Clinical trial NCT01316770
Conditions: Sjögren's Syndrome Xerostomia
Keywords: Xerostomia Sjögren's Syndrome Interventional Study Sjogren's Syndrome Dry Mouth
Sponsor: National Institute of Dental and Craniofacial Research (NIDCR)
Start date: 2011-05-01; Completion date: 2017-04-17
Enrollment: 14 participants; Allocation: RANDOMIZED; Intervention model: SINGLE_GROUP

Brief summary:
Background:

Sjögren's syndrome is an autoimmune disease (where the immune system attacks normal body tissues) that affects the salivary glands. Many people with Sjögren's syndrome are not able to make enough saliva because their salivary glands are inflamed. The dry mouth that results can interfere with daily activities and can lead to dental cavities, mouth sores, and infections. Injections of corticosteroids into the parotid glands can improve saliva production in people with Sjögren's syndrome, but current treatment practices may provide only temporary relief. Researchers are interested in studying the effectiveness of stronger corticosteroid injections (using dexamethasone) to determine how the corticosteroid treatment actually works.

Objectives:

\- To evaluate the effectiveness and mechanics of dexamethasone injections to improve saliva production in individuals with primary Sjögren's syndrome.

Eligibility:

\- Women between 18 and greater of age who have been diagnosed with primary Sjögren's syndrome, and have had a biopsy of the minor salivary glands in the past 5 years that shows a moderate level of inflammation.

Design:

* Participants will be screened with a full medical history and physical examination, blood and urine tests, and salivary gland biopsies. Participants will also be screened with tests of saliva flow production and evaluation of the salivary ducts and glands, and will complete questionnaires about dry mouth symptoms.
* At the first treatment visit, participants will receive an injection of dexamethasone into one parotid gland and an injection of saline into the other gland. After the injections, participants will provide a blood sample to test the level of dexamethasone in the blood.
* Two weeks after the first treatment, participants will return for an evaluation visit to have saliva flow rate measurements taken, and will complete a questionnaire about dry mouth symptoms.
* Four weeks after the first treatment, participants will have a second treatment for each parotid gland, with the same tests and questionnaires as before.
* Participants will have additional evaluation visits 6 and 8 weeks after the first treatment visit, with a followup telephone call approximately 6 weeks after the last dexamethasone treatment visit.

Detailed description:
BACKGROUND:

Salivary gland dysfunction is one of the major manifestations of Sjögren's (SS). Although inflammation is thought to play an important role in the exocrinopathy, the correlation between glandular dysfunction and inflammation is limited. Systemic anti-inflammatory therapies tested to date, such as tumor necrosis factor antagonists, have not been effective treatments for SS salivary hypofunction, raising doubts about inflammation being the sole cause of salivary gland dysfunction. However, none of these trials tested whether an anti-inflammatory effect was achieved in glandular tissues.

Studies by Izumi et al found that a limited course of low-dose topical corticosteroid applied to the parotid glands resulted in sustained improvement in saliva production. Unfortunately, these studies did not examine the mechanistic effects of corticosteroids on the major salivary glands. A plausible assumption is that corticosteroids improved salivary gland function by reducing inflammation, although other or associated mechanisms, such as an improved transcellular ion transport in epithelial cells cannot be ruled out. This study aims to study the efficacy of low-dose topical corticosteroid (dexamethasone) irrigation of the parotid gland in reducing salivary dysfunction in subjects with SS, and also to evaluate the effects of treatment on inflammation and other possible mechanistic processes.

PRIMARY OBJECTIVE:

\- To determine whether irrigation of the parotid gland with low-dose topical dexamethasone improves parotid salivary gland flow in SS subjects.

SECONDARY OBJECTIVES:

* To perform mechanistic studies to determine the mechanisms of action of low-dose topical corticosteroid irrigation of the parotid gland.
* To assess biomarkers of inflammation and salivary gland dysfunction in SS subjects treated with low-dose topical corticosteroid irrigation of the parotid glands.
* To assess localized safety of dexamethasone irrigation of the parotid gland, as compared with placebo.

STUDY POPULATION:

The study will enroll up to 20 adult females with primary SS in order to randomize and treat 16 subjects. Key enrollment criterion include a focus score of greater than or equal to 3 on minor salivary gland biopsy in the previous 5 years and measurable stimulated bilateral parotid salivary flow (greater than or equal to 0.01 mL/min per gland). Subjects will be recruited from protocol 84-D-0056, conducted at the National Institutes of Health (NIH).

DESIGN:

This will be a single-site, randomized-within-subject, double-blind, placebo-controlled, phase 2 pilot study in which all subjects receive both active drug (dexamethasone) and placebo (normal saline), thereby acting as their own controls.The study design is doubly-repeated measures; within a subject, measures are repeated in both time and treatment (i.e., one side of mouth receives dexamethasone while the other receives placebo.). After baseline assessment of salivary flow and other measurements of salivary function, subjects will be randomly assigned, in a double-blind fashion, to dexamethasone irrigation of one parotid gland and normal saline irrigation of the other parotid gland. They will undergo a total of 2 treatment sessions, 4 weeks apart (Days 0 and 28). Post-treatment assessments of salivary flow, dry mouth symptoms, and adverse events (AEs) will be performed at specified intervals.

OUTCOME MEASURES:

Primary Endpoint:

\- Change in salivary flow from Day 0 to Day 56.

Secondary Endpoints:

* Change in focus score on parotid biopsy from Screening to Day 56.
* Change in salivary flow from Day 0 to study Days 14, 28, 42, and 56.
* Changes in assessments on the Patient Dry Mouth Questionnaire from Day 0 to study Days 14, 28, 42, and 56.
* Changes in assessments on the Sj(SqrRoot)(Delta)gren s Disease Activity Index from Day 0 to study Days 14, 28, 42, and 56.
* Changes in other assessments of salivary function from baseline to study Day 56, including technetium scan of the salivary glands.
* Changes in laboratory measures of inflammation.
* Frequency of AEs related to treatment; AE location (body site, right or left), will be recorded and evaluated, as applicable.

Exploratory endpoints

\- Changes in mechanistic endpoints from baseline to study Days 14, 28, 42, and 56.

Arms: arm 1: Within-Subject, Double-Blind, Placebo-Controlled Study. This parotid gland is irrigated with saline (placebo). { UPDATE: drug(generic) was administered at what time pt, dose of drug, route administration, frequency} arm 2: Within-Subject, Double-Blind, Placebo-Controlled Study. This parotid gland is irrigated with dexamethasone {UPDATE: drug (generic) was administered at what time pt, dose of drug, route administration, frequency}
Interventions: intervention 1: Dexamethasone Parotid Irrigation intervention 2: Placebo Parotid Irrigation
Intervention descriptions: intervention 1: Irrigation of the parotid gland from one side of the mouth with dexamethasone. intervention 2: Irrigation of the parotid gland on the opposite side of the mouth with placebo saline.

Protocol documents:
Prot_000.pdf: 
PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 1 of 58 
Protocol Title:  A Randomized Within-subject, Double-blind, Placebo-controlled Study of 
Dexamethasone Irrigation of the Parotid Glands in Primary Sjögren’s Syndrome Subjects  
Abbreviated Title:  Dexamethasone Parotid Irrigation 
 
Protocol Number:  11-D-0094 
Date of This Submission/Version:    October 01, 2015/13.0 
Principal Investigator: 
Name, Degree 
Branch/Institute Bldg/Rm 
Phone 
E-mail 
Ilias Alevizos, 
DMD 
MPTB/NIDCR 
10/1N110 
(301) 496-6027 
alevizosi@mail.nih.gov 
Lead Associate Investigator: 
Name, Degree 
Branch/Institute 
Bldg/Rm 
Phone 
E-mail 
Ana Cotrim, 
DDS, PhD 
MPTB/NIDCR 
10/1N110 
(301) 451-7956 
acotrim@nidcr.nih.gov  
Associate Investigators: 
Name, Degree 
Branch/Institute 
Bldg/Rm 
Phone 
E-mail 
Indu Ambudkar, 
PhD 
MPTB/NIDCR 
10/1N113 
(301) 496-5298 
iambudkar@dir.nidcr. 
nih.gov 
Lolita Bebris, 
RN 
MPTB/NIDCR 
10/1N110 
(301) 594-1644 
bebrisl@mail.nih.gov 
Richard Chang, 
MD 
CC/ORIC/DDR 
10/1C363 
(301) 402-0256 
rchang@cc.nih.gov 
Clara Chen, MD 
CC/ORIS/DDR 
10/1C363 
(301) 402-0256 
cchen@cc.nih.gov 
Alan Baer, MD 
 
OCD/ NIDCR 
 
10/1N118 
 
(301)-827-1647 
 
alan.baer@nih.gov 
Margaret 
Grisius, DDS 
MPTB/NIDCR 
10/1B17 
(301) 435-8528 
mgrisius@mail.nih.gov 
Shmuel 
Muallem, PhD 
MPTB/NIDCR 
10/1N112 
(301) 594-7273 
muallems@mail.nih.gov 
David Kleiner, 
MD 
NCI 
10/2N119 
(301) 594-2942 
kleinerd@mail.nih.gov 
Nicholas 
Patronas, MD 
CC/ORIS/DDR 
10/1C361x 
(301) 402-5726 
npatronas@mail.nih.gov 
 
 
 
 
 
 
Sarfaraz Hasni, 
MD 
NIAMS 
10-CRC/ 
5-5521 
(301) 451-1599 
Sarfaraz.hasni@nih.gov 
 
 
 
 
 


PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 2 of 58 
Tammy Yokum, 
RN 
MPTB/NIDCR 
10/1N110 
(301) 594-3097 
yokumtk@mail.nih. 
gov 
Eileen Pelayo, 
RN 
MPTB/NIDCR 
10/1N110 
(301) 594-3097 
Eileen.pelayo@nih.gov 
Donna Kelly 
MPTB/NIDCR 
10/1B-17 
(301) 594-1904 
Donna.Kelly@nih.gov 
Research Contact: 
Name, Degree 
Branch/Institute 
Bldg/Rm 
Phone 
E-mail 
Eileen Pelayo, 
RN 
MPTB/NIDCR 
10/1N110 
(301) 594-3097 
Eileen.pelayo@mail.nih.
gov 
Medical Advisory Investigator:  
Name, Degree 
Branch/Institute 
Bldg/Rm 
Phone 
E-mail 
Sarfaraz Hasni, 
MD 
NIAMS 
10-CRC/5-
5521 
(301) 451-1599 
Sarfaraz.hasni@nih.gov 
 
Total requested accrual: 
Approximately 20 female subjects with primary Sjögren’s syndrome will be screened, to 
randomize and treat 16 subjects. 
 
Project Uses Ionizing Radiation 
 No   
 Yes (attach RSC/RDSC documentation) 
 
 
Medically-indicated only 
 
 
Research-related only 
 
 
Both 
IND/IDE 
 
 
 
 No   
Yes (attach FDA documentation) 
 
 
Drug/Device/#_____________________ 
 
 
Sponsor: _________________________ 
Durable Power of Attorney   
 No   
 Yes  
 
Multi-institutional Project 
 
 No   
 Yes  
Institution_________________    FWA #_________  
Date of IRB approval_________ (attach IRB documentation) 
 
Data and Safety Monitoring Board 
 No   
 Yes  
 
Technology Transfer Agreement 
 No   
 Yes  
Agreement type and number __________________ 
Expiration Date_____________ 
 
Confidential Disclosure Agreement  No  
Yes 
 
Samples are being stored  
 
 No   
 Yes  
 
Flesch-Kincaid reading level of consent form: 8.7 


PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 3 of 58 
Précis 
Salivary gland dysfunction is one of the major manifestations of Sjögren’s syndrome (SS).  
Although inflammation is thought to play an important role in the exocrinopathy, the correlation 
between glandular dysfunction and inflammation is limited.  Systemic anti-inflammatory 
therapies tested to date, such as tumor necrosis factor antagonists, have not been effective 
treatments for SS salivary hypofunction, raising doubts about inflammation being the sole cause 
of salivary gland dysfunction.  However, none of these trials tested whether an anti-inflammatory 
effect was achieved in glandular tissues. 
Studies by Izumi et al found that a limited course of low-dose topical corticosteroid applied to 
the parotid glands resulted in sustained improvement in saliva production.1,2  Unfortunately, 
these studies did not examine the mechanistic effects of corticosteroids on the major salivary 
glands.  A plausible assumption is that corticosteroids improved salivary gland function by 
reducing inflammation, although other or associated mechanisms, such as an improved 
transcellular ion transport in epithelial cells cannot be ruled out.  This study aims to study the 
efficacy of low-dose topical corticosteroid (dexamethasone) irrigation of the parotid gland in 
reducing salivary dysfunction in subjects with SS, and also to evaluate the effects of treatment on 
inflammation and other possible mechanistic processes. 
Primary Objective 
 To determine whether irrigation of the parotid gland with low-dose topical 
dexamethasone improves parotid salivary gland flow in SS subjects. 
Secondary Objectives 
 To perform mechanistic studies to determine the mechanisms of action of low-dose 
topical corticosteroid irrigation of the parotid gland. 
 To assess biomarkers of inflammation and salivary gland dysfunction in SS subjects 
treated with low-dose topical corticosteroid irrigation of the parotid glands. 
 To assess localized safety of dexamethasone irrigation of the parotid gland, as compared 
with placebo. 


PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 4 of 58 
Study Population 
The study will enroll up to 20 adult females with primary SS in order to randomize and treat 16 
subjects.  Key enrollment criterion include a focus score of ≥1 on minor salivary gland biopsy in 
the previous 7 years and measurable stimulated bilateral parotid salivary flow (≥0.01 mL/min per 
gland).  Subjects will be recruited from protocol 84-D-0056, conducted at the National Institutes 
of Health (NIH). 
Design 
This will be a single-site, randomized-within-subject, double-blind, placebo-controlled, phase 2 
pilot study in which all subjects receive both active drug (dexamethasone) and placebo (normal 
saline), thereby acting as their own controls.  The study design is doubly-repeated measures; 
within a subject, measures are repeated in both time and treatment (i.e., one side of mouth 
receives dexamethasone while the other receives placebo.)  After baseline assessment of salivary 
flow and other measurements of salivary function, subjects will be randomly assigned, in a 
double-blind fashion, to dexamethasone irrigation of one parotid gland and normal saline 
irrigation of the other parotid gland.  They will undergo a total of 2 treatment sessions, 4 weeks 
apart (Days 0 and 28).  Post-treatment assessments of salivary flow, dry mouth symptoms, and 
adverse events (AEs) will be performed at specified intervals. 
Outcome Measures 
Primary Endpoint 
 Change in salivary flow from Day 0 to Day 56. 
Secondary Endpoints 
 Change in focus score on parotid biopsy from Stage II Screening to Day 56. 
 Change in salivary flow from Day 0 to study Days 14, 28, 42, and 56. 
 Changes in assessments on the Patient Dry Mouth Questionnaire from Day 0 to study 
Days 14, 28, 42, and 56. 
 Changes in assessments on the Sjögren’s Disease Activity Index from Day 0 to study 
Days 14, 28, 42, and 56. 


PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 5 of 58 
 Changes in other assessments of salivary function from baseline to study Day 56, 
including technetium scan of the salivary glands. 
 Changes in laboratory measures of inflammation. 
 Frequency of AEs related to treatment; AE location (body site, right or left), will be 
recorded and evaluated, as applicable. 
Exploratory endpoints 
 Changes in mechanistic endpoints from baseline to study Days 14, 28, 42, and 56. 


PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 6 of 58 
Table of Contents 
PRÉCIS ........................................................................................................................................... 3 
TABLE OF CONTENTS ................................................................................................................ 6 
LIST OF ABBREVIATIONS ......................................................................................................... 9 
1 
INTRODUCTION ............................................................................................................... 10 
1.1 
Systemic and Other Treatments....................................................................................... 10 
1.2 
Current Study................................................................................................................... 13 
1.3 
Laboratory Research Studies ........................................................................................... 14 
2 
STUDY OBJECTIVES ........................................................................................................ 16 
2.1 
Primary Objective ............................................................................................................ 16 
2.2 
Secondary Objectives ...................................................................................................... 16 
3 
SUBJECTS .......................................................................................................................... 17 
3.1 
Description of Study Populations .................................................................................... 17 
3.2 
Inclusion Criteria ............................................................................................................. 17 
3.3 
Exclusion Criteria ............................................................................................................ 18 
4 
STUDY DESIGN AND METHODS................................................................................... 19 
4.1 
Study Overview ............................................................................................................... 19 
4.2 
Recruitment ..................................................................................................................... 20 
4.3 
Screening ......................................................................................................................... 20 
4.4 
Study Procedures ............................................................................................................. 21 
4.4.1 
Vital Signs Measurement .......................................................................................... 25 
4.4.2 
Medical history and examination .............................................................................. 25 
4.4.3 
Collection of Saliva/Measurement of Salivary Flow Rate ........................................ 25 
4.4.4 
Patient Dry Mouth Questionnaire .............................................................................. 26 
4.4.5 
Sjögren’s Disease Activity Index .............................................................................. 26 
4.4.6 
Parotid Fill Volume Determination ........................................................................... 26 
4.4.7 
Collection of Laboratory Tests .................................................................................. 26 
4.4.7.1 
Phlebotomy and Urine Tests ........................................................................... 26 
4.4.8 
Minor Salivary Gland Biopsy .................................................................................... 27 
4.4.9 
Ultrasound-guided Parotid Core Needle Biopsy ....................................................... 28 
4.4.10 Technetium Scan ....................................................................................................... 28 
4.4.11 Magnetic Resonance Imaging ................................................................................... 28 
4.4.12 Parotid Treatment Irrigation of the parotid duct (dexamethasone or saline) ............ 29 
4.4.13 Description of blood collected solely for research .................................................... 31 
4.4.14 Safety Follow-up ....................................................................................................... 32 
4.4.15 End of Participation ................................................................................................... 32 
5 
STORAGE OF DATA AND SAMPLES ............................................................................ 32 
5.1 
Data.................................................................................................................................. 32 
5.2 
Samples............................................................................................................................ 32 
6 
ADDITIONAL CONSIDERATIONS ................................................................................. 33 
6.1 
Research with Investigational Drugs or Devices ............................................................. 33 
6.2 
Concomitant Medication Contingencies ......................................................................... 33 
7 
RISKS AND DISCOMFORTS ........................................................................................... 33 
7.1 
Assessments/Procedures with No Risks .......................................................................... 33 


PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 7 of 58 
7.2 
Collection of Saliva/Measurement of Salivary Flow Rate .............................................. 33 
7.3 
Parotid Fill Volume Determination and Saline Irrigation of Parotid Gland ................... 34 
7.4 
Intraductal Dexamethasone ............................................................................................. 34 
7.5 
Ultrasound-guided Parotid Gland Core Needle Biopsy .................................................. 35 
7.6 
Technetium Scan and Radiation ...................................................................................... 35 
7.7 
Minor Salivary Gland Biopsy .......................................................................................... 36 
7.8 
Magnetic Resonance Imaging ......................................................................................... 36 
7.9 
Blood Collection .............................................................................................................. 38 
7.10 Risk of stopping salivary stimulants................................................................................ 38 
7.11 Unexpected Adverse Events ............................................................................................ 38 
8 
SUBJECT SAFETY MONITORING .................................................................................. 38 
9 
OUTCOME MEASURES ................................................................................................... 40 
9.1 
Primary Outcome Measure .............................................................................................. 40 
9.2 
Secondary Outcome Measures ........................................................................................ 40 
10 
STATISTICAL ANALYSIS ............................................................................................... 40 
10.1 Analysis of Data/Study Outcomes................................................................................... 40 
10.1.1 Safety Population ...................................................................................................... 40 
10.1.2 Primary Efficacy Population ..................................................................................... 40 
10.1.3 Secondary Efficacy Population ................................................................................. 41 
10.1.4 Demographic and Baseline Characteristics ............................................................... 41 
10.1.5 Primary Efficacy Analysis ......................................................................................... 41 
10.1.6 Secondary Analyses of Salivary Flow ....................................................................... 41 
10.1.7 Exploratory Analyses of Mechanistic and Inflammatory Biomarkers ...................... 42 
10.1.8 Criteria for Significance ............................................................................................ 43 
10.1.9 Interim Analysis ........................................................................................................ 44 
10.2 Power Analysis ................................................................................................................ 44 
11 
HUMAN SUBJECTS PROTECTION ................................................................................ 45 
11.1 Subject Selection ............................................................................................................. 45 
11.2 Justification for Exclusion of Children ............................................................................ 45 
11.3 Justification for Exclusion of Non-English speaking Subjects ....................................... 45 
11.4 Justification for Exclusion of Other Vulnerable Subjects ............................................... 45 
11.5 Justification of Sensitive Procedures ............................................................................... 45 
11.6 Safeguards for Vulnerable Populations ........................................................................... 46 
11.7 Qualifications of Investigators ........................................................................................ 46 
12 
ANTICIPATED BENEFIT .................................................................................................. 48 
13 
CLASSIFICATION OF RISK ............................................................................................. 48 
14 
CONSENT DOCUMENTS AND PROCESS ..................................................................... 48 
14.1 Designation of Those Obtaining Consent........................................................................ 48 
14.2 Consent Procedures ......................................................................................................... 48 
14.3 Consent Documents ......................................................................................................... 49 
14.3.1 Designation of Those Obtaining Consent ................................................................. 49 
14.3.2 Consent Procedures ................................................................................................... 49 
14.3.3 Consent Documentation ............................................................................................ 49 
15 
DATA AND SAFETY MONITORING .............................................................................. 49 
15.1 Data and Safety Monitor ................................................................................................. 49 


PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 8 of 58 
15.2 Data and Safety Monitoring Plan .................................................................................... 49 
15.3 Criteria for Stopping the Study or Suspending Enrollment or Procedures ..................... 50 
16 
QUALITY ASSURANCE ................................................................................................... 50 
16.1 Quality Assurance Monitor ............................................................................................. 50 
16.2 Quality Assurance Plan ................................................................................................... 51 
17 
ADVERSE EVENT, PROTOCOL DEVIATIONS AND UNANTICIPATED PROBLEM 
REPORTING ....................................................................................................................... 51 
18 
ALTERNATIVE THERAPIES ........................................................................................... 52 
19 
CONFIDENTIALITY.......................................................................................................... 52 
19.1 Stored Samples ................................................................................................................ 53 
19.2 Special Precautions .......................................................................................................... 53 
20 
CONFLICT OF INTEREST ................................................................................................ 53 
20.1 Distribution of NIH Guidelines ....................................................................................... 53 
20.2 Conflict of Interest ........................................................................................................... 53 
20.3 Role of a Commercial Company or Sponsor ................................................................... 53 
21 
TECHNOLOGY TRANSFER ............................................................................................. 53 
22 
RESEARCH AND TRAVEL COMPENSATION .............................................................. 54 
23 
REFERENCES .................................................................................................................... 55 
24 
APPENDICES ..................................................................................................................... 58 
24.1 Protocol Signature Page .................................................................................................. 58 
24.2 Definitions of Unanticipated Problems and Adverse Events .......................................... 58 
24.3 Eligibility Checklist ......................................................................................................... 58 
24.4 Rating Scales ................................................................................................................... 58 
24.5 Dexamethasone Package Insert ....................................................................................... 58 
24.6 Salivary Flow Collection Procedure ................................................................................ 58 
24.7 Subject Questionnaires .................................................................................................... 58 
24.8 American-European Consensus Sjögren’s Syndrome Classification Criteria ................. 58 
24.9 Sjögren’s Disease Activity Index .................................................................................... 58 
25 
CONSENT FORMS............................................................................................................. 58 
 


PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 9 of 58 
List of Abbreviations 
 
ADC 
apparent diffusion coefficient 
AE 
adverse event 
CBC 
complete blood count 
CFTR 
cystic fibrosis transmembrane conductance regulator 
CROMS 
Clinical Research Operations and Management Support  
CRP 
C-reactive protein 
DSMC 
Data and Safety Monitoring Committee 
eCRF 
electronic case report form 
EDC 
electronic data capture 
ESR 
erythrocyte sedimentation rate 
GEE 
generalized estimating equations 
Ig 
immunoglobulin 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
mCi 
millicurie 
MRI 
magnetic resonance imaging 
MSG 
minor salivary gland 
MPTB 
Molecular Physiology and Therapeutics Branch 
NIDCR 
National Institute of Dental and Craniofacial Research 
NIH 
National Institutes of Health 
NSAID 
nonsteroidal anti-inflammatory drug 
PEP 
Primary Efficacy Population 
SAE 
serious adverse event 
SD 
standard deviation 
SEP 
Secondary Efficacy Population 
SOP 
standard operating procedure 
SS 
Sjögren’s syndrome 


PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 10 of 58 
1 
INTRODUCTION 
Sjögren’s syndrome (SS) is a systemic autoimmune disease characterized by exocrinopathy, 
especially of the salivary and lacrimal glands, which is mediated by lymphocytic infiltration.  
This lymphocytic infiltration is thought to cause impaired glandular secretory function.  
Sjögren’s syndrome is a slowly progressing disease that primarily affects middle-aged women 
(female:male ratio of 9:1). 
Dry eyes, dry mouth (xerostomia), and fatigue are the most common symptoms of SS.  
Extra-glandular manifestations are fairly common; for example, gastric involvement has been 
reported in 55% of patients with primary SS.3  Major salivary gland enlargement is also very 
frequent.  Reduced salivary gland output leads to a significant increase in the incidence of dental 
caries, oral mucosal lesions, recurrent fungal infections, difficulty swallowing, and increased 
susceptibility to gastroesophageal reflux. 
Although the prevalence of SS in the United States has been estimated to 1 to 2 million persons, 
studies have shown that it may be much higher due to the difficulty in diagnosis.  The 
American-European consensus classification criteria published in 2002 are now widely accepted 
as the standard for diagnosing SS.4 
Secondary SS usually arises in the presence of another autoimmune disorder, such as rheumatoid 
arthritis, systemic lupus erythematosus, and polymyositis, whereas primary SS develops in the 
absence of other connective tissue diseases. 
1.1 
Systemic and Other Treatments 
To date, there is no established therapy to treat the cause of SS, with treatment being directed 
toward alleviation of symptoms.  A variety of medications commonly used in other autoimmune 
inflammatory diseases have been tested in patients with primary SS, including methotrexate,5 
cyclosporine,6 infliximab,7 etanercept,8 and oral interferon alpha-2.9  None of these treatments 
has showed any efficacy in increasing salivary flow. 
Relief of oral dryness is achieved by lifestyle modifications such as the use of humidifiers, 
artificial saliva, and saliva secretory stimulants (e.g., pilocarpine and Evoxac®).  Pilocarpine and 
Evoxac are both muscarinic receptor M3 agonists.  Muscarinic receptor activation has been 


PI name:  Ilias Alevizos, DMD 
 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version 13.0  
 
CNS and NIDCR IRB Protocol Template (rev.9.21.11)                                                                            Page 11 of 58 
shown to increase the secretory activity of exocrine glands such as salivary and sweat glands, 
and also to increase smooth muscle contraction in other organs such as the gastrointestinal 
tract.10  However, secretory stimulants are effective in only a small fraction of patients.  The 
muscarinic agonists have undesired affects on a wide spectrum of organs, resulting in side effects 
such as sweating, headache, nausea, rhinorrhea, and diarrhea.  Thus, a large percentage of the 
patients do not tolerate these medications for xerostomia relief. 
Often the presence of extra-glandular symptoms and complications dictate the necessity for other 
treatments for SS, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and Cox-2 inhibitors 
for arthralgias and myalgias11; hydroxychloroquine for musculoskeletal symptoms12; and 
systemic corticosteroids and pulse cyclophosphamide for severe vasculitis, diffuse interstitial 
pneumonitis, glomerulonephritis, and neurologic disease.13,14,15 
Biologics, such as rituximab, have also been tested for the treatment of the oral symptoms of SS.  
The studies of rituximab have been inconclusive, and its effect on salivary glands is only 
transient, lasting up to only 3 months.16  Multiple administrations of this biologic would be 
required, increasing the possibility of serious adverse events (SAEs).  The rate of adverse events 
(AEs) associated with rituximab is not insignificant either.17 
The disappointing experience with systemic immunosuppressive and immunomodulating 
therapies in SS, along with the limited and mainly symptom-targeted therapies for salivary 
hypofunction, emphasizes the need for a more effective local therapy for xerostomia that 
specifically targets the salivary glands.  An important goal of studies evaluating such therapies is 
obtaining information about the mechanism of functional improvement within the target organ.  
One limitation of previous clinical trials of systemic therapies for SS is the possibility that the 
study drugs had no anti-inflammatory effect on the glandular tissues.  Initial clinical studies of 
new local therapies for xerostomia in patients with SS should evaluate not only improvement in 
salivary flow, but also data on the mechanism of action and the relationship to clinically 
important outcomes.  Such an approach would confirm the biologic rationale of a particular 
intervention and allow the design of better and more sophisticated interventions to evaluate 
clinical efficacy. 


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Corticosteroids are members of the adrenal hormone family, which are secreted under the control 
of the hypothalamic-anterior pituitary-adrenocortical axis and include glucocorticoids, 
mineralocorticoids, and corticotrophins.  Glucocorticoids are considered mainly 
anti-inflammatory agents but have a large number of other functions, such as stabilization of 
vessel integrity, effects on the water reabsorption and electrolyte concentrations in the kidneys, 
and regulation of responses to stress. 
Because corticosteroids are anti-inflammatory, they have been considered for systemic therapy to 
prevent the chronic and destructive inflammation of SS within the salivary glands.18  The only 
in-depth study examining the effect of systemic corticosteroids on salivary function in SS 
demonstrated that 6 months of treatment with 30 mg prednisone every other day did not improve 
either histological or functional parameters of the salivary and lacrimal glands.18 
A more recent study by Izumi et al. found that a limited course of low-dose topical corticosteroid 
resulted in sustained improvement in saliva production.1 The investigators examined the effect of 
intraductal prednisolone on salivary flow in 31 subjects with SS (24 with primary SS and 7 with 
secondary SS).  They claimed that “corticosteroid irrigation significantly increased the salivary 
flow rate in patients with Sjögren’s syndrome.”  Study subjects were divided into 3 groups based 
on MRI findings:  early, intermediate, and advanced.  They underwent saline irrigation of both 
parotid glands for 2 to 3 months (1 irrigation every 2 weeks), followed by 4 weekly 
corticosteroid irrigations of both glands.  For the initial saline irrigations, 1 mL of saline was 
retained in each parotid gland for a period of 2 minutes.  During the treatment period, 1 mL of 
prednisolone sodium succinate at a concentration of 2 mg/mL was used to irrigate each gland, 
with a retention period of 2 minutes.  Whole salivary flow was measured before and after each 
irrigation with saline and prednisolone, and for a follow-up period of up to 35 months, even 
though only the parotid glands were irrigated.  The duration of effect of steroid irrigation on 
salivary flow improvement was defined as the time point at which 2 consecutive decreases in 
salivary flow occurred after the end of prednisolone irrigations.  Some of the subjects were 
treated with a second round of corticosteroid irrigations, most likely because of clinical 
indications. 
In the Izumi et al. study, the overall percentage of subjects with any recognized improvement in 
symptomatic xerostomia was 64% (18/28 subjects).  The mean (standard deviation [SD]) 


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sustained period of salivary flow improvement compared with baseline flow was 8.4 months 
(3.5 months).  Twelve responders who received more than 2 series of corticosteroid irrigations 
showed no refractoriness to the steroids; after repeated irrigations, their net increase in salivary 
flow did not diminish when compared with the initial treatment.  Eleven of the 12 subjects had 
net salivary flow increases equal to or more than the initial irrigation.  An equally important 
finding was that prolonged saline irrigation (19 to 35 months) did not significantly increase 
salivary flow rates. 
No adverse reactions due to catheter-administered irrigations were noted in the Izumi et al. study.  
A follow-up study by the investigators confirmed their earlier results regarding the efficacy of 
parotid corticosteroid irrigation in subjects with SS.2 Unfortunately, these studies with local 
corticosteroids did not examine the mechanism of action on the major salivary glands.  A 
plausible assumption is that corticosteroids improved salivary gland function by reducing 
inflammation, but other mechanisms cannot be ruled out.  A recent publication by Ko et al.19 
explored mechanisms by which corticosteroids improved pancreatic exocrine function and 
histopathology in autoimmune pancreatitis.  The investigators showed that corticosteroids 
decreased inflammation, restored digestive enzyme secretion through regeneration of acinar 
cells, and restored HCO3
– secretion by correcting cystic fibrosis transmembrane conductance 
regulator (CFTR) localization to the apical membrane (CFTR is known to play a central role in 
pancreatic duct HCO3
– secretion).  Similar mechanisms may play a role in restoring salivary 
gland function in SS. 
1.2 
Current Study 
The proposed clinical study aims to evaluate intraductal irrigation of the parotid glands with 
low-dose dexamethasone as a treatment for primary SS.  The study population will consist of 
subjects in Protocols 84-D-0056 and 99-D-0070 who were diagnosed with primary SS according 
to the American-European Consensus Group Sjögren’s Syndrome Classification Criteria 
(Appendix 24.8).  They will be adult female subjects with primary SS, a focus score of ≥1 on 
minor salivary gland (MSG) biopsy.  Minor salivary gland biopsy results up to seven years prior 
to enrollment will be considered. 
 


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Each subject will have both parotid glands irrigated—one with dexamethasone and the other 
with saline.  Because the potency of dexamethasone is approximately 4 to 5 times greater than 
prednisolone, it may have more sustained effects and thereby decrease the number of needed 
irrigations.  The study will have a single-group, single-arm design in which each subject receives 
active treatment in one parotid gland and placebo in the other.  Subjects will be evaluated for 
improvement in salivary flow from baseline, as well as changes in the parotid glands by 
magnetic resonance imaging (MRI), technetium scan, and biopsy. 
1.3 
Laboratory Research Studies 
Determination of presumed molecular mechanism of action of dexamethasone in the salivary 
glands of patients with SS 
It is firmly established that fluid secretion is impaired in SS, which is primarily an inflammatory 
disease.  Although knowledge of the molecular mechanism of fluid secretion and its regulation 
has markedly increased over the last 10 years, little is known about why fluid secretion is 
impaired in SS.  Several factors contributed to this paucity of information. 
One factor is the lack of reasonable animal models and the very limited availability of human 
tissue.  An additional significant factor is that, to date, this problem has not been addressed in a 
systematic way or by teams of investigators who have the required clinical experience, expertise 
in cell signaling and ion transport, and access to a good supply of tissue from SS patients.  
Fluid secretion is an osmotic process driven by transcellular ion transport and the function of 
water channels.  Studies over the last 20 years have established the molecular identity of the 
major transporters and their regulation.  A [Ca2+]i increase in acinar cells activates basolateral 
membrane Ca2+-activated K+ channels KCa3.1 (and perhaps the luminal KCa1.1) and the luminal 
Ca2+-activated Cl– channel Anoctamyin (TMEM16A).  This results in KCl efflux, an associated 
luminal water efflux through Aquaporin 5, and thus cell shrinkage.  
To maintain luminal electroneutrality, Na+ flows though the junctional complex from the 
basolateral to the luminal sides.  The end result is NaCl and fluid secretion and K+ and Cl– loss 
from the cytosol and cell shrinkage.  Cell shrinkage reduces [Ca2+]i to inhibit the K+ and Cl– 
channels and activates the basolateral membrane Na+-K+-2Cl– co-transporter NKCC1 to restore 
cellular ionic content and water.  A subsequent increase in Ca2+ (Ca2+ oscillations) starts the 


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cycle all over again.  NKCC1 is responsible for about 70% of the recovery of cytosolic ionic 
content, with the remaining mediated by the parallel functions of the basolateral Na+/H+ 
exchanger NHE1 and the Cl–/HCO3– exchanger AE2. 
The NaCl-rich fluid that enters the duct is modified, with the most important modification being 
the exchange of Cl– for HCO3–.  HCO3– is essential in maintaining the mucins and other 
macromolecules in the saliva in a soluble form.  Ductal HCO3– secretion entails HCO3– entry 
across the basolateral membrane that is mediated by the Na+-2HCO3– transporter NBCe1B.  
HCO3– exit is a complicated process involving the function of at least CFTR and the luminal Cl–
/HCO3– exchangers Slc26a6 and Slc26a4, which regulate the function of each other.  This 
activity is triggered by cAMP-mediated activation of CFTR that cycles the Cl– across the luminal 
membrane and activates the SLC26 transporters.  Hence, CFTR supplies the SLC26 transporters 
with Cl– and allows Cl– exchange with HCO3– by the SLC26 transporters.  The salivary gland 
duct also absorbs the Na+, in a process mediated by the 3 subunits ENaC, and exchanges it with 
K+, in a process that may be mediated by KCa1.1.  Ductal function is severely compromised by 
inflammatory mediators, and in the human pancreas, it has recently been shown that treatment of 
the inflammatory condition restores ductal function, in particular HCO3– secretion. 
To determine the molecular mechanism of action of dexamethasone in this study, the following 
investigations are planned: 
1. Characterize the fluid secretory mechanism after irrigation with corticosteroids, through 
assays of activities at different levels.  Immunofluorescence will be used to assay localization 
and expression levels of all key acinar and ductal transporters.  This will be followed by 
studies on the tissue level (sealed duct and gland section), then the cellular level (monitoring 
activity in single cells), and finally single-protein levels (activity of single channels). 
2. Identify changes in proteins involved in calcium signaling, such as Stim1.  In vitro and 
in vivo studies with salivary gland cell lines and primary cells will be run in parallel to 
examine the effect of dexamethasone on the epithelial cells. 


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Identification of saliva-derived biomarkers of inflammation and salivary gland dysfunction that 
can be tested in a future larger study 
While many biomarkers of salivary gland inflammation have been proposed, no biomarker has 
been identified that is strongly associated with SS salivary gland disease activity.  This study 
proposes to isolate exosomal microRNAs and other non-coding small RNAs to be tested for 
biomarkers.  The investigators have shown that they can isolate exosomes and their nucleic acid 
content from parotid saliva of SS patients and healthy volunteers.  Saliva collected during this 
study will be used for isolation of exosomes, and the nucleic acid content of those exosomes will 
be correlated with the inflammatory status of the glands.  The investigators are planning to use 
real-time quantitative polymerase chain reaction assays, microRNA microarrays, and/or deep 
sequencing for the identification of those microRNAs. 
The identification of salivary biomarkers, which have a strong enough correlation with tissue 
inflammation, will serve two objectives: 
 Use of salivary biomarkers for replacement of biopsy. 
 Dynamic monitoring of inflammation for interventional studies. 
If the studies show only an increase in salivary flow without a decrease in inflammation, the 
discovered microRNAs will serve as functional biomarkers and also be used for functional 
mechanistic studies of microRNAs affecting salivary flow. 
2 
STUDY OBJECTIVES 
2.1 
Primary Objective 
The primary objective of the study is to determine whether irrigation of the parotid gland with 
low-dose topical dexamethasone improves parotid salivary gland flow in SS subjects. 
2.2 
Secondary Objectives 
Secondary objectives of the study include the following: 
 To perform mechanistic studies to determine the mechanisms of action of low-dose 
topical corticosteroid irrigation of the parotid gland. 


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 To assess biomarkers of inflammation and salivary gland dysfunction in SS subjects 
treated with low-dose topical corticosteroid irrigation of the parotid glands. 
 To assess localized safety of dexamethasone irrigation of the parotid gland, as compared 
with placebo. 
 
 
3 
SUBJECTS 
3.1 
Description of Study Populations 
The study will enroll up to 20 adult female subjects with primary SS, a focus score of ≥1 on 
minor salivary gland (MSG) biopsy in the previous 7 years, and measurable bilateral parotid 
salivary flow (≥0.01 mL/min per gland) to randomize and treat 16 subjects.   
3.2 
Inclusion Criteria 
1. Female gender and age 18 and greater.. 
2. Diagnosed with primary SS in Protocol 84-D-0056.  
3. Stimulated salivary flow of at least 0.01 mL/min from each parotid gland, using the 
standard operating procedure (SOP) for the National Institute of Dental and Craniofacial 
Research (NIDCR) Molecular Physiology and Therapeutics Branch (MPTB) Sjögren’s 
Syndrome Clinic (Appendix 24.6). 
4. Minor salivary gland biopsy with a focus score of ≥1 obtained 0 to 7 years prior to study 
enrollment.  Biopsies from outside of the National Institutes of Health (NIH) must be 
reviewed by the NIH Pathology Department.  An MSG biopsy will be required for the 
following situations: 
a. The last biopsy was obtained before the use of rituximab. 
b. The last biopsy was obtained before the use of immunosuppressants, biologics, or 
disease-modifying antirheumatic drugs for more than 3 months. 
c. The last biopsy was obtained before the use of systemic corticosteroids (for more than 
2 weeks or for shorter periods at doses of more than 0.5 mg/kg) or local parotid 


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corticosteroids.  The use of topical or intra-articular/periarticular corticosteroids will 
not require a repeat biopsy. 
5. For women of childbearing potential, use of, or willingness to use, an effective method of 
birth control during the study.  Effective methods include abstinence, history of 
hysterectomy, tubal ligation, intrauterine device, licensed hormonal methods, condoms, 
diaphragm, and cervical cap.  
6. Ability to provide written informed consent prior to entry in the study. 
3.3 
Exclusion Criteria 
1. History of lymphoma. 
2. History of mycosis, aspergillosis, or other deep fungal infection of the parotid gland. 
3. History of salivary gland malignancy (primary or metastatic to the salivary gland). 
4. History of secondary Sjögren’s syndrome. 
5. Parotid infection that does not resolve at least 4 weeks before the start of Screening.  
6. Any active viral infection that does not resolve by the start of Screening.  
7. Pregnancy or lactation. 
8. Use of biologics within 3 months of the start of Screening. 
9. Any experimental therapy within 3 months before the start of Screening.  
10. Use of immunosuppressants such as methotrexate, leflunomide, azathioprine, 
cyclophosphamide, systemic cyclosporine, or systemic corticosteroids within 3 months 
prior to the start of the Screening.   
11. Use of inhaled corticosteroids within 3 months prior to the start of Screening. 
12. Use of antimalarials and regular use of NSAIDs unless the dose has been stable (or 
decreased) for at least 2 months. 
13. Inability to discontinue the use of saliva stimulants such as pilocarpine and cevimeline 
for 24 hours before each study visit. 
14. Parotid intraductal irrigation or instillation with steroids within the past year. 


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15. Use of rituximab within 6 months prior to the start of Screening. 
16. Allergy to steroids or technetium, or any components of the formulations. 
17. Current use of warfarin or heparin. 
18. History of bleeding disorder. 
19. Both severe atrophy and fibrosis of the MSG noted on the pathology report of the MSG 
biopsy. 
20. Inability to comply with protocol procedures and the number of required visits. 
21. Inability to cannulate one or both parotid glands. 
22. Parotid fill volume <0.5 mL in one or both parotid glands. 
23. Significant concurrent medical condition or other circumstances that, in the opinion of 
the principal investigator, could affect the subject’s ability to tolerate or complete the 
study. 
24. Unable to understand written English for completion of study questionnaires. 
The eligibility checklist is included in Appendix 24.3.  
4 
STUDY DESIGN AND METHODS 
4.1 
Study Overview 
This will be a single-site, randomized-within-subject, placebo-controlled, double-blind phase 2 
pilot study in which all subjects receive both active drug (dexamethasone) and placebo (normal 
saline), thereby acting as their own controls.  Subjects are required to enter this study from SS 
protocol 84-D-0056.  Subjects will have one parotid gland treated with dexamethasone irrigation 
and the other gland treated with normal saline irrigation.  The study design is doubly-repeated 
measures; within a subject, measures are repeated in both time and treatment (i.e., one side of 
mouth receives placebo while the other receives dexamethasone).   
Subjects will be required to attend a minimum of 7 out-patient clinic visits for study assessments 
and procedures.  The maximum duration of on-treatment study participation for each subject is 


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expected to be up to approximately 11 weeks, with an approximate Screening interval of up to 
3 months and an additional Safety Follow-up period of approximately 15 days. 
4.2 
Recruitment 
Subjects will be recruited from the subjects enrolled in Sjögren’s Clinic Protocols    and other 
sources, including physician referrals, self-referrals, Patient Recruitment Public Liaison, and 
www.clinicaltrials.gov.  Recruitment will include flyers for patients and physicians as well as 
dear doctor letters.  Flyers will be distributed to the Sjögren’s syndrome network at John’s 
Hopkins, the Sjögren’s Syndrome Foundation, attendees at the annual American College of 
Rheumatology (ACR) meeting and to other local physicians and dentists.  Recruitment efforts 
will also include posts on the NIH Facebook and Twitter accounts.  Patients not already enrolled 
in 84-D-0056 will be required to enroll to confirm the diagnosis of primary Sjögren’s syndrome.  
Estimated recruitment time will be up to two years. 
4.3 
Screening 
Subjects who have been diagnosed with primary SS in Protocol 84-D-0056 will be eligible for 
participation.  Subject consent will be obtained before any study activities or procedures.  
Screening will be conducted up to 12 weeks before Day 0 in two stages (Stage I & Stage II) to 
minimize procedures for subjects who do not meet initial salivary flow criteria. Multiple visits 
will be needed to complete the screening portion of the protocol.    
Stage I screening assessments will be done within 6 weeks prior to Stage II and will include vital 
signs, medical and medication history, review of  concomitant medications and evaluation of 
salivary flow.  If salivary flow meets eligibility criteria the following additional Stage I 
procedures will be done: physical examination, pregnancy testing, routine clinical laboratory 
tests, and review of previous MSG biopsy.  If the subject continues to meet eligibility for study 
participation according to the preceding assessments, she will undergo parotid saline irrigation 
and fill volume measurement.  If an MSG biopsy has not been performed within 7 years of 
screening and an MSG biopsy needs to be performed, the saline irrigation and fill volume 
measurement will occur after the results of the MSG biopsy are obtained, as the final assessment 
of Screening Stage I. 


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Screening Stage II will be done within 6 weeks prior to Day 0 and will include vital signs, 
administration of the dry mouth questionnaire (Appendix 24.7), Sjogren’s Disease Activity Index 
(Appendix 24.9), laboratory blood assessment for baseline values, magnetic resonance imaging, 
and technetium scan, and a parotid core needle biopsy.  For the Screening Stage II, the 
pregnancy test must be within 24 hours before the technetium and MRI scans (for subjects of 
childbearing potential).  A CBC with differential and platelets, PT, and PTT will be done within 
7 days before each of the ultrasound-guided core needle parotid biopsies. All study visit 
procedures are detailed below in section 4.4 as well as a description of the approximate time to 
complete each procedure.   
We will accept results of imaging procedures done elsewhere if completed within 3 months of 
enrollment (screen-stage 1 visit). 
Subjects who randomize and receive one study treatment (Day 0) and take an excluded 
concomitant medication (immunosupressants) may re-screen.  They will not have screening 
MRI, Technetium scan, or parotid biopsy procedures repeated.   
4.4 
Study Procedures 
The study scheme depicted in Figure 4-1 presents the study schedule of events. All procedures 
described are for the purposes of participation in this study and considered research.. 


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Figure 4-1  
Study Scheme 
 
 
a Conducted as last assessment of Stage I, only for otherwise eligible subjects 
b  Subjects progress to Stage II then to Day 0, based on their qualification  as determined by the assessments 
conducted during the prior Screening stage. 
c Conducted as final assessment in Stage II, only for otherwise eligible subjects
Eligibility 
Salivary flow 
Saline 
irrigation*irrigationa 
Fill volume*volumea 
MSG Biopsy 
Screening 
Stage IIb 
(within  
6 weeks 
 before Day 0) 
 
  
Day 0b 
Dry mouth questionnaire 
Sjögren’s Disease Activity 
Index 
Salivary flow 
First irrigation AFTER 
baseline assessments 
Dry mouth questionnaire 
Sjögren’s Disease Activity 
Index 
Technetium scan 
MRI 
Core needle biopsyc 
Screening: 
Stage I 
(within 6 wks  
before start of 
Screening  
Stage II ) 
Day 14 
±5 
Dry mouth questionnaire 
Sjögren’s Disease 
Activity Index 
Salivary flow 
Day 28 
±5 
Dry mouth questionnaire 
Sjögren’s Disease 
Activity Index 
Salivary flow 
Second irrigation 
Day 42 
±5 
Dry mouth questionnaire 
Sjögren’s Disease Activity 
Index 
Salivary flow 
Day 56 
-3/+14 
 
Dry mouth questionnaire 
Sjögren’s Disease Activity 
Index 
Salivary flow 
Technetium scan 
MRI 
Core needle biopsy 
Safety 
follow-up 
15 ±5 days 
after 
Day 56 
visit) 


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Table 4-1 
Schedule of Events 
 
 
 
On-treatment Visits 
 
 
Screening  
 
 
Procedure 
Stage I 
(within 
6 weeks 
before 
 Stage II) 
Stage IIa 
(within 6 
weeks 
before 
Day 0) 
Day 0a  
Day 14  
± 5 days 
Day 28  
± 5 days 
Day 42  
± 5 days 
Day 56  
-3/+14  
days 
Safety 
Follow-upb 
(15 ± 
5 days 
after Day 
56 Visit) 
Consent 
X 
 
 
 
 
 
 
 
Inclusion/exclusion criteria 
X 
 
 
 
 
 
 
 
Relevant medical history/current medical conditions 
X 
 
 
 
 
 
 
X15 
Vital signs1 
X 
X 
X 
X 
X 
X 
X 
X15 
Physical examination 
X 
 
X 
 
X 
 
X 
X15 
Urine or serum pregnancy test2 
X 
X 
X 
 
X 
 
X 
 
Patient Dry Mouth Questionnaire 
 
X 
X3 
X 
X3 
X 
X 
 
Sjögren’s Disease Activity Index 
 
X 
X3 
X 
X3 
X 
X 
 
Saliva collection (salivary flow measurement) 
X4 
 
X4 
X 
X4 
X 
X 
 
Adverse events evaluation 
X 
X 
X 
X 
X 
X 
X 
X14 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
X14 
Randomization 
 
 
X 
 
 
 
 
 
Saline irrigation of parotid glands & determination 
of fill volume 
X10 
 
 
 
 
 
 
 
Randomized irrigation treatment5 of parotid glands 
 
 
X 
 
X 
 
 
 
Ultrasound-guided core needle biopsy of right 
parotid gland6 
 
X11 
 
 
 
 
X 
 
Routine clinical laboratory tests7 
X 
X 
X 
 
X 
 
X 
X15 
Blood for immunologic tests8 
 
 
X 
 
X 
 
X 
 
Blood for dexamethasone concentration9 
 
 
X 
 
X 
 
 
 
Minor salivary gland biopsy10 
X 
 
 
 
 
 
 
 
Magnetic resonance imaging 
 
X 
 
 
 
 
X 
 
Technetium scan of salivary glands 
 
X 
 
 
 
 
X 
 


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Research blood 
 
 
X13 
 
X13 
 
X 
 
a 
Subjects progress to Stage II then to Day 0, based on their qualification  as determined by the assessments conducted during the prior Screening stage. 
b     Telephone contact or clinic visit. 
1 
Pulse rate, respiratory rate, systolic and diastolic blood pressures, and temperature. 
2 
For Stage II screening and Day 56, pregnancy test must be performed within 24 hours before technetium and MRI scans for subjects of childbearing potential.  
For Days 0 and 28, pregnancy test must be performed before irrigation treatment. 
3 
On Days 0 and 28, may be done 2 days before visit or prior to saliva collection. 
4 
Performed before irrigation treatments at Stage I screening and on Days 0 and 28. 
5 
Dexamethasone in one parotid gland and normal saline in the other parotid gland. 
6 
Baseline ultrasound-guided core needle biopsy will be performed at least 14 days before Day 0.  Follow-up biopsy will be performed after the technetium and 
magnetic resonance imaging scans on Day 56.  
7 
Complete blood count with differential and platelets, Chem 14, erythrocyte sedimentation rate, C-reactive protein, and amylase.  Prothrombin time and partial 
thromboplastin time will be obtained at Stage II screening and Day 56.  The completed blood count with differential and platelets, prothrombin time, and 
partial thromboplastin time must be done with 7 days before ultrasound-guided core needle biopsy of the parotid.  Clinical laboratory tests will be performed 
at the Safety Follow-up only if clinically indicated.  
8 
Antinuclear antibodies, antibodies to extractable nuclear antigens, rheumatoid factor, C3 complement, C4 complement, immunoglobulin (Ig)A, IgM, and IgG. 
9 
Two samples will be obtained:  one prior to randomized irrigation treatment of the parotid glands (baseline) and the other 75 (± 15) minutes after irrigation 
treatment. 
10 Performed as final step of Stage I, when subject has otherwise qualified for the study. 
11    Performed as final step of Stage II, when subject has otherwise qualified for the study. 
12   Performed if a minor salivary gland biopsy is needed based on criteria in Section 3.2.  Must be conducted and evaluated prior to any other procedures and 
activities associated with Stage II screening. 
13 On Days 0 and 28, obtained prior to irrigation treatment. 
14   Assessed via telephone.  Clinic visit scheduled, if deemed necessary based on medical need or per subject request. 
15  Performed only if clinic visit deemed necessary per telephone interview. 
 
 


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4.4.1 Vital Signs Measurement 
Vital signs measurements will include pulse rate, systolic and diastolic blood pressure, 
respiratory rate, and temperature.  Vital signs will be done at Screening Stage I and Stage II, Day 
0, 14, 28, 42, 56 and follow-up (if done in clinic).  Vital sign measurements take about 10 
minutes to complete.   
4.4.2 Medical history and examination 
A medical  and medication history will be reviewed at Screening Stage I and an oral and physical 
exam will be done at Screening Stage I, Day 0, 28, 56  and Safety follow-up (if clinically 
indicated) to assess overall physical health.  The exam will be targeted toward the assessment of 
Sjögren’s and not include a full gynecological exam.  These procedures take up to an hour to 
complete. 
4.4.3 Collection of Saliva/Measurement of Salivary Flow Rate 
Saliva will be collected separately from both parotid glands at the following time points:  
Screening Stage I and Days 0, 14, 28, 42, and 56.  The collection will take place before any 
saline or treatment irrigation (Screening and Days 0 and 28).  The saliva collection procedure is 
noninvasive and requires no anesthesia.  A Teflon collection cup will be placed over the parotid 
duct orifice and held in place by slight negative pressure.  Parotid saliva, either at rest or 
following a physiologic gustatory stimulus with 2% citric acid, will be allowed to flow freely via 
plastic tubing connected to the collection cup.  The Salivary Flow Collection Procedure is 
provided in Appendix 24.6.  This procedures takes up to 30 minutes to complete.  
Saliva samples will be used for the following: 1) identification of changes in proteins involved in 
calcium signaling, such as Stim1.  In vitro and in vivo studies with salivary gland cell lines and 
primary cells will be run in parallel to examine the effect of dexamethasone on the epithelial 
cells, 2) exosomal microRNA biomarkers of inflammation.  Saliva collected during the study 
will be used for isolation of exosomes, and the nucleic acid content of the exosomes will be 
correlated with the inflammatory status of the glands.  Real-time quantitative polymerase chain 
reaction assays, microRNA microarrays, and/or deep sequencing will be used for identifying 
microRNAs. 
 


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4.4.4 Patient Dry Mouth Questionnaire 
Subjects will be asked to complete a questionnaire about their dry mouth symptoms (see 
Appendix 24.7) once during Screening Stage II and on Days 0, 14, 28, 42, and 56.  Completing 
the questionnaire can take up to 15 minutes. 
4.4.5 Sjögren’s Disease Activity Index 
The clinician will use the Sjögren’s Disease Activity Index to assess disease activity in each 
subject (see Appendix 24.9) once during Screening Stage IIand on Days 0, 14, 28, 42, and 56.). 
This index review takes up to 30 minutes for the clinician to complete.   
4.4.6 Parotid Fill Volume Determination 
Most subjects are expected to have a fill volume of less than 1 mL per parotid gland.  To make 
certain that the subjects can be cannulated and determine whether the parotid fill volume is less 
than 1 mL, each subject will undergo cannulation and fill volume assessment at Stage I screening 
as follows:   
1. The parotid duct will be gradually dilated with increasing probe diameter sizes starting at 
0000. 
2. After the dilations, a soft catheter will be placed over the 000 probe and inserted into the 
duct. 
3. The probe will be slowly removed, and a syringe filled with 1.5 mL saline will be 
attached on the catheter and the saline slowly injected. 
4. The injection will be terminated when the fill volume is completely injected, up to 1 mL. 
This assessment takes up to 20 minutes to complete.   
4.4.7 Collection of Laboratory Tests 
4.4.7.1 Phlebotomy and Urine Tests 
 Participants will have a 30mL blood sample drawn through phlebotomy and provide a 
urine specimen. The laboratory at the NIH Clinical Center will be the central laboratory 
for all routine laboratory parameters (hematology, chemistry, and urinalysis).  Routine 
laboratory tests will be collected at Screening Stage I, Screening Stage II, and on Days 0, 
28, and 56, and, if clinically indicated for procedures at the Safety Follow-up assessment.  
The following hematology, chemistry, and urine parameters will be assayed. Complete 
blood count with differential and platelets. 
 Inflammatory markers:  erythrocyte sedimentation rate (ESR) and C-reactive protein 
(CRP). 
 Clotting parameters:  PT, PTT (required 7 days before each parotid biopsy) 


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 Chem  panel:  albumin, alkaline phosphatase, alanine aminotransferase, aspartate 
aminotransferase, blood urea nitrogen, calcium, chloride, carbon dioxide (bicarbonate), 
creatinine, glucose, potassium, sodium, total bilirubin, and total protein. 
 Serum amylase. 
 Pregnancy test (urine or serum) (24 hours prior to technetium, MRI or parotid gland 
biopsy)  
Other laboratory tests of immunologic function will be collected on Days 0, 28, and 56.  
Immunologic assessments will include: 
 antinuclear antibodies, extractable nuclear antigens 
 rheumatoid factor 
 C3 complement, C4 complement 
 immunoglobulin (Ig)A, IgG, and IgM.A  
In addition, on Days 0 and 28, blood samples will be drawn for measurement of 
plasmaconcentrations of dexamethasone prior to randomized irrigation treatment at Days 0 and 
28 to obtain a pre-irrigation baseline measure and post-irrigation at 75 (±15) minutes after 
irrigation. Laboratory assessment collections can take up to 20 minutes to complete. 
Blood will be collected at Day 0, Day 28, and Day 56, 24 mL total, to be used for these research 
tests:  The serum and peripheral blood mononuclear cells will be isolated and stored under 
appropriate conditions. To determine the molecular mechanism of action of dexamethasone in 
this study, the following investigations are planned: Characterization of the fluid secretion 
mechanism after irrigation with corticosteroids, through assays of activities at the following 
levels:  single protein (single-channel recording); subcellular; cellular (monitoring organellar and 
single-cell current, Ca2+, and pH); and tissue (use of volume changes as reported of fluid 
secretion by acinar cells and the micro-dissected sealed-duct system to measure all ductal 
secretory and signaling functions).  Immunofluorescence will also be used to assay localization 
and expression levels of all key acinar and ductal transporters. 
4.4.8 Minor Salivary Gland Biopsy 
Some subjects may require an MSG biopsy during Stage I screening to confirm eligibility if their 
last MSG biopsy was >7 years at the time of screening.  Medication to numb the lower inside lip 


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will be administered and a small incision will be made to extract salivary glands.  The area will 
be closed with stitches.  This procedure can take up to 30 minutes to complete. 
4.4.9 Ultrasound-guided Parotid Core Needle Biopsy 
 Ultrasound-guided core needle biopsy of the right parotid gland will be obtained at Screening 
Stage II and Day 56 to evaluate inflammation (including focus score).  Using ultrasound, the 
parotid gland will be visualized, a small incision will be made at the base of the jaw and a needle 
will be guided into the parotid gland to retrieve a biopsy tissue sample. Two cores will be 
submitted in a fixative to pathology to be processed for regular histological analysis.  The 
remaining cores will either be placed in cell culture medium or be snap-frozen for further 
processing.  This procedure can take up to 45 minutes to complete.  If the baseline measurements 
are not informative for the study as deemed by the PI, comparable readings at Day 56 will not be 
performed. 
 
4.4.10 Technetium Scan 
During Screening Stage II and on Day 56, subjects will have a dynamic technetium scan of the 
salivary glands to assess gland function.  For this scan, they will receive 7 millicuries (mCi) 
technetium 99m (99mTc) pertechnetate intravenously, followed immediately by imaging over the 
head and neck region with a gamma scintillation camera.  Subjects will be imaged for 
60 minutes, followed by several 2- to 5-minute spot views.  At 40 minutes post-injection, they 
will have 1 mL citric acid solution administered orally.  A urine or serum pregnancy test must be 
done within 24 hours prior to the procedure as applicable.  This procedure can take up to 2.5 
hours to complete.  If the baseline measurements are not informative for the study as deemed by 
the PI, comparable readings at Day 56 will not be performed. 
 
4.4.11 Magnetic Resonance Imaging 
Magnetic resonance imaging of the parotid glands will be performed once during Screening 
Stage II and again on Day 56.  Measurements will be checked for changes during the study, 
which will be compared with changes in inflammatory and functional parameters of the parotid 
glands.  The MRI scans will be performed in the Diagnostic Radiology Department at the NIH 


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Clinical Center.  If the subject is unable to have an MRI for clinical safety reasons, she may still 
participate in all other aspects of this protocol.  .  If the baseline measurements are not 
informative for the study as deemed by the PI, comparable readings at Day 56 will not be 
performed. 
  
A 3 Tesla magnet will be used for the MRI scans, which will include the following pulse 
sequences: 
1. Axial T1-weighted with fat suppression 
2. Axial T1-weighted without fat suppression 
3. Axial T2-weighted with fat suppression (short T1 inversion recovery) 
4. Diffusion-weighted imaging with apparent diffusion coefficient (ADC) maps 
5. Repeat of techniques #1 and # 2 after intravenous administration of contrast 
The signal intensity of the parotid glands will be assessed on the T1- and the T2-weighted scans 
before and after contrast.  To normalize the signal intensity values of the glands, the values will 
be compared with the signal intensity values of a normal structure not affected by the treatment, 
i.e., the masseter muscle.  In addition, the values of diffusivity in the ADC maps will be 
measured.  A urine or serum pregnancy test must be done within 24 hours prior to the procedure , 
as applicable.  This procedure can take up to 2 hours to complete. 
4.4.12 Parotid Treatment Irrigation of the parotid duct (dexamethasone or saline) 
Treatment irrigation will follow saliva collection on Days 0 and 28.  Subjects will be randomized 
to receive dexamethasone irrigation in either the left or right parotid gland, with placebo (normal 
saline) administered in the opposite gland.  Both the subject and the assessor of salivary flow 
will be blinded as to which parotid gland receives which treatment.  Randomization of parotid 
glands within subjects will be done by the Pharmaceutical Development Service Department of 
the Pharmacy at the NIH. The person assessing salivary flow will not be involved in performing 
the irrigation. 


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Information on the dexamethasone formulation used in the study is provided in the 
dexamethasone package insert in Appendix 24.5.  The Clinical Center Intravenous Admixture 
Unit at the NIH will prepare vials containing placebo or dexamethasone.  The placebo vial will 
contain 0.9% sodium chloride for injection.  The dexamethasone vial will contain 2 mg of 
dexamethasone sodium phosphate for injection diluted with 0.9% sodium chloride for injection.  
Solution will be drawn from the vial into a 1 mL syringe.  The volume of each irrigation syringe 
will be determined by the parotid gland filling volume and specified in the medication order.  
The total volume will be between 0.5 and 1 mL.  All vials will be labeled with the following 
information: 
 Dexamethasone or saline. 
 Subject name. 
 Subject study number. 
 Date dispensed. 
 The words “Right parotid” or “Left parotid”. 
 Dose (2 mg). 
 Volume. 
Dexamethasone and saline placebo will be dispensed by designated Pharmacy Department staff 
according to their SOPs.  The Pharmacy Department staff will document receipt and dispensation 
of study drug on drug accountability logs.  The dispensation records will identify the name, lot 
number, and expiration date of the drug, as well as the identification number of subject and the 
quantity of drug dispensed to each subject.  Accidental or intentional destruction of study drug 
will also be documented.  All records will be available for inspection by the clinical trial 
monitor.  Unused study drug will be discarded in the clinic post-procedure per standard NIH 
drug destruction policy. 
The duct system of each gland will be irrigated with the assigned treatment solution 
(dexamethasone 2 mg or normal saline).  For subjects with a fill volume ≥1 mL, Dexamethasone 
(2 mg/mL) 1mL will be administered.  For subjects with a fill volume <1 mL, the concentration 
of dexamethasone will be adjusted to administer a total dose of 2 mg.  Irrigation will be 
performed by inserting a 1-mm-caliber catheter filled with the appropriate solution 1 to 2 cm into 
Stensen’s duct.  For subjects with a fill volume ≥1 mL, a 5-mL syringe will be filled with the 


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Date:  October 01, 2015 
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dexamethasone or saline solution before insertion; the catheter will be connected to the syringe 
and the solution slowly instilled into to parotid.  The catheter will be left in place for 2 minutes 
of irrigation and then removed.  High-speed suction will be used to collect the solution as it runs 
out.  For subjects with a fill volume <1 mL, the dexamethasone or saline will be dispensed in a 
1-mL syringe.  A urine or serum pregnancy test must be done within 24 hours prior to irrigation, 
as applicable.  This procedure takes up to 30 minutes to complete. 
4.4.13 Description of blood collected solely for research 
Blood will be collected at Day 0 and Day 28 and Day 56, 24 mL total, to be used for future 
studies.  The serum and peripheral blood mononuclear cells will be isolated and stored under 
appropriate conditions.  
To determine the molecular mechanism of action of dexamethasone in this study, the following 
investigations are planned: 
1. Characterization of the fluid secretion mechanism after irrigation with corticosteroids, 
through assays of activities at the following levels:  single protein (single-channel recording); 
subcellular; cellular (monitoring organellar and single-cell current, Ca2+, and pH); and tissue 
(use of volume changes as reported of fluid secretion by acinar cells and the micro-dissected 
sealed-duct system to measure all ductal secretory and signaling functions).  
Immunofluorescence will also be used to assay localization and expression levels of all key 
acinar and ductal transporters. 
2. Identification of changes in proteins involved in calcium signaling, such as Stim1.  In vitro 
and in vivo studies with salivary gland cell lines and primary cells will be run in parallel to 
examine the effect of dexamethasone on the epithelial cells. 
3. Exosomal microRNA biomarkers of inflammation.  Saliva collected during the study will be 
used for isolation of exosomes, and the nucleic acid content of the exosomes will be 
correlated with the inflammatory status of the glands.  Real-time quantitative polymerase 
chain reaction assays, microRNA microarrays, and/or deep sequencing will be used for 
identifying microRNAs. 


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Date:  October 01, 2015 
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4.4.14 Safety Follow-up  
All subjects will be contacted by telephone for a Safety Follow-up, approximately 15 (±5) days 
after the last on-treatment visit (Day 56 Visit).  A clinic visit may be conducted if deemed 
medically necessary or at the subject’s request.  Routine laboratory tests will be drawn only if 
clinically indicated.  This contact will complete subject participation in the study. 
4.4.15 End of Participation 
During the study, subjects will continue receiving regular medical care from their primary 
physicians.  The investigators will follow any AEs reported.  Following completion of the study, 
subjects will continue medical care with their primary physicians.  Results of technetium scans, 
MRIs, core needle biopsies, and laboratory tests will be provided to the subjects and/or their 
primary care physicians upon request.  Subjects will be notified of their parotid gland treatment 
assignment only after data analysis has been completed and the investigators have been 
unblinded. 
5 
STORAGE OF DATA AND SAMPLES 
5.1 
Data 
Study staff will complete electronic case report forms (eCRFs) via a web-based electronic data 
capture (EDC) system that is compliant with Part 11 Title 21 of the Code of Federal Regulations.  
The investigators will retain all study-related records for at least 2 years after discontinuation of 
the study. 
5.2 
Samples 
Samples collected for the protocol will be used for data analysis.  Any remaining samples will be 
stored in the MTPB locked freezers according to subject consent sample designation. Samples of 
subjects who do not consent to future research use of samples will be destroyed at the end of the 
study.  Approval of the IRB will be obtained prior to any research use of stored samples beyond 
the scope of this protocol. Only study investigators and participating research personnel will 
have access to the samples.  The principal investigator will report to the IRB the loss or 
destruction of samples collected under this protocol. 


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6 
ADDITIONAL CONSIDERATIONS 
6.1 
Research with Investigational Drugs or Devices 
Review of the federal regulation, Title 21 (Food and Drugs) part 312 (Investigational New Drug 
Application [IND]), subpart A – General Provisions 312.2 (Applicability) was conducted, and it 
was determined that this protocol met all the exemptions for IND submission as described in 
21 CFR 312.2(b)(1).  It was determined that the route of study drug administration, dosage level, 
and use in the defined protocol patient population would not significantly increase the risk or 
decrease the acceptability of the risk associated with study drug use as planned in the protocol.  
Safety information on dexamethasone can be found in the package insert provided in 
Appendix 24.5.  Dexamethasone irrigation is used by specialists for xerostomia, sialadenitis 
treatment or to decrease inflammation during oral surgical procedures. 
6.2 
Concomitant Medication Contingencies  
During the period of the study, subjects will not be allowed to use the following medications:  
human or murine antibodies, rituximab, warfarin, heparin, immunosuppressants (e.g., 
methotrexate, leflunomide, azathioprine, cyclophosphamide, systemic cyclosporine, systemic 
corticosteroids, and intra-articular corticosteroids), or any experimental drug.  If it is necessary to 
prescribe one of these medications, the subject may  participate in  subsequent treatments, 
without repeating baseline MRI, NM Scan or Parotid Biopsy, after a washout of 3 months for 
immunosuppressants Additionally, subjects must refrain from the use of salivary stimulants 
within 24 hours prior to each study visit.  If a subject enters the study on a stable dose of 
antimalarial drug or NSAID, the dose should not be increased during the study.  All effort should 
be made to maintain stable dosing of other concomitant medications, including saliva substitutes. 
7 
RISKS AND DISCOMFORTS 
7.1 
Assessments/Procedures with No Risks 
The following assessments/procedures are deemed to have no risks and to cause no noteworthy 
discomfort: vital signs measurements, history and physical exam, urine collection, patient dry 
mouth questionnaire, and Sjögren’s Disease Activity Index. 
7.2 
Collection of Saliva/Measurement of Salivary Flow Rate 
There is no known risk associated with this procedure. Subjects may experience discomfort due 
to increased dryness caused by withholding salivary stimulants for 24 hours prior to saliva 


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collection. There may be mild discomfort from positioning of mouth during collection.  Citric 
acid (lemon juice) solution used to stimulate salivary flow may cause an unpleasant taste and 
mild discomfort in the salivary glands if the parotid duct is blocked and saliva cannot be 
expressed. 
7.3 
Parotid Fill Volume Determination and Saline Irrigation of Parotid Gland 
Parotid fill volume will be measured before irrigations.  Each subject will undergo 3 irrigations 
of each parotid gland, the first of which will use saline only.  This procedure will involve 
placement of a catheter within Stensen’s duct and filling of the duct with the appropriate 
solution, either dexamethasone or normal saline.  The procedure may cause minor trauma to the 
parotid ducts and/or infection or inflammation of the parotid gland (sialadenitis).  Other rare 
risks include perforation and/or scarring of the parotid duct(s) and damage to the facial nerve 
secondary to inflammation, infection, or scarring. 
7.4 
Intraductal Dexamethasone  
Dexamethasone sodium phosphate is a synthetic adrenocorticosteroid indicated for a variety of 
disorders associated with inflammation.  Like other glucocorticoids, it can cause profound and 
varied metabolic effects, as well as modify the body’s immune responses to diverse stimuli.  At 
equipotent anti-inflammatory doses, dexamethasone almost completely lacks the 
sodium-retaining property of hydrocortisone and closely related derivatives of hydrocortisone.  
Dexamethasone is contraindicated in persons with systemic fungal infections and in persons with 
hypersensitivity to any component of the formulation. 
In this study, dexamethasone will be used topically in small doses within the parotid ducts; 
therefore, systemic exposure to the drug is expected to be extremely low.  The dose (2 mg given 
twice 4 weeks apart) is within the range approved for intra-articular/intralesional use (0.2 to 6 mg 
administered once every 3 to 5 days to once every 2 to 3 weeks).  Possible risks from local 
exposure in the mouth include irritation of the oral mucosa, temporary unpleasant taste, and 
increased risk of infection, allergic reaction, and pain.  The risks associated with prolonged 
systemic exposure to dexamethasone (hypertension, diabetes, osteoporosis, glaucoma, increased 
risk of systemic infection, and adrenal insufficiency) are very unlikely to occur with this dosing 
regimen. 


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7.5 
Ultrasound-guided Parotid Gland Core Needle Biopsy 
Subjects will undergo a core needle biopsy of the right parotid gland during the Screening Period 
and on Day 56.  Ultrasound guidance will be used to localize the biopsy site within the gland, 
and local anesthetic will be administered to minimize pain during the procedure. 
Several recent publications have described ultrasound-guided core needle biopsy of the parotid 
gland as a low-risk alternative to open surgical biopsy.20,21,22  Available published data indicate 
that the procedure is relatively simple and safe to perform and yields sufficient tissue for 
accurate pathologic diagnosis.  The diagnostic accuracy (mainly for tumors) in 319 patients was 
96% to 100%, with only 5 (1.6%) reported complications.  Four of these complications were 
hematomas, most of which did not require any intervention.  One patient with metastatic 
squamous cell carcinoma developed a parotid fistula after biopsy.  The main risk of an open 
biopsy of the parotid is injury to the facial nerve (controlling motor function on the ipsilateral 
face); however, no such complication has been reported with ultrasound-guided core needle 
biopsy.  In the investigators’ experience with 24 subjects undergoing ultrasound-guided core 
needle biopsy of the parotid, no SAEs were reported.  One subject had an infected hematoma that 
responded promptly to antibiotics.  The most common complaint was mild to moderate pain or 
discomfort at the site of the biopsy, which responded to simple analgesics.  Other possible risks 
with the core needle biopsy are allergic reactions to the local anesthetic, bleeding at the biopsy 
site, and local infection; however, such events are rare. 
Subjects in this study will be screened for a history of bleeding disorder and have a CBC with 
differential and platelets, PT, and PTT before each core needle biopsy.  Any discomfort, pain, or 
swelling at the biopsy site will be treated with acetaminophen or more potent analgesics as 
needed.  If facial nerve injury should occur, the subject will be referred to an appropriate 
subspecialist for care to minimize the damage.  Subjects will be asked to sign a separate surgical 
consent form prior to the biopsy procedure. 
7.6 
Technetium Scan and Radiation 
Subjects will undergo technetium scans of the salivary glands.  In this procedure, they will 
receive an intravenous injection of 7 mCi of 99mtechnetium pertechnetate, which emits low-
energy (approximately 140 kev) gamma rays.  The effective radiation dose from the 2 scans will 
be 0.65 rem, which is below the maximum limit of 5 rem (0.05 rem) per year allowed for 


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research subjects by the NIH Radiation Safety Committee.  Subjects will not be allowed to eat or 
drink anything except water and medications for 4 hours before the scan.  If they have 
childbearing potential, they will be required to have a negative pregnancy test before the scan.  
The intravenous injection for the scan may cause discomfort or bruising at the needle site and, 
rarely, an infection may occur.  Allergic reactions to technetium pertechnetate are also possible, 
but rare. 
7.7 
Minor Salivary Gland Biopsy 
Some subjects may require an MSG biopsy if one has not been completed within the past 5 years 
during Stage I Screening to confirm eligibility (Section 3.2).  The biopsy will be performed 
according to NIDCR SOPs.  Local anesthetic will be administered to minimize pain during the 
procedure.  Biopsy of the MSG may cause discomfort, pain, and swelling at the site (usually 
lower lip) for several days following the procedure; these symptoms can be effectively treated 
with acetaminophen or more potent analgesics as needed.  Subjects may also experience transient 
paresthesias in the region of the biopsy.  Other possible risks are allergic reactions to the local 
anesthetic and bleeding and infection at the site of biopsy; however, such events are rare.  The 
subject will be asked to sign a separate surgical consent form prior to the procedure. 
7.8 
Magnetic Resonance Imaging 
During the study, subjects will undergo MRI scans of the parotid glands.  These scans will be 
performed at the NIH Clinical Center Diagnostic Radiology Department under the direction of a 
radiologist.  If not contraindicated, contrast agent will be used during the MRIs, which may be 
conducted with or without sedation.  For each MRI scan, the subject will have to lie in the 
scanner for approximately 30 minutes, and will have to lie still for up to 10 minutes at a time. 
Persons are at risk for injury from the MRI magnet if they have pacemakers or other implanted 
electrical devices, brain stimulators, some types of dental implants, aneurysm clips (metal clips 
on the wall of a large artery), metallic prostheses (including metal pins and rods, heart valves, 
and cochlear implants), permanent eyeliner, implanted delivery pump, or shrapnel fragments.  
Welders and metal workers are also at risk for injury because of possible small metal fragments 
in the eye, of which they may be unaware.  Subjects will be screened for these conditions before 
having the scan, and those determined to have any will not be allowed to undergo MRI without 


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approval of the radiologist.  Each subject will be asked to remove all magnetic objects (e.g., 
watches, coins, jewelry, and credit cards) before entering the MRI scan room. 
It is not known whether MRI is completely safe for a developing fetus.  All subjects of 
childbearing potential will have a urine or serum pregnancy test performed within 24 hours 
before each MRI scan.  The MRI scan will not be performed if the pregnancy test is positive. 
Subjects who fear confined spaces may become anxious during the MRI.  If sedation is 
necessary, oral diazepam or another benzodiazepine recommended by the radiologist will be 
offered prior to the study (all screening and consents will be administered before the subject 
receives any sedation).  Subjects with back problems may also experience back pain or 
discomfort from lying in the scanner.  The noise from the scanner is loud enough to damage 
hearing, especially in persons who already have hearing loss.  Subjects will be fitted with hearing 
protection during the scan.  All subjects will be asked to complete an MRI screening form for 
each scan.  There are no known long-term risks associated with MRI scans. 
As part of the MRI scans, it is planned that subjects receive an IV injection of contrast agent 
containing gadolinium.  The risks of an intravenous catheter include bleeding, infection, or 
inflammation of the skin and vein with pain and swelling.  These events will be treated if they 
occur.  Symptoms from the contrast infusion are usually mild and may include coldness in the 
arm during the injection, a metallic taste, headache, and nausea.  Possible mild allergic reactions 
include rash, sweating, and itching.  In an extremely small number of patients, more severe 
symptoms have been reported, including shortness of breath, wheezing, urticaria, and 
hypotension.  Persons with renal failure are also at risk for a serious reaction to gadolinium 
contrast called nephrogenic systemic fibrosis, which has resulted in a very small number of 
deaths.  Subjects will be asked about past allergic reactions to MRI contrast agents and impaired 
renal function prior to undergoing MRI.  Serum renal function test results will also be available 
to the principal investigator and radiologist at the time of the MRI.  The contrast agent will be 
omitted during the scan if hypersensitivity to gadolinium containing contrast agents is suspected, 
or if the subject is thought to be at increased risk for nephrogenic systemic fibrosis (glomerular 
filtration rate <60 mL/min). 


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7.9 
Blood Collection 
Blood will be drawn from subjects.  Approximately 16.5 mL of blood will be drawn during Stage 
I and Stage II screening; approximately 30 mL on Days 0 and 28; and approximately 24 mL on 
Day 56.  The total volume of blood drawn during the entire study will be approximately 154.5 
mL.  If clinically indicated, some subjects may have blood drawn at the Safety Follow-up. 
Subjects may experience discomfort, bleeding, or bruising at the venipuncture site, which should 
resolve with time.  There is also a small risk of fainting.  Pressure will be applied to the 
venipuncture site for several minutes after needle removal to prevent bruising or bleeding.  
Infection at the site of needle insertion may also occur but is rare with the use of sterile 
disposable needles and aseptic technique.  The amount of blood drawn for research purposes will 
be kept within the NIH guidelines for adults, not exceeding 10.5 mL/kg or 550 mL, whichever is 
smaller, over any 8-week period. 
7.10 Risk of stopping salivary stimulants  
Subjects will be required to suspend the use of salivary stimulants within 24 hours prior to each 
study visit, and this suspension could cause discomfort from dryness of the mouth. 
7.11 Unexpected Adverse Events 
Unforeseen adverse effects are a risk with every new drug treatment, including new routes of 
administration for approved drugs.  The risks of participating in this study are reasonable relative 
to the potential health benefits and generalizable medical knowledge that may be obtained. 
8 
SUBJECT SAFETY MONITORING 
All subjects will be monitored from the time of informed consent. Study procedures will be 
performed and monitored by licensed/certified NIH personnel.  At each study visit, subjects will 
be evaluated for AEs and will be followed until resolution or stabilization of any AEs.  All AEs 
will be graded according to a descriptive severity scale based on the National Institute of Allergy 
and Infectious Diseases (NIAID), Division of Acquired Immunodeficiency Syndrome Table for 
Grading the Severity of Adverse Events.  The scale has been slightly modified for this protocol 
(Appendix 24.4 ).  Pregnancy will be monitored throughout the study and subjects study 
participation will be stopped in the event of pregnancy.  Emergency unblinding of a subject’s 


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parotid gland randomization assignment will be allowed if the information is needed to treat a 
serious adverse event. 
Serious adverse events will be reported to CROMS Product Safety group; each event will be 
reviewed by a CROMS medical monitor.  The site’s medically responsible Investigator will 
determine follow-up actions based on event intensity and whether it was expected and at least 
possibly related to study drug.  
Subjects will be informed that they may withdraw or be excluded from the study at any time.  
The following conditions will require the discontinuation of study drug:   
 Pregnancy 
 New onset of a condition that requires treatment with any prohibited agent (Sections 3.3 
and 6.2). 
 Inability of study personnel to cannulate one or both parotid glands. 
 Noncompliance with study procedures. 
 Adverse event that would substantially increase the risk of continued participation. 
 Investigator discretion. 
 Violation of eligibility criteria. 
Subjects who stop study treatment after receiving 1 of the two doses will be asked to complete 
the Day 56 assessments and the Safety Follow-up, excluding core needle biopsy of the parotid.  
Subjects who qualify for the study and who, prior to the first dose of study medication, elect to 
not receive treatment, will have the following assessments: 
 Evaluation of AEs. 
 Vital sign measurements (pulse rate, systolic and diastolic blood pressure, respiratory 
rate, and temperature). 
 Laboratory tests if clinically indicated. 
No additional data will be collected from subjects who withdraw completely from the study. 


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9 
OUTCOME MEASURES 
9.1 
Primary Outcome Measure 
The primary endpoint of the study is the change in salivary flow from Day 0 to Day 56. 
9.2 
Secondary Outcome Measures 
Secondary endpoints include the following: 
 Change in focus score on parotid biopsy from Stage II screening to Day 56. 
 Changes in salivary flow from Day 0 to study Days 14, 28, 42, and 56. 
 Changes in assessments on the Patient Dry Mouth Questionnaire from Day 0 to study 
Days 14, 28, 42, and 56. 
 Changes in assessments on the Sjögren’s Disease Activity Index from Day 0 to study 
Days 14, 28, 42, and 56. 
 Changes in other assessments of salivary function from baseline to study Day 56, 
including technetium scan of the salivary glands. 
 Changes in laboratory measures of inflammation. 
 Frequency of AEs related to treatment; location of the AE (body site, right or left), will 
be recorded and evaluated, as applicable. 
Exploratory endpoints will be the changes in mechanistic endpoints from baseline to study 
Days 14, 28, 42, and 56. 
10 STATISTICAL ANALYSIS 
10.1 Analysis of Data/Study Outcomes 
10.1.1 Safety Population 
The Safety Population will consist of all enrolled subjects receiving any parotid saline irrigation 
used to determine parotid filling volume during Stage I screening.  
10.1.2 Primary Efficacy Population 
The Primary Efficacy Population (PEP) will consist of all enrolled subjects who receive all 
parotid irrigations on study Days 0 and 28, have the same treatment applied to the same parotid 


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(regardless of random assignment) at both visits, and have values for the primary endpoint (i.e., 
change in salivary flow from Day 0 to Day 56).  The PEP will be used in the primary analysis. 
10.1.3 Secondary Efficacy Population 
The Secondary Efficacy Population (SEP) will consist of all enrolled subjects who receive at 
least one on-treatment set of parotid irrigations and have at least one salivary flow assessment 
after study Day 0.  The SEP will be used in some secondary analyses. 
10.1.4 Demographic and Baseline Characteristics 
Demographic and baseline characteristics will be summarized in tables.  Continuous 
demographic and baseline variables will be summarized as means, medians, SDs, minimum 
values, and maximum values.  Categorical demographic (e.g., race) and baseline variables will 
be summarized as frequencies and percents.  Baseline variables pertaining to the parotid gland 
will be summarized by their assigned treatment.  Differences between parotid glands by side of 
the body (right or left) and assigned treatment will be estimated with 90% confidence intervals. 
10.1.5 Primary Efficacy Analysis 
The primary analysis will compare the change from Day 0 in salivary flow in the 
dexamethasone-irrigated parotid glands (active treatment) with the saline-irrigated parotid glands 
(placebo treatment) at study Day 56.  The treatment effects on the change from Day 0 will be 
analyzed using repeated measures with change from Day 0 to Day 56 as the dependent variable 
with random effects for subjects.  Day 0 salivary flow will be included as a covariate to adjust 
for any possible effects of baseline salivary flow on the degree to which salivary flow can change 
from Day 0.  Statistical inferences for treatment effects on salivary flow will be 1-sided (=0.05) 
and test for increased salivary flow in the dexamethasone-irrigated parotid glands compared with 
the saline-irrigated parotid glands.  The estimate of the treatment effect will be reported with the 
associated 1-way confidence interval.  The primary analysis will be performed on the PEP. 
10.1.6 Secondary Analyses of Salivary Flow 
Secondary analysis of salivary flow will test for increased salivary flow in the dexamethasone-
irrigated parotids compared with the saline-irrigated parotids with respect to change from Day 0 
at each of the remaining study days (study Days 14, 28, and 42).   


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The treatment effects on the change from Day 0 will be analyzed as doubly-repeated measures 
with change from Day 0 as the dependent variable, random effects for subjects, and repeated 
effects for treatment and post-Day 0 study day.  Day 0 salivary flow will be included as a 
covariate to adjust for any possible effects of baseline salivary flow on the degree to which 
salivary flow can change from Day 0.  Statistical inferences for treatment effects on salivary flow 
will be 1-sided (α=0.05) and test for increased salivary flow in the dexamethasone-irrigated 
parotid glands compared with the saline-irrigated parotid glands.  Contrast statements within 
doubly-repeated measures design will be used to compare the treatment effects on the change in 
salivary flow from Day 0 at study Days 14, 28, and 42.  If significant treatment effects are found 
at any of the study days, then additional secondary analyses will test for pair-wise differences in 
change from Day 0 salivary flow between the study days.  These tests for pair-wise differences 
in salivary flow between study days will use 2-sided tests since it is desirable to test for both 
negative and positive differences (e.g., it is of interest to test whether change in salivary flow 
from Day 0 to Day 42 is greater than or less than the change in salivary from Day 0 to Day 28).  
These secondary analyses will be performed on the SEP, with any endpoints following the 
second on-treatment irrigation set to missing, if the second on-treatment irrigation was 
discordant with the first treatment irrigation. 
The Patient Dry Mouth Questionnaire and the Sjögren’s Disease Activity Index will be 
summarized for each question and at each visit using frequencies and percents.  Questions 
pertaining to symptoms of SS (e.g., difficulty chewing food, changes in rate of tooth decay, 
mouth dryness, etc.) will be displayed graphically over time as frequencies for binomial and 
categorical outcomes, and as medians for ordinal outcomes.  Binomial- and ordinal-scaled 
symptoms of SS will be further summarized by visit as change from baseline (Day 0) using shift 
tables.  Shifts from baseline in frequencies or ordinal values that appear substantial will be 
further analyzed using the McNemar’s test.  If the data appears rich enough, further longitudinal 
analysis may be performed using generalized estimating equations (GEE).  Any p-values 
reported from the McNemar’s test or GEE analyses will be considered exploratory. 
10.1.7 Exploratory Analyses of Mechanistic and Inflammatory Biomarkers 
Mechanistic and inflammatory endpoints will be studied to gain insight into the molecular 
mechanism of action of the dexamethasone treatments and to generate hypotheses for future 


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research.  The mechanistic outcome measures may include, but will not be limited to, 
single-protein single-channel recordings, organellar and single-cell current (Ca+2, and pH), fluid 
secretion by acinar cells, and ductal secretory and signaling functions.  These mechanistic 
endpoints will be summarized by study day and as change from baseline.  Summary statistics 
employed may include means, geometric means, minimum and maximum values, standard 
deviations, 90% confidence limits, medians, and frequencies as appropriate for the measure.  Log 
or other transformations may be used if they improve the distributional properties of the outcome 
measure.   
Saliva-derived biomarkers of inflammation and salivary gland dysfunction may be identified 
from the exosomal microRNAs and non-coding small RNAs.  The frequency of the 
presence/absence of these biomarkers in the saliva both before and after treatment will be 
reported.  Concentrations of biomarkers above the threshold of detection will be summarized 
using the summary statistics listed above.  Biomarkers for inflammation other than non-coding 
RNAs might be measured in saliva, but those biomarkers will be determined by findings in the 
biopsies. 
Finally, mechanistic endpoints and biomarkers (including changes from baseline) that appear 
promising will be tested for association with inflammation, salivary flow, or other measures of 
salivary gland dysfunction.  Cross-sectional analyses may include measures of correlation such 
as Kendall’s tau, Spearman rank correlation, and polyserial correlation, as appropriate for the 
measure.  Biomarkers or outcomes that show evidence of correlation with salivary flow or 
salivary gland dysfunction may be further analyzed longitudinally using mixed-models analysis.  
These analyses are considered exploratory and hypothesis generating and, as such, will not be 
corrected for multiple comparisons. 
10.1.8 Criteria for Significance 
The hypothesis test and confidence interval of treatment effects for the primary analysis will be 
one-sided and test for a positive treatment effect.  Hypothesis tests and confidence intervals of 
secondary analyses will be either 1- or 2-sided as described above.  All statistical tests will use 
an α = 0.05. 


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10.1.9 Interim Analysis 
No interim analysis will be performed. 
10.2 Power Analysis 
The primary endpoint is the change in salivary flow (Day 56 – Day 0) following either saline 
(placebo) or dexamethasone irrigation.  Because each subject will simultaneously receive both 
irrigation treatments over several time points, the experimental design is a doubly-
repeated-measures design with one repeated effect for treatment and another repeated effect for 
study day, and random effects for subject.  The expected treatment effect of the dexamethasone 
irrigation over the saline (placebo) irrigation is an improvement in salivary flow of at least 40%. 
The power and sample size computations assume the final primary analysis will be doubly-
repeated-measures analysis, including an unstructured variance and random effects for subject to 
account for the non-independence between glands within a subject.  The “unstructured variance” 
allows the variances (SDs) of the change in salivary flow for each treatment to differ from each 
other.  The power analysis was performed in SAS using the methodology described by Kononoff 
and Hanford.23 
The power analysis is based upon the variance parameter estimates in Table 10-1. 
Table 10-1 
Assumptions for Power Analysis 
Parameter 
Estimate 
1. Standard deviation of the change in salivary flow for the saline-irrigated 
parotid gland 
 
0.0168 
2. Standard deviation of the change in salivary flow for the dexamethasone-
irrigated parotid gland 
 
0.0906 
3. Within subject correlation between parameters 1 and 2 above 
 
0.15 
 
The SDs of the change in salivary flow for the placebo and dexamethasone irrigations were 
estimated from data published by Izumi et al.1 the mean measures and SDs of change in total 
salivary flow during 2 minutes were converted to flow from a single parotid gland during 
1 minute by multiplying by 0.1625 (0.65 for the proportion of total flow from the parotid glands 
x 0.5 for a single parotid gland x 0.5 for 1 minute).  This conversion assumes a very high 
correlation between total salivary flow and parotid salivary flow. 


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The above power analysis at 80% power determined that 16 patients would be required to detect 
a one-sided 40% increase in dexamethasone-irrigated parotid glands compared with the 
saline-irrigated parotid glands with respect to change in salivary flow from Day 0.  
Approximately 20 subjects will be screened to ensure that 16 subjects will be randomized and 
treated with dexamethasone irrigation. Subjects who discontinue from the study before the Stage 
I screening parotid irrigation will be replaced.  Subjects who do not receive the first irrigation 
treatment and at least 1 post-treatment salivary flow assessment will also be replaced. 
11 HUMAN SUBJECTS PROTECTION 
11.1 Subject Selection 
Selection of subjects will not be limited by race or ethnicity.  Because SS occurs most frequently 
in adult females, males and children will be excluded from the study.  This inclusion strategy is 
important in a small study like this to insure as homogeneous a population as possible to stabilize 
the variance.  Also, recruitment may be difficult in males and children because it is uncommon.  
Having a very small set of males or children would make it difficult or even impossible to 
statistically adjust for their unique contribution to the data. 
11.2  Justification for Exclusion of Children 
Because SS occurs most frequently in adults, with less than 145 total cases of  primary SS 
reported internationally24, children will be excluded from the study to reduce variability of 
results.   
11.3 Justification for Exclusion of Non-English speaking Subjects 
Subjects that are not able to understand written English will not be included in the study. 
Subjects will be asked to complete several validated data questionnaires that are not translated 
and validated in their native languages. 
11.4 Justification for Exclusion of Other Vulnerable Subjects  
Pregnant women will be excluded from the study because dexamethasone should not be used 
during pregnancy because the potential benefit does not justify the potential fetal risks.   
11.5 Justification of Sensitive Procedures 
Although placebo will be used in the study, each subject will also receive active treatment.  The 
placebo treatment will serve as a comparator in evaluating subject response to dexamethasone 


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treatment.  Withholding salivary stimulants will be necessary 24 hour prior to saliva collections 
to determine baseline salivary flow.   
11.6 Safeguards for Vulnerable Populations 
All subjects of childbearing potential will be required to use an effective method of contraception 
during the study.  A pregnancy test will also be performed before any procedures requiring 
radiation and prior to any study treatment.  Women who are lactating will be excluded from the 
study because dexamethasone, which is secreted in breast milk, could suppress growth or 
endogenous corticosteroid production in the breastfed child, or cause other unwanted effects. 
11.7 Qualifications of Investigators 
The qualifications and roles of all investigators are shown in Table 11-1. Investigators obtaining 
consent are identified with an *. 


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Table 11-1 
Investigator Qualifications and Roles 
Investigator Name, 
Degree 
Qualifications/Role 
Ilias Alevizos, 
DMD* 
Dental clinician (oral pathologist); responsible for  saliva collections, 
treatment administration, oral examinations, protocol delegation of 
responsibilities, and clinical and laboratory aspects, oversight of all aspects 
of the study and obtaining informed consent. 
Indu Ambudkar, 
PhD 
Laboratory scientist; will perform multiple laboratory assays on saliva, 
serum, and tissue samples from subjects. 
Lolita Bebris, RN* 
Research nurse specialist with 11 years of research experience inclusive of 
auto-immune diseases and 4.5 years of experience with Sjögren’s syndrome 
research. Responsible for subject screening and recruitment, coordinating 
study visits, adverse event assessment, and obtaining informed consent. 
Richard Chang, MD 
Physician, board certified in nuclear medicine; will function as consultant for 
reading of protocol-required nuclear medicine studies and test 
interpretations.   
Clara Chen, MD 
Physician, board certified in nuclear medicine; will function as consultant for 
reading of protocol-required nuclear medicine studies and test 
interpretations.   
Anna Cotrim, DDS, 
PhD 
Dental clinician (oral pathologist); responsible for specimen saliva 
collections and assisting with treatment administration and oral 
examinations. 
 
Alan Baer, MD 
Physician, Board-certified Rheumatologist, responsible for physical 
assessments, adverse event assessments, ordering and interpreting tests, 
prescribing treatments, regulatory reporting, evaluation and interpretation of 
test results.  Will not obtain consent. 
Margaret Grisius, 
DDS 
Dental clinician (oral pathologist); responsible for saliva collections, 
treatment administration, and oral examinations.   
Donna Kelly 
Patient Care Coordinator has >14 years of Sjögren’s Syndrome research 
experience in processing and collection of samples (tissue, saliva, serum, 
PBMC and plasma isolation).  Biological lab tech has >10 years experience 
tracking and processing samples.  Trained in the processing of DNA 
samples.  May perform serum assays.  Performs data entry.  Will not consent 
patients. 
Shmuel Muallem, 
PhD 
Laboratory scientist; will perform multiple laboratory assays on saliva, 
serum, and tissue samples from subjects. 
David Kleiner, MD 
Board-certified pathologist; will evaluate clinical tissue samples and consult 
on pathology and tissue protocol samples. 
Nicholas Patronas, 
MD 
Physician, board certified in nuclear medicine; will function as consultant for 
reading of protocol-required nuclear medicine studies and test 
interpretations.   


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Sarfaraz Hasni, MD 
Physician, board-certified rheumatologist; responsible for the physical 
assessments, adverse event assessments, ordering and interpreting tests, 
prescribing treatments, regulatory reporting, evaluation and interpretation of 
test results. 
 
 
 
Eileen Pelayo, RN 
Research nurse specialist with >15 years of research experience, with one year of 
research experience inclusive of autoimmune diseases. Responsible for subject 
screening and recruitment, coordinating study visits, and adverse event assessment 
and obtaining informed consent. 
Tammy Yokum, 
RN* 
Research nurse specialist with 22 years of research experience inclusive of 
auto-immune diseases and 3 years of Sjögren’s Syndrome research 
experience.  Responsible for subject screening and recruitment, coordinating 
study visits, adverse event assessment, and obtaining informed consent. 
12 ANTICIPATED BENEFIT 
Subjects participating in this study may benefit from improved salivary function, which is 
important in the daily activities of chewing, swallowing, and speaking and is vital to good dental 
and oral health. 
13 CLASSIFICATION OF RISK 
This study is classified as research involving more than minimal risk with the prospect of 
individual benefit.  The risk is justified given the lack of effective treatments for many patients 
with xerostomia due to primary SS. 
14 CONSENT DOCUMENTS AND PROCESS 
14.1 Designation of Those Obtaining Consent 
The study investigators designated as able to obtain consent in Table 11-1, will obtain informed 
consent. 
14.2 Consent Procedures 
Investigators qualified and designated in Table 11-1 of the protocol will obtain informed consent.  
Written, informed consent will be obtained before any screening or study procedures are 
initiated.  All participants will receive a verbal explanation in terms suited to their 
comprehension of the purposes, procedures, and potential risks of the study and of their rights as 
research participants. Participants will have the opportunity to carefully review the written 
consent form and ask questions regarding this study prior to participation.   


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14.3 Consent Documents 
14.3.1 Designation of Those Obtaining Consent   
Study investigators designated as able to obtain consent above will obtain informed consent. 
14.3.2 Consent Procedures 
For inclusion in the study, each subject will be required to sign the patient population consent 
form.  Participants will have the opportunity to carefully review the written consent form and ask 
questions regarding this study prior to signing.  The original consent forms will become part of 
the permanent medical record, and copies will be provided to the subjects.  A copy of the consent 
form can be found in Section 25.  The fact that informed consent was obtained prior to the 
initiation of study procedures will be documented in the subject’s medical or research record. 
14.3.3 Consent Documentation 
The consent form has all the required elements 
15 DATA AND SAFETY MONITORING 
15.1 Data and Safety Monitor 
The principal investigator will be responsible for monitoring the conduct of the study and 
verifying adherence to the protocol.  The NIDCR Data and Safety Monitoring Committee 
(DSMC) will have safety oversight responsibilities for the study.  The committee will include 
members with expertise in a broad range of areas, including human subjects’ protection, research 
ethics, clinical trial implementation, biostatistics, and rheumatology.   
15.2 Data and Safety Monitoring Plan 
Approximately annually, the DSMC will review data related to enrollment progress, study 
implementation, subject safety, and protocol violations.  The DSMC will also consider current 
information from other sources on the biology of the disease and the subject population under 
study.  Based on these reviews, the DSMC will make recommendations to the principal 
investigator and the NIDCR Clinical Director concerning the continuation, modification, or 
termination of the study.  The DSMC will also meet ad hoc if relevant issues arise that require 
committee review.  The roles and responsibilities of committee members and meeting procedures 
will be formally described in a charter. 


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15.3 Criteria for Stopping the Study or Suspending Enrollment or Procedures 
The DSMC chair will be alerted if any of the following situations occur:  
 An unexpected fatal or life-threatening event assessed as related to the use of study drug. 
 Three or more subjects with similar severe AEs assessed as related to the use of study 
drug. 
 Three or more subjects with SAEs assessed as related to the use of study drug. 
 Any occurrence of facial nerve paralysis related to a study procedure. 
 Three or more occurrences of bacterial parotid infection requiring antibiotic 
administration, assessed as related to a study procedure or study drug. 
The principal investigator will be responsible for monitoring the accruing safety data related to 
suspension guidelines and for alerting the DSMC chair when a criterion is met.  The DSMC 
chair will be alerted by email within 7 calendar days of determination that a criterion has been 
met.  The DSMC will issue a recommendation on study continuation to the NIDCR Clinical 
Director after reviewing data related to the suspension guideline.  If the study is stopped, subjects 
will receive conventional care for any study-related AEs and continue to be followed for clinical 
and safety outcomes.  Otherwise, the study will continue per the DSMC recommendations.  The 
principal investigator and the Clinical Director will provide the recommendations of the DSMC 
to the IRB. 
16 QUALITY ASSURANCE 
16.1 Quality Assurance Monitor 
The principal investigator will be responsible for monitoring the conduct of the trial, for 
verifying adherence to the protocol, and for confirming the completeness, consistency, and 
accuracy of all study data.  The principal investigator is required to keep accurate records to 
ensure that the conduct of the study is fully documented. 
Staff from CROMS at Rho, Inc. will conduct the clinical monitoring activities and provide 
reports of the findings.  The purposes of the clinical monitoring activities are to ensure that the 
rights of human subjects are protected, the study is implemented in accordance with the protocol, 
and the integrity of study data is maintained.  Some monitoring activities will be performed 


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remotely (e.g., review of regulatory documents), while others will take place on site (e.g., 
verification of study databases against source documentation).  The principal investigator will 
receive copies of the final monitoring reports. 
16.2 Quality Assurance Plan 
Clinical monitoring for this study will be based on a clinical monitoring plan developed by the 
CROMS at Rho, Inc. in collaboration with the NIDCR Clinical Director and the principal 
investigator.  The clinical monitoring plan will specify the frequency, procedures, and levels of 
monitoring activities and the frequency of reporting.   
The clinical monitor from CROMS will verify that all study subjects have provided informed 
consent and that subject data agree with the source documents.  The monitor will also check that 
study procedures are compliant with the protocol. 
The components of the data quality control and assurance program are 1) real-time detection and 
correction of errors within the EDC system, 2) verification of key outcome measurements during 
clinical monitoring visits, and 3) periodic data review by the CROMS.  At the time of data entry, 
the EDC system alerts the user to missing, out-of-range, and inconsistent values and provides the 
user the opportunity to correct errors in real time.  In accordance with federal regulations, the 
system records all elements of data entry (i.e., time, date, verbatim text, and the name of the 
person performing the data entry).  During periodic clinical monitoring visits, monitors will 
verify key outcome measurements by comparing data in the EDC system to source 
documentation.  The frequency of monitoring visits and the number of records and data fields 
audited are described in the study Clinical Monitoring Plan.  Data managers at the CROMS will 
generate periodic summary reports for the study staff to review. 
Data fields in the EDC that are the initial source of the data record (i.e., no source documentation 
is maintained) are the telephone Safety Follow-up and Sjögren’s Disease Activity Index eCRF.   
Further details of measures for quality assurance of the study database are provided in the Data 
Management Plan. 
17 ADVERSE EVENT, PROTOCOL DEVIATIONS AND UNANTICIPATED 
PROBLEM REPORTING 
 


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The Principal Investigator is responsible for detecting, documenting, and reporting unanticipated 
problems, adverse events (AEs), including serious adverse events (SAEs), and deviations in 
accordance with NIH policy, IRB requirements, and federal regulations. Relatedness to the 
research of all serious adverse events will be determined by the PI in consultation with the CD. 
  
Serious unanticipated problems and serious protocol deviations will be reported to the IRB and 
CD as soon as possible and in writing on the Problem Report Form not more than 7 days after 
the PI first learns of the event.  Not serious unanticipated problems and not serious deviations 
will be reported to the IRB and CD as soon as possible and in writing on the Problem Report 
Form not more than 14 days after the PI first learns of the event.  
Deaths will be reported to the Clinical Director within 7 days after the PI first learns of the event.  
All adverse events, deviations, and unanticipated problems will be summarized and reported at 
the time of Continuing Review. 
18 ALTERNATIVE THERAPIES 
Current standard-of-care therapies for xerostomia due to primary SS are salivary stimulants and 
topical oral moisturizers.  Salivary stimulants may not be used in this protocol within 24 hours 
prior to saliva collection. 
Patients with internal organ manifestations of SS may be treated with systemic corticosteroids or 
immunosuppressive drugs.  During the study, subjects will not be allowed to use human or 
murine antibodies, rituximab, or immunosuppressants.   
19 CONFIDENTIALITY 
Research Data and Investigator RecordsThe subject’s name will appear only on the consent form 
and medical record, both of which will be kept separate from collected study data.  A unique 
coded study number will be assigned to each subject for data collection and will be used on the 
electronic CRF and in the clinical database.  The number will not contain any personal 
information (dates, age) to further ensure protection.  A subject code log that links the names to 
identification numbers will be securely maintained at the study site.  Charts will be kept in 
locked cabinets or rooms, and computer research databases will be stored on only NIH 


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computers, which are password protected and encrypted per standard NIH policy. Only members 
of the study staff will have access to study samples and data.  
Study data will be transmitted to the Clinical Research Operations and Management Support 
(CROMS) via a secure, encrypted Internet connection and stored on a secure server. De-
identified results will be posted on www.clinicaltrials.gov. 
19.1 Stored Samples 
Research samples collected from subjects consenting to this protocol will be stored in freezers 
belonging to the MPTB.  All of these freezers are located in Building 10, Room 1N121, on the 
NIH Bethesda campus.  All samples will be coded and will not have subject identifiers.  The 
codes for identifiers will be stored in either research charts or NIH computers. 
19.2 Special Precautions 
Only members of the study staff will have access to study data and samples. 
20 CONFLICT OF INTEREST 
20.1 Distribution of NIH Guidelines 
The NIH guidelines on conflict of interest have been distributed to all investigators. 
20.2 Conflict of Interest 
There are no conflicts of interest to report for NIH investigators. Non-NIH investigators will 
abide by the conflict-of-interest policies of their own institutions. 
The PI will seek prospective and continuing NIH IRB review and approval for research 
collaborations in which coded samples (for which the investigators maintain the key) are sent to 
non-NIH investigator(s). She will identify the names of the collaborating researchers and their 
affiliated institutions. 
20.3 Role of a Commercial Company or Sponsor 
Not applicable. 
21 TECHNOLOGY TRANSFER 
No technology transfer or confidential disclosure agreements are involved in this study. 
  There are no current tech transfer agreements. 


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22 RESEARCH AND TRAVEL COMPENSATION 
Subjects will be reimbursed $100 for each ultrasound-guided parotid core needle biopsy for the 
inconvenience of undergoing the biopsy.  Reimbursement of travel and subsistence will be 
consistent with NIH guidelines.  In this study, subjects will not be reimbursed for travel or 
subsistence costs related to study participation. 
 
 


PI name:  Ilias Alevizos, DMD 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
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23 REFERENCES
                                                 
1  Izumi M, Eguchi K, Nakamura H, Takagi Y, Kawabe Y, NakamureT.  Corticosteroid 
irrigation of parotid gland for treatment of xerostomia in patients with Sjögren’s syndrome.  
Ann Rheum Dis. 1998;57:464-69. 
2  Takagi Y, Katayama I, Tashiro S, Nakamura T.  Parotid irrigation and cevimeline gargle for 
treatment of xerostomia in Sjögren’s syndrome.  J Rheumatol.  2008;35:2289-91. 
3  Al-Hashimi I, Khuder S, Haghighat N, Zipp M.  Frequency and predictive value of the 
clinical manifestations in Sjögren’s syndrome.  J Oral Pathol Med.  2001;30:1-6. 
4  Vitali C, Bombardieri S, Jonsson R, Moutsopoulos HM, Alexander EL, Carsons SE, et al; 
European Study Group on Classification Criteria for Sjögren’s Syndrome.  Classification 
criteria for Sjögren’s syndrome:  a revised version of the European criteria proposed by the 
American-European Consensus Group.  Ann Rheum Dis.  2002;61:554-8. 
5  Skopouli FN, Jagiello P, Tsifetaki N, Moutsopoulos HM.  Methotrexate in primary Sjögren’s 
syndrome.  Clin Exp Rheumatol.  1996;14:555-8. 
6  Drosos AA, Skopouli FN, Costopoulos JS, Papadimitriou CS, Moutsopoulos HM.  
Cyclosporin A (CyA) in primary Sjögren’s syndrome: a double blind study.  Ann Rheum 
Dis.  1986;45:732-5. 
7  Mariette X, Ravaud P, Steinfeld S, Baron G, Goetz J, Hachulla E, et al.  Inefficacy of 
infliximab in primary Sjögren’s syndrome:  results of the randomized, controlled Trial of 
Remicade in Primary Sjögren’s Syndrome (TRIPSS).  Arthritis Rheum.  2004;50:1270-6. 
8  Sankar V, Brennan MT, Kok MR, Leakan RA, Smith JA, Manny J, et al.  Etanercept in 
Sjögren’s syndrome:  a twelve-week randomized, double-blind, placebo-controlled pilot 
clinical trial.  Arthritis Rheum.  2004;50:2240-5. 
9  Cummins MJ, Papas A, Kammer GM, Fox PC.  Treatment of primary Sjögren’s syndrome 
with low-dose human interferon alfa administered by the oromucosal route:  combined phase 
III results.  Arthritis Rheum.  2003;49:585-93. 


PI name:  Ilias Alevizos, DMD 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version:  13.0 
 
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10  Porter SR, Scully C, Hegarty AM.  An update of the etiology and management of 
xerostomia.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod.  2004;97:28-46. 
11  Carsons S.  A review and update of Sjögren’s syndrome:  manifestations, diagnosis, and 
treatment.  Am J Manag Care.  2001;7(14 Suppl):S433-43. 
12  Fox RI, Chan E, Benton L, Fong S, Friedlaender M, Howell FV.  Treatment of primary 
Sjögren’s syndrome with hydroxychloroquine.  Am J Med.  1988;85:62-7. 
13  Tzioufas AG, Moutsopoulos HM.  Sjögren’s syndrome.  In:  Hochberg MC, Silman AJ, 
Smolen JS, Weinblatt ME, Weisman M, eds.  Rheumatology.  Philadelphia, PA:  Mosby; 
2003, 1431-43. 
14  Kassan SS, Moutsopoulos H.  Clinical manifestations and early diagnosis of Sjögren’s 
syndrome.  Arch Intern Med.  2004;164:1275-84. 
15  Skopouli FN, Dafni U, Ioannidis JP, Moutsopoulos HM.  Clinical evolution, and morbidity 
and mortality of primary Sjögren’s syndrome.  Semin Arthritis Rheum.  2000;29:296-304. 
16  Meijer JM, Meiners PM, Vissink A, Spijkervet FK, Abdulahad W, Kamminga N, et al.  
Effectiveness of rituximab treatment in primary Sjögren’s syndrome:  a randomized, 
double-blind, placebo-controlled trial.  Arthritis Rheum.  2010;62:960-8. 
17  Dass S, Bowman SJ, Vital EM, Ikeda K, Pease CT, Hamburger J, et al.  Reduction of fatigue 
in Sjögren syndrome with rituximab:  results of a randomized, double-blind, 
placebo-controlled pilot study.  Ann Rheum Dis.  2008;67:1541-4. 
18  Fox PC, Datiles M, Atkinson JC, Macynski AA, Scott J, Fletcher D, et al.  Prednisone and 
piroxicam for treatment of primary Sjögren’s syndrome.  Clin Exp Rheumatol.  1993;11:149-
56. 
19  Ko SB, Mizuno N, Yatabe Y, Yoshikawa T, Ishiguro H, Yamamoto A, et al.  Corticosteroids 
correct aberrant CFTR localization in the duct and regenerate acinar cells in autoimmune 
pancreatitis.  Gastroenterology.  2010;138:1988-96. 


PI name:  Ilias Alevizos, DMD 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version:  13.0 
 
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20  Breeze J, Andi A, Williams MD, Howlett DC.  The use of fine needle core biopsy under 
ultrasound guidance in the diagnosis of a parotid mass.  Br J Oral Maxillofac Surg.  
2009;47:78-9. 
21  Pratap R, Qayyum A, Ahmed N, Jani P, Berman LH.  Ultrasound-guided core needle biopsy 
of parotid gland swellings.  J Laryngol Otol.  2009;123:449-52. 
22  Wan YL, Chan SC, Chen YL, Cheung YC, Lui KW, Wong HF, et al.  Ultrasonography-
guided core-needle biopsy of parotid gland masses.  AJNR Am J Neuroradiol.  
2004;25:1608-12. 
23  Kononoff PJ, Hanford KJ.  Technical note:  estimating statistical power of mixed models 
used in dairy nutrition experiments.  J Dairy Sci.  2006;89:3968-71. 
24 Civilibal M, Canpolat N, Yurt A, et al. A child with primary Sjogren syndrome and a review 
of the literature. Clin Pediatr (Phila). Oct 2007;46(8):738-42.    


PI name:  Ilias Alevizos, DMD 
Date:  October 01, 2015 
Protocol number:  11-D-0094 
Version:  13.0 
 
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24 APPENDICES 
24.1 Protocol Signature Page 
24.2 Definitions of Unanticipated Problems and Adverse Events 
24.3 Eligibility Checklist 
24.4 Rating Scales 
24.5 Dexamethasone Package Insert 
24.6 Salivary Flow Collection Procedure 
24.7 Subject Questionnaires 
24.8 American-European Consensus Sjögren’s Syndrome Classification Criteria 
24.9 Sjögren’s Disease Activity Index 
 
25 CONSENT FORMS 
Adult Subject Consent attached 
 
 

SAP_001.pdf: 
 
Version:  Alevizos 11-D-0094_ SAP version 1-2018-03-09.docx 
 
STATISTICAL ANALYSIS PLAN 
Version 1.0 
March 9, 2018 
 
 
 
 
 
A Randomized Within-subject, Double-blind, Placebo-controlled Study 
of Dexamethasone Irrigation of the Parotid Glands in Primary 
Sjögren’s Syndrome Subjects 
 
 
 
PROTOCOL NUMBER 11-D-0094 
 
 
 
 
SPONSORED BY 
 
NIDCR  
 
Principal Investigator: Ilias Alevizos, DMD 
 
 
 
 
 
PREPARED BY 
 
Rho, Inc. 
6330 Quadrangle Drive, Suite 500 
Chapel Hill, NC  27517 
Telephone:  (919) 408-8000 
Fax:  (919) 408-0999 
 
 
 
This document is confidential and proprietary to NIDCR.  Acceptance of this document constitutes 
agreement by the recipient that no unpublished information contained herein will be reproduced, 
published, or otherwise disclosed without the prior written approval of NIDCR, except that this document 
may be disclosed to appropriate Institutional Review Boards under the condition that they keep the 
information confidential. 


PI name: Ilias Alevizos 
CONFIDENTIAL 
Statistical Analysis Plan 
Protocol number: 11-D-0094 
 
09 March 2018 
Version:  Alevizos 11-D-0094_ SAP version 1-2018-03-09.docx 
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DOCUMENT VERSION CONTROL 
 
Version Number 
Date 
Comments/Changes 
 0.1 
23SEP2013 
Initial Draft  
1.0 
09MAR2018 
Added Section 10 Changes to the Statistical Analysis 
after Database Lock.  This summarizes changes to the 
SAP. 
Although the study was completed at the time of SAP 
finalization, the grammatical tense was left as future 
tense to be in keeping with the common text of a 
planning document.  Only the tense in Section 10 and 
Section 11 were changed, because these sections focus 
specifically on changes subsequent to database lock 
and unblinding. 
 
 


PI name: Ilias Alevizos 
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Statistical Analysis Plan 
Protocol number: 11-D-0094 
 
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APPROVALS 
 
Author: 
 
 
 
 
Robert James, Senior Biostatistician, Rho, Inc. 
 
Date 
By signing this document, I indicate that I have reviewed and hereby approve the contents, 
procedures, and standards described herein. 
 
 
 
 
 
Ilias Alevizos, Principal Investigator, NIDCR 
 
Date 
 
 
 
 


PI name: Ilias Alevizos 
CONFIDENTIAL 
Statistical Analysis Plan 
Protocol number: 11-D-0094 
 
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TABLE OF CONTENTS 
LIST OF ABBREVIATIONS ............................................................................................ 5 
1. 
THE STATISTICAL ANALYSIS PLAN ..................................................................... 6 
2. 
PROTOCOL SUMMARY .......................................................................................... 7 
2.1 
Study Objectives ........................................................................................... 7 
2.2 
Study Design ................................................................................................ 7 
2.3 
Sample Size Determination ........................................................................... 8 
3. 
GENERAL ANALYSIS AND REPORTING CONVENTIONS.................................. 10 
4. 
ANALYSIS POPULATIONS ................................................................................... 11 
4.1 
Safety Population ........................................................................................ 11 
4.2 
Primary Efficacy Population ........................................................................ 11 
4.3 
Secondary Efficacy Population .................................................................... 11 
5. 
STUDY SUBJECTS ............................................................................................... 12 
5.1 
Disposition of Subjects ................................................................................ 12 
5.2 
Protocol Deviations ..................................................................................... 12 
6. 
DEMOGRAPHIC AND OTHER BASELINE CHARACTERISTICS ......................... 13 
7. 
STATISTICAL ANALYSES .................................................................................... 15 
7.1 
Overview of Primary Statistical Analyses .................................................... 15 
7.1.1 
Handling of Dropouts or Missing Data ................................................ 15 
7.2 
Efficacy Variables ....................................................................................... 15 
7.3 
Analysis Methods ........................................................................................ 15 
7.3.1 
Primary Efficacy Analyses ................................................................. 15 
7.3.2 
Secondary Efficacy Analyses ............................................................. 17 
7.3.3 
Exploratory Efficacy Analyses ............................................................ 20 
8. 
SAFETY EVALUATION ......................................................................................... 21 
8.1 
Adverse Events ........................................................................................... 21 
8.2 
Deaths, Serious Adverse Events, and Other Significant Adverse Events .... 21 
8.3 
Routine Clinical Laboratory Evaluation ........................................................ 22 
8.4 
Additional Clinical Laboratory Evaluation .................................................... 22 
8.5 
Vital Signs, Physical Findings, and Other Observations Related to Safety .. 22 
8.5.1 
Vital Signs .......................................................................................... 22 
8.5.2 
Physical Examinations ....................................................................... 23 
8.5.3 
Concomitant Medications ................................................................... 23 
8.5.4 
Other Safety Evaluations ................................................................... 23 
9. 
INTERIM ANALYSES AND DATA MONITORING ................................................. 24 
10. SUBSTANTIVE CHANGES TO THE STATISTICAL ANALYSIS PLAN AFTER 
DATABASE LOCK ................................................................................................ 25 
11. CHANGES TO THE ANALYSES PLANNED IN THE PROTOCOL ........................ 28 
12. REFERENCES ....................................................................................................... 29 
13. APPENDICES ........................................................................................................ 30 
 


PI name: Ilias Alevizos 
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Statistical Analysis Plan 
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LIST OF ABBREVIATIONS 
ADC 
apparent diffusion coefficient 
AE 
adverse event 
CBC 
complete blood count 
CFTR 
cystic fibrosis transmembrane conductance regulator 
CROMS 
Clinical Research Operations and Management Support  
CRP 
C-reactive protein 
DSMC 
Data and Safety Monitoring Committee 
eCRF 
electronic case report form 
EDC 
electronic data capture 
ESR 
erythrocyte sedimentation rate 
GEE 
generalized estimating equations 
Ig 
immunoglobulin 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
mCi 
millicurie 
MRI 
magnetic resonance imaging 
MSG 
minor salivary gland 
MPTB 
Molecular Physiology and Therapeutics Branch 
NIDCR 
National Institute of Dental and Craniofacial Research 
NIH 
National Institutes of Health 
NSAID 
nonsteroidal anti-inflammatory drug 
PEP 
Primary Efficacy Population 
SAE 
serious adverse event 
SD 
standard deviation 
SEP 
Secondary Efficacy Population 
SOP 
standard operating procedure 
SS 
Sjögren’s syndrome 
 
 


PI name: Ilias Alevizos 
CONFIDENTIAL 
Statistical Analysis Plan 
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1. THE STATISTICAL ANALYSIS PLAN 
The Statistical Analysis Plan is not a stand-alone document but expands in further detail 
the statistical analysis and considerations already outlined the protocol.  The protocol 
background information, objectives, design, and procedures are fully described in the 
study protocol. 
 
 
 


PI name: Ilias Alevizos 
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Statistical Analysis Plan 
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2. PROTOCOL SUMMARY 
A brief summary of protocol objectives and study design are described below.  For 
further details refer to the protocol. 
2.1 
Study Objectives 
This study is designed to evaluate the efficacy of low-dose topical corticosteroid 
(dexamethasone) irrigation of the parotid gland in reducing salivary dysfunction in 
subjects with Sjögren’s syndrome (SS), and also to evaluate the effects of treatment on 
inflammation and other possible mechanistic processes. 
      The primary objective of this study is to determine whether irrigation of the parotid gland 
with low-dose topical dexamethasone improves parotid salivary gland flow in SS 
subjects. 
   The secondary objectives are: 
 To perform mechanistic studies to determine the mechanisms of action of low-
dose topical corticosteroid irrigation of the parotid gland. 
 To assess biomarkers of inflammation and salivary gland dysfunction in SS 
subjects treated with low-dose topical corticosteroid irrigation of the parotid 
glands. 
 To assess localized safety of dexamethasone irrigation of the parotid gland, as 
compared with placebo. 
2.2 
Study Design 
This will be a single-site, randomized-within-subject, double-blind, placebo-controlled, 
phase 2 pilot study in which all subjects receive both active drug (dexamethasone) and 
placebo (normal saline), thereby acting as their own controls.  A total of 20 adult females 
will be enrolled to have 16 subjects randomized and treated.  The study will recruit 
subjects with a focus score of ≥1 on minor salivary gland biopsy in the previous 7 years 
and measurable stimulated bilateral parotid salivary flow (≥0.01 mL/min per gland), who 
were diagnosed with Sjögren’s syndrome (SS) in protocol 84-D-0056 or 99-D-0070.  


PI name: Ilias Alevizos 
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Statistical Analysis Plan 
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The study design is doubly-repeated measures; within a subject, measures are repeated in 
both time and treatment (i.e., one side of mouth receives dexamethasone while the other 
receives placebo.)  After baseline assessment of salivary flow and other measurements of 
salivary function, subjects will be randomly assigned, in a double-blind fashion, to 
dexamethasone irrigation of one parotid gland and normal saline irrigation of the other 
parotid gland (i.e. active drug randomized to either left side or right side, with placebo 
administered in the opposite gland).  They will undergo a total of 2 treatment sessions, 4 
weeks apart (Days 0 and 28).  Post-treatment assessments of salivary flow, dry mouth 
symptoms, and adverse events (AEs) will be performed at specified intervals. 
 
2.3 
Sample Size Determination 
The primary endpoint is the change in salivary flow (Day 56 – Day 0) following either 
saline (placebo) or dexamethasone irrigation.  Because each subject will simultaneously 
receive both irrigation treatments over several time points, the experimental design is a 
doubly-repeated-measures design with one repeated effect for treatment and another 
repeated effect for study day, and random effects for subject.  The expected treatment 
effect of the dexamethasone irrigation over the saline (placebo) irrigation is an 
improvement in salivary flow of at least 40%. 
The power and sample size computations assume the final primary analysis will be 
doubly-repeated-measures analysis, including an unstructured variance and random 
effects for subject to account for the non-independence between glands within a subject.  
The “unstructured variance” allows the variances (standard deviations [SDs]) of the 
change in salivary flow for each treatment to differ from each other.  The power analysis 
was performed in SAS using the methodology described by Kononoff and Hanford.1 
The SDs of the change in salivary flow for the placebo and dexamethasone irrigations 
were estimated from data published by Izumi et al.2  The standard deviation of the change 
in salivary flow was assumed to be 0.0168 for the saline-irrigated parotid gland, and 
0.0906 for the dexamethasone-irrigated parotid  gland.  The within-subject correlation 
between two glands was assumed to be 0.15.  The mean measures and SDs of change in 
total salivary flow during 2 minutes were converted to flow from a single parotid gland 


PI name: Ilias Alevizos 
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Protocol number: 11-D-0094 
 
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during 1 minute by multiplying by 0.1625 (0.65 for the proportion of total flow from the 
parotid glands x 0.5 for a single parotid gland x 0.5 for 1 minute).  This conversion 
assumes a very high correlation between total salivary flow and parotid salivary flow. 
A total of 16 patients would be required to have 80% power to detect a one-sided 40% 
increase in dexamethasone-irrigated parotid glands compared with the saline-irrigated 
parotid glands with respect to change in salivary flow from Day 0 to Day 56.  
Approximately 20 subjects will be screened to ensure that 16 subjects will be randomized 
and treated with dexamethasone irrigation. Subjects who discontinue from the study 
before the Stage I screening parotid irrigation will be replaced.  Subjects who do not 
receive the first irrigation treatment and at least 1 post-treatment salivary flow assessment 
will also be replaced. 
 
 
 
 
 
 
 
 
 


PI name: Ilias Alevizos 
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3. GENERAL ANALYSIS AND REPORTING CONVENTIONS 
The following is a list of general analysis and reporting conventions to be applied for this 
study.  These are general guidelines and reporting conventions may deviate from these 
for publication and presentation purposes: 
 Categorical variables will be summarized using counts (n) and percents (%) and 
will be presented in the form n (%). 
 Mean, bias, standard deviation, and precision will be reported at 1 more 
significant digit than the precision of the data.  
 Order statistics including median, min and max will be reported to the same level 
of precision as the original observations.  If any values are calculated to have 
more significant digits then the value should be rounded so that it is the same 
level of precision as the original data. 
 The median will be reported as the average of the two middle numbers if the 
dataset contains even numbers. 
 P-values will be reported to 3 decimal places if greater than 0.001.  If less than 
0.001 then report ‘<0.001’.  P-values and significant levels will be displayed as 
0.05 rather than .05.  
 No preliminary rounding should be performed; rounding should only occur after 
analysis.  For rounding, digit to right of last significant digit will be considered:  if 
< 5 rounded down, if >=5 rounded up. 
 


PI name: Ilias Alevizos 
CONFIDENTIAL 
Statistical Analysis Plan 
Protocol number: 11-D-0094 
 
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4. ANALYSIS POPULATIONS 
4.1 
Safety Population  
The safety population will include all subjects who receive any parotid saline irrigation 
used to determine parotid filling volume during Stage I screening. 
4.2 
Primary Efficacy Population  
The primary efficacy population (PEP) will include subjects who receive all parotid 
irrigations on study Days 0 and 28, have the same treatment applied to the same parotid 
(regardless of random assignment) at both visits, and have values for the primary 
endpoint (i.e., change in salivary flow from Day 0 to Day 56).  The PEP will be used in 
the primary analysis. 
4.3 
Secondary Efficacy Population  
The Secondary Efficacy Population (SEP) will include all enrolled subjects who receive 
at least one on-treatment set of parotid irrigations and have at least one salivary flow 
assessment after study Day 0.  The SEP will be used in some secondary analyses. 
 
 
 


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5. 
STUDY SUBJECTS 
5.1 
Disposition of Subjects 
Subject disposition will be summarized for all enrolled subjects.  The number of subjects 
enrolled, randomized, and the number subjects in each of the analysis populations (safety, 
PEP, and SEP) will be presented by frequency and percentage.  The number of subjects 
who completed the study through Day 56, the number who discontinued before Day 56 
and the reason for discontinuation, and the number of subjects who completed the safety 
follow-up assessment will be summarized. 
5.2 
Protocol Deviations 
The number of subjects with at least one protocol deviation, the number of protocol 
deviations, type of protocol deviations, and impact of protocol deviation will be 
summarized for the safety population.  Each protocol deviations will be listed. 
 
 
 
 


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6. DEMOGRAPHIC AND OTHER BASELINE CHARACTERISTICS 
The following characteristics will be summarized for all subjects included in the safety 
population, as well as presented in data listings: 
 Sex 
 Age (years) 
 Race (Hispanic, Non-Hispanic, Unknown) 
 Weight (kg) 
 Height (cm) 
 Waist (cm) 
The following baseline variables pertaining to the parotid gland will be summarized by 
their assigned treatment for the safety population and presented in data listings:  
 MRI results (Normal, Abnormal-Not Clinically Significant, Abnormal- Clinically 
Significant) 
 Technetium results (Normal, Abnormal) including isotope uptake (Yes, No) and 
release with stimulation (Yes, No). 
 Salivary flow rate (mL/min)  
 Fill volume (mL)  
 Focus score     
Baseline is defined as the last evaluation prior to the first irrigation treatment. 
Age will be calculated as the number of years from the date of birth to the date of first 
dose. 
Continuous variables (age, weight, height, waist, salivary flow rate, fill volume, and 
focus score) will be summarized using descriptive statistics (number of subjects, mean, 
standard deviation, median, minimum, and maximum).  Categorical variables (sex, race, 
MRI results, and technetium results) will be summarized using counts and percentages 
for each category.  The differences between parotid glands by the assigned treatment will 
be estimated along with their 90% confidence intervals. 


PI name: Ilias Alevizos 
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To assess overall health of the study subjects prior to study treatment, any significant 
medical history will be included in the subject listings. 


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7. STATISTICAL ANALYSES 
7.1 
Overview of Primary Statistical Analyses 
7.1.1 
Handling of Dropouts or Missing Data 
Subjects who discontinue from the study before the Stage I screening parotid irrigation 
will be replaced.  Subjects who do not receive the first irrigation treatment and at least 1 
post-treatment salivary flow assessment will also be replaced. 
7.2 
Efficacy Variables 
The primary efficacy endpoint is the change in salivary flow from Day 0 to Day 56. 
Secondary efficacy endpoints include: 
 Changes in salivary flow from Day 0 to study Days 14, 28, 42, and 56.    
 Change in focus score on parotid biopsy from Stage II screening to Day 56  
 Changes in assessments on the Patient Dry Mouth Questionnaire from Day 0 to 
study Days 14, 28, 42, and 56  
 Changes in assessments on the Sjögren’s Disease Activity Index from Day 0 to 
study Days 14, 28, 42, and 56  
 Changes in MRI and technetium scan of the salivary glands from baseline to 
study Day 56   
Exploratory endpoints will be the changes in mechanistic endpoints from baseline to study 
Days 14, 28, 42, and 56. 
7.3 
Analysis Methods 
7.3.1 
Primary Efficacy Analyses 
The primary analysis will compare the change from Day 0 in salivary flow in the 
dexamethasone-irrigated parotid glands (active treatment) with the saline-irrigated parotid 
glands (placebo treatment) at study Day 56.  The analysis will be performed on the PEP 
population. 


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The study has a doubly repeated measures design with each subject measured repeatedly 
in two dimensions:  treatment versus placebo (of the paired parotid glands); and, study 
day.  A linear mixed effect model will be fit to a dataset including all the saliva flow 
measurements of both parotids from study days 0, 14, 28, 42, and 56.  The model 
included all time points for improved power.    However, the primary analysis will only 
focus on the treatment effects of the change in saliva flow from baseline in parotid 
salivary flow at Day56.   The statistical model will include parotid saliva flow as the 
dependent variable, a covariate for baseline saliva flow, parotid treatment and study day 
and their interaction as fixed effects, and subject as a random effect. 
Null hypothesis: No improvement in the saliva flow rate of the dexamethasone irrigated 
parotid glands compared to the saline irrigated parotid glands with respect to change from 
Day 0 in salivary flow at Day 56. 
Alternative Hypothesis: Improvement in the saliva flow rate of the dexamethasone 
irrigated parotid glands compared to the saline irrigated parotid glands with respect to 
change from Day 0 in salivary flow at Day 56. 
The least squares mean and its one-sided 95% confidence interval of the difference 
between dexamethasone and saline treatments with respect to the change from Day 0 in 
salivary flow at Day 56 will be reported.  The one-sided 95% confidence interval will be 
directly derived from the two-sided 90% confidence interval estimated in the model.  The 
alternative hypothesis will be accepted if the least squares mean estimate for treatment 
differences in change from baseline at Day 56 is positive and the lower bound of the one-
sided 95% confidence interval does not include 0.  The SAS code to be used is listed 
below: 
PROC MIXED data=a; 
   CLASS treatment day subjid; 
   MODEL change= baseline_rate  treatment|day; 
   REPEATED treatment day/ subject=subjid type=un@cs; 
   RANDOM subjid(treatment); 
   LSMEANS treatment*day / diff cl alpha=0.90; 


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RUN; 
 
If above mixed model fails to converge or their residual analysis indicates model 
assumptions are highly questionable, then a paired t-test of the change in saliva flow from 
baseline at Day 56 using Satterthwaite’s approximation will be used to test the primary 
efficacy endpoint. 
The above models will also be fit using log-transformed values for salivary flow.  If 
residual analysis shows the log-transformed saliva flow to better fit model assumptions 
then the primary analysis will be based on the log-transformed model and the antilog of 
least squares mean estimate (and confidence interval) of the primary endpoint will be 
reported as a ratio saliva flow at study Day 56 over its baseline value. 
7.3.2 
Secondary Efficacy Analyses 
The secondary analyses will be performed on the SEP population.  If the second on-
treatment irrigation was discordant with the first treatment irrigation, endpoints following 
the second on-treatment irrigation will be set to missing. 
 
Changes in salivary flow:  
The changes in salivary flow from baseline (Day 0) to Days 14, 28 and 42 will be 
analyzed using the same doubly-repeated-measures analysis described in Section 7.3.1.  
If significant treatment effects are found between baseline and any of the other study days 
(including Day 56), then additional analysis will be performed to test pair-wise 
differences in salivary flow change between Day 0 and other study days using two-sided 
tests. For instance, if a significant treatment effect is indicated by one-sided test between 
Day 0 and Day 42, then 2-sided tests will be performed to test whether salivary flow 
change from Day 0 to Day 42 is greater than or less than the change from Day 0 to Day 
56, the change from Day 0 to Day 28, and the change from Day 0 to Day 14.  Note that if 
the second treatment on Day 28 is different from the treatment on Day 0 for any reasons, 
any endpoints collected following second treatment on Day 28 will be set to missing. 


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Change in focus score on parotid biopsy   
Focus score and changes from screening to Day 56 will be summarized with descriptive 
statistics by visit and listed.   
Changes in assessments on the Patient Dry Mouth Questionnaire: 
Patient Dry Mouth Questionnaire responses and changes from baseline (Day 0) to Days 
14, 28, 42, and 56 will be summarized using frequencies and percentages by visit.   
Further analyses pertaining to symptoms of SS will be performed for the following binary 
outcome questions:  
 Do you have difficulty chewing your food?    
 Have you experienced any changes in your sense of smell?   
 Have you experienced any changes in your sense of taste?   
 Do you have any pain or burning in your mouth or head and neck region?   
 Do you use anything to keep your mouth moist?   
 Does your mouth feel dry when you eat a meal?   
 Does your mouth feel dry other times of the day?   
 Do you have difficulty swallowing dry foods without additional liquids?   
Change from baseline assessments of the symptoms of SS will be displayed graphically 
over time.  The frequency of subjects who answered ‘Yes’ to the applicable question will 
be displayed on the y- axis and days will be displayed on the x-axis for each assessment 
performed over multiple time points.  In addition, shift tables will be presented for 
changes from baseline (Day 0) to Day 14, baseline to Day 42, and baseline to Day 56 for 
questions related to symptoms of SS.  The shift from baseline in frequencies will be 
further evaluated using the McNemar’s test, in cases where the shift appears to be 
substantial.   
Changes in assessments on the Sjögren’s Disease Activity Index: 
Sjögren’s Disease Activity Index results and changes from baseline (Day 0) to Days 14, 
28, 42, and 56 will be assessed.  Categorical outcomes will be summarized using 


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frequencies and percentages by visit.  Ordinal outcomes will be summarized with 
descriptive statistics by visit.   
Further analyses pertaining to symptoms of SS will be performed for the following 
assessments:  
 Evaluation of Disease Activity (Ordinal scale: 0-10, Nominal scale: 
Inactive/Low/Moderate/High) 
 Evaluation of minimal disease activity state (Binomial outcome: Yes/No) 
 Evaluation of patient's symptoms (Ordinal scale: 0-10) 
 Evaluation of change in disease activity (Nominal scale: Much better/Better/The 
same/Worse/Much worse) 
 Determination of disease flare (Binomial outcome: Yes/No) 
 For binomial categorical outcomes, the frequency of subjects who answered ‘Yes’ to the 
applicable question will be displayed on the y- axis and days will be displayed on the x-
axis for each assessment performed over multiple time points.  For ordinal-scaled 
outcomes, the median score among subjects will be displayed on the y-axis and days will 
be displayed on the x-axis for assessments performed over multiple time points.  In 
addition, shift tables will be presented for changes from baseline (Day 0) to Day 14, to 
Day 42, and to Day 56 for questions related to symptoms of SS.  The shift from baseline 
in frequencies for binary outcomes will be further evaluated using the McNemar’s test, if 
the shift is substantial.  The results from Sjögren’s Disease Activity Index will be listed. 
Changes in MRI and technetium scan of the salivary glands: 
Scan results and changes from baseline for MRI and technetium scan will be summarized 
and visit.  Shift tables will also be displayed for the changes in the scan results between 
Day 0 and Day 56 (normal-abnormal, abnormal-normal, no change).  
 
 
 


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7.3.3 Exploratory Efficacy Analyses 
Exploratory analyses of mechanistic and inflammatory endpoints: 
Mechanistic and inflammatory endpoints will be studied to gain insight into the 
molecular mechanism of action of the dexamethasone treatments and to generate 
hypotheses for future research.  The mechanistic outcome measures may include, but will 
not be limited to, single-protein single-channel recordings, organellar and single-cell 
current (Ca+2, and pH), fluid secretion by acinar cells, and ductal secretory and signaling 
functions.  These mechanistic endpoints as well as their change from baseline results   
will be summarized by study day.  Summary statistics may include means, geometric 
means, minimum and maximum, standard deviations, 90% confidence limits, medians, 
and frequencies as appropriate for the measure.  Log or other transformations may be 
used if they improve the distributional properties of the outcome measure.   
Saliva-derived biomarkers of inflammation and salivary gland dysfunction may be identified 
from the exosomal microRNAs and non-coding small RNAs.  The frequency of the 
presence/absence of these biomarkers in the saliva both before and after treatment will be 
reported.  Concentrations of biomarkers above the threshold of detection will be summarized 
using the summary statistics listed above.  Biomarkers for inflammation other than non-
coding RNAs might be measured in saliva, but those biomarkers will be determined by 
findings in the biopsies.  
Finally, mechanistic endpoints and biomarkers (including changes from baseline) that 
appear promising will be tested for association with inflammation, salivary flow, or other 
measures of salivary gland dysfunction.  Cross-sectional analyses may include measures 
of correlation such as Kendall’s tau, Spearman rank correlation, and polyserial 
correlation, as appropriate for the measure.  Biomarkers or outcomes that show evidence 
of correlation with salivary flow, dexamethasone versus saline treatment,  or salivary 
gland dysfunction may be further analyzed longitudinally using mixed-models analysis.  
These analyses are considered exploratory and hypothesis generating and, as such, will 
not be corrected for multiple comparisons. 


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8. SAFETY EVALUATION 
8.1 
Adverse Events 
 AEs with a start date on or after the treatment initiation on Day 0 will be considered 
treatment-emergent AEs. 
AEs reported prior to treatment initiation will be summarized separately from treatment-
emergent AEs. 
Treatment-emergent AEs will be summarized over all subjects, and by relationship to 
study drug (unrelated, possibly, probably or definitely related) and severity (mild, 
moderate and severe) on the basis of incidence rates by system organ class and preferred 
term.  Displays will be sorted by descending order of overall incidence by treatment. 
All summary tables will include counts of subjects. Therefore, if a subject has more than 
1 adverse event within a system organ class, the subject will be counted only once in that 
system organ class. If a subject has more than 1 adverse event that codes to the same 
preferred term, the subject will be counted only once for that preferred term.  If a subject 
experiences more than 1 episode of a particular adverse event, that subject will be 
counted only once for that event under the maximum severity or most related category for 
the study drug.  Similarly, in the unlikely event that severity data are missing, the study 
analysis will follow the assumption of maximum severity in the summary tables. 
All AEs will be listed by subject.  AEs prior to treatment initiation and treatment-
emergent AEs will be only be presented in data listings. 
8.2 
Deaths, Serious Adverse Events, and Other Significant Adverse Events 
The most common AEs (experienced by >2% patients), serious AEs, AEs leading to 
study discontinuation, and deaths will be reported in frequency tables by system organ 
class and preferred term.  AEs leading to discontinuation, AEs leading to death, and 
serious AEs will be listed. 


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8.3 
Routine Clinical Laboratory Evaluation 
Clinical laboratory tests will be performed at Screening, Day 0, Day 28 and Day 56. All 
laboratory results (hematology, chemistry, and urinalysis) will be listed.  Summary 
statistics (mean, standard deviation, median, minimum, maximum and number of 
patients) will be provided for continuous results, including change from baseline results, 
by visit.  Changes from baseline for inflammatory markers: erythrocyte sedimentation 
rate (ESR) and C-reactive protein (CRP) will be summarized separately.  
8.4 
Additional Clinical Laboratory Evaluation 
Other laboratory tests of immunologic function will be collected on Days 0, 28, and 56. 
Immunologic assessments will include: 
 antinuclear antibodies, extractable nuclear antigens 
 rheumatoid factor 
 C3 complement, C4 complement 
 immunoglobulin (Ig)A, IgG, and IgM.A  
Summary statistics (mean, standard deviation, median, minimum, maximum and number 
of patients) will be provided by visit. 
In addition, on Days 0 and 28, blood samples will be drawn for measurement of plasma 
concentrations of dexamethasone prior to randomized irrigation to obtain a pre-irrigation 
baseline measure and post-irrigation measure.  The dexamethasone concentration and 
change from baseline results will be summarized using descriptive statistics by visit.  
 
8.5 
Vital Signs, Physical Findings, and Other Observations Related to Safety 
8.5.1 
Vital Signs 
Vital signs (blood pressure, respiration rate, oral body temperature, and pulse rate) will be 
collected at Screening, Day 0, Day 14, Day 28, Day 42, Day 56, and Follow-up.  


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Summary statistics for results and changes from baseline will be provided for each vital 
sign parameter by time point.  Additionally, vital signs will be listed by subject.   
8.5.2 
Physical Examinations 
Complete physical examinations will be performed on Days 0, 29 and 56.  A shift table 
will be provided to summarize change from baseline to each post-treatment period by 
body system.  The shift categories will include: 
 Normal at baseline to Abnormal at post-treatment(unfavorable change) 
 Abnormal at baseline to Normal at post-treatment (favorable change) 
 No change from baseline to post-Treatment 
All physical examination data will be presented in a listing.   
8.5.3 
Concomitant Medications 
Concomitant medications include all medications that continued after or started after 
treatment initiation.  The concomitant medications will be presented in a listing. 
8.5.4 Other Safety Evaluations 
The ultra-sound-guided core needle biopsy of right parotid gland and minor salivary 
gland biopsy will be displayed in the listings.  


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9. INTERIM ANALYSES AND DATA MONITORING 
No interim analyses are planned. 


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10. SUBSTANTIVE CHANGES TO THE STATISTICAL ANALYSIS PLAN 
AFTER DATABASE LOCK 
The study was terminated early due to difficulties in recruiting study subjects.  Only 9 of 
the planned 16 subjects had been treated prior to termination.  The database was locked 
on March 25, 2016.  At the time of database lock, the SAP was in draft form.  This 
locked draft (version 0.1) of the SAP is available upon request.   
Listed below are the substantive changes made to the SAP subsequent to database lock 
and unblinding but prior to any statistical analysis of the study.   
1) Section 5. Demographic and Other Baseline Characteristics. 
Added: “To access overall health of the study subjects prior to study treatment, 
any significant medical history will be included in the subject listings” 
 
2) Section 7.3.1. Primary Efficacy Analysis. 
The mixed model for the primary efficacy analysis was simplified from a direct 
product first-order auto-regressive covariance structure (un@ar(1)) to a direct 
product compound symmetry covariance structure (un@cs).  The statistical model 
was simplified because of the reduced sample size.  A baseline saliva flow 
covariate was also added to the model to adjust for possible baseline effects on 
changes in saliva flow (this covariate was specified in the protocol).  In addition, a 
paired t-test was included as an alternative, simplified model to be used if the 
mixed model fails to converge.  The revised SAP also added that log-
transformation of the model’s endpoint may be considered if it improves the 
model’s fit to the data, based upon residual analysis.  These changes to the 
primary analysis will also affect the secondary efficacy models whose models 
were based upon the primary efficacy models. 
 
3) Section 7.3.2. Secondary Efficacy Analyses, Changes in salivary flow. 
When discussing the secondary endpoint, changes in salivary flow at Study Days 
14, 28, and 42, the original draft SAP stated : “If significant treatment effects are 


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found between baseline and any of the other study days, then additional analysis 
will be performed to test pair-wise differences in salivary flow change between 
Day 0 and other study days using two-sided tests. “  However comparing 
differences among the Study Days with respect to change from baseline should 
have also included Study Day 56.  Indeed, Day 56 was listed in the secondary 
endpoint description in the protocol (Protocol Section 9.2 Secondary Outcome 
Measures) and the previous SAP (Section 7.2 Efficacy Variables), but was not 
previously included in the secondary analysis description of this parameter. The 
revised SAP was modified to include Study Day 56 in these statistical 
comparisons among the study days. 
 
4) Section 7.3.2. Secondary Efficacy Analyses, Changes in assessments on the 
Patient Dry Mouth Questionnaire. 
The generalized estimating equations (GEE) analyses were removed from the 
analysis of responses to the Sjögren’s Disease Activity Index since with the 
reduced sample size such a complex model would be of limited value. 
 
5) Section 7.3.2. Secondary Efficacy Analyses, Changes in assessment on Sjögren’s 
Disease Activity Index   
The original draft of SAP stated that shift tables will be presented for changes 
from baseline at Day 14, Day 42, and Day 56 for questions related to symptoms 
of SS.  The finalized SAP adds a shift table for change from baseline at Day 28 
for purposes of completeness and consistency with the protocol. 
Finally, the generalized estimating equations (GEE) analyses were removed from 
the analysis of responses to the Sjögren’s Disease Activity Index because the 
reduced sample size is not conducive to being analyzed with such a complex 
model. GEE models were mentioned in the protocol, but only recommended if the 
data were rich enough to warrant such analyses; therefore this is not a change 
from the original protocol. 
 
6) Section 8.5.3. Concomitant Medications. 


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This final version of the SAP eliminated the table summarizing the concomitant 
medications by therapeutic drug class and generic name.  Review of these data 
can be facilitated by a data listing alone.   
 
7) Appendix A:  The table shell for Demographics and Baseline Characteristics was 
separated into 2, so that the baseline assessment of sidedness parameters could be 
properly summarized as described in Section 6.  
 
 
 
 


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11. CHANGES TO THE ANALYSES PLANNED IN THE PROTOCOL 
There were no substantive changes from the analyses planned in the protocol.  
Modifications from version 0.1 to version 1.0 of the SAP are noted in Section 10. 


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12. REFERENCES 
1  
Kononoff PJ, Hanford KJ.  Technical note:  estimating statistical power of mixed models 
used in dairy nutrition experiments.  J Dairy Sci.  2006;89:3968-71. 
2  
Izumi M, Eguchi K, Nakamura H, Takagi Y, Kawabe Y, NakamureT.  Corticosteroid 
irrigation of parotid gland for treatment of xerostomia in patients with Sjögren’s syndrome.  
Ann Rheum Dis. 1998;57:464-69. 
 


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13. 
APPENDICES 
Appendix A – Sample Subset of Tables Shells.   
Changes to the structure and content of final data displays do not require an amendment 
to the SAP, unless they reflect analyses that are different from those described in earlier 
sections of this document. 
 
 


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           Table X. Summary of Patient Disposition 
                   All Consented (Enrolled) Subjects 
 
Dexamethasone 
(left)&placeb
o(right) 
Dexamethas
one 
(right)&pl
acebo(left
) 
 
 
Total 
 
N=xx 
N=xx 
N=xx 
 
n  (%) 
n  (%) 
n  (%) 
 
 
 
 
Enrolled 
      xx  
       xx  
       xx  
Randomized 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
Analysis  populations 
 
 
 
Safety 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Primary Efficacy Population (FEP) 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Secondary Efficacy Population 
(SEP) 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
Study completion 
 
 
 
Completed study through Day 56 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Discontinued before Day 56 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Completed safety follow-up 
assessment 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
Reason for discontinuation before 
Day 56 
 
 
 
Withdrew  consent 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
No longer meets eligibility 
criteria 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Lost to follow-up 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Investigator discretion 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Adverse events 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Death 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
      Other 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
 
 
 
 
 
 


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Table X. Summary of Protocol Deviations 
Safety Population 
 
Dexamethasone 
(left)& 
placebo(right) 
Dexamethasone 
(right)& 
placebo(left) 
 
 
Total 
 
N=xx 
N=xx 
N=xx 
 
n  (%) 
n  (%) 
n  (%) 
 
 
 
 
All deviations 
      xx  
       xx  
       xx  
 
 
 
 
 Type of Deviation 
 
 
 
   Informed consent 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
   Eligibility 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
   Study drug 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
   Missed visit 
 
 
 
   Out-of-window visit 
 
 
 
   Study procedure 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
   Other 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
  
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 Impact of Deviation 
 
 
 
   Patient safety 
 
 
 
   Outcome measurements 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
   Other 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
   No impact 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
 Type of Deviation 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
   Informed consent 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
   Eligibility 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
   Study drug 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Table X. Summary of Demographic and Baseline Characteristics  
Safety Population 
 
Dexamethasone 
(left)& 
placebo(right) 
Dexamethasone 
(right)& 
placebo(left) 
 
 
Total 
Characteristics 
N=xx 
N=xx 
N=xx 
 
n  (%) 
n  (%) 
n  (%) 
 
 
 
 
Sex – n (%) 
 
 
 
Female 
xx (100) 
xx (100) 
xx (100) 
 
Age (years) 
 
 
 
n 
    xx 
   xx 
xx 
Mean  
    xx.x 
   xx.x 
xx.x 
SD 
    xx.xx 
   xx.xx 
xx.xx 
Median 
    xx.x 
   xx.x 
xx.x 
Range (Min, Max) 
   (xx, xx) 
  (xx, xx) 
(xx, xx) 
 
 
 
 
Race – n (%) 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Hispanic 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Non Hispanic American 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Unknown 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
Ethnicity – n (%) 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Hispanic or Latino 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Non Hispanic or Latino 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
 
 
 
 
Baseline height(cm) 
 
 
 
n 
 xx 
xx 
xx 
Mean  
 xx.x 
xx.x 
xx.x 
SD 
 xx.xx 
xx.xx 
xx.xx 
Median 
 xx.x 
xx.x 
xx.x 
Range (Min, Max) 
(xx, xx) 
(xx, xx) 
(xx, xx) 
 
 
 
 
Baseline weight(lb) 
 
 
 
n 
 xx 
xx 
xx 
Mean  
 xx.x 
xx.x 
xx.x 
SD 
 xx.xx 
xx.xx 
xx.xx 
Median 
 xx.x 
xx.x 
xx.x 
Range (Min, Max) 
(xx, xx) 
(xx, xx) 
(xx, xx) 
 
 
 
 
Baseline waist(cm) 
 
 
 
n 
 xx 
xx 
xx 
Mean  
 xx.x 
xx.x 
xx.x 
SD 
 xx.xx 
xx.xx 
xx.xx 
Median 
 xx.x 
xx.x 
xx.x 
Range (Min, Max) 
(xx, xx) 
(xx, xx) 
(xx, xx) 
 
 


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Table X. Summary of Baseline Characteristics Associated with  
Later-Treated Body Side 
Safety Population 
 
 
Dexamethasone1  
 
Placebo1 
 
Overall 
 
N=xx 
N=xx 
N=xx 
 
 
 
 
MRI results 
 
 
 
 Normal 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 Abnormal-not clinically 
significant 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Abnormal-clinically 
significant 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
Technetium results 
 
 
 
 Normal 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 Abnormal 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
Salivary flow rate (mL/min) 
 
 
 
n 
xx 
xx 
xx 
Mean  
xx.x 
xx.x 
xx.x 
SD 
xx.xx 
xx.xx 
xx.xx 
Median 
xx.x 
xx.x 
xx.x 
Range (Min, Max) 
(xx, xx) 
(xx, xx) 
(xx, xx) 
 
 
 
 
 
 
 
 
Focus Score 
 
 
 
n 
xx 
xx 
xx 
Mean  
xx.x 
xx.x 
xx.x 
SD 
xx.xx 
xx.xx 
xx.xx 
Median 
xx.x 
xx.x 
xx.x 
Range (Min, Max) 
(xx, xx) 
(xx, xx) 
(xx, xx) 
 
 
 
 
1 Baseline assessment of body side -- later treated with product indicated. 
  
 


PI name: Ilias Alevizos 
CONFIDENTIAL 
Statistical Analysis Plan 
Protocol number: 11-D-0094 
 
09 March 2018 
Version:  Alevizos 11-D-0094_ SAP version 1-2018-03-09.docx 
Page 35 of 36 
 
Table X. Summary of Change in Salivary flow from Day 0 to Day 56 
Primary Efficacy Population 
 
 
Dexamethasone 
 
Placebo 
 
Statistics 
N=xx 
N=xx 
 
 
 
 
 
 
 
 
 
Estimated LS Mean (SE)  
xx.x (xx.xx) 
 xx.x (xx.xx) 
 
95% CI for LS Mean 
(xx.x, xx.x) 
(xx.x, xx.x) 
 
 
 
 
 
Estimated LS Mean 
Difference vs Placebo   
 xx.x (xx.xx) 
 
 
One-sided 95% CI for LS 
Mean Difference 
(xx.x, xx.x) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: The linear mixed effect model with doubly-repeated measures was used including 
treatment and day as fixed effects, subject as a random effect and baseline salivary flow 
as a covariate. 
LS = Least Squares; CI = Confidence Interval; SE= Standard Error. 
 
 
 


PI name: Ilias Alevizos 
CONFIDENTIAL 
Statistical Analysis Plan 
Protocol number: 11-D-0094 
 
09 March 2018 
Version:  Alevizos 11-D-0094_ SAP version 1-2018-03-09.docx 
Page 36 of 36 
 
Table X. Summary of Treatment-Emergent Adverse Events by System Organ Class, 
and Preferred Term for Events with a Sidedness Aspect 
 
Safety Population 
 
 
 
Dexamethasone 
 
Placebo 
 
Total 
System organ class 
N=xx 
N=xx 
N=xx 
  Preferred term 
n  (%) 
n  (%) 
n  (%) 
 
 
 
 
Any AEs 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
 
 
 
System organ class 1 
 
 
 
Preferred term 1 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Preferred term 2 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Preferred term 3 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
System organ class 2 
 
 
 
Preferred term 1 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Preferred term 2 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
Preferred term 3 
xx (xx.x) 
xx (xx.x) 
xx (xx.x) 
   Etc. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: n= Number of subjects reporting at least one adverse event with System 
Organ Class/Preferred Term;  
Note: If a subject experienced more than one episode of an adverse event, the 
subject is counted once for that Preferred Term. If a subject had more than one 
adverse event in a System Organ Class, the subject is counted only once in that 
System Organ Class.