Clinical trial NCT02677870
Conditions: Phenylketonuria
Keywords: Saproterin dihydrochloride Kuvan Amish
Sponsor: University Hospitals Cleveland Medical Center
Start date: 2018-01-22; Completion date: 2019-01-01
Enrollment: 7 participants; Allocation: RANDOMIZED; Intervention model: CROSSOVER

Brief summary:
The purpose of this study is to determine if Amish patients with PKU show responsiveness after a high dose, prolonged Saproterin trial. The population of interest has a high frequency of a specific splice site mutation, the 1066-11G\>A mutation. This splice site mutation activates a cryptic splice site resulting in an in frame insertion of 9 nucleotides preceding exon 11. This leads to protein conformational changes and abrogation of function. Previous studies of this genotype have indicated \<1% residual activity of the PAH enzyme and an insignificant responsiveness to Saproterin. However, in this specific study Phe levels were evaluated only over 24 hours after a single-dose BH4 challenge at the standard dose of 20mg/kg.

Based on new clinical information, the investigators hypothesize that if given a prolonged trial of Saproterin at a higher dose, Amish patients with PKU, specifically those homozygous for the c.1066-11G\>A mutation, will have a significant reduction in Phe levels or an increase in Phe tolerance and/or improvement in executive functioning and quality of life.

Detailed description:
Phenylketonuria (PKU) is caused by a deficiency of the enzyme phenylalanine hydroxylase (PAH). PAH is responsible for the rate limiting step in phenylalanine catabolism. This reaction is dependent on tetrahydrobiopterin (BH4). BH4 is a catalytic cofactor for the enzyme PAH. Supplementation with synthetic BH4 (saproterin dihydrochloride or KuvanTm) has been shown to activate residual PAH activity and lower Phe levels in certain patients. It may also have a chaperone effect by binding abnormal PAH protein and decreasing its degradation. Saproterin is an approved oral drug developed to reduce blood Phenylalanine (Phe) levels and increase Phe tolerance in BH4 responsive patients with hyperphenylalaninemia.

Certain genotypes have been found to be good predictors of Saproterin responsiveness; however, these correlations are imperfect. Therefore the standard of care is to perform a trial of Saproterin therapy to assess responsiveness in every PAH patient regardless of genotype. Currently this recommendation does not include patients with two null mutations.

The purpose of this study is to determine if Amish patients with PKU show responsiveness after a high dose, prolonged Saproterin trial. The population of interest has a high frequency of a specific splice site mutation, the 1066-11G\>A mutation. This splice site mutation leads to protein conformational changes and abrogation of function. Previous studies of this genotype have indicated \<1% residual activity of the PAH enzyme and an insignificant responsiveness to Saproterin. However, in this specific study Phe levels were evaluated only over 24 hours after a single-dose BH4 challenge at the standard dose of 20mg/kg.

Recently, observation in several Amish patients suggests some promise that these patients may be responsive to Saproterin after a longer trial of the medication (Personal comment - Samuel Yang, MD). In addition, studies evaluating PAH enzyme activity in these patients, have found evidence that this genotype may need higher cofactor concentrations for optimal enzyme activity and therefore may require a higher dose of Saproterin then the currently recommended 20mg/kg (9). To date, no formal clinical trial has been done.

To answer the question of whether this genotype is responsive to Saproterin at higher doses, over a prolonged period, the investigators propose a randomized clinical trial comparing blood Phe levels in patients treated with standard-dose Saproterin to those treated with high-dose Saproterin. The results of this study could reveal a new population of Saproterin responsive PKU patients. This could call into question other null mutations of the PAH gene and their responsiveness to Saproterin. This may lead to the investigation of genotypes previously thought to be unresponsive to Saproterin. Further, diet treatment alone has proven to be difficult for the Amish population for cultural and economic reasons.

This study will include patients from three local centers with the potential of a fourth, out of state, center participating. All patients will be enrolled through University Hospitals Case Medical Center. Consent will be obtained over the phone or in person.

* Amish patients from University Hospitals Case Western Reserve/Rainbow Babies and Children's Hospital/Center for Human Genetics
* Amish patients from Akron Children's hospital in Akron, Ohio
* Amish patients from The Center for Children with Special Needs (DDC clinic), Middlefield, Ohio
* Patients from Shodair Children's Hospital in Helena, Montana. These patients may be recruited if more patients are required to meet our enrollment goal.

Study patients will present to their preferred clinic for 5 office visits. Initial testing/Part 1: length 4 weeks

Recruited patients will present to clinic for part 1 of the study. After informed consent is obtained, molecular genetic testing will be performed. Testing will include sequence analysis of the PAH gene. This testing is necessary to identify the specific genotypes present in each patient. The investigators expect the majority of this population to be homozygous or heterozygous for the above described splice site mutation. Any patients found to have one (or no) identifiable mutations after sequencing will not be included in the study. Genotypes will be grouped and analyzed separately at the conclusion of the study. Patients who do not wish to undergo genetic testing will not be included in the study.

Each patient will also have an initial blood Phe level drawn in the form of a dried blood spot on filter paper card that will be supplied by the testing company. All Phe testing will be performed in a Clinical Laboratory Improvement Amendment (CLIA) certified laboratory at The Clinic for Special Children in Strasburg, PA.

Baseline assessment tools (BRIEF, PKU-QOL) will also be performed at this initial visit. Patients will be given a unique study number by our investigational drug pharmacy and will begin part 1 of the study as described below.

In part 1 of the study, patients will not receive any medication. Each patient will be treated with diet alone. Patients will maintain a stable, Phe restricted diet (including formula) that is consistent with their diet at the time of enrollment. This will be monitored by food diaries kept for 3 days of each week. Specifically, patients will be expected to keep diaries for the 3 consecutive days leading up to blood draw. Based on these diaries, average weekly Phe intake and Phe tolerance will be calculated and recorded. Patients will also complete a food frequency tool, which will be reviewed at part 1, 2 and 3's initial visit. We will use all of the tools above, plus allow patients regular access to our dietician in order to encourage the maintenance of a stable diet.

Blood Phe concentration will be measured weekly (each Monday) by blood spot cards. Patients will not require weekly clinic visits to have Phe levels drawn. Blood spot cards will be performed at their home and then mailed to the reference laboratory. In order to teach and enable patients to become comfortable performing their own blood spots at home, nursing staff (from the DDC clinic) will travel to each patient's house weekly for part 1 of the study (total of 3 home blood spots). For parts 2 and 3 of the study, those patients and families who are able, will perform their own blood spots at home. Those families who remain uncomfortable performing their own blood spots will continue to have their blood spots collected by home nursing.

Initial visit:

* Venous blood draw for PAH gene sequencing
* Baseline Phe level by dried blood spot card in office
* Executive functioning and quality of life assessment tools (BRIEF, PKU-QOL) given
* Baseline diet information collected and recorded. Average weekly Phe calculated, Phe tolerance calculated.
* Food frequency tool completed and reviewed.

Blood Phe values and Phe tolerance from part 1 of the study (on diet treatment alone) will be compared to blood Phe values and Phe tolerance from parts 2 and 3, on low-dose and high-dose treatment.

Part 2: length - 4 weeks

Study numbers will be randomized into "standard-dose Saproterin" or "high-dose Saproterin" groups (treatment group A or treatment group B). The investigational drug pharmacy will provide study patients with their medication in kits, at the beginning of each treatment period. Goal high-dose Saproterin dosing will be 40mg/kg (rounded up to the nearest 500mg), provided in the form of pre-packaged 500mg packets of powder. Labeled dosing on these packets will be covered by the investigational drug pharmacy and unidentifiable to patients. Standard-dose Saproterin will be 20mg/kg (rounded to the nearest 100mg) provided in the form of 100mg tablets. Dosing of the tablets will be unidentifiable to patients. Medication will be given orally once daily.

Initial part 2 visit: after 4 week diet only period

* Food diaries collected for the previous 4 weeks (3 per week). Average weekly Phe calculated, Phe tolerance calculated.
* Food frequency tool completed and reviewed.
* Baseline Phe level drawn by dried blood spot card in office
* Executive functioning and quality of life assessment tools (BRIEF, PKU-QOL) given
* Provided with medication kits (high or standard-dose, 4 week supply)

Final part 2 visit: after 4 weeks of treatment

* Food diaries collected for the previous 4 weeks (3 per week). Average weekly Phe calculated, Phe tolerance calculated.
* Executive functioning and quality of life assessment tools (BRIEF, PKU-QOL) given
* Empty medication bottles/packet kits collected from each patient to assess compliance
* Review of any potential adverse events

This is the end of part 2. There will then be a 2 week "wash out period" where patients receive no treatment. The length of this washout period was determined based on the mean elimination half-life of saproterin and previous clinical trials. The mean elimination half-life of saproterin ranges from 3.9 to 17 hours. In previous trials, washout periods have consisted of 7 and 30 days. No efficacy assessments have been performed to differentiate or support one washout period over the other (BioMarin Pharmaceuticals, Inc. Data on file). Based on the elimination range above, we determined that a two week washout period is sufficient. Patients should maintain their steady diet during this time.

Part 3: length - 4 weeks The cross-over will occur between treatment groups: A to B and B to A.

Initial part 3 visit: after 2 week washout period

* Food diaries collected for the previous 2 weeks (3 per week). Average weekly Phe calculated, Phe tolerance calculated.
* Food frequency tool completed and reviewed.
* Baseline Phe level performed by dried blood spot card in office
* Executive functioning and quality of life assessment tools (BRIEF, PKU-QOL) given
* Provided with medication kits (high or standard-dose, 4 week supply)
* Review of any potential adverse events

Final part 3 visit: after 4 weeks of treatment

* Food diaries collected for the previous 4 weeks (3 per week)
* Executive functioning and quality of life assessment tools (BRIEF, PKU-QOL) given
* Empty medication bottles/ kits collected from each patient to assess compliance
* Review of any potential adverse events

During all parts, patients will maintain a stable, Phe restricted diet including formula (same diet as in part 1 of the study). All Phe levels will be blinded and researchers will not have access to them until the conclusion of the study. At the conclusion of the study, after all data have been analyzed, a complete list of blood Phe levels obtained during the study (both on high and low-dose treatment) will be sent to each patient's primary metabolic physician. Physicians can then discuss long term Saproterin treatment with their patients based on their Phe levels.

The study will conclude after all parts are complete and groups A and B have both received a trial of high and standard-dose Saproterin. All medication will be discontinued at this time.

Arms: arm 1: In part 1 of the study, patients will not receive any medication. Each patient will DIET treatment alone. They will maintain a stable, Phe restricted diet (including formula) that is consistent with their diet at the time of enrollment. This will be monitored by food diaries kept for 3 days of each week. Based on these diaries, average weekly Phe intake and Phe tolerance will be calculated and recorded. arm 2: Study numbers will be randomized into "standard-dose saproterin dihydrochloride (Kuvan)" or "high-dose saproterin dihydrochloride (Kuvan) " groups (treatment group A or treatment group B). Both groups will receive a trial of both standard and high dose saproterin dihydrochloride before the end of the study. Standard-dose saproterin dihydrochloride will be 20mg/kg (rounded up to the nearest 100mg) provided in the form of 100mg tablets. Dosing of the tablets will be unidentifiable to patients. Medication will be given orally once daily. arm 3: Study numbers will be randomized into "standard-dose saproterin" or "high-dose saproterin" groups (treatment group A or treatment group B). Both groups will receive a trial of both standard and high dose saproterin dihydrochloride before the end of the study. Goal high-dose saproterin dihydrochloride dosing will be 40mg/kg (rounded up to the nearest 500mg), provided in the form of pre-packaged 500mg packets of powder. Labeled dosing on these packets will be covered by the investigational drug pharmacy and unidentifiable to patients. Dosing of the tablets will be unidentifiable to patients. Medication will be given orally once daily.
Interventions: intervention 1: saproterin dihydrochloride intervention 2: Diet treatment
Intervention descriptions: intervention 1: The drug will be given as described in the arm/group descriptions. intervention 2: Patients will maintain a stable, Phe restricted diet (including formula) that is consistent with their diet at the time of enrollment. This will be monitored by food diaries kept for 3 days of each week.

Protocol documents:
Prot_SAP_004.pdf: 
APPROVAL  
Principal Investigator: Lori-anne Schillaci  
Title: The effectiveness of synthetic BH4 (saproterin dihydrochloride or “Kuvan”) in Amish PKU patients 
IRB Number: 01-16-41.  
Submission Number: CR00001889  
IRB Office:  
UH IRB Approval Date: 6/25/2019 Effective Date: 6/25/2019  
Approval End Date: 6/24/2020  
Type of Submission: Continuing Review  
Type of Review: Full  
The IRB reviewed this submission. 
 Per Federal regulation, changes MAY NOT be made to any element of the current research without 
prior IRB approval, except to eliminate an immediate and apparent hazard to subjects enrolled in the 
study.  Per Federal regulation, the research may not continue beyond the Approval End date. You must 
submit a continuing review form 6-8 weeks before this Approval End date in order to maintain IRB 
approval. Failure to maintain IRB approval is human subjects non-compliance.  Please note that even if 
your study falls into a category that does not require an Approval End date, the institution may require a 
yearly “checkin” to confirm the status of the study.   
***Approval by the IRB does NOT mean that you have permission to start your study. Prior to starting 
your study, you may be required to obtain (1) a coverage analysis for studies that involve patient care, 
regardless of source of funding, and/or (2) a contract with the Sponsor of your study or an agreement 
with any third-party collaborator that 
The UH IRB operates under HHS Federalwide Assurance (FWA) number 00003937 and IRB registration 
numbers 00000684, 00001691 and 00008600. The CWRU IRB operates under DHHS FWA00004428 and 
IRB registration number 00000683. 
 
 
 
 
 
 
 
 


PROPOSED STUDY: The effectiveness of high-dose synthetic BH4 (saproterin dihydrochloride or 
KuvanTm) in Amish PKU patients   
  
Phenylketonuria (PKU) is caused by a deficiency of the enzyme phenylalanine hydroxylase (PAH). PAH is 
responsible for the rate limiting step in phenylalanine catabolism. This reaction is dependent on 
tetrahydrobiopterin (BH4). BH4 is a catalytic cofactor for the enzyme PAH. Supplementation with 
synthetic BH4 (saproterin dihydrochloride or KuvanTm) has been shown to activate residual PAH activity 
and lower Phe levels in certain patients. It may also have a chaperone effect by binding abnormal PAH 
protein and decreasing its degradation. Saproterin is an approved oral drug developed to reduce blood 
Phenylalanine (Phe) levels and increase Phe tolerance in BH4 responsive patients with 
hyperphenylalaninemia. Data from BH4 loading tests indicate an incidence of BH4 responsiveness of 
>40% in the general PKU population and >80% in mild PKU patients (6). This therapy is most effective in 
patients with mild PAH deficiency because they are more likely to have some residual PAH activity. 
However, there have been a small number of patients with less then 1% residual PAH activity that have 
been identified as BH4 responsive (2,8).   
  
Certain genotypes have been found to be good predictors of Saproterin responsiveness; however, these 
correlations are imperfect. Therefore the standard of care is to perform a trial of Saproterin therapy to 
assess responsiveness in every PAH patient regardless of genotype. Currently this recommendation does 
not include patients with two null mutations.  
  
The purpose of our study is to determine if Amish patients with PKU show responsiveness after a high 
dose, prolonged Saproterin trial. Our population of interest has a high frequency of a specific splice site 
mutation, the 1066-11G>A mutation. This splice site mutation activates a cryptic splice site resulting in 
an in frame insertion of 9 nucleotides preceding exon 11. This leads to protein conformational changes 
and abrogation of function. Previous studies of this genotype have indicated <1% residual activity of the 
PAH enzyme and an insignificant responsiveness to Saproterin. However, in this specific study Phe levels 
were evaluated only over 24 hours after a single-dose BH4 challenge at the standard dose of 20mg/kg 
(2).   
  
Recently, observation in several Amish patients suggests some promise that these patients may be 
responsive to Saproterin after a longer trial of the medication (Personal comment - Samuel Yang, MD). 
In addition, studies evaluating PAH enzyme activity in these patients, have found evidence that this 
genotype may need higher cofactor concentrations for optimal enzyme activity and therefore may 
require a higher dose of Saproterin then the currently recommended 20mg/kg (9). To date, no formal 
clinical trial has been done.    
  
To answer the question of whether this genotype is responsive to Saproterin at higher doses, over a 
prolonged period, we propose a randomized clinical trial comparing blood Phe levels in patients treated 


with standard-dose Saproterin to those treated with highdose Saproterin . Responsiveness (primary 
outcome) will be defined as a 20% reduction  
in baseline Phe levels on a stable diet or a 20% increase in Phe tolerance while taking Saproterin. As a 
secondary outcome, executive functioning will be evaluated using the Behavior Rating Inventory of 
Executive Function (BRIEF), which was previously identified as part of the “uniform assessment method 
for PKU” (10). Appropriate versions of the BRIEF will be used for each age group. In addition to executive 
functioning, we will measure quality of life through the previously validated PKU-QOL survey (11).   
  
The results of this study could reveal a new population of Saproterin responsive PKU patients. This could 
call into question other null mutations of the PAH gene and their responsiveness to Saproterin. This may 
lead to the investigation of genotypes previously thought to be unresponsive to Saproterin. Further, diet 
treatment alone has proven to be difficult for the Amish population for cultural and economic reasons 
and Saproterin may help improve Phe control in responsive patients.   
  
Hypothesis: Based on new clinical information, we hypothesize that if given a prolonged trial of 
Saproterin at a higher dose, Amish patients with PKU, and more specifically those homozygous for the 
c.1066-11G>A mutation, will have a significant reduction in Phe levels or an increase in Phe tolerance 
and/or improvement in executive functioning and quality of life.  
  
PROPOSED METHODS:  
  
This study will include Amish patients from three local centers. All patients will be enrolled through 
University Hospitals Case Medical Center. Consent will be obtained in person at UHCMC. These centers 
include: - University Hospitals Case Western Reserve/Rainbow Babies and Children’s Hospital/Center for 
Human Genetics  - Akron Children’s hospital in Akron, Ohio  - DDC center for children with special needs, 
Middlefield, Ohio   
  
IRB approval: University Hospitals Case Western Reserve IRB   
  
Inclusion Criteria: - Current diagnosis of PKU with the following: - Age of at least 2 years or older - 
Baseline Phe level of > 360 umol/L - Willing to maintain a stable diet  - Patient or guardian are willing 
and able to provide written, signed informed consent after the nature of the study has been explained 
and prior to any researchrelated procedures - Are willing to comply with all study procedures - Have any 
two identifiable mutations found on PAH gene sequencing OR have at least one copy of the splice site 
mutation of interest (c.1066-11G>A)  
- Any patients already taking Saproterin (or have taken in the past), must have a treatment end date at 
least 14 days prior to Day 1 of the study.   


  
Exclusion Criteria: - Any patient currently taking Saproterin who has taken the medication at any point in 
the 14 days prior to Day 1 of the study - Under 2 years of age - Unwilling to maintain a stable diet - 
Patients with baseline Phe levels < 360 umol/L - Patients unable to comply with all study procedures - 
Patients unable to provide written, signed informed consent  
  
Recruitment:  
Will be performed through the following ways:  
 Amish patients will be identified through their primary metabolic physicians/genetic counselors at 
three different sites – University Hospitals, DDC clinic in Middlefield, Ohio and Akron Children’s hospital. 
Despite, recruiting patients from the three centers above, throughout the study, all patients will be seen 
at University Hospitals for study visits. UH will be the only clinic site involved in this study.  The study 
team will only have access to electronic records from the UH site, for patients of people on the study 
team.   Letters will be mailed to each patient thought to meet inclusion criteria  Follow-up phone calls 
will be made to these patients  Patients will be recruited in-person by their primary metabolic 
physicians or genetic counselors as they are seen in each of the above clinics for follow-up  
Informed consent process:  
The majority of patients will be transported to University Hospitals Center for Human Genetics to 
discuss the study and review the informed consent.  For patients that are our regular clinic patients, we 
will see them following a scheduled clinical visit to discuss the study and review the informed consent. 
At the request of the patient, we will arrange to travel to their community clinic or home to discuss the 
study and review the informed consent.   Informed consent for patients will consist of:  1. The research 
project goals, risks and benefits will be explained to each patient in person by either myself (Dr. Lori-
Anne Schillaci) or Dr. Shawn McCandless. 2. Written informed consent will be obtained by either myself 
(Dr. Lori-Anne Schillaci) or Dr. Shawn McCandless from any patient wishing to participate, prior to the 
initial blood draw is performed. For minors, written informed consent will be obtained from one parent.  
  Study patients will present to their preferred clinic for 5 office visits. - Visit at beginning of part 1 (initial 
visit) - Visit at beginning of part 2 - Visit at conclusion of part 2 - Visit at the beginning of part 3 - Visit at 
the conclusion of part 3  
  
Primary Outcome: - Reduction of baseline Phe levels by 20% OR an increase in dietary Phe tolerance by 
20%  
  
Secondary Outcome: - Improved executive functioning and/or quality of life based on BRIEF and 
PKUQOL surveys as described above.   
  
Initial testing/Part 1: length 4 weeks   


  
Recruited patients will present to clinic for part 1 of the study. After informed consent is obtained, 
molecular genetic testing will be performed. Testing will include sequence analysis of the PAH gene. This 
testing is necessary to identify the specific genotypes present in each patient. We expect the majority of 
this population to be homozygous or heterozygous for the above described splice site mutation. Any 
patients found not to meet inclusion criteria after PAH gene sequencing will not be able to continue in 
the study past part I. Genotypes will be grouped and analyzed separately at the conclusion of the study. 
Patients who do not wish to undergo genetic testing will not be included in the study.   
  
Each patient will also have an initial blood Phe level drawn in the form of a dried blood spot on filter 
paper card that will be supplied by the testing company. All Phe testing will be performed in a CLIA 
certified laboratory at The Clinic for Special Children in Strasburg, PA.   
  
Baseline assessment tools (BRIEF, PKU-QOL) will also be performed at this initial visit. Patients will be 
given a unique study number by our investigational drug pharmacy and will begin part 1 of the study as 
described below.    
  
In part 1 of the study, patients will not receive any medication. Each patient will be treated with diet 
alone.  They will maintain a stable, Phe restricted diet (including formula) that is consistent with their 
diet at the time of enrollment. This will be monitored by food diaries kept for 3 days of each week. 
Specifically, patients will be expected to keep diaries for the 3 consecutive days leading up to blood 
draw. Based on these diaries, average weekly Phe intake and Phe tolerance will be calculated and 
recorded. Patients will also complete a food frequency tool, which will be reviewed at part 1, 2 and 3’s 
initial visit. We will use all of the tools above, plus allow patients regular access to our dietician in order 
to encourage the maintenance of a stable diet.   
  
Blood Phe concentration will be measured weekly (each Monday) by blood spot cards. Patients will not 
require weekly clinic visits to have Phe levels drawn. Blood spot cards will be performed at home and 
then mailed to the reference laboratory. In order to teach and enable patients to become comfortable 
performing their own blood spots at home, nursing staff (from the DDC clinic) will travel to each 
patient’s house weekly for part 1 of the study (total of 3 home blood spots). For parts 2 and 3 of the 
study, those patients and families who are able, will perform their own blood spots at home. Those 
families who remain uncomfortable performing their own blood spots will continue to have their blood 
spots collected by home nursing.   
  
Initial visit: - Venous blood draw for PAH gene sequencing  - Baseline Phe level by dried blood spot card 
in office - Urine pregnancy testing in females of reproductive age  - Executive functioning and quality of 
life assessment tools (BRIEF, PKU-QOL) given - Baseline diet information collected and recorded. 


Average weekly Phe calculated, Phe tolerance calculated.  - Food frequency tool completed and 
reviewed.  
  
Blood Phe values and Phe tolerance from part 1 of the study (on diet treatment alone) will be compared 
to blood Phe values and Phe tolerance from parts 2 and 3, on low-dose and high-dose treatment.   
  
Part 2: length - 4 weeks  
  
Study numbers will be randomized into “standard-dose Saproterin” or “high-dose Saproterin” groups 
(treatment group A or treatment group B). The investigational drug pharmacy will provide study patients 
with their medication in kits, at the beginning of each treatment period. Goal high-dose Saproterin 
dosing will be 40mg/kg (rounded up to the nearest 500mg), provided in the form of pre-packaged 
500mg packets of powder. Labeled dosing on these packets will be covered by the investigational drug 
pharmacy and unidentifiable to patients. Standard-dose Saproterin will be 20mg/kg (rounded to the 
nearest 100mg) provided in the form of 100mg tablets. Dosing of the tablets will be unidentifiable to 
patients. Medication will be given orally once daily.   
  
Initial part 2 visit: after 4 week diet only period  - Food diaries collected for the previous 4 weeks (3 per 
week). Average weekly Phe calculated, Phe tolerance calculated.  - Food frequency tool completed and 
reviewed.  - Baseline Phe level drawn by dried blood spot card in office - Urine pregnancy testing in 
females of reproductive age  - Executive functioning and quality of life assessment tools (BRIEF, PKU-
QOL) given - Provided with medication kits (high or standard-dose, 4 week supply)  
  
Final part 2 visit: after 4 weeks of treatment - Food diaries collected for the previous 4 weeks (3 per 
week). Average weekly Phe calculated, Phe tolerance calculated.  - Executive functioning and quality of 
life assessment tools (BRIEF, PKU-QOL) given - Empty medication bottles/packet kits collected from each 
patient to assess compliance  - Review of any potential adverse events  
  
This is the end of part 2. We will then have a 2 week “wash out period” where patients will receive no 
treatment. The length of this washout period was determined based on the mean elimination half-life of 
saproterin and previous clinical trials. The mean elimination half-life of saproterin ranges from 3.9 to 17 
hours. In previous trials, washout periods have consisted of 7 and 30 days. No efficacy assessments have 
been performed to differentiate or support one washout period over the other (BioMarin 
Pharmaceuticals, Inc. Data on file). Based on the elimination range above, we determined that a two 
week washout period is sufficient. Patients should maintain their steady diet during this time.   
  
Part 3: length – 4 weeks  


  
The cross-over will occur between treatment groups: A  B and B A.  
  
Initial part 3 visit: after 2 week washout period - Food diaries collected for the previous 2 weeks (3 per 
week). Average weekly Phe calculated, Phe tolerance calculated.  - Food frequency tool completed and 
reviewed. - Baseline Phe level performed by dried blood spot card in office - Urine pregnancy testing in 
females of reproductive age  - Executive functioning and quality of life assessment tools (BRIEF, PKU-
QOL) given - Provided with medication kits (high or standard-dose, 4 week supply) - Review of any 
potential adverse events  
  
Final part 3 visit: after 4 weeks of treatment - Food diaries collected for the previous 4 weeks (3 per 
week)  - Executive functioning and quality of life assessment tools (BRIEF, PKU-QOL) given - Empty 
medication bottles/ kits collected from each patient to assess compliance - Review of any potential 
adverse events  
  
During all parts, patients will maintain a stable, Phe restricted diet including formula (same diet as in 
part 1 of the study). All Phe levels will be blinded and researchers will not have access to them until the 
conclusion of the study. At the conclusion of the study, after all data have been analyzed, a complete list 
of blood Phe levels obtained during the study (both on high and standard-dose treatment) will be sent 
to each patient’s primary  
metabolic physician. Physicians can then discuss long term Saproterin treatment with their patients 
based on their Phe levels.   
  
The study will conclude after all parts are complete and groups A and B have both received a trial of high 
and standard-dose Saproterin. All medication will be discontinued at this time. The primary outcome 
evaluated will be Saproterin responsiveness based on blood Phe concentration and Phe tolerance. The 
secondary outcome evaluated will be changes in adaptive behavior, executive functioning and/or quality 
of life assessments. Improvement in these scores may be an indication for long term Saproterin 
treatment in these patients.  
  
Safety Management Plan:  
  
BioMarin Standard  Language for Adverse Event Reporting: IST Program, Saproterin   Adverse Events 
According to the ICH definition, an adverse event (AE) is any untoward medical occurrence in a patient 
or clinical investigation subject administered a pharmaceutical product, and that does not necessarily 
have a causal relationship with this treatment.  An AE can therefore be any unfavorable and unintended 
sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use 


of a medicinal (investigational) product, whether or not considered related to the investigational 
product.  
  
This definition includes intercurrent illnesses or injuries that represent an exacerbation (increase in 
frequency, severity, or specificity) of pre-existing conditions.  Whenever possible, it is preferable to 
record a diagnosis as the AE term rather than a series of terms relating to a diagnosis.   
  
Adverse event information will be collected in an ongoing fashion through patient reporting AEs to their 
physician, health care provider or to the investigator.  Seriousness and relatedness will be assessed by 
the investigator, with appropriate reporting. A designated primary contact person based at the 
treatment center will be responsible for the collection and reporting of AEs for patients participating in 
the program.    
  
Serious Adverse Events A serious adverse event (SAE) is defined as any AE that:  Results in death  Is 
life threatening, that is, places the subject at immediate risk of death from the event as it occurred. This 
definition does not include a reaction that, had it occurred in a more severe form, might have caused 
death  Requires in-patient hospitalization or prolongation of an existing in-patient hospitalization. 
Admission of a subject to the hospital as an in-patient as a result of an AE, even if the subject is released 
on the same day, qualifies as hospitalization  
 Results in persistent or significant disability or incapacity. An event qualifies as resulting in a persistent 
or significant disability or incapacity if it involves a substantial disruption of the subject’s ability to carry 
out usual life functions. This definition is not intended to include experiences of relatively minor or 
temporary medical significance.  Is a congenital anomaly or birth defect, an AE that occurs in the child 
or fetus of a subject exposed to the product prior to conception or during pregnancy  Important 
medical event that does not meet any of the above criteria, but may jeopardize the subject or require 
medical or surgical intervention to prevent one of the outcomes listed above. More than one of the 
above criteria may apply to any specific event.   
  
Pregnancy   Pregnancy in a subject being treated with the product should be reported immediately 
(within 24 hours of becoming aware of the pregnancy) to BioMarin Pharmacovigilance by using the FDA 
3500A (MedWatch Form).  Every effort should be made to follow the patient through resolution of the 
pregnancy (termination or delivery) and report the resolution of the FDA 3500A (MedWatch Form) to 
BioMarin Pharmacovigilance.   
  
SAE and Pregnancy Reporting  
  


[In Investigator IND studies,  SAPROTERIN ™ serious, related, unlabelled, (unexpected) adverse events 
will be reported to the FDA as required by 21 CFR 312.32 by the Investigator/Sponsor. These reports 
may be filed utilizing the Form FDA 3500A (MedWatch form).  The Investigator/Sponsor will provide 
BioMarin Pharmacovigilance, with a copy of this report. All serious adverse events (SAEs) and pregnancy 
reports whether or not considered drug-related should be reported to BioMarin Pharmacovigilance 
(contact information below) within 24 hours of receipt by the investigator/sponsor by using the FDA 
3500A (MedWatch Form).  For Comparator Drugs / Secondary Suspects (Concomitant Medications), all 
serious adverse experiences will be forwarded to the product manufacturer].  Not pertinent to this 
study.  
  
In IND-exempt studies,   All serious adverse events (SAEs) and pregnancy reports whether or not 
considered drugrelated should be reported to BioMarin Pharmacovigilance within 24 hours of receipt by 
the investigator/sponsor  by using the FDA 3500A (MedWatch Form).  For Comparator Drugs / 
Secondary Suspects (Concomitant Medications), all serious adverse experiences will be forwarded to the 
product manufacturer.  Clinicians should not wait to collect additional information that fully documents 
the event before notifying BioMarin’s Pharmacovigilance Department of an SAE or pregnancy.  BioMarin 
may be required to report certain SAEs to regulatory authorities within 7 calendar days of being notified 
about the event; therefore it is important that clinicians submit additional information requested by 
BioMarin Pharmacovigilance as soon as it becomes available.  Reporting of SAEs to the IRB will be done 
in compliance with the  
standard operating procedures and policies of the IRB and with applicable regulatory requirements.    
  
Contact information for BioMarin’s Pharmacovigilance Department is as follows: BioMarin 
Pharmaceutical Inc.  105 Digital Drive  Novato, CA  94949  Phone: (415) 506-6179 Fax: (415) 532-3144  
Email: drugsafety@bmrn.com   
  
Product Complaints Reporting  A product complaint (“Complaint”) is any direct, written, electronic, or 
oral communication of dissatisfaction that alleges deficiencies related to the identity, quality, durability, 
labeling, purity, stability, appearance, effectiveness, safety, and/or design of a drug  product after it is 
released for distribution. Complaints that simultaneously fall under Adverse Event definitions under this 
Protocol need only be reported via the Adverse Event reporting procedure set forth in this Protocol.  
Investigator or designee (Reporter) shall capture the following Complaint information as relates to 
Saproterin  used under this Protocol:  •     Date complaint received •     Product Name and Lot Number •     
Indicate if the product is available for return to BioMarin for investigation  •     Quantity Affected •     
Detailed Description of complaint •     Study Protocol Number •     Investigator Name •     Site Contact •     
Site Number •     Subject Number  •     Name and contact information of the person who is reporting the 
complaint as well as name and contact information of the complainant.  The reporter will be contacted 
by BioMarin Product Complaint Quality Assurance Department. Investigator or designee (Reporter) will 
use his or her best efforts to report Complaints to BioMarin within five days of learning of the 
Complaint. Investigator or designee will submit the complaint information by email at 


productcomplaint@bmrn.com or by fax at 415-523-1457.   AE language approved 28 May 15, PC 
language approved 28 May 2015  
  
Statistical Methods:  
  
We will use student’s T-test to compare the mean Phe values for diet treatment alone to both the low 
and high-dose treatment values. The goal is to determine if there is a significant difference between the 
groups. Similarly, we will compare calculated phe tolerance from each part of the study.   
  
Power calculations were performed and the following was determined:  
If the P value (type 1 error) is set at 0.05 and the power (type II error) is set at 80% and the minimal 
detectable difference between means is set at 200, then 15 patients would be required to find 
significance. Our enrollment goal is up to 25 patients to allow for dropouts and to increase the 
probability of having 15 patients homozygous for the common mutation.   
  
Improvement in adaptive behavior/executive functioning and quality of life will be based on our chosen 
assessment tools. Scores from the surveys will be compared from each group (diet, high-dose and 
standard-dose).   
  
  
Timeline for Project:  
  
Regulatory Prep: ~5 months Enrollment: ~ 2 months  Phase 1: 4 weeks Washout: 2 weeks Phase 2: 4 
weeks Phase 3: 4 weeks: Analysis: 6 weeks  Paper preparation: 8 weeks   
  
REFERENCES:  
  
1. H. Wang, L. Nye, E. Puffenberger, H. Morton, Phenylalanine hydroxylase deficiency exhibits mutation 
heterogeneity in two large old order Amish settlements, Am J Med Gen 143A (2007) 1938-1940. 2. S. 
Dobrowolski, C. Heintz, molecular genetics impact of residual in vitro phenylalanine hydroxylase activity 
on tetrahydrobiopterin responsiveness in Turkish PKU population, Mol Gen and Met 10 (2011) 116-121. 
3. B. Dworniczak, C. Aulehla-Scholz, L. Kalaydjieva, K. Bartholome, K. Grudda, J. Horst, Aberrant splicing 
of phenylalanine hydroxylase mRNA: the major cause for phenylketonuria in parts of southern Europe, 
Genomics 11 (1991) 242-246. 4. I. Karacic, D. Meili, V. Sarnavka, C. Heintz, B. Thony, D. Petkovic 


Ramadza, K. Fumic, D. Mardesic, I. Baric, N. Blau, Genotype-predicted tetrabiopterinresponsiveness and 
molecular genetics in Croatian patients with phenylalanine hydroxylase deficiency, Mol Gen and Met 97 
(2009) 165-171.  5. J. Vockley et al. Phenylalanine hydroxylase deficiency: diagnosis and management 
guideline, Gen in Med 16 (2013) 188-200. 6. M. Zurfluh at al. Molecular genetics of tetrahydrobiopterin-
responsive phenylalanine hydroxylase deficiency, Hum Mut 29 (2008) 167-175. 7. S. Keil at al. Long-term 
follow-up and outcome of pheylketonuria patients on sapropterin: A retrospective study. Pediatrics 131 
(2013) 1881-1888.  8. N. Blau, W. Yue, B. Perez, (2006-2013) BioPKU database, retrieved from 
http://www.biopku.org/biopku  
9. Danecka, M. et al. Mapping the functional landscape of frequent phenylalanine hydroxylase (PAH) 
genotypes promotes personalized medicine in phenylketonuria, J Med Genet 52 (2015) 175-185. 10. 
Waisbren, S. and White, D.A. Screening for cognitive and social-emotional problems in individuals with 
PKU: Tools for use in the metabolic clinic, mol gen and met 99 (2010) S96-S99 11. Regnault, A. et al. 
Development and psychometric validation of measures to assess the impact of phenylketonuria and its 
dietary treatment on patients’ and parents’ quality of life: the phenylketonuria – quality of life (PKU-
QOL) questionnaires, Orphanet journal of rare diseases 10:59 (2015) 1-18.  
  
 

ICF_003.pdf: 
UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 1 of 16
PROTOCOL NO.:  1.0
FUNDING: Biomarin Pharmaceutical Inc. 
You refers to “You” or “Your Child” throughout this document
Introduction/Purpose
Before agreeing to participate in this research study, it is important that you read and 
understand the following explanation of the proposed research study.  This consent 
document describes the purpose, procedures, benefits, risks, discomforts and 
precautions of the study.  It also describes the alternative procedures that are available to 
you and your right to withdraw from the study at any time.  No guarantees or assurances 
can be made as to the results of the study.
It is important for you to be truthful with your study doctor regarding your health history, in 
order to avoid harm to yourself by participating in this study.
The study is being funded by Biomarin Pharmaceutical Inc. 
The Institutional Review Board at University Hospitals Cleveland Medical Center has 
approved the information in this consent document and has given approval for the study 
doctor to do the study.  An institutional review board (IRB) is an independent committee 
established to help protect the rights of research subjects.  This does not mean the IRB 
has approved your participation in the study.  You must think about the information in this 
consent document for yourself.  You must then decide if you want to be in the study.
BACKGROUND AND PURPOSE 
This is a research study to examine Amish people with Phenylketonuria (PKU). PKU is a 
genetic disorder. It is caused by problems with the enzyme phenylalanine hydroxylase 
(PAH). This enzyme normally breaks down the amino acid (building block of protein) 
phenylalanine (Phe). Tetrahydrobiopterin (BH4) is a cofactor (‘helper’) that helps the 
enzyme work better.  Man-made BH4 (saproterin dihydrochloride) is called “Kuvan”.  
Kuvan is an FDA approved drug. Treatment with Kuvan and a low Phe diet, help improve 
PAH enzyme activity and lower blood Phe levels in some people. 
Previous studies of Kuvan suggested that the more severe the PKU, the less likely Kuvan 
will help.  However, we think that for patients with the more severe PKU, a higher dose of 
Kuvan given for a longer time than in the previous studies, might work better for these 
patients. Amish people most often have one particular genetic change causing PKU.  
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 2 of 16
Some people thought that Kuvan probably wouldn’t help people with that genetic change. 
Some doctors have found that people with the same genetic change seen in the Amish, 
might just need a higher dose of Kuvan and to stay on the medication longer to see if it 
helps. 
We created this research study to find out if Amish people with PKU will have lower Phe 
in their blood if they take a higher dose of Kuvan for a longer period of time than was 
previously tested.  Even though the FDA has approved Kuvan to treat PKU patients, for 
this study Kuvan is considered to be an experimental drug.  
You are being asked to participate in this research study because you are Amish and you 
have PKU. 
The purpose of this research study is to see if for Amish people:
-
a higher dose of Kuvan for one month helps to lower Phe levels in the blood; or if it 
allows people to eat more protein.
-
a higher dose of Kuvan for one month makes them feel better, pay attention better 
or feel more organized.
NUMBER OF SUBJECTS / LENGTH OF PARTICIPATION 
About 25 subjects will participate in this study. Your participation in this study will last 
approximately 14 weeks and include 5 clinic visits. These clinic visits can occur at 
University Hospitals Cleveland Medical Center or at the DDC Clinic for Special Needs 
Children in Middlefield, OH.  If you choose to come to University Hospitals Cleveland 
Medical Center in Cleveland, Ohio, these visits will require a car ride that will take 
approximately 50 minutes each way.  We can help to arrange these car rides if needed.
The study will consist of the following periods:
-
Part 1 (diet treatment only): 1 clinic visit , one blood draw, and 3 blood spot cards 
done at home (4 weeks)
-
Part 2 (high-dose or low-dose treatment): 2 clinic visits and 3 blood spot cards 
done at home (4 weeks)
-
Wash out period: no treatment, no clinic visits, no blood spot cards (2 weeks)
-
Part 3 (high-dose or low-dose treatment): 2 clinic visits and 3 blood spot cards 
done at home (4 weeks)
Total = 5 clinic visits + 9 home blood spot draws (14 weeks total)
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 3 of 16
Study Procedures
Before any study-related tests and procedures are performed, you will be asked to read 
and sign this consent document.  
TREATMENT PERIOD 1
You will be asked to come to clinic for a first visit. During this visit the study doctor will 
explain the requirements of the study to you and your caregiver and determine if you are 
a good fit for the study.  
At the beginning of the visit, you will be given as much time as you need to read this 
consent form and ask questions about the study.  If you agree to take part, you will be 
asked to sign this consent form.  A copy of the signed consent will be given to you.  
Once you have signed the consent form, a blood draw will be performed for genetic 
testing. This testing is being done to determine the specific genetic mutations present in 
your PAH gene (see genetic testing section below).  Knowing your specific mutations will 
help us figure out which mutations may need higher doses of Kuvan over longer periods 
of time in the future. At this time, you will also have a blood spot to determine your blood 
Phe level. If you are female you will also be asked for a urine sample to check if you are 
pregnant. 
You will then begin part 1 of the study. During part 1, you will not receive any medication. 
You will follow a stable, Phe-restricted diet (including formula) for 4 weeks. You will also 
be asked to maintain food diaries for 3 days of each week (Specifically, the 3 consecutive 
days prior to when your weekly Phe level is drawn). Blood Phe levels will be obtained 
weekly by home blood spot cards. Each blood spot in part 1 will be performed by nursing 
staff that will travel to your house and perform the blood spots once per week. During 
these 3 weeks, this nursing staff will also teach you how to perform these blood spots 
properly yourself. 
Genetic testing results will be available 3 weeks after your first blood draw. There is a 
chance that we will not be able to determine your specific genetic mutations with this 
testing. If your genetic testing finds only one, or no genetic mutations, you will be not be 
included in the study after part I. People not found to have two mutations in the PAH gene 
will not go on to complete parts 2 and 3 of the study. 
TREATMENT PERIOD 2 (Part 2)
After part 1 is complete you will continue on to part 2. In part 2, you will be randomly 
assigned by chance (like the flip of a coin) to receive either high-dose Kuvan (40 mg/kg) 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 4 of 16
or standard-dose Kuvan (20 mg/kg). Kuvan will either be in tablet or powder form and will 
be taken by mouth, once daily. Below are your chances of receiving high-dose or low-
dose Kuvan.
Treatment
Chances of Recieving
Standard-dose Kuvan
½ (50%)
High-dose Kuvan 
½ (50%)
You will be required maintain a stable, Phe-restricted diet including formula (the diet that 
you followed in part 1) during this treatment period. You will be required to attend 2 clinic 
visits during this part (one at the beginning of the treatment period and one at the 
conclusion). During these visits the following will take place:
Initial visit:
-
Medical history and physical exam
-
Food diaries collected for the previous 4 weeks (3 days per week)
-
Baseline Phe level drawn by dried blood spot card in office
-
Urine pregnancy test (females only) 
-
Behavioral and quality of life assessment tools (BRIEF, PKU-QOL) 
-
Provided with high or low-dose medication kits (supply for 4 weeks)
-
Provided with instruments for weekly blood measurement – 3 blood spot cards to 
be performed at home starting week 2 (each Monday) and mailed into the 
appropriate lab. People or families who are uncomfortable or unable to perform 
their own blood spots at home will continue to have home nursing visits weekly to 
obtain the blood spots. 
Second visit: conclusion of part 2 after 4 weeks of treatment
-
Food diaries collected for the previous 4 weeks (3 per week)
-
Behavioral and quality of life assessment tools (BRIEF, PKU-QOL) 
-
Empty medication bottles/packet kits collected to assess compliance 
Study visits are expected to take 2-3 hours. 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 5 of 16
WASHOUT PERIOD 
At the conclusion of part 2 there will be a 2 week ‘washout period’.  During these two 
weeks you will not receive any study medication and you will have no clinic visits. You 
should continue to maintain your stable, Phe-restricted diet. 
TREATMENT PERIOD 3 (Part 3)
At the end of the washout period, another 4 week treatment period will begin.  Study 
participants that initially received high-dose Kuvan will receive standard-dose Kuvan for 
the next 4 weeks and study participants that initially received standard-dose Kuvan will 
receive high-dose Kuvan for the next 4 weeks. You will again be required to maintain a 
stable, Phe-restricted diet including your formula (the diet you followed in parts 1 and 2).  
You will again be required to attend 2 clinic visits during this time (one at the beginning of 
the treatment period and one at the conclusion). The procedures performed at these visits 
will be exactly the same as above in Part 2. 
This is a blinded study, which means you will not know which of these treatments you 
have been assigned.  In case of an emergency, however, the study doctor can get this 
information.  
DRUG TRANSPORT/STORAGE
At each initial study visit for Part 2 and Part 3, you will be given a 4 week supply of 
medication for you to take home. Please keep medication in its original container, protect 
it from getting damp or wet and do not expose it to extreme temperatures.
SAMPLE COLLECTION AND STORAGE
Throughout the study, at various time points, blood samples will be collected to help the 
study doctor and sponsor better understand how, and if, the study drug works.  At the 
initial visit, each participant will have a ‘blood draw’ where the doctor or nurse will insert a 
needle into your vein and obtain 2-5mL (1/2-1 teaspoon) of blood. For the remainder of 
the study, ‘blood spots’ will be collected through a finger prick where 100 microliters of 
blood per spot will be placed onto filter paper cards each week. Four spots will be 
collected with each finger stick and twelve finger sticks will be done over the course of the 
study for a total of 4,800 microliters (or 4.8 mL or approximately 1 teaspoon). The total 
blood collected throughout the study will be less than 10 mL (or approximately 2 
teaspoons). 
Blood samples collected for genetic testing at the initial study visit will be analyzed by the 
DDC clinic laboratory in Middlefield, Ohio. If you have your initial study visit at University 
Hospitals Cleveland Medical Center, your blood sample will be mailed to the DDC clinic 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 6 of 16
for analysis.  Blood spot samples collected during clinic visits for Phe analysis will be 
mailed directly from our clinic to the reference laboratory in Pennsylvania. Our study staff 
will handle and mail out these samples. 
During the weeks that you do not visit our clinic, you will perform blood spot cards at 
home. In order to teach you to become comfortable performing your own (or your child’s) 
blood spots cards at home, nursing staff (from the DDC clinic) will travel to your house 
weekly for part 1 of the study (a total of 3 home blood spots). During parts 2 and 3 of the 
study, you will perform your own (or your child’s) blood spots at home. If you are 
uncomfortable performing these blood spots, blood spots will continue to be collected by 
home nursing. 
Blood spot cards collected at home, by either you or the nurse, will be mailed that day, 
directly from your home to the reference laboratory in Pennsylvania.  Addressed 
envelopes and stamps will be provided to mail these blood spot cards.
EXPECTATIONS 
If you participate in this study, you will be expected to: 

Attend each site visit described above

Complete laboratory tests and procedures as instructed by the site staff and study 
doctor, including obtaining blood spots at home once per week (performed by 
yourself or home nursing staff)

Complete all surveys given at site visits and bring diet diaries in good condition to 
each site visit

Communicate any side effects, changes in your health or behavior or changes in 
your medication usage to the site staff 
If you participate in this study, your caregiver will be expected to: 

Assist the site staff to ensure your compliance with the study requirements and 
schedule 

Accompany you at each site visit 

Communicate any side effects, changes in your health or behavior or changes in 
your medication usage to the site staff

Complete the assessment tools given at each site visit and help maintain and bring 
diet diaries to each visit. 
It should be noted that if a caregiver is answering the assessment surveys at each site 
visit, it is important for these to be completed by a consistent primary caregiver who is 
able to reliably and accurate assess the changes in your health, habits, and behavior 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 7 of 16
throughout your participation in the study.  
Risks 
Medical treatments often cause side effects.  You may have none, some or all of the 
effects listed below, and they may be mild, moderate or severe.  If you have any of these 
side effects, or are worried about them, talk with your study doctor.  Your study doctor will 
also be looking out for side effects.
There may be side effects that the researchers do not expect or do not know about and 
that may be serious.  Tell your study doctor immediately about any new or unusual 
symptoms that you experience while in this study.
Many side effects go away shortly after treatment ends.  However, sometimes side effects 
can be serious, long lasting or permanent.  If a severe side effect or reaction occurs, your 
study doctor may need to stop your treatment.  Your study doctor will discuss the best 
way of managing any side effects with you.
RISKS OF STUDY MEDICATION
Kuvan is an FDA approved drug taken by people with PKU at a dose of 20 mg/kg daily. 
This is the first time it is being given to participants at a dose of 40 mg/kg daily.  So, it is 
not known if there are specific side effects that will show up only at this elevated dose.  
The study drug must be taken only by you.  It must be kept in a safe place out of reach of 
children and other people who cannot read well or understand that they should not take it.
The most common side effects of Kuvan at a dose of 20mg/kg include:

Headache

Nausea (feeling sick in the stomach, queasy)

Vomiting (throwing up)

Diarrhea

Gastritis (inflammation of the stomach lining) 

Upper respiratory tract infection (cold-type symptoms)

Pharyngolaryngeal pain (throat pain)

Hyperactive behaviors (such as fidgeting or constant activity)

Hypophenylalaninemia (low blood phenylalanine)
RISKS OF STUDY PROCEDURES
The insertion of the needle to draw blood is painful; however, this discomfort is brief.  For 
most people, needle punctures to get blood samples to not cause any serious problems; 
however, they may cause bleeding, bruising, discomfort, infections, dizziness, or fainting. 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 8 of 16
There may be risks associated with genetic testing; these risks will be discussed in the 
separate consent for genetic testing.
UNFORESEEN RISKS 
Since the study drug is being given at a higher dose than usual, there may be other risks 
that are unknown.  All drugs have a potential risk of an allergic reaction, which if not 
treated promptly, could become life-threatening.
PREGNANCY / BIRTH CONTROL 
Kuvan is rated by the FDA as a category C drug if taken during pregnancy. Adverse 
events have been observed in some animal reproduction studies.  Because of this, it is 
important that you do not participate in this study if you are pregnant or breast-feeding.  It 
is also important that you do not become pregnant during the course of the study.  If you 
are female and child-bearing is a possibility, you will be required to undergo a pregnancy 
test prior to starting the study. If you are sexually active and not surgically sterile or post-
menopausal, you must use effective contraception approved by the study guidelines.  You 
should discuss methods of effective contraception with your study doctor.  Medically 
acceptable contraceptives include: (1) surgical sterilization, (2) approved hormonal 
contraceptives such as birth control pills, (3) barrier methods (such as a condom or 
diaphragm) used with a spermicide, or (4) an intrauterine device (IUD).  Barrier 
contraceptives (condoms or diaphragm) with spermicide, intrauterine devices, hormonal 
contraceptives (Depo-Provera, Norplant), oral contraceptive pills, and complete 
abstinence are examples of effective methods.  
If you are female and become pregnant while participating in this research project, you 
should advise your study doctor immediately.  Your study doctor will withdraw you from 
the research project and advise on further medical attention should this be necessary.  
You must not continue in the research if you become pregnant.  You will be referred to 
appropriate counseling and informed of the possible risks with pregnancy associated with 
Kuvan.  If you have a positive pregnancy test during a study visit and you are younger 
than 14 years of age the study team is required to tell you, your parent or legal guardian 
and the Department of Children and Family Services. If you are 14 years of age or older 
and tell the study team that you are pregnant or have a positive pregnancy test during a 
study visit, the study team must give this information to your parent/legal guardian if they 
ask.  The study team can help you share this information with your parent or legal 
guardian.  
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 9 of 16
Benefits
Prolonged increased Phe concentrations are toxic to the brain and lead to the impairment 
of intelligence and other brain functions. Kuvan has been shown to help maintain reduced 
blood Phe concentrations in certain people with PKU.  There is a possibility that you may 
decrease your blood Phenylalanine levels and increase your Phenylalanine tolerance by 
taking Kuvan, but there is no guarantee. Some subjects may not benefit from participation 
in this study; however, their participation in this study might help in the future treatment of 
individuals with PKU. 
Alternatives to Study Participation
You do not have to be in this study to receive treatment for your PKU. You may choose 
other treatments or procedures to help with your symptoms, such as maintaining a Phe-
restricted diet. The study doctor will discuss with you the risks and benefits of the 
alternative treatments.
Consequences of Withdrawing or Being Discontinued From the 
Research 
Your decision to participate in this study is voluntary.  You may choose to not participate 
or you may withdraw from the study for any reason without penalty or loss of benefits to 
which you are otherwise entitled and without any effect on your future medical care.  If 
you decide to stop for any reason, it is important to let the study doctor know as soon as 
possible so you can stop safely.  If you withdraw from the study prior to its completion, 
you will be asked to return all study medication to the study doctors. 
The study doctor will tell you about new information or changes in the study that may 
affect your health or your willingness to continue in the study.
The study doctor may take you out of the study:

If your health changes and the study is no longer in your best interest

If new information becomes available

If you do not follow the study requirements

If the study is stopped by the sponsor, Institutional Review Board (IRB) or FDA.
Financial Information
Your participation in this study will involve no cost to you.  Kuvan will be provided at no 
cost to you while you are participating in this study.   As a participant in the study, we will 
arrange and cover all travel to and from site visits at University Hospitals Cleveland 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 10 of 16
Medical Center, as well as, all medical care received at these visits at no cost. You will 
not be charged for anything else we do that is part of the study.  
During the study, you will still have to pay for any medical care that you receive during 
this time that is not part of the study.  
You will not receive any payment for your participation in this study.  
Research-Related Injury 
In the event that a research activity results in injury, you/your medical insurance may be 
charged for the cost of diagnosing and treating your condition.  You may be responsible 
for co-pays or deductibles.  A research injury is an injury that happens as a result of 
taking part in this research study.  If you are injured by a medical treatment or procedure 
that you would have received even if you weren’t in the study, that is not considered a 
“research injury”.  If you/your insurance company does not pay the cost of diagnosing and 
treating your condition, the cost will be covered by Biomarin Pharmaceutical if they agree 
the injury was caused by the research or research activity as described in the Protocol 
and not the fault of the researchers or study staff.  There are no plans for payment for lost 
wages or other expenses.  To help avoid injury, it is very important to follow all study 
directions.
Genetics Studies
Molecular genetic testing will be performed at your first visit. Specifically, testing will 
include a blood draw for sequencing of the entire PAH gene looking for your specific 
genetic mutations.The results of the analysis of your DNA done as part of this study will 
be given to you at the conclusion of the study. Your DNA sample will be identified by a 
code number, and all other identifying information will be removed.  The principal 
investigator, Lori-Anne Schillaci, MD, will have access to a separate code sheet that links 
the DNA sample code number with your identity. The benefit of this testing is that your 
results may identify the two specific genetic mutations causing your condition. Your DNA 
sample will only be used for the specific purpose described in this consent form.  When 
the study is complete your sample will be destroyed.  You will not be allowed to 
participate in this study if you do not have this genetic testing.
A Federal law, called the Genetic Information Nondiscrimination Act (GINA), effective May 
21, 2010, generally makes it illegal for health insurance companies, group health plans, 
and most employers to discriminate against you based on your genetic information. This 
law generally will protect you in the following ways: 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 11 of 16

Health insurance companies and group health plans may not request your genetic 
information that we get from this research.

Health insurance companies and group health plans may not use your genetic 
information when making decisions regarding your eligibility or premiums. 

Employers with 15 or more employees may not use your genetic information that 
we get from this research when making a decision to hire, promote, or fire you or 
when setting the terms of your employment. 
Be aware that this Federal law does not protect you against genetic discrimination by 
companies that sell life insurance, disability insurance, or long-term care insurance.
All health insurance companies and group health plans must follow this law by May 
21, 2010. All employers with 15 or more employees must follow this law as of 
November 21, 2009. Be aware that this new Federal law does not protect you 
against genetic discrimination by companies that sell life insurance, disability 
insurance, or long-term care insurance.
Clinical Trial Information
U.S. NATIONAL INSTITUTES OF HEALTH (NIH) CLINICAL TRIAL DATABASE: A 
description of this clinical trial will be available on http:///www.clinicaltrials.gov, as required 
by U.S. Law.  This website will not include information that can identify you.  At most, the 
website will include a summary of the results.  You can search this website at any time to 
find out information about the trial and basic results.
Confidentiality
Records of your participation in this study will be held confidential except when sharing 
the information is required by law or as described in this informed consent. The study 
doctor, the funding company or persons working on behalf of the funding company, and 
under certain circumstances, the United States Food and Drug Administration (FDA) and 
the Institutional Review Board (IRB) will be able to inspect and copy confidential study-
related records which identify you by name.  This means that despite taking the 
appropriate precautions, absolute confidentiality cannot be guaranteed and there is a risk 
that confidentiality may be lost. If the results of this study are published or presented at 
meetings, you will not be identified.
Privacy of Protected Health Information
The Health Insurance Portability & Accountability Act (HIPAA) is a Federal law that helps 
to protect the privacy of your health information and to whom this information may be 
shared within and outside of University Hospitals.  This Authorization form is specifically 
for a research study entitled “The effectiveness of high-dose Synthetic BH4 (Saproterin 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 12 of 16
Dihydrochloride or “Kuvan”) in Amish PKU patients” and will tell you what health 
information (called Protected Health Information or PHI) will be collected for this research 
study, who will see your PHI and in what ways they can use the information.  In order for 
the Principal Investigator, Lori-Anne Schillaci, M.D., and the research study staff to collect 
and use your PHI, you must sign this authorization form.  You will receive a copy of this 
signed Authorization for your records.  If you do not sign this form, you may not join this 
study.  Your decision to allow the use and disclosure of your PHI is voluntary and will 
have no impact on your treatment at University Hospitals. By signing this form, you are 
allowing the researchers for this study to use and disclose your PHI in the manner 
described below.  
Generally the Principal Investigator and study staff at University Hospitals and Case 
Western Reserve University who are working on this research project will know that you 
are in a research study and will see and use your PHI.  The researchers working on this 
study will collect the following PHI about you name, birth date, address, phone number, 
medical record number.  This PHI will be used to identify you and contact you throughout 
the study if needed.  Your access to your PHI may be limited during the study to protect 
the study results.  
Your PHI may also be shared with the following groups/persons associated with this 
research study or involved in the review of research:  Biomarin Pharmaceutical, the 
funding company for this study; other staff from the Principal Investigator’s medical 
practice group, including Dr. Katherine Dempsey, Ms. Heidi Reilly, the metabolic dietician 
involved with this study, and Ms. Valeria Sency, a clinical nurse involved with this study; 
as well as persons associated with University Hospitals, including the Center for Clinical 
Research and the Law Department; Government representatives or Federal agencies, 
when required by law. 
Your permission to use and disclose your PHI does not expire.  However, you have the 
right to change your mind at any time and revoke your authorization.  If you revoke your 
authorization, the researchers will continue to use the information that they previously 
collected, but they will not collect any additional information.  Also, if you revoke your 
authorization you may no longer be able to participate in the research study.  To revoke 
your permission, you must do so in writing by sending a letter to Dr. Lori-Anne Schillaci, 
11100 Euclid Avenue, Cleveland, Ohio, 44106, Lakeside suite 1500; If you have a 
complaint or concerns about the privacy of your health information, you may also write to 
the UH Privacy Officer,  Management Service Center, 3605 Warrensville Center, MSC 
9105, Shaker Heights, OH 44122 or to the Federal Department of Health and Human 
Services (DHHS) at DHHS Regional Manager, Office of Civil Rights, US Department of 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 13 of 16
Health and Human Services Government Center, JF Kennedy Federal Building, Room 
1875, Boston, MA 02203.  Complaints should be sent within 180 days of finding out about 
the problem.   
The researchers and staff agree to protect your health information by using and disclosing 
it only as permitted by you in this Authorization and as directed by state and Federal law. 
University Hospitals is committed to protecting your confidentiality.  Please understand 
that once your PHI has been disclosed to anyone outside of University Hospitals, there is 
a risk that your PHI may no longer be protected; however other Federal and State laws 
may provide continued protection of your information.  
Summary of your rights as a participant in a research 
Your participation in this research study is voluntary.  Refusing to participate will not alter 
your usual health care or involve any penalty or loss of benefits to which you are 
otherwise entitled.  If you decide to join the study, you may withdraw at any time and for 
any reason without penalty or loss of benefits.  If information generated from this study is 
published or presented, your identity will not be revealed.  In the event new information 
becomes available that may affect the risks or benefits associated with this study or your 
willingness to participate in it, you will be notified so that you can decide whether or not to 
continue participating.  If you experience physical injury or illness as a result of 
participating in this research study, medical care is available at University Hospitals 
Cleveland Medical Center (UHCMC) or elsewhere; however, UHCMC has no plans to 
provide free care or compensation for lost wages.
Disclosure of your study records
Efforts will be made to keep the personal information in your research record private and 
confidential, but absolute confidentiality cannot be guaranteed.  The University Hospitals 
Cleveland Medical Center Institutional Review Board may review your study records.  If 
this study is regulated by the Food and Drug Administration (FDA), there is a possibility 
that the FDA might inspect your records. In addition, for treatment studies, the study 
sponsor and possibly foreign regulatory agencies may also review your records. If your 
records are reviewed your identity could become known.
Contact information
________________________________________ has described to you what is going to 
be done, the risks, hazards, and benefits involved. The Principal Investigator, Dr. Lori-
Anne Schillaci, can also be contacted at (216) 844-3936, option 2. If you have any 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 14 of 16
questions, concerns or complaints about the study in the future, you may also contact 
them later.
If the researchers cannot be reached, or if you would like to talk to someone other than 
the researcher(s) about; concerns regarding the study; research participant’s rights; 
research- related injury; or other human subject issues, please call the University 
Hospitals Cleveland Medical Center’s Research Subject Rights phone line at (216) 983-
4979 or write to: The Chief Medical Officer, The Center for Clinical Research, University 
Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 1400, Cleveland, 
Ohio, 44106-7061.
Signature
Signing below indicates that you have been informed about the research study in which 
you voluntarily agree to participate; that you have asked any questions about the study 
that you may have; and that the information given to you has permitted you to make a 
fully informed and free decision about your participation in the study.  By signing this 
consent form, you do not waive any legal rights, and the investigator(s) or sponsor(s) are 
not relieved of any liability they may have.  A copy of this consent form will be provided to 
you.
x
Signature of Participant                                                                                           Date
x
Printed Name of Participant
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 15 of 16
[USE THIS FOR STUDIES ENROLLING DECISIONALLY IMPAIRED ADULTS]
x
Signature of Participant                                                                                           Date
x
Printed Name of Participant
If participant does not have the capacity to consent and protocol is approved for inclusion
x
Signature of Legally Authorized Representative (LAR) or Next of Kin                  Date
x
Printed name of Legally Authorized Representative (LAR) or Next of Kin                  
If Next of Kin, please mark ONE relationship from list below (in decending order of priority): 
Spouse
Adult 
Child
Custodial 
Parent
Adult 
Sibling
Adult relative (related by 
blood or adoption)
[USE THIS FOR STUDIES ENROLLING MINORS where the IRB has determined ONE PARENT SIGNATURE is sufficient]
x
Signature of Participant                                                                                           Date
x
Printed name of minor if used to obtain assent
x
Signature of Parent/Legal Guardian                                        Date
x
Printed name of Parent/Legal Guardian 
x
If Legal Guardian, indicate relationship to child
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020


UNIVERSITY HOSPITALS 
CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Project Title:  The effectiveness of high-dose Synthetic BH4 (Saproterin Dihydrochloride 
or “Kuvan”) in Amish PKU patients
Principal Investigator:  Lori-Anne Schillaci, M.D.
                   
Version date 28 June 2018
Page 16 of 16
Study personnel (only individuals designated on the checklist may obtain consent)
x
Signature of person obtaining informed consent                                                    Date
x
Printed name of person obtaining informed consent 
    
        IRB NUMBER: 01-16-41.
        IRB APPROVAL DATE: 6/25/2019
        IRB EFFECTIVE DATE: 6/25/2019
        IRB EXPIRATION DATE: 6/24/2020