Clinical trial NCT03062449
Conditions: Alzheimer Disease
Keywords: L-Serine, Alzheimer's Disease, AD, Memory,
Sponsor: Aleksandra Stark
Start date: 2017-03-01; Completion date: 2021-07-20
Enrollment: 29 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This is a Phase IIa, randomized, double-blind, placebo controlled trial. Subjects for participation in this study will be identified by the Investigator based on their Clinical Dementia Rating score which will be completed as part of standard practice. Patients meeting the criteria for early Alzheimer's disease will be considered for study participation, with the Investigator taking the additional inclusion/exclusion criteria into consideration. Up to 40 subjects will be enrolled. Subjects participating in the study will be randomized to receive either gummies containing L-Serine or placebo gummies, with the Investigator and study staff blinded to the group assignments.

Detailed description:
L-serine (C3H7NO3; 105.09 g/mol; synonym (S)-2-amino-3-hydroxypropanoic acid) is a naturally-occurring dietary amino acid. It is abundant in soy products, some edible seaweeds, sweet potatoes, eggs, and meat. Since some L-serine is produced by astrocytes in the brain, it is considered a non-essential amino acid. L-serine is directly involved in the biosynthesis of purines, pyrimidines, and other amino acids. Serine residues are found in most proteins and within proteins function as a site for phosphorylation.

L-serine is considered as GRAS (generally recognized as safe) by the FDA and has been approved as a normal food additive under CFR172.320. It is widely sold as a dietary supplement. A pilot study of L-serine supplementation of 14 patients with hereditary sensory neuropathy has been published, and subsequent trial is on-going (ClinicalTrials.gov identifier NCT01733407). The authors did not report adverse effects at doses of 400mg/kg/day, which for an average American of 75.5kg is about 30 grams, the dose which we propose to use in this study.

L-serine will be administered orally through gummies. Each gummy contains 1 g L-serine (treatment) and will be packaged in a foil packet containing 15 pieces to be taken both morning and evening for nine months. The placebo will be a gummy containing no L-serine, packaged and taken in the same manner. In order to assess tolerability in patients, we have designed a 4 week dose ramp-up. We will monitor side-effects and amino acid balances in blood samples in the early Alzheimer's Disease patients during a dose ramp-up period. If a patient cannot tolerate the full dose of gummies, they will remain in the study taking a total of 1 package of gummies split into two time periods within the day. The same ramp-up schedule and procedures will be observed for both placebo and L-serine patients. Patients will be assessed at baseline, 3 months, 6 months, and 9 months.

Arms: arm 1: L-serine will be presented in gummies containing 1g serine each. Subjects randomized into the L-serine arm will take 15 grams of L-Serine (15 gummies containing 1g of L-serine) orally twice daily for 246 days after the initial ascending dose period to confirm tolerability of the dose. arm 2: Placebo gummies containing no L-serine will be packaged in the same manner as that of the L-Serine gummy arm and be given to patients to take two times a day.
Interventions: intervention 1: L-Serine intervention 2: Placebo Gummy
Intervention descriptions: intervention 1: Gummy containing L serine dose intervention 2: Gummy with no dosing of L Serine

Protocol documents:
Prot_SAP_000.pdf: 
1
CLINICAL RESEARCH PROTOCOL
A Phase IIa proof of concept, randomized, double-blind, placebo-controlled 
study of the effects of L-serine on early stage Alzheimer's disease patients
Sponsor :
Aleksandra C.  Stark, MD
Department of Neurology
One Medical Center Drive Lebanon, NH 03576
603-650-4649
Study Product:
L-serine
Protocol Number:
LSPI-2
D16180
Revised version: 9 Nov 2016
Amended: 12 May 2017
Amended: 10 Oct 2017
Amended: 04 Sep 2018
Amended: 06 Nov 2018
Amended: 14 Feb 2019
Amended: 14 APR 2020
NCT03062449


L-Serine Phase IIa 14 APR2020
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Table of Contents
STUDY SUMMARY........................................................................................................6
1
INTRODUCTION....................................................................................................7
1.1
BACKGROUND .....................................................................................................7
1.2
INVESTIGATIONAL AGENT ..................................................................................8
1.3
PRECLINICAL DATA.............................................................................................9
1.4
CLINICAL DATA TO DATE .................................................................................11
1.5
DOSE RATIONALE AND RISK/BENEFITS ............................................................12
2
STUDY OBJECTIVE..............................................................................................13
3
STUDY DESIGN....................................................................................................13
3.1
GENERAL DESIGN..............................................................................................13
3.2
PRIMARY ENDPOINT..........................................................................................14
3.3
SECONDARY  ENDPOINT....................................................................................14
3.4
PRIMARY SAFETY ENDPOINT.............................................................................15
4
SUBJECT SELECTION AND WITHDRAWAL ...............................................15
4.1
INCLUSION CRITERIA.........................................................................................15
4.2
EXCLUSION CRITERIA ........................................................................................15
4.3
SUBJECT RECRUITMENT AND SCREENING.........................................................16
4.4
EARLY WITHDRAWAL OF SUBJECTS: .................................................................16
4.4.1
DOSING DELAYS AND DOSE MODIFICATIONS.............................................17
4.4.2
DATA COLLECTION AND FOLLOW-UP FOR WITHDRAWN SUBJECTS……..18
5
STUDY DRUG........................................................................................................18
5.1
DESCRIPTION .....................................................................................................18
5.2
TREATMENT REGIMEN.......................................................................................18
5.3
METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS.........................19
5.4
PREPARATION AND ADMINISTRATION OF STUDY DRUG .................................19
5.5
SUBJECT COMPLIANCE MONITORING ...............................................................19
5.6
PRIOR AND CONCOMITANT THERAPY..............................................................20


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5.7
PACKAGING.......................................................................................................20
5.8
BLINDING OF STUDY DRUG...............................................................................20
5.9
RECEIVING, STORAGE, DISPENSING AND RETURN ...........................................21
5.9.1
Receipt of Drug Supplies ...........................................................................21
5.9.2
Storage ..........................................................................................................21
5.9.3
Dispensing of Study Drug .........................................................................21
5.9.4
Return or Destruction of Study Drug ......................................................21
6
STUDY PROCEDURES ........................................................................................22
6.1
VISIT 1................................................................................................................22
6.2
FOLLOW-UP PHONE CALL................................................................................22
6.3
VISIT 2................................................................................................................22
6.4
VISIT 3................................................................................................................22
6.5
VISIT 4................................................................................................................23
6.6
FOLLOW-UP PHONE CALL................................................................................23
6.7
BLOOD DRAWS AND SPECIMEN PROCESSING...................................................23
6.8
OPTIONAL BLOOD DONATION..........................................................................24
7
STATISTICAL PLAN............................................................................................24
7.1
SAMPLE SIZE DETERMINATION.........................................................................25
7.2
STATISTICAL METHODS.....................................................................................25
7.3
SUBJECT POPULATION(S) FOR ANALYSIS ..........................................................26
8
SAFETY AND ADVERSE EVENTS...................................................................26
8.1
DEFINITIONS ......................................................................................................26
8.2
RECORDING OF ADVERSE EVENTS ....................................................................29
8.3
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS
29
         8.3.1 Investigator reporting: notifying the Dartmouth IRB .............................30
        8.3.2  Sponsor reporting: Notifying the FDA…………………………………...32
8.4
UNBLINDING PROCEDURES...............................................................................33
8.5
MEDICAL MONITORING ....................................................................................33
9  Data Handling and Record Keeping……………………………………………...34
9.1
CONFIDENTIALITY .............................................................................................34


L-Serine Phase IIa 14 APR2020
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9.2
SOURCE DOCUMENTS........................................................................................34
9.3
CASE REPORT FORMS ........................................................................................35
9.4
RECORDS RETENTION........................................................................................35
10
ETHICAL CONSIDERATIONS .........................................................................35
11
STUDY FINANCES...............................................................................................36
11.1
FUNDING SOURCE .............................................................................................36
11.2
CONFLICT OF INTEREST .....................................................................................36
11.3
SUBJECT STIPENDS OR PAYMENTS.....................................................................36
12
REFERENCES .........................................................................................................37
13
ATTACHMENTS..................................................................…………………….38


L-Serine Phase IIa 14 APR2020
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List of Abbreviations
AD: Alzheimer’s Disease
AE: Adverse Event
BMAA:  β-N-methylamino-L-alanine
BMP: Basic Metabolic Panel
CBC: Complete Blood Count
eAD: Early Stage Alzheimer’s Disease
GCP: Good Clinical Practice
GMP: Good Manufacturing Practice
GRAS: Generally recognized as safe
IRB: Institutional Review Board
LFT: Liver Function Tests
MoCA: Montreal Cognitive Assessment
NFT: neurofibrillary tangles 
SAE: Serious Adverse Event
 
CDR: Clinical Dementia Rating Scale
Hemoglobin A1C: Hgb A1C


L-Serine Phase IIa 14 APR2020
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Study Summary
Title
A Phase IIa proof of concept, randomized, double-blind, placebo-
controlled study of the effects of L-serine on early stage 
Alzheimer's disease patients
Short Title
Phase IIa L-serine trial for eAD
Protocol Number
LSPI-2, D16180
Phase
Clinical study Phase IIa
Methodology
Randomized, double-blind, placebo controlled 
Study Duration
Approximately2.5 years
Study Center(s)
Single-center 
Objectives
Determine tolerability of L-serine for early stage Alzheimer's 
disease patients and assess preliminary indications of efficacy. 
Number 
of Subjects
40
Diagnosis and 
Main Inclusion 
Criteria
Patients with a clinical diagnosis of early stage Alzheimer's disease.
Study Product, 
Dose, Route, 
Regimen
L-Serine 30g / day oral dose of 15 x 1g gummy chews morning and 
night with an ascending dose for two weeks of 2 x 1g gummies BID, 
two weeks of 8 x 1g gummies BID, and 246 days of 15 x 1g gummies 
BID.
Duration of 
administration
36 weeks
Reference therapy
Placebo, 15 gummies without L-serine morning and night with an 
ascending dose for two weeks of 2 gummies BID, two weeks of 8 
gummies BID, and 246 days of 15 gummies BID.
Statistical 
Methodology
Non-parametric statistical analysis based on Mann-Whitney U test, 
with the critical value set at p<0.05.


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1 Introduction
This document is a protocol for a human research study. This study is to be 
conducted according to US and international standards of Good Clinical Practice 
(FDA Title 21 part 312 and International Conference on Harmonization 
guidelines), applicable government regulations and Institutional research 
policies and procedures. 
1.1 Background
Early stage Alzheimer's disease (eAD) represents a clinical syndrome which 
encompasses an underlying neuropathological process, beginning with a long 
asymptomatic period followed by indications of mild cognitive impairment. 
Clinically this is characterized by cognitive declines with lapses in episodic 
memory, decline in speed of processing information, difficulty performing tasks, 
misplacing valuable objects, and a decreased ability to plan or organize activities. 
At this point, only palliative treatment is available, and no drug has been 
discovered which can slow the progression of eAD. 
The Institute for Ethnomedicine and the Miller School of Medicine Department 
of Neurology recently were able to produce a model tauopathy with sparse 
amyloid deposits in a non-human primate, vervets (Chlorocebus sabaeus)(Cox et 
al. 2016) which has some aspects similarto Braak 1 early stage Alzheimer’s 
disease pathology (Braak 1995, Cox et al. 2016). These Alzheimer's-type features 
include neurofibrillary tangles (NFT) formed from misfolded tau as determined 
by AT8 immunohistological staining and β-amyloid deposits determined byβ-
amyloid(1-42) immunohistological stain; both of these neuropathological 
hallmarks of Alzheimer's disease were confirmed with Thioflavine-S IHC 
staining. Dense NFT were found in brain regions consistent with eAD although 
they occurred primarily in cortical layer I, rather than cortical layers I-II. The 
Institute for Ethnomedicine and the Miller School of Medicine Department of 
Neurology were unable to assess cognitive decline in these animals and so this 
model at this point in time is based solely on neuropathology. However, it is 
believed that an increasing density of NFT and β-amyloid plaques in human 
beings is correlated with cognitive declines in human Alzheimer's patients 
(Nelson et al. 2012).


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The Institute for Ethnomedicine and the Miller School of Medicine Department 
of Neurologyused this non-human primate model to test the naturally-occurring 
dietary amino acid L-serine and found that dietary supplementation in non-
human primates reduced the density of NFT by 35-50% in eight regions of the 
brain including the amygdala and anterior cingulate gyrus (Cox et al. 2016). L-
serine is a naturally-occuring amino acid that is a normal part of the human diet, 
regarded as GRAS by the FDA with the average American receiving 3.5 
grams/day from all sources. Since the Institute for Ethnomedicine and the Miller 
School of Medicine Department of Neurologyhave found in replicated studies in 
non-human primates that supplementing the diet with L-serine results in a 
decreased density of NFT, we now seek to evaluate the tolerability of L-Serine 
and the potential of L-serine in slowing cognitive declines associated with early 
Alzheimer's disease. 
1.2 Investigational Agent
L-serine (C3H7NO3; 105.09 g/mol; synonym (S)-2-amino-3-
hydroxypropanoic acid) is a naturally-occurring dietary amino acid. 
It is abundant in soy products, some edible seaweeds, sweet 
potatoes, eggs, and meat. Since some L-serine is produced by 
astrocytes in the brain, it is considered a non-essential amino acid. L-
serine is directly involved in the biosynthesis of purines, 
pyrimidines, and other amino acids. Serine residues are found in most proteins 
and within proteins functions as a site for phosphorylation.
L-serine is considered as GRAS (generally recognized as safe) by the FDA and 
has been approved as a normal food additive under CFR172.320. It is widely sold 
as a dietary supplement. An FDA-approved Phase I human clinical trial of L-
serine for ALS patients, sponsored by the Institute for Ethnomedicine and 
conducted by the Phoenix Neurological Associates, has now been published 
(Levine et al. 2016); patients were found to tolerate well doses up to 30 
grams/day (ClinicalTrials.gov identifier NCT01835782). Similarly, Harvard 
University and Massachusetts General Hospital are conducting a two-year study 
on L-serine supplementation to correct biochemistry associated with hereditary 
sensory neuropathy type 1 at doses of 400mg/kg/day which for an average 


L-Serine Phase IIa 14 APR2020
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American of 75.5kg is about 30 grams, the dose which we propose to use in this 
study (ClinicalTrials.gov identifier NCT01733407). 
1.3 Preclinical Data
In human neuronal cell cultures, L-serine blocks misincorporation of β-N-
methylamino-L-alanine (BMAA) into neuroproteins, which otherwise leads to 
protein misfolding, aggregation, and cell apoptosis (see insert: Fig 4 from Dunlop 
et al. 2013). This protective effect of L-serine was replicated in a non-cell 
synthesis system, where protein incorporation of BMAA increased when L-serine 
was removed from the system and when human DNA templates were available 
in comparison with bacterial DNA templates (Glover et al. 2014).  Data on fruit-
flies, Drosophila melanogastor, reveals that the presence of L-serine decreases the 
amount of BMAA incorporated into protein by half (Fig. 1, below).  In addition, 
40% of flies fed BMAA die within three days, however, co-administration with L-
serine saves every fly within this time frame (Fig. 2, below). 


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Figure 1:  Protein incorporation in fruit flies fed BMAA and co-administered L-
serine.
Figure 2: Survival of fruit flies fed BMAA and co-administered L-serine. 
(Fig. 2)
(Fig. 1)
Based on these in vitro and in vivo results suggesting a neuroprotective function 
of L-serine, the Institute for Ethnomedicine and the Miller School of Medicine 
Department of Neurologysupplemented the diet of vervets (Chlorocebus sabaeus) 
exposed to BMAA with L-serine for 140 days. In replicated experiments, we 
found that co-administration of the dietary amino acid L-serine significantly 
reduced the density of NFT, with greater than 50% reduction in median NFT 
densities within the temporal (dorsal and ventral), primary motor, and 
entorhinal (posterior) and insula cortices, and a greater than 35% reduction of 
NFT density in the perirhinal cortex, amygdala, and anterior singulate cortex 
(Fig. 3).


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Figure 3: Reduction of NFT production in vervets fed both BMAA and L-serine 
(pink:high+SER) in comparison with equal amount of BMAA without L-serine 
(purple: high). Data from Cox et al. 2016.
1.4 Clinical Data to Date
A phase I human clinical trial for safety of L-serine for ALS patients 
(NCT01835782) has just been published (Levine et al. 2016). Patients (n=20) were 
given either 1, 5, 15, or 30 g/day for six months. Very few side-effects were 
reported (bloating, nausea, and loss of appetite; Levine et al., 2016). Analysis of 
the ALSFRS-R slopes indicates that ALS patients taking L-serine had a reduction 
in rate of functional loss compared to historical ALS control patients (5 studies 
that included patients with symptom duration <3 yrs and FVC>=60% to compare 
with the L-serine patients). There is no evidence of neurological harm to ALS 
patients as compared to controls.  Sample sizes within a dose group are small, 
and so a Phase II trial of L-serine for 66 ALS patients is planned to see if this 
preliminary indication of efficacy can be replicated in a larger group.  What we 
can currently conclude is that L-serine at doses up to 30g/ day is safe for ALS 
patients. 
In the Harvard study of 14 subjects with hereditary sensory autonomic 
neuropathy (HSAN1) L-serine was given at either 200 mg/kg or 400 mg/kg 
(roughly 15 and 30 g/day respectively) and no adverse effects were reported with 
either dose after 10 weeks of therapy (Garolfalo et al. 2011).


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There are three additional trials currently reported by clinicaltrials.gov involving 
L-serine: 1) NCT01733407, 400mg/kg/d L-serine, L-Serine Supplementation in 
Hereditary Sensory Neuropathy Type 1; 2) NCT02528994, 6, 12, 24, or 48 g/day, 
Short Term Dietary Serine Supplementation and Circulating Serine Levels; 3) 
NCT02599038, 20 or 200 mg/kg/day, Serine Supplementation for Obese Subjects 
With Fatty Liver Disease.  None of these trials currently have reported data, but 
it is important to note that trials with L-serine at doses of 30 and 48 g/day are 
underway. 
1.5 Dose Rationale and Risk/Benefits
Since there is no literature as to how much L-serine is tolerated or beneficial in 
eAD patients, we considered doses generally tolerated by humans in the above 
reported clinical trials. The dose selected for this trial will be 30g/day as this dose 
was well-tolerated by both ALS patients and HSAN1 patients. L-serine will be 
administered orally through gummies being produced in a GMP compliant 
facility (Knechtel, Chicago, IL). Each gummy contains 1 g L-serine (treatment) 
and will be packaged in a foil packet containing 15 pieces to be taken both 
morning and evening (with or without food) for nine months.  The placebo will 
be a gummy with no L-serine, packaged and taken in the same manner. 
Although chewing this quantity of gummies, and the dose of 30g/day of L-serine 
has been well tolerated by other neurological patients, we will monitor side-
effects in these eAD patients during a dose ramp-up period. We will also monitor 
amino acid balances in blood serum samples. In order to assess tolerability in 
patients, we have designed a 4 week dose ramp-up.  Patients will take 2g (BID) 
for the first two weeks followed by 8g (BID) for the next two weeks.  If patients 
tolerate these doses without negative effects, then they will begin taking 15g 
(BID) for the remainder of the study.  If a patient cannot tolerate either 2 or 8g 
(BID) they will be dropped from the study, however, if a patient can tolerate 8g 
(BID) but not 15g (BID), they will remain in the study through an additional 246 
day period taking a total of 15g per day (1 package of gummies split into two 
time periods within the day).  The same ramp-up schedule and procedures will 
be observed for both placebo and L-serine patients.  


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2 Study Objective
Determine tolerability of L-serine for early stage Alzheimer's disease patients and 
assess preliminary indications of efficacy. Efficacy will be assessed by cognitive 
testing and biomarkers in plasma.
3
Study Design
3.1 General Design
This is a Phase IIa, randomized, double-blind, placebo controlled trial. Potential 
subjects for participation in this study will be identified by the Investigatorbased 
on their clinical and radiographic diagnosis of Alzheimer’s disease, which will be 
completed as part of standard care.Up to 40 subjects will be enrolled. Subjects 
participating in the study will be randomized to receive either gummies 
containing L-Serine or placebo gummies, with the Investigator and study staff 
blinded to the group assignments. An individual subject’s participation in the 
study will last approximately 40 weeks from time of enrollment. Study office visits 
will take place at Day 0, week 12, week 24 and week 36. Phone contact will be 
made at week 2, week 4 and week 8 to assess compliance, adverse events and 
concomitant medication. A follow-up phone call will also be made at week 40 to 
inquire about adverse events, concomitant medication, subject impression of 
study, subjective L-serine tolerability, and if they are continuing L-serine 
supplementation.  If, due to study-related events, the PI judges that a participant 
should be seen in office during study participation, a visit will be scheduled 
(Unscheduled Visit)
The Day 0 visit includes subject consent, administration and scoring of the Clinical 
Dementia Rating Scale, review of medical history including any family history of 
Alzheimer’s disease, a brief neurological and physical exam, capture and grading 
of baseline conditions, and a review of concomitant medications. Hemoglobin 
A1C, safety labs (CBC,BMP)  and research only blood draw will be completed. 
Eligibility will be confirmed by the PI prior to randomization. If a participant fails 
to qualify based on their CDR score or Hgb A1 level, the portion of their blood 
drawn for research only will be discarded. 


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All subsequent study visits include a brief physical/neurological exam, adverse 
event assessment, study medication compliance assessment, concomitant 
medications review, safety blood draws (CBC, BMP) and research-specific blood 
draws.
Study medication will be dispensed at Day 0, week 12, and week 24, and collected 
at week 12, week 24 and week 36.  All unused study drug will be collected and 
returned to the study sponsor. 
The MoCA will be performed at Visits 0, week 24, week 36, and at early 
withdrawal or unscheduled visits.  Three different MoCA versions will be 
administered in a random order during these assessments.
At week 24 and week 36, we propose to utilize a portion of the blood sample to 
examine neurally derived blood exosomes as potential biomarkers. Exosomes are 
a class of endosome-derived membrane vesicles which are shed by neural cells 
and transported in blood plasma. Thus, they provide an accessible measure of 
proteins excreted by neuronal cells. Since two proteins, phosphorylated tau and 
beta-amyloid-42, are implicated in the formation of neurofibrillary tangles and 
amyloid plaques, they can potentially be used as biomarkers of disease status. 
Fiandaca et al. (2015) found that the concentrations of phosphorylated tau and 
beta-amyloid present within exosomes were significantly higher for AD patients 
than case controls and that they increased progressively with time and disease 
progression. We propose to examine, in this proof-of-concept trial, if these 
exosome biomarkers change as a result of L-serine treatment. Furthermore, we will 
assess whether the concentrations or presence of these biomarkers show any 
correlation with cognitive decline. 
3.2 Primary Endpoint
This proof-of-concept trial will assess the MoCA score at the week 36 study visit 
in patients with L-serine treatment compared to placebo. Slopes reflecting the 
change in MoCA score from Day 0  to the week 36 visit will be compared between 
treatment and placebo groups.
3.3 Secondary Endpoints


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The Institute of Ethnomedicine will also assess plasma neurally derived exosome 
protein levels of beta-amyloid, as a biomarker which may be related to cognitive 
decline in eAD (Fiandaca et al. 2015).  Slopes reflecting the change in biomarker 
protein level will be compared between treatment and placebo groups. In addition, 
we will assess the relationship between the MoCA scores and the concentration of 
plasma neuronal derived exosome biomarkers (Fiandaca et al. 2015) to 
demonstrate that this biomarker is related to cognitive decline, and that the MOCA 
assessment and neural exosome biomarkers are useful for future studies. 
3.4. Primary Safety Endpoint
Patients will be asked to report on the tolerability of the gummies. Safety labs will 
be drawn at baseline and at subsequent study visits to monitor for any adverse 
effects. These labs include CBC, BMP, and LFT’s which will allow the Investigator 
to screen for any baseline blood values that could be considered clinically 
significant prior to study entry, and then continue to monitor throughout the trial. 
Additional blood from the draw will be sent to the Institute of Ethnomedicine to 
be tested for the amount of L-serine present.  
4
Subject Selection and Withdrawal
4.1 Inclusion Criteria
1. Diagnosis of early stage Alzheimer’s disease as scored by the Clinical 
Dementia Rating Scale score of 0.5 -1.0 upon enrollment.
2. Participants able to provide informed consent.
3. Participants taking NMDA receptor antagonist medications or 
acetylcholinesterase inhibitor medications must be on a stable dose of 
these medications for at least 30 days prior to enrolling in this clinical 
trial. 
4. Participants able to consume study gummy chews throughout the 
course of the clinical trial.
4.2 Exclusion Criteria
1. Diagnosis or previous history of ischemic stroke, astrocytoma, 
meningioma or oligodendroma.


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2. Diagnosis or previous history of any other comorbid diagnosis of 
neurodegenerative disease including amyotrophic lateral sclerosis, 
Parkinson’s disease, Lewy Body Disease, Pick’s Disease, Huntington’s 
Disease, or Progressive Supra Nuclear Palsy.
3. Undergoing any chemotherapy or radiation therapy for any tumor or 
carcinoma.
4. Diagnosis or previous history of type I or type II diabetes.  Subjects with 
no history of diabetes will have a hemoglobin A1C test as part of their 
initial labs at V1. Subjects with a Hgb A1C value of less than 6.5 will be 
considered eligible. Subjects will be referred to their PCP if their Hgb 
A1C indicates they may be at  increased risk to develop diabetes, though 
will be allowed to participate if they meet all other inclusion/exclusion 
criteria, and if deemed appropriate by the Investigator.
5. Diagnosis or previous history of psychiatric illness that in the 
investigator’s opinion would affect the subject’s ability to successfully 
participate in the study.
6. In the Investigator’s opinion, subject would be unable to successfully 
participate in the study for any reason.
4.3 Subject Recruitment and Screening
Participation in this research requires informed consent according to Institutional 
Review Board (IRB) guidelines. A signed IRB approved Consent Form is the means 
of documenting this understanding. Subjects must be able to consent for 
themselves to be able to participate in this study and have received an exact copy 
(at point of signature acquisition). Potential recruits are instructed that their 
participation is completely voluntary and that their medical care will not be 
altered in any way should they elect not to participate. Subjects are recruited from 
patients presenting to the Dartmouth-Hitchcock Medical Center Department of 
Neurology in Dr. Stark’s practice or referred by outside neurologists to the 
department. All study enrollment, visits and procedures will take place at 
Dartmouth Hitchcock Medical Center, Lebanon, NH. 
4.4 Early Withdrawal: When and How to Withdraw Subjects


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Participants taking NMDA receptor antagonist or Acetylcholinesterase inhibitor 
medications must be on a stable dose for 30 days prior to beginning the study. 
Participants may come off these medications during the course of the study if it is 
in their best interest, though should consult with the PI regarding this decision. 
Participants will be asked to refrain from starting NMDA receptor antagonist or 
Acetylcholinesterase inhibitor medications throughout the duration of this trial. If 
they wish to begin these therapies, they may opt to do so and be withdrawn from 
this clinical trial
Participants will be placed on an ascending dose for two weeks of 2 x 1g gummies 
BID, two weeks of 8 x 1g gummies BID, and then provided the target dose of 15 x 
1g gummies BID for 36 weeks if they are able to tolerate these doses without 
negative effects. If a patient cannot tolerate 2 or 8g (BID) they will cease treatment. 
If a patient can tolerate 8g (BID) but not 15g (BID), they will remain in the study 
through the remainder of the study timeline taking a total of 15g per day (1 
package of gummies split into two time periods within the day). The same 
escalating dose schedule and procedures will be observed for both placebo and L-
serine patients.   If a participant experiences an adverse event which is serious in 
nature, and deemed to be drug related, the study medication will be discontinued 
immediately. The Investigator may reserve the right to discontinue a subject from 
treatment if the PI feels it is not in the best interest of the participant to continue in 
the study.
If a participant discontinues study medication they will be encouraged to remain 
in the study and complete study related procedures and assessments while not 
receiving study medication. 
If a participant discontinues study medication and does not wish to return for the 
remainder of study visits, this decision will be documented.  They will be asked to 
return to the site for a final study visit. This visit will be conducted with the same 
study procedures and assessments as “Visit 4” listed in Section 6.5. 
4.4.1 Dosing delays and dose modifications
Dose modification for the following adverse events:  nausea, vomiting, diarrhea 
will proceed as follows:


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Nausea, vomiting, 
diarrhea
Management/Next Dose for L-serine
≤ Grade 1
No change in dose
Grade 2
Hold until ≤ Grade 1.  Resume at same dose level.
Grade 3
Hold* until < Grade 2.  Resume at one dose level lower, if 
indicated.**
Grade 4
Off protocol therapy
*Patients requiring a delay of >2 weeks should go off protocol therapy.
**Patients requiring > two dose reductions should go off protocol therapy.
Recommended management:  antiemetics, or antidiarrheal therapy.
Adverse events will be classified using the Common Terminology Criteria for 
Adverse Events (CTCAE) Version 4.03, June 14, 2010.
4.4.2 Data Collection and Follow-up for Withdrawn Subjects
If a patient is terminated early from the study as a result of an adverse event, every 
effort will be made to follow the patient until the adverse event resolves. 
5
Study Drug 
5.1 Description
L-serine is a naturally-occurring, non-essential amino acid present in the human 
diet.  L-serine will be presented in gummies containing 1g serine each.  Gummies 
will be packaged into a foil package containing 2, 8, or 15 gummies with 
instructions to take one package in the morning and one in the evening, for a total 
of 4, 16, and 30g of L-serine/day, respectively.  Placebo gummies containing no L-
serine will be packaged in the same manner and given to patients to take two times 
a day.
5.2 Treatment Regimen
Participants will take the study drug or placebo in the form of gummies as 
described above.  Subjects randomized into the L-serine arm will take 15 grams of 
L-Serine (15 gummies containing 1g of L-serine) orally twice daily for 246 days 
after the initial ascending dose period to confirm tolerability of the dose. 
Participants will be given three boxes of gummies to take home at each study visit. 
If the participant is unable to attend the study visit within the date range for the 


L-Serine Phase IIa 14 APR2020
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scheduled visit the three boxes of gummies may be shipped to the participant. 
Email or phone contact from the participant confirming receipt of the study 
medication is required. Each box will weigh approximately five pounds and 
contain thirty days (60 packets) of gummies.  During the initial period of 
accelerating doses, the gummies will be grouped and labeled into packages 
containing weeks one and two and weeks three and four respectively. 
5.3 Method for Assigning Subjects to Treatment Groups
Participants will be randomized using an urn randomization procedure to ensure 
equal numbers of patients in both the placebo and L-serine groups receive either 
Placebo gummies or L-Serine gummies. 
Foil packets will be pre-numbered with a lot number and then boxed by the 
manufacturer prior to shipment and delivery to DHMC. Boxes will contain either 
60 packets of L-serine gummies or 60 packets of placebo gummies exclusively. The 
manufacturer will randomly assign kit numbers 1 through 40 to be used for either 
the L-serine arm or the placebo arm, with 20 kit numbers associated with each arm. 
Boxes will be labeled with a kit number corresponding to the correct arm, L-serine 
or placebo. Each kit number will be assigned to 9 boxes, the total number to be 
given to the subject. Randomization of the kit numbers and labeling of the 
corresponding boxes will take place at the manufacturer prior to being shipped to 
the study site. Patients will be assigned randomized kits in order of numbers 1-40 
as they are consented into the study by study coordinators at DHMC. 
The Investigational Pharmacy at DHMC, which does not have patient contact in 
the study, will have access to a sealed envelope which will contain the numbered 
box randomization key if necessary in an emergency unblinding scenario. The 
participants and DHMC study team will be unaware of the L-serine or placebo 
assignment.    
5.4 Preparation and Administration of Study Drug
L-serine and placebo preparation will be produced in a GMP compliant facility by 
Knechtel Laboratories, Inc. (7341 Hamlin Ave, Skokie, IL 60076). The dose will be 
placed in sealed foil packages. Foil packages sufficient for 3 months will be given 
to the patients at each visit.  Doses will be sent to Dartmouth Hitchcock Medical 
Center at the beginning of the study. 


L-Serine Phase IIa 14 APR2020
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5.5 Subject Compliance Monitoring
Participants will be given study drug diaries and reminder sheets to attach to their 
wall/refrigerator in order to improve compliance and provide assistance to study 
staff in compliance monitoring. Participants will be asked to bring their drug 
diaries with them at each in person  study visit for the study coordinator to review 
and log reported compliance into the CRF. Written instructions on how to take the 
medication and what to save and return will also be issued with each medication 
dispensation.
5.6 Prior and Concomitant Therapy   
There are no prohibited concomitant medications. Participants are discouraged 
from taking any additional L-Serine supplementation as there is not any research 
to show the effects of higher dosing of L-serine. As part of the patient’s history 
intake, concomitant medications will be recorded and then reviewed at each study 
visit. Patients must be on a stable dose of NMDA receptor antagonist medications 
or acetylcholinesterase inhibitor medication for at least 30 days prior to enrolling 
in the study and taking their first dose of study drug.
5.7     Packaging
L-serine and placebo preparation will be conducted in a GMP facility by Knechtel 
Laboratories, Inc. Foil packets will be pre-numbered with a lot number and then 
boxed by the manufacturer prior to shipment and delivery to DHMC. The dose 
will be placed in sealed foil packages. Stability testing will be completed on all lots 
by the Brain Chemistry Laboratory on a quarterly basis throughout the study. 
Packages will not be labeled with an expiration date. Packages are not expected to 
expire during the course of the study. Each package will contain 2, 8, or 15 gummy 
pieces either 1 g of L-serine or serine-free pieces. 
5.8   Blinding of Study Drug
Packages will be labeled with a lot number. Kits will be assigned a number 1-40 to 
indicate subject number, and will include 9 boxes, each labeled with the subject 
number, box number and lot number. Randomization will take place at the 
manufacturer.  Forty sealed envelopes will be sent by the Institute of 
Ethnomedicine to study site, DHMC, for emergency unblinding. Unblinding 
information will be kept in the Investigational Pharmacy and accessible 24/7 in 
case of emergency unblinding.


L-Serine Phase IIa 14 APR2020
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5.9    Receiving, Storage, Dispensing and Return
5.9.1
Receipt of Drug Supplies
The L-serine will be shipped directly from Knechtel Laboratories to Dartmouth- 
Hitchcock Medical Center Department of Neurology, 4th Floor Research Offices, 
One Medical Center Drive, Lebanon, NH 03756.  Upon receipt of the of the study 
treatment supplies, an inventory will be performed and a drug receipt log will be 
filled out and signed by the person accepting the shipment. The designated study 
staff will count and verify that the shipment contains all the items noted in the 
shipment inventory.  Any damaged or unusable study drug in a given shipment 
(active drug or comparator) will be documented in the study files. The investigator 
will notify the Institute for Ethnomedicine of any damaged or unusable study 
treatments that were supplied to the site.
5.9.2
Storage
L-serine foil packages should be kept in a cool, dry location during storage and 
patients will be advised to keep their monthly packets in a cool, dry location. 
5.9.3
Dispensing of Study Drug
The boxes of packets will be dispensed at study visits or shipped to the 
participant.Patients should return any unused packets or gummies and report 
compliance during study visits. The Dartmouth Hitchcock Investigational 
Pharmacy will keep record of all study drug issued and study drug returned by 
participants. Notation will also be made in the participants’ electronic medical 
records regarding the dispensation and collection of the study medication. 
5.9.4
Return or Destruction of Study Drug
At the completion of the trial, a final reconciliation of all study drug shipped, 
consumed and remaining will be performed. All remaining drug will be returned 
to the Institute for Ethnomedicine, 240 East Deloney Avenue, PO Box 3464, Jackson, 
WY 83001. 
6
Study Procedures
The study timeline includes four clinic visits and three telephone calls as well as 
one follow-up phone call that will occur at 0 weeks (30 days after the last clinic 
visit). The study visits and timeline are as follows:


L-Serine Phase IIa 14 APR2020
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6.1   Visit 1: Screening and Enrollment (Day 0)

Obtain Informed Consent

Clinical Dementia Rating Scale

Brief review of medical history and demographic collection

Neurological and physical exam

Capture and grade baseline conditions

Concomitant medication assessment

Montreal Cognitive Assessment (MoCA) 

Blood Draw: 
o
Safety Labs completed locally (BMP, CBC)
o
Hemoglobin A1C level
o
Samples sent to the Brain Chemistry Laboratories for L-serine 
levels and neurally-derived exosomes with optional excess 
blood set aside for future protein expression and RNA 
blueprints

Review of Inclusion/Exclusion Criteria

Randomization

Dispense study medication, dosing instructions and calendar
6.2   Follow-Up Phone Call #1: Week 2 

Medication Compliance

Adverse Events

Concomitant Medications
6.3 Follow-Up Phone Call #2: Week 4 

Medication Compliance

Adverse Events

Concomitant Medications
6.4 Follow-Up Phone Call #3: Week 8

Medication Compliance

Adverse Events

Concomitant Medications


L-Serine Phase IIa 14 APR2020
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6.5    Visit 2: Week 12 (+/- 2 weeks)
•   Brief neurological and physical exam

Review of adverse events

Review current medications

Blood Draw: Safety Labs completed locally and samples sent to the 
Brain Chemistry Laboratories for L-serine levels optional excess blood 
set aside for future protein expression and RNA blueprints at 
scheduled visit date or next in person visit if there are restrictions in 
place for in person visits

Collect unused study medication and calendar at next in person visit

Dispense study medication and calendar (may be shipped to the 
participant to be received at scheduled visit date)
6.6   Visit 3: Week 24  (+/- 2 weeks)

Brief neurological and physical exam
•   Montreal Cognitive Assessment, (MoCA) 

Review of adverse events

Review current medications

Blood draw: Safety Labs completed locally and samples sent to the 
Brain Chemistry Laboratories for levels and neurally-derived 
exosomes with optional excess blood set aside for future protein 
expression and RNA blueprints at scheduled visit date or next in 
person visit if there are restrictions in place for in person visits

Collect unused study medication and calendar at next in person 
visitDispense study medication and calendar (may be shipped to the 
participant to be received at scheduled visit date)
6.7  Visit 4: Week 36 (+/- 2 weeks) 

Brief neurological and physical exam
•   MoCA exam

Review of adverse events

Review current medications

Blood draw: Safety Labs completed locally and samples sent to the 
Brain Chemistry Laboratories for L-Serine levels and neurally-derived 


L-Serine Phase IIa 14 APR2020
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exosomes with optional excess blood set aside for future protein 
expression and RNA blueprints

Collect unused study medication and calendar.  If participant unable 
to do this in person due to restrictions in place, provisions will be 
made to assist participant to mail the study medication and calendar to 
the research team at no expense to the participant.
6.8 
Follow-Up Study Coordinator Phone Call: 4 weeks (+/- 2 weeks) after Visit 
4:

Review of adverse events

Continued supplementation status

L-Serine Tolerability

Overall study impression
At study conclusion, the data will be collected and analyzed. Unblinding of 
study participants will occur after final analysis of all data.
6.9 Blood Draws and Specimen Processing, Storage and Shipment
Safety labs will be drawn at four time points: Visit 1 (Baseline/enrollment), Visit 2 
Visit 3 and Visit 4.  Blood draws may be delayed and obtained at a later date (next 
in person visit due to restrictions placed on participant in person visits by 
Dartmouth-Hitchcock or the participant).
Safety labs include:

Complete Blood Count

Liver Function Test

Basic Metabolic Panel
Blood samples will be drawn and sent to the Brain Chemistry Laboratories for 
analysis of L-Serine levels and neurally-derived exosomes at four time points: Visit 
1 (Baseline/enrollment), Visit 2, Visit 3 and Visit 4 which may include delays in 
obtaining due to participant unable to attend the visit at the scheduled date  
6.10 Optional Blood Donation
There will be an option in the consent for patients to have a portion of their blood 
drawn to be saved and used for future use by the Institute of Ethnomedicine. The 
researchers at the Brain Chemistry Laboratories wish to utilize the optional 


L-Serine Phase IIa 14 APR2020
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donations to possibly evaluate for protein expression and corresponding RNA 
blueprints. These exploratory evaluations will not be reported back to patients.  
No extra blood is required for the blood donation. Opting in is not required for 
study participation. 
7
Statistical Plan
7.1 Sample Size Determination
In a previous study (Fiandaca, 2014), the neurally derived blood exosomal beta-
amyloid protein level of eAD patients had a standard deviation of 2.8 pg/ml.  The 
minimum detectable difference in the means of the treatment and placebo 
subjects is 2.5 pg/ml, with power 0.8 (alpha = 0.05). An increase of approximately 
7 pg/ml was observed between preclinical AD and AD patients (Fiandaca, 2014).  
Based on Nasreddine et al. (2005), the standard deviation of the MoCA is 
approximately 4 points. Power calculations suggest that the minimum detectable 
difference in mean MoCA scores for two groups, each with 20 patients, is 3.65 
points. A similar result for sample size comes from Mead’s resource equation to 
predict adequate sample size, e.g. E= N-B-T, where N is the required sample size, 
E is the degrees of freedom of the error component (usually around 20), B is the 
blocking component for environmental effects, and T is the number of 
Treatments plus controls,
Placebo:20 patients
L-serine:20 patients
Total treatments:2 
Total patients: 40
Subtracting one degree of freedom from each value before inserting it in the 
equation, we have E= 39- 1-1 = 37, Understanding that individual patients may 
drop out of the study before the 36 week dosing completion for various reasons, 
this sample size will be adequate to provide the needed statistical power.


L-Serine Phase IIa 14 APR2020
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7.2 Statistical Methods
Nonparametric statistics are proposed since it is not known in advance if MoCA 
scores or levels of neurally-derived exosomes will approximate, or can be 
transformed, to a normal distribution. A Mann-Whitney U-test will compare 
exosomal protein levels or MoCA scores between the L-serine treatment and 
placebo patients at a p<0.05 level. Parametric equivalents will be considered if 
appropriate to the distribution of the data.
First, we will check the effectiveness of the randomization by comparing the 
baseline characteristics of the L-serine and placebo groups according to 
demographic factors (e.g. age, gender).  We will also assess whether the levels of 
biomarkers or cognitive impairment in the treatment group differ from the placebo 
group at time zero. This first test will check whether the randomization procedures 
were sufficient for the study. Next we will compare the exosomal protein levels or 
MoCA scores at the last study visit (month 9). (H0 = there is no difference between 
the median exosomal protein level or MoCA score for treatment patients and 
control patients; H1 = there is a difference between the median exosomal protein 
level MoCA score for treatment patients and control patients). A Mann-Whitney 
U-test will examine exosomal protein levels or MoCA scores of each patient, by 
comparing median values between groups. Second, we will assess the slope of the 
exosomal protein levels or MoCA scores over time to see if they differ among the 
treatment and control groups by Mann-Whitney U-test. We will use Spearman’s 
Rank correlation, in which rho is the equivalent of the parametric correlation 
coefficient, to determine if there is a monotonic relationship between levels of 
proteins in the neurally-derived exosomes and the MoCA scores.
7.3 Subject Population(s) for Analysis
The subject populations whose data will be subjected to the study analysis – both 
for the primary analysis and any applicable secondary analyses include:
Any subject randomized into the study that received at least one dose of study 
drug.
8 Safety and Adverse Events


L-Serine Phase IIa 14 APR2020
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8.1 Definitions
Unanticipated Problems Involving Risk to Subjects or Others
Any incident, experience, or outcome that meets all of the following criteria: 

Unexpected in nature, severity, or frequency (i.e. not described in study-
related documents such as the IRB-approved protocol or consent form, the 
investigators brochure, etc.)

Related or possibly related to participation in the research (i.e. possibly 
related means there is a reasonable possibility that the incident experience, 
or outcome may have been caused by the procedures involved in the 
research)

Suggests that the research places subjects or others at greater risk of harm 
(including physical, psychological, economic, or social harm).
Adverse Event
An adverse event (AE) is any symptom, sign, illness or experience that develops 
or worsens in severity during the course of the study.  Intercurrent illnesses or 
injuries should be regarded as adverse events.  Abnormal results of diagnostic 
procedures are considered to be adverse events if the abnormality:

results in study withdrawal

is associated with a serious adverse event

is associated with clinical signs or symptoms

leads to additional treatment or to further diagnostic tests

is considered by the investigator to be of clinical significance
Serious Adverse Event
Adverse events are classified as serious or non-serious.  A serious adverse event 
is any AE that is: 

fatal

life-threatening

requires or prolongs hospital stay

results in persistent or significant disability or incapacity

a congenital anomaly or birth defect

an important medical event


L-Serine Phase IIa 14 APR2020
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Important medical events are those that may not be immediately life threatening, 
but are clearly of major clinical significance.   They may jeopardize the subject, and 
may require intervention to prevent one of the other serious outcomes noted above.  
For example, drug overdose or abuse, a seizure that did not result in in-patient 
hospitalization or intensive treatment of bronchospasm in an emergency 
department would typically be considered serious. 
All adverse events that do not meet any of the criteria for serious should be 
regarded as non-serious adverse events. 
Adverse Event Reporting Period
The study period during which adverse events must be reported is normally 
defined as the period from the initiation of any study procedures to the end of the 
study treatment follow-up.  For this study, the study treatment follow-up is 
defined as 30 days following the last administration of study treatment.
Preexisting Condition
A preexisting condition is one that is present at the start of the study.  A preexisting 
condition should be recorded as an adverse event if the frequency, intensity, or the 
character of the condition worsens during the study period.
General Physical Examination Findings
At screening, any clinically significant abnormality should be recorded as a 
preexisting condition.  Any new clinically significant findings/abnormalities that 
meet the definition of an adverse event must also be recorded and documented as 
an adverse event. 
Post-study Adverse Event
All unresolved adverse events should be followed by the investigator until the 
events are resolved, the subject is lost to follow-up, or the adverse event is 
otherwise explained.  At the last scheduled visit, the investigator should instruct 
each subject to report any subsequent event(s) that the subject, or the subject’s 
personal physician, believes might reasonably be related to participation in this 
study.  The investigator should notify the FDA of any death or adverse event 
occurring at any time after a subject has discontinued or terminated study 


L-Serine Phase IIa 14 APR2020
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participation that may reasonably be related to this study.  The FDA should also 
be notified if the investigator should become aware of the development of cancer 
or of a congenital anomaly in a subsequently conceived offspring of a subject that 
has participated in this study. 
Abnormal Laboratory Values
Study lab results will be reviewed by the PI when results are available, prior to 
dispensation of the following visit study medication. The PI will make the 
determination of clinical significance of lab values that are out of normal range. 
Those of clinical significance will be reported as adverse events. No lab values are 
identified as exclusionary but the PI may withdraw a subject if they feel it is in the 
subject’s best interest. 
Hospitalization, Prolonged Hospitalization or Surgery
Any adverse event that results in hospitalization or prolonged hospitalization 
should be documented and reported as a serious adverse event unless specifically 
instructed otherwise in this protocol.  Any condition responsible for surgery 
should be documented as an adverse event if the condition meets the criteria for 
and adverse event.
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are 
reported as an adverse event in the following circumstances:

Hospitalization or prolonged hospitalization for diagnostic or elective 
surgical procedures for a preexisting condition.  Surgery should not be 
reported as an outcome of an adverse event if the purpose of the surgery 
was elective or diagnostic and the outcome was uneventful.

Hospitalization or prolonged hospitalization required to allow efficacy 
measurement for the study.

Hospitalization or prolonged hospitalization for therapy of the target 
disease of the study, unless it is a worsening or increase in frequency of 
hospital admissions as judged by the clinical investigator.
8.2   Recording of Adverse Events
At each contact with the subject, the investigator must seek information on adverse 
events by specific questioning, review of medical records, and, as appropriate, by 


L-Serine Phase IIa 14 APR2020
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examination.  Information on all adverse events should be recorded immediately 
in the source document, and also in the appropriate adverse event module of the 
case report form (CRF).  All clearly related signs, symptoms, and abnormal 
diagnostic procedures results should recorded in the source document, though 
should be grouped under one diagnosis.
8.3   Reporting of Serious Adverse Events and Unanticipated Problems
Investigators and the protocol sponsor must conform to the adverse event 
reporting timelines, formats and requirements of the various entities to which they 
are responsible, but at a minimum those events that must be reported are those 
that are:

related to study participation,

unexpected, and 

serious or involve risks to subjects or others 
If the report is supplied as a narrative, the minimum necessary information to be 
provided at the time of the initial report includes:

Study identifier

Study Center

Subject number

A description of the event

Date of onset

Current status

Whether study treatment was 
discontinued

The reason why the event is classified as 
serious

Investigator assessment of the association 
between the event and study treatment
8.3.1 Investigator reporting: notifying the Dartmouth IRB
This section describes the requirements for safety reporting by investigators who 
are Dartmouth faculty, affiliated with a Dartmouth research site, or otherwise 
responsible for safety reporting to the Dartmouth IRB. The Dartmouth College IRB 
(CPHS) requires expedited reporting of those events related to study participation 
that are unforeseen and indicate that participants or others are at increased risk of 
harm.  The Dartmouth IRB will not acknowledge safety reports or bulk adverse 
event submissions that do not meet the criteria outlined below:

Any adverse event (regardless of whether the event is serious or non-serious, 
on-site or off-site) that occurs any time during or after the research study, 
which in the opinion of the principal investigator is:


L-Serine Phase IIa 14 APR2020
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Unexpected (An event is “unexpected” when its specificity and severity are 
not accurately reflected in the protocol-related documents, such as the IRB-
approved research protocol, any applicable investigator brochure, and the 
current IRB-approved informed consent document and other relevant 
sources of information, such as product labeling and package inserts.)
AND
Related to the research procedures (An event is “related to the research 
procedures” if in the opinion of the principal investigator or sponsor, the 
event was more likely than not to be caused by the research procedures.)
1. Unanticipated problems that are serious adverse events should be reported to 
the IRB within 1 week of the investigator becoming aware of the event.
2. Any other unanticipated problem should be reported to the IRB within 2 weeks 
of the investigator becoming aware of the problem.
Reporting Process
Unanticipated problems posing risks to subjects or others as noted above will be 
reported to the Dartmouth IRB using the form: “Unanticipated Problems Posing 
Risks to Subjects or Others Including Reportable Adverse Events” or as a written 
report of the event (including a description of the event with information 
regarding its fulfillment of the above criteria, follow-up/resolution and need for 
revision to consent form and/or other study documentation).
Copies of each report and documentation of IRB notification and receipt will be 
kept in the Clinical Investigator’s study file.
Reporting Deaths:  
Concerning deaths that occur during the course of a research study:  

Report the event when the death is unforeseen (unexpected) and possibly 
related indicating participants or others may be at increased risk of harm.  
The AE/Unanticipated Problem Form is required.

Report the event at the time of continuing review, for all other deaths, 
regardless of whether the death is related to study participation.
Other Reportable events:


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For clinical drug trials, the following events are also reportable to the Dartmouth 
IRB:

Any adverse experience that, even without detailed analysis, represents a 
serious unexpected adverse event that is rare in the absence of drug 
exposure (such as agranulocytosis, hepatic necrosis, Stevens-Johnson 
syndrome).

Any adverse event that would cause the sponsor to modify the investigators 
brochure, protocol or informed consent form, or would prompt other action 
by the IRB to assure protection of human subjects.

Information that indicates a change to the risks or potential benefits of the 
research, in terms of severity or frequency. For example: 
– An interim analysis indicates that participants have a lower rate of 
response to treatment than initially expected.
– Safety monitoring indicates that a particular side effect is more severe, 
or more frequent than initially expected.
– A paper is published from another study that shows that an arm of your 
research study is of no therapeutic value.

Change in FDA safety labeling or withdrawal from marketing of a drug, 
device, or biologic used in a research protocol.

Breach of confidentiality

Change to the protocol taken without prior IRB review to eliminate apparent 
immediate hazard to a research participant.

Incarceration of a participant when the research was not previously 
approved under Subpart C and the investigator believes it is in the best 
interest of the subject to remain on the study.

Complaint of a participant when the complaint indicates unexpected risks 
or the complaint cannot be resolved by the research team.

Protocol violation (meaning an accidental or unintentional deviation from 
the IRB approved protocol) that in the opinion of the investigator placed one 
or more participants at increased risk, or affects the rights or welfare of 
subjects.
8.3.2 Sponsor reporting: Notifying the FDA
The study sponsor is required to report certain study events in an expedited 
fashion to the FDA.  These written notifications of adverse events are referred to 
as IND safety reports. The following describes the safety reporting requirements 
by timeline for reporting and associated type of event:


L-Serine Phase IIa 14 APR2020
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
Within 7 calendar days
Any study event that is:
– associated with the use of the study drug
– unexpected, 
– fatal or life-threatening, and 

Within 15 calendar days
Any study event that is:
– associated with the use of the study drug,
– unexpected, and
– serious, but not fatal or life-threatening
-or-
– a previous adverse event that was not initially deemed reportable but is 
later found to fit the criteria for reporting (reporting within 15 calendar 
days from when event was deemed reportable).
Any finding from tests in laboratory animals that: 
– suggest a significant risk for human subjects including reports of 
mutagenicity, teratogenicity, or carcinogenicity.
Additional reporting requirements
Sponsors are also required to identify in IND safety reports all previous reports 
concerning similar adverse events and to analyze the significance of the current 
event in light of the previous reports.
Reporting Process
Adverse events may be submitted on FDA Form 3500A or in a narrative format. If 
supplied as in a narrative format, the minimum information to be supplied is 
noted above at the beginning of section The contact information for submitting 
IND safety reports is noted below:
FDA Contact: Teresa Wheelous, Division of Neurology Phone: 1 (301) 796-1161
8.4   Unblinding Procedures
Randomization information may be made available to the Investigator only in the 
event of a medical emergency or an AE that necessitates identification of the study 
drug for the welfare of that patient. Except in a medical emergency, the 
Investigator (or designee) and study site clinical staff will remain blinded for the 
duration of the study. 


L-Serine Phase IIa 14 APR2020
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8.5 Medical Monitoring
It is the responsibility of the Principal Investigator to oversee the safety of the 
study at his/her site.  This safety monitoring will include careful assessment and 
appropriate reporting of adverse events as noted above. In addition to PI oversight, 
a medical monitor external to the study team will be identified.  Medical 
monitoring will include an assessment of the number and type of serious adverse 
events.
9 Data Handling and Record Keeping
9.1 Confidentiality
Information about study subjects will be kept confidential and managed according 
to the requirements of the Health Insurance Portability and Accountability Act of 
1996 (HIPAA).  
Those regulations require a signed subject authorization informing the subject of 
the following: 

What protected health information (PHI) will be collected from subjects in 
this study

Who will have access to that information and why

Who will use or disclose that information

The rights of a research subject to revoke their authorization for use of their 
PHI. 
In the event that a subject revokes authorization to collect or use PHI, the 
investigator, by regulation, retains the ability to use all information collected prior 
to the revocation of subject authorization.  For subjects that have revoked 
authorization to collect or use PHI, attempts will be made to obtain permission to 
collect at least vital status (i.e. that the subject is alive) at the end of their scheduled 
study period.
9.2 Source Documents
Source data is all information, original records of clinical findings, observations, 
or other activities in a clinical trial necessary for the reconstruction and evaluation 
of the trial.  Source data are contained in source documents.  Examples of these 
original documents, and data records include: hospital records, clinical and office 


L-Serine Phase IIa 14 APR2020
36
charts, laboratory notes, memoranda, subjects’ diaries or evaluation checklists, 
pharmacy dispensing records, recorded data from automated instruments, copies 
or transcriptions certified after verification as being accurate and complete, 
microfiches, photographic negatives, microfilm or magnetic media, x-rays, subject 
files, and records kept at the pharmacy, at the laboratories, and at medico-technical 
departments involved in the clinical trial.
9.3 Case Report Forms
Both written study case report forms (CRF) and RedCap will be data collection 
instruments for this study.  All data requested on the CRF must be recorded.  All 
missing data must be explained.  If a space on the CRF is left blank because the 
procedure was not done or the question was not asked a written notation will be 
made. If an item is not applicable to the individual case, written notation will be 
made. All changes made to written CRF’s will be initialed and dated. Changes 
made to data recorded in RedCap will be recorded by an audit trail. 
 
9.4 Records Retention
It is the investigator’s responsibility to retain study essential documents for at least 
2 years after the last approval of a marketing application in their country and until 
there are no pending or contemplated marketing applications in their country or 
at least 2 years have elapsed since the formal discontinuation of clinical 
development of the investigational product. In such an instance, it is the 
responsibility of the sponsor to inform the institution as to when these documents 
no longer need to be retained. 
10 Ethical Considerations
This study is to be conducted according to US and international standards of Good 
Clinical Practice (FDA Title 21 part 312 and International Conference on 
Harmonization guidelines), applicable government regulations and Institutional 
research policies and procedures.
This protocol and any amendments will be submitted to a properly constituted 
independent Ethics Committee (EC) or Institutional Review Board (IRB), in 
agreement with local legal prescriptions, for formal approval of the study conduct.  
The decision of the EC/IRB concerning the conduct of the study will be made in 


L-Serine Phase IIa 14 APR2020
37
writing to the investigator and a copy of this decision will be provided to the 
sponsor before commencement of this study.  The investigator should provide a 
list of EC/IRB members and their affiliate to the sponsor.
All subjects for this study will be provided a consent form describing this study 
and providing sufficient information for subjects to make an informed decision 
about their participation in this study.    The consent form will be submitted with 
the protocol for review and approval by the EC/IRB for the study.  The formal 
consent of a subject, using the EC/IRB-approved consent form, must be obtained 
before that subject undergoes any study procedure.  The consent form must be 
signed by the subject and the investigator-designated research professional 
obtaining the consent.
11 Study Finances
11.1   Funding Source
This study will be funded by the Institute for Ethnomedicine private donations to 
Dartmouth-Hitchcock Medical Center. 
11.2    Conflict of Interest
All Dartmouth investigators will follow the Dartmouth conflict of interest policy.
11.3    Subject Stipends or Payments
Patients will be paid a $50 travel and time spent on study activities stipend per 
study visit 


L-Serine Phase IIa 14 APR2020
38
References
Braak H, Braak E. Staging of Alzheimer's disease-related neurofibrillary changes. 
Neurobiol Aging, 1995. 16:271-278. (doi:10.1016/0197-4580(95)00021-6)
Cox, P. A., Davis, D. A., Mash, D. C., Metcalf, J. S., & Banack, S. A. Dietary exposure 
to an environmental toxin triggers neurofibrillary tangles and amyloid deposits in 
the brain. In Proc. R. Soc. B 2016. 283 ( 1823):20152397). The Royal Society.
Dunlop RA, Cox PA, Banack SA, Rodgers KJ. The Non-Protein Amino Acid BMAA 
Is Misincorporated into Human Proteins in Place of L-Serine Causing Protein 
Misfolding 
and 
Aggregation. 
PLOS 
ONE 
2013.8, 
e75376. 
(doi:10.1371/journal.pone.0075376)
Fiandaca, MS, Kapogiannis D, Mapstone M, Boxer A, Eitan E, Schwarz JB, Abner 
EL, Petersen RC, Fegeroff HJ, Miller BL, Goetzl EJ. Identification of prelincial 
Alzheimer's disease by a profile of pathogenic proteins in neurally derived blood 
exosomes: A case-control study. Alzheimer's & Dementia 2015. 11:600-607.
Garofalo K, Penno, A, Schmidt BP, Lee HJ, Frosch P, von Eckardstein A, Brown 
RH, Hornemann T., Eichler Oral FS. L-serine supplementation reduces production 
of neurotoxic deoxysphingolipids in mice and humans with hereditary sensory 
autonomic neuropathy type 1. J Clin Invest 2011. 121(12):4735–4745. 
doi:10.1172/JCI57549
Glover, W.B., Mash, D.C. & Murch, S.J. Amino Acids 2014. 46:2553. 
doi:10.1007/s00726-014-1812-1
Levine T, Miller R, Bradley W, Moore D, Saperstein D, Flynn L, Katz J, Forshew D, 
Metcalf J, Banack SA, Cox PA. Phase I Clinical Trial of Safety of L-Serine for ALS 
Patients.  Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration, 
DOI:10.1080/21678421.2016.1221971.


L-Serine Phase IIa 14 APR2020
39
Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I, 
Cummings,JL, Chertkow H. The Montreal cognitive assessment, MoCA: A brief 
screening tool for mild cognitive impairment. J. Am Geriatrics Soc. 2005. 53(4):695-
699.
Nelson PT, Alafuzoff I, Bigio EH, Bouras C, Braak H, Cairns NJ, et al. Correlation 
of Alzheimer disease neuropathologic changes with cognitive status: a review of 
the literature. J Neuropathol Exp Neurol. 2012 .71(5):362 P.T.
14 Attachments

L-Serine Study Visit Grid

  Lab Processing and Shipping Manual/Instructions


L-Serine Phase IIa 14 APR2020
40
Blood Processing for Exosome recovery 
A Phase IIa proof of concept, randomized, double-blind, placebo-controlled 
study of the effects of L-serine on early stage Alzheimer's disease patients
 
1.  Fill one EDTA tube (lavender top at least 6 mls) completely and record 
collecting time. Time between blood collection and freezing should be less than 
one hour.
2.  Mix immediately by gently inverting the tube(s) at least 8-10 times.
3.  Centrifuge immediately at 2,200 x g (5000 rpm) for 15 minutes to separate cells 
and platelets from the plasma.
4.  Transfer plasma (top layer) into pre-labeled cryovials* in 1 ml aliquots (n = 2-
3).  Verify that cryovials have patient ID, visit #, date on them. Spreadsheet with 
draw and process time, process date, and ship date will be completed by 
coordinator and shipped with samples.  
5. Transfer buffy coat (middle layer) and erythrocytes (bottom layer) in separate, 
labeled cryovials.  Freeze at -80oC in same box as plasma. Study coordinator will 
document cryovial placement and number on spreadsheet included with subject 
information. 
5.  Immediately put the cryovials upright into a small box suitable for storing 
cryovials in a unique space in a -80oC freezer and store at -80oC until shipping on 
dry ice.  
*Please Note:
Plasma = Yellow tops
Buffycoat = Clear tops
Erythrocyte = Red tops
Shipping instructions
1. Prior to placing the specimens in the shipping containers, verify that all tubes 
have been properly identified.
2. Verify that the specimens match those listed on the Laboratory Requisition Form.
3. Be sure to inspect the shipping boxes for accurate labeling information. 
4. Remove the box containing the vials from the freezer.


L-Serine Phase IIa 14 APR2020
41
5. Place a layer of dry ice at the bottom of the frozen shipper.
6. Ensure that the absorbent sheet is placed in the transport bag with the box of 
cryovials. Place the lab requisition into the outer pouch of the bag. It is acceptable 
to ship the entire box of specimens from more than one patient together in the 
transport bag.
7. Seal the transport bag and place it into the bottom of the shipping box.
8. Fill the remainder of the box with dry ice (minimum of 8 lbs or ~4 kg). Place the
Styrofoam cover on the inner Styrofoam container. DO NOT TAPE THE 
STYROFOAM BOX CLOSED.
9. Close box flaps and seal the exterior box with tape. 
10. Complete the necessary sections on the pre-printed FedEx Air Waybill. Date 
all forms where necessary and retain the “Sender’s Copy” for files. Place 
completed air waybill into the clear plastic air bill pouch face up. Make sure 
outside of box has been properly marked with amount of dry ice.

Packages will be shipped frozen on dry ice to Brain Chemistry Lab 
approximately every 4-6 weeks.

Brain Chemistry Lab will be notified by email with fed ex tracking 
number when labs have been shipped.

Other arrangements can be made prior to shipping with prior approval 
by both parties.


42
L-Serine Study Timeline of Events- 
LSPI-2
D16180
 
+/- 2 week
+/- 2 week
+/- 2 week
+/- 2 week
+/- 2 week
+/- 2 week
+/- 2 week
Day 0
Visit 1
Week 2
Phone 
Call
Week 4 
Phone 
Call
Week 8 
Phone Call
   Week 12
Visit 2
Week 24
Visit 3
Week 36
Visit 4
Week
40 Follow-Up 
Call
Early 
Withdrawal/
Unscheduled 
Visit
Procedures
 
 
 
 
 
Consent
x
 
 
 
 
Clinical Dementia Rating Scale
x
Medical History 
x
 
 
 
 
Adverse event tracking
 
x
x
x
x
x
x
x
x
Drug Collect/accountability
 
x
x
x
x
Medication compliance inquiry
 
x
x
x
 x
 x
 x
x
Concomitant Medication
x
 x
x
x
x
x
x
x
x
 
Neuro/Physical Exam
x
 
x
x
x
x
MoCA (Montreal Cog Assessment)
x
 
x
x
x


L-Serine Phase IIa 14 APR2020
43
Gummy dispense and instruction
x
 
x
x
 
Medication calendar issue and 
instruction
x
x
x
Continued Supplementation Status
 
 
 
 
 
x
Subject Impression of Study
x
L-Serine tolerability
x
LFT, (liver function),
CBC,BMP
x
 
x
x
x
x
Hemoglobin A1C
x
Blood Sample for Brain Chemistry 
Labs
x
 
x
x
x
x


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