Conditions: Empaglifozin Physiological Effects of Drugs Hypoglycemic Agents Sodium-Glucose Transporter 2 Inhibitors
Keywords: Ketones Metabolism Hormones Alzheimer's Disease
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 21
Healthy volunteers: no

Brief summary:
Background:

The drug empagliflozin treats diabetes. It lowers blood sugar by increasing glucose the kidneys excrete. This increases levels of ketones formed in the blood. The body makes ketones when it does not have enough glucose for fuel. The brains of many people with age-related diseases like Alzheimer's do not use glucose well. Brain use of ketones might improve mental ability. We investigated how empagliflozin affects ketone levels, which could lead to ways to improve brain health as people age.

Objectives:

To study how taking empagliflozin affects systemic and brain metabolism including ketone levels in people without diabetes.

Eligibility:

Adults at least 55 years old without diabetes

Design:

After a screening Visit, eligible participants were admitted to the NIA Clinical Unit during Visits 1 (baseline), 2 (first dose) and 3 (last/14th dose). On each Visit, blood draws were performed and circulating metabolites and hormones were repeatedly measured over 34-hour periods. Using plasma from fasting state only, we isolated total and neuronal-origin extracellular vesicles to measure proteins of the IGF-1 and insulin signaling cascades. Furthermore, on each Visit, we performed magnetic resonance spectroscopy (MRS) to measure concentrations of a plethora of metabolites in the brain. Between Visits 2 and 3, participants were taking the drug at home. A continuous glucose monitoring device was placed to detect potential glucose fluctuations while at home. The study was concluded for participants after the end of Visit 3.

Detailed description:
Objective and Specific Aims: The objective of this proof-of-concept study was to demonstrate in non-diabetic men and women age \> 55 years that a sGLT2 inhibitor (empagliflozin) can increase ketone bodies and metabolites used for gluconeogenesis. We also hypothesized that empagliflozin would increase circulating glucagon and fatty acids, decrease circulating amino acids, upregulate IGF-1 and insulin cascades in plasma extracellular vesicles, and change MRS brain metabolism measures.

Experimental Design and Methods: men and women (total n=21) were recruited for this pilot study. Each eligible participant had a screen visit (Visit 0) and three additional 2-day study visits (Visit 1-3). On Visits 1, 2 and 3, frequent blood sampling for beta-hydroxybutyrate butyrate (BHB), acetoacetate (AcAc), fatty and amino acids, glucagon, insulin and glucose levels will be carried out; these visits also included blood work for extracellular vesicle biomarkers and brain MRS. In addition, placement of a continuous glucose monitor (CGM) along with a 34-hour urine collection was carried out. On Visit 2 the participants wore the CGM until they returned for their next Visit. On Visit 3 the CGM was removed at the end of the study Visit. On Visit 1, no empagliflozin was administered. Participants returned in 13 +/- 2 days for Visit 2. Visit 2 was the same as Visit 1 except empagliflozin 25 mg was administered both mornings, at least 30 minutes before eating breakfast and participants continueed empagliflozin 25 mg once every morning, at least 30 minutes before eating breakfast, at home until they returned in 13 +/- 2 days for Visit 3. At the end of Visit 3, empagliflozin was stopped.

Medical Relevance and Expected Outcome: Elevating ketone bodies may bolster neuronal health and delay onset and progression of cognitive impairment. The expected outcome of this study was an increase in circulating levels of ketones, glucagon and fatty acids, an increased expression of receptors and mediators of ketone metabolism in plasma exosomes, an upregulation of IGF-1/insulin cascades in exosomes, and a change in Magnetic Resonance Spectroscopy (MRS) brain metabolism measures, in subjects taking a sGLT2 inhibitor. We expected circulating amino acid levels to decrease, especially during the overnight hours. This study will aid in deciding whether this class of compound may be used in a larger study to improve cognitive function in patients with diagnosis consistent with declining cognitive function. We required that empagliflozin was taken for up to 2 weeks before returning for Visit 3, because we needed to fully understand the homeostatic adaptations that may occur in the metabolite response to empagliflozin due to prolonged (up to 2 weeks) sGLT2 inhibition. It is our goal in the future to use the information gathered in this pilot study to design a long-term study in people who actually suffer from mild cognitive impairment/Alzheimer's disease and therefore a Visit 2 (34-hour acute study) only, as outlined above, would not give us the full picture of the metabolic changes that might occur with prolonged use, especially in a non-diabetic population.

Arms:
arm 1: Single group

Interventions: intervention 1: empagliflozin (Jardiance) 25 mg
Intervention descriptions: intervention 1: Oral empagliflozin 25 mg/day x 14 days

Protocol document:
Prot_SAP_000.pdf: 
 
CLINICAL RESEARCH PROTOCOL 
NATIONAL INSTITUTE OF HEALTH (NIH) 
NATIONAL INSTITUTE ON AGING (NIA) 
 
PROTOCOL NUMBER: 19AG0060 
PROTOCOL VERSION: 1.3 
TITLE: Sodium-glucose CoTransporter 2 (sGLT2) Inhibitor and Endogenous Ketone 
Production  
 
SHORT TITLE: sGLT2 Inhibitor 
 
IDENTIFYING WORDS: Alzheimer’s Disease, ketones, hormones, metabolism 
 
PRINCIPAL INVESTIGATOR:  Josephine M. Egan, M.D., LCI, NIA, NIH 
 
ESTIMATED DURATION OF STUDY: 3 Years 
 
START DATE: 
2018  
END DATE:  
2021  
 
 
NUMBER AND TYPE OF PATIENTS: Accrual Ceiling:  _100__ 
 
 
 
 
 
PROJECT USES IONIZING RADIATION: __X__None   
PROJECT USES "DURABLE POWER OF ATTORNEY":  N/A 
OFF-SITE PROJECT: N/A 
MULTI-SITE STUDY:  N/A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Number 
Sex 
Age Range 
Patients 
N/A 
N/A 
N/A 
Volunteers 
20 
M/F 
55 and older 


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Précis ..................................................................................................................... 5 
1 
Background Information and Scientific Rationale ........................................... 6 
1.1 
Background and Rationale ....................................................................... 6 
1.2 
Description of the Study ........................................................................... 7 
2 
Study Objectives ............................................................................................ 7 
2.1 
Primary Objective ..................................................................................... 7 
2.2 
Secondary Objectives .............................................................................. 8 
3 
Study Design .................................................................................................. 8 
3.1 
Description of the Study Design ............................................................... 8 
3.2 
Study Endpoints ....................................................................................... 8 
4 
Study Population ............................................................................................ 8 
4.1 
Rationale for Subject Selection ................................................................ 9 
4.2 
Recruitment Plan ...................................................................................... 9 
4.3 
Participant Inclusion Criteria ..................................................................... 9 
4.4 
Participant Exclusion Criteria (Screening Visit) ........................................ 9 
4.5 
Justification for Exclusion of Women, Minorities, and Children 
             (Special Populations) .............................................................................. 10 
    4.6    Justification for Inclusion of Other Vulnerable Subjects (NIH Staff) ....... 11                       
5 
Study Schedule ............................................................................................ 12 
5.1 
Phone Screening (Pre- Study) ............................................................... 12 
5.2 
Screening Visit ....................................................................................... 12 
5.3 
Visit 1 ...................................................................................................... 12 
   5.4     Visit 2 ………………………………………………………….………………13 
   5.5     Visit 3 ………………………………………………………………………….14 
 
 
5.6 
Follow-up Phone Call ............................................................................. 13 
5.7 
Participant Withdrawal ............................................................................ 15 
5.8 
Early Termination Visit ............................................................................ 15 
6 
Study Procedures/Evaluations ..................................................................... 15 
6.1 
Clinical Evaluations ................................................................................ 16 
6.2 
Laboratory Evaluations ........................................................................... 18 
6.2.1 
Laboratory Samples ......................................................................... 18 
6.2.2 
Specimen Preparation, Handling and Shipping ............................... 19 
7     Potential Risks and Benefits ......................................................................... 20 
7.1 
Potential Risks ........................................................................................ 20 
7.2 
Potential Benefits ................................................................................... 21 
8 
Research Use of Stored Human Samples, Specimens or Data ................... 22 
    8.1    Storage ………………………………………………………………………..22 
    8.2    Tracking …………………………………………………………………….…22 
    8.3   Data…………………………………………………………………………….22 
    8.4    Disposition at the Completion of the Protocol………………………….….22 
    8.5    Reporting the Loss or Destruction of Samples/Specimens/Data  
             to the IRB……………………………………………………..…………….…22  
9 
Assessment of Safety ................................................................................... 23 
9.1     Event Characterization and Reporting to the IRB and the  
          Clinical Director (CD) ............................................................................. 23 
9.2       Replacement of a Participant Who Discontinues Study Participation .... 23 


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10 Remuneration Plan for Subjects ................................................................... 23 
11 Study Monitoring Structure ........................................................................... 24 
11.1   Site Monitoring Plan ............................................................................... 24 
11.2   Safety Monitoring Plan ........................................................................... 24 
12 Statistical Considerations ............................................................................. 24 
12.1   Participant Enrollment and Follow-Up .................................................... 24 
13 Ethics/Protection of Human Subjects ........................................................... 24 
    13.1   Responsibilites of Investigators…………………………………………… 25     
    13.2   Protection of Vulnerable Subjects (Employees)………………………… 26 
    13.3   Informed Consent Process…………………………………………………27 
14   Participant Confidentiality ............................................................................. 26 
15 Data Handling and Record Keeping ............................................................. 26 
15.1 
Data Management Responsibilities ..................................................... 26 
15.2 
Data Capture Methods ........................................................................ 26 
15.3 
Source documents and Access to Source Data/Documents .............. 27 
Appendix A: Scientific References ...................................................................... 28 
Appendix B: Information Sheet for NIH Employees Participating in Intramural  
 
          Research Protocols ……………………………………………………31  
Appendix C: Inpatient Food Diary …………………………………………………...32 
Appendix D: Discharge Instructions Visit 1 …………………………………………37 
Appendix E: Intake Diary ……………………………………………………………..38 
Appendix F: Discharge Instructions Visit 2 …………………………………………40 
Appendix G; Medication Log …………………………………………………………41 
Appendix H: Discharge Instructions Visit 3 …………………………………………43 
Appendix I:  Symptom Review ……………………………………………………….44 
Appendix J: Study flyer………………………………………………………………..45 
 
 
 


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List of Abbreviations  
 
AD 
 
Alzheimer’s Disease 
AE 
 
Adverse Event 
ALT 
 
Alanine transaminase 
AST 
 
Aspartate transaminase 
ATP 
 
Adenosine Triphosphate 
ß-OHB  
Beta-hydroxy butyrate 
CBC 
 
Complete Blood Count 
CD 
 
Clinical Director 
CGM  
Continuous Glucose Monitor 
C-peptide 
Connecting peptide 
COPD  
Chronic Obstructive Pulmonary Disease 
CRC 
 
Clinical Research Coordinator 
DHHS  
Department of Health and Human Services  
EV 
 
Extracellular vesicles  
FDA 
 
Food and Drug Administration 
fMRI 
 
Functional Magnetic Resonance Imaging 
GABA  
Gamma-Aminobutyric Acid 
GCP 
 
Good Clinical Practice 
GNG  
Gluconeogenesis 
HbA1C 
Hemoglobin A1C 
HBsAG 
Hepatitis B surface antigen 
HIV 
 
Human Immunodeficiency Virus 
ICH 
 
International Conference on Harmonization 
I.V. 
 
Intravenous 
IRB  
 
Institutional Review Board 
IRP 
 
Intramural Research Program 
IRS 
 
Internal Revenue Service 
ISSO  
Information System Security Officer 
LCI 
 
Lab of Clinical Investigation 
LNS 
 
Lab of Neurosciences 
MAI 
 
Medical Advisory Investigator 
MCTs  
Monocarboxylate transporters  
mGluR  
Metabotropic glutamate receptors 
MRI 
 
Magnetic Resonance Imaging 
MRS  
Magnetic Resonance Spectroscopy 
(mTOR) 
Mechanistic target of rapamycin  
NAA 
 
N-acetyl-L-aspartic acid  
NIA 
 
National Institute on Aging 
NIDDK  
National Institute of Diabetes, Digestive and Kidney Diseases 
NIH 
 
National Institutes of Health 
NSAIDS 
Non-Steroidal Anti-Inflammatory Agents 
OHRP  
Office of Human Research Protections 
PI 
 
Principal Investigator 
R.N. 
 
Registered Nurse 
SAE 
 
Serious Adverse Event 
sGLT2  
Sodium-Glucose CoTransporter2. 
SOP 
 
Standard Operation Procedure 
VGLUT 
Vesicular Glutamate Transporters  


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Précis 
 
 
Objective and Specific Aims: The objective of this proof-of-concept study is to 
demonstrate in non-diabetic men and women age > 55 years that a sGLT2 inhibitor 
will increase ketone bodies and metabolites used for gluconeogenesis. We also 
hypothesize that sGLT2 inhibitor (empagliflozin) will increase circulating glucagon 
and fatty acids, decrease circulating amino acids, increase expression of receptors 
and mediators of ketone metabolism in plasma exosomes and change Magnetic 
Resonance Spectroscopy (MRS) brain metabolism measures.  
 
Experimental Design and Methods: 10 men and 10 women will be recruited for 
this pilot study. Each eligible participant will have a screen visit (Visit 0) and three 
additional 2-day study visits (Visit 1-3). On Visits 1, 2 and 3, frequent blood sampling 
for ß-hydroxybutyrate butyrate (ß-OHB), acetoacetate, fatty and amino acids, 
glucagon, insulin and glucose levels will be carried out; these visits will also include 
blood work for exosome markers and brain MRS. In addition, placement of a 
continuous glucose monitor (CGM) along with a 34-hour urine collection will be 
carried out. On Visits 1 and 2 the participants will wear the CGM until they return for 
their next visit. On Visit 3 the CGM will be removed at the end of the study visit. On 
Visit 1, no empagliflozin will be administered. Participants will return in 13 +/- 2 days 
for Visit 2. Visit 2 is the same as Visit 1 except empagliflozin 25 mg will be 
administered both mornings, at least 30 minutes before eating breakfast and 
participants will continue empagliflozin 25 mg once every morning, at least 30 
minutes before eating breakfast,  at home until they return in 13 +/- 2 days for Visit 3. 
At the end of Visit 3, empagliflozin will be stopped. 
 
Medical Relevance and Expected Outcome: Elevating ketone bodies may bolster 
neuronal health and delay onset and progression of cognitive impairment. The 
expected outcome of this study is that we will see an increase in circulating levels of 
ketones, glucagon and fatty acids, an increased expression of receptors and 
mediators of ketone metabolism in plasma exosomes and a change in Magnetic 
Resonance Spectroscopy (MRS) brain metabolism measures, in subjects taking a 
sGLT2 inhibitor. We expect circulating amino acid levels will decrease, especially 
during the overnight hours. This study will aid in deciding whether this class of 
compound may be used in a larger study to improve cognitive function in patients 
with diagnosis consistent with declining cognitive function. We require that 
empagliflozin be taken for up to 2 weeks before returning for Visit 3, because we 
need to fully understand the homeostatic adaptations that may occur in the 
metabolite response to empagliflozin due to prolonged (up to 2 weeks) sGLT2 
inhibition. It is our goal in the future to use the information gathered in this pilot study 
to design a long-term study in people who actually suffer from mild cognitive 
impairment/AD and therefore a Visit 2 (34-hour acute study) only, as outlined above, 
would not give us the full picture of the metabolic changes that might occur with 
prolonged use, especially in a non-diabetic population. 
 


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1  Background Information and Scientific Rationale 
1.1 
Background and Rationale 
Cognitive decline and Alzheimer’s disease (AD) are leading sources of morbidity and 
mortality in the aging population. In the U.S. there were an estimated 4.7 million individuals 
over the age of 65 with clinical AD and the number is projected to rise to 13.8 million by 
2050 (10). Currently, there is no cure for dementia and no ways to delay its onset or slow 
its progression in humans Therefore, it is imperative that more research be focused on 
pathogenesis, pathophysiology and investigation of repurposing of drugs presently 
available so that treatments can be developed for managing dementia, and maybe at least 
preventing on-going neuronal functional decline. It is generally accepted that neurons use 
glucose as their primary source of energy. But neurons (as well as other cell types, such as 
heart muscle) can use ketone bodies (ß-OHB, acetoacetate) that are generated by the liver 
and transported to extrahepatic tissue as an energy source. There are elements of glucose 
dysregulation and decreased uptake in neurons of people with dementia, especially 
Alzheimer’s disease (AD). The high metabolic efficiency of ketone bodies had implications 
for brain because ketone bodies can be an energy source when glucose availability is 
limited due to a pathological event, such as AD. 
 
SGLT2 inhibitors are now approved treatment for type 2 diabetes since 2016. They lower 
blood glucose because they allow glycosuria to occur due to glucose not being resorbed 
from the collecting tubules. This leads to loss of glucose from the body, resulting in lower  
blood glucose and weight loss. Additionally, empagliflozin, in a large multicenter study, has  
been shown to be beneficial in patients with known cardiac disease.  
 
SGLT2 inhibitors would be expected to increase endogenous ketone bodies (ß-OHB, 
acetoacetate) because when glucose is not resorbed back into circulation, glucagon levels 
in circulation become elevated and drive gluconeogenesis (GNG) in the liver. In order to 
provide substrate for GNG, lipolysis occurs, thereby supplying fatty acids for glucose and 
ATP formation. This should result in slightly increased ketone bodies in circulation, in 
particular during the overnight period. With this study, we wish to prove in the population 
who might benefit the most from increased endogenous ketone bodies whether this in fact 
occurs, and if it is sustainable – hence the need for at least the 14-day duration of 
treatment.  
 
If SGLT2 inhibitors increase endogenous ketone bodies, then brain neurons and astrocytes 
may increase their metabolic reliance on ketone metabolism. This would be reflected in 
upregulation of monocarboxylate transporters (MCTs) required to import ketone bodies into 
the cell. MCT1 is not normally expressed in neurons or astrocytes, but it may be 
upregulated in astrocytes because of ketogenic diets. 
(https://www.proteinatlas.org/ENSG00000155380SLC16A1/tissue/cerebral+cortex#img) 1. 
On the other hand, MCT2 and MCT4 are highly expressed in neurons and would be 
expected to be upregulated with SGLT2 inhibitors 


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(https://www.proteinatlas.org/ENSG00000118596-SLC16A7/tissue/cerebral+cortex#img; 
https://www.proteinatlas.org/ENSG00000141526-SLC16A3/tissue/cerebral+cortex#img).  
We can probe the expression of these transporters in neurons and astrocytes using plasma 
exosomes enriched for neuronal and astrocytic origin as a source of biomarkers 2,3. Other 
neuronal markers that mediate the effects of ketogenic diet in epilepsy and may change 
with sGLT2 inhibitors are the metabotropic glutamate receptor (mGluR) and VGLUT, which 
may also be probed with neuronal-origin exosomes. Finally, we can measure EV 
biomarkers reflecting the status the insulin – Akt – mTOR signaling pathway that 
determines cell energy metabolism 3. These outcomes can be obtained through regular 
blood draws and shed light on the impact of the intervention on neuronal cellular 
metabolism. 
 
Another methodology that can show changes in brain metabolism in response to SGLT2 
inhibitors is brain Magnetic Resonance Spectroscopy (MRS). At the NIA 3T MRI Facility, 
we have the capacity to implement an advanced MRS method called J-PRESS. It can 
reliably detect previously elusive signals of important metabolites, such as glucose, lactate, 
ascorbate, as well as traditionally measured (but still important) metabolites, such as N-
acetyl-aspartate (NAA) 4. Applying this technique on a voxel within the bilateral precuneus, 
a region known for its susceptibility to AD pathogenic processes, we recently showed large 
and significant elevations in glucose and lactate and reductions in N-acetyl aspartate (NAA) 
in AD subjects compared to both older and younger controls 4. In particular, NAA is a 
logical outcome for an intervention aiming to increase ketone availability and brain ketone 
utilization, since it was shown to increase in the hippocampus of mice consuming ketone 
esters 5. In addition, we have shown that functional connectivity within brain networks is 
related to MRS levels of neurotransmitters 6. To provide context and understand the impact 
of brain metabolic changes induced by SGLT2 inhibitors on brain function, resting fMRI will 
also be conducted. Any changes observed in these a priori hypothesized exosomal and 
MRS outcomes in this pilot study may be used to determine outcomes for future proof of 
concept studies of SGLT2 inhibitors in cognitive impairment and AD and inform the relevant 
power analyses. 
1.2 
Description of the Study  
This pilot study is designed as a proof-of-concept study to examine the acute and chronic 
effects of a sGLT2 inhibitor (empagliflozin) on ketone body and metabolite production, as 
well as hormones directly involved in metabolism and nutrient utilization. This study will aid 
in deciding whether this class of compounds may be used for repurposing to improve 
cognitive function in patients with diagnosis consistent with declining cognitive function in a 
larger study. 
 
2 
Study Objectives 
2.1 
Primary Objective 


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To demonstrate that in non-diabetic humans, late middle-age to elderly, a sGLT2 
inhibitor will increase ketone bodies, and metabolites used for GNG, especially during 
the night. 
2.2 
Secondary Objectives  
• To determine the effects of such inhibition on a range of hormones and 
metabolites: insulin, glucagon, amino and fatty acid levels, especially overnight. 
• To determine the effects of such inhibition on plasma exosomes biomarkers 
related to ketone metabolism (such as MCTs, receptors, intracellular mediators 
of insulin signaling and ketone metabolism). 
• To determine the effects of such inhibition on brain MRS measures of neuronal 
integrity and metabolism (NAA, glucose, lactate). 
• To investigate if this age group will tolerate this class of anti-diabetic drugs, for 
re-purposing. 
 
3 
Study Design 
3.1 
Description of the Study Design 
This study involves a screening visit (Visit 0) and 3 study visits (Visits 1, 2 and 3) to the 
NIA Clinical Unit.  In this pilot study, each enrolled participant will have a baseline visit 
(Visit 1) where no medication will be given and frequent blood draws x 34 hours for β-
hydroxybutyrate butyrate (β-OHB), acetoacetate, fatty acids, glucagon, insulin and 
glucose levels will be done. Exosome studies, as well as brain MRS will also be done. 
The participant will have a continuous glucose monitoring system placed.  
 
Visit 2 will take place in 13 +/-2 days from Visit 1.  It will be the same as Visit 1, 
however, on Visit 2 participants will receive a daily (morning) oral dose of empagliflozin 
(Jardiance) 25 mg, followed by breakfast within 30 minutes. They will continue the daily 
dose of empagliflozin (Jardiance) 25 mg orally after discharge until they return for Visit 3 
in 13 +/-2 days.   
 
Visit 3 will be the same as Visit 2. At the end of Visit 3 the study drug will be 
discontinued, and the participant will have completed the study. 
3.2 
Study Endpoints 
The primary study endpoint will be the level of circulating ketones on Visit 3 with a target 
of 1.5 times that of the participant’s baseline (Visit 1). Other outcomes will be 
secondary. 
 
4 
Study Population 


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Twenty participants, ten males and ten females, age 55 and older will complete this pilot 
study.  The ceiling for this study (100) reflects the additional accrual that we may 
anticipate.  If needed, the protocol will be amended to account for an increase in the 
number of participants needed to be recruited.    
 
4.1 
Rationale for Subject Selection 
This is a pilot study.  We will enroll non-diabetic men and women age 55 and older. This 
age group is at greatest risk of cognitive decline. Therefore, the safety of sGLT2 
inhibitors needs to be assessed in this non-diabetic population.  
4.2 
Recruitment Plan  
Subjects will be recruited using multiple strategies, including but not limited to 
advertising in newspapers, flyers, Internet, NIH and NIA websites, expos and health 
fairs, volunteers who have expressed interest in NIA studies, and word of mouth from 
other study participants.  All participants are recruited based on the same inclusion and 
exclusion criteria.   
4.3 
Participant Inclusion Criteria 
Inclusion Criteria: 
•  Age 55 years and older. 
•  Healthy (see exclusion criteria below). 
•  Able to understand the study risks and procedures, and consent to participate in the 
study. 
•  Able to read and speak English. 
4.4 
Participant Exclusion Criteria (Screening Visit) 
Exclusion Criteria:  
• History of diabetes (requiring any medical treatment other than diet and exercise) or 
fasting plasma glucose > 126 mg/dl or HbA1c> 6.5 %. 
•  History of hypoglycemia.  
•  BMI > 35 kg/m2. 
•  Creatinine clearance less than 60 ml/min as measured by GFR.  
• Glucosuria  
• History of anemia within the past 6 months or Hgb <11.0 mg/dL for women and Hgb 
<12.5 mg/dL for men. 
• Current steroid use or steroid use within 90 days of screening, excluding eye drops. 
•  Currently taking loop diuretics (Lasix, for example).  
• Participant presently following a calorie restriction diet, low carb/high fat diet.  
• HIV virus infection  


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• Hepatitis B infection, as evidenced by a positive HBsAG at screen visit.  
• Hepatitis C infection that has not been treated. (The screen blood work must show 
HCV RNA quantitative is not detectable).  
• Active infection/fever that may cause changes in glucose metabolism.  
• Known allergy to sGLT2 inhibitors in the past. 
• Thyroid dysfunction that is not controlled or treated. This will be determined by Free 
T3, T4, Free T4 or TSH  not within MedStar Harbor Hospital laboratory normal 
ranges for this pilot study. 
• Adrenal dysfunction as determined by a cortisol level not within the normal range for 
MedStar Harbor Hospital Laboratory for this pilot study.  
• Kidney or liver disease, (GFR < 60 mL/min/1.73 m² and/or liver enzymes not within 
normal ranges for MedStar Harbor Hospital Laboratory for this pilot study. 
• Severe gastrointestinal diseases such as Crohn’s disease or ulcerative colitis 
requiring continuous treatment.  
• History of severe pulmonary disease such as chronic obstructive pulmonary disease 
(COPD) or asthma requiring continuous medication use.  
• Patients with known, or evidence of, peripheral vascular disease.  
• History of chronic urinary tract infections.  
• History of recurrent or recent dehydration in the past year. 
• History of recurrent or recent vaginal yeast infection.  
• Alcohol intake greater than 30 grams (drink more than 2 beers OR equivalent per 
day).  
• History of severe psychiatric conditions associated with behavioral problems or 
requiring chronic medical treatment.  
• Poor venous access.  
• Inability to walk 2,000 steps  
• Donation or loss of 400 mL or more of blood within 56 days prior to and subsequent 
to screening. 
• Participation in another study in the past 30 days, in which a study drug was 
administered. 
• Currently participating in another study unless the investigator feels it would not 
interfere with the study.   
• History of a medical condition or any other reason that, in the opinion of the 
investigator, will make participation in this study unsafe.  
• Blood work or urine tests that are not considered by the study physician to be in an 
acceptable range for the study.  
• Metal implants and devices incompatible with 3T Magnetic Resonance Imaging 
(MRI), or another contraindication to MRI. 
4.5 
Justification for Exclusion of Women, Minorities, and Children 
(Special Populations) 


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Exclusion of Children:  
This Pilot study is being specifically undertaken in a population at risk for cognitive 
decline, thus our recruitment of people 55 years or older. 
Other Exclusionary Criteria: 
• Participants with creatinine clearance less than 60 ml/min will be excluded due to 
investigating the effects on metabolites relevant to neuronal health. We do not want 
interference from alterations in metabolites due to renal insufficiency.  
• Diabetics will be excluded because they are likely to have an increase in circulating 
ketones and a lowering of blood glucose while on sGLT2 inhibitors. We want to 
study if this will occur in non-diabetic subjects in the specified age group of interest.   
• BMI > 35 kg/m2 are excluded due to production and use of ketone bodies which are 
impaired in obese individuals (Vice E et al.  Metabolism 2005).  
Exclusion of Non-English-Speaking Subjects:   
• The NIA Clinical Research Unit is located in Baltimore, Maryland.  We do not have 
ready access to interpreters of different languages. 
 
4.6  
Justification for Inclusion of Other Vulnerable Subjects (NIH 
Staff) 
We intend to include NIH staff (to include NIH contractors and special volunteers, guest 
researchers and trainees) in this study. The staff may through standard recruitment 
efforts screen for the study. No direct solicitation of employees/staff will take place. 
Participation will be voluntary and neither participation nor refusal to participate will have 
an effect either beneficial or adverse, on the participant’s employment or position at 
NIH. Informed Consent Process and confidentiality maintained as per Section 13.3, 
Subject Confidentiality, Section 14, discussed below. All staff interested in enrolling in 
this study will be given a copy of the NIH Information Sheet on Staff Research 
Participation (Appendix B). 
For NIH employees:  
 
• Neither participation nor refusal to participate will have an effect, either beneficial 
or adverse, on the participant’s employment or work situation.  
 
• The NIH information sheet regarding NIH employee research participation will be 
distributed to all potential subjects who are NIH employees.  
 
• The employee subject’s privacy and confidentiality will be preserved in 
accordance with NIH policies, which define the scope and limitations of the 
protections.  
 
• 
Subjects that are employees/staff will be consented in the usual manner. The 
inclusion of employees or staff is not anticipated to affect the research outcome; 
therefore, if the subject is a co-worker (including a supervisor, subordinate or 
coworker) the subject may be consented by another co-worker and/or 


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subordinate.  The study PI will not be involved in the consenting of employees or 
staff. 
 
• Remuneration for employees/staff will follow the leave policy for NIH Employees 
Participating in NIH Medical Studies (Appendix B).  
 
 
5 
Study Schedule 
The study is expected to be completed by the end of 2021.  
5.1 
Phone Screening (Pre- Study) 
Initially, potential participants are screened by the NIA recruiter using a standardized 
telephone screen.  The PI, CRC or research nurses will review the telephone screen for 
completeness and contact the participant if there are any questions. 
5.2 
Screening Visit (Visit 0) 
Participants who are eligible following the phone screen will come to the NIA Clinical 
Research Unit for about 1.5 hours.  The screening visit will include the following tests 
and procedures:    
a. Informed Consent. 
b. Height/Weight and Vital Signs (blood pressure, pulse, temperature, respirations and 
pulse oximetry). 
c. Fasting Blood Tests (fasting at least 8 hours): fasting glucose, Complete Blood 
Count (CBC), Liver and Kidney function, Thyroid function, Serum Chemistries, 
HbA1c, cortisol level, HIV, Hepatitis B surface antigen, and Hepatitis C antibodies.(If 
a participant has a positive Hepatitis C test, the MedStar Harbor Hospital Lab will 
automatically have further testing on the blood sample for HCV RNA quantitative). 
Positive HIV and Hepatitis testing results are reported to the Maryland Department 
of Health and the screened participant will receive counseling by the study medical 
staff.   
d. Medical History and Physical Exam. 
e. A snack or meal will be provided. 
Based on the information collected, study eligibility is established, and the participant is 
invited to come for Visit 1. For eligible participants, a copy of their laboratory results will 
be provided prior to or at their Baseline Visit. If ineligible, a letter is sent within 1-3 
weeks confirming ineligibility along with the results of their laboratory testing.   
5.3 
Visit 1 
Baseline – No study medication given                        
At Visit 1, the enrolled participant will come to the NIA Clinical Research Unit for a two-
day visit, lasting approximately 34 hours. The following procedures will be done: 


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a. Height/weight, orthostatic blood pressure measurements, pulse, temperature, 
respirations and pulse oximetry. 
b.  I.V. placement for fasting blood tests (fasting for at least 8 hours) including CMP, 
lipids, insulin and other hormones, and exosomes. Followed by blood sampling every 
1.5-hours x 2, then q 1-hour x 1, then q 1.5-hours x 8, then q 2-hours x 4, then q 1.5-
hours x 2, then q1-hour x 1, then q 1.5-hours x 4 (completes 34-hours). This frequent 
sampling will include β-hydroxybutrate (β-OHB), acetoacetate, fatty and amino acids, 
glucagon, insulin and glucose levels. On Day 2, exosomes will be repeated and 
oxysterols and lipidomics will be drawn.  
c.  Placement of a continuous glucose monitor (CGM) used to collect data for up to 14 
days, worn by the participant until they return for Visit 2. 
d.  34-hour urine collection for creatinine clearance, C-peptide, and other hormones. 
e.  Brain MRS and limited brain MRI for voxel placement, required anatomical studies 
and resting functional connectivity will be conducted. 
f.  All meals will be provided. The meals on visits 1, 2 and 3 will be pre-selected by the 
participant. Food intake will aim to be uniform at all visits and at consistent times. 
Participants will be asked to record the time and items they eat on a Food Diary 
(Appendix C). They will also be instructed to hydrate. This includes drinking 8 ounces of 
water every 4 hours except when asleep.  
g.  On the evening of Day 1, the participants will be given an activity monitor and will be 
instructed to walk 2,000 steps before bedtime.  
h.  Discharge instructions will be given (Appendix D). They will wear the CGM and be 
asked to complete an Intake Diary (Appendix E) to record consuming anything other 
than water to assist with the CGM data collection.  
 
5.4 
Visit 2 occurs 13 +/- 2 days from Visit 1  
 
Initiation of sGLT2 inhibitor (empagliflozin)  
At Visit 2, the enrolled participant will come to the NIA Clinical Research Unit for a two-
day visit, lasting approximately 34 hours. This visit will be the same as Visit 1, except 
the participant will receive a daily dose of empagliflozin (Jardiance).  
The following procedures will be done: 
a. Height/weight, orthostatic blood pressure measurements, pulse, temperature, 
respirations and pulse oximetry. 
b.  I.V. placement for fasting blood tests (fasting for at least 8 hours) including CMP, 
CBC, lipids, insulin and other hormones, and exosomes. The study drug empagliflozin 
(Jardiance) will be administered at approximately 8:00 a.m. followed by blood sampling 
every 1.5 hours x 2, then q 1-hour x 1, then q 1.5-hour x 8, then q 2-hours x 4, then q 
1.5-hours x 2, then q 1-hour x 1, then q 1.5-hours x4 (completes 34-hours). This 
frequent sampling will include β-hydroxybutrate (β-OHB), acetoacetate, fatty and amino 
acids, glucagon, insulin and glucose levels. On Day 2, exosomes will be repeated and 
oxysterols and lipidomics will be drawn.  
c.  Placement of a continuous glucose monitor (CGM) used to collect data for up to 14 
days, worn by the participant until they return for Visit 3. 
d.  34-hour urine collection for creatinine clearance, C-peptide, and other hormones.  


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e.  Breakfast will be given within 30 minutes of dosing. 
f.  All meals will be provided. They will aim to be consistent items and times as what 
was consumed on Visit 1. Participants will be asked to record the time and items they 
eat on a Food Diary (Appendix C). They will also be instructed to hydrate. This includes 
drinking 8 ounces of water every 4 hours except when asleep.  
g. On the evening of Day 1, the participants will be given an activity monitor and will be 
instructed to walk 2,000 steps before bedtime. They will be instructed when they are 
discharged to continue to walk 2,000 steps every evening while wearing the activity 
monitor. This will occur during the time they are taking the study medication at home.  
h. Day 2: Participants will receive empagliflozin (Jardiance) 25 mg followed by breakfast 
within 30 minutes.   
i.  Brain MRS and limited brain MRI for voxel placement, required anatomical studies 
and resting functional connectivity will be conducted. 
j.  Following the final blood draw, participants will be sent home and instructed on self-
administration of a daily morning dose of empagliflozin (Jardiance) 25 mg and will wear 
the CGM until returning for Visit 3.   
k.  Discharge instructions will be given (Appendix F). They will wear the CGM and be 
asked to complete an Intake Diary (Appendix E) to record consuming anything other 
than water to assist with the CGM data collection.  
 l. A staff member will phone participants daily to assure they are taking the study 
medication and to assess for any symptoms. We will also remind them about the 
importance to hydrate, as stated above (f).  
 
     5.5 
Visit 3 occurs 13 +/- 2 days from Visit 2 
At Visit 3, the enrolled participant will come to the NIA Clinical Research Unit for a two-
day visit, lasting approximately 34 hours. The following procedures will be done: 
a. Height/weight, orthostatic blood pressure measurements, pulse, temperature, 
respirations and pulse oximetry. 
b.  I.V. placement for fasting blood tests (fasting for at least 8 hours) including CMP, 
lipids, insulin and other hormones. The study drug empagliflozin (Jardiance) will be 
administered at approximately 8:00 a.m. followed by blood sampling the same as visits 
1 and 2.  Breakfast will be given within 30 minutes of dosing. 
c.  Placement of a continuous glucose monitor (CGM) used to collect data for up to 14 
days, worn by the participant until the end of Visit 3. 
d.  34-hour urine collection for creatinine clearance, C-peptide, and other hormones.  
e.  All meals will be provided. They will aim to be consistent items and times as what 
was consumed on Visits 1 and 2. Participants will be also be instructed to hydrate. This 
includes drinking 8 ounces of water every 4 hours except when asleep.  
f.  On the evening of Day 1, the participants will be given an activity monitor and will be 
instructed to walk 2,000 steps before bedtime. 
g.  Day 2: Participants will receive empagliflozin (Jardiance) 25 mg followed by 
breakfast within 30 minutes.   
h.  Brain MRS and limited brain MRI for voxel placement, required anatomical studies 
and resting functional connectivity will be conducted. 


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i.  Following the final blood draw, participants will have completed the study. They will 
no longer take the study medication or wear the CGM.  
j. Discharge instructions will be given (Appendix G).  
 
     5.6 
Follow-up Phone Call 
Participants will be contacted by a staff member within one week to assess whether 
they are  having any symptoms. 
    5.7 
Participant Withdrawal 
Participants may decide to withdraw from the study at any point in time. Participants will 
be instructed to either write a letter or email their wishes to the Principal Investigator.   
The NIA will retain custody of the samples as outlined.  The NIA is the exclusive owner 
of any data, discoveries or derivative materials from the sample materials and is 
responsible for the restriction of sample use at the participant’s request.  The samples 
collected in the study can be used by NIA investigators and their collaborators.   
5.8 
Early Termination Visit 
The Principal Investigator may decide to take a participant off this study if it is believed 
to be in their best interest, if they fail to follow instructions, if new information becomes 
known about the safety of the study, or for other reasons the investigator believes are 
important.  Participation in this study may be stopped at any time by the Principal 
Investigator without a participant’s consent. 
 
6 
Study Procedures/Evaluations 
 
Procedure 
 
Screen Visit 1 Visit 2 
13 +/- 2 days 
post Visit 2 
Visit 3 
Informed Consent 
X 
 
 
 
 
Review of Inclusion/Exclusion Criteria 
X 
 
 
 
 
Medical History 
X 
 
 
 
 
Physical Exam 
X 
 
 
 
 
Height (cm) and Weight (kg)  
X 
X 
X 
 
X 
Vital signs/orthostatic blood pressure 
measurements 
X 
X 
X 
 
X 
CMP, ALT, AST, Alk. Phos., Total 
Bilirubin, CBC, Hepatitis B surface 
antigen, Hepatitis C, HIV and HbA1c, 
thyroid panel, cortisol level 
X 
 
 
 
 
Urinalysis  
X 
X 
X 
 
X 


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Procedure 
 
Screen Visit 1 Visit 2 
13 +/- 2 days 
post Visit 2 
Visit 3 
Blood samples for chemistry, lipids, 
oxysterols, lipodomics and exosomes 
(e.g., beta-amyloid) 
 
X 
X 
 
X 
CBC (Safety check) 
 
 
X 
 
X 
Concomitant medication review 
X 
X 
X 
 
X 
Insertion of venous catheter for 
frequent blood draws  
 
X 
X 
 
X 
Study medication (empagliflozin 25 
mg daily) 
 
 
X 
X 
X 
Application of CGM  
 
X 
X 
 
X 
Diet Instructions / Record 
 
X 
X 
X 
X 
Baseline blood and then frequent 
sampling (1.5-hours x 2, then q 1-
hour x 1, then q 1.5-hours x 8, then q 
2-hours x 4, then q 1.5-hours x 2, 
then q 1- hour x 1, then q 1.5-hours x 
4. for β-hydroxybutrate (β-OHB), 
acetoacetate, fatty and amino acids, 
glucagon, insulin and glucose levels,  
 
X 
X 
 
X 
34-hour urine sampling for creatinine 
clearance, C-peptide and other 
hormones 
 
X 
X 
 
X 
MRS/MRI 
 
X 
X 
 
X 
Self-administration of study drug x 13 
+/-2 days 
 
 
 
X 
 
Meals/Snacks 
X 
X 
X 
 
X 
Phone calls to monitor 
symptoms/compliance 
 
 
 
X 
 
Adverse Event monitoring 
X 
X 
X 
X 
X 
 
6.1 
Clinical Evaluations and MRI/MRS 
 
 
Medical History and General Physical Examination 
Participants receive a standardized physical exam and medical evaluation to include 
vital signs. Review of concomitant medications. This evaluation is required for study 
participation. 


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Body Measurements 
Height and weight will be measured. These measurements are required for study 
participation. 
 
Vital signs/Orthostatic blood pressures 
This will be done to monitor for any problems of potential hypotension or dehydration.  
 
Blood samples 
Blood work for clinical chemistry, hematology, lipids, oxysterols, lipidomics, and 
exosomes will be done along with frequent blood sampling for hormones and ketones. 
An intravenous catheter will be placed for frequent sampling.  
 
Safety Labs 
Participants will have a fasting CMP/Lipid Panel on Day 1 of Visits 1, 2 and 3. On Visits 
2 and 3 they will also have a CBC to monitor hemoglobin and hematocrit levels. Should 
a participant have a decrease of greater than 10% from the screening visit, the number 
of frequent blood draws would be decreased to every 2 hours. Therefore, the amount of 
blood taken on that visit would be approximately 130 ml (8.8 tablespoons).  
 
Continuous Glucose Monitor (CGM) 
The Free Style Libre Pro Continuous Glucose Monitor (CGM) device will be placed to 
measure interstitial glucose concentrations on Visits 1, 2 and 3. At the end of Visits 1 
and 2 participants will wear the device until they return for Visits 2 and 3. The device will 
be removed at the end of Visit 3. The monitor consists of a small sensor that is inserted 
with a small needle and measures glucose levels just underneath the skin on the 
abdomen or the arm. The monitor will be inserted by the staff and the participant will be 
trained on wearing the device and who to call with questions or problems.  A transmitter 
sends data wirelessly to the receiver. Once completed, data will be downloaded from 
the device to secure NIA servers. 
Activity Monitor 
On the evening of Day 1, participants will be given an activity monitor to wear on their 
wrist and will be instructed to walk approximately 2,000 steps. This will be done to try 
and keep activity levels similar in the 20 participants.  
Study Medication 
Empagliflozin (Jardiance) is an FDA approved drug used to treat type 2 diabetes. It is 
effective in lowering blood glucose levels in type 2 diabetic subjects, however, it is not 
known to lower blood glucose below normal levels (13). In other words, hypoglycemia is 
not a side-effect, it has not been reported to occur and is not therefore expected.  An 
oral dose of 25 mg will be administered in the morning of days 1 and 2 of Visit 2. The 
participants will continue the study medication by self-administering for 13 +/- 2 days at 
home and recording on the medication log the time that they take their dose (Appendix 
G). The study medication will be discontinued at the end of Visit 3.  
 
 


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Diet Instructions/Records 
Participants will be asked to record what they eat and drink during their inpatient visit on 
the Food Diary (Appendix C). They will be instructed on the importance of drinking 8 
ounces of water every 4 hours, except when asleep. At discharge, they will be 
instructed to try and eat at the same times each day and record what time they eat or 
drink anything other than water on the Intake Diary (Appendix E).  
 
Symptom Review Questionnaire 
This will be used to assess the participant for any symptoms while taking the study 
medication. (Appendix I).  
 
Compliance and symptom monitoring 
Participants will be contacted daily between Visits 2 and 3 (during the days of self-
administration of study drug) to ensure compliance and assess for any symptoms. We 
will also remind them about the importance of drinking water. It is imperative that 
participants do not miss 2 consecutive days of study medication or they will be 
excluded. The goal will be 100 percent compliance, however, greater than 90% will be 
acceptable.  
 
Brain MRI: In total, structural MRI, fMRI and MRS will last about 1 hour. 
 
• Structural MRI -- Standard structural brain images will be collected for coregistration, 
MRS voxel placement and to allow for clinical over-read. 
 
• Resting state fMRI study in a single run. Subjects will be asked to keep their eyes 
open and fixate on a cross. This study will be used to assess intrinsic functional 
connectivity between different brain regions 6.  
 
• MRS -- We will assess the concentrations of several brain metabolites, including 
glutamate, GABA, NAA, creatine, lactate, and glucose, using J-PRESS MRS in a 
voxel over bilateral precuneus, followed by fitting of metabolites using ProFit 6-8. 
Each of these metabolites has a characteristic pattern of spectral lines defined by 
the energy of transitions that occur when nuclei are excited into a higher energy 
state through radio frequency pulses. The spectral lines from all metabolites present, 
taken together, make up the observed spectrum. Concentrations of individual 
metabolites can be determined through evaluation of the relative sizes of the 
spectral lines in the observed spectra. The reliability of the measurement and fitting 
procedure for each metabolite can be assessed using Cramer-Rao lower bounds 
9. We will use standard localization techniques based on magnetic field gradient 
sequences to obtain spectra from within the voxel of interest.  
 
6.2 
Laboratory Evaluations 
6.2.1 
Laboratory Samples 
Blood Samples 
Fasting blood samples are used to measure levels of chemicals, proteins, enzymes, 
inflammatory markers, markers of oxidative stress, lipids, minerals, hormones, 


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ketones and blood cells. Blood samples may include but are not limited to the 
following list.   
  
Screen Visit: Fasting for at least 10 hours  
• Comprehensive Chemistry Panel, ALT, AST, Alkaline Phosphatase, Total 
Bilirubin, thyroid panel  
• Complete Blood Count (CBC) with Differential and Related Variables 
• Hepatitis B surface antigen  
• Hepatitis C antibody total  
• HIV 1-2 antibody screen  
• HbA1C  
• Cortisol level 
• Urinalysis  
             
    Visit 1 
• Fasting Comprehensive Chemistry Panel, Lipids, oxysterols, lipidomics 
• Exosomes (e.g., beta amyloid) 
• β-hydroxybutrate (β-OHB), acetoacetate, fatty acids and amino acids 
• Glucose, insulin and glucagon 
• Urinalysis  
 
 
Visits 2 and 3: 
• Same as Visit 1, except CBC will be done for safety 
 
Urine Sample 
A 34-hour urine sample will be collected for creatinine clearance, C-Peptide and other 
hormones on Visits 1, 2 and 3.  
6.2.2  
Specimen Preparation, Handling and Shipping 
Specimens are collected by research staff for clinical laboratory analysis and for 
research related to endocrinology and metabolism. No genetic testing will be 
performed.  
All samples will be sent to the Core Lab via courier for pick-up by LCI staff. 
 
Stored Samples:  Samples of blood and tissue are stored in a deep freeze (-80 to -
150˚C). Samples are labeled with the participant’s study identification code.  All 
specimens collected are assembled in a “biological bank” of samples that are used by 
NIA to address questions related to the aims of this study. Samples used for 
exosome studies will be pulled and thawed once immediately prior to exosome 
isolation and biomarker determination at LNS. 
 
The stored samples are kept indefinitely, controlled and managed by the Principal 
Investigator and the NIA.  Study information is kept private to the extent possible by 
the law.  Use of the biological samples is limited to designated NIA investigators or 
their collaborators under the auspices of the NIA Scientific Director and the 


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authorization and supervision of the PI.  Strict privacy about the samples is 
maintained. 
 
 
7 
Potential Risks and Benefits 
7.1 
Potential Risks 
Risks of Blood Drawing and Intravenous (I.V.) insertion:  The total amount of blood 
taken during a screening visit is up to 30 milliliters (ml) or 2 tablespoons. The total 
amount taken for Visits 1, 2 and 3 will be about 504 ml or 34 tablespoons. Participants 
may experience some discomfort and/or bruising at the site of needle entry.  There is a 
remote chance of fainting or infection.  The I.V. may need to be inserted if unable to 
obtain frequent blood samples.  
Risk of Stored Samples: The greatest risk from the use of stored samples is the 
unplanned release of information from medical records.  The chance that this 
information will be given to an unauthorized person without the participant’s permission 
is very small.  We will not enter any experimental information (research results) into any 
other medical record and we will not release information to a third party unless 
specifically authorized by the participant.  Possible problems with the unplanned release 
of information include discrimination when applying for insurance and employment.  
Some problems may occur if a participant discloses information or he or she agrees to 
have his or her medical records released. 
 
Risk of Hepatitis Virus B, hepatitis virus C, and human immunodeficiency virus (HIV) 
Testing: This study involves a number of blood tests that require the subject’s blood be 
tested for blood-transmitted diseases such as hepatitis virus B, hepatitis virus C, and 
human immunodeficiency virus (HIV). If the participant is infected with HIV, hepatitis B 
(positive HBsAG) or C (HCV RNA quantitative is detectable), he/she will not be able to 
participate in this study. We will tell the subject what the results mean, how to find care, 
how to avoid infecting others, how we report these infections, and the importance of 
informing any partners of possible risk. 
 
Risks of Study Medication empagliflozin (Jardiance): The most common adverse 
reactions associated with administration of empagliflozin are dehydration, dizziness, 
lightheadedness, weakness, yeast and urinary tract infections. To decrease these risks, 
participants will be encouraged to hydrate and to maintain good hygiene.  Other side 
effects may include low blood sugar, nausea, and upper respiratory tract infections. 
There also may be other side effects that we cannot predict, including hypersensitivity 
reaction. Rarely, sudden episodes of kidney injury may occur. Also, the Food and Drug 
Administration (FDA) has issued a warning about rare occurrences of a serious infection 
of the genital area (necrotizing fasciitis of the perineum) associated with sGLT2 
inhibitors. Both of these have only been known in people who have diabetes. We will 
monitor for any symptoms during our daily calls to the participant while they are on 
study medication. This will include questioning any symptoms of tenderness, redness, 


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or swelling of the genitals or the area from the genitals back to the rectum. We will also 
monitor for fever or  general feeling of being unwell.  
 
Risks of Continuous Glucose Monitor (CGM): Potential risks include a slight skin 
irritation from the adhesive.  
 
Risks of Brain MRI and MRS: The Food and Drug Administration (FDA) has recently 
established safety criteria for human exposure to MRI studies. The MRI scanner used in 
this study satisfies these safety criteria. People are at risk for injury from the MRI 
magnet if they have pacemakers or other implanted electrical devices, brain stimulators, 
dental implants, aneurysm clips (metal clips on the wall of a large artery), metallic 
prostheses (including metal pins and rods, heart valves, and cochlear implants), 
permanent eyeliner, implanted delivery pump, or shrapnel fragments. Welders and 
metal workers are also at risk for injury because of possible small metal fragments in 
the eye of which they may be unaware. Participants will be asked to complete an MRI 
screening form for each MRI. If any participant is found not to be eligible for the MRI or 
refuse the MRI, they will be disqualified from the study. In addition, all magnetic objects 
(for example, watches, coins, jewelry, and credit cards) will be removed before entering 
the MRI scan room. Participants with history of surgeries, implanted devices, etc. will be 
asked to provide us with surgical reports mentioning the type of the clips, prostheses, 
etc. used. Every effort will be made to establish the MR compatibility or incompatibility 
of these implants, according to the safety standards of the NIA 3T MRI center, including 
obtaining reports by manufacturing companies for MR compatibility. The research staff 
will evaluate each person with a less severe history of claustrophobia on a case-by-
case basis. 
Regarding minor discomforts, radiofrequency pulses emitted by the MRI machine can 
induce mild muscle twitching in some participants. If the sensation becomes overly 
uncomfortable, the scan will be stopped. The loud sounds (> 120 dB) emitted by the 
MRI machine during scanning require earplugs but may cause mild acoustic discomfort.  
7.2 
Potential Benefits 
This is not a treatment study.  Participants can decide not to participate in the study.  
Participants do receive copies of laboratory tests within1-3 weeks after their study visit. 
These results do not replace tests completed by their primary care physicians.  Copies 
of these tests will only be provided to their physicians after proper written release has 
been obtained.  
 
Results that require immediate follow-up are communicated to the participant within 1 
business day after the results become available to the staff, in person or by telephone. 
Information is provided to the participant’s physician if the participant consented to the 
release of information to the physician (completed the Medical Release form).  We do 
not provide treatment for these conditions at NIH. The long-term benefit is that data and 
information gathered from this pilot will be used to design a treatment study in people 
with mild cognitive impairment/AD. 
 


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8 
Research Use of Stored Human Samples, Specimens or Data 
 
 
Intended Use: Specimens of blood, cells and other biological material are stored in a  
“biological bank” and used for this study only.  Strict privacy about the samples is 
maintained.   
 
     8.1  
Storage  
 
 
Samples are kept at between -80 and -150˚C. Barcoded labels will contain the following 
information:  the participant ID, the date and visit number of the sample collected and 
the specimen type.  No other information is reported on the label.  Samples are kept 
indefinitely, controlled and managed by the Principal Investigator (PI) and the NIA.  The 
origin of the samples is kept private to the extent possible by the law.  Use of the 
biological samples is limited to designated investigators under the auspices of the NIA 
Scientific Director and the authorization and supervision of the Principal Investigator. 
Official NIA collaborators may receive samples as part of a collaborative project with 
NIH.   
 
     8.2  
Tracking   
 
 
Tracking of samples is done through an electronic database that creates a 
correspondence between the information contained in the specimen label and its 
position in the specific freezer of the biological bank.  All freezers are maintained by the 
NIA.  Specimens are managed only by NIA authorized employees.  Random quality 
control checks are conducted regularly.   
      
     8.3        Data 
The NIA ISSO approved secure web-based study repository system will present 
electronic source documents and Case Report Forms ( CRFs) for collecting and storing 
study data.  The web-based study repository is password protected and maintained on 
the secure NIA/NIH Intranet with access limited to authorized NIA personnel 
only.  Research use of stored study data can only be granted by the Study PI. with the 
appropriate documentation and approvals.     
 
     8.4         Disposition at the Completion of the Protocol  
All samples in this pilot study will be stored in the NIA biological bank and will be 
maintained indefinitely.   
 
      8.5          Reporting the Loss or Destruction of Samples/Specimens/Data  
                  to the IRB  
Regardless of the reason or circumstances, loss of any biological samples will be 
reported to the IRB. 


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• Any loss or unanticipated destruction of samples or data (for example, due to 
freezer malfunction) that compromises the scientific integrity of the data collected 
for the study; will be reported to the NIDDK IRB. 
• Additionally, participants may decide at any point not to have their samples 
stored. In this case, the principal investigator will destroy all know remaining 
samples and report what was done to both the subject and the IRB. This decision 
will not affect the subject’s participation in any other protocol at NIH.  
 
9 
Assessment of Safety 
9.1 
Event Characterization and Reporting to the IRB and the Clinical 
Director (CD) 
Adverse events, non-compliance both serious or continuing, protocol deviations both major 
and minor, as well as unanticipated problems are defined and described by the NIH Office 
of Human Subjects Research Protection policy #801, and will be reported in accordance 
with this policy.  
9.2 
Replacement of a Participant Who Discontinues Study 
Participation   
Participants lost to follow-up, drop out, or are unable to participant any longer will be 
replaced at the discretion of the Principal Investigator. 
 
10 
Remuneration Plan for Subjects 
 
The amount of payment to research volunteers is guided by the National Institutes of Health 
policies. In general, participants are not paid for taking part in research studies at the 
National Institutes of Health. Meals will be provided to participants.  
  
Participants will be compensated for research-related discomfort and inconveniences in 
accord with NIH guidelines. Compensation of $600 or more in one year will be reported to 
the IRS per federal regulation. The participants will be given 30 dollars at the Screening 
visit (Visit 0); The maximum amount allowable for the study is 1870 dollars, unless the 
study physician asks the participant to return to the NIA Clinical Unit for an unplanned visit.  
Then they will be paid an additional $20 for each unplanned visit.   
     The participant will receive the following for completing each of the study visit:  
 
Screening (Visit 0) 
 
 
 
 
 
 
30 dollars 
Visit 1 
 
 
 
 
 
 
 
 
540 dollars 
Visit 2 
 
 
 
 
 
 
 
 
600 dollars 
Visit 3 
 
 
 
 
 
 
 
 
700 dollars 
Unplanned Visit  
 
 
 
 
 
 
20 dollars 


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The breakdown of payments is as follows:  
Frequent blood sampling 
 
 
 
 
 
140 dollars 
Continuous Glucose Monitor  
 
 
 
 
150 dollars 
Food Diary (in-patient)  
 
 
 
 
 
20 dollars ($10/day) 
Intake Diary (out-patient) 
 
 
 
 
 
65 dollars 
MRI 
 
 
 
 
 
 
 
 
125 dollars 
Activity Monitor/completing steps (in-patient) 
 
 
25 dollars 
34-hour urine collection  
 
 
 
 
 
50 dollars 
Study medication (self-dosing)  
 
 
 
 
100 dollars 
 
 
11 
Study Monitoring Structure  
11.1 
Site Monitoring Plan  
No data and safety monitoring board are required for this study.  Data and safety will be 
monitored by the Principal Investigator.  
11.2 
Safety Monitoring Plan  
All protocols at the NIA follow the NIA Data and Safety Monitoring Plan.  This includes 
using the Level of Risk Assessment Monitoring Guidelines that has been established for 
the NIA following NIH rules and regulations to ensure good clinical practices in the 
conduct of clinical research.  Participants will be informed about new information from 
this or other studies that may affect their health, welfare, or willingness to stay in this 
study. 
 
12 
Statistical Considerations 
 
This is a pilot study therefore no power calculation can be done. 
12.1 
Participant Enrollment and Follow-Up 
This is a pilot study of volunteers that consent to join the study.  Potential participants 
who express the desire to be enrolled in the study are screened in the NIA Clinical 
Research Unit. Participants are enrolled once the informed consent is signed by the 
participant. Participants lost to follow-up, drop out, or are unable to participate any 
longer will be replaced at the discretion of the Principal Investigator.  
 
13 
Ethics/Protection of Human Subjects 
 


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25 
 
Research conducted under this protocol will be conducted in compliance with the 
protocol, Good Clinical Practices (GCP) and all applicable regulatory requirements. 
 
13.2 
Protection of Vulnerable Subjects (Employees) 
Protections for employees and staff participating in this study include 1) assuring that 
the participation or refusal to participate will have no effect, either beneficial or adverse, 
on the subject’s employment or position at the NIH, 2) giving employees and staff who 
are interested in participating the “NIH Information Sheet on Employee Research 
Participation” prior to obtaining consent, and 3) assuring that there will be no direct 
solicitation of employees or staff.  
This study collects sensitive information, i.e. collection of blood for HIV, Hepatitis B and 
C. The PI will train study staff regarding obtaining and handling potentially sensitive and 
private information about co-workers through staff discussions and written NIA 
procedures. Information pertaining to these sensitive blood results will be in the 
participant’s NIH medical record. NIA procedures for medical records will apply for the 
protection of the employee’s privacy and confidentiality.  
13.3 
Informed Consent Process 
Informed consent is a process where information is presented to enable persons to 
voluntarily decide whether or not to participate as a research subject. It is an on-going 
conversation between the human research subject and the researchers about the 
essential information about the study, which begins before consent is given and 
continues until the end of the subject’s involvement in the research. Discussions of 
essential information about the research will include the study’s purpose, duration, 
experimental procedures, alternatives, risks, and benefits, and subjects will have the 
opportunity to ask questions and have them answered. 
Written informed consent will be obtained from the participant prior to any screening 
visits, study procedures or treatments. The Principal Investigator or other designated 
qualified protocol investigators (listed on the protocol’s face page) will explain the study 
in language understandable to the subject. Sufficient time and opportunity will be given 
for discussion of the research as well as to answer any questions they may have, taking 
care to minimize or eliminate the perception of coercion or undue influence. The 
participant and the investigator will sign the current IRB-approved informed consent 
document. A witness will also sign the consent document to attest only to the validity of 
the signature of the subject, not the validity or quality of the consent. A copy of the 
consent will be given to the subject for future reference. The signed documents will be 
placed in the subject’s medical record .The consent process will additionally be 
documented in the medical record. 
The rights and welfare of the participants will be protected by emphasizing to them that 
the quality of their medical care will not be adversely affected if they decline to 
participate in this study.  
Participants that are employees/staff will be consented in the usual manner as noted 
above. Because this is a pilot protocol, the inclusion of employees or staff is not 
anticipated to affect the research outcome, therefore if the subject is a co-worker the 


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subject may be consented by another co-worker and/or subordinate. The study PI will 
not be involved in the consenting of employees or staff.  
We do not plan or anticipate the enrollment of non-English speaking subjects in this pilot 
study. The NIA at this location does not have sufficient resources (interpreters) to assist 
with questions the participant may have during the informed consent process.  
Therefore, a short form consent will not be utilized.  
Subjects may withdraw consent at any time throughout the course of the study.  
14 
Participant Confidentiality 
 
All records will be kept confidential to the extent provided by federal, state and local law.     
The study monitors and other authorized representatives may inspect all documents 
and records required to be maintained by the Investigator, including but not limited to, 
medical records. Samples and data will be stored using codes assigned by the 
investigators. Records will be kept locked and all computer entry and networking 
programs will be done with coded numbers only.  Clinical information will not be 
released without written permission of the subject, except as necessary for audit 
purposes by the IRB or OHSRP. 
 
When results of an NIH research study are reported in medical journals or at scientific 
meetings, the people who take part are not named or identified.  In most cases, the NIH 
will not release any information about a participant’s research involvement without their 
written permission.  However, if they sign a release of information form, for example, for 
an insurance company, the NIH will give the insurance company information from the 
participant’s medical record.  This information might affect (either favorably or 
unfavorably) the willingness of the insurance company to sell the participant insurance. 
 
The Federal Privacy Act protects the confidentiality of a participants NIH medical record. 
However, participants should know that the Act allows for the release of some 
information from their medical record without their permission, for example, if it is 
required by the Food and Drug Administration (FDA), members of Congress, law 
enforcement officials, or authorized hospital accreditation organizations. 
 
15 
Data Handling and Record Keeping 
15.1 
Data Management Responsibilities 
Electronic records will be kept using secure computer databases. These databases are 
password protected and maintained on a secure NIA/NIH Intranet with access limited to 
authorized NIA staff members.  All NIA members who have access to these databases 
have the proper training on patient confidentiality as well as the required Human Subject 
Protection Training. 
15.2 
Data Capture Methods 


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The study will utilize both hard medical record copies/reports as well as electronic data.  
Our web-based application supports flexible data capture and reporting. The system is 
hosted at the NIA in Baltimore, MD.  It is accessible via the Internet through the NIH 
firewall, on both Mac and Windows based computers.  An Oracle relational database is 
utilized to capture and secure data entered through the web interface. 
The study will be conducted with the protocol, DHHS, FDA, ICH and all applicable 
institutional, state and local requirements. 
15.3 
Source documents and Access to Source Data/Documents 
Study data will be collected as noted above.  The Principal Investigator is responsible 
for assuring that the data collected is complete, accurate, and recorded in a timely 
manner.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix A: Scientific References 
 
1. 
Forero-Quintero LS, Deitmer JW, Becker HM. Reduction of epileptiform activity in 
ketogenic mice: The role of monocarboxylate transporters. Sci Rep. 2017;7(1):4900. 
2. 
Goetzl EJ, Schwartz JB, Abner EL, Jicha GA, Kapogiannis D. High complement levels 
in astrocyte-derived exosomes of Alzheimer disease. Annals of neurology. 
2018;83(3):544-552. 
3. 
Mustapic M, Eitan E, Werner JK, Jr., et al. Plasma Extracellular Vesicles Enriched for 
Neuronal Origin: A Potential Window into Brain Pathologic Processes. Front Neurosci. 
2017;11:278. 
4. 
Mullins R, Reiter D, Kapogiannis D. Magnetic resonance spectroscopy reveals 
abnormalities of glucose metabolism in the Alzheimer's brain. Ann Clin Transl Neurol. 
2018;5(3):262-272. 
5. 
Pawlosky RJ, Kemper MF, Kashiwaya Y, King MT, Mattson MP, Veech RL. Effects of a 
dietary ketone ester on hippocampal glycolytic and tricarboxylic acid cycle intermediates 
and amino acids in a 3xTgAD mouse model of Alzheimer's disease. Journal of 
neurochemistry. 2017;141(2):195-207. 
6. 
Kapogiannis D, Reiter DA, Willette AA, Mattson MP. Posteromedial cortex glutamate 
and GABA predict intrinsic functional connectivity of the default mode network. 
NeuroImage. 2013;64:112-119. 
7. 
Schulte RF, Lange T, Beck J, Meier D, Boesiger P. Improved two-dimensional J-
resolved spectroscopy. NMR Biomed. 2006;19(2):264-270. 
8. 
Schulte RF, Boesiger P. ProFit: two-dimensional prior-knowledge fitting of J-resolved 
spectra. Nmr in Biomedicine. 2006;19(2):255-263. 
9. 
Bolliger CS, Boesch C, Kreis R. On the use of Cramer-Rao minimum variance bounds 
for the design of magnetic resonance spectroscopy experiments. NeuroImage. 
2013;83:1031-1040. 
10.  
Hebert LE, Weuve J, Scherr PA, Evans DA: Alzheimer disease in the United States 
(2010-2050) estimated using the 2010 census. Neurology 2013;80:1778-1783 
11.  
Miller IJ: Variation in human fungiform taste bud densities among regions and subjects. 
The Anatomical Record 1986;216:474-482 
12.  
Cheng LHH, Robinson PP: The distribution of fungiform papillae and taste buds on the 
human tongue. Archives of Oral Biology 1991;36:583-589 
13.  
Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and 
mortality in type 2 diabetes. N Engl J Med.2015; 373:2117–2128). 
14.  
Al Jobori H, Daniele G, Adams J, Cersosimo E, Triplitt C, DeFronzo RA, Abdul-Ghani 
M. Determinants of the increase in ketone concentration during SGLT2 inhibition in 
NGT, IFG and T2DM patients. Diabetes Obes Metab. 2017 Jun;19(6):809-813. 
15.   Filippas-Ntekouan, S., Filippatos, TD., Elisaf, MS, SGLT2 inhibitors: are they safe? Oct 
2017; 72-82.  
 
 
 


Protocol Version 1.3 
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Appendix B: Information Sheet for NIH Employees Participating in Intramural 
Research Protocols  
 
 Information Sheet for NIH Employees Participating in Intramural Research Protocols  
As an NIH employee, contractor, IRTA or other associate, you may participate in Intramural research studies. You 
may be motivated by altruism, a commitment to research in your own or related fields, or want access to clinical 
trials of potential direct therapeutic benefit. When deciding, you should make an informed decision about 
participation. This information sheet offers some points to consider for employees who are considering research 
participation at NIH.  
First, similar to any individual who is considering research participation, you should seek adequate information 
about the study purpose, what is required of you in terms of procedures, interventions and time, and what the 
potential risks and benefits are expected to be. For more information, see 
http://www.cc.nih.gov/participate/studies.shtml  
Whether you are thinking about participation in a research study that is being conducted by your supervisor, or 
others who you work closely within your laboratory, branch, or unit, or research that is being conducted in an 
area for which you have no affiliation, you should consider some additional factors:  
1. Possible bias. Are you confident that you can be unbiased about reporting answers, side effects, or other 
information that could influence the study outcome or risk to you?  
2. Confidentiality. Are you comfortable sharing your medical history (including, for example, mental health 
history or sexually transmitted diseases) and your social history (e.g. substance use) with study investigators 
who may or may not be your coworkers, or with the possibility of them discovering something about your health 
during the study?  
3. Pressure. Do you perceive any pressure or expectations from either the study team or your supervisor or 
colleagues regarding participation? If so, does that pressure influence your decision or make it difficult for you to 
choose whether or not to participate? Remember it is your choice whether or not to participate. If you have 
concerns about enrolling in a study, the Department of Bioethics and the Office of Human Subjects Research 
Protections (OHSRP) are both available to help.  
4. Time. Can you take time off from work to complete the study requirements or participate solely during non-
duty hours? See the NIH Policy Manual 2300-630-3 “Leave policy for NIH employees participating in NIH medical 
research studies”  
 
According to NIH guidance, anticipated inclusion of employees in research studies must be approved by the IRB, 
and when the individual obtaining consent is a supervisor or co-worker of a prospective participant, an 
independent person (e.g. through the Clinical Center Department of Bioethics, National Institute of Mental 
Health Human Subjects Protection Unit, or other entity as approved by the Institutional Review Board (IRB)) 
should monitor the consent process, unless waived by the IRB.  
If you have any questions or concerns, please contact the Department of Bioethics at (301) 496-2429 or the 
OHSRP at 301-402-3444. 
 
 
 
 
 
 


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Appendix C: Inpatient Food Diary 
 
Sodium-glucose CoTransporter 2 (sGLT2) Inhibitor and Endogenous Ketone 
Production  
Participant Inpatient Food Diary 
 
                    Study I.D.: ____________        Date: ____________ 
   Visit # ______ 
 
 
 
  
Time of Day 
Approximate  
Amount 
(Wt. or Vol) 
EXAMPLES 
FOOD DESCRIPTION 
(One item per line) 
0600 8 FLUID OZ. TROPICANA ORANGE JUICE WITH EXTRA PULP 
  8 FLUID OZ. COFFEE, REGULAR BREWED 
  
2 CUPS KELLOGG’S CORN FLAKES CEREAL WITH….. 
  
1 CUP SKIM MILK AND... 
  
1 MEDIUM BANANA 
10:00 A.M. 
2 OZ. FAT FREE, UNSALTED PRETZELS, LABEL INCLUDED 
  
1 TBSP. REGULAR MUSTARD 
12:00 P.M. 
1 TURKEY SANDWICH ON…. 
  
2 SLICES WHITE “WONDER” BREAD 
  
3 OZ. SLICED DELI TURKEY, LOW SALT 
  
    


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Sodium-glucose CoTransporter 2 (sGLT2) Inhibitor and Endogenous Ketone 
Production  
Participant Inpatient Food Diary 
 
                    Study I.D.: ____________        Date: ____________ 
   Visit # ______ 
Drinking water is very important. Please check box after 
drinking 8 ounces of water. Please drink at least (6) 8 ounces.  
(1) □ (2)□ (3) □ (4) □ (5) □ (6) 
DAY 1 – Page 1 
 
 
  
Time of Day 
Approximate  
Amount 
(Wt. or Vol) 
  
FOOD DESCRIPTION 
(One item per line) 
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
  
  
 
 
 


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Sodium-glucose CoTransporter 2 (sGLT2) Inhibitor and Endogenous Ketone 
Production  
Participant Inpatient Food Diary 
 
                    Study I.D.: ____________        Date: ____________ 
   Visit # ______ 
 
  
Time of Day 
Approximate  
Amount 
(Wt. or Vol) 
  
FOOD DESCRIPTION 
(One item per line) 
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
  
  
 
 
 
 
 
 
 
 
 


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DAY 1 – Page 2 
 
Sodium-glucose CoTransporter 2 (sGLT2) Inhibitor and Endogenous Ketone 
Production  
Participant Inpatient Food Diary 
 
                    Study I.D.: ____________        Date: ____________ 
   Visit # ______ 
Drinking water is very important. Please check box after 
drinking 8 ounces of water. Please drink at least (6) 8 ounces.  
(1) □ (2)□ (3) □ (4) □ (5) □ (6) 
 
 
 
  
Time of Day 
Approximate  
Amount 
(Wt. or Vol) 
  
FOOD DESCRIPTION 
(One item per line) 
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
  
  


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DAY 2 – Page 1 
 
Sodium-glucose CoTransporter 2 (sGLT2) Inhibitor and Endogenous Ketone 
Production  
Participant Inpatient Food Diary 
 
                    Study I.D.: ____________        Date: ____________ 
   Visit # ______ 
 
 
 
 
 
 
 
 
 
 
  
Time of Day 
Approximate  
Amount 
(Wt. or Vol) 
  
FOOD DESCRIPTION 
(One item per line) 
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
    
  
  
  


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DAY 2 – Page 2 
 
 
Appendix D: Discharge Instructions Visit 1 
 
v Should you experience any problems with your I.V. site, notify the nursing staff. 
Mild tenderness and some bruising are not unusual.       
v The Continuous Glucose Monitor will measure and store your sugar levels for up to 
14 days. When you return for Visit 2, we will download the data which will show us 
how your sugar levels are trending throughout the day and night.   
The sensor is comfortable enough to forget it is there. However, use care to avoid 
catching the sensor on clothing while getting dressed. 
Your sensor is water resistant and can be worn while bathing, showering or 
swimming as long as you do not take it deeper than 3 feet. Also, do not keep it 
under water for longer than 30 minutes at a time.  
Intense exercise may cause the sensor to loosen due to sweat or movement of the 
sensor. Please contact us if you have any skin irritation or discomfort or if the 
sensor should become loose or removed.  
v Try to eat the same times each day. Record what times you are eating or drinking 
on the log provided.  
v Please drink plenty of fluids.   
v Please do not donate any blood to the Red Cross during your study participation.  
 
Your next study appointment (Visit 2) is __________________________________ 
 
Please arrive fasting. This visit will be the same as Visit 1 except you will be given 
the study medication.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Contacts:  
 
Denise Melvin, R.N. 
 
410-350-3924 
(Monday to Friday 6:30 am to 3 pm) 
NIA Clinical Research Unit  
410-350-3955  
(Sunday 3 pm until Friday 5 pm) 
Dr. Josephine Egan, M.D.  
410-294-4759 
 
 
 
  
 
 
If you are having a medical emergency, please call 911 and go to your local hospital for assistance.  
 
Participant Signature: ____________________ 
Date: __________ 
Staff Signature: ____________________    
 
 
Appendix E: Intake Diary 
                                          sGLT2 Inhibitor – INTAKE DIARY 
PLEASE RECORD TIME YOU PUT ANYTHING INTO YOUR MOUTH,  
OTHER THAN WATER 
 
Day 1 - 
Date 
Day 2 - 
Date 
Day 3 - 
Date 
Day 4 - 
Date 
Day 5- 
Date 
Day 6- 
Date 
Day 7 - 
Date 
Day 8 - 
Date 
Day 9 - 
Date 
 
 
 
 
 
 
 
 
 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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IF YOU RUN OUT OF LINES, PLEASE USE THE BACK OF THIS FORM TO RECORD 
EATING/DRINKING 
                                            
 
 
 
 
sGLT2 Inhibitor– INTAKE DIARY 
PLEASE RECORD TIME YOU PUT ANYTHING INTO YOUR MOUTH,  
OTHER THAN WATER 
Day 10 - 
Date 
Day 11 - 
Date 
Day 12 - 
Date 
Day 13 - 
Date 
Day 14- 
Date 
Day 15- 
Date 
Day 16 - 
Date 
 
 
 
 
 
 
 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
Time 
hh:mm 
(am/pm) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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IF YOU RUN OUT OF LINES, PLEASE USE THE BACK OF THIS FORM TO RECORD 
EATING/DRINKING 
 
 
Appendix F: Discharge Instructions Visit 2 
 
v Should you experience any problems with your I.V. site, notify the nursing staff. Mild tenderness 
and some bruising are not unusual.       
v The Continuous Glucose Monitor will measure and store your sugar levels for up to 14 days. 
When you return for Visit 2, we will download the data which will show us how your sugar levels 
are trending throughout the day and night.   
 
The sensor is comfortable enough to forget it is there. However, use care to avoid catching the 
sensor on clothing while getting dressed. 
Intense exercise may cause the sensor to loosen due to sweat or movement of the sensor. Please 
contact us if you have any skin irritation or discomfort or if the sensor should become loose or 
removed.  
Your sensor is water resistant and can be worn while bathing, showering or swimming as long as 
you: 
• Do not take it deeper than 3 feet 
• Do not keep it under water for longer than 30 minutes at a time.  
 
If necessary, notify security at the airport checkpoint that you are wearing the device. If you have 
an MRI or CT scan for medical purposes, you must remove your sensor prior to the procedure and 
notify us.  
v Try to eat the same times each day. Record what times you are eating or drinking on the log 
provided.  
v Please drink plenty of fluids.  Drink at least 8 ounces of water every 4 hours, except when asleep.  
v Please maintain good hygiene to prevent urinary tract or yeast infections. Daily baths/showering 
recommended.  
v Study Medication:  
It is important that you take the study medication (1 pill) the same time every morning 
followed by breakfast within 30 minutes.  


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A staff member will contact you to see if you are having any symptoms and to confirm you 
are taking the medication.  
Your next study appointment (Visit 3) is __________________________________ 
Please arrive fasting. This visit will be the same as Visit 2.  
 
Contacts:  
 
NIA Clinical Research Unit  
410-350-3955  
(Sunday 3 pm until Friday 5 pm) 
Denise Melvin, R.N. 
 
410-350-3924 
(Monday to Friday 6:30 am to 3 pm) 
Josephine Egan, M.D.  
 
410-294-4759 
 
 
 
  
 
 
If you are having a medical emergency, please call 911 and go to your local hospital for assistance.  
 
Participant Signature: ____________________ 
Date: __________ 
Staff Signature: ____________________         
Appendix G: Medication Log 
Medication Log (Page 1 of 2) 
*** Remember to take study medication empagliflozin (Jardience) 1 pill every morning,      
followed by breakfast within 30 minutes 
DRINKING WATER IS VERY IMPORTANT 
Please check box after drinking 8 ounces of water. Please drink at least (6) 8 ounces. 
Day 1 
___/___/___ 
Saturday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 2 
___/___/___ 
Sunday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 3 
___/___/___ 
Monday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 4 
___/___/___ 
Tuesday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 5 
___/___/___ 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 


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Wednesday 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 6 
___/___/___ 
Thursday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 7 
___/___/___ 
Friday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 8 
___/___/___ 
Saturday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Medication Log (Page 2 of 2) 
*** Remember to take study medication empagliflozin (Jardience) 1 pill every morning,     
followed by breakfast within 30 minutes 
DRINKING WATER IS VERY IMPORTANT 
Please check box after drinking 8 ounces of water. Please drink at least (6) 8 ounces. 
Day 9 
___/___/___ 
Sunday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 10 
___/___/___ 
Monday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 11 
___/___/___ 
Tuesday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 12 
___/___/___ 
Wednesday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 13 
___/___/___ 
Thursday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 


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(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 14 
___/___/___ 
Friday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 15 
___/___/___ 
Saturday 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
Day 16 
___/___/___ 
 
Time pill taken 
Breakfast 
time 
Comments/Symptoms 
 
WATER: 8 OUNCES 
(1) □  (2) □  (3) □  (4) □  (5) □  (6) □ 
 
 
 
Appendix H: Discharge Instructions Visit 3 
 
 
v Should you experience any problems with your I.V. site, notify the nursing staff. 
Mild tenderness and some bruising are not unusual.     
 
v If you have any questions or symptoms in the next few days, please give us a call.  
 
v A staff member will contact you within one week to check if you are having any 
symptoms.  
 
 
 
Contacts:   
NIA Clinical Research Unit  
410-350-3955   (Sunday 3 pm until Friday 5 pm) 
 
Denise Melvin, R.N. 
   
410-350-3924   (Monday to Friday 6:30 am to 3 pm) 


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Dr. Josephine Egan, M.D.   
410-294-4759 
 
 
  
 
 
Participant Signature: ____________________ 
Date: __________ 
 
Staff Signature: ____________________         
 
                                                                                                                            
   
 
 
 
 
Appendix I: Symptom Review 
 
I.D.# - ___ ___ ___        Date: ____________        Time: ________        Visit # ______ 
 
Do you have any of the following symptoms? 
 
Symptom 
Yes  No 
Comment 
Dizziness 
 
 
 
Lightheadedness 
 
 
 
Weakness 
 
 
 
Yeast infection  
(i.e. itching, 
burning, redness, 
smelly discharge 
from genital area)  
 
 
 
Genital infection: 
tenderness, pain, 
swelling, flu-like 
symptoms 
 
 
 
Burning on 
urination  
 
 
 
Nausea 
 
 
 
Vomiting 
 
 
 
Diarrhea 
 
 
 
Constipation  
 
 
 


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Confusion 
 
 
 
Feeling shaky 
 
 
 
Increased hunger 
 
 
 
Decreased hunger 
 
 
 
Headache 
 
 
 
Irritability 
 
 
 
Palpitations 
 
 
 
Anxiety 
 
 
 
Coughing 
 
 
 
Sneezing 
 
 
 
Nasal congestion 
 
 
 
Runny nose 
 
 
 
Fever 
 
 
 
Sore throat 
 
 
 
Shortness of breath 
 
 
 
Other 
 
 
 
  Appendix J: Study Flyer 
 

ICF_001.pdf: 
CONSENT TO PARTICIPATE IN AN NIH CLINICAL RESEARCH STUDY
PATIENT IDENTIFICATION
Consent to Participate in a Clinical Research Study
Version Date:05/05/2020
Page 1 of 12
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PRINCIPAL INVESTIGATOR:  Josephine M. Earley, M.D
STUDY TITLE: Sodium-glucose Co Transporter 2 (sGLT2) Inhibitor and Endogenous Ketone Production
STUDY SITE: National Institute on Aging at MedStar Harbor Hospital
Cohort: Healthy volunteers age 55 and older
Consent Version:  05/05/2020
WHO DO YOU CONTACT ABOUT THIS STUDY? 
Josephine M. Earley, M.D.  Phone: 410-350-3922  
email: eganj@mail.nih.gov
Denise Melvin, R.N.  
Phone: 410-350-3924  
email: melvinde@mail.nih.gov
This consent form describes a research study and is designed to help you decide if you would like to be a part of 
the research study.  
You are being asked to take part in a research study at the National Institutes of Health (NIH). Members of the 
study team will talk with you about the information described in this document. Some people have personal, 
religious, or ethical beliefs that may limit the kinds of medical or research treatments they would want to receive 
(such as blood transfusions). Take the time needed to ask any questions and discuss this study with NIH staff, and 
with your family, friends, and personal health care providers. Taking part in research at the NIH is your choice.
IT IS YOUR CHOICE TO TAKE PART IN THE STUDY
You may choose not to take part in this study for any reason. If you join this study, you may change your mind 
and stop participating in the study at any time and for any reason. In either case, you will not lose any benefits to 
which you are otherwise entitled. However, to be seen at the NIH, you must be taking part in a study or are being 
considered for a study. If you do choose to leave the study, please inform your study team to ensure a safe 
withdrawal from the research.  
WHY IS THIS STUDY BEING DONE?
This study is being done to look at how your body responds to a medication approved by the Food and Drug 
Administration (FDA) for treating diabetes. The medicine is called empagliflozin (Jardiance). Diabetes is a 
disease that occurs when your blood glucose, also called blood sugar, is too high. Empagliflozin (Jardiance) 
lowers blood sugar by increasing the amount of glucose excreted by the kidneys. This results in more than usual 
amounts of ketones being formed in the blood stream. Ketones are made when your body either does not have 
enough glucose available or cannot use glucose as fuel for its energy needs. They are made in the liver mostly 
from the breakdown of fats. We would like to study whether giving empagliflozin (Jardiance) to you and other 
people who do not have diabetes will increase the amounts of ketones in your blood. This medication does not 
lower blood glucose levels below usual levels in people without diabetes.
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


CONSENT TO PARTICIPATE IN AN NIH CLINICAL RESEARCH STUDY
PATIENT IDENTIFICATION
Consent to Participate in a Clinical Research Study
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Normally, the food in our diets is broken down into glucose (sugar), fats and amino acids. These are then used 
as fuel sources for energy. Food products that are not needed right away as fuel by the body are stored in the 
liver, fat and muscle tissue for future use. During fasting periods and overnight, the body will adapt by using the 
fuel that is stored, mainly as fat. The breakdown of the stored fat results in ketones being released into the blood 
stream. These ketones are taken up by the brain and other organs and are used as energy in place of glucose. 
When the brain burns ketones for energy instead of glucose it changes brain metabolism. Many people with 
age-related neurological diseases, such as Alzheimer’s Disease, share the problem that their brain cells do not 
use glucose as well as they used to when they were younger. Research has shown that when fuel is supplied to 
the brain in the form of ketones, memory and mental tasks seem to improve in older animals. We would like to 
study what will happen to your ketone levels while taking the study drug for about 2 weeks. We believe it will 
cause an increase in ketones in your blood and other people without diabetes. In the future, we would like to see 
if we could use this medication to improve brain health in people as they age. 
What if I am presently participating in another study?
Are you presently participating in any other research studies?     Yes 
No 
     If yes, please state which study (ies) ______________________________________________
If you are taking part in another study, the investigator wants to make sure that it is safe to be in this study. This 
will protect you from things such as extra blood drawing or drug interactions.
Screening Visit (Visit 0)
We will ask that you do not eat anything for 8 hours before the screening visit. You may drink water. We will 
take a health history and perform a physical exam. You will have a blood draw. About 2 tablespoons of blood 
will be drawn at this visit. The screening visit will last about 1.5 hours. Following the visit, a snack or meal will 
be provided.
Screening Visit Procedures
Medical history and physical examination:
One of the doctors or nurse practitioners will review your medical history. You will change into a hospital 
gown. We will measure your height, weight, body temperature, and blood pressure, breathing and pulse rates. 
This will take about 30 minutes.
Fasting Blood Samples:
Blood will be drawn for a complete blood count (CBC), liver and kidney function, thyroid function, glucose and 
basic chemistry (CMP). You will also be tested for Human immunodeficiency virus (HIV), Hepatitis B, and 
Hepatitis C viruses.
Hepatitis B and Hepatitis C Testing:
This study requires that your blood be tested for these diseases that can be spread through your blood. You will 
be informed of the results of these tests. If you have Hepatitis B or untreated Hepatitis C, you will not be 
eligible for the study and the results will be reported to the state health department. If you are infected with any 
of these viruses, we will tell you what the results mean, how to find care, how to avoid infecting others and 
informing your partners of possible risks.
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


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Human immunodeficiency virus (HIV) test:
As part of this study, we will test you for infection with the human immunodeficiency virus (HIV), the virus 
that causes AIDS. If you are infected with HIV you will not be able to participate in this study. We will tell you 
what the results mean, how to find care, how to avoid infecting others, how we report HIV infection, and the 
importance of informing your partners at possible risk because of your HIV infection. If you decide not to 
provide an HIV blood sample, you will not be eligible to participate in the study.
Urine Sample:
A urinalysis will be done to check for glucose (sugar) in your urine. If you have glucose in your urine at the 
screening visit, you will not be eligible to participate in this study.
If you are eligible after the screening visit, there will be 3 study visits. These visits will be scheduled about 13 
days apart. All these visits will involve the same study procedures. The only difference will be on Visit 1, you 
will not receive any study medication. We want to see how your glucose, insulin and other hormones respond 
before and after taking the study medication.
Study Visit (Visit 1)
You will arrive on the NIA Clinical Research Unit for a 2-day visit. We will ask that you do not eat or drink 
anything except water for 8 hours before your visit. We will place an intravenous (I.V.) catheter into an arm 
vein. We will use this catheter to obtain frequent blood samples every 1-2 hours for 34 hours. You will have a 
continuous glucose monitor (CGM) placed to measure your blood sugar during your visit. This monitor is 
commonly use in people with diabetes and will be worn until you return for Visit 2. During your visits, your 
meals will be provided, and we will ask you to drink plenty of water. We will ask you to record the time and 
items you eat during your study visits on a Food Diary. On the evening of your arrival day, you will be given an 
activity monitor and asked to walk approximately 2,000 steps on the unit after your evening meal, but before 
bedtime. That evening you will be asked to fast after 7:00 p.m. About 165 ml (11.2 tablespoons) of blood will 
be drawn at this visit.
Visit 1 Procedures
Fasting Blood Samples / Frequent blood draws:
Blood will be drawn for liver and kidney function, glucose, basic chemistry (CMP), proteins, lipids, ketones, 
insulin and other hormones. We will also look at various chemicals that are possibly related to age-related 
cognitive decline and metabolism for research purposes only. Since the significance of these research tests may 
not be known, we will not share these results with you or your primary care provider.
Urine Sample and 32-hour Continuous Urine Collection:
A urinalysis will be done to check for glucose (sugar) in your urine. We will also collect your urine throughout 
the visit to measure hormones and to determine how well your kidneys function.
Continuous Glucose Monitoring System (CGM):
This monitor consists of a small sensor that is placed by using a small needle just beneath the skin on the back 
of your upper arm. It will measure glucose levels in daily living and is used frequently in patients with diabetes 
to evaluate their treatments and guide their care. In this study, it will be used to record your blood glucose levels 
both during your stay and while you are at home. You will not be able to see your blood glucose values in real 
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


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PATIENT IDENTIFICATION
Consent to Participate in a Clinical Research Study
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time. The device will be downloaded and reviewed by the investigators after the sensor is removed. The 
monitor will be inserted by the staff and you will be trained on using the device and who to call with questions 
or problems.
Food Diary:
You will be asked to write on paper, the time and what items you eat and drink during your 2-day visits. We 
will aim to have you eat similar items during visits 1-3.
Intake Diary Instructions:
You will be asked to write on paper, the time you eat and drink anything besides water while you are wearing 
the Continuous Glucose Monitor.
Symptom Review Questionnaire:
On each visit you will be asked questions to see how you are feeling. These questions will let us know if you 
are having any side effects from the study.
Activity Monitor:
On the evening of Day 1, on all of your visits a staff member will assist you to wear a device on your wrist that 
records the number of steps you walk. We will ask that you do your best to walk at least 2,000 steps following 
dinner and before bedtime. Following Visit 2, while you are taking the study medication at home, we will 
instruct you to wear the monitor continuously for about 13 days and ask that you walk approximately 2,000 
steps every evening, following dinner and before bedtime.
Magnetic Resonance Spectroscopy/ Magnetic Resonance Imaging (MRS/MRI scan):
MRI/MRS uses a strong magnetic field and radio waves to take pictures of your brain, measure its blood flow 
and function. The MRI scanner is a metal cylinder surrounded by a strong magnetic field. During the MRI, you 
will lie on a table that can slide in and out of the cylinder. A plastic device called a “coil” will be placed over 
your head. While in the scanner you will hear loud knocking noises, and you will be fitted with earplugs or 
earmuffs to muffle the sound. You will be able to communicate with the MRI staff at all times during your scan, 
and you may ask to be moved out of the machine at any time. The entire procedure should take about 60 
minutes. You will complete a screening form before you are allowed to perform the MRI and if it is determined 
that you meet any criteria that would exclude you from the MRI (for example pacemakers and some metal 
implants) then you will not be able to participate in this study.
Study Visit (Visit 2)
This visit will take place approximately 13 +/- 2 days following Visit 1. It will be the same as Visit 1, except 
you will be given the study drug empagliflozin (Jardiance) 25 mg followed by breakfast on both mornings of 
your visit. You will be asked to continue taking the study drug at home once a day, in the morning followed by 
breakfast within 30 minutes. You will take the study drug at home for about 13 days. You will wear the 
Continuous Glucose Monitor (CGM) until you return for Visit 3. 
A staff member will contact you daily to make sure you have taken the study medication and monitor you for 
any symptoms. 
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


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If you should have any symptoms while you are taking the study medication at home, call Dr. Earley at 410-
294-4759 or Dr. Chia at 410-900-2216.
We will draw the same blood work as Visit 1. In addition, we will check your blood count to determine it is safe 
for you to again have the frequent blood sampling. About 168 ml (11.4 tablespoons) of blood will be drawn at 
this visit. If your blood count is found to have decreased more than 10% from the screening visit, we will then 
reduce the number of blood draws to every 2 hours for the remainder of the visit. In this case the amount of 
blood taken will be about 130 ml (8.8 tablespoons). In addition, we will conduct the same MRS/MRI scan 
lasting about 1 hour.
Study Medication
Empagliflozin (Jardiance) is a pill used to treat type 2 diabetes. It works by helping the kidneys remove glucose 
from the bloodstream through the urine. The usual dose is 10 mg or 25 mg. The dose we will be studying is 25 
mg.
Study Visit (Visit 3)
This visit will take place approximately 13 +/- 2 days following Visit 2. It will be the same as Visit 2 (including 
the same MRS/MRI scan). When you complete this visit, you will no longer take the study medication or wear 
the Continuous Glucose Monitor (CGM). A staff member will contact you within one week to see if you have 
any symptoms.
Risks, Inconveniences and Discomforts
If you decide to participate in this study, you should know there may be risks. You should discuss these with the 
investigator(s) and/or your regular doctor. We encourage you to speak with your family and friends about any 
risks involved before deciding to make a decision. Potential risks and side effects related to this study are 
described below.
Risks and side effects that may occur include:
Risk of Study Medication - Empagliflozin (Jardiance):
While on the study medication you are at risk for the side effects as described below. You should discuss these 
with the researcher and/or your regular doctor. There also may be other side effects that we cannot predict. As 
with all medications, undesirable events are sometimes experienced. This includes a hypersensitivity (allergic) 
reaction. Side effects reported with empagliflozin were dehydration, dizziness, lightheadedness, weakness, yeast 
and urinary tract infections. 
Empagliflozin will result in you excreting more sugar than usual in your urine. More water will also be pulled 
into your kidneys. This may cause you to urinate more than is usual for you. Because of the added sugar in the 
urine, bacteria and yeast are more likely to grow in your pelvic area and bladder. To decrease these risks, we 
will encourage you to drink lots of non-sugary, non-energy containing fluids. We prefer that you drink water or 
flavored water and maintain good hygiene. We will ask that you drink 8 ounces of water every 4 hours, except 
when you are asleep.
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


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________ Placing my initials here, means that I understand the importance and agree to drinking 8 ounces of 
water every 4 hours, except when I am asleep during the times I will be taking the study medication.
Other side effects may include nausea, which can occur with any drug taken by mouth, and upper respiratory 
tract infections. Rarely, sudden episodes of kidney failure or kidney damage may occur. The FDA has issued a 
warning about a serious infection of the genital area (necrotizing fasciitis of the perineum) associated with this 
class of drugs. This infection has rarely occurred, and non-diabetics have generally not taken this medication. 
In order to prevent many of these side effects, we encourage you to drink water and to maintain good hygiene 
(bathe or shower daily). We will contact you daily to assess for any symptoms, i.e. tenderness, redness or 
swelling of the genital area, fever or general feeling of being unwell.
Risk of Medical history and physical examination: 
There are no risks to having a physical exam.
Risk of blood drawing/ I.V. placement:
It may hurt a little when we stick you with the needle. You may get a little bruise (black-and-blue mark).
Some people feel dizzy or faint when they have blood drawn. To reduce the risk of injury because of a fall, you 
will be closely monitored and asked about these symptoms before you can stand. There is minimal risk that you 
may get an infection by puncturing the skin. During the frequent blood sampling, the I.V. catheter may stop 
working and the I.V. may need to be reinserted to obtain the blood samples. The amount of blood drawn is 
within the NIH guidelines which are 550 ml (2.3 cups) in an 8-week period. The total amount of blood collected 
if you are eligible for this study is no more than 531 ml (36 tablespoons or about 2 ¼ cups).
Risk of Hepatitis B, Hepatitis C and HIV testing: 
The results of these blood tests, if positive, will be reported to you and the state health department.
Risk of Incidental Findings: 
It is possible that one or more of the tests undertaken as part of this study will show that you
have a condition you did not know about or that will need to be investigated. It is possible that discovering a 
condition may make obtaining insurance difficult in the future.
Risk of Continuous Glucose Monitor:
Potential risks include a slight skin irritation from the adhesive.
Risk of Magnetic Resonance Spectroscopy/ Magnetic Resonance Imaging (MRS/MRI scan):
People are at risk for injury from the MRI magnet if they have pacemakers or other implanted electrical devices, 
brain stimulators, some types of dental implants, aneurysm clips (metal clips on the wall of a large artery), 
metallic prostheses (including metal pins and rods, heart valves, and cochlear implants), permanent eyeliner, 
implanted delivery pump or shrapnel fragments. Welders and metal workers are also at risk for injury because 
of possible small metal fragments in the eye of which they may be unaware. You will be screened for these 
conditions before having any scan, and if you have any, you will not receive an MRI scan. If you have a 
question about any metal objects being present in your body, you should inform the staff. In addition, all 
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


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magnetic objects (for example, watches, coins, jewelry, and credit cards) must be removed before entering the 
MRI scan room. 
People with fear of confined spaces may become anxious during an MRI. Those with back problems may have 
back pain or discomfort from lying in the scanner. The noise from the scanner is loud enough to damage 
hearing, especially in people who already have hearing loss. Everyone having a research MRI scan will be fitted 
with hearing protection. If the hearing protection comes loose during the scan, you should let us know right 
away. Please notify the investigator if you have hearing or ear problems. You will be asked to complete an MRI 
screening form for each MRI scan you have. There are no known long-term risks of MRI scans.
Incidental findings (brain MRI scan):
A potential risk of participating in this study is that the radiologist who reviews brain images may find a brain 
abnormality of uncertain significance. We will inform you about any finding that may require further evaluation 
or care. We are not able to provide evaluation or treatment for these conditions at NIH. If needed, we will refer 
you to a health care provider. We may not inform you about minor abnormalities that do not have importance 
for your health or wellbeing.
Risks associated with Stored Specimens:
What will happen to the samples and information that are collected during the study?
Samples of your blood and tissue may be kept in a research laboratory at the National Institutes of Health or one 
of our contract facilities. Your samples may be tested immediately, or they may be frozen and used later. The 
greatest risk associated with stored samples is the unplanned release of information from the medical records. 
The chance that this information will be given to an unauthorized person without your permission is very small. 
Possible problems with the unplanned release of information include discrimination when applying for 
insurance or employment. Similar problems may occur if you disclose information yourself or agree to have 
your medical record released. 
Samples may be kept indefinitely or until no cells and/or tissues remain or until the investigators decide to 
destroy them. Your name and identifying information will be removed and we will assign the sample a code. 
The key to the code will be kept in a separate, secure area. Research records with personal identifiers (such as 
your name) will be stored in our locked offices, the medical record department, and the electronic study data 
base. Any identifying information about you will be kept confidential to the extent permitted by law. The NIA 
will retain custody of your samples for studies as outlined above.
The NIA will be exclusive owner of any data, discoveries or derivative materials from the sample materials and 
is responsible for the restriction of sample use at your request. If a potential commercial product is developed 
from the research project, the NIA will develop patents and promote commercialization of the product as 
required by law. You will not profit financially from such a product.
Are there any benefits to you if you take part in this research study?
This study is not designed to provide direct benefits to any participants. We hope the information learned from 
this study will benefit others in the future.
What choices you have besides taking part in this study?
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


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You have the choice not to participate in this study.
Results From this Study
We will provide you with a copy of your screening clinical laboratory blood work within 1-3 weeks of your 
screening visit. You will also receive any other clinically significant lab results from your remaining study 
visits. We will also provide you copies of your MRI reports should the results show that you need further 
evaluation or care.
What if I want to withdraw from the study?
You may voluntarily withdraw from this study at any time and for any reason without loss of benefits or 
privileges to which you are otherwise entitled. 
Any data or blood collected will remain part of the study and the property of the National Institute on Aging. 
You may request that we destroy any remaining blood/tissue by contacting the Principal Investigator (see page 
6 for contact information). If you suddenly decide to stop participating in the study, we do not know of any 
serious consequences. However, we do encourage you to talk to the investigator. There are conditions that may 
require us to withdraw you from the study, including but not limited to the following:

You are unable or unwilling to comply with the study requirements.

The Principal Investigator, Dr. Josephine M. Earley, deems it unsafe for you to remain in the study.

The study is terminated.
Discussion of new findings
If any new information is learned, at any time during the research, which might affect your willingness to 
participate in the study, we will tell you.
COMPENSATION, REIMBURSEMENT, AND PAYMENT
Will you receive compensation for participation in the study?
Some NIH studies offer compensation for participation in research. The amount of compensation, if any, is 
guided by NIH policies and guidelines.
This study will provide compensation in the form of a debit card upon completion of your visit. 
You will receive $30 for completing the screening visit. You will receive $540 for completing Study Visit 1; 
$600 for completing Visit 2 and $700 for completing Visit 3. The total compensation for successful completion 
of this study will be $1870.  Should the study physician ask you to return for any unplanned visits, you will be 
compensated $20.
If you are unable to finish the study, you will receive compensation for the parts you completed as follows:
Frequent blood sampling 
140 dollars
Continuous Glucose Monitor 
150 dollars
Food Diary (in-patient) 
20 dollars ($10/day)
Intake Diary (out-patient) 
65 dollars
MRI 
125 dollars
Activity Monitor/completing steps 
25 dollars
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


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34-hour urine collection 
50 dollars
Study medication (self-dosing) 
100 dollars
With few exceptions, study compensation is considered taxable income that is reportable to the Internal Revenue 
Service (IRS). A “Form 1099-Other Income” will be sent to you if your total payments for research participation 
are $600 or more in a calendar year. If you have unpaid debt to the federal government, please be aware that some 
or all of your compensation may be automatically reduced to repay that debt on your behalf.
Will you receive reimbursement or direct payment by NIH as part of your participation?
Some NIH studies offer reimbursement or payment for travel, lodging or meals while participating in the 
research. The amount, if any, is guided by NIH policies and guidelines. This study does not offer reimbursement 
for, or payment of, travel or lodging. Meals will be provided in the form of a food voucher.
Will taking part in this research study cost you anything? 
NIH does not bill health insurance companies or participants for any research or related clinical care that you 
receive at the NIH. You do not have to pay anything to be in this study. However, if taking part in this study leads 
to procedures or care not included in the study, it may lead to added costs for you or your insurance company. 
Conflict of Interest
The investigators and personnel involved in this study do not have any conflicts of interest to disclose. The 
National Institutes of Health reviews NIH staff researchers at least yearly for conflicts of interest. The following 
link contains details on this process http://ethics.od.nih.gov/forms/Protocol-Review-Guide.pdf. You may ask 
your research team for additional information or a copy of the Protocol Review Guide. 
CLINICAL TRIAL REGISTRATION AND RESULTS REPORTING 
A description of this clinical trial will be available on http://www.Clinicaltrials.gov, as required by U.S. Law. 
This web site will not include information that can identify you. At most the Web site will include a summary 
of the results. You can search this web site at any time.
CONFIDENTIALITY PROTECTIONS PROVIDED IN THIS STUDY
Research records will be kept using secure computers. These are password protected and maintained on a secure 
server with access limited to authorized NIA staff members. All NIH investigators and NIA staff members who 
have access to these databases have the proper training on patient privacy as well as the required Human Subject 
Protection Training. 
Your samples will be stored in a secured area at an NIA facility. The only information on the sample is your 
study ID number. The key to the ID number will be kept in a separate, secure area to which only the clinical 
study staff have access. 
We will ask you for your social security number in order to compensate you for your participation. If you do 
not wish to provide this information, you may still participate. However, you may not be able to receive 
compensation. 
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


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Will your medical information be kept private? 
We will do our best to make sure that the personal information in your medical record will be kept private.  
However, we cannot guarantee total privacy.  Organizations that may look at and/or copy your medical records 
for research, quality assurance, and data analysis include:

The NIH and other government agencies, like the Food and Drug Administration (FDA), which are 
involved in keeping research safe for people.

National Institutes of Health Intramural Institutional Review Board
When results of an NIH research study are reported in medical journals or at scientific meetings, the people who 
take part are not named and identified.  In most cases, the NIH will not release any information about your 
research involvement without your written permission.  However, if you sign a release of information form, for 
example, for an insurance company, the NIH will give the insurance company information from your medical 
record.  This information might affect (either favorably or unfavorably) the willingness of the insurance company 
to sell you insurance.
If we share your specimens or data with other researchers, in most circumstances we will remove your identifiers 
before sharing your specimens or data. You should be aware that there is a slight possibility that someone could 
figure out the information is about you. 
Further, the information collected for this study is protected by NIH under a Certificate of Confidentiality and the 
Privacy Act. 
Certificate of Confidentiality
To help us protect your privacy, the NIH Intramural Program has received a Certificate of Confidentiality 
(Certificate). With this certificate, researchers may not release or use data or information about you except in 
certain circumstances.  
NIH researchers must not share information that may identify you in any federal, state, or local civil, criminal, 
administrative, legislative, or other proceedings, for example, if requested by a court.  
The Certificate does not protect your information when it:  
1. is disclosed to people connected with the research, for example, information may be used for auditing or 
program evaluation internally by the NIH; or 
2. is required to be disclosed by Federal, State, or local laws, for example, when information must be 
disclosed to meet the legal requirements of the federal Food and Drug Administration (FDA); 
3. is for other research;
4. is disclosed with your consent. 
The Certificate does not prevent you from voluntarily releasing information about yourself or your involvement 
in this research. 
The Certificate will not be used to prevent disclosure to state or local authorities of harm to self or others including, 
for example, child abuse and neglect, and by signing below you consent to those disclosures. Other permissions 
for release may be made by signing NIH forms, such as the Notice and Acknowledgement of Information 
Practices consent.
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


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Privacy Act
The Federal Privacy Act generally protects the confidentiality of your NIH medical records we collect under the 
authority of the Public Health Service Act.  In some cases, the Privacy Act protections differ from the Certificate 
of Confidentiality.  For example, sometimes the Privacy Act allows release of information from your medical 
record without your permission, for example, if it is requested by Congress. Information may also be released for 
certain research purposes with due consideration and protection, to those engaged by the agency for research 
purposes, to certain federal and state agencies, for HIV partner notification, for infectious disease or abuse or 
neglect reporting, to tumor registries, for quality assessment and medical audits, or when the NIH is involved in 
a lawsuit.  However, NIH will only release information from your medical record if it is permitted by both the 
Certificate of Confidentiality and the Privacy Act.
POLICY REGARDING RESEARCH-RELATED INJURIES  
NIA will provide short-term medical care for any physical injury resulting from your participation in research 
here. In general, no long-term medical care or financial compensation for research-related injuries will be 
provided by the NIH, NIA, or the Federal Government. However, you have the right to pursue legal remedy if 
you believe that your injury justifies such action.
PROBLEMS OR QUESTIONS
If you have any problems or questions about this study, or about your rights as a research participant, or about 
any research-related injury, contact the Principal Investigator, Josephine M. Earley, M.D. eganj@mail.nih.gov; 
410-350-3922; Other researchers you may call are: Chee Chia, M.D. at 410-350-7376; Ajoy Karikkineth at 410-
350-3970; You may also call the Clinical Director at (410) 350-3922; the NIA Clinical Research Protocol Office 
at (410) 350-3947, or the NIH Office of IRB Operations at 301-402-3713, if you have a research-related complaint 
or concern.
CONSENT DOCUMENT 
Please keep a copy of this document in case you want to read it again.
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020


CONSENT TO PARTICIPATE IN AN NIH CLINICAL RESEARCH STUDY
PATIENT IDENTIFICATION
Consent to Participate in a Clinical Research Study
Version Date:05/05/2020
Page 12 of 12
NIA ICF template version 09.27.19
Adult Research Participant: I have read the explanation about this study and have been given the opportunity 
to discuss it and to ask questions. I consent to participate in this study.
Signature of Research Participant
Print Name of Research Participant
Date
Investigator:
Signature of Investigator
Print Name of Investigator
Date
IRB NUMBER: 19AG0060
IRB APPROVAL DATE: 05/13/2020