preexisting condition.  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. 
8.2 Recording of Adverse Events 
At each contact with the subject, the investigator will seek information on adverse events (AEs) 
by specific questioning and, as appropriate, by examination.  Information on all adverse events 
will be recorded immediately in the source document.  All clearly related signs, symptoms, and 
abnormal diagnostic procedures results will be recorded in the source document. 
 
All adverse events occurring during the study period will be recorded.  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.  Serious adverse events that are still ongoing at 
the end of the study period will be followed up to determine the final outcome.  Any serious 
adverse event 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 immediately. 
 
As per CUMC IRB’s Policy, Unanticipated Problems will be defined as follows: 
 
Unanticipated Problem (UP) is any incident, experience or outcome involving risk to subjects or 
others in any human subjects research that meets all of the following criteria: 
 
• Unexpected (in terms of nature, severity or frequency) given (a) the research procedures that 
are described in the IRB-approval protocol and informed consent document and (b) the 
characteristics of the subject population being studied; 


 
 
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• Related or possibly related to participation in such research (i.e., there is a reasonable 
possibility that the incident, experience or outcome may have been caused by the procedures 
involved in such research); and 
• Suggests that the research places subjects or others at a greater risk of harm (including physical, 
psychological, economic or social harm) than was previously known or recognized (HHS IRB 
Guidance, Section I). 
 
The following AEs will be considered Unexpected Problems: 
 
• A single occurrence of a serious, unexpected event that is uncommon and strongly associated 
with drug exposure 
• A single occurrence, or a small number of occurrences, of a serious, unexpected event that is 
not commonly associated with drug exposure 
• Multiple occurrences of an AE that, based on an aggregate analysis, are determined not to be 
isolated occurrences and involve risk to human subjects 
• An AE that is described or addressed in the investigator's brochure, protocol or informed 
consent documents (a Described AE), but occurs at a specificity or severity that is inconsistent 
with prior observations 
• A serious Described AE, but for which the rate of occurrence represents a clinically significant 
increase in the expected rate of occurrence 
• Any other AE or safety finding that would cause the sponsor to modify the investigator's 
brochure, study protocol or informed consent documents or would prompt other action by the 
IRB to ensure the protection of human subjects (2009 FDA Guidance, Section III (A)). 
8.3 Reporting of Serious Adverse Events 
8.3.1 IRB Notification by Investigator 
At the time of the Occurrence of an Unanticipated Problem: 
 
Each UP will be reported to the IRB, whether or not (a) it is serious or non-serious or (b) 
it occurs at a site at which the PI is conducting the research. 
 
The UP will be reported promptly, but not later than one week following the occurrence 
of the UP or the PI's acquiring knowledge of the UP. 
 
The PI will make the determination as to whether an incident, experience or outcome 
constitutes a UP. 
 
Each Unanticipated Problem will be reported to the IRB using the Unanticipated Problem 
Report module in Rascal. 
 
The investigator must conclude in the Unanticipated Problem Report whether the 
protocol and/or consent form(s) should be modified as the result of the UP.  If the 
protocol and/or consent document(s) requires a revision, a modification must be 
submitted in Rascal. 
 


 
 
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At the Time of Continuing Review of a Protocol: 
 
At the time of continuing review of a protocol, the PI will submit a summary of all UPs 
that occurred during the review period and since the beginning of the study.  The 
summary for each UP should include: 
 
• The number of subjects who experienced the UP; 
• The investigator's determination as to whether or not the UP was serious; 
• The investigator's determination as to the UP's relationship to the study procedures (e.g., 
definitely related, probably related or possibly related). 
8.3.2 FDA Notification by Investigator 
The principal investigator shall notify the FDA by telephone or by facsimile transmission 
of any unexpected fatal or life-threatening experience associated with the use of the drug 
as soon as possible but no later than 7 calendar days from the investigator’s original 
receipt of the information. 
 
If a previous adverse event that was not initially deemed reportable is later found to fit 
the criteria for reporting, the principal investigator will submit the adverse event in a 
written report to the FDA as soon as possible, but no later than 15 calendar days from the 
time the determination is made. 
8.4 Unblinding Procedures 
N/A 
8.5 Stopping Rules  
N/A 
8.6 Medical Monitoring 
We will not have a specific Data and Safety Monitoring Board. Adverse events will be 
documented in the patient’s chart. Notification of UPs to the IRB and FDA will take place as 
described in Section 8.3. We will also report all adverse events to Piramal Imaging who is 
monitoring safety data for 18F-florbetaben. 
 
9 Data Handling and Record Keeping 
9.1 Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act (HIPAA).  Those 
regulations require a signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 


 
 
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• The rights of a research subject to revoke their authorization for use of their PHI.  
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization.  For subjects that have revoked authorization to collect or use PHI, attempts 
should be made to obtain permission to collect at least vital status (i.e. that the subject is alive) at 
the end of their scheduled study period. 
9.2 Source Documents 
Source data is all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial.  Source 
data are contained in source documents   Examples of these original documents, and data records 
include: hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ 
diaries or evaluation checklists, pharmacy dispensing records, recorded data from automated 
instruments, copies or transcriptions certified after verification as being accurate and complete, 
microfiches, photographic negatives, microfilm or magnetic media, x-rays, subject files, and 
records kept at the pharmacy, at the laboratories, and at medico-technical departments involved 
in the clinical trial. 
9.3 Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the study.  All 
data requested on the CRF must be recorded.  All missing data must be explained.  If a space on 
the CRF is left blank because the procedure was not done or the question was not asked, write 
“N/D”.  If the item is not applicable to the individual case, write “N/A”.  All entries should be 
printed legibly in black ink.  If any entry error has been made, to correct such an error, draw a 
single straight line through the incorrect entry and enter the correct data above it.  All such 
changes must be initialed and dated.  DO NOT ERASE OR WHITE OUT ERRORS.  For 
clarification of illegible or uncertain entries, print the clarification above the item, then initial and 
date it. 
 
10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
This study will be monitored by the Principal Investigator. Dr. Kreisl will submit annual progress 
reports to the FDA within 60 days of the anniversary of the date that the IND became active (the 
date clinical studies were permitted to begin) in accordance with 21 CFR 312.33. 
11 Ethical Considerations 
This study is to be conducted according to US and international standards of Good Clinical 
Practice (FDA Title 21 part 312 and International Conference on Harmonization guidelines), 
applicable government regulations and Institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted independent 
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 


 
 
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be made in writing to the investigator and a copy of this decision will be provided to the sponsor 
before commencement of this study.  The investigator should provide a list of EC/IRB members 
and their affiliate to the sponsor. 
 
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.  See attached copy of the Subject Informed Consent Form.  This consent form will be 
submitted with the protocol for review and approval by the IRB for the study.  The formal 
consent of a subject, using the IRB-approved consent form, must be obtained before that subject 
is submitted to any study procedure.  This consent form must be signed by the subject or legally 
acceptable surrogate, and the investigator-designated research professional obtaining the consent.  
 
12 Study Finances 
12.1 Funding Source 
This study is funded by a Rose and Boris Katz Assistant Professorship endowed to Dr. Kreisl. 
Additional funding is being sought through application to the Alzheimer’s Drug Discovery 
Foundation (PI = Dr. Kreisl).  
12.2 Conflict of Interest 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, or 
financial gain greater than the minimum allowable by their institution, etc.) must have the 
conflict reviewed by a properly constituted Conflict of Interest Committee with a Committee-
sanctioned conflict management plan that has been reviewed and approved by the study sponsor 
prior to participation in this study.  All Columbia University Medical Center investigators will 
follow the University conflict of interest policy. 
12.3 Subject Stipends or Payments 
Subjects will be compensated commensurate to similar studies at CUMC. We wish to reduce the 
burden of travel and inconvenience of study procedures on patients and caregivers. Subjects will 
be given $100 for the screening visit, $100 for the MRI, and $100 for each PET scan. 
13 Publication Plan 
Neither the complete nor any part of the results of the study carried out under this protocol, nor 
any of the information provided by the sponsor for the purposes of performing the study, will be 
published or passed on to any third party without the consent of the study sponsor.  Any 
investigator involved with this study is obligated to provide the sponsor with complete test 
results and all data derived from the study. 
14 References 
 
1. 
McGeer, P.L. and E.G. McGeer, The amyloid cascade-inflammatory hypothesis of 
Alzheimer disease: implications for therapy. Acta Neuropathol, 2013. 126(4): p. 479-97. 


 
 
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2. 
Maezawa, I., et al., Amyloid-beta protein oligomer at low nanomolar concentrations 
activates microglia and induces microglial neurotoxicity. J Biol Chem, 2011. 286(5): p. 
3693-706. 
3. 
Serrano-Pozo, A., et al., Reactive glia not only associates with plaques but also parallels 
tangles in Alzheimer's disease. Am J Pathol, 2011. 179(3): p. 1373-84. 
4. 
Neniskyte, U., J.J. Neher, and G.C. Brown, Neuronal death induced by nanomolar 
amyloid beta is mediated by primary phagocytosis of neurons by microglia. J Biol Chem, 
2011. 286(46): p. 39904-13. 
5. 
Ghosh, S., et al., Sustained interleukin-1beta overexpression exacerbates tau pathology 
despite reduced amyloid burden in an Alzheimer's mouse model. J Neurosci, 2013. 
33(11): p. 5053-64. 
6. 
Morales, I., et al., Tau oligomers and fibrils induce activation of microglial cells. J 
Alzheimers Dis, 2013. 37(4): p. 849-56. 
7. 
Braak, H., et al., Stages of the pathologic process in Alzheimer disease: age categories 
from 1 to 100 years. J Neuropathol Exp Neurol, 2011. 70(11): p. 960-9. 
8. 
Ossenkoppele, R., et al., Long-term effects of amyloid, hypometabolism, and atrophy on 
neuropsychological functions. Neurology, 2014. 82(20): p. 1768-75. 
9. 
Stephenson, D.T., et al., Peripheral benzodiazepine receptors are colocalized with 
activated microglia following transient global forebrain ischemia in the rat. J Neurosci, 
1995. 15(7 Pt 2): p. 5263-74. 
10. 
Cagnin, A., et al., In-vivo measurement of activated microglia in dementia. Lancet, 2001. 
358(9280): p. 461-7. 
11. 
Edison, P., et al., Microglia, amyloid, and cognition in Alzheimer's disease: An 
[11C](R)PK11195-PET and [11C]PIB-PET study. Neurobiol Dis, 2008. 32(3): p. 412-9. 
12. 
Wiley, C.A., et al., Carbon 11-labeled Pittsburgh Compound B and carbon 11-labeled 
(R)-PK11195 positron emission tomographic imaging in Alzheimer disease. Arch Neurol, 
2009. 66(1): p. 60-7. 
13. 
Schuitemaker, A., et al., Microglial activation in Alzheimer's disease: an (R)-
[(1)(1)C]PK11195 positron emission tomography study. Neurobiol Aging, 2013. 34(1): 
p. 128-36. 
14. 
Okello, A., et al., Microglial activation and amyloid deposition in mild cognitive 
impairment: a PET study. Neurology, 2009. 72(1): p. 56-62. 
15. 
Imaizumi, M., et al., Brain and whole-body imaging in nonhuman primates of 
[11C]PBR28, a promising PET radioligand for peripheral benzodiazepine receptors. 
Neuroimage, 2008. 39(3): p. 1289-98. 
16. 
Kreisl, W.C., et al., Stroke incidentally identified using improved positron emission 
tomography for microglial activation. Arch Neurol, 2009. 66(10): p. 1288-9. 
17. 
Owen, D.R., et al., An 18-kDa translocator protein (TSPO) polymorphism explains 
differences in binding affinity of the PET radioligand PBR28. J Cereb Blood Flow Metab, 
2012. 32(1): p. 1-5. 
18. 
Kreisl, W.C., et al., A genetic polymorphism for translocator protein 18 kDa affects both 
in vitro and in vivo radioligand binding in human brain to this putative biomarker of 
neuroinflammation. J Cereb Blood Flow Metab, 2013. 33(1): p. 53-8. 
19. 
Zanotti-Fregonara, P., et al., Synthesis and evaluation of translocator 18 kDa protein 
(TSPO) positron emission tomography (PET) radioligands with low binding sensitivity to 


 
 
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human single nucleotide polymorphism rs6971. ACS Chem Neurosci, 2014. 5(10): p. 
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