Clinical trial NCT02850276
Conditions: HIV Disease
Keywords: HIV disease gastrointestinal problems
Sponsor: Icahn School of Medicine at Mount Sinai
Start date: 2015-11-01; Completion date: 2018-06-01
Enrollment: 76 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this study is to explore a possible link between the autonomic nervous system and immune function in patients with HIV. Sometimes HIV can cause these nerves to function abnormally, this is called HIV-associated autonomic neuropathy (HIV-AN). HIV-AN is a condition that is different from person to person. In some people it causes no symptoms and is not harmful, in others it may cause symptoms such as dizziness or lightheadedness, nausea, vomiting, diarrhea, constipation, or problems urinating. Most people with HIV-AN don't know that they have it. One of the important nerves in the autonomic nervous system is the vagus nerve. Abnormal function of the vagus nerve may cause stomach and intestinal slowing, which could lead to an overgrowth of bacteria. The body senses these bacteria and tries to fight them, leading to inflammation.

In this study the researchers will test whether abnormal function of the vagus nerve in HIV is associated with stomach slowing and overgrowth of bacteria, and if a drug called pyridostigmine can help.

Detailed description:
HIV-infected patients commonly develop autonomic neuropathy (HIV-AN), which is a heterogeneous disorder characterized by varying degrees of both sympathetic and vagal dysfunction. We hypothesize that the vagal component of HIV-AN contributes to chronic inflammation, both directly via loss of cholinergic activity, and indirectly via effects on the GI tract, and that these effects will be treatable using the acetylcholinesterase inhibitor pyridostigmine. The autonomic nervous system controls the inflammatory response to lipopolysaccharide (LPS) via the cholinergic anti-inflammatory pathway. This pathway is mediated by the vagus nerve, and is therefore likely impaired in HIV-AN with vagal dysfunction. Vagal dysfunction also causes slowed GI transit, which could exacerbate LPS-driven inflammation by promoting bacterial overgrowth. However, the anti-inflammatory impact of cholinergic pathways is almost completely unstudied in HIV, despite the known importance of inflammation in HIV disease progression. Therefore, in this exploratory pilot, we seek to establish associations between vagal dysfunction, GI motility and inflammation in virally suppressed, CART-treated individuals with HIV-AN.

Specific Aim 1: To determine whether vagal dysfunction is associated with immune activation in CART-treated participants with HIV-AN, and if so to estimate the extent to which this association is mediated by GI effects (i.e. slowed motility, bacterial overgrowth, microbial translocation) versus direct effects of vagal dysfunction.

Specific Aim 2: In a subset of participants who have both vagal and GI dysfunction, to investigate whether 8 weeks of pyridostigmine: a) reduces immune activation, and b) improves GI motility; and if the immune effect depends on the GI effect.

To achieve these aims, participants with HIV-AN and GI symptoms will be assessed for: vagal dysfunction (heart rate variability); GI dysmotility (gastric emptying scintigraphy); small intestinal bacterial overgrowth (breath testing); microbial translocation (LPS and sCD14); and immune activation (IL-6 and CRP). Participants meeting threshold criteria for both vagal and GI dysfunction will then be treated with pyridostigmine for 8 weeks, after which GI and immune measures will be reassessed.

Objectives Specific Aim 1: To determine whether vagal dysfunction is associated with immune activation in HIV-infected participants treated with combination antiretroviral therapy (CART), and if so to estimate the extent to which this association is mediated by GI effects (i.e. slowed motility, bacterial overgrowth, microbial translocation) versus direct effects of vagal dysfunction.

Specific Aim 2: In a subset of participants who have both vagal and GI dysfunction, to investigate whether 8 weeks of pyridostigmine: a) reduces immune activation, and b) improves GI motility; and if both effects are present to determine whether the immune effect depends on the GI effect.

Arms: arm 1: 30mg PO three times a day
Interventions: intervention 1: Pyridostigmine
Intervention descriptions: intervention 1: None

Protocol documents:
Prot_SAP_000.pdf: 
Autonomic neuropathy, gastrointestinal motility, and inflammation in HIV
PI: Jessica Robinson-Papp
NCT02850276
Document Date: July 1, 2016 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
1 
Revised 9/2/14 
Brief Summary of Research:  
HIV-infected patients commonly develop autonomic neuropathy (HIV-AN), which is a 
heterogeneous disorder characterized by varying degrees of both sympathetic and vagal 
dysfunction.  We hypothesize that the vagal component of HIV-AN contributes to chronic 
inflammation, both directly via loss of cholinergic activity, and indirectly via effects on the GI 
tract, and that these effects will be treatable using the acetylcholinesterase inhibitor 
pyridostigmine.  The autonomic nervous system controls the inflammatory response to 
lipopolysaccharide (LPS) via the cholinergic anti-inflammatory pathway.  This pathway is 
mediated by the vagus nerve, and is therefore likely impaired in HIV-AN with vagal dysfunction.  
Vagal dysfunction also causes slowed GI transit, which could exacerbate LPS-driven 
inflammation by promoting bacterial overgrowth.  However, the anti-inflammatory impact of 
cholinergic pathways is almost completely unstudied in HIV, despite the known importance of 
inflammation in HIV disease progression. Therefore, in this exploratory pilot, we seek to establish 
associations between vagal dysfunction, GI motility and inflammation in virally suppressed, 
CART-treated individuals with HIV-AN.  
Specific Aim 1: To determine whether vagal dysfunction is associated with immune activation in 
CART-treated participants with HIV-AN, and if so to estimate the extent to which this association 
is mediated by GI effects (i.e. slowed motility, bacterial overgrowth, microbial translocation) 
versus direct effects of vagal dysfunction.  
Specific Aim 2: In a subset of participants who have both vagal and GI dysfunction, to investigate 
whether 8 weeks of pyridostigmine: a) reduces immune activation, and b) improves GI motility; 
and if the immune effect depends on the GI effect.  
To achieve these aims, participants with HIV-AN and GI symptoms will be assessed for: vagal 
dysfunction (heart rate variability); GI dysmotility (gastric emptying scintigraphy); small intestinal 
bacterial overgrowth (breath testing); microbial translocation (LPS and sCD14); and immune 
activation (IL-6 and CRP).  Participants meeting threshold criteria for both vagal and GI 
dysfunction will then be treated with pyridostigmine for 8 weeks, after which GI and immune 
measures will be reassessed.   
1) Objectives 
Specific Aim 1: To determine whether vagal dysfunction is associated with immune activation in 
HIV-infected participants treated with combination antiretroviral therapy (CART), and if so to 
estimate the extent to which this association is mediated by GI effects (i.e. slowed motility, 
bacterial overgrowth, microbial translocation) versus direct effects of vagal dysfunction.  
Specific Aim 2: In a subset of participants who have both vagal and GI dysfunction, to investigate 
whether 8 weeks of pyridostigmine: a) reduces immune activation, and b) improves GI motility; 
and if both effects are present to determine whether the immune effect depends on the GI effect.  
 


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Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
3 
Revised 9/2/14 
sweating, and nausea.  The only symptom that was significantly associated with HIV-AN was 
constipation (p<.001), suggesting possible slowed GI transit time. 
 
The end-organ effects of HIV-AN are currently unknown, although in the broader field of autonomic 
dysfunction, GI dysmotility is a well-recognized effect,11-14 which is characterized clinically by symptoms 
of nausea, vomiting or bloating especially after meals, and constipation and/or diarrhea.15,16  In addition to 
these bothersome symptoms, GI dysmotility can promote bacterial overgrowth,17-22 and increased 
translocation across the gut wall.23-25  There is a single anatomical study demonstrating loss of autonomic 
fibers in jejunal biopsies from individuals with HIV,26 and a few studies suggesting GI dysmotility in 
HIV,27-30 however these studies were all pre-CART.  Only one study attempted to correlate gastric 
motility with HIV-AN, however autonomic function was characterized solely by spectral analysis of heart 
rate variability which is not considered to be the diagnostic gold standard.30  
 
Autonomic neuropathy, cholinergic anti-inflammatory pathways, and pyridostigmine.  Outside of the 
realm of HIV research, autonomic effects on inflammation, particularly in response to lipopolysaccharide 
(LPS), have been extensively studied and dubbed the “cholinergic anti-inflammatory reflex.”31  Both the 
afferent and efferent limbs are contained within the vagus nerve.  In rodent models, the afferent limb is 
demonstrated by intra-abdominal administration of IL-1 to vagotomized animals, which fails to produce 
the normal fever and sickness behavior.32  The efferent limb is demonstrated in models of sepsis, where 
vagal nerve stimulation attenuates LPS-induced hypotension, and vagotomy has the opposite effect.33  In 
humans, it has been observed that trauma patients undergoing vagotomy experience greater rates of 
sepsis, ulcers, and mortality when compared to those without vagotomy.34  Additionally, in septic 
humans, decreased heart rate variability, a marker of vagal dysfunction, is correlated with inflammatory 
markers (e.g. IL-6, CRP) and poor outcomes including progression to shock and death.35,36  
The vagus nerve regulates inflammation via release of ACh, which can bind the nicotinic ACh receptor 
subunit α7 (α7nAChR) present on monocytes, macrophages, B cells, T cells and dendritic cells.  In the GI 
tract, vagal action on macrophages and dendritic cells is thought to be mediated through stimulation of the 
myenteric plexuses, and subsequent release of ACh to immune effectors in the muscularis.37,38  In the 
spleen, vagal stimulation of the celiac ganglion may result in adrenergic stimulation of T cells, a subset of 
which release ACh to stimulate macrophages.31  In both gut wall and circulating monocytes/macrophages, 
the effect of α7nAChR activation is to induce intracellular signaling which suppresses the transcription of 
pro-inflammatory cytokines and mediators, dependent upon upregulation of heme oxygenase 1 (HO-1).39  
In dendritic cells and monocytes/macrophages, activation of α7nAChR also inhibits secretion of high 
mobility group box 1 (HMGB1), an alarmin essential to the innate immune reponse.40  While most 
observations of cholinergic effects have been in murine models, there is experimental evidence that 
similar effects may be seen in man (in addition to the clinical observations described above).  In primary 
human macrophages, ACh inhibits the LPS-stimulated release of TNF-α, IL-1β, IL-6, and IL-18, but has 
no effect on IL-10.33,41  In human monocytes, stimulation of α7nAChR suppresses LPS-associated 
expression of CD14, TLR4, CD40, ICAM-1, and B7.1.42 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
4 
Revised 9/2/14 
In our study (described in the sub-section immediately above), we found that the severity of HIV-AN was 
correlated with the Veteran’s Aging Cohort Study (VACS) index, which itself has been shown to be 
correlated with inflammation.5  This suggests that HIV-AN could also be associated with inflammation.  
To our knowledge, a potential role for cholinergic anti-inflammatory effects in HIV has been tested 
directly by only one small proof-of–concept study examining 19 HIV-infected patients, who were not 
CART-treated.43  Participants were randomized to receive a low dose of the acetylcholinesterase inhibitor 
(AChEI) pyridostigmine (30mg PO tid) or placebo.  Participants who received pyridostigmine exhibited a 
reduction of CD4+ T cell activation (defined as the percent of cells expressing CD69), as well as in vitro 
reduction of T cell proliferation, decrease of IFN-γ production, and increase of IL-10 production.  
Autonomic indices were not measured in this study.  Pyridostigmine is a peripherally acting AChEI that 
has been FDA approved for the treatment of myasthenia gravis since 1955.  It is generally well tolerated, 
with a well-known side effect profile that is largely dose dependent.  Although it is an old drug that is 
very familiar to neurologists, there has been considerable recent investigation surrounding its use.  In 
addition to the single study in HIV described above, pyridostigmine has been studied for autonomic 
symptoms including orthostatic hypotension and constipation.44-46    
Summary.  There is substantial evidence that chronic inflammation is important in HIV, and that vagal 
dysfunction may contribute to inflammation directly via loss of cholinergic activity or indirectly via 
effects on GI motility.  We have demonstrated that HIV-AN is common in CART-treated individuals and 
commonly involves vagal dysfunction.  However other than a single study of 19 participants,43 there has 
been no attempt to study the intersection of these important and interrelated conditions, in order to 
determine whether vagal dysfunction contributes to the pro-inflammatory state seen with chronic HIV.   
 
3) Setting of the Human Research 
All research procedures will be conducted at Mount Sinai.  All potential participants will be 
identified and recruited at Mount Sinai.  There will be no active recruitment outside of Mount 
Sinai, however if patients or providers at other sites become aware of the study we may accept 
referrals.  All study procedures will be conducted on the main campus of Mount Sinai, 1468 
Madison Avenue, Annenberg building, Second Floor with the exception of the gastric emptying 
scintigraphy and the hydrogen breath testing.  Gastric emptying scintigraphy is performed in the 
main campus of Mount Sinai, 1468 Madison Avenue, Guggenheim Building, MC level.  
Hydrogen breath testing is performed in the main campus of Mount Sinai, either at 1468 Madison 
Avenue, Annenberg building, Second Floor; or at 17 East 102nd Street 5th Floor (depending on 
appointment availability).  
4) Resources Available to Conduct the Human Research 
As described below, the study has two phases.  Participants in phase 2 will be a subset of 
participants in phase 1.  Our goal is to recruit 80-100 participants for phase 1, and from this group 
to have 35-45 participants eligible for phase 2.  This is based on the estimate that 45% of phase 1 
participants will be eligible for phase 2.   


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
5 
Revised 9/2/14 
As described in greater detail in the “Recruitment Methods” section, we plan to recruit patients 
already known to us from previous and ongoing research studies and/or clinical care, and patients 
not previously known to us from the Jack Martin Fund Clinic (JMFC).  Eligibility rests in part on 
the results of autonomic testing.  We are currently aware of about 30 eligible patients meeting 
eligibility criteria including the appropriate autonomic testing results.  Based on our prior studies 
in this population, we estimate that about 15% of JMFC patients will meet study criteria, and that 
this will be somewhat higher (~20%) in our research population since these patients are pre-
selected for criteria (such as older age) that makes AN more likely.  There are currently about 
1500 patients in active care at JMFC, and about 200 participants actively participating in our 
longitudinal neuroAIDS studies.  Thus we estimate that we have access to an eligible population 
of about 265, from which we will need to recruit 50-70.   
Eight persons will be involved with the study: Jessica Robinson-Papp MD MS who is the PI and 
will oversee the study as a whole and interpret and oversee the autonomic testing; Susan Morgello, 
MD who will oversee all the non-routine laboratory testing (e.g. cytokines); Gina Sam, MD who 
will oversee the hydrogen breath testing; Josef Machac MD who will oversee the gastric emptying 
scintigraphy; Emma Benn PhD who will assist Dr. Robinson-Papp with the statistical analyses; 
research manager Mary-Catherine George; research coordinator Alexandra Nmashie MD; and 
Sandeep Sharma, Dr.PH.  The last three staff members will oversee the coordination of the 
project.   
Dr. Morgello is the PI of the Manhattan HIV Brain Bank (MHBB), and is Dr. Robinson-Papp’s 
research mentor.  She has extensive experience in neuroAIDS research over decades and will use 
the infrastructure of the MHBB to help Dr. Robinson-Papp with the laboratory aspects of this 
project.  Dr. Sam is a gastroenterologist with additional sub-specialty training in 
neurogastroenterology and GI motility.  She has extensive clinical experience diagnosing and 
treating GI dysmotility.  Dr. Machac is board certified in internal medicine, nuclear medicine, and 
cardiology, and has been an integral part of the nuclear medicine department at Mount Sinai for 
over 20 years, during which time he has served as director of the Clinical PET and Nuclear 
Medicine Center at Mount Sinai.  He has published in the area of neuroAIDS, and has 
collaborated on previous studies of dysautonomia.  Dr. Benn is a professor of biostatistics at 
Mount Sinai.  She has experience analyzing clinical research data, as well as teaching medical and 
graduate students to do so.  Ms. George is a senior research coordinator and program manager 
with extensive experience in neuroAIDS research spanning nearly two decades.  She has provided 
organizational oversight and guidance for all Dr. Robinson-Papp’s prior studies.  Dr. Nmashie has 
worked with Dr. Robinson-Papp as a research coordinator on multiple prior studies, including a 
recent study which examined autonomic function in HIV.   
In order to ensure that all persons involved with the study are adequately trained, Dr. Robinson-
Papp will review the protocol in detail with all study staff prior to beginning any study procedures, 
and as needed throughout the study.  Questions and an open dialog among the study staff will be 
encouraged.   
5) Study Design 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
6 
Revised 9/2/14 
a) Recruitment Methods 
Participants will be drawn from three main sources: the Jack Martin Fund Clinic (JMFC), 
where Dr. Robinson-Papp is the attending neurologist, other research studies in which Dr. 
Robinson-Papp is an investigator, and the FPA Neurodiagnostic Center, which is the other 
location (in addition to JMFC) where Dr. Robinson-Papp’s sees patients.  We will also 
consider patients referred by health care providers or other patients, but do not have an active 
recruitment plan for these sources.   
JMFC patients will be initially pre-screened using a Mount Sinai Data Warehouse (MSDW) 
Search.  We will create a de-identified dataset from the MSDW that includes all JMFC patients 
with at least1 visit in calendar year 2015, who are being treated with CART (N≈700).  The 
dataset will include the following information relevant to pre-screening for this study: HIV-1 
viral load, urine toxicology screening, smoking status, diagnosis of diabetes, diagnosis of 
COPD or asthma, diagnosis of peptic ulcer disease, diagnosis of PN, treatment with opiate 
medication.   
Using this dataset, we will identify a subset of potentially eligible patients, and will request the 
patients’ names and medical record numbers, and the name of the last prescriber of the CART, 
who is very likely to be the primary care provider.  A waiver of informed consent will be 
requested for this portion of the study.  This information will be requested without linkage of 
this new identifying information to the pre-existing de-identified dataset, so as to minimize the 
amount of PHI obtained.  It is likely that some of these patients will be patients of Dr. 
Robinson-Papp, and those patients will be contacted directly.  For patients who are not patients 
of Dr. Robinson-Papp, we will initially contact the provider, and ask whether in their opinion 
the patient would qualify for the research, and might be interested in participating.  If the 
provider thinks the patient would qualify, might be interested, and would not find contact 
intrusive, the patient will be contacted through the provider (typically physician or nurse 
practitioner or member of the clinic staff).  Initial contact will be the minimum required to 
ascertain whether the patient is willing to hear about the study.  More detailed information will 
be provided only if the patient assents.  With the patient’s permission, this will include mailing 
a copy of the informed consent to the patient in advance of the screening visit so that they have 
time to review it, discuss it with others and prepare questions for the study team.  The research 
team will not review the subject’s charts for HIV information prior to obtaining informed 
consent. 
Patients who are known to Dr. Robinson-Papp (either clinically or through research) who she 
believes to be eligible and open to participation in research will be contacted directly.  Patients 
who are referred to the study will also be contacted directly. 
There is also a previously IRB approved printed recruitment flyer which is included with this    
submission. 
b) Inclusion and Exclusion Criteria 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
7 
Revised 9/2/14 
Inclusion criteria are: 
 ≥18 years old 
 Documented evidence of HIV-1 infection 
 Stable CART therapy for ≥3 months  
 Most recent HIV-1 viral load ≤100 copies/ml (value must be within the past six 
months) 
 English speaking 
 Able to tolerate autonomic testing (e.g. able to stand, able to perform Valsalva 
maneuver).   
 If using nicotine-containing products willing to refrain from use for 24 hours prior to all 
testing procedures (autonomic reflex screen, breath testing, and gastric emptying) 
 ≥1 GI symptom on the Survey of Autonomic Symptoms  (SAS)47 
Exclusion criteria are: 
 Diagnosis known to cause autonomic dysfunction other than HIV (e.g. Parkinson’s 
disease, diabetes) 
 Diagnosis known to cause GI dysfunction other than HIV (e.g. peptic ulcer disease, 
infectious diarrhea) 
 Current use of any of the following classes of medications (due to potential for significant 
autonomic or GI effects, interaction with pyridostigmine, or interference with one or more 
of the testing procedures) 
o Prokinetics (e.g. metoclopramide) 
o Anti-diarrheals (e.g. loperamide) 
o Antibiotics 
o Mefloquine 
 Medical or psychiatric conditions precluding safe participation in study procedures or 
deemed likely to result in hospitalization during the study period.  
 The presence of one or more of the following diagnoses which render the Valsalva 
maneuver relatively or absolutely contraindicated: uncontrolled glaucoma, aortic stenosis, 
myocardial infarction in the last 6 months, other retinopathy or unclipped cerebral 
aneurysm.  
 The presence of one or more of the following diagnoses which impede interpretation of 
autonomic testing: cardiac arrhythmias or pacemakers.   
 An allergy to eggs (contraindication to gastric emptying scintigraphy)  
 Any of the following laboratory results: 
o Positive pregnancy test (administered to women of childbearing potential only) 
o Urine toxicology screen positive for stimulants (e.g. amphetamines, cocaine) or 
opiates/opioids.  


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
8 
Revised 9/2/14 
Screening procedure: 
No research procedures will be performed prior to obtaining informed consent.  The 
majority of inclusion/exclusion criteria are ascertainable from the patient and the medical 
record, with the following exceptions (in order of increasing complexity): the SAS which 
is a questionnaire; pregnancy and toxicology screening which requires a urine sample; and 
the CASS which requires autonomic testing.  In order to limit participant exposure to 
unnecessary testing, the screening will be performed in a tiered manner.  The simplest 
criteria (i.e. those items obtainable from the medical record) will be assessed first, and the 
most involved (i.e. the autonomic testing) will not be performed unless all other criteria 
have been satisfied.  The screening process will end at the first evidence of ineligibility.  
c) Number of Subjects 
We intend to pre-screen about 700 JMFC patients using our automated MSDW search.  
We will also pre-screen patients known to Dr. Robinson-Papp or referred to the study.  We 
will enroll (i.e. obtain informed consent from) up to 250 participants as required to identify 
up to 100 participants eligible for full baseline assessment, and up to 45 participants to 
enter the intervention phase. 
d) Study Timelines 
The maximum expected duration of individual subject participation is 6 months for 
participants who complete both phase 1 and 2.  For patients who complete phase 1 but are 
found to be ineligible for phase 2, study participation will be much shorter, typically 1-2 
weeks.  The duration anticipated to enroll all study subjects is 18 months.  The estimated 
date for the investigators to complete this study (complete primary analyses) is 24 months. 
e) Endpoints 
The study endpoints are: vagal sub-score of mCASS (vagal dysfunction, calculated from 
autonomic testing), GE T½ (GI dysmotility, calculated from gastric emptying 
scintigraphy), CRP and IL-6 (immune activation), LPS (bacterial translocation), total 
hydrogen excretion in the breath (ppm x min) over 2 hours following ingestion of 50g 
glucose (SIBO).  Secondary measures include: vagal baroreflex sensitivity; Valsalva ratio; 
heart rate variability with deep breathing; percent gastric emptying at 1-4h; CRP; sCD14. 
Participants who are eligible for the intervention phase of the study in which they will 
receive treatment with pyridostigmine will be monitored for adverse events.  Adverse 
events, including anticipated medication side effects, may be grounds for discontinuation 
of study drug, based on the judgment of the PI and the preferences of the participant.  If the 
study drug is to be discontinued early, and it is a non-emergent discontinuation, effort will 
be made to perform follow-up measurements (see intervention visit 3 in the subsequent 
section) prior to discontinuation of the drug. 
f) Procedures Involved in the Human Research 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
9 
Revised 9/2/14 
The study design has two phases.  In the first phase (baseline) cross-sectional data will be 
collected for correlational analyses, and for determination of participant eligibility for 
phase two.  In the second phase, the subset of eligible participants will be treated with 
pyridostigmine for 8 weeks, at the end of which the measures will be repeated to assess for 
drug effect.  A summary of study visits is provided here, followed by a detailed description 
of each of the individual procedures.  All procedures are performed solely for the research, 
and not for clinical purposes. However all tests to be performed are standardized tests 
which are performed clinically.  
Screening visit: All participants will be seen for a screening visit which consists of 
informed consent and assessment of eligibility including: documentation of medical 
history and current medications; the SAS questionnaire; brief neurologic examination; 
urine pregnancy and toxicology screening; and autonomic function testing.  All 
procedures, including the informed consent process will take place on Annenberg 2 in a 
private exam room.  The informed consent process will take place prior to any research 
related activities.  Participants meeting all inclusion/exclusion criteria will then proceed to 
the baseline visit.  The screening visit will last about approximately 4 hours unless there is 
a test or questionnaire that reveals ineligibility, in which case the screening process will be 
stopped and so will be shorter in duration. 
Baseline visit: The baseline visit may occur over several days (7-10 days) and will include 
hydrogen breath test (approximately 3.5 hours), blood collection (approximately 2-3 
tablespoons), gastric emptying scintigraphy (approximately 4 hours), and questionnaires as 
listed below (approximately 30 minutes).   
Participants will then move on to additional visits if they meet ALL of the following 
criteria: 
1) CASS ≥ 3 OR at least one abnormal vagal parameter on the autonomic function testing 
(vagal baroreflex sensitivity; Valsalva ratio; heart rate variability with deep breathing). 
2) Abnormality in gastric emptying scintigraphy (retention at 30 min: <70%; 60 
min:<30%, >90%; 120 min: >60%; 180 min: >30%; 240 min: >10%). 
3) No use of pyridostigmine within the past 6 months   
4) No contraindication to pyridostigmine including current: mechanical intestinal or urinary 
obstruction, known hypersensitivity to anticholinesterase agents, bradycardia, cardiac 
arrhythmias, or asthma or chronic obstructive pulmonary disease.  
Participants with an abnormality in hydrogen breath testing suggestive of small intestinal 
bacterial overgrowth (SIBO), will be informed of this finding (which may warrant 
treatment).  Permission will also be sought from the participant to convey this information 
to their primary care provider (PCP).  The participant will not have any further study visits 
until a course of treatment has been decided upon.   


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
10 
Revised 9/2/14 
If the PCP chooses to treat the participant with a course of oral antibiotics, the hydrogen 
breath test will be repeated after the treatment is complete.  If the test is still abnormal, and 
the above criteria 1, 3 and 4 are met, the participant will proceed to intervention visit 1.  If 
the test is normal the participant will proceed to intervention visit 1 only if all the above 
criteria are met (1-4). 
If the PCP decides that oral antibiotics are not indicated, and the above criteria 1, 3 and 4 
are met then the participant will proceed to intervention visit 1.       
For participants not meeting the criteria, study participation will end with the baseline visit. 
Intervention visit 1: Participants will begin treatment with pyridostigmine 30mg PO tid.  
This visit will last about 1 hour. 
Phone contact: Participants will be contacted by phone two days after pyridostigmine 
initiation to assess for adverse events and adherence. 
Intervention visit 2:  Approximately 4 weeks after initiation of study drug, participants will 
repeat all questionnaires and be assessed for adverse events and adherence.  This visit is 
expected to last less than one hour.  
Intervention visit 3: Approximately 8 weeks after initiation of study drug, participants will 
be seen for blood collection, gastric emptying scintigraphy, hydrogen breath test, 
questionnaires, and assessment for adverse events and adherence.  Urine toxicology and 
pregnancy test (for women of childbearing potential) will also be repeated at this visit prior 
to other testing.  This visit will be conducted in essentially the same manner as the baseline 
visit.  Pyridostigmine will be discontinued at the end of this visit. 
Intervention visit 4: Approximately 10 weeks after initiation of study drug (which is 
approximately 2 weeks after cessation of study drug), participants will repeat all 
questionnaires and be assessed for adverse events.  This visit is expected to last less than 
one hour.  
Autonomic function testing is performed under the supervision of Dr. Robinson-Papp.  
This is a standard battery of non-invasive physiologic tests to assess autonomic nervous 
system function.10,49  The patient is asked to lie supine on the tilt table for all the tests.  
Quantitative Sudomotor Axon Reflex Testing (QSART) is performed by placing a capsule 
containing acetyl choline (ACh) on the skin in four standardized locations (forearm, 
proximal leg, distal leg and foot).  The capsule is attached to a computer system which 
delivers a small continuous electrical stimulus to the capsule causing iontophoresis of ACh 
into the skin.  The ACh causes a reflexive sweat response which is collected by the 
capsule.  The total sweat volume is measured by the computer system and compared to 
standardized values.  Following the QSART, a non-invasive continuous beat-to-beat blood 
pressure monitoring device is attached to the participant’s finger (Nexfin system; 
www.bmeye.com) and a 3-lead surface electrocardiogram is attached to the chest.  
Continuous blood pressure (BP) and heart rate (HR) are recorded during Valsalva 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
11 
Revised 9/2/14 
maneuver (VM; forced exhalation to a pressure of 40 mmHg for 15 seconds) and during a 
standardized paced deep breathing exercise (heart rate response to deep breathing; HRDB).  
BP and HR responses during VM are analyzed manually according to the Composite 
Autonomic Scoring Scale (CASS).  For the HRDB test, the average change in HR from 
peak inspiration to expiration is calculated for 5 consecutive cycles of breath and compared 
to standardized values.  Finally the participant is secured to the tilt table and tilted to the 
upright position.  Continuous HR and BP are recorded for 10 minutes (as tolerated).  
Criteria for immediate return to the supine position are: 1) the patient becomes 
symptomatic or asks to end the test; 2) there is hemodynamic evidence of orthostatic 
intolerance (HR increase of >30 bpm, systolic BP decrease >20 mmHg, diastolic BP 
decrease >10 mmHg); 3) the clinician’s discretion. 
The hydrogen breath test is currently in clinical use for the detection of small intestinal 
bacterial overgrowth (SIBO) and is performed under the supervision of Dr. Sam.51  Breath 
samples are obtained throughout the testing by having participants exhale into a plastic 
bag.  The hydrogen content of the samples is measured using a commercially available 
analyzer (Quintron; http://www.breathtests.com).  A baseline breath sample is collected.  
The participant then ingests 50g of glucose after which breath samples are collected every 
10 minutes for three hours.   
Gastric emptying scintigraphy is a clinically established diagnostic test performed under 
the supervision of Dr. Machac.52  It is used to study the mechanical and autonomic 
innervation integrity of the upper GI tract. The total examination scan time is 4 hours.  The 
subject is asked to fast overnight.  The study begins when the subject, in an upright sitting 
position, ingests a standard meal, consisting of four ounces (118 mL) of liquid egg whites 
(equivalent of 2 eggs) (e.g., Eggbeaters [ConAgra Foods, Inc.] or equivalent generic liquid 
egg whites), mixed with 0.5 mCi 99mTc sulfur colloid, cooked to a firm consistency, 
served together with toasted two slices of white bread and 30 g of jam or jelly. The subject 
drinks 4-8 oz of water after ingesting the meal.  Additional water may be given if any 
residual activity is seen in the mouth or esophagus is seen on the gamma camera 
persistence scope on the first frame of the image set.  Standard anterior  and posterior 
128x128 matrix images are aquired for 60 seconds at four time points (0, 1, 2, 3 and 4 
hours) on the same gamma camera.  The subject must remain in the upright sitting or 
standing position the entire 4 hours. If vomiting occurs at any point, the study is ended. 
The acquired images are displayed for review by a nuclear medicine physician. A nuclear 
medicine technologist draws a region of interest around the stomach in both anterior and 
posterior views. The total counts in the anterior and posterior regions of interest are 
multiplied, and a square root is obtained to yield the geometric mean at that time point, 
which is plotted for all time points.  The total body absorbed radiation dose from the 
ingested 0.5 mCi activity is 0.45 mSv. The organ receiving the largest exposure is the large 
intestine, which receives 2.1 mSv. 
Routine blood tests (CRP, T cell enumeration (CD4/CD8), HIV-1 viral load) will be 
performed by Mount Sinai’s clinical laboratory services.  Blood for experimental assays 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
12 
Revised 9/2/14 
(IL-6, LPS, sCD14) will be processed in the laboratory of Dr. Susan Morgello, utilizing the 
infrastructure of the MHBB.  Additional markers may also be added based on the 
availability of funding (e.g. IFN-γ, IL1-β, IL-10, IL-18, TNF-α, sCD163, IL-18, HMGB-1, 
HO-1 and TLR4 mRNA quantitation). 
The questionnaires will include: Survey of Autonomic Symptoms,47 the Composite 
Autonomic Symptom Score (COMPASS),56 Medical Outcomes Study (MOS-HIV) quality 
of life questionnaire.57  
Every effort will be made to minimize risk to participants as follows.  Risks to privacy will 
be minimized by conducting all procedures in a calm and private environment staffed by 
experienced and professional personnel, and by carefully explaining all procedures before 
they are performed, and by minimizing physical exposure.  The confidentiality of 
participant data will be preserved by never removing research records from Mount Sinai, 
separating identifiable data from the source documents, physically locking up all paper 
source documents, physically and password locking all computer data, and restricting 
access to data to study personnel who need such access to do their job.  The risks 
associated autonomic testing are minimized by excluding participants for whom transient 
alterations in blood pressure might be dangerous, for example those with certain medical 
conditions such as recent myocardial infarction.  Syncope and pre-syncope during tilt-table 
testing are minimized by continuous monitoring by experienced personnel, and by clear 
instructions to the participant to report any symptoms.  The risk of radiation exposure 
during the gastric emptying scintigraphy is minimized by performing the procedure 
according to established protocols, and by performing a pregnancy test in women of 
childbearing potential prior to the study.  The risks associated with pyridostigmine are 
minimized by using a low dose, and by performing a careful medical evaluation prior to 
initiating therapy, including assessment for drug-drug interactions and contraindications.  
In addition, Dr. Robinson-Papp and study staff will make certain that participants know 
that they should contact the study team with any safety concerns at any time, and ensure 
that they know how to do so. 
g) Specimen Banking 
Blood samples identified by study ID only, will be stored within the laboratories of the 
MHBB.  Other data will include the specimen type and the date of collection.  This is not 
optional because specimens must be analyzed in batches in order to minimize cost.  In 
addition, PBMCs from the blood samples will be frozen viably after Ficoll-Hypaque 
separation (as per MHBB protocol), so that HO-1 and TLR4 mRNA quantitation can be 
undertaken via rtPCR when funding becomes available to do so.  These specimens may be 
stored until such funding is available.  MHBB laboratory staff will have access to these 
specimens (as necessary to do their jobs) which will be clearly marked as separate from 
MHBB specimens.  Specimens will not be released to investigators outside this study. 
h) Data Management and Confidentiality 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
13 
Revised 9/2/14 
Source documents will be created during each study visit for each participant and stored in 
Dr. Robinson-Papp’s locked office.  Only study staff will have access to these paper 
records, and only as required to perform their roles.  The participant demographics form 
and the informed consent document, which contain identifying data will be separated from 
the other documents.  All other documents will be identified by the participant’s study 
identification (ID) number only.  De-identified data will be entered into a password 
protected database that is housed on a secure, encrypted, Mount Sinai network drive.  No 
data will be sent out or received.  All GI testing data will be reviewed for quality by Drs. 
Machac or Sam as appropriate.  All laboratory data will be reviewed for quality by Dr. 
Morgello or her delegate.  All autonomic testing data and all data overall will be reviewed 
by Dr. Robinson-Papp to assure its quality, and also by Dr. Benn who will look 
particularly for statistical evidence of errors e.g. outliers.  In addition the database will be 
programmed to only accept data within an expected range, which minimizes error.   
Eighty participants in phase 1 provide >80% power (α=0.05) for detecting a “Medium” 
effect size for both “paths” depicted in figure 1, where “Medium” corresponds to an effect 
accounting for 13% of the variance (as per Cohen’s criteria).  However since all phase 2 
participants are drawn from phase 1, the sample size requirements of phase 2 and the 
expected percent eligibility must also be considered in choosing the phase 1 sample size.  
Forty phase 2 participants provide at least 80% power to detect a standardized difference of 
0.45 in the change scores on any outcome.  However this is a conservative calculation, 
since it is based on a paired t-test, and the mixed model to be used will reduce the estimate 
of the standard error by estimating the correlation between the repeated outcomes from the 
same subjects, thus providing a more powerful test.  Thus our phase 2 enrollment target is 
about 40 participants.  Based on our previous study we expect 45% of participants with 
HIV-AN to have vagal dysfunction, and based on a prior study of HIV-infected 
participants with GI symptoms, we expect a similar percentage with abnormal gastric 
emptying.  Although the extent of overlap between these two groups is not known, in 
diabetics 80% of those with vagal dysfunction have gastric emptying abnormalities.  Thus 
we estimate that about 35-40% of phase 1 participants will meet criteria for phase 2, and 
therefore 80-85 phase 1 participants should be sufficient.  However we recognize that these 
estimates contain significant uncertainty, thus planning for up to 100 phase 1 participants 
provides a safety margin. 
Primary measures for the analyses will be: vagal sub-score of mCASS (vagal dysfunction), 
GE T½ (GI dysmotility), IL-6 (immune activation), LPS (bacterial translocation), total 
hydrogen excretion in the breath (ppm x min) over 2 hours following ingestion of 50g 
glucose (SIBO).  Secondary measures include: vagal baroreflex sensitivity; Valsalva ratio; 
heart rate variability with deep breathing; percent gastric emptying at 1-4h; CRP; sCD14.  
The remainder of the cytokines and inflammatory mediators described above will be used 
in exploratory analyses to generate hypotheses regarding the function of the cholinergic 
anti-inflammatory pathway and the effects of pyridostigmine in HIV.  Covariates to be 
included in all analyses as appropriate are: age, gender, duration of known HIV infection, 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
14 
Revised 9/2/14 
current and nadir CD4+ cell count.  All analyses will be two-tailed, conducted at the α = 
0.05 level, and adjusted for multiple comparisons as appropriate. 
Specific Aim 1 is to determine whether vagal dysfunction is associated with immune 
activation in CART-treated participants with HIV-AN, and if so to estimate the extent to 
which this association is mediated by GI effects (i.e. slowed motility, SIBO, microbial 
translocation) versus direct effects of vagal dysfunction.  Initially, Spearman rank 
correlations will be performed pairwise between IL-6, the vagal sub-score of mCASS, GE 
T½, breath hydrogen excretion, and LPS. If correlations are demonstrated we will use the 
method of direct acyclic graphs (DAG) to test the paths hypothesized in figure 1.  This 
method can also be used to test whether any of the secondary measures of the constructs in 
the DAG support the hypothesized paths. The rules for testing the various paths in a DAG 
for significance are based on regression coefficients obtained from statistical models 
constructed using the particular DAG under investigation.  Statistical testing of the 
regression coefficients will be carried out using PRODCLIN software.  Power for the 
effects of mediation variables in the DAGs is estimated using tables provided by Fritz and 
MacKinnon.  Since different DAGs have different numbers of variables in them, with 
many distinct possible paths, power is calculated for any given “triangle” formed by a 
mediator (M) between a predictor (X) and an outcome (Y).  The power is given in terms of 
Small, Medium, and Large effect sizes for the paths.   
Specific Aim 2 is to investigate whether pyridostigmine reduces immune activation and/or 
improves GI function, and if so to estimate the extent to which the reduction in immune 
activation is mediated by GI effects (i.e. improved motility, SIBO, microbial translocation) 
versus direct cholinergic effects.  Following appropriate transformation of non-normally 
distributed variables, linear mixed models for longitudinal data will be used to evaluate the 
longitudinal trend in each of the following outcomes in participants who receive 
pyridostigmine: IL-6, GE T½, breath hydrogen excretion and LPS.  In these models, the 
dependent variable will be the outcomes listed above, and the independent variables will be 
time (fixed effect) and subject (random effect).  We will also construct a multivariate 
mixed linear model to estimate the contribution of each variable’s change to the change in 
IL-6.  In secondary analyses we will perform similar calculations using secondary 
measures of immune activation, GI motility, and translocation.   
i) Provisions to Monitor the Data to Ensure the Safety of Subjects 
 
Part I: Elements of a Data and Safety Monitoring Plan 
1. Dr. Robinson-Papp is the principal investigator and will be the principle monitor responsible for 
monitoring the data to ensure the safety of all the participants in the study. 
 
MSSM Principal Monitor: 
Principal Investigator  
Last Name: Robinson-Papp  


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
15 
Revised 9/2/14 
First Name: Jessica 
Academic Title: Assistant Professor 
Department: Neurology 
Mailing Address: Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1052, 
New York, NY 10029 
Phone: 212-241-8390  
Fax: 212-987-3301 
E-mail: jessica.robinson-papp@mssm.edu 
 
MSSM Additional Monitor: 
Independent 
Last Name: Rodriguez-Caprio 
 
First Name: Gabriela 
Academic Title: Assistant Professor 
Department: Medicine, Infectious Diseases 
Mailing Address: Mount Sinai Medical Center, 
 
 
, New York, 
NY 10029 
Phone: 212-824-7393 
Fax: 212-824-2312 
E-mail: gabriela.rodriguez@mssm.edu 
 
2. Dr. Robinson-Papp is a neurologist with special expertise in caring for patients with HIV/AIDS 
and patients with neuromuscular disorders.  She has experience with the study population and 
with the study drug and will be involved with the day to day activities of the study and is 
therefore the most suitable person to be the primary safety monitor, particularly since this is an 
open label study and so there is no difficulty regarding blinding.  Dr. Rodriguez-Caprio is an 
internist and an infectious disease specialist, focusing in HIV/AIDS treatment.  She is the 
medical director of the clinic from which a large proportion of the research participants will be 
drawn.  Dr. Rodriguez-Caprio and Dr. Robinson-Papp work together at the clinic and have 
several mutual patients.  The rationale for selecting Dr. Rodriguez-Caprio was that as the 
director of the clinic, and as a clinician not involved in the research, her primary interest is in 
the safety and wellbeing of the patient population. We also wanted an independent monitor 
with a general medical background so as to complement Dr. Robinson-Papp’s more focused 
neurologic expertise. 
 
3. Adverse events (AE) will be monitored for safety, including those events related and unrelated 
to the study procedures.  All such events will be characterized as described in item 7, and 
documented in the AE log.  In addition to AEs, self-reported adherence to study drug will be 
queried including the reason for any missed doses.  Any drop-outs from the interventional 
phase will also be recorded, along with the reason. 
 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
16 
Revised 9/2/14 
4. Internal monitoring of subject participation will occur as the data is collected.  With each study 
visit, at least one member of the team will have knowledge of all events occurring on the date 
of evaluation, and will alert the PI in real time to any AEs.  In addition, the research team will 
meet each week for detailed review of all subjects seen that week.  Informed consent 
documentation and subject eligibility is monitored and verified for each enrolled subject.  
Accumulated safety information will be reviewed by the PI and the additional monitor at least 
semi-annually. 
 
5.   Should an unanticipated event occur related to drug, the study will be halted while the need for 
modification is considered.  A report will be provided both to the IRB and funding agency.  If 
modifications are deemed necessary, these will also be presented to the IRB and funding 
agency for review and approval.   
 
6. There are no dose selection procedures.  The same dose (30mg PO tid) will be used for all 
participants throughout the entire 8-week interventional period of the study. This is a 
commonly used starting dose for pyridostigmine in clinical practice, and lower doses are not 
practicable due to the lack of smaller pill sizes.  This low dose has been chosen to minimize 
toxicity.  
 
7. AEs will be classified as mild, moderate or severe based upon the following criteria:   
 Mild: symptoms do not alter the subject’s normal functioning. 
 Moderate: symptoms produced some degree of impairment to function but are not 
dangerous, uncomfortable or embarrassing to the subject. 
 Severe: symptoms are dangerous to the subject’s well-being and cause significant 
impairment of function or incapacitation. 
 
The relationship of the AE to the treatment will be classified as follows:  
 Related:  there is good reason and sufficient evidence to assume that there is a causal 
relationship with the treatment.   
 Not related:  there is good reason and sufficient evidence to exclude a causal 
relationship with the treatment.  
 
All AEs will require the investigator to obtain adequate information to determine the outcome of 
the AE and to assess whether it meets criteria as a serious adverse event (SAE), which requires 
immediate notification to the funding agency and IRB.  The investigator will obtain sufficient 
information to determine the causality of the AE (i.e. treatment or other cause); and provide an 
opinion on causal association (i.e., whether they consider the AE related or not related to the 
study intervention).  Subjects will receive follow up until the AE either resolves completely or 
stabilizes to a level acceptable to the PI.  
 
All SAEs will be reported within 24 hours of the investigator’s knowledge of the event to the IRB 
and/or funding agency.  An SAE is any AE that fulfills one of the following criteria:   


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
17 
Revised 9/2/14 
 Results in death  
 Is life threatening and places the subject at immediate risk of death 
 Results in hospitalization 
 Results in significant disability/incapacity, where the disability is a substantial 
disruption of a person’s ability to conduct normal daily life functions 
 Is an important medical event that may not result in death, be life threatening, or 
require hospitalization, but which based upon the appropriate medical judgment may 
require medical and/or surgical intervention to prevent one of the outcomes listed 
above   
 
8. All GI testing data will be reviewed for quality by Drs. Machac or Sam as appropriate.  All 
laboratory data will be reviewed for quality by Dr. Morgello or her delegate.  All autonomic 
testing data and all data overall will be reviewed by Dr. Robinson-Papp to assure its quality 
(i.e. accuracy and completeness), and also by Dr. Benn who will look particularly for statistical 
evidence of errors e.g. outliers.  In addition the database will be programmed to only accept 
data within an expected range, which minimizes error. 
 
9. Should a temporary or permanent suspension of the study occur, this will be reported to the 
PPHS/IRB and the funding agency. 
 
 
 
A data safety monitoring board will not be formed. 
 
j) Withdrawal of Subjects 
A subject may be withdrawn from the research without their consent if they exhibit 
behavior that is disruptive to study procedures.  Prior to such a termination, the patient will 
be assessed by Dr. Robinson-Papp, and then informed of the termination in a calm, secure 
and private setting, and the encounter documented in writing.  If termination occurs further 
data collection will not continue.  However we anticipate that our familiarity with this 
patient population, close collegial relationship with JMFC primary care providers and the 
screening process will help us avoid this scenario.  Participants may also be withdrawn 
without their consent if continuation in the study is deemed inappropriate due to a change 
in medical condition, for example if a subject becomes acutely ill and is hospitalized. 
Participants may voluntarily withdraw from the protocol at any time.  A member of the 
study staff will meet privately with any participant wishing to withdraw in order to 
determine the reason if possible, and also to determine if the participant would be willing 
to consider partial withdrawal, which might include termination of the intervention, but 
completion of the remaining study assessments.     
6) Risks to Subjects 
The procedures involved in the research include: documentation of medical history, 
physical/neurologic exam, answering of questionnaires, autonomic testing, gastric 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
18 
Revised 9/2/14 
emptying scintigraphy, hydrogen breath testing, collection of blood and urine, answering 
of questionnaires, and for a subset of participants taking pyridostigmine 30mg PO tid for 8 
weeks. 
We do not foresee significant psychological, social, financial, legal or economic risks.  The 
main risks of documentation of medical history, physical/neurological exam, and 
answering of questionnaires relate to issues of privacy and confidentiality.  This is 
discussed in sections 5h and 9. 
The potential physical risks to subjects include those associated with venipuncture, gastric 
emptying scintigraphy, hydrogen breath testing, autonomic testing and in a subset of 
participants: pyridostigmine.  Risks associated with venipuncture include pain and 
bruising.  The discomfort associated with the insertion of the needle is likely to be 
experienced by most or all participants, more significant pain is unlikely.  Mild bruising 
may occur in a minority of participants, more significant bruising is unlikely.  The main 
risk of gastric emptying scintigraphy is that of radiation exposure.  All participants will be 
exposed, but the small amount of radiation involved is not considered to be clinically 
significant.  There is essentially no significant risk associated with hydrogen breath testing.  
There are some physical risks associated with autonomic testing.  Valsalva maneuver 
causes brief (< 1 minute) alterations in blood pressure which are unlikely to be of clinical 
significance.  Tilt-table testing may cause hypotension in subjects with autonomic 
dysfunction leading to unpleasant pre-syncopal symptoms or rarely, syncope.  Pre-
syncopal symptoms may occur in a minority of participants, syncope is considered unlikely 
because subjects are immediately returned to the supine position if there are changes in 
blood pressure or pre-syncopal symptoms.  Other potential risks of autonomic testing 
include mild discomfort associated with lying supine for a prolonged period of time and 
local skin discomfort or irritation from the quantitative sudomotor axon reflex testing.  
These events are considered moderately likely, but not very burdensome.  Loss of 
confidentiality is also a potential risk with these procedures but is considered unlikely, and 
of low burden. 
Pyridostigmine has been in clinical use for over 50 years, primarily in the treatment of 
myasthenia gravis (MG).  The dose used in this study is a common starting dose, the 
maintenance dose used clinically is usually substantially higher and is taken for life.  MG 
is a neurologic autoimmune disease that typically requires long-term treatment with 
immunosuppressive medications and can affect children and adults of all ages.  MG 
patients often experience medical co-morbidities including other autoimmune conditions 
and the effects of long term iatrogenic immunosuppression.  The population in this study is 
similar to the MG population in that they are medically complicated adults with varying 
degrees of immunosuppression.  However well-controlled HIV is an inclusion criterion for 
this study, and so we will not have participants with advanced immunosupression. 
According to the FDA, there are no known long-term side effects of pyridostigmine 
(http://www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/uc


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
19 
Revised 9/2/14 
m130343.htm#8).  Possible short term side effects included in the prescribing information 
are: stomach cramps, gas, diarrhea, nausea, increased urge to urinate, drooling, sweating, 
headaches, dizziness, eye tearing, blurred vision, runny nose, shortness of breath, acid 
stomach, including heartburn or reflux, tingling, muscle twitching, weakness, or cramping.  
The incidence of these side effects is not reported in the prescribing information as it 
would be for a more recently developed drug, however clinical experience suggests that 
side effects are fairly infrequent at the low dose used in this study.  When side effects do 
occur, they are short-lived, resolving within a few hours or less.  We expect the dose used 
in this study to be well-tolerated.  An excerpt from the drug brochure regarding adverse 
effects is included below for completeness: 
“The side effects of pyridostigmine bromide are typically of two varieties, muscarinic and 
nicotinic. Muscarinic side effects include abdominal cramps, bloating, flatulence, diarrhea, 
emesis, increased peristalsis, nausea, hypersalivation, urinary incontinence, increased 
bronchial secretion, diaphoresis, miosis, and lacrimation. Nicotinic side effects are 
comprised chiefly of muscle cramps, fasciculations, and weakness.  Pyridostigmine is a 
quaternary ammonium compound and does not readily cross the blood-brain barrier. 
Compared to the peripheral effects of pyridostigmine bromide, central nervous system 
manifestations are less frequent and less serious, primarily consisting of headache and 
vertigo, with minor and clinically insignificant changes in heart rate, blood pressure, and 
respiratory function. Extremely high doses may produce CNS symptoms of agitation, 
restlessness, confusion, visual hallucinations, and paranoid delusions. Electrolyte 
abnormalities, possibly resulting from high serum bromide concentrations, also have been 
reported. Death may result from cardiac arrest or respiratory paralysis and pulmonary 
edema.   
 
“In a controlled study of 90 healthy volunteers comparing pyridostigmine 30 mg every 8 
hours to placebo for 21 days, the following incidence of adverse events was reported. 
 
Table 1 Incidence of Adverse Events  
Event:  
% 
Pyridostigmine 
N = 60 
% 
Placebo 
N = 30 
Diarrhea  
7  
0 
Abdominal Pain  
7  
0 
Dysmenorrhea  
5  
0 
Twitch  
3  
0 
Myalgia  
2  
0 
Dry Skin  
2  
0 
Urinary 
Frequency  
2  
0 
Epistaxis  
2  
0 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
20 
Revised 9/2/14 
Amblyopia  
2  
0 
Hypesthesia  
2  
0 
Neck pain  
2 
0 
 
Other less common adverse events seen during controlled and uncontrolled clinical trials 
for pyridostigmine include the following: 
· Pulmonary: Exacerbation of acute bronchitis and asthma 
· Cardiovascular: Elevated blood pressure, decreased heart rate (4-6 beats per minute), 
chest tightness 
· Eyes: Change in vision, eye pain 
· Neurologic: Headache, hypertonia, difficulty in concentrating, confusion, disturbed 
sleep, tingling of extremities, numbness of the tongue 
· Skin: Increased sweating, rash, alopecia 
· Digestive: Vomiting, borborygmi, nausea, bloating, flatulence 
· General: Warm sensation, lethargy/drowsiness, depressed mood 
 
During safety studies at the recommended dosage, there were two reports of loss of 
consciousness, one of which also included urinary and fecal incontinence, stiffness of the 
upper torso and arms, post syncopal skin pallor, post syncopal confusion, and post 
syncopal weakness (suggesting a seizure event).As with any compound containing 
bromide, a skin rash may be observed in an occasional patient, which usually subsides 
promptly upon discontinuance of the medication.” 
 
7) Provisions for Research Related Harm/Injury 
The study team will be available for the participant should any anticipated or unanticipated 
injury occur.  The team will assess the patient and facilitate referral to the appropriate medical 
care.  All necessary care will be billed in the manner customary for clinical services, i.e. to the 
patients’ insurance and/or the patients themselves as applicable.    
8) Potential Benefits to Subjects 
Individual participants may experience no benefit.  Those treated with pyridostigmine may 
benefit from reduction in inflammation or amelioration of GI symptoms.  Others may 
experience satisfaction from contributing to scientific research in HIV.  Some participants 
may benefit if undiagnosed neurologic or GI conditions are revealed by study related 
procedures.   
9) Provisions to Protect the Privacy Interests of Subjects 
 
As described above in the recruitment section, participants will be sought from three main sources: the 
Jack Martin Fund Clinic (JMFC), other research studies in which Dr. Robinson-Papp is an 
investigator, and Dr. Robinson-Papp’s clinical practice.  In recruiting subjects, consideration must 
be given to a person’s desire to control how, and with whom, they interact and communicate.  


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
21 
Revised 9/2/14 
Thus it is recognized that not all potentially eligible patients may wish to communicate with the 
study team.  Dr. Robinson-Papp will pre-screen potential participants who are known to her to 
determine whether (based on previous interactions) such participants are likely to be eligible and 
to welcome contact with the study team.  For potential participants not known to Dr. Robinson-
Papp, the first point of contact will be health care provider, who will be asked to make a 
preliminary assessment of eligibility and of willingness to be contacted.  In all cases the initial 
contact will seek first to establish interest in hearing about the study, prior to initiating a more 
lengthy communication regarding the details.  Care to respect the participants’ privacy will be 
taken in this, and all subsequent communications.  No specific information will ever be left with 
family members or in voice messages.   
 
Throughout the study, ensuring that participants feel comfortable with the study staff and procedures 
will be a high priority.  It is our practice to carefully review all procedures (including timing and 
the necessary space, staff and equipment) for each study visit in advance so that the visits are well 
organized. An organized and punctual visit helps put participants at ease.  All procedures will be 
conducted in a calm and private environment staffed by experienced and professional personnel.  
All procedures will be carefully explained before they are performed, and physical exposure will 
be minimized.  Staff always endeavors to be caring and respectful in their communications with 
participants. 
 
It is acceptable and appropriate for members of the research team to approach prospective participants 
because we are very familiar with the population and have expertise in recruiting here in an 
inoffensive manner.  Furthermore, it is our experience that this population usually enjoys 
participating in research, but also feels empowered to decline if the subject is not of interest to 
them. 
10) 
Economic Impact on Subjects 
In the event of a study-related adverse event or injury, subjects will be responsible for any 
expenses not covered by health insurance. 
 
11) 
Payments to Subjects 
Participants will be reimbursed $150 for completing the screening and baseline visits.  If 
prior to completing the baseline visit they are deemed a screen failure then this payment 
will be prorated as follows: $20 for screen failure prior to autonomic testing, $50 for 
screen failure after autonomic testing.  Participants who enter the interventional phase will 
receive $20 for visits 1, 2 and 4 and $100 for visit 3. All reimbursements are paid in cash at 
each visit. 
12) 
Consent Process 
Typically initial contact with a potential participant will be by phone.  Once the potential 
participant expresses interest in the study, an informed consent document will be mailed to 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
22 
Revised 9/2/14 
their home for their review (with their permission), and an in person visit will be 
scheduled.  The informed consent document will contain an explanation of all study 
procedures, including risks and benefits, explained in lay language.  The informed consent 
process will be performed at the time of the study visit by the PI or a delegate.  The 
delegate must have fulfilled all the mandatory regulatory requirements and training, have 
had additional specific training in the protocol, and have undergone a period of 
observation by the PI.  At the time of the visit, the informed consent document will be 
reviewed with the participant in a quiet, private setting to ensure understanding of the 
protocol and willingness and ability to adhere to the study procedures.  This is done by 
engaging the potential participant in a dialogue about the study, asking the participant to 
reiterate protocol procedures, and encouraging the participant to ask questions.  This 
process is then documented in a narrative progress note and in the signed consent 
document.  The team will adhere to “SOP HRP-090 Informed Consent Process.”   
The research will not include children, or cognitively impaired adults who are unable to 
provide informed consent for themselves. 
Non-English Speaking Subjects 
In general subjects will be required to read and understand English, but should a 
participant be eligible whose primary language is Spanish, a Spanish consent form would 
be provided to the PPHS for review in order to include these participants in the study.  
Also, a translator would be arranged for all of the study visits, because the study team does 
not have a member fluent in Spanish. We do not have significant numbers of patients in 
our population who speak neither English nor Spanish. 
Waiver or Alteration of the Consent Process 
We are requesting a waiver of consent (and a HIPAA waiver of authorization) to access data for 
the purposes of pre-screening from the Mount Sinai Data Warehouse (MSDW).  As described 
above in the recruitment section, we currently have a de-identified dataset from the MSDW that 
includes all JMFC patients (N≈700) with at least 3 visits between 11/1/13-10/31/14, who are 
treated with CART.  The dataset, which was assembled for an unrelated project, includes several 
variables which are useful for pre-screening for this study.  We are requesting a waiver of 
informed consent in order to obtain from the MSDW a list of potentially eligible patients, which 
will include names, medical record numbers, and the name of the prescriber of their HIV-
medications (who is very likely to be the primary care provider) for the patients in our list who 
have an undetectable HIV-1 viral load, no urine toxicology positive for opiates/opioids or other 
illicit substances, no diagnosis of diabetes, no diagnosis of peptic ulcer disease, and no 
prescriptions for opiate/opioid medications.  This information will be requested without linkage of 
the identifying information to the de-identified information so as to minimize the amount of PHI 
obtained.  Also we are using the search to exclude patients who have certain characteristics (e.g. a 
particular diagnosis, test result, or medication), and so we will have very little specific information 
about the patients who are included on the list.  The process of contacting the patients identified 
by this process is described above in the recruitment section. 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
23 
Revised 9/2/14 
We believe that this portion of the protocol meets the requirements set forth in criteria set 
#2 of the HRP-415 checklist, namely:  
 This portion of the research is not FDA-regulated. 
 This research does not involve non-viable neonates. 
 This portion of the research involves no more than minimal risk to the subjects, namely 
a contact from the research team, after obtaining permission from their healthcare 
provider.  
 The waiver will not adversely affect the rights and welfare of the subjects.   
 The research could not be practicably carried out without the waiver.  In order to be 
able to identify a sufficient number of potential participants, while remaining within 
the resources of the project, an automated pre-screening process is necessary. 
 There will be no new/timely information discovered by this process that would be 
pertinent to reveal to participants. 
13) 
Process to Document Consent in Writing 
Consent will be documented in writing using the standard PPHS consent template. The 
team will adhere to "SOP HRP-091 Written Documentation of Consent.” 
 
14) 
Vulnerable Populations 
As indicated in the table below, vulnerable populations will not be included. 
Include 
Exclude 
Vulnerable Population Type 
 
X 
Adults unable to consent 
 
X 
Individuals who are not yet adults (e.g. infants, children, teenagers) 
 
X 
Wards of the State (e.g. foster children) 
 
X 
Pregnant women 
 
X 
Prisoners 
 
15) 
Multi-Site Human Research (Coordinating Center) 
 
N/A. 
 


 
Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
24 
Revised 9/2/14 
16) 
Community-Based Participatory Research 
N/A. 
17) 
Sharing of Results with Subjects 
Results that are deemed to be clinically relevant by the PI will be shared with the 
participant.  Permission will also be sought from the participant to share such results with 
their primary care provider. 
18) 
External IRB Review History 
 
N/A. 
 
19) 
Control of Drugs, Biologics, or Devices 
 
The Mount Sinai research pharmacy will provide the study drug to the participants. Accountability 
and destruction will also be managed by the research pharmacy.   
 
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Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
25 
Revised 9/2/14 
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Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
26 
Revised 9/2/14 
30. Neild PJ, Nijran KS, Yazaki E, et al. Delayed gastric emptying in human immunodeficiency virus 
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Protocol Name: 
Autonomic neuropathy, gastrointestinal motility, and inflammation 
in HIV 
Principal Investigator:  
Jessica Robinson-Papp MD, MS 
Primary Contact 
Name/Contact Info: 
Mary Catherine George; mary-catherine.george@mssm.edu; 212-
241-0784  
Date Revised: 
7/1/2016 
Study Number: 
HS#: 15-00605/GCO#: 14-1454(0001) NIH 
 
27 
Revised 9/2/14 
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disorders. Gastroenterology. 2006;130(5):1480-1491. 
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composite autonomic symptom score. Mayo Clin Proc. 2012;87(12):1196-1201. 
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symptom index. J Clin Epidemiol. 2001;54 Suppl 1:S77-90.