Clinical trial NCT01192828
Conditions: Homocystinuria
Keywords: cystathionine beta-synthase (CBS)
Sponsor: University of Colorado, Denver
Start date: 2010-01-01; Completion date: 2017-12-01
Enrollment: 15 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
Cystathionine beta-synthase deficiency is an inherited disease that results in elevation of a substance called homocysteine (Hcy) in blood and urine. Individuals with this disorder have a very high risk for developing blood clots and are at risk for developing eye and bone abnormalities. Current treatments are generally difficult to follow and can fail. Development of additional therapies has been limited by lack of understanding of how the disease works.

The purpose of this study is to see if oxidative stress and inflammation are involved in the disease process and if short-term supplementation with taurine is an effective treatment.

Funding source: FDA.

Detailed description:
Cystathionine beta-synthase deficient homocystinuria(CBSDH) is an inherited disease that results in elevation of a substance called homocysteine(Hcy)in blood and urine. Individuals with this disorder have a very high risk for developing blood clots that can cause a stroke or other life-threatening problems. In addition, these individuals have bone and joint tissue abnormalities.

Current treatment with an extremely strict diet and medication (betaine) is very difficult to follow, and often fails. Development of additional treatment strategies has been limited by a lack of knowledge and understanding of how this disease works. Hence, there is a need to better understand what causes the blood clots and the bone and joint tissue abnormalities.

New data suggest that oxidative stress and inflammation play a central role in animals with this disease. Limited data on humans with this disease support this as well. Further, data from animals with this disease suggests that taurine, a natural body substance and food product, which is low in these patients, mitigates this effect. This study is designed to follow-up on these data.

The purpose of the study is to increase our understanding of the disease process in this disorder, and to see in a pilot study if short-term supplementation with taurine is an effective intervention. The aims of the study are to:

1. see if substances (markers) associated with oxidative stress and inflammation are increased in individuals with CBSDH
2. see if the levels of these markers relate to the levels of homocysteine
3. see if the levels of these markers decrease with short-term taurine supplementation
4. see how bood vessels and platelets (small substances in the blood that help blood clot) work in individuals with CBSDH, if their ability to work is related to levels of markers of oxidative stress and inflammation, and if taurine supplementation improves how they work
5. see if alterations of bone strength are related to levels of markers of inflammation.

The hypotheses to be investigated are as follows:

* Biomarkers of oxidative stress and inflammation are increased in individuals with CBSDH
* The degree of elevation of the biomarkers of oxidative stress and inflammation is relative to the degree of elevation of homocysteine, the main accumulating substance for this disease.
* Treatment with taurine mitigates the elevation of biomarkers of oxidative stress and inflammation.
* Endothelial function (blood vessel function) is abnormal in individuals with CBSDH even when receiving standard therapy and is improved with taurine supplementation.
* Chronic platelet aggregation, a variable finding in individuals with CBSDH, is mitigated with taurine supplementation.
* Decreased bone mineral density relates to the increase in inflammatory markers in CBSDH.

In addition, baseline pharmacokinetics (how much taurine is in the blood) of oral pharmacologic doses of taurine will be developed.

Arms: arm 1: Treatment with Taurine
Interventions: intervention 1: taurine
Intervention descriptions: intervention 1: Take Taurine for 4 1/2 days, two doses per day

Protocol documents:
Prot_SAP_000.pdf: 
On the Web at http://comirbweb.uchsc.edu
COMIRB Application for Protocol Review (9/9/2011)                                                                Page 1 of 42
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COMIRB Protocol
PROTOCOL #: 08-1376 
(July 30, 2014)
(Use Protocol Manager on the 
COMIRB Website)
COLORADO MULTIPLE INSTITUTIONAL REVIEW BOARD
CAMPUS BOX F-490    TELEPHONE:  303-724-1055  Fax:  
303-724-0990
Project Title: Oxidative Stress Markers In Inherited Homocystinuria And The Impact 
Of Taurine
Principal Investigator: Johan Van Hove, MD, PhD
 
1. Abstract
Cystathionine beta-synthase deficient homocystinuria (CBSDH) is an inherited disorder 
that is clinically silent at birth but with significant morbidity and mortality over time.  
Affected individuals exhibit a dramatic predisposition for thrombosis with a 50% risk of 
suffering a thromboembolic event by age 29.  In addition, individuals incur cognitive 
impairment and connective tissue symptoms. Although current treatments improve 
outcome, limitations and adverse side effects exist, and treatment compliance is very 
poor.  Consequently, a need for novel therapeutic strategies exists.  The design of such 
strategies has been hampered by lack of understanding of the pathophysiology of the 
disease.  While no single mechanism has been satisfactorily defined, data implicating 
oxidant stress exists.  Also, CBSDH mouse model data indicate oxidative stress and 
inflammation play a role and that supplementation with taurine, a known antioxidant food 
supplement, mitigates this effect.  This pilot study translates this laboratory research into 
clinical studies.  It proposes that biomarkers of oxidative stress and inflammation are 
increased in human patients, that the degree of elevation is relative to the degree of 
elevation of homocysteine, and that short-term taurine supplementation mitigates the 
elevation of the biomarkers. Further, markers of oxidative stress and inflammation as well 
as disease-related metabolites will be related to clinically relevant platelet aggregation, 
vascular endothelial function and bone mineral density. 
2. Hypothesis and Specific Aims
Cystathionine beta-synthase deficient homocystinuria is an inherited disorder that is 
clinically silent at birth but with significant morbidity and mortality over time even with best 
therapeutic intervention.   Data from CBSDH mouse model research indicate oxidative 
stress and inflammation play a primary role in the pathophysiology of this disorder and 
that treatment with taurine, a nutritional supplement with known potent antioxidant and 
anti-inflammatory properties, mitigates this effect.  This study translates this basic 
laboratory research into clinical studies, and investigates a proposed mechanism for the 
pathophysiology of CBSDH and the efficacy of a promising novel therapeutic intervention. 
The long range goal of the study is to enhance our ability to prevent adverse disease 
related outcomes throughout the life of individuals affected with this disorder.  
Study hypothesis:
COMIRB
APPROVED
08-Aug-2014


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
Biomarkers of oxidative stress and inflammation are increased in CBSDH human 
patients 

The degree of elevation of the biomarkers of oxidative stress and inflammation is 
relative to the degree of elevation of homocysteine.

Taurine supplementation mitigates the elevation of biomarkers of oxidative stress 
and inflammation.

Endothelial function is abnormal in individuals with CBSDH even when receiving 
standard therapy, and is mitigated with taurine supplementation.

Altered platelet aggregation is seen in CBSDH, and is mitigated with taurine 
supplementation.

Decrease in bone mineral density relates to inflammatory markers, in particular 
TNF-α
Additional study aim:

Pharmacokinetic analysis of taurine levels to derive Cmax, T1/2, and AUC .
.
3. Background and Significance
CBSDH is an inherited inborn error of metabolism caused by inactivation of cystathionine 
beta-synthase. This enzyme is a pyridoxal-phosphate-dependent heme protein that 
catalyzes the condensation of serine and homocysteine (Hcy) to form cystathionine in the 
first step of the cysteine biosynthetic transsulfuration pathway.  The disorder is 
characterized by profound elevations in plasma levels of the thombogenic amino acid, 
Hcy, as well as elevations of methionine and S-adenosylmethionine (SAM) and S-
adenosylhomocysteine (SAH). Conversely, cystathionine and cysteine synthesis is 
effectively abolished.  
Clinically, individuals with CBSDH exhibit a dramatic predisposition for thrombosis.  Time-
to-event graphs generated from data compiled from 629 untreated individuals show the 
risk of suffering a thromboembolic event is 25% by age 16 and 50% by age 29 (Mudd et al 
1985).  Of the events reported, 31% were cerebrovascular accidents, 51% were 
peripheral vein thrombosis with roughly one fourth of these involving pulmonary embolism, 
4 % produced myocardial infarctions, 11% affected peripheral arteries, and 2% fell into 
none of these categories. These thromboembolic events constitute the major cause of 
morbidity and mortality in this disease (Schriver et al, 2001).  In addition to the propensity 
toward clotting, individuals with CBSDH frequently incur cognitive impairment and exhibit 
a range of connective tissue disorders including markedly increased risk for ectopia lentis, 
marfanoid skeletal abnormalities, and osteoporosis. Incidence of CBSDH varies 
significantly in different populations with a recent estimate in Europe of 1 in 20,000. 
There is a functional trichotomy in the nature of pathogenic mutations in CBSDH. One 
group of mutations is classified as “pyridoxine-responsive” as CBS enzyme function can 
be restored by high dose pyridoxine therapy. Such treatment effectively mitigates the 
biochemical and clinical findings in these individuals.  The second group of functional 
mutations is represented by the “c-terminal CBS mutants” that are defective in their ability 
to respond to post-translational up-regulation by S-adenosylmethionine. Patients with this 
class of mutations lack mental retardation and connective tissue aspects of the phenotype 
and are detected after investigation of plasma Hcy levels following an idiopathic 
thrombotic event before the age of 40 (Maclean et al., 2004). The final group of CBSDH 
mutations is “classical homocystinuria” which represents the severest form of the disease. 


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For these latter two groups of patients, the standard treatment is a methionine (hence 
natural protein) restricted diet and supplementation with betaine (trimethylglycine) which 
serves as a methyl donor for the remethylation of Hcy to methionine catalyzed by betaine-
homocysteine methyltransferase in the liver. Although methionine restriction and betaine 
supplementation have been successful in terms of improving clinical outcome, limitations 
and adverse side effects exist.  Methionine restriction adversely impacts quality of life and 
is often associated with poor compliance. Patients diagnosed after the infantile period are 
very rarely able to sufficiently comply with its severe restrictions and special products. 
Betaine treatment in isolation often does not sufficiently lower plasma Hcy levels and can 
exacerbate already elevated methionine levels with a risk of cerebral edema.  Illustrating 
the above, this clinic follows seven patients with B6 non-responsive CBSDH.  All require 
diet therapy, as betaine therapy in isolation is not sufficient.  Only one of the seven 
individuals is able to adhere to the dietary recommendation required to achieve a 
reduction in Hcy levels to a range that is therapeutic (< 50 µM total homocysteine, but still 
well elevated above normal which is 2-12 µM).  Consequently, there is currently a need 
for novel therapeutic strategies for CBSDH.  To date, the rational design of such 
strategies has been hampered by the lack of understanding of the underlying 
pathophysiological mechanisms involved in the disease leading to the thromboembolic 
events. Similarly, there is currently no knowledge about the mechanism of the skeletal and 
connective tissue defects in this condition. Symptoms of lens detachment, arachnoid 
status, and osteoporosis have persisted even in treated patients, and will require a new 
approach. 
While no single mechanism has been satisfactorily defined in CBSDH-related 
thromboembolic events, a body of data has accumulated implicating oxidative stress.  
General evidence: 
An association between increased plasma Hcy levels and markers of oxidative stress has 
been reported in homocystinuria due to environmental and/or polygenic causes, as well as 
in CBSDH and inherited remethylation disorders.  Animal studies on diet-induced 
homocysteinemia have shown evidence of oxidative stress, such as: (1) in rabbits 
elevations of thiobarbituric acid reactive substances (TBARS), a measure of reactive 
aldehydes formed from lipid peroxidation in rabbits (Toberek et al, 1995) and, (2) in rats 
elevations of monocyte chemoattractant protein-1 (MCP-1) (Hwang et al, 2008), and 3. in 
the aorta of rats activation of nuclear factor-Kappa-β (NF-κβ), a mediator of response to 
oxidative stress, with associated increased superoxide anion levels (Au-Yeung, 2004). 
Cultured vascular endothelial cells exposed to Hcy had induced NF-κβ activation and 
elevated superoxide anion levels, which was reversed by treatment of with a superoxide 
anion scavenger (polyethylene glycol-superoxide dismutase), supporting a causal 
relationship.  In humans, in children and adolescents at high risk for coronary artery 
disease based on family history, increased plasma total Hcy (tHcy) levels and increased 
fasting plasma TBARS were observed, with interestingly a significant correlation between 
both reported (Szamosi et al, 2004).  
CBSDH specific evidence: 
In human CBSDH patients, reported evidence for oxidative stress includes an increase in 
8-iso-prostane F2α and an increase in extracellular superoxide dismutase.  Eight-iso-
PGF2α is created by nonenzymatic lipid peroxidation by oxygen free radicals on cell 
membranes and LDL-particles and induces vasoconstriction and modulates the function of 
human platelets, hence it is particularly relevant here.  Individuals with CBSDH as 


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compared to normal controls had increased urinary 8-iso-PGF2α  (640 ± 348 versus 321 ± 
43 pg/mg creatinine; P = 0.0015, N = 13 patients with 3 or more samples of urine per 
individual), and this increase was positively correlated with plasma Hcy levels (range of 
tHcy levels was 17.1 umol/L – 287 umol/L; Spearman p = 0.398, P = 0.0076, N = 8 
patients with 3 or more samples of urine per patient) (Davi et al, 2001).  Excretion of 11-
dehydro-thromboxane (TX)B2, a marker for persistent platelet activation, in individuals 
with CBSDH was increased (1166 ± 415 versus 324 ± 72 pg/mg creatinine; P= 0.0015) 
and correlated with the urinary 8-iso-PGF2α (p= 0.362, P = 0.0153).  To investigate a 
cause and effect relationship, vitamin E supplementation (600 mg/day for two weeks) was 
given in 7 patients. This was associated with a decrease but not normalization in urinary 
8-iso-PGF2α (from 790 ± 159 to 559 ± 111 pg/mg creatinine, P=0.018) and in 11-dehydro-
TXB2 (from 1273 ± 383 to 913 ± 336 pg/mg creatinine, P=0.028), with an inverse 
correlation between urinary 8-iso-PGF2α and plasma vitamin E levels.  
A positive relationship between plasma tHcy levels and extracellular superoxide 
dismutase (EC-SOD) was found in a study of 62 samples in 18 individuals with CBSDH 
and 3 individuals with homocysteimia due to a remethylation defect over a 3.5 year period 
(Wilcken et al, 2000). In two newly diagnosed cases, initiation of treatment and lowering of 
the tHcy levels resulted in an approximate 50% reduction in plasma EC-SOD (for instance 
patient 1 pretreatment: tHcy 337 µmol/l and ED-SOD level 161.4 ng/ml; after treatment: 
tHcy 72 µmol/L and EC-SOD 71.5 ng/ml).
Finally, antioxidant therapy with oral vitamin C 1 gram per day in CBSDH showed 
improvement in vascular endothelial function assessed as brachial artery endothelium-
dependent flow-mediated dilatation measured using high-resolution ultrasonic vessel wall-
tracking (Pullin et al, 2002), but biochemical evidence of oxidative stress was not done. 
Endothelial dysfunction has also been reported previously in children with CBSDH 
(Celermajer, 1993). 
Taurine is a member of the sulfur-containing amino acids and is a constituent of dietary 
protein being present in human milk, meat, and fish. Vegans who restrict natural protein 
have low plasma and urine taurine levels (Laidlaw et al, 1988) (McCarty, 2004).  Taurine 
is also synthesized endogenously in the liver from cysteine via several enzymatic steps.  
Paradoxically, CBSDH blocks this natural pathway for endogenous taurine synthesis and 
the methionine (hence natural protein) restricted diet typically given to CBSDH patients 
restricts their exogenous supply of this amino acid.  Low taurine levels are variable 
findings in patients with CBSDH followedChildren’s Hospital Colorado. 


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Taurine’s physiological properties have been extensively investigated.  They involve a role 
in osmoregulation, an activity on calcium homeostasis, conjugation for instance with bile 
acids, an influence on proteins, and an overall function as a cellular protectant (Huxtable, 
1992). Taurine’s antioxidant properties are well recognized and its use as a protective 
agent in disorders resulting in oxidative stress has been investigated (Huxtable, 1992).  
Recent studies showing amelioration of oxidative stress include models such as rats with 
experimental hypothyroidism, mice with experimentally induced iron overload, and 
tamoxifen-induced mitochondrial oxidative damage in mice (Tas et al, 2006) (Oudit et al, 
2004) (Parvez et al, 2008). Blood platelets are rich in taurine leading to the hypothesis 
that taurine status may impact platelet aggregation. (McCarty, 2004).  To date, contrasting 
results of its therapeutic effect in hyperaggregation have been reported.
Typical daily taurine intake from food ranges from 40 -400 mg/day.  The safety of 
supplementation above that was recently comprehensively reviewed by Shao and 
Hathcodk with the Counsel for Responsible Nutrition. (Shao and Hathcock, 2008)  They 
looked at 30 peer-reviewed, published controlled clinical trials in humans involving 
administration of taurine. No significant adverse effects were seen in any trial. The highest 
oral dosage used in randomized controlled trials was 150 mg/kg/day or 10 grams per day 
over 6 months (also Durelli et al, 1983).  Variable findings reported in the reviewed studies 
include gastric discomfort, increased as well as decreased triglycerides, and decrease in 
blood pressure in hypertensive individuals (but not in other patients).  The lack of any 
consistent pattern over the 245 individuals taking the supplement provides support for its 
safe use.  A single uncontrolled study used intravenously infused taurine 150 mg/kg 
2x/day without noted side effects (Mutani et al, 1978). A single uncontrolled study noted 
nausea, headache, and dizziness in 2 patients (Takahashi and Nakane, 1978). 
Interestingly, a negative correlation was found in one uncontrolled study between plasma 
taurine and tHcy in normal middle-aged Korean women after taking 3 g taurine per day, 
reducing the tHcy level from 8.5 ±1.2 µM to 7.6 ± 1.1 µM (Ahn, 2009). Of note, taurine is 
available over the counter as a supplement.  Suggested dosing varies and is often vague; 
however, Web posting comment that up to 6 grams per day as well as 12 grams per day, 
have been used for “treatment” with positive effect (Tolson) (Monson and Schoenstadt, 
2008).  In addition, taurine is found in a number of energy drinks.  For instance, one can of 
“Monster Energy” has 1 g of taurine as does “Red Bull”, “Vitamin Energy” has 2 g taurine 
as does “SoBe sugar free No Fear”. 
In humans, a 13 fold elevation in plasma taurine concentration was observed two hours 
after a one time dose of 1.66 grams (778 +/- 139 µM 2 hours post intake versus 64 +/- 4 
µM at baseline) (Galloway et al, 2008).  This decreased to a 6 fold elevation 4 hours after 
intake. Administration of a second 1.66 gm dose 4 hours post initial dose resulted in 16 
fold elevation at five hours post initial dose (one hour post second dose).  The taurine 
concentration then fell over the next three hours but remained significant elevated above 
baseline at 8 hours (161 +/- 31 µM at 8 hours versus 64 +/- 4 µM at base line).  When 
studied and reported in other human studies, serum and urinary taurine levels increased 
with supplementation but effects varied widely (Sho and Hatchock, 2008).  An increase in 
peak taurine concentration from 54.8±2.3 to 275.6±77.9 µM was reported with a dose of 6 
g/day (Fujiuta et al, 1987). However, no formal pharmacokinetic data such as t½ are 
available for pharmacological doses of taurine. Platelets contain large quantities of 
taurine, and hence only plasma levels can be relied on; whereas older studies using 


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serum or whole blood have inconsistent and variable results due to the variable and 
uncontrolled degrees of release of taurine from platelets into serum. 
 
4. Preliminary Studies; Progress Reports
To investigate in an unbiased way the mechanisms whereby CBSDH brings about its 
adverse effects, a microarray analysis of hepatic gene expression in a mouse model of 
CBSDH was done. The expression pattern was altered for multiple genes induced by 
`tumor necrosis factor-α (TNF-α), an inflammatory mediator, and by NF-κβ, a mediator of 
response to oxidative stress. Biochemical markers for oxidative stress and inflammation in 
the CBSDH mice were then investigated.  Oxidative stress was assessed by TBARS, a 
measure of reactive aldehydes formed from lipid peroxidation, and was elevated in 
CBSDH mice (p < 0.001, N = 10) compared to control mice. Betaine therapy, decreased 
but did not normalize, the TBARS levels. In addition, adduction products with reactive 
aldehydes to proteins were increased, with fibrillin-1 being prominently sensitive to this 
damage. Fibrillin-1 is interesting given its role in lens fixation and marfanoid habitus.  
Activation of NF-κβ leads to increased cytokines such as TNF-α. Plasma levels of TNF- α 
and C-reactive protein (CRP) were significantly elevated in the mouse model of CBSDH (p 
< 0.0001 and p< 0.005 respectively). Subsequent Luminex-based cytokine profiling 
confirmed an increase in TNF-α in the CBSDH mice (p < 0.0001), and showed elevation 
of the inflammatory cytokines IL-1α and IL-1β (p < 0.001). TNF-α stimulates osteoclasts 
and may be important in the pathogenesis of osteoporosis. Betaine treatment lowered 
TNF-α and IL-1β, but did not normalize it. 
Supplementation with 1% taurine in drinking water given ad libitum over 1 and over 2 
weeks resulted in improvements of both TBARS levels and of TNF-α, IL1-α, and IL-1β 
without an effect on Hcy levels. For functional effects, coagulation was assessed in the 
mice by the bleeding time from tail cutting. CBSDH mice clot approximately 3 times faster 
than control mice, and taurine treatment completely abrogated this hypercoagulative 
phenotype.  Taurine did not affect coagulation time in normal mice, indicating this effect is 
limited to the CBSDH pathology and is not a general effect on the components of the 
coagulation cascade or the natural anticoagulant/fibrinolytic system or platelet function. 
This implies that taurine treatment of CBSDH would have less undesirable side-effects as 
compared to conventional anticoagulant therapy, which currently is being taken by some 
adults with CBSDH. 
 
Taken together, these observations indicate that dietary supplementation with taurine has 
significant therapeutic potential for treating CBSDH in humans. With its low-cost and low 
risk of side-effects, we propose investigation of taurine as an adjuvant therapy for betaine 
supplementation and methionine restriction.
Preliminary data from human CBSDH patients poorly compliant with standard therapy 
showed elevations of TNF-α (39.36 ± 4.85 pg/ml in un- or poorly treated and 19.33 ± 5.56 
pg/ml in treated patients, versus controls 1.89 ± 0.53 pg/ml,  N = 10, p< 0.0001) and 
TBARS (4.08 ± 0.56 nmol/ml in un- or poorly treated and 2.92 ± 0.38 treated patients, 
versus controls 2.23 ± 0.33 nmols/ml, N = 10, p< 0.0001 and <0.0027 respectively). 
Cytokine profiling confirmed significant elevations in TNF-α, and the inflammatory 
cytokines IL-1α and IL-1ß.  Study subjects provided informed written consent for COMIRB 
protocol number 00-359.  


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5. Research Design and Methods
A. Overview - Brief Summary of Study Rationale:
Data from CBSDH mouse model research indicate that oxidative stress and 
inflammation play a primary role in the pathophysiology of CBSDH in its 
hypercoagulable state and possible in connective tissue pathology.  The mouse model 
data also suggest that treatment with taurine, a nutritional supple ment with known 
antioxidant and anti-inflammatory properties, mitigates this effect.  The data suggest 
that the effect is independent of the effect of betaine treatment, and additive to it. This 
basic laboratory research must be translated into clinical studies, and this study 
provides the first systematic study on a local scale.  It investigates a proposed 
mechanism for the pathophysiology of CBSDH, and evaluates the efficacy of a novel 
therapeutic intervention. The study proposes that biomarkers of oxidative stress are 
elevated in individuals with CBSDH and that the elevation is relative to the elevation of 
Hcy.  It will then treat patients with taurine (maximum 5 grams) twice a day for a total 
dose of 150 mg/kg/day (maximum 10 grams per day) for 4½ days. It proposes that 
supplementation with taurine has the potential to significantly decrease the oxidative 
stress and inflammation in CBSDH in humans.  Biomarkers of oxidative stress and 
inflammation will be assessed and compared to normal values.  They will also be 
compared to Hcy levels, levels of other disease intermediary metabolites, and markers 
of standard therapy for this disorder.  The impact of taurine supplementation on the 
biomarkers of oxidative stress and inflammation will be assessed.  The impact of 
taurine supplementation on Hcy and disease intermediary metabolites, and standard 
disease treatment markers will also be assessed.  Further, markers of oxidative stress 
and inflammation as well as disease-related metabolites will be related to the clinically 
relevant platelet function and vascular endothelial function studies assessed via a 
standardized doppler method available through the UCH CCTSI.  Brachial artery flow-
mediated dilation (FMD) will be used as a non-invasive measure of endothelial-
dependent dilatation (EDD), mediated in part by nitric oxide (Liao et al, 1991) (Dakak 
et al, 1998).  Platelet function will be assessed by markers of chronic platelet 
activation and by platelet aggregation studies. The impact of taurine treatment on 
FMD and platelet aggregation will also be assessed.  
Since inflammatory messengers such as TNF-α can stimulate osteoclasts without 
stimulating osteoblasts, long term elevation of TNF-α can cause osteoporosis. We will 
measure bone mineral density and will evaluate if the Z-scores are related to the 
inflammatory markers in particular to TNF-α. Such a finding would strengthen the 
development of a hypothesis of a possible relation, whereas its absence of such a 
relation would not necessarily negate this given the many parameters that can 
influence bone mineral density. 
Finally, baseline pharmacokinetics of oral pharmacologic doses of taurine will be 
developed.
For safety reasons, the first two patients will be treated with a dose of 25 mg/kg/dose 
(maximum 1.5 g) twice daily. After review of safety parameters, the dose will then be 
increase to the planned dose of 75 mg/kg/dose (maximum 5 g) twice daily. The first 
four patients will be adults, before recruiting children in the study. 
This short-term local pilot study will form the basis on which to later develop a national 
long-term study (orphan drug study), 4 years duration and placebo controlled, that will 
expand on the findings and include long-term variables such as those related to 
connective tissue and bone. 


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Primary Outcome Measure(s): 
Oxidative stress and inflammation measures as follows:

Luminex cytokine array studies to include the following cytokines

Interleukin 1-alpha (IL-1)

Interleukin 1-beta  (IL-1)

Interleukin 1-ra (IL-1ra)

Interleukin 4 (IL-4)

Interleukin 8 (IL-8)

Interleukin 10 (IL-10) 

TNF-alpha (TNF-)

Monocyte Chemoatractant Protein-1 (MCP-1)

Interleukin 6 (IL-6)

Interleukin 12 (IL-12p70)

Interleukin 17 (IL-17)

MIP-1

MIP-1

C-reactive protein (high sensitivity)

Myeloperoxidase

Transforming Growth Factor Beta (TGF-)

Extracelluar superoxide dismutase

TBARS

ELISA Assay

Interleukin 1-alpha (IL)

Interleukin 1-beta  (IL-)

Interleukin 10 (IL-10) 

TNF-alpha (TNF-)

8-Isoprostane metabolites (2,3-dinor-F2-IsoPs combined signal) of 8-isoPGF2α, 
urine 

Dityrosine, urine

Glutathione reduced (GSH) and oxidized (GSSG) in whole blood
Vascular coagulability markers:

Endothelial Function as assessed by brachial artery flow-mediated dilation 
(FMD): percent change induced by hypoxemia in brachial artery diameter and 
flow measurement (derived from diameter and flow velocity)


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
Platelet aggregation

11-dehydro-thromboxane B2 (11-dehydro-TXB2) and 2,3-dinor-TXB2, urine 
Bone mineral density by DEXA
B. Secondary Outcome Measure(s):
The relationship between the above noted oxidative stress markers and the related 
methionine cycle metabolites will be assessed

Hcy

Methionine

Cystathionine

Cysteine 

SAM (S-adenosylmethionine)

SAH (S-adenosylhomocysteine)

Dimethylglycine 

Betaine
Lipoprotein A will be assessed as confounding variable potentially modulating 
platelet aggregation and inflammatory response.
Molecular studies will be done given the known genotype/phenotype correlations 
in this disease and for verification of diagnosis.  
Pharmacokinetic studies of taurine will be done for the first 12 hours following the 
first dose of taurine, and a steady state concentration will be obtained after 4 days 
of treatment. 
C. Study Population Description:
Participants will be recruited from the Inherited Metabolic Diseases Clinic at 
Children’s Hospital Colorado, The Children’s Hospital of Philadelphia, and Duke 
University Hospital.  Recruitment of patients being followed by other metabolic 
clinics may also be pursued if additional participants are needed.  This will be done 
through their metabolic physician and / or through family support groups. Patients 
must meet all inclusion criteria.  There will be no discrimination based on age 
gender, or ethnic heritage. 
D. Total Planned Number of Subjects:
a.
For Single-Center Studies: NA
b.
For Multi-Center Studies – Up to20
i.
For this location: Up to 12
ii.
For all locations: Up to 20
Up to 16 patients will be exposed to taurine and analyzed. Allowing for 20 
patients to sign consent is based upon the potential for patients who 
withdraw consent prior to drug exposure, may be potential screen failures, 
or fail to proceed to study after signing consent.
E. Inclusion Criteria:


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Minimal inclusion criteria are: 
1. A confirmed biochemical, molecular, or enzymatic diagnosis of classic 
homocystinuria due to cystathionine beta-synthase deficiency (OMIM 236200)
2. And not fully responsive to therapy (eg, tHcy levels above 50 µmol/L on therapy 
including on B6 therapy) 
3. Be over 8 years old and less than 50 years.  The first four patients will be adults 
(age 18 – 50 years).
4. Be able and willing to provide informed consent
Exclusion Criteria:
1. Age < 8 years: Individuals under 8 years of age will be excluded due to blood 
volume issues and concerns regarding their ability to assent
2. Age > 50 years: Individuals over 50 years will be excluded due to possible age 
related differences in markers of oxidative stress and inflammation
3. Pregnancy: Females who are pregnant or lactating will be excluded from the 
study as the influence of pregnancy on the markers is not known nor is the safety 
of taurine supplementation in pregnancy. 
4. Continued antioxidant intake: 
a. Individuals currently taking taurine, over the counter energy drinks containing 
taurine or other high dose antioxidants and unwilling to discontinue this for the 
study period (including a 2 week wash out period) will be excluded as such intake 
will likely impact laboratory results. 
b. Individuals taking Vitamin C as a prescribed treatment for their homocystinuria 
will be excluded as the antioxidant therapy may impact antioxidant and 
inflammation markers.  (As Vitamin C is not standard of care for this disease we 
anticipate this to have minimal impact on recruitment.)
c. Individuals currently taking platelet aggregation inhibitors such as salicylate on a 
self prescribed PRN basis and unwilling to discontinue this for the study period 
(including a washout period of at least two weeks prior to the study) will be 
excluded as salicylate intake will impact platelet study results.  Individuals taking 
salicylate (or other platelet aggregation inhibitors) prescribed as a therapy for their 
homocystinuria or other health issues will not be asked to stop the medication. 
They will participate in the study, but will be excluded only from the platelet 
studies.  
5. Medication interactions: Individuals unable or unwilling to abstain from use of 
cGMP phosphodiesterase 5 inhibitors (such as Viagra) during the study period will 
be excluded from the nitroglycerin-induced flow-mediated dilatation studies in 
accordance with known labeling contraindications.  
6. Inflammatory status: 
a. Individuals who have a significant chronic illness that has a marked 
inflammatory component will be excluded from the study as the illness will impact 
inflammatory markers.  


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b. Patients with an acute illness, which may impact inflammatory biomarkers, will 
be postponed for study entry until the acute illness is resolved. Entry into the study 
at a later day will be offered. 
7. Cardiovascular status
a.Recent cardiovascular event. Cardiovascular events (stroke, myocardial infact, 
deep vein thrombosis, pulmonary embolus or thrombosis) may interfere with 
platelet function studies and with various mediators during the first months after 
the event. Patients who had such an event within the last 6 months will be 
excluded.
b.Patients with uncontrolled hypertension. This will remove a confounding factor 
from analysis of the endothelial flow studies and increase safety. 8. Informed 
consent: Individuals who are unwilling or unable to consent, or in the case of 
minors who are unwilling or unable to assent will be excluded due to lack of ability 
to ensure informed consent.
9. Study compliance and integrity: Individual who anticipate an inability to comply 
with study procedures and requirements will be excluded.
10.  Hypertriglyceridemia.  Individuals with a triglyceride level above 300 mg/dl will 
be excluded from the study.  An associated increase in triglyceride levels with 
administration of taurine has been reported (as has a decrease in triglycerides)  
Exclusion of individuals who have a history of hypertriglyceridemia will decrease 
the likelihood that a study related increase in serum triglycerides would result in 
health care risks.  This is a conservative approach as acute health care risk is 
generally seen in the setting of triglycerides > 1000 mg/dl.  Historic triglyceride 
levels (within 5 years of the date of consent) can be used to assess eligibility. This 
lacking, triglycerides can be obtained as part of the study and assessed prior to 
administration of taurine.
F. Planned Enrollment: Enter # of Subjects in the Table Below: review the 
numbers for 12 and women = male (given your statement in 7A inclusion of 
women)
Gender
Ethnic Categories
Females
Males
Total
Hispanic or Latino
2
2
4
Not Hispanic or Latino
8
8
16
Ethnic Categories: Total of All Subjects
10
10
20
 
Racial Categories
American Indian/Alaska Native
0
0
0
Asian
1
0
1
Native Hawaiian or Other Pacific Islander
0
0
0
Black or African American
1
2
3
White
8
8
16


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Effective 10/01/2006
Racial Categories: Total of All Subjects*
10
10
20
*The “Ethnic Categories Total of All Subjects” must be equal to the “Racial 
Categories Total of All Subjects”
Data listed here reflects US population demographics and is an estimate.. 
G. Study Design Details:
First informed consent will be obtained (see section III. Informed consent plan). This 
section describes the active portion of the study.  Patients will be evaluated after a two 
week washout period if the subject was taking taurine supplementation or other high dose 
antioxidant supplements.  Prior to start of study, the PI or one of the MD co-investigators 
will review the list of medications and supplements used, and determine if the participant 
should be excluded from platelet function studies (use of platelet aggregation inhibitors) or 
should be excluded from FMD studies (use of cGMP phosphdiesterase 5 inhibitors) (see 
special considerations below in this section). Base-line observational studies will be done 
first.  While the patient is on their standard treatment regime blood and urine samples will 
be obtained for biomarkers of oxidative stress, inflammatory mediators, Hcy, and other 
disease-specific intermediary metabolites, and for markers of treatment compliance. (See 
below table for laboratory study details.) The inflammatory mediators to be investigated 
were selected based on findings from the mouse studies. They include markers that are 
positively changed in the mouse model, as well as markers that have been selected to 
document the specificity of this inflammatory response as different from a non-specific 
response (e.g. IL-4 can decrease TNF-α production and we want to see that the increased 
TNF-α is not caused by a decrease in these factors; IL-10 would be a specific negative 
control not expected to be changed). The oxidative stress markers, TBARS and 
superoxide dismutase, were selected based on mouse model data and data from human 
studies in CBSDH.  The oxidative stress markers, 8-isoprostane and dityrosine, are 
established markers of lipid and protein damage and are included in the study because 
they are stable and independent of dietary intake (Dalle-Donne et al, 2006).  Instead of 
the CTSI available immunoassay for the critical oxidative stress marker 8-isoprostane, we 
will use the more specific and sensitive mass spectrometric assay available at Duke 
University Medical involving our new collaborator David Millington, PhD.  Normal values 
for comparison will be developed by Dr. Millington. Glutathione reduced and oxidized will 
be measured by HPLC – tandem mass spectrometry (Steghens et al. 2003) in the 
laboratory of Dr. Tina Cowan, PhD at Stanford, who has used this assay in patients with 
metabolic diseases and has developed normal values. Processing and stabilization of 
samples will be done locally in the laboratory of Dr. Van Hove. Specific interleukins are 
repeated in the laboratory of Dr. MacLean using the same Elisa method as previous 
studies for comparison. Using an ELISA method to compare to the Luminex assay 
increases the validity of the findings, as discussed with Dr. Accurso. The above noted 
markers will be related to normal values as well as Hcy and other disease related 
metabolites.  Also, a bone mineral content and density will be done using a DEXA scan. 
TNF-α activates osteoclasts but not osteoblasts. We will relate the DEXA results to the 
level of TNF-α.
The above biomarkers and disease-related metabolites will be further related to the 
clinically relevant vascular endothelial function studied via a standardized doppler method 
available through the UCH CCTSI.  Brachial artery flow-mediated dilation (FMD) will be 
used as a non-invasive measure of endothelial dependent dilatation (EDD), mediated in 
part by nitric oxide (Liao et al, 1991) (Dakak et al, 1998). Ultrasound measurements of 


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brachial artery EDD (i.e., FMD studies) during forearm reactive hyperemia and in 
response to sublingual nitroglycerine (0.4mg), well-established measures of vascular 
endothelium–dependent and –independent vasodilatation, respectively, will be performed 
as previously described (Celermajer et al, 1992) (Eslirza et al, 2004).   This entails 
ultrasound measurement of brachial arterial diameter in the resting state, followed by 
occlusion of the brachial artery by a blood pressure cuff for 5 minutes. The cuff is then 
rapidly deflated.  The ensuing turbulent blood flow results in endothelial sheer stress.  This 
activates a cascade of endothelial mediated events resulting in dilation of the vessel.  The 
dilation is quantified by ultrasound. The maximum percent increase in vessel size after the 
release of the blood pressure cuff, or FMD, is a measure of endothelial-dependent 
vasodilatation.  Following this, endothelial-independent vasodilatation is assessed. 
Brachial artery ultrasound measurements are again obtained in the resting state.  
Following this, 0.4 mg of nitroglycerin, source being Nitrostat SL tablets, is given 
sublingually. Nitroglycerin will not be used in patients under age 18 years.  Nitric oxide is 
produced from the nitroglycerin without need for the endothelial cells. The nitric oxide has 
a direct vasodilator effect.  Brachial artery diameter is again assessed via ultrasound.  The 
maximum percent increase in vessel size after the nitroglycerin is as a measure of nitrate-
mediated, endothelium-independent vasodilatation.  Abnormal FMD results in the setting 
of normal endothelial-independent vasodilatation results suggest endothelial dysfunction.  
To avoid confounding variables subjects will be asked not to eat 4 hours prior to study or 
consume caffeine 10 hour prior to study .
The above biomarkers and disease related metabolites will be also related to clinically 
relevant platelet function studies. We hypothesize that the inflammatory and oxidant 
environment pushes normal platelets into a chronic low-grade aggregation status, and that 
this improves with taurine. We will measure urinary 11-dehydroTXB2 and 2,3-dinor-TXB2 
to reflect aggregation status, and in vitro platelet aggregation studies to reflect the platelet 
function. The metabolites 11-dehydroTXB2 and 2,3-dinor-TXB2 have been reported as 
elevated in CBSDH patients. 
Following the observational studies, participants will be treated with oral taurine 75 
mg/kg (maximum5 grams) BID for 4 ½ days.  The first two patients will be treated with 
a dose of 25 mg/kg (maximum 1.5 g) twice daily, before increasing the dose to the full 
study dose. USP grade taurine supplied by Solace Nutrition, lot number 6608 (Solace 
Nutrtition, One Research Court, Suite 450, Rockville, MD 20850) and Medisca Inc, lot 
number 105927 (Medisca Inc, 661 Route 3 Unit C, Plattsburgh, NY 12901) will be 
used.    If for any reason this lot number changes, we will submit additional Certificate 
of Analysis to the FDA and COMIRB for the new lot numbers.  Participants will be 
weighted on visit day one.  Based on the patient weight, a prescription order will be 
written by the MD Co-investigator or CTRC nurse practitioner for taurine and will be 
given to The Children’s Hospital Pharmacy Investigational Drug Services.  Individual, 
single dose packets will be weighed and dispensed by the pharmacy to the Clinical 
and Translational Research Center (CTRC).  Each single dose packet will be labeled 
with the study medication name and dose.  The amount of product needed for the first 
4 days of the study period will be dispensed up front  in a container that is labeled with 
subject’s name, medication name, medication dose, and directions for administration. 
Based on the prescription order, the Children’s Hospital Pharmacy will dispense the 
medication to the inpatient Clinical and Translation Research Center (CTRC).  The 
first dose of study medication will be administered orally to the study patient by a RN. 
The RN will mix taurine with 150mls of water or the individual’s favorite juice. The RN 


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 14 of 42
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will review administration instructions and observe intake of the first oral dose.  There 
after the medication will be self administered by the participant in the same manner; 
the patient will be instructed that once taurine is mixed with a liquid it must be 
consumed within thirty minutes of mixing. The last dose will be dispensed in a 
separate container by the Investigational Pharmacy to the outpatient CTRC with 
labeling and administration as that described above.  
Disease metabolites and biomarkers of oxidative stress and inflammation laboratory 
studies will be obtained at 4 hours after the first dose, and after completion of 4 days 
of treatment. Comparison of results prior to treatment with results after one dose and 
after 4 days of treatment will be done.  Functionally relevant platelet aggregation will 
be obtained after 4 days of treatment.  Functionally relevant FMD studies will be 
obtained after the blood work and the last taurine dose, this being after 4 ½ days of 
treatment.  After the blood flow studies have been completed, the patient will be 
discharged. Comparison of results prior to treatment and results after treatment will be 
done.  
Pharmacokinetic studies will be done after the first dose with blood samples obtained 
before administration (time 0), and after 30 min, 1, 2, 4, 6, 8, and 12 hours. A steady state 
level will be obtained after 4 days treatment. Plasma samples will be spun down 
immediately to avoid platelet aggregation, and samples stored at – 70 degrees Celsius 
until analysis (to prevent hypotaurine from oxidation to taurine). Sample will be analyzed 
using an LC- MS/MS system in combination with online extraction (LC/LC-MS/MS by Dr. 
Uwe Christians, and pharmacokinetic results modeled using SAAM II (University of 
Washington) by Drs. Jeffrey Galinkin and Thomas Henthorn. 
The study will usually start on a Thursday and end on a Tuesday to allow for the four 
day treatment period with blood and urine sample collections and ultrasound and FMD 
studies to be done on work-week days.  Laboratory will be taken at 8:00 AM after 
overnight fasting or at 12 noon before lunch and after a 3 hour fast to limit the impact 
of dietary intake of protein . Should the taurine study be terminated early, then 
laboratory studies and FMD studies may be collected earlier at closing. Taurine will be 
dispensed by the centers investigational pharmacy, enough product given for the total 
length of the study.  Bottles of product will be collected at the end of the study and 
amount of left-over product determined as a compliance check in addition to 
participant self-report compliance.  Participants will be asked to stop use of any anti-
oxidation supplement, in excess of standard multi-vitamins (1 table/day) for two weeks 
prior to the study.  They will also be requested to avoid use of non-prescription 
salicylates (Aspirin) two weeks prior to the study.  Potential confounding variables of 
(1) hormone replacement therapy, (2) other significant chronic disease (3) high 
physical activity, (4) smoking habits, and (5) anticoagulant use will be determined for 
each individual. Safety will be assessed by vital signs and a physical examination, a 
questionnaire on possible side effects, and basic laboratory tests of CBC, CMP, and 
lipid panel. 
Molecular analysis of the CBSDH gene will be done in the Children’s Hospital 
Colorado DNA Diagnostic laboratory, where this test is clinically available. We 
anticipate that about half the patients will already have this information clinically 
available, with about half the patients requiring further analysis as part of this study. 


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H. Laboratory Assays, Examinations and Procedures:
Study 
Purpose
Laboratory
Luminex, 8 plex (IL-1α, IL-1β, IL-
1ra, IL-4, IL-6, IL-10, TNF-α, MCP-
1, IL,-8, IL-12p70, IL-17, MIP-1α, 
MIP-1β)
inflammation
CTRC
CRP
inflammations
CTRC
Myeloperoxidase
oxidative stress
CTRC
TGF-beta
inflammation
CTRC
superoxide dismutase
oxidative stress
MacLean/UCD
TBARS
oxidative stress
MacLean/UCD
Elisa assay (IL-1α,IL-1β, IL-10, 
TNF-α)
inflammation
MacLean/UCD
Isoprostane, urine
oxidative stress
Millington/Duke University
Dityrosine, urine
oxidative stress
Uwe Christians 
Anesthesiology Laboratory
Glutathione, whole blood
oxidative stress
Cowan/ Stanfod
tHcy 
disease primary marker
Metabolite Laboratory,  Inc
Methionine
disease intermediary
Metabolite Laboratory,  Inc
Cystathionine
disease intermediary
Metabolite Laboratory,  Inc
Cysteine
disease intermediary
Metabolite Laboratory,  Inc
S-adenosylmethionine
disease intermediary
Uwe Christians
Anesthesiology Laboratory
S-adenosylhomocystiene
disease intermediary
Uwe Christians
Anesthesiology Laboratory
Dimethylglycine
compliance of standard Tx
Metabolite Laboratory,  Inc
Betaine
compliance of standard Tx
MacLean/UCD
Serum amino acids (includes 
taurine)
compliance of 
experimental Tx
Denver Genetic Laboratory - 
Biochemical Genetic 
Laboratory
Taurine
Pharmacokinetics
Uwe Christians, 
Anesthesiology Laboratory
Platelet aggregation
Coagulation assessment
local lab*
Lipoprotein A
Atherosclerotic disease  
marker
Mayo
11-dehydroTXB2, 2,3-dinor-TXB2, 
urine
Coagulation assessment
MacLean/UCD
CBC 
Safety
local lab**
CMP
Safety
local lab**
Lipid panel
Safety
local lab**
Triglyceride level
Safety
local lab**
pregnancy, urine
Safety
local lab**
Cystathionine β-synthase 
molecular (CBS)
Genotype
Denver Genetic Laboratories 
– Molecular Laboratory 
Plasma, serum and urine freeze -
70, save
MacLean/UCD
Estradiol/Progesterone (Females 
Menstrual cycle timing for 
UCH CTRC


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only)
FMD interpretation
*  For Colorado, this will be University of Colorado Hospital Laboratory
** For Colorado, this will be Children's Hospital Colorado
THUR*
Day 1
FRI
Day 2
8 AM 
FRI
Day  2 
12 PM
TUE
Day 6
8 AM
TUE
Day 6
After
8 AM
Informed consent 
X
Intake sheet (see appendix )
X
Adverse Event/Compliance 
Sheet (see appendix)†
X
X
Medical History 
X
Physical exam
X
X
Endothelial function studies
X
X
DEXA scan
X
Blood Luminex, CRP, 
myeloperoxidase, TGF-β 
(CTRC)
X
X
X
X
Urine isoprostane, dityrosine
X
X
Glutathione
X
X
X
X
Lipoprotein A 
X
CBC, CMP, Lipid panel
X
X
Estradiol/Progesterone 
(Females only) 
X‡
X‡
Urine pregnancy tests
X
Superoxide dismutase, 
TBARS, Elisa, (McLean)
X
X
X
X
Homocysteine and metabolites 
(Metabolite Inc)
X
X
X
X
Betaine (MacLean)
X
X
X
X
Serum amino acids 
(Biochemical Genetics)
X
X
X
X
Plasma taurine
X
X¶
X¶
X


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Platelet aggregation studies 
(local lab)
X
X₸
ThromboxaneB2 metabolites , 
urine
X
X
X
Cystathionine beta-synthase 
molecular studies
X
Plasma, serum and urine to 
freeze and save
to include 1.0 ml EDTA plasma 
on the second day of the study
C
C
C
C
*Day one of study will typically be on a Thursday, exceptions may exist
† The adverse event survey will also be administered over the phone one to two 
weeks after study completion
X = collected and analyzed
C= collected and stored for possible studies during study period
¶ = collected before administration (time 0), and after 30 min, 1, 2, 4, 6, 8, and 12 
hours.
‡ = collection can occur on Day 1 or Day 2 based upon site maximum blood 
volume
₸= will not be collected if site maximum blood volume is reached
Practical Aspects:  Samples not obtained for safety reasons will be batched to 
avoid inter-day variation. Analysis will be done at midway point and at study end. 
All samples will be stored at – 70 °C before being processed. Accurate SAM and 
SAH determination necessitates special handling of specimens and will be done in 
accordance with directions from assaying laboratory.  The processing and freezing 
of samples for these studies will be done by the local laboratory in collaboration 
with the CTRC.  The laboratory will be notified of anticipated samples per local 
standards.  Accurate platelet aggregation studies necessitate that samples be 
analyzed within 3 - 4 hours of collection. In addition, platelet aggregation studies 
are sensitive to sample handling as sheer stress promotes platelet aggregation.  
Therefore, the samples for this study will be hand carried by study personnel (PI or 
assistant) to the main laboratory where they will be analyzed.  Finally, collection of 
samples for platelet aggregation, should a heparin lock be in place, will be done in 
accordance to standard methods used for drawing coagulation studies, to avoid 
any potential confounding impact from heparin.  All platelet aggregation studies will 
be scheduled with the local laboratory in advance in accordance with their 
protocol.  For all draws from the heparin lock, specimens will be drawn per nursing 
protocol, and if not contraindicated at the time, the waste will be returned to the 
patient. A stopcock is used to decrease the risk of infection with returned blood. 
The line will be flushed with 0.9% normal saline and/or heparin as needed based 
on laboratory testing to be done. Flushing will use the Turbulent (push/pause) 
method to wash out any infusate or blood from the catheter. Samples for the 2,3-
dinor-8-isoprostaglandin-F2α are collected in the morning, which reduces 
intraperson variation, and stored at – 70 degrees Celsius until analysis (Zhang et 


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al, 2009). Samples for glutathione will be placed on ice and carried to the local 
laboratory where they will be prepared by diluting it with the precipitating solution 
containing N-ethylmaleimide, sulfosalicylic acid, EDTA and methanol, and the 
supernatant stored at – 80 °C until shipment on dry ice to the receiving laboratory 
for analysis.
All specimens will be routed through either the CTRC, Children's Hospital 
Colorado, or MacLean laboratory for processing and distribution to appropriate 
laboratories as well as for freezing of samples for batching and freezing of 
samples for possible studies in the future.
To reduce pain with venipuncture and or peripheral catheter placement, use of 
EMLA cream will be offered.  
Special considerations:
Patients taking salicylates or other platelet function modifying drugs (such as 
dipyridamole, ticlopidine, clopidogrel) will be excluded from the platelet function 
studies (platelet aggregration study and urine thromboxane B2 metabolites) but 
will otherwise participate in this study. 
Patients taking cGMP phosphodiesterase 5 inhibitors (such as sildenafil, tadalafil, 
vardenafil) will be excluded from the FMD studies, but can participate in all other 
parts of the study. 
These drugs will be identified during the screening interview and during the intake 
exam at the start of the study. 
I.
Documentation of a triglyceride level, obtained within the last five years, less than 
or equal to 300 mg/dl is required. If not available a level can be obtained any time 
after phone or in person consent and prior to in person re-consent at the start of 
the active protocol.  For those living locally, they can come to Children’s Hospital 
Colorado outpatient laboratory to have the sample collected and run as part of the 
study.  For those living distantly, the sample can be drawn locally and sent to the 
Children’s Hospital Colorado to be run as part of the study.  Participants will be 
provided with a shipping container and billing code for shipping expense.  The 
shipping cost and the cost of the lipid panel will be billed to the study.  Specimen 
drawing fees will also be reimbursed upon receipt of bill documenting charge.  
Expected Results:
It is anticipated that the biomarkers of oxidative stress and inflammation will be 
increased above the norm in participants and the degree of elevation will be 
related to Hcy levels.  A decrease in the elevation of the biomarkers is anticipated 
following treatment with taurine.  It is also anticipated that FMD studies will be 
abnormal in participants and that improvement will be seen following taurine 
supplementation.  We anticipate that platelet aggregation studies will be normal, 
but that markers of generalized activation of platelets, thromboxane B2 
metabolites, are elevated, and will reduce with treatment. Bone mineral density Z-
scores will be related to baseline TNF-α levels. 
J.
Potential Problems:
1. Recruitment: Given the rarity of the disorder, our potential participant sample 
volume is low.  Geographic and economic issues may make it difficult for some 


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potential subjects to participate in the study.  Low participation in the study might 
impact the statistical analysis of data. Should insufficient patients be recruited 
locally, then advertisement through national organization will be done to increase 
participation. Of note, while there is one report of Vitamin C supplementation 
ameliorating endothelial dysfunction in individuals with CBSDH, its use has not 
been widely investigated and use of Vitamin C to treat homocystinuria is not 
standard of care.  We therefore do not anticipate this excluding criteria to markedly 
effect recruitment.  
Patients with prescribed salicylate (such as Aspirin) therapy will not have this 
discontinued but will be excluded from the platelet function studies. We anticipate 
that this will impact up to 25% of the recruited population. A recruitment of 12 
patients will likely provide a minimum of 8 patients in which this clinically relevant 
measure can be analyzed. Should the percentage of patients taking platelet 
aggregation inhibitors exceed our anticipated number, then we will plan to extend 
the study to increase the number of patients to be enrolled.  Similar considerations 
are for use of cGMP phosphodiesterase 5 inhibitors (such as Viagra) and 
exclusion of FMD studies, although we doubt that the rate of patients taking this 
medication in our young age group would be as high as 25%. Overall, our goal is 
to recruit 8 patients that participate in all aspects of the study and are treated at 
the target dose of 150 mg/kg/day (maximum 10 g/day). 
Patients taking platelet aggregation inhibitors such as salicylate on a PRN basis 
that are unwilling or unable to stop taking the medication for the study period to 
include the two week washout period will be excluded from the study for the impact 
on platelet function but will participate in the remainder of the study 
2. Normal values: Normal values are available for nearly all measurements. 
Normal values are being developed by the CTRC laboratory for the Luminex panel 
of inflammatory markers and for TGF-beta.. Normal values for FMD studies will be 
developed from patients previously analyzed in the adult CTRC using the same 
methodology as discussed with Kerrie Moureau. 
K. Statistical Sampling, Sample Size and Analytical Plan 
This study benefits from the statistical assistance provided through the CCTSI. The 
protocol was reviewed by biostatistician Dexiang Gao, PhD. The services of Dr. Gao will 
be retained through the study. 
I.
The primary efficacy outcome parameters (Aim 2) are TBARS and TNF-α.
For each of these two parameters, there are two questions: 
A. Is the biomarker elevated in the untreated patient compared to control?
This question is required to validate the preliminary data. 
B. Does the biomarker decrease following treatment with taurine, after 4 hours 
treatment (immediate response) and after 4 days of treatment (short term 
treatment)? 
This question evaluates the impact or treatment on the primary outcome markers
Sample size and statistical power consideration: 
A. Is the biomarker (TNF-α, TBARS) elevated in CBSDH patients? Hypothesis 1 states 
that extracellular biomarkers of oxidative stress and inflammation in CBSDH patients will 
be increased compared with control patient values. The proposed study will include mostly 
patients who are untreated or poorly treated (non-compliant patients) for conventional 


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treatment, but can also have treated patients. To be conservative, we will use the 
preliminary data from the treated patients to power the study. 
For TNF-α, preliminary data showed a mean of 19.33±5.56 pg/ml in CBSDH 
conventionally treated patients compared with a mean in controls of 1.89±0.53 pg/ml. 
When the sample size is 8, a single group t-test with a 0.05 two-sided significance level 
will have 99% power to detect the difference between a null hypothesis mean TNF-α of 
1.89 pg/ml and an alternative mean of 19.33, assuming that the standard deviation is 5.56 
pg/ml. 
For TBARS, conventionally treated CBSDH patients had a mean TBARS of 2.92±0.38 
nmols/ml compared with mean TBARS of 2.23±0.33 nmols/ml in controls. When the 
sample size is 8, a single group t-test with a 0.05 two-sided significance level will have 
99% power to detect the difference between a null hypothesis mean TBARS of 2.23 
nmols/ml and an alternative mean of 2.92, assuming that the standard deviation is 0.38 
nmols/ml. 
Analysis plan: The mean, median, standard deviation, and 95% confidence intervals for 
TNF-α and TBARS will be generated. 
B. Does taurine decrease the primary outcome biomarkers of TNF-α and TBARS? 
Sample size and statistical power consideration: We hypothesize that taurine treatment 
will decrease oxidative stress and inflammation in CBSDH patients, which will be 
evaluated by comparing the levels of  TBARS and TNF-α after 4 hours and 4 days on 
taurine compared to the corresponding baseline levels (before treatment). The minimum 
number of evaluable patients on high dose taurine therapy is eight, but can be as high as 
10. Eight evaluable baseline paired samples provide 80% or higher power to detect an 
effect size in the range of 1.2-1.5, which is the standardized (by the standard deviation of 
the changes) mean difference between the alternative hypothesis of reduced oxidative 
stress/inflammation due to taurine therapy and the null hypothesis of high oxidative 
stress/inflammation before taurine treatment. A paired t-test was used for the calculation 
with a one-sided significance level of 0.05.
Power
Effect Size
0.95
1.30
0.9
1.15
0.8
0.98
To translate the effect size into the actual detectable level of the two markers, preliminary 
data showed a mean baseline TNF-α of 19.33±5.56 pg/ml in treated CBSDH patients. 
Assume the correlation coefficient (Rho) of TNF-α between baseline and 4 days (or 4 
hours) on taurine therapy is in the typical range of 0.1-0.5, and the variance of TNF-α on 
four days (or 4 hours) at taurine therapy time points are the same as at the baseline, then 
the detectable mean value of TNF-α at 4 days (or 4 hours) on therapy is 12.0 (for 
Rho=0.1)-13.9 (for Rho=0.5) with 80% power.   Similarly, mean baseline TBARS of 
2.92±0.38 nmols/ml were observed in CBSDH (treated) patients, assume that taurine can 
reduce TBARS level, the detectable mean value of TBARS at 4 days (or 4 hours) on 
therapy is 2.42 (for Rho=0.1)-2.55 (for Rho=0.5) with 80% power. 
Analysis plan: The mean and standard deviation of TNF-α and TBARS at baselines and 
on therapy will be calculated, and the changes from baseline to therapy times will also be 
calculated and reported along with 95% confidence intervals. One-sample t-test will be 
used to test if the changes are significantly different from zero for both TNF-α and TBARS. 


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 21 of 42
Effective 10/01/2006
II.
Secondary outcome measures: exploratory studies of other biomarkers 
of oxidative stress and inflammation,  relationship to metabolites and to 
markers relevant of symptomatology 
A. Other biomarkers of oxidative stress and inflammation: A similar analysis as 
outlined above for TNF-α and TBARS will be done for the exploratory biomarkers 
of oxidative stress and inflammation. Because of the multiple comparisons in the 
many biomarkers, an adjustment of p-values will be done (such a Bonferroni or 
given the exploratory nature, a more relaxed method such as a family wised 
approach (false discovery rate) may be used). The findings will be used to 
generate new hypotheses for further study on independent datasets.
B. Relationship to metabolites: For the relation to metabolites, the biomarkers listed in 
Table 1 will be correlated with total Hcy concentration using a Spearman’s rank 
correlation coefficient, since the Hcy values are not likely to be normally 
distributed. 
C. Relationship to pathophysiologically relevant parameters of major 
symptomatology: For the evaluation of endothelial function abnormalities in 
CBSDH patients and its mitigation with taurine supplementation, the percent 
change in brachial artery diameter and the percent change in brachial artery flow 
induced by hypoxemia, will be compared between pre-treatment and after 4 days 
treatment. A paired t-test will be calculated to test if the percent change is 
significantly different from zero. To test whether platelet aggregation is mitigated 
by taurine supplementation, percent aggregation will be compared pre-treatment 
and at day 4 post-treatment using a paired t-test. Also, urine levels of thromboxane 
B2 metabolites will be similarly compared. To relate the bone mineral density to 
TNF-α levels, the Z-score of the BMD will be related to pre-treatment TNF-α levels 
and the correlation assessed using a Spearman or a Pearson product moment 
correlation coefficient, depending on the evaluation of normality of distribution. 
Normality of distribution will be assessed as needed with Shapiro-Wilk test. Statistical 
analysis will be done using SAS or SPSS16.0. 
L. Data Management and Security Plan (contact Jeff Magouirk for assistance at 
720-777-8373):
The original data are paper-based, and paper copies of the data will be kept in a 
locked cabinet in the office of the PI. The investigators of this protocol will be 
working with the Data Management Services unit, of the Research Informatics 
department of the CCTSI to make sure the data collected in this protocol is 
managed in a proper fashion. The data collection for this protocol will be in a web-
based application that is HIPAA compliant.  It will only be access with a strong 
password and a user’s login.  The data is backed up nightly and backup tapes are 
sent to an offsite location.  The database has a transaction log of users and an 
audit trail of data changes.  Deidentified data will be exported for analysis in SPSS 
16.0 and Excel. 
M. Research Nursing Service Requirements (contact Diane Branham for 
assistance at 720-777-3195):
Nursing assistance is sought for patients at the outpatient unit of the pediatric 
CTRC (see details from Section 9). Nurses will be involved in, physical exam, 


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 22 of 42
Effective 10/01/2006
obtaining data forms, placement of a venous cathether and blood collection and 
urine collection, medication administration. 
I.
Source(s) of Research Material(s):
Taurine will be obtained via The Children’s Hospital Pharmacy, product 
having a certificate of analysis. Nitroglycerin will be supplied by The 
Children’s Hospital Pharmacy as Nitrostat. 
II.
Alternative Treatments Considered:
All participants have been and will continue to be offered the opportunity to 
be followed by their local inherited metabolic disease clinic wherein treatment 
recommendations for their disease are provided in accordance with the 
medical staff at that clinic.  There will be no recommendations for alteration 
of the participant’s standard treatment (i.e. diet, betaine (Cystadane), 
vitamins B12, B6, and/or folate) during the study.  Individuals prescribed 
Vitamin C for treatment of their homocystinuria will be excluded from the 
study.  While there is one report of Vitamin C supplementation ameliorating 
endothelial dysfunction in individuals with CBSDH, its use has not been 
widely investigated and it is not standard of care. There will be no 
recommendations for changes in any anticoagulation management that the 
subject might have been prescribed.  
Participants could choose to experiment with taking over the counter taurine. 
However, no data will then be available to the effects of such treatment. 
Blood Draws During Study Period:
For all protocols collecting blood the following is required.
Weight of eligible subjects (in kilograms): index case an 8 year old (the lower 
limit of age inclusion) 30 kg child.  For this index case a 3 mL/kg of body 
weight blood draw would be 90 mL; a 5 mL/ kg blood draw would be 150 mL.
Blood draw volumes: A maximum of 44.2mL of blood will be drawn at a given 
time point.  The maximum volume of blood drawn in one day is 70 mL.  The 
maximum volume of blood drawn for the entire study is 121.5mL.   These 
quantities of blood are well within 3 mL/kg of body weight for a single blood 
draw and a 5 mL/kg of body weight for any 8 week period for anticipated 
subject population.  In the unforeseen event, where in the sample volumes 
exceed the above noted limits; the volume drawn will be adjusted down to 
comply with the recommended limits.    
Study Visit 
description
Blood 
drawn 
for 
research 
(in mL)
Blood 
drawn 
for 
clinical 
purposes  
(in mL)
Total 
mL per 
visit
Total mL 
per day
Total 
research in 
ml. per 8 
week 
period
Total mL 
per 8 
week 
period


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Effective 10/01/2006
Prior to active 
study
1.5 
0
1.5
1.5
1.5
1.5
Study day 1, 
SUN
12 noon
(biochemical 
research labs 
and DNA)
21.2
0
21.2
21.2
22.7
22.7.
Study day 2, FRI 
8:00 AM 
Baseline, 
(biochemical 
research labs, 
safety labs, and 
platelet 
aggregation 
studies) 
44.2
0
44.2
44.2
66.9
66.9
Study day 2, FRI
30 min taurine 
level
0.5
0
0.5
44.7
67.4
67.4
Study day 2, FRI 
1 hr taurine level
0.5
0
0.5
45.2
67.9
67.9
Study day 2, Fri
2 hr taurine level
0.5
0
0.5
45.7
68.4
68.4
 Study day 2, FRI
 4 hours post 
initiation of 
therapy studies 
 (peak value 
levels)
1st day of therapy
(biochemical 
research labs)
15.2
0
15.2
60.9
83.6
83.6
Study day 2, FRI
6 hour taurine 
level
0.5
0
0.5
61.4
84.1
84.1
Study day 2 FRI
8 hr taurine level
0.5
0
0.5
61.9
84.6
84.6
Study day 2 FRI
12 hour taruine 
level
0.5
0
0.5
62.4
85.1
85.1
Study  day 6, 
TUE
8:00 AM
last day of 
therapy and end 
of study
(biochemical 
39.2
0
39.2
39.2
124.3 
124.3


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 24 of 42
Effective 10/01/2006
research labs, 
safety labs, and 
platelet studies) 
III.
Describe Recruitment Plan. How Will You Identify and Recruit Enough 
Subjects:
Subjects will be primarily recruited from the Inherited Metabolic Disease 
Clinic patient population.  All individuals identified by the PI or co-
investigators as receiving care at the Inherited Metabolic Disease Clinic for 
CBSDH who meet the inclusion criteria will be given the opportunity to 
participate.  Patients will be informed of the study and provided the option to 
participate by either (1) face to face conversation at a clinic visit, (2) by 
phone conversation or (3) by letter.  A maximum of three phone contacts or 
letters will be sent to potential participants.  A script for the conversation or 
the letter to inform of the study and to check interest will be as outlined 
below. 
If more subjects are needed, we will also contact other physicians who 
provide care to patients with CBSDH in the region, informing them of our 
study and providing them with HIPAA-A forms to give to their patients.  For 
the advertisement about this study, see Appendix V Supplemental Materials. 
It will be the duty of these non-investigator physicians and/or the patient to 
contact the PI regarding interest in enrollment into the study.  Additional 
physicians specialized in metabolic diseases caring for patients with CBSDH 
may be informed through e-mail on the widely subscribed metab-l listing, 
through the SIMD website (Society for Inherited Metabolic Diseases) and 
through the on-line journal Perspectives in Genetic Counseling, which lists 
such studies for genetic counselors. This would be done via an 
announcement about the study by the PI. Recruitment of patients through 
family support groups is another option. The study will be listed on 
clinicaltrials.gov as required by the FDA, and may be listed with NORD 
(National organization for Rare Disorders). Interested individuals would then 
need to contact the PI regarding interest in enrollment.  There will be no 
discrimination based on age, gender, or ethnic heritage. 
Informed Consent Plan. Who/How/Where Will You Get Consents? HIPAA 
Authorizations?:
The consenting process consists of 5 phases: 
1.
Identification of potential participants
2.
Screening interview (See Appendix - V Supplemental Material)
3.
Consent 
4.
Lack of documentation of a less than or equal to 300 mg/dl 
triglyceride level collected within the last five years triggers a need 
to obtain a triglyceride level before in person re-consent process 
when active portion of the study starts.
5.
Re-consent at start of the active phase of the study
Part 1: Identification of potential participants


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Effective 10/01/2006
Potential subjects identified from the PI’s and co-investigators’ patient 
population will be informed of the study in person, per phone, or via letter by 
the PI or co-investigators. This will be done without making a database as 
the number of potential subjects is small and eligible participants easily 
recalled by the PI and co-investigators.  Ideally potential participants will be 
informed of the study face to face, most likely at a clinic visit.  If they express 
interest in the study a screening interview will ensue (see phase 2). 
Due to geographic considerations and the two week wash-out period contact 
of potential subjects, screening interview, and consent process may 
necessarily be done by phone and/or mail prior to the subject’s long-distance 
travel to Denver.  In these cases, potential subjects will be notified of the 
study by the PI or co-investigators by phone or mail.  If the potential subject 
expresses interest in the study, with their consent, a screening interview will 
ensue.  
For potential subjects recruited outside of the PI’s clinical population the PI or 
co-investigator will respond to a HIPAA authorization (obtained by non-
investigating physician) and to direct requests by the patient for information 
in the fashion outlined above for phone contacts. 
Part 2: Screening interview. 
First participants will be consented on their participation into the screening 
interview for eligibility into the study (See Appendix V Supplemental 
Materials for a script). We are asking for a waiver of the documentation of the 
consent of the screening interview. 
Part 3: Consent: 
If they meet criteria for enrollment, options to consent per phone or in person 
will be given.  Consent process will proceed accordingly. Prior to consenting 
subjects/parents/guardians will be given a copy of the IRB approved consent 
form (Attachment A) as well as the Patient Information and Authorization 
(HIPAA) form. For patients not in the clinic, these forms will be mailed to 
them with their permission. The study will be reviewed and participants will 
have the opportunity to review the consents and ask questions about the 
study.  All questions will be answered prior to signing the consent/assent.  
Phone consents will be done after asking the participant if they have time to 
do the process in a manner that will ensure they are fully informed. For a 
face to face consenting process, this will be documented by original 
signatures. For phone consents, participants will give consent to both the 
consenting investigator and a witness, which will be documented by the 
signatures of the consenting investigator and witness. Further paper-based 
documentation of the consent will then be done upon reconsenting (see part 
4). 
1.
Lack of documentation of a less than or equal to 300 mg/dl 
triglyceride level collected within the last five years triggers a need 
to obtain a triglyceride level before in person re-consent process 
when active portion of the study starts.


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 26 of 42
Effective 10/01/2006
Part 4. Re-consent
All patients will be re-consented when they are at the center, on the first day, 
prior to the active phase of the research study.  Face to face consents will be 
done in a private room with ample time to answer any questions raised and 
to discuss all issues of concern to the potential subject. Consent will be 
documented on paper with all signatures. 
Special Consent/Assent Plan (if applicable):
Assent will be obtained for children ages 8 to 17 or as per local IRB regulations.  
This includes phone assents when appropriate.  For children ages 8 to 17 signed 
consent from both parents, should both parents be involved in medical care 
decision making, will be required. If only one parent can be reached, this will be 
documented. 
 
8. Data and Safety Monitoring Plan*
A. Summarize the Data and Safety Monitoring Plan (DSMP) for this protocol:
The PI will monitor data and report on the protocol safety issues.  Pregnancy test 
results which are part of the inclusion criteria will be reviewed the day of specimen 
collection, prior to 5 PM (and hence prior to start of taurine supplementation).  
Serum triglyceride level will also be reviewed prior to start of taurine 
supplementation.  Those with levels greater than 300 mg/dl will be excluded from 
the study.  Participants will be encouraged to call regarding any adverse event of 
concern to them during the period of supplementation.  A review of systems, 
utilizing a form with questions targeted to capture potential adverse effects (See 
Intake Sheet and Adverse Event/Compliance Sheet, Appendix V – Supplemental 
Materials) will be administered prior to the first dose and with the last dose of 
taurine, and again 1 week after completion of the study (the last survey 
administered by telephone).  This questionnaire will be administered by the PI, co-
investigator, or CTRC nursing staff   Participants will also be questioned directly 
about potential adverse effects relative to taurine intake at the time of their last 
dose.  A physical examination including blood pressure will be done prior to taurine 
administration, and at the completion of the study.  Blood samples for complete 
blood count, comprehensive metabolic panel, and a lipid panel will be obtained 
prior to taurine administration, and at the completion of the study.  
Adverse events and monitoring lab studies data will be reviewed within 5 working 
days after the subject has completed the study protocol.  Compiled data will be 
examined 1. after the first two patients have been treated at the lower dose of 50 
mg/kg/day (3 g/day), 2. after the first four adults have completed the study prior to 
opening the study for recruitment of children, 3. at the mid-point of the next patient 
recruitment (after 7 subjects have completed the protocol and after 12 subjects) 4. 
at the end of the study by the PI, co investigators and data Safety Officers.  The 
data Safety Officers will consist of two clinical geneticists and one alternate clinical 
geneticists not associated with the study but knowledgeable of the studied 
condition.  The PI and the data Safety Officers board will be looking for repeat 


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 27 of 42
Effective 10/01/2006
adverse events (AEs) or trends in AEs. In addition, the data Safety Officers and PI 
and co-investigators will convene within one week of reporting of a SAE. 
Current Safety Officers: 
Ellen Elias, MD
Tel. 720-777-5401
Children’s Hospital Colorado
Special Care Clinic
13123 E 16th Ave Box B-032
Aurora, Co 80045
Laura Pickler, MD
 Tel. 720-777-7450
AOB building TCH, B032
David Manchester, MD (alternate)
Tel. 303-724-2332
Education 2 South, Room L28-4120
Unanticipated problem or events, especially problems or events that are possibly 
or probably related to the study or research procedures will also be looked for.  
This includes monitoring for serious adverse events (SAEs) since such an event is 
not anticipated.  In an event of an SAE, the monitoring PI will discuss the event 
with one of the co-investigator MDs within 24 hours of knowledge of the event to 
allow for decisions regarding the data and the safety to all participants.  All 
unanticipated problems and unanticipated events will also be discussed with one 
of the co-investigating MDs within five working days of knowledge of the problem 
or event.  Any identified trend in AEs will also be discussed within five working 
days of knowledge of the trend with one of the co-investigator MDs.  Of note, the 
minimal risk for adverse events relative to taurine intake,  the low number of 
participants (N=16 with drug exposure) and short duration of the study (5 days) 
make it very unlikely that any AE trend would be detected much before the end of 
the study.     
 There are no conflicts of interest for the PI or the co-investigator MDs responsible 
for data safety management.  
B. Describe SAEs and AEs for this protocol and the SAE/AE reporting plan:
Events that result in death, immediate hospitalization, or prolonged hospitalization 
to prevent death or serious disability will be considered SAEs.  Any other untoward 
medical occurrence temporally associated with the study will be considered AE.  
This includes headaches, gastrointestinal discomfort, and other events captured 
on the adverse event/compliance sheet that are without significant health risk 
and/or are potentially unrelated to study.  Clinically significant changes in blood 
pressure or safety monitoring labs will be considered an AE. Specifically, liver 
function results that exceed two times the upper limit of normal, triglycerides 
greater than 400 mg/dl, and/or hypotension, with a blood pressure <90mmHg in 
adults or <the 5th percentile for age in children after taurine supplementation, will 


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 28 of 42
Effective 10/01/2006
be considered an adverse event in the setting of normal subject values prior to 
taurine supplementation.  Any intercurrent illness or injury that represents an 
exacerbation of pre-existing condition (e.g., increase frequency or severity) will 
also be considered an AE.  In such cases it will be preferred to record the 
diagnosis as the AE rather than a series of terms relating to the diagnosis (e.g., 
worsening of asthma).   An adverse drug reaction will be all noxious and 
unintended responses to taurine product.  This means that a causal relationship 
between taurine and an AE is at least a reasonable possibility (i.e., he relationship 
cannot be ruled out).  
The PI and one of the co-investigating MDs will determine the severity of the event 
and if the SAE or AE is related to the protocol using the categories noted below.  
Review of their determination will be sought from the Safety Officers.  In the case 
of deferring opinions, higher grade of severity the more related rating will be 
accepted
Grade
Description
Mild
No limitation of usual activities
Moderate
Some limitation of usual activities
Severe
Inability to carry out activities
Not 
Related
The adverse finding was present prior to exposure to the 
investigational product, having the same or milder intensity
OR
The finding is considered likely to be related to an etiology other than 
the investigational product, that is, there is no evidence or arguments 
to suggest a causal relationship to the investigational product.
Possibly 
related
Exposure to investigational product and onset of the finding are 
reasonably related in time
AND
The adverse finding could be reasonably be explained by factors or 
causes other than exposure to investigational product.
Probably 
related
Exposure to investigational product and onset of the finding are 
reasonably related in time
AND
The adverse finding is more likely explained by exposure to 
investigational product than by other factors or causes.
SAEs will be reported to one of the co-investigator MDs as well as the Safety 
Officers, FDA, COMIRB, the CTRC within five working days of knowledge of the 
event.  The participant’s PCP will also be notified if deemed appropriate by the co-
investigator MD.  Unanticipated problems or events that result in an actual 
unforeseen harmful or unfavorable occurrence to the subject or others with also be 
reported to one of the co-investigating MDs within five working days of knowledge 
of the event. Information that indicates a change to the risks or benefits of the 
study will also be reported within five days of discovery to the Safety Officers, 


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 29 of 42
Effective 10/01/2006
FDA, COMIRB and CTRC. No new patients will be enrolled or studied until the 
SAE has been reviewed and appropriate action taken by the above listed bodies. 
The PI will notify co-investigator MDs of abnormal safety monitoring lab results 
within five working days of resulted values.  If deemed clinically appropriate by co-
investigator MD, the subjects PCP will be notified.  All other AEs will be logged and 
reported to COMIRB yearly or at the time of continuing review.  
For full list of events to be reported to COMIRB see the Reportable Event Sheet to 
be used for monitoring and tracking individual events attached in Appendix V - 
Supplemental Materials.   
A summary of data monitoring and reporting flow during the active portion of the 
study is noted below.  A flow diagram of this information can be found in Appendix 
V - Supplemental Materials in the CTRC protocol application. 
 
Pregnancy testing will be done on day 1, one day prior to the administration of 
taurine and reviewed by 5:00 PM that day.  Positive test results will exclude the 
individual from participation in the study.  A physical examination (to include blood 
pressure) and the Adverse Event Sheet Questionnaire will be completed on day 1 
and just prior to taurine administration respectively.  They will be repeated after 
administration of the last taurine dose.  This data will be reviewed within 5 working 
days after the subject has completed the study protocol.  Liver function study 
results that exceed two times the upper limit, triglycerides results that are greater 
than 400 mg/dl, and/or hypotension (blood pressure <90mmHg in adults or < the 
5th percentile for age in children) as well as any clinically significant alteration in 
safety monitoring laboratory studies (as assessed by the co-investigating MD) that 
is present in two or more subjects in the setting of normal subject values before 
taurine supplementation will be reported to the co-investigators, FDA, COMIRB, 
CTRC, and Safety Officers within 5 working days of knowledge of this data.  The 
protocol will be temporarily suspended pending review of collected data and 
recommendation about study continuance by Safety Officers, FDA, COMIRB and 
CTRC.
All unanticipated problems and unanticipated events will also be discussed with 
one of the co-investigating MDs within five working days of knowledge of the 
problem or event.  Any identified trend in AEs will also be discussed within five 
working days of knowledge of the trend with one of the co-investigator MDs. 
Compiled data will be examined for safety after 2, 4, and 8  subjects have 
completed the protocol  and at the end of the study by the PI, co investigators and 
data Safety Officers The PI, co-investigators and the data Safety Officers board 
will be looking for repeat adverse events (AEs) or trends in AEs.
SAEs will be reported to the study project manager, the PI or one of the lead site 
co-investigator MDs , FDA, COMIRB, local IRB as per their requirement, and the 
CTRC within five working days of knowledge of the event.  In addition, the data 
Safety Officers and PI and co-investigators will convene within one week of 
reporting of a SAE.


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C. Describe both subject discontinuation criteria and protocol stopping criteria:
With respect to the FMD studies, if an adult systolic blood pressure is < 105 mmHg 
or a child’s blood pressure is < 10th percentile for age, nitroglycerin will not be 
administered.  The subject will otherwise be maintained in the study.  
With respect to the study in general, subject discontinuation criteria are as follows.

Positive pregnancy test

Any SAE that is possibly related to the study protocol.   
Protocol stopping criteria are listed below.  Such events will result in the study 
being temporarily suspended pending review of collected data and 
recommendation about study continuance by Safety Officers, FDA, COMIRB and 
CTRC.

Any SAE that is possibly related to the study protocol.  

Liver function study results that exceed two times the upper limit, if 
triglycerides are greater than 400 mg/dl, and/or if hypotension (blood 
pressure <90mmHg in adults or < the 5th percentile for age in children) is 
present in two or more subjects in the setting of normal subject values 
before taurine supplementation.

Any clinically significant alteration in safety monitoring laboratory studies, 
as assessed by the co-investigating MD and/or the Safety Officers that is 
present in two or more subjects in the setting of normal subject values 
before taurine supplementation.  
Currently there is no funding source outside of the university, thus we do not 
expect an outside agent to have authority to suspend this trial, other than general 
regulatory authorities of the institution and the FDA in its general capacity to 
oversee drugs and food supplements. Actions that result in suspension or 
termination of the protocol, whether by COMIRB or some other entity, will be 
reported to the Pediatric General Clinical Research Center and the IRB verbally 
within 24 hours and via written documentation within 2 working days.  
D. Plans for assuring data accuracy and protocol compliance:
The PI will conduct protocol compliance checks.  Accuracy of the laboratory data 
related to safety is assured via use of Clinical Laboratory Improvement 
Amendments (CLIA) certified laboratory. 
The investigators of this protocol will be working with the Data Management 
Services Unit of the Research Informatics department of the CCTSI to ensure the 
data collected in this protocol is managed in a proper fashion. The data collection 
for this protocol will be in a web-based application that is HIPAA compliant.  It will 
only be access with a strong password and a user’s login.  The data is backed up 
nightly and backup tapes are sent to an offsite location.  The database has a 
transaction log of users and an audit trail of data changes.  The paper copies of 
the data will be kept in a locked cabinet


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 31 of 42
Effective 10/01/2006
10. References/Literature Cited
Au-Yeung KK, Woo CW, Sung FL, Yip JC, Siow YL, O K. Hyerhomocysteinemia 
activates nuclear factor-kappaB in endothelial cells via oxidative stress. Circ Res. 
2004 Jan 9;94(1):28-36. 
Ahn C S. Effect of taurine supplementation on plasma homocysteine levels of the 
middle-aged Korean women. Adv Exp Med Biol 2009;643:415-422.
 
Boger RH, Bode-Boger SM, Thiele W, Creutzig A, Alexander K, Frolich JC. 
Restoring vascular nitric oxide formation by L-arginine improves the symptoms of 
intermittent claudication in patients with peripheral arterial occlusive disease. J Am 
Coll Cardiol. 1998;32:1336-1344.
Celermajer DS, Sorensen K, Ryalls M, Robinson J, Thomas O, Leonard JV, 
Deanfield JE. Impaired endothelial function occurs in the systemic arteries of 
children with homozygous homocystinuria but not in their heterozygous parents. J 
Am Coll Cardiol. 1993 Sep;22(3):854-858.
Corretti MC, Anderson TJ, Benjamin EJ, Celermajer D, Charbonneau F, Creager 
MA, Deanfield J, Drexler H, Gerhard-Herman M, Herrington D, Vallance P, Vita J, 
Vogel R. Guidelines for the ultrasound assessment of endothelial-dependent flow-
mediated vasodilation of the brachial artery: a report of the International Brachial 
Artery Reactivity Task Force. J Am Coll Cardiol. 2002;39:257-265.
Corretti MC, Plotnick GD, Vogel RA. Technical aspects of evaluating brachial 
artery vasodilatation using high-frequency ultrasound. Am J Physiol. 
1995;268:H1397-1404.
Davì G, Di Minno G, Coppola A, Andria G, Cerbone AM, Madonna P, Tufano A, 
Falco A, Marchesani P, Ciabattoni G, Patrono C. Oxidative stress and platelet 
activation in homozygous homocystinuria. Circulation. 2001 Sep 4;104(10):1124-
1128.
Dakak N, Husain S, Mulcahy D, Andrews NP, Panza JA, Waclawiw M, Schenke 
W, Quyyumi AA. Contribution of nitric oxide to reactive hyperemia: impact of 
endothelial dysfunction. Hypertension. 1998;32:9-15.
Dalle-Donne I, Rossi R, Colombo R, Giustarini D, Milzani A. Biomarkers of 
oxidative damage in human disease. Clin Chem 2006;52(4):601-623.
De Curtis M, Santamaria F, Ercolini P, Vittoria L, De Ritis G, Garofalo V, 
Ciccimarra F. Effect of tuarine supplementation on fat and energy absorption in 
cystic fibrosis. Arch Dis Child 1992;67:1082-1085.
Durelli L, Mutani R, Fassio F. The treatment of myotonia : evaluation of chronic 
oral taurine threapy. Neurology 1983;33:599-603.
Eskurza I, Monahan KD, Robinson JA, Seals DR. Ascorbic acid does not affect 
large elastic artery compliance or central blood pressure in young and older men. 
Am J Physiol Heart Circ Physiol. 2004;286:H1528-1534.


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 32 of 42
Effective 10/01/2006
Fujita T, Ando K, Noda H, Ito Y, Sato Y. Effects of increased adrenomedullary 
activity and taurine in young patients with borderline hypertension. Circulation 
1987;75:525-532.
Galloway SD, Talanian JL, Shoveller AK, Heigenhauser GJ, Spriet LL.  Seven 
days of oral taruine supplementation does not increase muscle taurine contenet or 
alter substrate metabolsim during prolonged exercise in humans.  J Appl Physiol 
2008:105(2):643-51
Greiner LS, Raab B, Stabler SP, Allen RH, Kraus JP, Overdier KL, Crnic LS, 
Maclean KN. Mouse models of CBS deficient homocystinuria: From microarrays to 
a novel improved treatment. Abstract C060. 5th Annual International 
Homocysteine Conference, Milan, Italy June 26-30,2005. Published in 
Haematologica Reports; p25, 1(3) June 2005
Haas, E. Health world on line. Staying healthy with nutrition: the complete guide to 
diet and nutritional medicine. Taurine [on line]. [July 27, 2009]. Available from 
World Wide Web: <http://www.healthy.net/scr/article.asp?ID=1971>
Huxtable R. J. Physiological actions of taurine. Physiol Rev 1992;72:101-163.
Hwang SY, Woo, CW, Au-Yeung KK, Siow YL, Zhu TY, OK,  Homocysteine 
stimulates monocyte chemoattractant protein-1 expression in the kidney via 
nuclear factor-kappB activation.  Amer J Physiol Renal Physiol. 2008 
Jan:294(1):F236-244.
Laidlaw S, Shultz T, Cecchino J, Kopple J.  Plasma and urine taurine levels in 
vegans. Am J Clin Nutr. 1988 Apr;47(4):660-663.
Liao JK, Bettmann MA, Sandor T, Tucker JI, Coleman SM, Creager MA. 
Differential impairment of vasodilator responsiveness of peripheral resistance and 
conduit vessels in humans with atherosclerosis. Circ Res. 1991;68:1027-1034.
Machado-Vieira R, viale CI, Kapczinski F. Mania associated with an energy drink: 
the possible role of caffeine, taurine, and inositol. Can J Psychiatry 
2001;46(5):454-455. 
Maclean KN, Gaustadnes M, Oliveriusová J, Janosík M, Kraus E, Kozich V, Kery 
V, Skovby F, Rüdiger N, Ingerslev J, Stabler SP, Allen RH, Kraus JP. High 
homocysteine and thrombosis without connective tissue disorders are associated 
with a novel class of cystathionine beta-synthase (CBS) mutations. Hum Mutat. 
2002 Jun;19(6):641-655.
McCarty MF. Sub-optimal taurine status may promote platelet hyperaggregability 
in vegetarians. Med Hypotheses. 2004;63(3):426-33.
Monson, K, Schoenstadt, A.  2008. Med TV, Information brought to life. 
Congestive heart. Taurine dosage [on line]. [July 27 2008].  Available from World 


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 33 of 42
Effective 10/01/2006
Wide Web:  <http://congestive-heart-failure.emedtv.com/taurine/taurine-
dosage.html>
Mudd SH, Skovby F, Levy HL, Pettigrew KD, Wilcken B, Pyeritz RE, Andria G, 
Boers GH, Bromberg IL, Cerone R, et al.The natural history of homocystinuria due 
to cystathionine beta-synthase deficiency. Am J Hum Genet. 1985 Jan;37(1):1-31.
Mutani R, Bergamini L, Durelli L. Taurine in experimental and human epilepsy. In: 
Barbeau A and Huxtable R J (eds) Taurine and Neurological Disorders. Raven 
Press, New York, 1978, pp. 359-373.
Nakamura T, Saito Y, Kato T, Sumino H, Hoshino J, Ono Z, Sakamaki T, Nagai R. 
Flow-mediated vasodilation of a conduit artery in relation to downstream peripheral 
tissue blood flow during reactive hyperemia in humans. Jpn Circ J. 1997;61:772-
780.
Nonaka H, Tsujino T, Watari Y, Emoto N, Yokoyama M. Taurine prevents the 
decrease in expression and secretion of extracellular superoxide dismutase 
induced by homocystine: Amerlioration of homocystine-induced endoplasmic 
reticulum stress by taurine.  Circulation 2001;104:1165-1170
Obermann M, Schorn CF, Mummel P, Kastrup O, Maschke M. Taurine induced 
toxic encephalopathy? Clin Neurol Neurosurg 2006;108(8):812-813. 
Oudit GY, Trivieri MG, Khaper N, Husain T, Wilson GJ, Liu P, Sole MJ, Backx PH. 
Taurine supplementation reduces oxidative stress and improves cardiovascular 
function in an iron-overload murine model. Circulation. 2004 Apr 20;109(15):1877-
1885.
Passantes-Morales H, Quiroz H, Quesada O. Treatment with taurine, diltiazem, 
and vitamin E retards the progressive visual field reduction in retinitis pigmentosa: 
a 3-year follow-up study. Metab Brain Dis 2002;17(3): 183-197.
Parvez S, Tabassum H, Banerjee BD, Raisuddin S. Taurine prevents tamoxifen-
induced mitochondrial oxidative damage in mice. Basic Clin Pharmacol Toxicol. 
2008 Apr;102(4):382-387. 
Pullin CH, Bonham JR, McDowell IF, Lee PJ, Powers HJ, Wilson JF, Lewis MJ, 
Moat SJ. Vitamin C therapy ameliorates vascular endothelial dysfunction in treated 
patients with homocystinuria. J Inher Metab Dis. 2002 May;25(2):107-118.
Ryan M, McInerney D, Owens D, Collins P, Johnson A, Tomkin GH. Diabetes and 
the Mediterranean diet: a beneficial effect of oleic acid on insulin sensitivity, 
adipocyte glucose transport and endothelium- dependent vasoreactivity. Q J Med. 
2000;93:85-91.
Scriver SR, Beaudet AL, Sly WS, Valley D, Childs B, Kinzler K, Vogelstein B. The 
Metabolic and Molecular Bases of Inherited Disease. Eight Edition. McGraw-Hill 
Medical Publishing Division 2001. Disorders of Transsulfuration. P.2007-2056.


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Effective 10/01/2006
Shao A, Hathcock JN. Risk assessment for the amino acids taurine, l-glutamine 
and l-arginine. Regul Toxicol Pharmacol. 2008 Apr;50(3):376-399.  
Szamosi T, Roth E, Szamosi T Jr, Tomsits E, Tordai A, Szabo T. 
Hyperhomocysteinemia, enzyme polymorphism and thiobarbituric acid reactive 
system in children with high coronary risk family history. J Am Coll Nutr. 2004 
Oct;23(5):386-390. 
Takahashi R, Nakane Y. Clinical trial of taurine in epilepsy. In: Barbeau A and 
Huxtable R J (eds) Taurine and Neurological Disorders. Raven Press, New York, 
1978, pp. 375-385.
Taş S, Dirican M, Sarandöl E, Serdar Z.The effect of taurine supplementation on 
oxidative stress in experimental hypothyroidism. Cell Biochem Funct. 2006 Mar-
Apr;24(2):153-158.
Toborek M, Kopieczna-Grzebieniak E, Drózdz M, Wieczorek M. Increased lipid 
peroxidation as a mechanism of methionine-induced atherosclerosis in rabbits. 
Atherosclerosis. 1995 Jun;115(2):217-24.
Wilcken DE, Wang XL, Adachi T, Hara H, Duarte N, Green K, Wilcken B. 
Relationship between homocysteine and superoxide dismutase in homocystinuria: 
possible relevance to cardiovascular risk. Arterioscler Thromb Vasc Biol. 2000 
May;20(5):1199-1202. 
Zhang M, Izumi I, Kagamimori S, Sokejima S, Yamagami T, Liu Z, Qi B. Role of 
taurine supplementation to prevent exercise-induced oxidative stress in healthy 
young men.Amino Acids. 2004 Mar;26(2):203-207. 
Supplementary materials:
1. Intake Sheet
Oxidative Stress Markers in Inherited Homocystinuria and the Impact of Taurine
Intake Sheet
Subject Name:_________________  Date:__________ 
Characteristic 
Comment
Sex
 
Age
 
BMI
Salicylate intake over last two weeks
Vitamin intake over last two weeks
Supplement intake over last two weeks 
(taurine) 
 
Viagra intake over last two week/possible 
use over next 6 days
Smoking habits
 
Hypertension
 
Diabetes
 


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Other chronic disease
 
Infection
Hormone replacement use
Pregnancy
Physical activity
Diet prescription/compliance 
Medications/compliance
(list all medications and dosing_
Reviewed by PI or co-investigator on: ____
Proceed for nitroglycerin induced FMD YES/NO*
Proceed for platelet studies YES/NO*
*circle appropriate
System
Yes 
No 
Comments
(to include any limitations of 
activity)
General/Constitutional
 
 
 
 
general state of health
 
 
 
 
sense of well being 
 
 
 
 
fever
 
 
 
 
other
 
 
 
Skin
 
 
 
 
rash
 
 
 
 
moisture/dryness
 
 
 
 
other
 
 
 
HEENT
 
 
 
 
headaches
 
 
 
 
vision
 
 
 
 
hearing
 
 
 
 
other
 
 
 
Cardiovascular
 
 
 
 
palpitations
 
 
 
 
syncope
 
 
 
 
other
 
 
 
Respiratory
 
 
 
 
difficulty breathing
 
 
 
 
wheezing
 
 
 
 
cough
 
 
 
 
other
 
 
 
Gastrointestinal
 
 
 
 
appetite
 
 
 
 
abdominal pain
 
 
 
 
heartburn
 
 
 
 
diarrhea
 
 
 


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nausea
 
 
 
 
other
 
 
 
Musculoskeletal
 
 
 
 
pain
 
 
 
 
cramps
 
 
 
 
other
 
 
 
Genitourinary
 
 
 
 
dysuria
 
 
 
 
other
 
 
 
Neurologic/Psychiatric
 
 
 
 
seizures
 
 
 
 
muscular coordination
 
 
 
 
emotional mood
 
 
 
 
other
 
 
 
Allergic/Immunologic
 
 
 
 
reactions to drugs/foods
 
 
 
 
other
 
 
 
II. Adverse Event Sheet:
Oxidative Stress Markers in Inherited Homocystinuria and the Impact of Taurine
Adverse Event/Compliance Sheet
Subject Name:_________________  Date:_____   Taurine intake: 
______________
System
Yes 
No 
Comments
General/Constitutional
 
 
 
 
general state of health
 
 
 
 
sense of well being 
 
 
 
 
Fever
 
 
 
 
Other
 
 
 
Skin
 
 
 
 
Rash
 
 
 
 
moisture/dryness
 
 
 
 
Other
 
 
 
HEENT
 
 
 
 
Headaches
 
 
 
 
Vision
 
 
 
 
Hearing
 
 
 
 
Other
 
 
 


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Effective 10/01/2006
Cardiovascular
 
 
 
 
Palpitations
 
 
 
 
Syncope
 
 
 
 
Other
 
 
 
Respiratory
 
 
 
 
difficulty breathing
 
 
 
 
Wheezing
 
 
 
 
Cough
 
 
 
 
Other
 
 
 
Gastrointestinal
 
 
 
 
Appetite
 
 
 
 
abdominal pain
 
 
 
 
Heartburn
 
 
 
 
Diarrhea
 
 
 
 
Nausea
 
 
 
 
Other
 
 
 
Musculoskeletal
 
 
 
 
Pain
 
 
 
 
Cramps
 
 
 
 
Other
 
 
 
Genitourinary
 
 
 
 
Dysuria
 
 
 
 
Other
 
 
 
Neurologic/Psychiatric
 
 
 
 
Seizures
 
 
 
 
muscular coordination
 
 
 
 
emotional mood
 
 
 
 
Other
 
 
 
Allergic/Immunologic
 
 
 
 
reactions to drugs/foods
 
 
 
 
Other
 
 
 
III. Reportable event sheet
Oxidative Stress Markers in Inherited Homocystinuria  and the Impact of Taurine
Reportable Event Sheet
EVENT
Date of 
Knowledge 
of Event
Date 
Reported 
to 
COMIRB
Comments
Unforeseen harmful/unfavorable 
event, felt to possibly  be related  
to study
injury
psychological event
other


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Unforeseen harmful/unfavorable 
event, felt to be unrelated to study
injury
psychological event
other
Unforeseen development that 
increases likelihood of harm
midterm review
new safety data on taurine 
supplementation
other
Problem involving data
data collection
data storage
data privacy
data confidentiality
Change in subjects status
incarceration of subject
pregnancy of subject
other
Change in protocol for subject 
safety done prior to COMIRB 
review
apparent immediate hazard
Complaint of participant that can't 
be resolved or suggest risk
complaint
Unintentional protocol violation 
that harmed or may cause harm
violation
Noncompliance by the PI or 
research team
noncompliant activity
Other
other
IV. Advertisement for subject recruitment
Advertisement for subject recruitment: 
You are invited to participate in a study investigating homocystiuria. The 
study is being conducted by  (Site Specific Providers) at (Site Location).  The 
study investigates why individuals with homocystinuria have health problems 
and if a new investigative treatment with taurine is beneficial. The study will 
not provide direct benefit to the participant but will provide generalizable 
information on homocystinuria.  


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To be eligible to participate in the study individuals must be between the 
ages of 8 to 50 year and have a diagnosis of homocystinuria due to 
cystathionine beta-synthase deficiency that is not fully responsive to therapy 
withtotal homocysteine (tHcy) levels greater than 50 μmol/L. Individuals 
cannot participate if they are (1) pregnant, (2) have hypertriglyceridemia, (3) 
have another significant illness, and/or (4) are being treated with Vitamin C, 
taurine supplementation, and/or high dose antioxidant supplementation and 
cannot discontinue this.. Participants who have a cold, the flu or other short 
term illness will be asked to delay participation until they are recovered.
The study will require the participant to be in (Site Location)  for three days of 
the six day study period. Most commonly, participants will be in  (Site 
Location) on Thursday and Friday and on Tuesday of the next week.  Some 
compensation for travel and time is available.  
For further information, please contact
 (Insert Site Specific Information)
V. Information letter to physician for patient referral 
Date
Dear 
We are currently recruiting for a research study title “Oxidative Stress Markers in Inherited 
Homocystinuria and the Impact of Taurine”, which has been approved by the Colorado 
Multiple Institution Review Board.  The study examines individuals with homocystinuria 
due to cystathionine β-synthase deficiency. It looks at biochemical markers of oxidative 
stress and inflammation, platelet function and endothelial function. It also examines the 
response to short-term taurine supplementation. 
We would greatly appreciate your assistance in notifying individuals or families of 
individuals with homocystinuria due to cystathionine β-synthase deficiency of this study.  
The family can call us directly to discuss the protocol should they be interested.  This is an 
approach which has worked well in the past.  Alternatively, we have enclosed a HIPAA 
Research Recruitment Form.  When signed, this form allows you to release contact 
information on the family to us. Once we have it, we will initiate the call to the family. 
Please do not hesitate to call should you have questions or need more packets.
Contact Information:
(Insert Site Specific Information)
Sincerely,
(Insert Site Specific Information)
Johan L. Van Hove, MD, PhD, Lead Principal Investigator
VI. Letter and Phone Scripts for intake screening


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Effective 10/01/2006
Oxidative Stress Markers in Inherited Homocystinuria and the Impact of Taurine
Letter and Phone Recruitment Scripts
Letter script to inform of study:
Dear _________.  This letter is to inform you of our research study looking at 
homocystinuria.   The purpose of the study is to learn more about why people with 
homocystinuria have health problems and if a new investigational treatment with taurine is 
helpful.  We are currently inviting participants.  If you would like to learn more about the 
study, please let us know.  You may talk to (Insert Site Specific Information – for 
Colorado: Cindy Freehauf, RN, CGC at 303-724-2342)).
Phone script to inform of study:
This is ________ from the Metabolic Clinic at (Site). Is this a good time to talk or would 
you prefer I call back.
If request is to call back later:
Thanks, I will be happy to call back., Is there a time that is better than others to call?
If request is to continue:
Thanks. I’m calling to inform you of our research study looking at homocystinuria.  [OR 
Thank you for calling to find out more about our research study looking at homocystinuria.]  
The purpose of the study is to learn more about why people with homocystinuria have 
health problems and if a new investigational treatment is helpful. Specifically, we want to 
see if markers of oxidative stress and inflammation are increased in individuals with 
homocystinuria.  We also want to see if taking taurine for a short period of time can 
decrease the markers of stress and oxidation.  As part of the study, participants will be 
asked to come to (Site Location) for blood studies and studies that look at blood vessels 
and bone density.  Some compensation for travel and time is available.  Do you think you 
might be interested in participating in the study?
If answer is no:
“Thank you for your time.  Good bye.”
If answer is yes: 
Go to screening interview. 
Phone script for screening interview:
Before enrolling people in the study we need to determine if they are eligible.  So what I 
would like to now is to ask you a series of question about your health and medications and 
supplements you might take. The questions will take about 15 minutes.  The risk to take 
part in this interview is very small. The questions are not designed to ask you for sensitive 
personal information, but it is possible that some people may feel uncomfortable 
answering these questions.  You may choose not to answer or stop participating in this 
interview at any time [IF APPLICABLE Deciding not to take part in the interview or the 
research study will not change any medical care you might receive from the Inherited 
Metabolic Diseases Clinic.].  If you qualify to take part in the study and enroll in the study, 
your name and the information I taking will be kept private and confidential and used only 
in the research study we are talking about.   If you do not qualify to take part in the study 


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COMIRB Application for Protocol Review (9/9/2011)                                                                Page 41 of 42
Effective 10/01/2006
and/or do not enroll in the study the information including your name will be discarded.  Do 
I have your permission to continue with the interview?
If the answer is “yes”
Criteria
Description
Criteria: Diagnostic confirmation of 
CBSDH:
How was homocystinuria diagnosed in 
you?  Did anyone do a mutation 
analysis?  Are you willing to have your 
doctor share or send us this 
information for the research study? 
Criteria: Therapeutic responsiveness
What is your treatment for 
homocystinuria and what is your 
current homocysteine level?
Are you willing to have your doctor 
share or send this information with us 
for the research study?
Criteria: Age
.  
Are you between 8 and 50 years of 
age?
Criteria: Pregnancy
If a female: Are you, or is there a 
chance, that you are pregnant?
Criteria: Chronic illness with 
inflammatory component.
Do you have a chronic disease other 
than homocystinuria?
If the answer is yes
Could you tell me more about this, 
such as the name of the disorder and 
how severe it is?
Criteria: Taurine
Do you take energy drinks with taurine 
or take taurine as a supplement?
Are you willing to avoid taurine or 
taurine containing supplements for the 
study period?
Criteria: Antioxidant intake
Is vitamin C prescribed as part of your 
treatment for homocystinuria?
If answer is no:
Do you take vitamins or other 
supplements with antioxidant 
properties outside of a typical one-a 
day vitamin pill?
If answer is yes, 
Are you willing to stop the 


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Effective 10/01/2006
supplements with the exception of a 
one a day vitamin for the study period?
Criteria: Salicylate (Aspirin) intake
Do you take medications that contain 
Aspirin or any other medication that 
affects platelets?
If answer is “yes” 
Is it prescribed by your physician to 
treat your homocystinuria or other 
disease state?
If answer is “no”
Are you willing to stop taking Aspirin 
for a three week study period?
Criteria: Do you take Viagra or similar 
products?  
If answer is yes:
Would you be willing or able to stop it 
for the study period?
If answer is no:
Would you let us know that you are 
using it during the study period? 
 
Criteria: Intercurrent Illness
Participants who have a cold, the flu, 
or other short term illness will be 
asked to delay participation in the 
study until they are recovered.  Would 
this be a problem for you? Will you let 
us know if you become ill when 
scheduled for this study? 
Criteria: Recent cardiovascular event:
Did you have a stroke, a myocardial 
infarct or a deep vein thrombosis or 
pulmonary thrombosis or embolus in 
the past 6 months? 
Criteria: Uncontrolled hypertension:
Do you have a history of high blood 
pressure?
If answer is yes:
Is it controlled by diet or medication?
For all individuals:
Would you be willing to share medical 
records showing your recent blood 
pressure readings? 
What medications are you taking?
Criteria: Hypertriglyceridemia:
Do you have a history of elevated 


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Effective 10/01/2006
triglyceride levels?
Would you be willing to share your 
medical record documenting 
triglyceride level(s) or have a level 
drawn so that we can ensure your 
levels are not high at study start?
 
“Based on the information you gave me, it looks like you are eligible for this study.  At this 
point you have several options.  (1)  I can take down you contact information, mail you the 
consent forms then and call you in a week or so to answer questions, go over the consent 
form, and consent you if you remain interested in participating in the study. (2) We can set 
up a time to discuss the study and consent in person, or (3) If you are not interested in the 
study you can let me know and the information I collected will be discarded.
_______________ OK to mail information and re-contact
________________Schedule appointment
________________Not interested. Destroy all information
OR
“Based on the information you gave me, it looks like you are NOT eligible for this study.  
At this point, all information that you provided me in this screening interview will be 
destroyed.”
________________Not eligible. Destroy all information


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VI. Data Safety Monitoring Plan for active portion of study
DATA SAFETY MONITORING PLAN FOR ACTIVE PORTION OF STUDY
negative pregnancy 
no
Viagara  use 
during study
endothelial flow studies
with nitroglycerin
induced FMD
no 
salicylate 
use during 
platelet function studies 
done
salicylate use 
during study
known or 
potential 
Viagra use 
during 
study
endothelial flow studies
without nitorglycerin
 induced FMD
platelet function studies 
excluded
ACTIVE PORTION 
OF STUDY
DAY 1
intake sheet 
physical exam
pregnancy test (with
results reviewed by 
5:00 PM on day of test)
excluded or participation 
postponed 
liver function studies twice normal,
 triglycerides greater than 400 mg/dl,
clinically significant alteration in safety labs as assessed by 
co-investigating MD and/or Safety Officers, and/or
hypotension (<90mmHg in adults or < the 5th percentile for 
age in children) present in two or more subjects in the 
setting of normal subject values before taurine 
supplementation
DAY 6
AE/compliance sheet
physical exam
research labs
saftey labs (lab 
results reviewed 
within 5 working days 
of draw
co-investigating 
MD notified and 
if problem 
considered 
serious will meet 
with Safety 
Officers
unanticipated 
problem or event 
and/or identified trend 
in AEs
compiled data examined 
for safety by PI & co- 
investigating MDs, and  
by Safety Officers
After 2 and 6 subjects have 
completed the study and at study 
end
SAEs will be reported to the study projec
manager, the PI or one of the lead site 
co-investigator MDs , FDA, COMIRB, 
local IRB as per their requirement, and 
CTRC within five working days of 
knowledge of the event.  In addition, the 
data Safety Officers and PI and co-
investigators will convene within one 
week of reporting of a SAE.
DAY 2
AE/compliance sheet
research labs
safety  labs
study temporarily suspended 
pending review of collected data and 
recommendation about study 
continuance by Safety Officers, FDA, 
COMIRB and CTRC
pregnant
breast feeding, and/or 
positive pregnancy test
1-2 WK 
AFTER 
STUDY END
follow-up call 
for safety 
assessment