Conditions: Alzheimer Disease
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 46
Healthy volunteers: no

Brief summary:
This is a pilot randomized controlled trial in individuals with probable Alzheimer's disease testing the effects of 10 mg dapagliflozin, taken daily for 12 weeks, on cerebral n-acetyl aspartate (NAA) levels using magnetic resonance spectroscopy (MRS). The investigators will also examine the safety and tolerability of dapagliflozin and explore the effects on systemic NAA levels in blood and urine, cerebral metabolism (fluorodeoxyglucose \[FDG\] PET), systemic metabolic biomarkers that indicate and quantify secondary metabolic effects, and cognitive performance.

Detailed description:
This is a double-blind, randomized, placebo-controlled, parallel group, 12-week study performed at a single site (University of Kansas Alzheimer's Disease Center) to investigate the effect of dapagliflozin in participants with probable AD (MMSE 15-26 inclusive). A total of 48 participants will be enrolled with 2:1 randomization to 10mg dapagliflozin once daily (n=32) for 12 weeks vs matching placebo (n=16).

The primary objective of the study is to assess the effect of 12 weeks of 10mg dapagliflozin once daily on cerebral NAA (a proxy measure of mitochondrial mass) in participants with AD.

Procedures will include phlebotomy, urine collection, MRI/MRS, FDG-PET, cognitive testing, DEXA scanning, and indirect calorimetry at baseline and 12 weeks to assess these outcomes:

* N Acetyl-Aspartate (NAA): Cerebral NAA (as measured by MRS) and Systemic NAA levels (in blood and urine)
* Cerebral metabolism (by FDG PET)
* Systemic metabolic effects: Lipids (total cholesterol, LDL, HDL), Plasma beta-hydroxybutyrate, Insulin resistance (Hemoglobin A1c, glucose and insulin during tolerance testing), Catabolic/Anabolic state \[activated AKT and MTOR\], Mitochondrial function measures \[platelet cytochrome oxidase and citrate synthase\], Inflammatory mechanisms \[MCP-1, eotaxin, TNF alpha, CRP\], Body composition (DEXA scanning for fat and lean mass), Resting metabolic rate (indirect calorimetry),
* Cognitive effects will be assessed at baseline and week 12 using the Alzheimer's Disease Assessment Scale-Cognitive Subscale 14 (ADAS-Cog14) and individual tests of Logical Memory I and II, Trailmaking A and B, and Stroop Word Color Test.
* 12 participants will be enrolled in an optional MRI/MRS sub-study with repeat MRI/MRS prior to randomization to assess scan-rescan reliability of the NAA measure.

Safety and tolerability of dapagliflozin (10mg daily) will be monitored throughout the study and formally at every study visit to assess the incidence and severity of AEs and the rate of discontinuations due to AEs. Safety assessments will include measuring vital signs and body weight, safety labs (including a comprehensive metabolic panel \[CMP\] and complete blood count \[CBC\] with differential) and physical and neurological examinations at screening and at end of treatment (EOT).

Arms:
arm 1: 10 mg dapagliflozin oral tablet taken once daily for 12 weeks arm 2: Placebo oral tablet taken once daily for 12 weeks

Interventions: intervention 1: Dapagliflozin intervention 2: Placebo
Intervention descriptions: intervention 1: 10 mg oral tablets taken once daily for 12 weeks intervention 2: Placebo tablet (matched in size and color to active tablet) taken once daily for 12 weeks

Protocol document:
Prot_SAP_000.pdf: 
Protocol Version 8.0, 22JAN2021 
1 
 
 
 
 
 
 
RANDOMIZED CONTROLLED PILOT TRIAL 
OF DAPAGLIFLOZIN IN ALZHEIMER’S 
DISEASE 
 
 
 
 
 
 
 
PI: Jeffrey Burns, M.D., M.S. 
Co-PI: Russell Swerdlow, MD 
 
 
 
 
Supported by: Astra Zeneca (ESR-17-13342 – dapagliflozin) 
 
 
 
 
 
University of Kansas Alzheimer's Disease Center (KU ADC) 
 
 
 
 
Sponsor : KU ADC 
 
 
Version 8.0 
JANUARY 22, 2020                                TABLE OF CONTENTS 
Page 
PRÉCIS ..................................................................................................................................... 3 
Study Title ................................................................................................................................  
Objectives .............................................................................................................................. 3 
Design and Outcomes ............................................................................................................ 3 
Interventions and Duration ..................................................................................................... 4 
Sample Size and Population .................................................................................................. 4 
STUDY TEAM ROSTER ............................................................................................................ 5 
Principal Investigator: 
Name ............................................................................................... 5 
Co-Investigators: Name ....................................................................................................... 5 
PARTICIPATING STUDY SITES ............................................................................................... 6 


Protocol Version 8.0, 22JAN2021 
2 
1 
Study objectives ............................................................................................................... 7 
1.1 
Primary Objective ....................................................................................................... 7 
1.2 
Secondary Objectives ................................................................................................. 7 
2 
BACKGROUND AND RATIONALE ................................................................................... 8 
2.1 
Background on Condition, Disease, or Other Primary Study Focus ............................ 8 
2.2 
Study Rationale .......................................................................................................... 9 
3 
STUDY DESIGN ...............................................................................................................10 
4 
SELECTION AND ENROLLMENT OF PARTICIPANTS ...................................................10 
4.1 
Inclusion Criteria ........................................................................................................11 
4.2 
Exclusion Criteria .......................................................................................................12 
4.3 
Study Enrollment Procedures ....................................................................................13 
5 
STUDY INTERVENTIONS ................................................................................................14 
5.1 
Interventions, Administration, and Duration ...............................................................14 
5.2 
Handling of Study Interventions .................................................................................14 
5.3 
Concomitant Interventions .........................................................................................14 
5.3.1 Allowed Interventions .............................................................................................14 
5.3.2 Required Interventions ...........................................................................................14 
5.3.3 Prohibited Interventions .........................................................................................14 
5.4 
Adherence Assessment .............................................................................................15 
6 
STUDY PROCEDURES ....................................................................................................17 
6.0 
Schedule of Evaluations ............................................................................................17 
6.1 
Description of Evaluations .........................................................................................18 
6.2.1 Screening Evaluation .............................................................................................18 
6.2.2 Enrollment, Baseline, and/or Randomization .........................................................19 
6.2.3 Treatment Period ...................................................................................................23 
6.2.4 Completion/Final Evaluation ..................................................................................23 
7 
SAFETY ASSESSMENTS ................................................................................................24 
7.1 
Specification of Safety Parameters ............................................................................24 
7.2 
Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters ....25 
7.3 
Adverse Events and Serious Adverse Events ............................................................26 
7.4 
Reporting Procedures ................................................................................................27 
7.5 
Follow-up for Adverse Events ....................................................................................28 
7.6 
Safety Monitoring .......................................................................................................28 
8 
INTERVENTION DISCONTINUATION ..............................................................................29 
9 
STATISTICAL CONSIDERATIONS ..................................................................................29 
9.1 
General Design Issues ..............................................................................................30 
9.2 
Sample Size and Randomization ...............................................................................30 
9.2.1 Treatment Assignment Procedures ........................................................................30 
9.3 
Interim analyses and Stopping Rules .........................................................................30 
9.4 
Outcomes ..................................................................................................................30 
9.4.1 Primary outcome ....................................................................................................30 
9.4.2 Secondary outcomes .............................................................................................31 
 
 9.4.3    Safety outcomes………………………………………………………………………….31 
9.5 
Data Analyses ...........................................................................................................31 
10 DATA COLLECTION AND QUALITY ASSURANCE ........................................................32 
10.1 
Data Collection Forms ...............................................................................................32 
10.2 
Data Management .....................................................................................................32 
10.3 
Quality Assurance .....................................................................................................32 
10.3.1 
Training ..............................................................................................................32 
10.3.2 
Quality Control Committee .................................................................................32 
10.3.3 
Metrics ...............................................................................................................33 
10.3.4 
Protocol Deviations ............................................................................................33 


Protocol Version 8.0, 22JAN2021 
3 
10.3.5 
Monitoring ..........................................................................................................33 
11 PARTICIPANT RIGHTS AND CONFIDENTIALITY ..........................................................33 
11.1 
Institutional Review Board (IRB) Review ....................................................................33 
11.2 
Informed Consent Forms ...........................................................................................33 
11.3 
Participant Confidentiality ..........................................................................................33 
11.4 
Study Discontinuation ................................................................................................34 
12 ETHICAL CONSIDERATIONS ..........................................................................................34 
13 PUBLICATION OF RESEARCH FINDINGS .....................................................................34 
14  REFERENCES …………………………………………………………………………………. 35 
 
 
 


Protocol Version 8.0, 22JAN2021 
4 
PRÉCIS 
Study Title: Randomized Controlled Pilot Trial of Dapagliflozin in Alzheimer’s Disease 
 
Objectives  
1. Examine the effect of 12 weeks of 10mg dapagliflozin once daily on cerebral n-
acetyl aspartate (NAA) levels using magnetic resonance spectroscopy (MRS). 
2. Explore the effect of dapagliflozin on 
a. Systemic NAA levels in blood and urine. 
b. Cerebral metabolism (fluorodeoxyglucose [FDG] PET). 
c. Systemic metabolic biomarkers that indicate and quantify secondary 
metabolic effects.  
d. Cognition 
3. Examine the safety and tolerability of dapagliflozin in individuals with AD including 
Mild Cognitive Impairment due to AD). 
 
 
Design and Outcomes   
 
This is a double-blind, randomized, placebo-controlled, parallel group, 12-week study performed 
at a single site (KU ADC) to investigate the effect of dapagliflozin in participants with probable 
AD  or MCI due to AD.  A total of 48 participants will be enrolled with 2:1 randomization to 10mg 
dapagliflozin once daily (n=32) for 12 weeks vs matching placebo (n=16).   
 
The primary objective of the study is to assess the effect of 12 weeks of 10mg dapagliflozin 
once daily on cerebral NAA (a proxy measure of mitochondrial mass) in participants with AD or 
MCI due to AD.   
 
Exploratory outcomes will be assessed with phlebotomy, urine collection, MRI/MRS, FDG-PET, 
cognitive testing, DEXA scanning, and indirect calorimetry at baseline and 12 weeks.  These 
procedures will allow us to assess: 
• 
N Acetyl-Aspartate (NAA) 
o Cerebral NAA (as measured by MRS)  
o Systemic NAA levels (in blood and urine) 
• 
Cerebral metabolism (by FDG PET) 
• 
Systemic metabolic effects  
o Lipids (total cholesterol, LDL, HDL) 
o Plasma beta-hydroxybutyrate 
o Insulin resistance (Hemoglobin A1c, glucose and insulin during tolerance 
testing) 
o Catabolic/Anabolic state [activated AKT and MTOR] 
o Mitochondrial function measures [platelet cytochrome oxidase and citrate 
synthase] 
o Inflammatory mechanisms [MCP-1, eotaxin, TNF alpha, CRP] 
o Body composition (DEXA scanning for fat and lean mass)  
o Resting metabolic rate (indirect calorimetry).   
• 
Cognitive effects will be assessed at baseline and week 12 using the Alzheimer’s 
Disease Assessment Scale-Cognitive Subscale 14 (ADAS-Cog14) and individual 
tests of Logical Memory I and II, Trailmaking A and B, and Stroop Word Color Test.  
• 
12 participants will be enrolled in an optional MRI/MRS sub-study with repeat 
MRI/MRS prior to randomization to assess scan-rescan reliability of the NAA 
measure.   
 


Protocol Version 8.0, 22JAN2021 
5 
Safety and tolerability of dapagliflozin (10mg daily) will be monitored throughout the study and 
formally at every study visit by assessing for any adverse events (AE’s), measuring vital signs 
and body weight, and performing safety labs (including a comprehensive metabolic panel [CMP] 
and complete blood count [CBC] with differential).  In addition, we will conduct physical and 
neurological examinations at screening and at end of treatment (EOT). We will examine the 
incidence and severity of AEs and the rate of discontinuations due to AEs.   
 
Interventions and Duration  
Participants will be randomized (2:1 ratio) to either dapagliflozin 10mg a day vs matching 
placebo for a treatment duration of 12 weeks.  The total study duration for participants will be 
will be up to 18 weeks.  In-person screening and baseline assessments will occur within a 4-
week time-window prior to randomization.  Study drug (or placebo) will begin at randomization 
(time 0) and in person assessments will occur at weeks 1, 4, 8, and 12 weeks (when study drug 
is stopped) and an end of study visit at 14 weeks.  
  
Sample Size and Population  
A total of 48 participants with probable AD or MCI due to AD will be enrolled in the study with 
2:1 randomization to 10mg dapagliflozin (n=32) vs matching placebo (n=16) for 12 weeks. To 
minimize potential risks that may associate with weight loss we will only enroll participants 
whose BMI is greater than or equal to 23.0.  
 
 


Protocol Version 8.0, 22JAN2021 
6 
 
STUDY TEAM ROSTER  
Principal Investigators:    
    Jeffrey Burns, M.D., M.S.  
 
4350 Shawnee Mission Parkway Fairway, KS 66205 
 
ADC office:  913-588-0555 
 
ADC Fax:  913-945-5035 
    Jburns2@kumc.edu  
 
Main responsibilities/Key roles: PI 
 
 
 
Russell Swerdlow, MD 
 
4350 Shawnee Mission Parkway Fairway, KS 66205 
 
ADC office:  913-588-0555 
 
ADC Fax:  913-945-5035 
    rswerdlow@kumc.edu     
 
Main responsibilities/Key roles: Co-PI 
 
Co-Investigators:   
William Brooks, PhD  
Hoglund Brain Imaging Center 
 
wbrokks@kumc.edu  
     
Main responsibilities/Key roles: neuroimaging analyses 
 
 
 
Megan Baumgardner, D.O 
4350 Shawnee Mission Parkway Fairway, KS 66205 
 
mbaumgardner@kumc.edu  
     
Main responsibilities/Key roles: medical ratings 
 
 
 
In-Young Choi, PhD 
Hoglund Brain Imaging Center 
 
ichoi@kumc.edu  
     
Main responsibilities/Key roles: MRS analyses 
 
 
Aditi Gupta, MD 
 
Department of Nephrology 
 
agupta@kumc.edu 
 
Main responsibilities/Key roles: Safety and medical ratings 
 
 
Jonathan Mahnken, PhD 
 
Department of Biostatistics 
 
jmahnken@kumc.edu 
 
Main responsibilities/Key roles: Lead statistician 
 
 
 
Jill Morris, PhD 
4350 Shawnee Mission Parkway Fairway, KS 66205 
 
Jmorris2@kumc.edu  
     
Main responsibilities/Key roles: metabolic laboratory analyses 
 
 
 
 
Eric Vidoni, PhD 
4350 Shawnee Mission Parkway Fairway, KS 66205 
 
evidoni@kumc.edu  
     
Main responsibilities/Key  roles: FDG PET analyses 
 
 
Heather Wilkins, PhD 
4350 Shawnee Mission Parkway Fairway, KS 66205 
 
hwilkins@kumc.edu  
     
Main responsibilities/Key roles: mitochondrial analyses 
  
 
 
 
 
 
 


Protocol Version 8.0, 22JAN2021 
7 
PARTICIPATING STUDY SITES: SINGLE SITE STUDY 
 
University of Kansas Alzheimer’s Disease Center 
4350 Shawnee Mission Parkway Fairway, KS 66205 
913-588-0555 
ADC office:  913-588-0555 
ADC Fax:  913-945-5035 
 Jburns2@kumc.edu 
 
 
 


Protocol Version 8.0, 22JAN2021 
8 
1 
STUDY OBJECTIVES 
 
1.1 Primary Objective 
 
The primary objective of the study is to assess the effect of 12 weeks of 10mg 
dapagliflozin once daily on cerebral NAA (a proxy measure of mitochondrial mass) in 
participants with AD and MCI due to AD. 
 
 
1.2 Exploratory Objectives 
 
The exploratory objectives are to evaluate the effect of 12 weeks of 10mg dapagliflozin 
once daily on systemic measures of NAA, metabolic biomarkers in the brain and 
periphery, and cognition in participants with AD and MCI due to AD. 
 
Specifically we will test the effects of dapagliflozin on 
a. Systemic NAA levels in blood and urine. 
b. Cerebral metabolism (FDG-PET) 
c. Systemic metabolic biomarkers that indicate and quantify secondary metabolic 
effects (lipids, ketones, insulin resistance, anabolic/catabolic response measures, 
mitochondrial function, inflammatory markers, body composition, and resting 
metabolic rate).  
d. Cognition   
 
 
1.3 
Safety Objective 
 
Examine the safety and tolerability of 12 weeks of 10mg dapagliflozin once daily in 
participants with AD and MCI due to AD.    
 
 
 


Protocol Version 8.0, 22JAN2021 
9 
 
2 
BACKGROUND AND RATIONALE  
 
2.1 Background on Condition, Disease, or Other Primary Study Focus 
 
2.1.1 Alzheimer’s Disease 
 
Increased life expectancy in the US has fueled an unprecedented growth in the 
prevalence of AD, with over 5 million Americans affected and nearly 15 million projected 
to have the disease by 2050. AD is now America’s most expensive disease (~$259 
billion), more costly than cancer and heart disease.1 Treatment options are limited.  
FDA-approved therapies are available but have modest and limited symptomatic 
benefits.   
 
Drug development efforts are largely focused on disease-modifying approaches, with the 
majority of these efforts aimed at interfering with a hallmark neuropathological change of 
AD, amyloid plaques.  These efforts to target and disrupt amyloid have not yet produced 
evidence of clinical benefit.   These failures have led, in part, to a diversifying portfolio of 
approaches that includes targeting neurofibrillary tangles, inflammation, synaptic activity, 
vascular function, and mitochondrial and metabolic function.   
 
2.1.2 AD and Energy Metabolism  
 
Abundant evidence demonstrates aberrant energy metabolism occurs in AD.2-26   Energy 
metabolism research constitutes a major component of our federally supported 
University of Kansas Alzheimer’s Disease Center (KU ADC) (P30AG035982), with 
investigators focused on defining the nature, causes, and consequence of altered 
energy metabolism in AD.  The KU ADC supports an Alzheimer’s Treatment Program 
(ATP) that conceptualizes, translates, and tests approaches that target energy 
metabolism for AD treatment and prevention.27-33 
 
Fluorodeoxyglucose positron emission tomography (FDG PET) and mitochondria studies 
demonstrate perturbed energy metabolism in AD.34  Brain glucose utilization declines 
with advancing age35-38 and this decline extends in magnitude and distribution in those 
with AD.20, 21, 39-43  Direct measures of metabolism in brain tissue homogenates from 
individuals with AD show less glucose consumption than control homogenates.44  
Electron microscopy reveals perturbed mitochondrial structures6, 45-47 and increased 
mitochondrial fission.48-50 Several mitochondria-localized enzymes, including pyruvate 
dehydrogenase complex,51 α-ketoglutarate dehydrogenase complex,14 and cytochrome c 
oxidase (COX) demonstrate reduced activities.12, 13, 52-60 The AD COX defect, 
interestingly, also exists outside the brain12, 53-55, 60-62 and at least partly depends on 
mitochondrial DNA (mtDNA).34, 63, 64 Additionally, asymptomatic individuals at higher risk 
of AD (both due to the presence of an APOE4 allele or an AD-effected mother) also 
show AD-like glucose utilization patterns on FDG-PET.23, 24, 65  Although neuron loss and 
synaptic degradation could contribute to reduced brain glucose utilization in AD, the 
presence of metabolic changes in preclinical and asymptomatic at-risk individuals 
suggests primary bioenergetic brain changes play an important role in the AD 
pathophysiological process.  
 
Targeting Energy Metabolism. We were among the first to propose using energy 
metabolism manipulation to treat AD.66-68 Currently, the KU ADC supports the 


Protocol Version 8.0, 22JAN2021 
10 
development of new energy metabolism interventions. Our bench-to-bedside programs 
focus on the molecular and clinical impact of exercise and diet,30, 32, 69-74 the causes and 
consequences of altered insulin signaling,75-77 developing new energy metabolism 
biomarkers,78 and developing rational new pharmacologic approaches.27-29, 33, 79, 80   
 
To date, clinical trials that intentionally target energy metabolism in AD include 
coenzyme Q and idebenone (to enhance electron transfer through the electron transport 
chain),81-84 rosiglitazone (promote mitochondrial biogenesis),85, 86 and latrepirdine 
(claimed to stabilize mitochondrial membranes).87, 88  These interventions showed little to 
no benefit in clinical trials, which could reflect no physiologic engagement of their 
intended targets (coenzyme Q, idebenone), concentrations insufficient to alter targets 
(rosiglitazone), or a profoundly limited understanding of their mitochondrial effects 
(latrepirdine). This experience underscores why rational bioenergetic medicine design 
must consider existing mechanistic data and pursue new mechanistic insight.28 
 
2.1.3 Dapagliflozin and Metabolic Effects  
 
Dapagliflozin is a sodium-glucose transporter 2 (SGLT2) inhibitor used to treat Type 2 
diabetes.  The SGLT2 inhibition results in a loss of glucose and its associated energy via 
the urine.  This has prominent systemic metabolic effects in Type 2 diabetes, resulting in 
reduced HbA1c and body weight.  In a 2-year study, dapagliflozin reduced HbA1c by 
0.3%, weight by 4.5kg and fat mass by 2.8kg (Bolinder et al 2013). The reduction in 
body weight is faster over the first few weeks, followed by a more gradual decline that 
plateaus between 24 and 50 weeks of therapy (Bolinder et al 2012). Insulin sensitivity 
increased, as measured by a 20% increase in glucose disappearance rate, after 12 
weeks of 5mg dapagliflozin (Mudaliar S et al 2014), a finding that was also repeated in a 
2 week study (Merovci A et al 2014).  Dapagliflozin also results in increased hepatic 
glucose production, increased fasting glucagon levels, and decreased fasting insulin 
levels (Merovci A et al 2014). An increased glucagon/insulin ratio is expected to reduce 
hepatic de novo lipogenesis and in parallel increase hepatic fatty acid oxidation that 
results in reduced liver fat content.    
 
Additionally, chronic dapagliflozin treatment led to robust increases in systemic 
measures of NAA, which is synthesized within mitochondria and considered a biomarker 
of mitochondrial mass (confidential Metabolon data).  Inducing mitochondrial biogenesis 
to mitigate or reverse failing AD bioenergetics is increasingly considered a rational AD 
therapeutic goal, and dapagliflozin represents a logical agent for achieving this goal. 
 
2.2 Study Rationale 
 
2.2.1 Rationale for Study 
 
This study is an exploratory pilot study investigating safety, tolerability and metabolic 
effects of dapagliflozin in individuals with AD and MCI due to AD.  Dapagliflozin has 
been shown to have effects on glucose, insulin and the production of ketone bodies.  
Additionally metabolomic data suggests potential mitochondrial effects. As AD is 
increasingly recognized as having metabolic manifestations, new therapeutic strategies 
are targeting metabolic processes.  Therefore, this study assesses the effect of 
dapagliflozin 10mg daily for 12 weeks on cerebral and systemic NAA, secondary 
metabolic effects (glucose, insulin, ketones, lipids, mitochondrial function, inflammation), 
cognitive function, and safety and tolerability. 


Protocol Version 8.0, 22JAN2021 
11 
 
2.2.2 Rationale for Study Design 
 
This is an exploratory pilot study to examine the effects of dapagliflozin in participants 
with AD and MCI due to AD to provide an estimate of its effect on cerebral NAA (a proxy 
measure of mitochondrial mass), explore other metabolic effects, and to collect 
information to further understand and establish its safety and tolerability in our target 
population.  
 
Participants will be randomized to either 12 weeks of 10mg dapagliflozin once daily vs 
placebo to examine potential effects on cerebral and systemic NAA (reflective of 
mitochondrial mass or respiration-related carbon flux) and other potentially beneficial 
secondary metabolic effects.  This study will be conducted in individuals with AD or MCI 
due to AD with a BMI greater than or equal to 23 to reduce the risk of potentially 
exacerbating weight loss in more frail individuals.  
 
The study duration of 12 weeks was chosen based on prior studies of dapagliflozin that 
demonstrated metabolic effects are present before 12 weeks including effects on liver 
fat, body weight, and insulin sensitivity in those with diabetes.  Moreover, 12 weeks is 
sufficient for expecting that putative effects on cerebral NAA will be present.   
 
2.2.3 Dose Rationale 
 
Dapagliflozin is FDA-approved as an adjunct to diet and exercise to improve glycemic 
control in patients with type 2 diabetes.  The recommended dose is 10 mg orally once 
daily at any time of the day regardless of meals.  There are no dose adjustments 
required or recommended for individuals with renal impairment, geriatric patients, or 
those without diabetes.  Thus, the dose of dapagliflozin 10mg daily will be used in this 
study.   
 
2.3 
Benefit/Risk and Ethical Assessment 
 
This study will provide important data on the potential role of dapagliflozin in treating 
individuals with AD or MCI due to AD.  Additionally, it will provide data to better 
understand the role of therapeutically targeting metabolic processes as a treatment 
strategy for individuals with AD or MCI due to AD.  Advancing these scientific themes 
benefits humankind though it may not provide clear clinical benefits to those enrolled.   
 
There are, however, potential clinical benefits for those enrolled in this study, including 
potentially beneficial effects on glucose and insulin levels, blood pressure, and body 
weight.   
 
Establishing the safety and tolerability of dapagliflozin in AD and MCI due to AD is a goal 
of this study.  Dapagliflozin is associated with small increases in AEs including urinary 
tract and genital infections (dysuria, polyuria, vulvovaginitis, balanitis) and back pain 
which occurred more commonly in placebo-controlled studies in the dapagliflozin group 
versus placebo.  Other potential AEs include orthostatic hypotension and volume 
depletion. The risk for hypoglycemia is low even in diabetics treated with mono therapy.   
 
 
 
 


Protocol Version 8.0, 22JAN2021 
12 
3 
STUDY DESIGN 
 
A double-blind randomized, placebo-controlled, parallel group, 12 week study to 
investigate the effect of 10mg daily dapagliflozin vs. placebo for 12 weeks in participants 
with probable AD or MCI due to ADwhose BMI is greater than or equal to 23.0. 
  
3.1 Primary Objective 
 
The primary objective of the study is to estimate the effect of 12 weeks of 10mg 
dapagliflozin once daily on cerebral NAA (a proxy measure of mitochondrial mass) in 
participants with AD or MCI due to AD. 
 
3.2 Exploratory Objectives 
 
The exploratory objectives are to evaluate the effect of 12 weeks of 10mg dapagliflozin 
once daily on systemic measures of NAA (a proxy measure of mitochondrial mass), 
metabolic biomarkers in the brain and periphery, and cognition in participants with AD and 
MCI due to AD. Specific exploratory outcomes are:  
• 
Systemic NAA levels in blood and urine. 
• 
Cerebral metabolism (FDG-PET) 
• 
Systemic metabolic biomarkers that indicate and quantify secondary metabolic 
effects (lipids, ketones, insulin resistance, anabolic/catabolic response measures, 
mitochondrial function, inflammatory markers, body composition, and resting 
metabolic rate).  
• 
Cognition   
2. 12 participants will be enrolled in an optional MRI/MRS sub-study with repeat 
MRI/MRS prior to randomization to assess scan-rescan reliability of the NAA 
measure.   
 
3.3 
Safety Objective 
 
Examine the safety and tolerability of 12 weeks of 10mg dapagliflozin once daily in 
participants with AD and MCI due to AD.    
 
 
 
4 
SELECTION AND ENROLLMENT OF PARTICIPANTS  
 
4.1 Inclusion Criteria  
 
For inclusion in the study, participants must fulfil the following criteria: 
1. 
Provision of informed consent prior to any study specific procedures.  
2. 
Have a diagnosis of probable AD, or MCI due to AD per McKhann et al. criteria 
3. 
Have a body mass index (BMI) ≥23 
4. 
Age 50-85  
5. 
Have a reliable and competent study partner who is willing to accompany the 
participant to all study visits, monitor compliance of study medication 
administration, and observe/report any changes in the participant’s health 
throughout the study duration  
6. 
Are on stable doses of concurrent medications for at least 4 weeks prior to the 
screening visit  
7. 
Speaks English as his/her primary language. 


Protocol Version 8.0, 22JAN2021 
13 
8. 
Females of child-bearing potential (i.e., pre-menopausal) must have a negative 
urine pregnancy test at the screening visit and must agree to use of 
contraception throughout the trial and for 30 days after the last dose of study 
medication. The approved methods of contraception are abstinence, the 
consistent use of an approved oral contraceptive (birth control pill or “the pill”), an 
intrauterine device (IUD), hormonal implants, contraceptive injection, double 
barrier method (diaphragm with spermicidal gel or condom with contraceptive 
foam). 
 
 
4.2 Exclusion Criteria  
Participants will not be enrolled if any of the following exclusion criteria are met: 
1. 
Received an investigational product in another clinical study during the last 4 
weeks prior to screening 
2. 
Diagnosis of Type 1 diabetes  
3. 
Diagnosis of Type 2 diabetes treated with insulin, sulfonylureas, glucagon like 
peptide1 receptor agonists (GLP-1), thiazolidinedione (TZD) or SGLT2 inhibitors 
(metformin monotherapy is allowed). 
4. 
Estimated Glomerular Filtration Rate (eGFR; MDRD) <45 mL/min/1.73m2 at 
screening or unstable renal disease.  
5. 
Any condition when MRI is contraindicated such as, but not limited to, having a 
pacemaker or claustrophobia. 
6. 
Severe hepatic injury and/or significant abnormal liver function defined as 
aspartate aminotransferase (AST) >3x upper limit of normal (ULN) and/or alanine 
aminotransferase (ALT) >3x ULN.  Total bilirubin >2.0 mg/dL (34.2 μmol/L) 
7. 
Intolerance or allergy to dapaglifozin or any other SGLT2 inhibitor or any other 
substance in the tablets. 
8. 
Dementia or cognitive impairment due to causes other than AD  
9. 
History of recurrent urinary tract infection 
10. Active mycotic genital infection 
11. History of diabetic ketoacidosis  
12. Potentially confounding, serious, or unstable medical conditions such as: 
a. 
cancer within the past 3 years (except basal cell, squamous cell, or 
localized prostate cancer) 
b. 
a recent cardiac event (i.e. heart attack, angioplasty, etc. within the 3 
months prior to screening visit) 
c. 
other conditions that pose a potential safety risk or confounding factor in 
the investigator’s opinion 
13. Any abnormal physical examination assessment or vital sign assessment at the 
screening visit that is deemed to be clinically significant by the principal 
investigator. 
14. Any abnormal clinical laboratory test result at the screening visit that is deemed 
to be clinically significant by the principal investigator. 
 


Protocol Version 8.0, 22JAN2021 
14 
 
4.3 Study Enrollment Procedures  
 
4.3.1 Recruitment 
Participants for this trial will be recruited through the KU ADC’s Recruitment program.  
Methods include referrals from KU Memory Disorders Clinic, referrals from outside 
physicians, regular community outreach / education seminars about KU ADC currently 
enrolling trials, and posted IRB-approved advertisements on social or other traditional 
media.  
 
Once an individual contacts the KU ADC indicating interest in the trial, a full intake of 
information for recruitment consideration is obtained through the KU ADC Recruitment 
and Eligibility program, with the potential participant’s consent.  During the initial pre-
screening process, if it is determined that medical records are needed to assist in 
making an initial eligibility determination, the potential participant (or their legally 
authorized representative) is asked to complete a Release of Medical Information form 
and records from the potential participant’s applicable physicians are requested and 
obtained.  If the potential participant appears to be a good candidate for the trial, their 
recruitment intake information is provided to the study team for further review and 
discussion with the potential participant and his/her study partner. 
 
4.3.2 Informed Consent, Screening, and Enrollment  
The potential participant and his/her study partner are provided with the informed 
consent form (ICF) for their review prior to scheduling a study screening visit. Any initial 
questions they may have are addressed.  It is explained to potential participants and 
their study partners that, although some eligibility criteria (such as age and medical 
conditions) can be determined ahead of time, many eligibility criteria cannot be 
determined until after all screening procedures take place. 
 
It is also explained to the participant that, due to the nature of this trial enrolling 
individuals with known cognitive impairment, there may be a need for the participant’s 
legally authorized representative to actually provide the consent for their participation 
using a surrogate consent form, with the participant providing his/her assent.  The 
assessment and determination of whether the participant has sufficient capacity to 
provide his/her own consent is made during the consenting process at the first study visit 
by the delegated study team member.   For this reason, it is established with the 
potential participant prior to the screening visit who has legal authority to serve as 
his/her representative per the state of Kansas, the state in which all study procedures 
take place.   If any legal documents, such as durable power of attorney, are available, 
these will be requested to be brought with the participant to the first study visit. 
 
Following the screening visit, the results of all eligibility testing are provided to the 
principal investigator for his review. The investigator documents review and whether the 
participant met all inclusion criteria and did not meet any exclusion criteria.  A clear 
statement of the investigator’s determination for the participant’s suitability to be enrolled 
in the trial is documented prior to any subsequent baseline procedures taking place.  
 
Participants who fail to meet the eligibility criteria will be excluded.  Participants who are 
enrolled, but subsequently found not to meet all the eligibility criteria will be withdrawn 
from the study. 


Protocol Version 8.0, 22JAN2021 
15 
 
A participant screening log will document all participants who sign informed consent for 
this trial and will list their final disposition, including whether they were determined to be 
ineligible/screen failed, were enrolled and completed the study, and whether they were 
enrolled but withdrew or their participation was stopped early.  The reason for screen 
failure and for withdrawal/early termination will also be recorded. 
  
Eligible participants will be randomized in a 2:1 ratio to either 10 mg dapaglifozin (n=32) 
or matching placebo (n=16). Randomization will be completed by an unblinded staff 
member using a randomization table to create the order of dispensing active vs. 
placebo. This unblinded staff member will use the table to create code numbers for the 
bottles of study medication and will be responsible for labeling the bottles in a manner to 
ensure blinding of all other study staff.  A second unblinded staff member will assist in 
labeling of the bottles to provided second verification of correct labeling and will also 
serve as a back-up to provide randomization bottle numbers to blinded staff if needed. 
 
When each participant has been determined to be eligible for the trial, the blinded staff 
member will submit a request to the unblinded staff member for randomization.  The 
unblinded staff member will provide the blinded staff member with a document listing 
only the participant identification number and the bottle numbers to be dispensed.  
 
4.3.3 Randomization  
The Lead Statistician will generate a randomization schedule upon study approval using 
a statistical software package.  The Lead Statistician will send the schedule directly to 
the site pharmacy for package labeling, and will be stored in an electronic, password-
protected file to maintain appropriate levels of blinding for other members of the study 
team during the conduct of this trial. Randomization codes will be assigned to eligible, 
consented participants on a strictly sequentially basis. 
 
 
5 
STUDY INTERVENTIONS  
 
5.1 Interventions, Administration, and Duration  
 
Dapagliflozin 10mg po daily or placebo for 12 weeks.  Study drug or placebo will be 
provided to the participants at baseline, week 4, and week 8.  Pill compliance 
assessments will be completed at week 4, week 8, and week 12.  
  
5.2 Handling of Study Drug  
 
Identity of investigational product(s) 
Investigational 
product 
Dosage form and strength 
Manufacturer 
Dapagliflozin  
10 mg, Green, plain, diamond 
shaped, film coated tablet (orally)  
AstraZeneca 
 
Matching 
placebo for 
dapagliflozin  
Green, plain, diamond shaped, 
film coated tablet (orally). Does 
not contain active ingredient 
AstraZeneca 
 
 
 


Protocol Version 8.0, 22JAN2021 
16 
Primary packaging of the Investigational Medicinal product (IMP) will be carried out by 
AstraZeneca or their designee in accordance with Good Manufacturing Practice (GMP).  
Unlabeled bottles (identical) containing 35 tablets of each IMP will be provided by 
AstraZeneca. 
 
The tablets contain lactose, which may cause discomfort in lactose-intolerant individuals. 
Label, storage and distribution are a sponsor’s responsibility.  
 
Preparation and labelling of Investigational Medicinal Product 
The sponsor or their designee (will issue labels, label the bottles and release package 
study drug/IMP) will label the IMP in accordance with Good Manufacturing Practice (GMP) 
and local regulatory guidelines for labelling. The labels will fulfill GMP Annex 13 
requirements for labelling.   
 
Drug accountability logs will be maintained throughout the study and will document study 
drug dispensation, return, and destruction.   Unused study drugs will be destroyed locally 
per the site’s Standard Operating Procedure. 
 
Storage 
All study drugs should be kept in a secure place under appropriate storage conditions. The 
IMP label on the bottle specifies the appropriate storage. 
 
The study treatment is double blind for participants, investigators and study personnel 
(other than the Lead statistician) and will remain so throughout the entire study unless the 
blind must be broken for safety concerns. To ensure blinding of the treatments, the active 
and dose-matched placebo tablets will be identical in appearance and in identical 
packaging and labelling. 
 
5.3 Concomitant Interventions  
 
All current medications taken by the participant will be recorded at the first study visit.  All 
changes in medications during the study will also be recorded.  
• 
The participants should not use or have not used dapagliflozin or any other SGLT2 
inhibitors within 4 weeks of visit 1  
• 
The participants should not use or have not used insulin, GLP-1 or GLP-1 
analogues, and sulfonylureas within 4 weeks of visit 1 
• 
Oral antidiabetic therapies other than the pre-specified use of metformin and TZDs 
should not be used or have not been used within 4 weeks of visit 1 
• 
Other medication other than that described above, which is considered necessary 
for the participant’s safety and well-being, may be given at the discretion of the 
Investigator and recorded in the appropriate sections of the Case Report Form. 
 
5.4 Adherence Assessment  
 
Study medication adherence will be monitored throughout the trial.  The study partner will 
oversee administration of the study mediation in the participant’s home.   The participant 
and study partner will be instructed to return all used and unused study medication 
containers to the study staff at specified visits.  At these visits, medication compliance will 
be measured by pill count and a percent compliance will be calculated based on the 
number of pills taken (not returned) divided by the number of pills expected to have been 
taken.  Accountability for pills dropped/lost will be recorded and factored into the 
calculation.  


Protocol Version 8.0, 22JAN2021 
17 
If compliance is less than 90% or greater than 100%, participants and their study partners 
will be counseled on the importance of accurate compliance and methods to help improve 
compliance will be discussed. Only study drug compliance of less 80% compliance or 
greater than 110% will be considered a protocol deviation.  Participants will not be 
removed from the study for non-compliance. 
 


Protocol Version 8.0, 22JAN2021 
18 
6 STUDY PROCEDURES 
 
6.0 Schedule of Evaluations 
Procedure 
Screening 
(-30 to 0 days) 
Baseline 
(-30 to 0 
days) 
Week 1   (+/- 3 
days) 
Week 4 (+/- 7 
days) 
Week 8 (+/- 7 
days) 
Week 12 
(+/- 7 days) 
Week 14 
End-of-Study 
(+/- 7 days) 
Visit Number 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Informed Consent 
X 
  
  
  
  
  
  
Medical History Review 
X 
  
  
  
  
  
  
Adverse Event Review 
X 
X 
X 
X 
X 
X 
X 
Concurrent Medication Review 
X 
X 
X 
X 
X 
X 
X 
Vital Signs, including weight 
X 
X 
X 
X 
X 
X 
X 
Blood (8 ml)  and Urine Collection 
for Safety Labs*  
X 
X 
X 
X 
X 
X 
X  
Neurological Exam 
X 
  
  
  
  
X 
  
Physical Exam 
X 
X 
X 
X 
X 
X 
X 
Urine Pregnancy Test, As Needed 
X 
  
  
  
  
  
  
MMSE 
X 
  
  
  
  
 X 
  
Review of Inclusion/Exclusion 
Criteria 
X 
  
  
  
  
  
  
Blood Collection (56 ml) for 
Biomarker Outcome Measures**  
  
X 
  
  
  
X 
  
Blood Collection (5ml) for ApoE 
genotype 
 
X 
 
 
 
 
 
Urine collection for NAA**  
 
X 
 
 
 
X 
 
Cognitive Testing***   
  
X 
  
  
 
X 
  
FDG PET 
  
X 
  
  
  
X 
  
MRI/MRS 
  
X 
  
  
  
X 
  
Resting Metabolic Rate (Indirect 
Calorimetry) 
  
X 
  
  
  
X 
  
Oral Glucose Tolerance Test, 
including blood draws at 7 
timepoints for each test 
  
X 
  
  
  
X 
  
DEXA 
  
X 
  
  
  
X 
  
Dispense Study Medications  
  
X 
  
X 
X 
  
  
Compliance Pill Count 
  
  
  
X 
X 
X 
  
 
 
 
 
 
 
 
 
*  Comprehensive Metabolic Panel and Complete Blood Count  
** Outcome measures include Lipids, Ketones, HbA1c, AKT, mTOR, Platelet Cytochrome Oxidase and Citrate Synthase, MCP-1, Eotaxin, TNFalpha, CRP, 
& NAA 
*** Cognitive testing: ADAS Cog-14, Logical Memory I and II, Stroop Color Word Test, Trailmaking A and B 


Protocol Version 8.0, 22JAN2021 
19 
6.1 Description of Evaluations  
 
The study will consist of 7 study visits.  The more intensive baseline and week 12 visits will 
require 3 to 5 trips to different locations.  Primary study visits will be conducted at the 
Clinical and Translational Science Unit (CTSU), 2 MRI sessions will be conducted at the 
Hoglund Brain Imaging Center to acquire MRI/MRS data, and 2 FDG PET sessions will be 
conducted at the University of Kansas Hospital.  The visits and detailed study procedures 
are outlined below.   
 
6.2.1 Screening Period (Visit 1) 
 
The initial screening visit will occur in the Clinical and Translational Science Unit (CTSU) 
as a single visit to complete the following procedures:    
• 
Informed consent 
• 
Medical history  
• 
Review of concurrent medications 
• 
Mini Mental Status Examination (MMSE) administered by a trained 
psychometrician 
• 
Blood and urine collection for safety labs  
• 
Vital signs 
• 
Height measurement using a standard stadiometer 
• 
Body weight measurement using a calibrated scale  
• 
A physical and neurological examination.  
• 
If the participant is a female of childbearing potential, a urine pregnancy test will 
be conducted.   
• 
Adverse event (AE) review/check 
• 
Review of inclusion / exclusion criteria 
 
The screening period lasts up to 4 weeks and includes the time from signing of the 
consent form until enrollment.   At or before Visit 1, the study details will be explained to 
the participant (or his or her legally authorized representative) and the study partner.  
Before any study procedures take place, full informed consent will be obtained and 
documented.  
 
 
6.2.1.1 Description of Screening Procedures  
 
Review of Medical History: A complete medical history will be obtained, including a history 
of cognitive impairment and diagnosis of Alzheimer’s disease. 
 
Review of Concurrent Medications:  Ongoing concurrent medications taken by the 
participant (including prescription and over-the-counter/vitamins/herbal supplements) and 
any medications taken within 30 days prior to the screening visit (Visit 1) will be recorded. 
 
Mini Mental Status Exam (MMSE): The MMSE will be completed at screening and Week 
12 (Visit 6).  The MMSE is a brief, 30-item questionnaire that is widely used to provide an 
estimate of the severity of cognitive impairment at any given point in time.  Lower scores 
indicate greater impairment.   
 
Vital Signs: Body temperature, sitting and standing blood pressure, respiratory rate, heart 
rate, and body weight will be measured at every study visit.  At the screening visit, height 
will also be measured. 


Protocol Version 8.0, 22JAN2021 
20 
 
Physical and Neurological Examination:  The study clinician will conduct a physical 
examination at screening and all visits, of the participant’s skin, head, neck, nose, throat, 
eyes, chest, lungs, heart, abdomen, and muscles to check for signs of disease. During the 
neurological examination, the study clinician will check the participant’s mental status, 
cranial nerve function, motor system, sensory system, reflexes, coordination, gait, posture, 
and stability.  If any abnormal signs are detected in these examinations that the 
investigator determines to be clinically significant, the participant will not be eligible for the 
trial. 
 
Clinical Safety Urine and Laboratory Tests:   Approximately 8 ml of blood will be drawn at 
Screening Visit 1 and all subsequent visits  to assess a comprehensive metabolic panel 
(CMP) and complete blood count with differential (CBC) in the fasting or non-fasting state.  
Fasting state will be recorded at time of collection. Baseline and Week 12 blood draws will 
be done in the fasting state at the same time as the collection of blood for the biomarker 
outcome assessments.  A urine sample will also be collected for routine safety tests at all 
subsequent visits. 
 
On screening labs, if eGFR is <45 mL/min/1.73m2, the participant will not be eligible to 
enroll in this trial.  If AST is  >3x upper limit of normal (ULN) and/or ALT is  >3x ULNand/or  
total bilirubin  is >2.0 mg/dL (34.2 μmol/L), the participant will not be eligible for this trial.  If 
any other clinical laboratory findings from this screening visit are abnormal and determined 
to be clinically significant, the participant will not be eligible for this trial. 
 
Urine Pregnancy Test:  Female participants who are still of child-bearing potential must 
undergo a urine pregnancy test at the screening visit.  Any participant with a positive 
pregnancy test will not be eligible for the trial. 
 
Review of Inclusion/ Exclusion Criteria:  Once all screening visit procedures are complete, 
the principal investigator, or his/her delegate in his absence, will review the findings to 
make a determination of whether the participant has met all inclusion criteria and not met 
any exclusion criteria and whether the participant is suitable to enroll in the trial.  This 
review will be conducted before any Visit 2 / Baseline procedures are conducted. 
 
 
     6.2.2   Baseline and Enrollment Visit (Visit 2) 
 
Baseline procedures may begin anytime following completion of all screening 
procedures and determination that the participant meets entry criteria.  Baseline 
measures may be completed in any order to accommodate the participant and 
scheduling limitations of ancillary support facilities with the exception that the 
dispensation of the study medication occurs last.  This final baseline procedure must be 
completed within 30 days of Visit 1/ Informed Consent.   
 
Baseline measures to be completed include: 
• 
Review of concurrent medications 
• 
Review of adverse events 
• 
Vital signs 
• 
Weight 
• 
Blood and urine collection for clinical safety laboratory tests 
• 
Blood collection for blood biomarker outcome measures 
• 
Urine collection for NAA testing 


Protocol Version 8.0, 22JAN2021 
21 
• 
Physical examination 
• 
Cognitive battery 
• 
MRI/MRS 
• 
FDG-PET 
• 
Metabolic assessments 
• 
Study medication dispensation and instruction 
 
Description of Baseline Procedures 
Prior to administering any study medication, the following baseline measures will be 
completed: 
 
Blood Biomarker Outcome Measures:  Blood will be collected in the AM (after an 
overnight fast to assess biomarker outcomes at Baseline (Visit 2) and at Week 12 
(Visit 6).   Approximately 70 mL of blood will be collected to conduct the following 
biomarker assessments. Specific blood collection and processing instructions will be 
defined in a separate laboratory manual. 
• 
Apolipoprotein E genotyping (at Baseline only) using a validated allelic 
discrimination PCR assay (Swerdlow Lab). 
• 
NAA using UPLC-MS/MS method sent to Reed Laboratory to quantify.  
• 
Lipids (LDL, HDL, triglycerides) at the KU Clinical Lab 
• 
Serum β-hydroxybutyrate levels at the KU Clinical Lab 
• 
HgbA1c at the KU Clinical Lab 
• 
Mitochondrial, inflammatory, catabolic/anabolic state biomarkers and banking of 
additional fluid for future potential purposes will be collected and sent to the 
Swerdlow lab for processing. 
o The platelet fraction is used for platelet mitochondrial COX 
activity and CS measurements.  
− COX Vmax activity is determined as a pseudo first order-
rate constant (sec-1/mg protein) by measuring the 
oxidation of reduced cytochrome c at 550 nm.12, 89-91    
− The CS Vmax assay is performed spectrophotometrically 
by following the formation of 5-thio-2-nitrobenzoate (412 
nm) following the addition of 100 μM oxaloacetate at 
30°C,89, 91, 92 and when referenced to protein yields a value 
in nmol/min/mg protein. 
o The lymphocytes are used to prepare protein lysates that will be 
immunochemically analyzed to assess the catabolic/anabolic 
state by measuring activated AKT and mTOR phosphorylation. 
o The platelet free plasma will be used to perform ELISA 
measurements of the inflammatory biomarkers: Monocyte 
chemotactic protein 1(MCP-1; also called CCL2), eotaxin-1 (also 
called CCL11), and plasma tumor necrosis factor α (TNFα), and 
C-reactive protein.  
o Samples will be banked for future potential uses (metabolomics, 
exosome analyses, etc).   
 
Urine n-acetyl aspartate (NAA):  A urine sample will be collected at Baseline (Visit 2) 
and at Week 12 (Visit 6) to assess NAA in the Reed Laboratory.    
 
Metabolic Assessments:  This 3-hour visit will occur in the CTSU after a 8hour 
overnight fast and the following metabolic assessments will be completed: 


Protocol Version 8.0, 22JAN2021 
22 
 
Indirect Calorimetry: Resting metabolic rate will be assessed using indirect 
calorimetry which measures CO2 production and O2 consumption to calculate 
total energy produced. The subject will rest quietly for 10 minutes in an isolated 
room with the temperature controlled to 18-22 degrees centigrade. Subsequently, 
an Oro-Nasal Mask (Hans Rudolph- 7450 Series Silicone V2 ) will be placed over 
the subject’s nose and mouth.   The subject will continue to rest quietly while the 
measurements are taken for up to 30 minutes. Expired gases will be collected 
with a Parvo Medics TrueOne 2400 system. Criteria for a valid metabolic rate is a 
minimum of 15 minutes of steady state with steady state determined as less than 
10% fluctuation in minute ventilation and oxygen consumption and < 5% 
fluctuation in respiratory quotient. RMR will be calculated using the Weir 
equations.215 
 
Dual Energy Xray Absorptiometry (DEXA): Body composition will be assessed 
using dual energy x-ray absorptiometry (GE Lunar iDEXA) to determine fat-free 
mass, fat mass, and percent body fat at baseline, and week 12. DEXA uses very 
low X-ray doses (0.02mREM) to detect changes in body composition on the 
order of 1.6-3.8%.177, 178 
 
Oral Glucose Tolerance Test:  An Oral Glucose Tolerance test (OGTT) will be 
conducted in the CTSU to determine glucose tolerance, insulin secretion and 
insulin sensitivity. Participants will be provided a standard 75g oral glucose bolus  
followed by blood draws at 0, 10, 20, 30, 60, 90, and 120min, a time course that 
allows for accurate estimation of both insulin secretion and action.93  Glucose will 
be assayed with a YSI 2300 Analyzer. Whole blood will be collected into EDTA-
plasma Vacutainer tubes for analysis of insulin using plasma ELISA assay 
(Alpco).  We will calculate insulin secretion and insulin sensitivity. 
 
 
MRI / MRS: MRI/MRS scans will be obtained during a 1.5-hour visit to the KUMC 
Hoglund Brain Imaging Center.  Given the theoretical issue of diurnal variations in 
cerebral NAA, we will obtain longitudinal MRI / MRS scans at approximately the same 
time of day (+/-) 2 hours at baseline and week 12.  MRI/ MRS data is obtained using a 
3T system (Skyra, Siemens, Erlangen, Germany) equipped with a 32-channel receiver 
head coil.  
 
After positioning the participant supine in the magnet, three-plane scout MR images 
are acquired followed by sagittal MPRAGE MRI. We will acquire MRS data from a 
chemical shift imaging (CSI) slab oriented oblique-axial, parallel to the AC-PC line, in 
the fronto-parietal area, superior to the lateral ventricles.  From this CSI slab, we will 
determine concentrations of NAA, creatine, choline, and  myo-inositol, and glutathione 
(GSH)  from the same location using a multiple-quantum filtered CSI sequence 
developed by Dr. Choi (Co-Inv). Both NAA (the study’s primary outcome measures) 
and GSH are known to represent mitochondrial and neuronal integrity. MR spectra will 
be analyzed using the LCModel package and in-house MR data processing pipeline to 
correct for tissue fraction in each voxel using the segmented MPRAGE MRI 
corresponding to the CSI slab. 
 
Optional MRS Sub-study: A total of 12 participants will be enrolled into an optional 
MRI/MRS sub-study.  These participants will undergo an additional MRS scan during 
the baseline period. The scan will be conducted within 2 weeks of the original baseline 


Protocol Version 8.0, 22JAN2021 
23 
scan, at approximately the same time of day (+/-) 2 hours.  This optional scan will take 
place prior to any study drug dosing. This second scanning session will be used to 
assess scan-rescan reliability of the NAA measure compared to their baseline 
measure.   
 
 
FDG PET:   FDG PET images will be obtained during a 1.5-hour visit to a satellite 
location of the University of Kansas Hospital at Baseline (Visit 2) and at Week 12 (Visit 
6).  The scanner is accredited by the American College of Radiology (ACR), and our 
physicists perform annual required testing by scanning an Esser PET phantom with 
18F to assess SUV range, contrast resolution, spatial resolution, and uniformity. In 
addition to the ACR annual testing, the nuclear medicine department routinely 
performs quality control procedures on a daily, weekly, and quarterly basis.  Subjects 
will arrive for FDG PET after having fasted for a minimum of 6 hours and will have a 
catheter placed for IV administration of FDG.  Subjects will receive a single IV bolus of 
FDG.  After the appropriate amount of time has elapsed, frames are reconstructed to a 
single PET image in native space. Adverse events will be continuously monitored 
during the imaging session. The radiation dose from the two FDG PET scans our 
subjects will receive will not exceed 2100 mrem. While this amount of radioactivity 
obviously exceeds the amount obtained through normal background exposure, it is still 
considered by Radiation Safety to be well below the risk levels acceptable in research 
and medical practice. 
 
Cognitive Battery:  A cognitive battery will be conducted at Baseline (Visit 2) and at 
Week 12 (Visit 6).  The battery will include the ADAS-Cog 14, Stroop Color Word test, 
Trailmaking test (A and B) and Logical Memory I and II.  It will take approximately 1.5 
hours to complete these measures.  The ADAS-Cog is a measure of cognition that is 
widely used in clinical trials.  The 14-item version includes measures of delayed recall, 
attention, and executive function and is considered more sensitive to change than the 
original 11-item version.  We are also performing additional individual tests of verbal 
memory (Logical Memory I and II) and executive function (Stroop Color-Word test and 
Trailmaking).  
 
 
Study Medication Dispensation and Instruction:  The final baseline procedure to be 
completed will be dispensation of the study medication.  The participant will receive a 
one-month supply of study medication.  Both the participant and the study partner will 
be instructed in study medication dosing, as the study partner will oversee that the 
medication is taken per instruction.  The participant will be instructed to take one 10  
mg pill of study medication every day, starting at the baseline visit. The study 
medication can be taken anytime during the day and with or without meals but should 
be taken at about the same time every day.   
 
 
 
6.2.3    Treatment Period 
 
6.2.3.1 Week 1 (Visit 3), Week 4 (Visit 4), and Week 8 (Visit 5) Safety Assessments 
 
At each of these visits, participants will return to the CTSU to assess for safety and 
tolerability of the study drug.  Participants will undergo a review of concurrent 


Protocol Version 8.0, 22JAN2021 
24 
medications, a physical examination, review/check for any adverse events, vital signs 
including body weight and clinical safety laboratory tests.  
 
Procedures (described above) completed at these visits: 
• 
Review of concurrent medications 
• 
Review/check for any adverse events 
• 
Vital signs 
• 
Physical examination 
• 
Body weight 
• 
Blood and urine collection for clinical safety laboratory tests 
• 
Study medication compliance check (Week 4 & Week 8 only) 
• 
Dispensation of study medication (Week 4 & Week 8 only) 
 
At weeks 4 and week 8 visits, compliance will be assessed and study medication will be 
dispensed.   
• 
Study Medication Compliance Check: The participant will be asked to return 
all used and unused study medication containers for an assessment of 
study medication compliance.  A percentage compliance will be calculated 
for each of these time points.  
• 
Study Medication Dispensation:  (Week 4 & Week 8) At these visits, 
another 30-day supply of study medication will be dispensed. 
 
6.2.3.2 Week 12 (Visit 6) Safety and Other Outcome Assessments  
 
Safety assessments and outcome measures will be completed after 12 weeks (Visit 6) of 
intervention, including the following: 
• 
Review of concurrent medications 
• 
Review/check for any adverse events 
• 
Vital signs 
• 
Body weight 
• 
Physical and neurological examination 
• 
Blood and urine collection for clinical safety laboratory tests and biomarker 
outcomes 
• 
Urine collection for NAA levels 
• 
Cognitive battery 
• 
MRI/MRS 
• 
FDG PET 
• 
Metabolic assessments 
• 
Study medication compliance check 
 
The Week 12 (Visit 6) procedures may be completed in any order depending on ancillary 
facility scheduling availability and participant convenience, but all Week 12 procedures 
will be completed while the participant continues to take the study drug (+/- 7 days of the 
12-week time point).  As a result, participants may take the study drug for up to 13 
weeks in duration.   
 
A description of each procedure listed can be found above under Screening or Baseline 
Visit procedures. 
 
 
 


Protocol Version 8.0, 22JAN2021 
25 
6.2.4 Follow Up Period: End of Study Visit (Visit 7) 
At week 14, two weeks after stopping study drug, participants will return for a final visit to 
the CTSU to assess for a final safety check. 
The following procedures will be conducted: 
• 
Review of concurrent medications 
• 
Review of adverse events 
• 
Vital signs, including body weight 
• 
Physical examination 
• 
Blood and urine collection for clinical safety laboratory tests (fasting not required, 
but is acceptable. Fasting status will be recorded)) 
 
 
 
7 
SAFETY ASSESSMENTS  
 
7.1 
Dapagliflozin Safety Profile 
 
Randomized clinical trials and post-marketing data have found the dapagliflozin is 
associated with potential adverse effects including hypoglycemia, laboratory increases in 
hematocrit, serum phosphorus and LDL-C, ketoacidosis, urinary tract infections, genital 
infections, and weight loss. When used as monotherapy, the risk for hypoglycemia was 
low and similar to those taking placebo.  Higher rates of hypoglycemia were seen when 
dapagliflozin was used in combination with sulfonylurea or insulin therapy.  A small 
reduction in blood pressure has been seen in patients treated with dapagliflozin.   
 
 
Hypoglycemia: Dapagliflozin promotes glycosuria. Hypoglycemia has been reported with 
dapagliflozin, especially with dapagliflozin as an add-on to sulfonylureas or insulin. In 
studies with dapagliflozin used as monotherapy, or as add-on to metformin or pioglitazone 
there were no reported major episodes of hypoglycemia in up to 102 weeks (ref). 
 
Increase in hematocrit and serum phosphorus: Other AEs reported with dapagliflozin 
include an increased hematocrit (+2.3% compared to Baseline versus -0.33% in the 
placebo group) and serum inorganic phosphorus (+0.13 mg/dL vs -0.04 mg/dL in the 
placebo group).   
 
Ketoacidosis: Ketoacidosis has been reported in post-marketing studies in patients with 
type 1 and type 2 diabetes.   
Infections: Treatment with dapagliflozin increases the risk for urinary tract and genital 
infections. The most frequently reported genital infections are vulvovaginal mycotic 
infections in females, and balanitis in males. Most patients responded to an initial course 
of standard treatment, and these infections rarely caused discontinuation from the study. 
 
Weight loss: Urinary glucose excretion induced by dapagliflozin is associate with caloric 
loss and reduction in weight.  The majority of weight reduction is body-fat loss (rather than 
lean tissue) and fluid loss.  In a 24 week placebo controlled study in type 2 diabetes 
comparing dapagliflozin in combination with antidiabetic agents, body weight dropped 2.26 
kg in the dapagliflozin group vs 0.72kg in placebo.  Though weight loss is beneficial in 
diabetes patients, weight loss in patients with AD is often a poor prognostic sign and 


Protocol Version 8.0, 22JAN2021 
26 
associated with greater clinical progression. No studies have demonstrated that the loss of 
body fat rather than lean tissue is detrimental.   
 
7.2 
Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters 
 
Patients on insulin and sulfonylureas have a higher risk of hypoglycemia with dapagliflozin 
and GLP-1 agonists may influence cognitive outcomes and will be excluded. Ketoacidosis 
has been reported with dapagliflozin in type 1 diabetes and patients with type 1 diabetes 
will be excluded from the study. Since the efficacy of dapagliflozin is dependent on renal 
function, we will exclude individuals with an eGFR below 45 ml/min/1.73m2.   
 
In addition, participant safety will be ensured through education, clinical assessment, and 
laboratory testing.  
 
Education: Dapagliflozin has been associated with reduced blood volume.. Participants 
will thus be educated on symptoms of volume depletion such as lethargy, fatigue or 
dizziness.  Before initiating dapagliflozin, volume status will be assessed and suspected 
hypovolemia will be corrected through increased oral intake.   
 
For early diagnosis of infectious AEs associated with dapagliflozin, participants will also be 
educated on the signs and symptoms of urinary tract infections, vaginal yeast infections, 
and balanitis, such as dysuria, hematuria, increased urinary frequency, tenderness, 
pruritus or erythema in the genital areas.  
 
Clinical assessment: Assessment of fluid status with vitals and physical exam will be 
performed at baseline visit before initiating dapagliflozin. Symptoms of hypovolemia will be 
assessed at all visits during therapy.  Sitting and standing blood pressure and body weight 
will be assessed at every visit. At each visit, participants will be evaluated and provide a 
urine sample for signs and symptom of urinary tract or genital infections, and treated 
appropriately as indicated.  Participants will be encouraged to increase fluid intake in 
those with evidence of hypovolemia.   
 
 
Laboratory testing: Safety laboratory testing will be conducted at baseline, week 1, week 
4, week 8, week 12, and week 14 to monitor for acute kidney injury, hypoglycemia, 
dehydration, infections, ketoacidosis, and hypo- or hyperphosphatemia. Laboratory tests 
included will be: complete blood count with differential (hemoglobin, hematocrit, red blood 
cell count, white blood cell count, platelet count, neutrophil count, lymphocyte count, 
monocyte count, eosinophil count, basophil count), comprehensive metabolic panel (blood 
urea nitrogen, creatinine, eGFR, albumin, calcium, bicarbonate, glucose, potassium, 
sodium, total bilirubin, total protein, alanine aminotransferase, alkaline phosphatase,  and 
aspartate aminotransferase) and serum phosphorus. Fasting lipid panel will be checked at 
baseline and week 12 to monitor cholesterol including LDL-C.   
 
In addition to these labs, a safety urinalysis will be performed at every visit. 
 
Weight Loss: Body weight will be assessed at baseline, week 1, week 4, week 8, week 12, 
and week 14/end-of-study.  If total weight loss reaches 5% of total body weight compared 
to baseline and is associated with any concomitant clinical symptoms (fatigue, weakness, 
reports of cognitive worsening, etc), the study drug will be held or stopped per the 
judgment of the investigator.   
 


Protocol Version 8.0, 22JAN2021 
27 
Temporary interruption or cessation of the investigational product (IP) will be considered 
for individuals per the judgment of the investigator for those who develop orthostatic 
hypotension or other symptoms of volume depletion, renal impairment, weight loss greater 
than 5% total body weight at baseline, ketoacidosis or other AEs judged to be related to 
the study drug.   
Overdose:  An overdose is defined as a patient receiving a dose of IP in excess of that 
specified in the Investigator’s Brochure, unless otherwise specified in this protocol. 
Any overdose of a study patient with the investigational product., with associated 
AEs/SAEs, is required to be reported within 24 hours of knowledge of the event to the 
sponsor and AstraZeneca Patient Safety or designee using the designated Safety e-
mailbox (see Section 1.6 or contact information). If the overdose results in an AE, the AE 
must also be recorded as an AE. Overdose does not automatically make an AE serious, 
but if the consequences of the overdose are serious, for example death or hospitalization, 
the event is serious and must be recorded and reported as an SAE (see Section 1.6 ).  
The investigator will use clinical judgment to treat any overdose. 
 
7.3 Adverse Events and Serious Adverse Events  
 
An adverse event (AE) is generally defined as any unfavorable and unintended 
diagnosis, symptom, sign (including an abnormal laboratory finding), syndrome or disease, 
which occurs during the study, having been absent at baseline, or if present at baseline, 
appears to worsen. Adverse events are to be recording regardless of their relationship to 
the study intervention. 
 
A serious adverse event (SAE) is generally defined as any untoward medical 
occurrence,  occurring after the signing of the informed consent through the follow-up 
period that fulfils one or more of the following criteria: that results in death, is life 
threatening, requires hospitalization or prolongation of existing hospitalization, results in 
persistent or significant disability/incapacity, , an important medical event that may 
jeopardize the patient or may require medical intervention to prevent one of the outcomes 
listed above.. or is a congenital anomaly. 
 
All SAEs will be reported, whether or not considered causally related to the IP, or to the 
study procedure(s). All SAEs will be recorded in the CRF.  The causality of SAEs (their 
relationship to all study treatment/procedures) will be assessed by the investigator(s) and 
communicated to AstraZeneca. 
 
AEs and SAEs will be collected from the time of informed consent until end of study (week 
14). 
 
The following variables will be collected for each AE; 
• 
AE term, using the diagnosis if known, or signs or symptoms when  diagnosis is 
not known 
• 
The date when the AE started and stopped 
• 
Maximum intensity (mild, moderate or severe) 
• 
Whether the AE is serious or not 
• 
Investigator causality rating against the Investigational Product (yes or no) 
• 
Action taken with regard to investigational product 
• 
Outcome.   
• 
In addition, the following variables will be collected for SAEs: 


Protocol Version 8.0, 22JAN2021 
28 
 
Date AE met criteria for serious AE 
 
Date Investigator became aware of serious AE 
 
Criterion that classifies AE as serious  
 
Date of hospitalization 
 
Date of discharge 
 
Probable cause of death 
 
Date of death 
 
Autopsy performed 
 
Causality assessment in relation to Study procedure(s) 
 
Description of AE. 
 
7.4 Reporting Procedures 
 
All AEs (related or unrelated to the study intervention) will be reported quarterly to the 
Safety Officer for review.  A summary of these quarterly reports will be provided to the KU 
IRB on an annual basis.  In addition, expedited reporting to the KU IRB will follow IRB 
guidelines.   
 
Serious Adverse events i.e. Suspected, unexpected, serious, adverse, reaction (SUSAR) 
will also be reported to the FDA in an expedited fashion, following these guidelines: 
• Within 7 calendar days 
Any adverse event that is: 
– associated with the use of the study drug 
– unexpected,  
– fatal or life-threatening, and  
 
• Within 15 calendar days 
Any adverse event that is: 
– associated with the use of the study drug, 
– unexpected, and 
– serious, but not fatal or life-threatening 
– a previous adverse event that was not initially deemed reportable but is later 
found to fit the criteria for reporting (reporting within 15 calendar days from when 
event was deemed reportable). 
The investigator must inform the FDA, e.g. via a MedWatch form, of any serious or 
unexpected adverse events that occur in accordance with the reporting obligations of 21 
CFR 312.32. A copy of the MedWatch report must be emailed concurrently to 
AstraZeneca (TCS vendor) at the time the event is reported to the FDA. It is the 
responsibility of the sponsor to compile all necessary information and ensure that the FDA 
receives a report according to the FDA reporting requirement timelines and to ensure that 
these reports are also submitted to AstraZeneca at the same time. 
• Sponsor must also indicate, the causality of events in relation to all study 
medications and if the SAE is related to disease progression, as determined by 
the principal investigator. 
• Send SAE report and accompanying cover page by way of email to 
AstraZeneca’s designated mailbox: 
AEMailboxClinicalTrialTCS@astrazeneca.com 


Protocol Version 8.0, 22JAN2021 
29 
• 
If a non-serious AE becomes serious, this and other relevant follow-up 
information must also be provided to AstraZeneca and the FDA. 
• 
Serious adverse events that do not require expedited reporting to the FDA still 
need to be reported to AstraZeneca.  
• 
The investigator will report to AstraZeneca any unblinding that occurs due to 
critical patient safety concern related to an SAE.  
 
 
7.5    Follow-up for Adverse Events 
All AEs reported during time of study, will be followed by the study team up to 14 days 
after last dose administration. Any unresolved AEs considered probably study drug 
related, will be followed up by the study team until the AE has resolved or is considered 
stable.   
 
 
7.6    Safety Monitoring 
 
A safety officer with expertise in clinical trials and in use of SGLT2 inhibitors will be 
appointed to monitor drug safety.  The safety monitor will review AE’s and study data 
quarterly and advise the study team on additional monitoring if needed or need for 
termination of study in case of unexpected serious AE’s.  
 
The study may be stopped if, in the judgment of the safety officer, study participants are 
placed at undue risk because of clinically significant findings that are assessed to be  
causally related to the study drug. 
  
Safety measures to be reviewed by the safety officer include, laboratory abnormalities, 
AEs, and discontinuations.  These safety measures will be carefully collected and 
recorded by the study team as they have extensive prior experience and expertise with 
these procedures.   
 
 
 
8 
INTERVENTION DISCONTINUATION 
 
Screening failures are participants who do not fulfill the eligibility criteria for the study, and 
therefore must not be randomized. Participants may be discontinued from investigational 
product (IP) in the following situations: 
• 
Participant withdrawal of consent. The participant is at any time free to discontinue 
treatment, without prejudice to further treatment.  
• 
Adverse Event. The investigator may elect to discontinue the participant from 
treatment if he feels it is in the best interest of the participant. 
• 
Significant noncompliance (<80% medication compliance) on the part of the 
participant with the study protocol 
 
At any time, participants are free to discontinue IP or withdraw from the study (i.e. IP and 
assessments), without prejudice to further treatment. A participant that decides to 
discontinue IP will always be asked about the reason(s) and the presence of any adverse 
events (AEs). If the participant is discontinued from IP, the participant will be asked to 


Protocol Version 8.0, 22JAN2021 
30 
return to site for an optional safety follow-up visit. The study drugs should be returned by 
the participant at this visit.  
 
If a participant withdraws from participation in the study, then his/her 
enrolment/randomization code will not be reused. Withdrawn participants will not be 
replaced.  All data available for the participant at the time of discontinuation of follow-up will 
be recorded.  All reasons for discontinuation of treatment will be documented.  
 
 
 
9 
STATISTICAL CONSIDERATIONS  
9.1 General Design Issues  
This study is a double-blind, randomized, placebo-controlled parallel group study.  The 
primary objective is to obtain estimates of the effect of the study drug on cerebral NAA.  
Secondary and safety and tolerability measures will also be collected and compared 
between treatment groups. 
9.2 Sample Size and Randomization 
Forty-eight (48) subjects will be enrolled and randomized 2:1 to either treatment (n=32) or 
placebo (n=16).  Our sample size of 48 subjects was determined consistent with our 
primary objective of estimation rather than hypothesis testing; the latter (hypothesis 
testing) we deemed more appropriate for confirmatory studies that we anticipate will follow 
this initial pilot trial.  We anticipate the results of this study will inform the power 
calculations of those subsequent trials.  Thus, we base our sample size justification on 
providing sufficient precision for estimating our effect with a 95% confidence interval.  
Assuming 32 subjects in the active group and 16 subjects in the placebo group  and 
allowing for up to 15% attrition  our sample size of 48 will enable estimates of the 
difference in cerebral NAA to be within approximately 0.69 standard deviations for a 95% 
confidence interval.  This magnitude of the half-width of the confidence intervals (0.69 
standard deviations) was derived from the confidence interval formula for estimating a 
difference between two treatment means using quantiles from a t distribution, using the 
pooled variance formula for a common variance, and post-attrition group sizes of 27 and 
13 subjects. From Kalra, Cashman, Genge, and Arnold (1998, NeuroReport 9, 1757-61), 
estimated standard deviations for changes in NAA/Cr both in treated and control 
conditions were approximately 0.2.  For the regression techniques to apply that we 
described below, we anticipate our results will produce similar sized magnitudes for 
estimating the standard deviations for this study (i.e., we anticipate our confidence 
intervals to be within a magnitude of approximately 0.14). 
 
9.2.1 Treatment Assignment Procedures 
Subjects will be randomly assigned to treatment or placebo based on the randomization 
schedule developed by the lead study statistician.  This procedure will be balanced 
within random blocks to increase the balance between treatments over the recruitment 
period.  Treatment order within blocks will be determined by randomly selecting and 
sorting random draws from a uniform distribution using a pseudo-random number 
generator on a statistical software package. 
9.3 Interim analyses and Stopping Rules 
No interim analyses or stopping rules are planned for this trial. 


Protocol Version 8.0, 22JAN2021 
31 
9.4 Outcomes  
9.4.1 Primary outcome   
MR spectra will be analyzed to determine the concentration of NAA (as a continuous 
measure) using the LCModel package and in-house MR data processing pipeline to 
correct for tissue fraction in each voxel using the segmented MPRAGE MRI 
corresponding to the CSI slab.  
 
9.4.2 Exploratory outcomes   
MRS Measures:  In addition to NAA, we will assess the concentration (as continuous 
measures) of several other neurochemicals including glutathione, creatine, choline, myo-
inositol, and glutamate+glutamine from the same location using a multiple-quantum 
filtered CSI sequence. 
 
Cerebral metabolism by FDG PET: PET images will be analyzed using custom software 
written for Statistical Parametric Mapping (SPM12). Pre- and post-intervention P images 
will be co-registered. A priori regions of interest masks from the Automated Anatomic 
Labeling series will be inverse warped to match native space images. The PET images 
will be standardized to the uptake value of the cerebellum and standardized uptake 
value ratios (SUVR) will be calculated from native-space ROIs.  
 
Systemic metabolic measures will be continuous measures.    
o Systemic NAA levels (in blood and urine) 
o Lipids (total cholesterol, LDL, HDL) 
o Plasma beta-hydroxybutyrate 
o Hemoglobin A1c 
o Glucose and insulin Area Under the Curves (tolerance testing) 
o Catabolic/Anabolic state [activated AKT and MTOR] 
o Mitochondrial function measures [platelet cytochrome oxidase and citrate 
synthase] 
o Inflammatory mechanisms [MCP-1, eotaxin, TNF alpha, CRP] 
o Body composition (DEXA scanning for fat and lean mass)  
o Resting metabolic rate (indirect calorimetry).   
 
Cognitive performance will be assessed using the ADAS-cog 14 (total score) and 
individual performance scores on Trailmaking A and B, Stroop Word Color test, and 
Logical Memory I and II.  
 
9.4.3 Safety Outcomes 
 
We will examine the incidence and severity of AEs and the rate of discontinuations due 
to AEs.  Additionally, we will examine changes in cognitive performance, body weight, 
and laboratory values observed during the course of the study.  
9.5 Data Analyses 
Unless otherwise specified, all efficacy analyses will be carried out on all subjects 
enrolled. Continuous variables will be summarized (using number of participants, mean, 
standard deviation, and percentiles) by treatment group and visit. For baseline, all end-of-
study measurements, the changes, or relative changes from baseline will be presented by 
treatment group for all efficacy variables to be analyzed.  Categorical variables will be 
summarized, by treatment group, using frequency count and the percentage of 


Protocol Version 8.0, 22JAN2021 
32 
participants in each category.  This will facilitate assessment for independence in these 
baseline measures across treatment groups, which we anticipate given treatment will be 
allocated at random.  (Notably, this inference of independence is equivalent to testing for 
no difference in proportional distributions across treatment groups.)  
 
The primary objective is estimation, so we will generate 95% confidence intervals for 
“adjusted” treatment means and their differences based on the formulas analogous to an 
analysis of covariance (ANCOVA)/ordinary least squares (OLS) regression model 
hypothesis testing procedure.  For these models we will use the baseline measure as a 
covariate, including assigned treatment as a fixed effect, and change from baseline 
measure (i.e., follow-up minus baseline) as the response/outcome measure.  To deem the 
adequacy of normal distribution quantiles for confidence interval estimation we will carry 
out the residual analyses to assess the assumptions of that test for each measure.  In the 
event that the residual diagnostics (including residual vs. predicted value plots, quantile-
quantile plots, etc.) do not conform to the underlying normality and other assumptions of 
this test, we will revert to nonparametric rank-based approach using ANCOVA as 
described above with ranks used instead for the response to derive model-based p-values.  
For categorical measures, we will use confidence intervals based on the Wald estimate of 
the standard error in comparisons of proportions between assigned treatment for 
dichotomous responses/outcomes if the expected cell counts (under the hypothesis of 
independence) for corresponding contingency tables are at least five in most (>80%) cells.  
If the expected cell counts are not sufficiently large, we will instead estimate using exact, 
Clopper-Pearson confidence intervals. 
 
To assess scan-rescan reliability for NAA on the 12 subjects, we will estimate the variance 
in the difference scores between each of these 12 subjects’ pre-randomization MRI/MRS 
scans.  This will provide information on intra-individual scan-to-scan variation for 
consideration as we interpret differences (time one minus time two) estimated between 
treatment groups.  
 
As only pre- and post-treatment measures are obtained, subjects missing post-treatment 
follow-up measures will be excluded from these analyses. 
 
 
10 
DATA COLLECTION AND QUALITY ASSURANCE 
 
10.1 Data Collection  
Data collection will initially be captured on paper case report forms (CRF’s) in real time by 
appropriate study team members who have been adequately trained for their roles.   
 
10.2 Data Management  
Data from paper CRF’s will be entered into a secure electronic database, accessible only 
by study team members, housed on an institutional server. 
 
Designated study staff will review the data entered into the eCRFs for completeness and 
accuracy and make any required corrections or additions.  
 


Protocol Version 8.0, 22JAN2021 
33 
10.3 Quality Assurance  
 
10.3.1 Training  
 
Study staff will complete Good Clinical Practice and HIPAA training prior entry on the 
study roster. Training and certification will be completed based on study role as 
appropriate. 
 
10.3.2 Quality Control Committee  
 
No Quality Control Committee will be appointed for this single-site trial. Quality will be 
assured through trained staff following Good Clinical Practice standards and appropriate 
data validation of the eCRF through range limits, data audit trails and appropriate role-
based access to forms. The study Statistician will review these metrics quarterly. 
 
10.3.3 Metrics 
 
Missing and out-of-range values will be queried in the eCRF and reported on a quarterly 
basis to the PI by the study Statistician. 
 
10.3.4 Protocol Deviations 
 
Protocol deviations and adverse events will be captured at all study contacts by study 
staff, recorded on eCRFs, and reported to the PI. Documentation of the deviation or 
adverse event will be kept in the participant’s paper chart. 
 
10.3.5 Monitoring 
 
The Data Monitoring plan for this trial focuses on monitoring by the PI and the trial 
coordinator.  Before study initiation, the study team will review the protocol and eCRFs. 
During the study, the study team will employ several methods of ensuring protocol and 
Good Clinical Practice (GCP) compliance and the quality/integrity of the data. The 
Investigator will maintain source documents for each participants in the study, consisting 
of case and visit notes (hospital or clinic medical records) containing demographic and 
medical information, laboratory data, and the results of any other tests or assessments. 
All information on the eCRFs will be traceable to these source documents in the 
participant’s file. The Investigator will also keep the original informed consent form 
signed by the participant (a signed copy is given to the participant). Checks of the 
consistency of the source data with the eCRFs will be performed using validation tools in 
the eCRF software. Review of the rate of participant accrual and adherence to 
inclusion/exclusion criteria will occur during the recruitment phase to assure that 
participants meet eligibility criteria. 
 
 
 
11 
PARTICIPANT RIGHTS AND CONFIDENTIALITY  
 
11.1 Institutional Review Board (IRB) Review 
 
This protocol and the informed consent document and any subsequent modifications will 
be reviewed and approved by the IRB or ethics committee responsible for oversight of the 
study.  The consent form should be separate from the protocol document.  


Protocol Version 8.0, 22JAN2021 
34 
 
11.2 Informed Consent Forms 
 
A signed consent form will be obtained from each participant.   For participants who 
cannot consent for themselves, such as those with a legal guardian (e.g. person with 
power of attorney), this individual must sign the consent form. The consent form will 
describe the purpose of the study, the procedures to be followed, and the risks and 
benefits of participation. A copy will be given to each participant or legal guardian and this 
fact will be documented in the participant’s record.  
 
11.3 Participant Confidentiality  
 
Any data, specimens, forms, reports, video recordings, and other records that leave the 
site will be identified only by a participant identification number (Participant ID, PID) to 
maintain confidentiality.  All records will be kept in a locked file cabinet.  All computer entry 
and networking programs will be done using PIDs only. Information will not be released 
without written permission of the participant, except as necessary for monitoring by IRB, 
the FDA, the NIA, and the OHRP. 
 
11.4 Study Discontinuation  
 
The study may be discontinued at any time by the IRB, the NIA, the OHRP, the FDA, or 
other government agencies as part of their duties to ensure that research participants are 
protected.  
 
 
12 
ETHICAL CONSIDERATIONS 
 
The study will be performed in accordance with ethical principles that have their origin in 
the Declaration of Helsinki and are consistent with ICH/Good Clinical Practice.  
 
 
13 
PUBLICATION OF RESEARCH FINDINGS 
 
Any presentation, abstract, or manuscript will be made available for review by the sponsor 
prior to submission. 
 
 
 
 


Protocol Version 8.0, 22JAN2021 
35 
14    REFERENCES 
 
1. 
Alzheimer's A. 2016 Alzheimer's disease facts and figures. Alzheimers Dement 
2016;12:459-509. 
2. 
Gibson GE, Starkov A, Blass JP, Ratan RR, Beal MF. Cause and consequence: 
mitochondrial dysfunction initiates and propagates neuronal dysfunction, neuronal death and 
behavioral abnormalities in age-associated neurodegenerative diseases. Biochim Biophys Acta 
2010;1802:122-134. 
3. 
Beal MF. Mitochondria take center stage in aging and neurodegeneration. Ann Neurol 
2005;58:495-505. 
4. 
Wallace DC. Mitochondrial genetics: a paradigm for aging and degenerative diseases? 
Science 1992;256:628-632. 
5. 
Reddy PH, Beal MF. Are mitochondria critical in the pathogenesis of Alzheimer's disease? 
Brain Res Brain Res Rev 2005;49:618-632. 
6. 
Hirai K, Aliev G, Nunomura A, et al. Mitochondrial abnormalities in Alzheimer's disease. J 
Neurosci 2001;21:3017-3023. 
7. 
Moreira PI, Carvalho C, Zhu X, Smith MA, Perry G. Mitochondrial dysfunction is a trigger of 
Alzheimer's disease pathophysiology. Biochim Biophys Acta 2010;1802:2-10. 
8. 
Schon EA, Area-Gomez E. Mitochondria-associated ER membranes in Alzheimer disease. 
Mol Cell Neurosci 2013;55:26-36. 
9. 
Yao J, Brinton RD. Estrogen regulation of mitochondrial bioenergetics: implications for 
prevention of Alzheimer's disease. Adv Pharmacol 2012;64:327-371. 
10. Trushina E, Nemutlu E, Zhang S, et al. Defects in mitochondrial dynamics and metabolomic 
signatures of evolving energetic stress in mouse models of familial Alzheimer's disease. PLoS 
One 2012;7:e32737. 
11. Zhu X, Perry G, Smith MA, Wang X. Abnormal mitochondrial dynamics in the pathogenesis 
of Alzheimer's disease. J Alzheimers Dis 2013;33 Suppl 1:S253-262. 
12. Parker WD, Jr., Filley CM, Parks JK. Cytochrome oxidase deficiency in Alzheimer's 
disease. Neurology 1990;40:1302-1303. 
13. Kish SJ, Bergeron C, Rajput A, et al. Brain cytochrome oxidase in Alzheimer's disease. J 
Neurochem 1992;59:776-779. 
14. Gibson GE, Sheu KF, Blass JP, et al. Reduced activities of thiamine-dependent enzymes in 
the brains and peripheral tissues of patients with Alzheimer's disease. Arch Neurol 
1988;45:836-840. 
15. Sims NR, Finegan JM, Blass JP, Bowen DM, Neary D. Mitochondrial function in brain tissue 
in primary degenerative dementia. Brain Res 1987;436:30-38. 
16. Blass JP, Zemcov A. Alzheimer's disease. A metabolic systems degeneration? Neurochem 
Pathol 1984;2:103-114. 
17. Hoyer S. Brain oxidative energy and related metabolism, neuronal stress, and Alzheimer's 
disease: a speculative synthesis. J Geriatr Psychiatry Neurol 1993;6:3-13. 
18. Mancuso M, Siciliano G, Filosto M, Murri L. Mitochondrial dysfunction and Alzheimer's 
disease: new developments. J Alzheimers Dis 2006;9:111-117. 
19. Turnbull HE, Lax NZ, Diodato D, Ansorge O, Turnbull DM. The mitochondrial brain: From 
mitochondrial genome to neurodegeneration. Biochim Biophys Acta 2010;1802:111-121. 
20. de Leon MJ, Ferris SH, George AE, et al. Positron emission tomographic studies of aging 
and Alzheimer disease. AJNR Am J Neuroradiol 1983;4:568-571. 
21. Foster NL, Chase TN, Fedio P, Patronas NJ, Brooks RA, Di Chiro G. Alzheimer's disease: 
focal cortical changes shown by positron emission tomography. Neurology 1983;33:961-965. 
22. Frackowiak RS, Pozzilli C, Legg NJ, et al. Regional cerebral oxygen supply and utilization 
in dementia. A clinical and physiological study with oxygen-15 and positron tomography. Brain 
1981;104:753-778. 


Protocol Version 8.0, 22JAN2021 
36 
23. Mosconi L, Brys M, Switalski R, et al. Maternal family history of Alzheimer's disease 
predisposes to reduced brain glucose metabolism. Proc Natl Acad Sci U S A 2007;104:19067-
19072. 
24. Reiman EM, Caselli RJ, Yun LS, et al. Preclinical evidence of Alzheimer's disease in 
persons homozygous for the epsilon 4 allele for apolipoprotein E. N Engl J Med 1996;334:752-
758. 
25. Roses AD, Saunders AM, Huang Y, Strum J, Weisgraber KH, Mahley RW. Complex 
disease-associated pharmacogenetics: drug efficacy, drug safety, and confirmation of a 
pathogenetic hypothesis (Alzheimer's disease). Pharmacogenomics J 2007;7:10-28. 
26. Castellano CA, Nugent S, Paquet N, et al. Lower Brain 18F-Fluorodeoxyglucose Uptake 
But Normal 11C-Acetoacetate Metabolism in Mild Alzheimer's Disease Dementia. J Alzheimers 
Dis 2014. 
27. Wilkins HM, Harris JL, Carl SM, et al. Oxaloacetate activates brain mitochondrial 
biogenesis, enhances the insulin pathway, reduces inflammation and stimulates neurogenesis. 
Hum Mol Genet 2014;23:6528-6541. 
28. Swerdlow RH. Bioenergetic medicine. Br J Pharmacol 2014;171:1854-1869. 
29. Swerdlow RH. Bioenergetics and metabolism: a bench to bedside perspective. J 
Neurochem 2016;139 Suppl 2:126-135. 
30. Burns JM, Cronk BB, Anderson HS, et al. Cardiorespiratory fitness and brain atrophy in 
early Alzheimer disease. Neurology 2008;71:210-216. 
31. Burns JM, Mayo MS, Anderson HS, Smith HJ, Donnelly JE. Cardiorespiratory fitness in 
early-stage Alzheimer disease. Alzheimer Dis Assoc Disord 2008;22:39-46. 
32. Morris JK, Vidoni ED, Johnson DK, et al. Exercise as an intervention for Alzheimer's 
disease:  A randomized controlled pilot trial. PloS one:in press. 
33. Swerdlow RH, Bothwell R, Hutfles L, Burns JM, Reed GA. Tolerability and 
pharmacokinetics of oxaloacetate 100 mg capsules in Alzheimer's subjects. BBA clinical 
2016;5:120-123. 
34. Swerdlow RH. Mitochondria and cell bioenergetics: increasingly recognized components 
and a possible etiologic cause of Alzheimer's disease. Antioxid Redox Signal 2012;16:1434-
1455. 
35. Nugent S, Tremblay S, Chen KW, et al. Brain glucose and acetoacetate metabolism: a 
comparison of young and older adults. Neurobiology of aging 2014;35:1386-1395. 
36. De Santi S, de Leon MJ, Convit A, et al. Age-related changes in brain: II. Positron emission 
tomography of frontal and temporal lobe glucose metabolism in normal subjects. Psychiatr Q 
1995;66:357-370. 
37. Marano CM, Workman CI, Kramer E, et al. Longitudinal studies of cerebral glucose 
metabolism in late-life depression and normal aging. Int J Geriatr Psychiatry 2013;28:417-423. 
38. Willis MW, Ketter TA, Kimbrell TA, et al. Age, sex and laterality effects on cerebral glucose 
metabolism in healthy adults. Psychiatry research 2002;114:23-37. 
39. Mosconi L, Mistur R, Switalski R, et al. FDG-PET changes in brain glucose metabolism 
from normal cognition to pathologically verified Alzheimer's disease. European journal of 
nuclear medicine and molecular imaging 2009;36:811-822. 
40. Ferris SH, de Leon MJ, Wolf AP, et al. Positron emission tomography in the study of aging 
and senile dementia. Neurobiology of aging 1980;1:127-131. 
41. Friedland RP, Budinger TF, Ganz E, et al. Regional cerebral metabolic alterations in 
dementia of the Alzheimer type: positron emission tomography with [18F]fluorodeoxyglucose. J 
Comput Assist Tomogr 1983;7:590-598. 
42. Parker WD, Jr., Parks J, Filley CM, Kleinschmidt-DeMasters BK. Electron transport chain 
defects in Alzheimer's disease brain. Neurology 1994;44:1090-1096. 
43. Parker WD, Jr., Parks JK. Cytochrome c oxidase in Alzheimer's disease brain: purification 
and characterization. Neurology 1995;45:482-486. 


Protocol Version 8.0, 22JAN2021 
37 
44. Swerdlow R, Marcus DL, Landman J, Kooby D, Frey W, 2nd, Freedman ML. Brain glucose 
metabolism in Alzheimer's disease. Am J Med Sci 1994;308:141-144. 
45. Baloyannis SJ. Mitochondrial alterations in Alzheimer's disease. J Alzheimers Dis 
2006;9:119-126. 
46. Johnson AB, Blum NR. Nucleoside phosphatase activities associated with the tangles and 
plaques of alzheimer's disease: a histochemical study of natural and experimental neurofibrillary 
tangles. J Neuropathol Exp Neurol 1970;29:463-478. 
47. Wisniewski H, Terry RD, Hirano A. Neurofibrillary pathology. J Neuropathol Exp Neurol 
1970;29:163-176. 
48. Gan X, Huang S, Wu L, et al. Inhibition of ERK-DLP1 signaling and mitochondrial division 
alleviates mitochondrial dysfunction in Alzheimer's disease cybrid cell. Biochim Biophys Acta 
2014;1842:220-231. 
49. Manczak M, Calkins MJ, Reddy PH. Impaired mitochondrial dynamics and abnormal 
interaction of amyloid beta with mitochondrial protein Drp1 in neurons from patients with 
Alzheimer's disease: implications for neuronal damage. Hum Mol Genet 2011;20:2495-2509. 
50. Wang X, Su B, Lee HG, et al. Impaired balance of mitochondrial fission and fusion in 
Alzheimer's disease. J Neurosci 2009;29:9090-9103. 
51. Sorbi S, Bird ED, Blass JP. Decreased pyruvate dehydrogenase complex activity in 
Huntington and Alzheimer brain. Ann Neurol 1983;13:72-78. 
52. Mutisya EM, Bowling AC, Beal MF. Cortical cytochrome oxidase activity is reduced in 
Alzheimer's disease. J Neurochem 1994;63:2179-2184. 
53. Bosetti F, Brizzi F, Barogi S, et al. Cytochrome c oxidase and mitochondrial F1F0-ATPase 
(ATP synthase) activities in platelets and brain from patients with Alzheimer's disease. 
Neurobiol Aging 2002;23:371-376. 
54. Cardoso SM, Proenca MT, Santos S, Santana I, Oliveira CR. Cytochrome c oxidase is 
decreased in Alzheimer's disease platelets. Neurobiol Aging 2004;25:105-110. 
55. Curti D, Rognoni F, Gasparini L, et al. Oxidative metabolism in cultured fibroblasts derived 
from sporadic Alzheimer's disease (AD) patients. Neurosci Lett 1997;236:13-16. 
56. Maurer I, Zierz S, Moller HJ. A selective defect of cytochrome c oxidase is present in brain 
of Alzheimer disease patients. Neurobiol Aging 2000;21:455-462. 
57. Simonian NA, Hyman BT. Functional alterations in Alzheimer's disease: diminution of 
cytochrome oxidase in the hippocampal formation. J Neuropathol Exp Neurol 1993;52:580-585. 
58. Valla J, Berndt JD, Gonzalez-Lima F. Energy hypometabolism in posterior cingulate cortex 
of Alzheimer's patients: superficial laminar cytochrome oxidase associated with disease 
duration. J Neurosci 2001;21:4923-4930. 
59. Wong-Riley M, Antuono P, Ho KC, et al. Cytochrome oxidase in Alzheimer's disease: 
biochemical, histochemical, and immunohistochemical analyses of the visual and other 
systems. Vision Res 1997;37:3593-3608. 
60. Valla J, Schneider L, Niedzielko T, et al. Impaired platelet mitochondrial activity in 
Alzheimer's disease and mild cognitive impairment. Mitochondrion 2006;6:323-330. 
61. Parker WD, Jr., Mahr NJ, Filley CM, et al. Reduced platelet cytochrome c oxidase activity in 
Alzheimer's disease. Neurology 1994;44:1086-1090. 
62. Fisar Z, Hroudova J, Hansikova H, et al. Mitochondrial Respiration in the Platelets of 
Patients with Alzheimer's Disease. Current Alzheimer research 2016;13:930-941. 
63. Sheehan JP, Swerdlow RH, Miller SW, et al. Calcium homeostasis and reactive oxygen 
species production in cells transformed by mitochondria from individuals with sporadic 
Alzheimer's disease. J Neurosci 1997;17:4612-4622. 
64. Swerdlow RH, Parks JK, Cassarino DS, et al. Cybrids in Alzheimer's disease: a cellular 
model of the disease? Neurology 1997;49:918-925. 
65. Small GW, Mazziotta JC, Collins MT, et al. Apolipoprotein E type 4 allele and cerebral 
glucose metabolism in relatives at risk for familial Alzheimer disease. JAMA 1995;273:942-947. 


Protocol Version 8.0, 22JAN2021 
38 
66. Swerdlow R, Marcus DM, Landman J, Harooni M, Freedman ML. Brain glucose and ketone 
body metabolism in patients with Alzheimer's disease. Clin Res 1989;37:461A. 
67. Ghosh S, Patel N, Rahn D, et al. The thiazolidinedione pioglitazone alters mitochondrial 
function in human neuron-like cells. Mol Pharmacol 2007;71:1695-1702. 
68. Swerdlow RH. Treating neurodegeneration by modifying mitochondria: potential solutions to 
a "complex" problem. Antioxid Redox Signal 2007;9:1591-1603. 
69. Vidoni ED, Johnson DK, Morris JK, et al. Dose-Response of Aerobic Exercise on Cognition: 
A Community-Based, Pilot Randomized Controlled Trial. PloS one 2015;10:e0131647. 
70. E L, Lu J, Burns JM, Swerdlow RH. Effect of exercise on mouse liver and brain bioenergetic 
infrastructures. Exp Physiol 2013;98:207-219. 
71. E L, Burns JM, Swerdlow RH. Effect of high-intensity exercise on aged mouse brain 
mitochondria, neurogenesis, and inflammation. Neurobiol Aging 2014;35:2574-2583. 
72. Selfridge JE, Wilkins HM, E L, et al. Effect of one month duration ketogenic and non-
ketogenic high fat diets on mouse brain bioenergetic infrastructure. J Bioenerg Biomembr 
2015;47:1-11. 
73. E L, Lu J, Selfridge JE, Burns JM, Swerdlow RH. Lactate administration reproduces specific 
brain and liver exercise-related changes. J Neurochem 2013;127:91-100. 
74. McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to 
Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's 
Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement 
2011;7:263-269. 
75. Burns JM, Donnelly JE, Anderson HS, et al. Peripheral insulin and brain structure in early 
Alzheimer disease. Neurology 2007;69:1094-1104. 
76. Morris JK, Vidoni ED, Wilkins HM, et al. Impaired fasting glucose is associated with 
increased regional cerebral amyloid. Neurobiology of aging 2016;44:138-142. 
77. Morris JK, Vidoni ED, Mahnken JD, et al. Cognitively impaired elderly exhibit insulin 
resistance and no memory improvement with infused insulin. Neurobiol Aging 2016;39:19-24. 
78. Macchi Z, Wang Y, Moore D, et al. A multi-center screening trial of rasagiline in patients 
with amyotrophic lateral sclerosis: Possible mitochondrial biomarker target engagement. 
Amyotroph Lateral Scler Frontotemporal Degener 2015;16:345-352. 
79. Wilkins HM, Koppel S, Carl SM, et al. Oxaloacetate enhances neuronal cell bioenergetic 
fluxes and infrastructure. J Neurochem 2016;137:76-87. 
80. E L, Swerdlow RH. Lactate's effect on human neuroblastoma cell bioenergetic fluxes. 
Biochemical pharmacology 2016;99:88-100. 
81. Thal LJ, Grundman M, Berg J, et al. Idebenone treatment fails to slow cognitive decline in 
Alzheimer's disease. Neurology 2003;61:1498-1502. 
82. Weyer G, Babej-Dolle RM, Hadler D, Hofmann S, Herrmann WM. A controlled study of 2 
doses of idebenone in the treatment of Alzheimer's disease. Neuropsychobiology 1997;36:73-
82. 
83. Gutzmann H, Hadler D. Sustained efficacy and safety of idebenone in the treatment of 
Alzheimer's disease: update on a 2-year double-blind multicentre study. Journal of neural 
transmission Supplementum 1998;54:301-310. 
84. Galasko DR, Peskind E, Clark CM, et al. Antioxidants for Alzheimer disease: a randomized 
clinical trial with cerebrospinal fluid biomarker measures. Archives of neurology 2012;69:836-
841. 
85. Gold M, Alderton C, Zvartau-Hind M, et al. Rosiglitazone monotherapy in mild-to-moderate 
Alzheimer's disease: results from a randomized, double-blind, placebo-controlled phase III 
study. Dement Geriatr Cogn Disord 2010;30:131-146. 
86. Risner ME, Saunders AM, Altman JF, et al. Efficacy of rosiglitazone in a genetically defined 
population with mild-to-moderate Alzheimer's disease. Pharmacogenomics J 2006;6:246-254. 
87. Bezprozvanny I. The rise and fall of Dimebon. Drug News Perspect 2010;23:518-523. 


Protocol Version 8.0, 22JAN2021 
39 
88. Zhang S, Hedskog L, Petersen CA, Winblad B, Ankarcrona M. Dimebon (latrepirdine) 
enhances mitochondrial function and protects neuronal cells from death. J Alzheimers Dis 
2010;21:389-402. 
89. Mosconi L, de Leon M, Murray J, et al. Reduced mitochondria cytochrome oxidase activity 
in adult children of mothers with Alzheimer's disease. Journal of Alzheimer's disease : JAD 
2011;27:483-490. 
90. Harrison DE, Strong R, Sharp ZD, et al. Rapamycin fed late in life extends lifespan in 
genetically heterogeneous mice. Nature 2009;460:392-395. 
91. Wilkins HM, Koppel SJ, Bothwell R, Mahnken J, Burns JM, Swerdlow RH. Platelet 
cytochrome oxidase and citrate synthase activities in APOE epsilon4 carrier and non-carrier 
Alzheimer's disease patients. Redox biology 2017;12:828-832. 
92. Wilkins HM, Mahnken JD, Welch P, et al. A Mitochondrial Biomarker-Based Study of S-
Equol in Alzheimer's Disease Subjects: Results of a Single-Arm, Pilot Trial. J Alzheimers Dis 
2017;59:291-300. 
93. Dalla Man C, Campioni M, Polonsky KS, et al. Two-hour seven-sample oral glucose 
tolerance test and meal protocol: minimal model assessment of beta-cell responsivity and 
insulin sensitivity in nondiabetic individuals. Diabetes 2005;54:3265-3273.