Conditions: Peripheral Artery Disease
Keywords: Peripheral Artery Disease PAD Resveratrol Nicotinamide riboside (NR) Six-minute walk Functional performance
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 90
Healthy volunteers: no

Brief summary:
NICE is a randomized clinical trial that will examine the effects of nicotinamide riboside (NR) both with and without resveratrol to test whether, among people with PAD, NR significantly improves walking performance more than placebo and whether NR combined with resveratrol significantly improves walking performance more than placebo. If findings support the hypotheses, results will be used to design a large, definitive randomized clinical.

The study will randomize 90 participants with PAD to one of the following three groups: NR + resveratrol, NR + placebo, or placebo + placebo.

Detailed description:

Arms:
arm 1: Participants randomized to the NR + resveratrol arm of the study will receive 1,000 mg of NR and 125 mg of resveratrol daily for six months. arm 2: Participants randomized to the NR + placebo arm of the study will receive 1,000 mg of NR and a placebo daily for six months. arm 3: Participants randomized to the placebo + placebo arm of study will receive placebo pills.

Interventions: intervention 1: Nicotinamide riboside intervention 2: Resveratrol intervention 3: Placebo
Intervention descriptions: intervention 1: Participants randomized to the NR + resveratrol arm or the NR + placebo arm of the study will receive 1,000 mg of NR daily for six months. intervention 2: Participants randomized to the NR + resveratrol arm of the study will receive 125 mg of resveratrol daily for six months. intervention 3: Participants randomized to the NR + placebo arm of the study will receiving placebo pills that are identical in appearance to resveratrol. Participants randomized to the placebo + placebo arm of the study will receive pills that are identical in appearance to NR and resveratrol. Participants will receive placebo pills daily for six months.

Protocol document:
Prot_SAP_000.pdf: 
STU00206660 
 
 
SUPPLEMENTAL FILES 
 
 
 
NICOTINAMIDE RIBOSIDE FOR PERIPHERAL ARTERY DISEASE:  
 THE NICE RANDOMIZED CLINICAL TRIAL 
 
 
 


STU00206660 
 
 
PROTOCOL TITLE:  NICotinamidE Riboside With and Without Resveratrol to Improve 
Functioning in Peripheral Artery Disease: The NICE Trial 
 
 
PRINCIPAL INVESTIGATOR: 
Mary McDermott, MD 
Division of General Internal Medicine and Geriatrics 
Department Medicine 
312-503-6419 
mdm608@northwestern.edu 
 
VERSION NUMBER: Version #15. 
 
 
VERSION DATE: 
3/6/2023 
 
  
STUDY SUMMARY: 
 
Investigational Agent(s)  
(Drugs or Devices) 
Nicotinamide riboside (NR) 
Resveratrol 
IND #  139436 
Sample Size 90 
Funding Source American Heart Association (AHA) 
Indicate the type of consent 
to be obtained 
Written  
Verbal/Waiver of Documentation of Informed Consent 
Waiver of HIPAA Authorization  
Waiver/Alteration of Consent Process   
Research Related 
Radiation Exposure 
Yes  
 No  
DSMB / DMC / IDMC 
Yes  
No 
 
OBJECTIVES: 
Our work shows that people with lower extremity peripheral artery disease (PAD) have greater 
functional impairment, faster functional decline, and higher rates of mobility loss compared to 
people without PAD (1-6).  PAD-related ischemia-reperfusion of calf skeletal muscle during 
walking activity increases calf muscle oxidative stress and is associated with calf muscle fiber 
damage (7-12).  Preliminary evidence also suggests that PAD is associated with calf muscle 
mitochondrial dysfunction (10-14).  Calf muscle abnormalities are associated with functional 
impairment and mobility loss in people with PAD (15-18).  No medical therapies have been 
identified that target these calf skeletal muscle abnormalities in PAD.  Few medical therapies 
improve functioning or prevent functional decline in people with PAD. 
 
Nicotinamide riboside (NR), a B vitamin and precursor to nicotinamide adenine dinucleotide 
(NAD+), significantly increases bioavailability of NAD+ in animals and humans (19). NAD+ is 
essential for mitochondrial respiration. NAD+ is also an essential cofactor for sirtuin1 (SIRT1) 


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activity (19-21).  SIRT1 stimulates mitochondrial activity, activates endothelial nitric oxide 
synthase (eNOS) and reduces oxidative stress (22-29).   
 
Oral administration of NR in mice increases skeletal muscle abundance of NAD+, increases 
skeletal muscle SIRT-1 activity, increases mitochondrial activity, and improves limb grip strength 
and running endurance (19,31-35).  NR also increases muscle stem cell abundance and 
improves muscle fiber quality in mice (31,32).  Therefore, we hypothesize that in people with 
PAD, NR will increase calf muscle mitochondrial activity, promote calf muscle regeneration, 
improve calf muscle quality, increase nitric oxide, and reduce calf muscle oxidative stress, 
thereby achieving better walking performance in PAD.   
 
Resveratrol is a natural polyphenol and a supplement found in grape skin with pharmacological 
properties that also enhance mitochondrial activity through SIRT1 (30,36-40).  Resveratrol 
increases SIRT1 affinity for its substrate and for NAD+.  NAD+ is an essential cofactor for 
SIRT1 activity.  Resveratrol also protects tissue against ischemia reperfusion injury (41,42).  
Because resveratrol increases SIRT1 affinity for NAD+, while NR increases calf muscle NAD+ 
abundance, we hypothesize that the combination of resveratrol and NAD+ will have a 
particularly potent stimulatory effect on SIRT-1 activity.  Stimulating SIRT1 activity will increase 
calf skeletal muscle mitochondrial biogenesis, reduce oxidative stress, increase eNOS, and 
increase mitochondrial activity in people with PAD. In a randomized trial of 66 participants with 
PAD, we recently reported that 125 mgs of resveratrol increased the six-minute walk by 16.9 
meters at 6-month follow-up, compared to placebo (P=0.07) (44).  However, NAD+ is required 
for SIRT1 activity and our preliminary data show that people with PAD have lower NAD+ 
abundance than those without PAD (see Section B4).  For these reasons, we hypothesize that 
combining resveratrol (a SIRT1 activator) with NR (which increases NAD+, an essential SIRT1 
substrate) will have a particularly potent effect on calf skeletal muscle mitochondrial activity and 
walking performance in people with PAD.   
 
The NICE Trial is a double-blind proof-of-principle randomized clinical trial to test two 
hypotheses:  a) among people with PAD, NR significantly improves walking performance more 
than placebo and that b) among people with PAD, NR combined with resveratrol significantly 
improves walking performance more than placebo.  In an exploratory aim, we will determine 
whether NR combined with resveratrol increases the six-minute more than NR alone.  If our 
findings support our hypotheses, results will be used to design a large, definitive randomized 
clinical trial.   
 
We will randomize 90 participants with PAD to one of the following three groups:  NR + 
resveratrol, NR + placebo, or placebo + placebo.  From this point forward, “NR alone” refers to 
NR + placebo and “placebo” refers to the combination of placebo+ placebo.  Our primary 
outcome is change in six-minute walk between baseline and 6-month follow-up.  Secondary 
outcomes are change in maximal treadmill walking time, patient-reported walking ability 
(measured by the Walking Impairment Questionnaire (WIQ)), and quality of life (measured by 
the Short Form-36 Physical Functioning (SF-36 PF) score).  Calf skeletal muscle collected in 
participants in the NICE Trial will be analyzed for stem cell (satellite cell) abundance and muscle 
fiber phenotype.   
 
BACKGROUND: 
Lower extremity peripheral artery disease (PAD) is common and is associated with 
greater functional impairment, faster functional decline, and higher rates of mobility loss 
compared to the absence of PAD.  PAD affects 8 million people in the U.S. and more than 
200 million worldwide (45,46).  Our work has established that people with PAD have greater 


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functional impairment and more rapid functional decline than those without PAD (1-6).  PAD 
related functional impairment is associated with increased rates of hospitalization, nursing home 
placement, and mobility loss (5,47-49).  Chronic disability, such as that associated with PAD, 
now accounts for more than half of the U.S. health burden (50). Yet therapeutic advances have 
not kept pace with the growing burden of disability from chronic disease (50).   
 
Few effective medical therapies are available to improve walking ability in people with 
PAD.  Only two medications, cilostazol and pentoxifylline, are FDA approved for treating PAD-
associated walking impairment.  Recently published American Heart Association (AHA) clinical 
practice guidelines for PAD recommend against pentoxifylline due to lack of efficacy (51).  
Benefits from cilostazol are modest and many patients with PAD discontinue cilostazol due to 
side effects (51-55).  Most PAD patients are not candidates for revascularization (51,56).  Even 
among PAD patients who undergo revascularization, up to 25-30% of lower extremity 
angioplasty/stent procedures fail within one year (57).  Supervised treadmill exercise improves 
walking ability in patients with PAD, and the Center for Medicare and Medicaid Services (CMS) 
recently approved medical insurance reimbursement for 12 weeks of supervised treadmill 
exercise for people with PAD (58).  However, most people with PAD opt not to participate in 
supervised exercise because of inconvenience or lack of interest (59).  Furthermore, people 
with PAD live with disability for many years, while CMS covers just 12 weeks of supervised 
exercise.  Identifying effective and safe therapies to improve walking performance and prevent 
mobility loss in PAD is an AHA priority that is directly addressed by the NICE Trial. 
 
PAD is associated with ischemia-reperfusion injury of calf skeletal muscle.  Patients with 
PAD experience calf muscle ischemia during walking, when metabolic demands exceed oxygen 
supply.  Patients with PAD experience calf muscle reperfusion during rest, when blood supply 
increases sufficiently to meet calf muscle oxygen requirements.  This phenomenon of ischemia-
reperfusion generates reactive oxygen species (ROS), such as superoxide anion and hydrogen 
peroxide (7-14).  ROS damage muscle fibers, impair mitochondrial activity, and promote 
apoptosis (7-14).  Consistent with these phenomena, several small studies have described 
pathologic abnormalities in calf muscle of people with PAD (7,10,11,13-14).  First, electron 
microscopy shows pathologic changes in inter-myofibrillar mitochondria, nuclei, and 
sarcolemma in calf muscle from patients with PAD (12).  Second, several studies reported a 
quantitative mitochondria dysfunction in calf muscle of patients with PAD, with reduced energy 
production (10,13,14).  Third, oxidative stress is increased in calf muscle of patients with PAD, 
compared to those without PAD (7).  Among 34 participants with PAD and 21 without PAD who 
underwent calf muscle biopsy, PAD participants had a greater abundance of protein carbonyl 
content and 4-hydroxy-2-nonenal (HNE) (P<.001) than those without PAD, indicating a greater 
abundance of oxidative stress in calf muscle of participants with PAD compared to those without 
PAD.   In the participants with PAD, greater abundance of oxidative stress was associated with 
more myofibrillar damage (7).  Together these data suggest significant calf muscle pathology in 
patients with PAD, resulting in poorer mitochondrial activity, damaged myofibers, and reduced 
abundance of skeletal muscle fibers.  We hypothesize that therapies reversing this calf muscle 
pathology will improve walking performance in patients with PAD.  Consistent with our 
hypothesis, two recent studies in a mouse model of hind-limb ischemia showed that therapies 
targeting skeletal muscle mitochondrial damage significantly increased mitochondrial activity 
and improved skeletal muscle contractility (60,61). 
 
Rationale for studying nicotinamide riboside (NR) in PAD.  NR is rapidly metabolized to 
nicotinamide adenine dinucleotide (NAD+) and increases NAD+ abundance in animal and 
human tissue (19,31-35).  We hypothesize that increasing NAD+ abundance in calf muscle of 
patients with PAD will improve their walking performance for the following reasons.  First, NAD+ 


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is essential for mitochondrial respiration and oxidative phosphorylation. Second, NR-induced 
increases in NAD+ promotes skeletal muscle regeneration in senescent animals by increasing 
skeletal muscle stem cells, called satellite cells (32).  Third, NAD+ is an essential and rate 
limiting co-factor for SIRT1 activity, a histone deacetylation protein that promotes cell survival 
and longevity (31-35).  SIRT1 has multiple beneficial functions that are likely to directly benefit 
people with PAD (27-29,62,63).  Examples of how increasing SIRT1 activity is likely to improve 
walking performance in PAD are as follows.  First, SIRT1 promotes mitochondrial activity by 
increasing abundance of PGC-1α, the master regulator of mitochondrial biogenesis and activity 
in muscle cells (28-30).  In addition to promoting mitochondrial biogenesis, PGC-1α upregulates 
genes important for mitochondrial activity and stimulates angiogenesis (24,25,64).  Second, 
increasing SIRT1 activity activates endothelial nitric oxide synthase (eNOS) and promotes 
angiogenesis (62,63).  Third, increasing SIRT1 reduces cellular inflammation and oxidative 
stress by reducing NFkB (27-28,30).  For these reasons, we hypothesize that by increasing 
NAD+ abundance, NR will increase calf muscle mitochondrial activity, improve calf muscle 
perfusion, and promote calf muscle regeneration in patients with PAD.  Evidence from pre-
clinical models to support our hypotheses follow. 
 
NR activates SIRT1. Canto and colleagues fed 16 mice for one week with chow that contained 
either placebo or NR (31). The mice who ate NR enriched chow had a significantly greater 
abundance of NAD+ in their limb skeletal muscle than mice who ate placebo containing chow.  
Canto and colleagues then fed 40 mice chow that contained either placebo or NR for 16 weeks 
(31).  Half of the mice received a normal diet and half received a high fat diet.  After 12 weeks, 
the 20 mice receiving a high fat diet enriched with NR had significantly greater oxygen 
consumption and significantly greater treadmill running distance than those receiving a high fat 
diet with placebo.  After 16 weeks, the mice fed the high fat diet were sacrificed.  Mice receiving 
NR had greater mitochondrial activity and more abundant mitochondrial cristae in their 
gastrocnemius muscle, compared to mice receiving placebo.  Mice receiving NR also had 
greater SIRT1 activation and greater PGC-1α activation, compared to mice receiving placebo. 
Canto and colleagues also observed greater expression of nuclear genes encoding regulators 
of oxidative metabolism in mice fed NR, but this phenomenon was not observed in mice fed 
placebo. None of the favorable changes in SIRT1 activity and none of the increases in 
mitochondrial activity were observed in the brain, where NAD+ did not increase.  In summary, in 
a murine model, oral NR increased skeletal muscle NAD+ abundance and this increased NAD+ 
abundance increased SIRT1 activity, mitochondrial biogenesis, mitochondrial activity, treadmill 
running distance and oxygen consumption, compared to placebo. 
 
NR promotes muscle regeneration, increases muscle quality, and increases 
mitochondrial respiration in aged mice (32). Zhang and colleagues fed young and aged mice 
NR enriched chow or regular chow for six weeks and reported the following results.  First, in 
both young and old mice, mice that received NR enriched chow had a greater abundance of 
NAD+ in skeletal muscle stem cells compared to mice that received regular chow.  Second, 
maximal running time, maximal running distance, and grip strength were significantly higher in 
aged mice fed NR enriched chow for six months, compared to aged mice fed plain chow for six 
weeks.  Third, aged mice fed NR enriched chow had a significantly greater abundance of 
skeletal muscle stem cells compared to aged mice fed regular chow.  Fourth, the aged mice fed 
NR enriched chow had significantly greater expression of genes responsible for mitochondrial 
respiration compared to aged mice fed plain chow.  In summary, in aged mice, NR increased 
skeletal muscle NAD+ abundance, increased genes responsible for mitochondrial respiration, 
increased abundance of muscle satellite cells, and increased maximal running time, running 
distance, and grip strength. These results support our hypotheses that NR will improve walking 
performance in PAD. 


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NR improves mitochondrial activity in animals with mitochondrial myopathy.  Khan and 
colleagues fed mice with a mitochondrial myopathy either an NR enriched chow or a regular 
chow for 16 weeks (21).  After 16 weeks, the mice fed NR had greater skeletal muscle 
mitochondrial biogenesis, ATP production capacity, and oxygen consumption, than mice fed the 
regular chow.  On electron microscopy, the mice fed NR had a greater abundance of 
mitochondrial cristae, consistent with a greater volume of mitochondria, compared to the mice 
fed regular chow.  These findings also support our hypotheses that NR will increase 
mitochondrial activity in people with PAD. 
 
Evidence of NR-induced bioavailability of NAD+ in humans.  Trammell and colleagues 
demonstrated meaningful increases in NAD+ in human tissue following oral NR administration 
(19).  A single oral 1,000 mgs dose of NR (approximately 15 mg/kg) increased peripheral blood 
mononuclear cell concentrations of NAD+ by 2.7 fold in a 52 year old healthy male.  After taking 
1,000 mg of NR daily for seven days, NAD+ levels achieved sustained elevations of 2.0 to 15.0-
fold in peripheral blood mononuclear cells compared to baseline.  These elevations in NAD+ 
were measurable by 4.1 hours after ingesting the first dose of NR 1,000 mgs (19).  Next, oral 
NR was administered to 12 healthy men and women for three consecutive days at three 
different doses (100 mgs, 300 mgs, and 1,000 mgs). Each dose was separated by seven days.  
Peripheral blood mononuclear cell levels of NAD+ increased in a dose-dependent fashion, with 
meaningful increases in NAD+ observed in peripheral blood mononuclear cells within 8 hours of 
NR administration. Elevated levels were sustained 23 hours later.  There were no adverse 
events associated with the 1,000 mg dose (19).  A separate randomized trial by consultant and 
collaborator Dr. Chris Martens demonstrated significantly improved peripheral vascular stiffness, 
measured by tonometry, in healthy participants without cardiovascular disease (65).  In 
summary, orally administered NR significantly increases NAD+ bioavailability in humans.  
 
In summary, preclinical evidence supports our hypotheses that orally administered NR will 
activate SIRT1 in skeletal muscle, increase expression of genes responsible for mitochondrial 
activity, and provide substrate for mitochondrial activity.  Preclinical evidence also supports our 
hypotheses that NR administration will promote calf skeletal muscle regeneration and increase 
walking endurance in patients with PAD.   
 
Rationale for studying NR combined with resveratrol. Resveratrol (3,5,4’-hydroxystilbene) is 
a natural polyphenol that is present in grape skin.  Resveratrol changes the conformational 
shape of the SIRT1 protein, increasing affinity of SIRT1 for its substrate and for NAD+.  NAD+ is 
an essential co-factor for SIRT1 activity.  Resveratrol increases the affinity of SIRT1 for 
substrate by 35-fold and increases the affinity of SIRT1 for NAD+ by more than five-fold, 
lowering the Michaelis constant (Km) for both substrate and NAD+ (43).  In animals, resveratrol 
improves skeletal muscle oxidative metabolism and increases mitochondrial biogenesis (30,36-
40).  For example, LaGouge and colleagues fed male mice resveratrol enriched chow or regular 
chow for 15 weeks.  After 15 weeks, non-oxidative muscle fibers had larger and more abundant 
mitochondria with increased mitochondrial enzyme activity (30).  After 15 weeks, mice fed a 
high fat diet enriched with resveratrol ran further on a treadmill than mice fed a high fat diet 
without resveratrol.  Gene expression showed that gastrocnemius expression of PGC-1α and 
SIRT1 were higher in mice treated with resveratrol compared to control mice.  In a randomized 
controlled cross-over trial of 11 obese men (mean age 52.5 + 2.1), Timmers and colleagues 
demonstrated that 150 mgs of resveratrol therapy for 30 days significantly increased 
mitochondrial respiration, PGC-1α abundance (P<0.05), and SIRT1 abundance (P<0.05) (66).   
 


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We recently completed the RESTORE Trial, a randomized double-blinded pilot clinical trial in 
which 66 participants with PAD age 65 and older were randomized to 500 mgs of resveratrol, 
125 mgs of resveratrol, or placebo (44).  Growing evidence suggests that lower doses of 
resveratrol are more effective than higher doses (67-73).  Specifically, at lower doses, 
resveratrol increases proteins associated with cell survival and reduces ischemic damage, while 
at higher doses resveratrol promotes apoptosis (68-73).  Therefore, we tested a high (500 mgs) 
and a low (125 mgs) dose of resveratrol and we hypothesized that the lower dose (125 mgs) of 
resveratrol would be more effective than high dose.  After six months, 125 mgs of resveratrol 
increased the six-minute walk distance (primary outcome) by 16.9 meters compared to placebo 
(P=0.07).  However, 500 mgs of resveratrol did not change the six-minute walk compared to 
placebo (-1.6 meters, P=0.965).  As noted above, NAD+ is an essential cofactor for SIRT1 
activity.  Our pilot data from 16 people with PAD and six without PAD showed lower NAD+ 
abundance in calf skeletal muscle of those with PAD (107.5 vs. 117.6 pmol/mg, P=0.24).  
Therefore, we expect that combining resveratrol with NR, which increases NAD+ abundance, 
will achieve greater improvement in the six-minute walk than we observed in the RESTORE 
Trial. 
 
Knowledge gaps that the NICE Trial will fill.  Despite extremely promising evidence in pre-
clinical models, no studies have tested NR or NR combined with resveratrol in humans with 
cardiovascular disease.  If NR alone and/or NR with resveratrol improves functional 
performance and prevents functional decline in PAD, these widely available, inexpensive, and 
well-tolerated therapies will have a major impact on preventing mobility loss and improving 
quality of life in the large and growing number of people with PAD.  No prior studies have 
assessed the therapeutic efficacy of these supplements in people with PAD. 
 
Innovation. First, no prior studies have tested whether NR alone or NR combined with 
resveratrol significantly improves walking performance in people with PAD or in any populations 
with cardiovascular disease.  Second, no prior randomized trials in PAD have tested 
interventions that simultaneously increase SIRT1 activity and increase abundance of NAD+, an 
essential substrate for both SIRT1 and mitochondrial activity.  Third, our plan to test the efficacy 
of NR while simultaneously measuring change in calf muscle biopsy abundance of NAD+ in 
response to the intervention is innovative.    
 
STUDY ENDPOINTS: 
Primary Aim #1.  Among participants with PAD, we will determine whether NR alone improves 
six-minute walk performance at 6-month follow-up, compared to placebo.  We hypothesize that 
participants randomized to NR alone will have greater increases or less decline in six-minute 
walk at 6-month follow-up, compared to those randomized to placebo.  
 
Primary Aim #2.  Among participants with PAD, we will determine whether NR combined with 
resveratrol improves six-minute walk performance at 6-month follow-up, compared to placebo.  
We hypothesize that participants randomized to NR combined with resveratrol will have greater 
increases or less decline in six-minute walk performance at 6-month follow-up, compared to 
those randomized to placebo.  
 
Secondary Aim #1.  Among participants with PAD, we will determine whether NR alone 
improves six-minute walk performance at 3-month follow-up, compared to placebo.  We 
hypothesize that participants randomized to NR alone will have greater increases or less decline 
in six-minute walk at 3-month follow-up, compared to those randomized to placebo.  
 


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Secondary Aim #2.  Among participants with PAD, we will determine whether NR combined 
with resveratrol improves six-minute walk performance at 3-month follow-up, compared to 
placebo.  We hypothesize that participants randomized to NR combined with resveratrol will 
have greater increases or less decline in six-minute walk performance at 3-month follow-up, 
compared to those randomized to placebo.  
Secondary Aim #3.  Among participants with PAD, we will determine whether NR combined 
with resveratrol improves six-minute walk performance at 3-month follow-up and at 6-month 
follow-up, respectively, compared to NR alone.  We hypothesize that participants randomized to 
NR combined with resveratrol will improve six-minute walk at 3-month follow-up and at 6-month 
follow-up, compared to NR alone.  
 
Secondary Aim #4.  Among participants with PAD, we will determine whether NR alone 
improves maximal treadmill walking time, the WIQ distance score, and physical activity at 6-
month follow-up, compared to placebo.  We hypothesize that participants randomized to NR 
alone will have greater improvement or less decline in maximal treadmill walking time, the WIQ 
distance score, and physical activity at 6-month follow-up, compared to those randomized to 
placebo. 
 
Secondary Aim #5.  Among participants with PAD, we will determine whether NR combined 
with resveratrol improves maximal treadmill walking time, the WIQ distance score, and physical 
activity at 6-month follow-up, compared to placebo.  We hypothesize that participants 
randomized to NR plus resveratrol will have greater improvement or less decline in maximal 
treadmill walking time, the WIQ distance score, and physical activity at 6-month follow-up, 
compared to those randomized to placebo. 
 
Secondary Aim #6.  Among participants with PAD, we will determine whether those 
randomized to NR + resveratrol have greater improvement in each outcome defined in 
Secondary Aims #4 and #5, compared to those randomized to NR alone.  We hypothesize that 
participants randomized to NR combined with resveratrol will improve each outcome at 6-month 
follow-up, compared to NR alone.  
 
Secondary Aim #7. Participants with PAD who received NR alone and those who received NR 
+ resveratrol will be combined into one group and compared to the group receiving placebo, to 
determine whether NR alone or NR + resveratrol (combined group) have greater improvement 
in six-minute walk distance at 3-month follow-up and at 6-month follow-up, compared to those 
randomized to placebo.  We hypothesize that the combined NR group will improve six-minute 
walk distance at 3-month follow-up and at 6-month follow-up, compared to placebo. 
 
Secondary Aim #8.  Participants who received NR alone and those who received NR + 
resveratrol will be combined into one group and compared to the group receiving placebo, to 
determine whether those randomized to NR alone or NR + resveratrol (combined group) have 
greater improvement in maximal treadmill walking time, the WIQ distance score, physical 
activity, and calf muscle biopsy measured NAD+ abundance, satellite cell abundance, and 
muscle fiber phenotype, compared to the placebo group.  We hypothesize that the combined 
NR group will improve each outcome at six-month follow-up, compared to placebo. 
 
Exploratory Aim #1.  We will perform calf muscle biopsies to determine whether among 
participants with PAD, those randomized to NR + resveratrol or NR alone have increased calf 
muscle NAD+ abundance, increased satellite cell abundance and improved muscle fiber 
phenotype, compared to the placebo group. We hypothesize that PAD participants randomized 
to either NR+ resveratrol or NR alone will achieve increases in each of these measures, 


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compared to those randomized to placebo.  Additional calf muscle measures will be assessed in 
Specific Aim #1 of a separate project funded as part of this American Heart Association 
Strategically Funded Research Network (SFRN) (PI: C. Leeuwenburgh, PhD). 
 
 
Exploratory Aim #2.  Among participants with PAD, we will determine whether NR alone 
improves the WIQ speed and stair climbing scores and the Short-Form Physical Functioning 
score at 6-month follow-up, compared to placebo.   
 
Exploratory Aim #3.  Among participants with PAD, we will determine whether NR combined 
with resveratrol improves the WIQ speed and stair climbing scores and the Short-Form Physical 
Functioning score at 6-month follow-up, compared to placebo.  
 
Exploratory Aim #4.  Among participants with PAD, we will determine whether NR combined 
with resveratrol improves the WIQ speed and stair climbing scores and the Short-Form Physical 
Functioning score at 6-month follow-up, compared to NR alone.   
 
Exploratory Aim #5. Participants who received NR alone and those who received NR + 
resveratrol will be combined into one group and compared to the group receiving placebo, to 
determine whether those randomized to NR alone or NR + resveratrol (combined group) have 
greater improvement in the WIQ speed and stair climbing scores and the Short-Form Physical 
Functioning score at 6-month follow-up, compared to placebo.   
 
STUDY INVESTIGATIONAL AGENTS: 
Participants will be randomized to one of three groups: NR + resveratrol, NR + placebo, or 
placebo + placebo. Chromadex will supply the NR and matching placebo to the Northwestern 
Medicine Investigational Pharmacy. Reserveage Organics will supply resveratrol and matching 
placebo to the Northwestern Medicine Investigational Pharmacy. 
 
The pharmacist will dispense study drug according to group assignment.  Study medication is 
dispensed in bottles labeled with the participant name and study identification number.  Bottles 
will NOT be labeled with the group assignment, ensuring that both the research team collecting 
data and study participants are blinded to group assignment (i.e. double blinded status). Study 
pills are stored and handled according to the Northwestern Medicine Research Pharmacy SOP. 
 
Dr. Mary McDermott is the holder of the IND for the study (IND#139436).  
 
PROCEDURES INVOLVED: 
Initial eligibility criteria will be assessed by telephone. Potential participants who remain eligible 
after the telephone screening will be scheduled for a baseline visit, where they will undergo 
additional testing to determine their eligibility for randomization. 
 
Baseline testing. Participants will provide written informed consent at baseline. An ankle 
brachial index (ABI) will be performed. Questionnaires will be administered and physical 
functioning tests will be performed. A treadmill exercise stress test will be performed. A blood 
sample will be obtained and height and weight will be measured. If the participant agrees to the 
optional muscle biopsy, they will be asked to undergo a biopsy. Baseline testing will require 
testing at multiple visits performed over multiple days. Research procedures are described in 
more detail below. 
 


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Run-in. The run-in is designed to exclude people who may not be adherent to the study drugs.  
To help ensure that randomized participants are adherent to study drug, we will ask all potential 
participants to complete a two week run-in prior to randomization.  For the run-in, participants 
will be asked to take five study pills (2 NR placebo pills twice daily and 1 resveratrol placebo pill 
daily) for two weeks.  Potential participants who take less than 70% of their placebo pills (i.e. 
less than 10 of 14 resveratrol placebo pills and/or less than 40 NR placebo pills) will be 
excluded.   
 
Randomization.  We will randomize participants to NR + resveratrol, NR + placebo, or placebo 
+ placebo using a SAS computer program.  Participants will be randomized using randomly 
selected block sizes of 4 and 6, to ensure random allocation between the three groups. A data 
analyst will perform the randomization and the group assignment will be communicated directly 
to the Northwestern Medicine Investigational Pharmacy.   
 
Intervention and placebo. Participants will be asked to take pills daily (NR/placebo and 
resveratrol/placebo according to randomization assignment). Participants randomized to either 
NR + placebo or NR + resveratrol will receive 1,000 mg of NR daily (250 mg each; total of 4 
pills). Participants randomized to NR + resveratrol will receive 125 mg of resveratrol daily (1 pill 
daily). Bottles will be picked up by a study coordinator and given to the participant in-person or 
sent via mail. 
 
Participants will be asked to keep a daily medication log to record each time they take their 
study pills. They will be asked to retain their pill bottles and provide the bottles to study staff so 
that remaining pills (if any) can be counted. Additionally, relatively inexpensive items that may 
help participants better adhere to study procedures may be purchased on a case-by-case basis 
to assist with maximizing adherence to study procedures.  An example is a pill organizing box 
that helps participants to better adhere to study pills.  
 
Participants will be given their study pills in three-month supplies.  
 
In-Person Visits, Telephone Calls, and 3-month follow-up testing. Participants will be asked 
to come in to the medical center up to once per month to monitor adverse events and to assess 
adherence to study medication by reviewing the medication logs and pill count. If a participant 
does not come to the medical center, a telephone call will be made to monitor adverse events.  
 
At three months, participants will be asked to return to the medical center to perform a six-
minute walk, return their pill log and pill bottles, and to receive a new three-month supply of 
study pills. Participants may be asked to return for additional visits at the discretion of the 
investigator to monitor adherence or for safety during the study period.  
 
Six-month follow-up testing. Participants will return after taking the study pills for six months 
to complete final follow-up testing. Measures and tests that were conducted at baseline will be 
repeated and the pill logs and bottles will be collected.  
 
Some or all study measures may be repeated at baseline or follow-up for data quality (e.g. if a 
treadmill test must be stopped due to extremely high blood pressure before the patient 
completed the test is one potential example of why a measure may need to be repeated). In 
some cases, it may be necessary to take an additional, unscheduled blood pressure 
measurement. For instance, if a participant has high blood pressure during the ABI and 
investigators would like to double check their arm pressure measurement before performing the 
six-minute walk either at the same visit or at a subsequent visit.  Determinations about blood 


STU00206660 
pressure checks will be made on a case-by-case basis in consultation with Dr. McDermott or Dr. 
Lloyd-Jones or other qualified personnel. 
 
In some cases, participants may be asked to take study pills for longer than six months. For 
example, if a participant has an illness that prevents them from returning at six months for 
follow-up testing or if they are out of town during their six-month follow-up window.  In these 
instances, participants will be asked to continue taking their study pills for more than six months. 
Participants may be asked to take up to an additional three months of study pills. 
 
Research procedures: 
Ankle Brachial Index (ABI). After the participant rests supine for five minutes, the right 
brachial, dorsalis pedis (DP), posterior tibial (PT) and left DP, PT, and brachial artery pressures 
are measured using a hand-held Doppler probe. Pressures are measured twice. The ABI is 
calculated for each leg by dividing the average of the DP and PT pressures by the average 
brachial pressure. If an ankle brachial index result yields an equivocal result or suggests that a 
participant’s lower extremity arteries are calcified, investigator discretion may be used to order a 
lower extremity vascular test with toe pressures at Northwestern Memorial Hospital to determine 
eligibility at baseline. The test will repeat blood pressures in the arms and legs and will include a 
toe pressure measurement, which is performed by placing a small blood pressure cuff around 
the great toe and attaching a plethysmography probe (circulatory sensor) on the pulpy part of 
the tip of the great toe. 
 
Questionnaire Administration. Participants will be administered IRB-approved study 
questionnaires by a trained and certified study coordinator. Health-related quality of life will be 
assessed with the SF-36 Physical Functioning questionnaire (SF-36) and the Walking 
Impairment Questionnaire (WIQ). Patient report will be used to document comorbidities and 
physical activity. 
 
COVID-19 Questionnaire. Currently enrolled and past participants may be called to see if they 
are willing to complete a questionnaire related to the COVID-19 pandemic. The questionnaire 
will be completed over the telephone and will help investigators determine how the pandemic is 
affecting older adults with PAD and how physical activity levels are affected during this time. 
 
 
Six-minute walk. In the six-minute walk, participants walk back and forth along a 100-ft hallway 
for six minutes after standardized instructions to complete as many laps as possible. Distance 
covered in six minutes is recorded.  
 
Treadmill testing. The Gardner graded treadmill exercise test will be used to measure change 
in maximal treadmill walking time in response to the study intervention. Speed is maintained at 
2.0 miles per hour (mph) and treadmill grade increases by 2.0% every two minutes. If patients 
cannot walk at 2.0 mph, a Modified Gardner will be used, where treadmill speed is started at 0.5 
mph and increased by 0.5 mph every 2 minutes until the participant reaches 2.0 mph, after 
which the treadmill grade is increased every two minutes while the speed remains at 2.0 mph. 
 
Measuring physical activity.  Physical activity will be measured in all participants over 10 days 
at baseline and follow-up, using the ActiGraph accelerometer.  Participants are asked to wear 
the ActiGraph on the right side of their beltline for 10 days, removing it only for bathing or 
sleeping.  After 10 days, participants mail the accelerometer back in a stamped, pre-addressed 
envelope provided to them at their study visit.  We also contact participants by telephone to 
ensure monitors are returned.   


STU00206660 
 
Blood collection and long-term storage. At baseline and six-month follow-up study visits, 
participants may have approximately 50 ml of blood drawn for processing and long-term storage 
at -70 degrees Celsius. Approximately 10% of participants selected by chance will have an 
additional set of 45 ml of blood drawn for quality assurance at baseline and six-month follow-up 
(total 95 ml at baseline, 90 ml at follow-up). Blood will be tested for kidney and liver function at 
baseline. Stored blood will await later analyses for biomarkers and other emerging blood 
markers related to peripheral artery disease that may change in response to the intervention. A 
subset of participants will be invited to have an extra 9 ml tube of blood obtained to measure 
senescent cells (i.e. P16+ cells).  For participants who agree to the optional element, blood will 
be obtained in blood tubes supplied by Sapere Bio, labeled with study ID number, and sent to 
Sapere Bio (400 Park Offices Dr, Research Triangle Park, NC 27709) for measurement of 
senescent cells. Sapere Bio will either destroy or return to Northwestern the remaining blood 
after measuring senescent cells. Genetic testing may also be performed on stored DNA if the 
participant agrees to this optional study element on the consent document. Results of the 
genetic testing on the sample will be stored with other data collected. Samples will be labeled 
with the participant’s study identification number and will not be stored with other health or 
identifying information. Information associated with the sample will be stored a secure database 
on password protected computers that are secured by Northwestern University firewalls. Access 
is limited to study staff. If the samples are shared with other researchers not part of the current 
study, the PI will grant permission to the other researchers to analyze the samples after 
receiving IRB approval. Samples will be identified with a study identification number and the 
other researchers will not have access to PHI. Results of testing on the blood samples for long-
term storage will not be shared with the study participants. Results of kidney and liver 
functioning will be shared upon request or if a value is medically significant and requires follow-
up.  
 
Calf muscle biopsies. Muscle biopsies will be performed by co-investigator Robert Sufit, MD, a 
board-certified neurologist with > 30 years of experience performing muscle biopsies. Muscle 
biopsies are obtained in the medial head of the gastrocnemius muscle in the leg with lowest 
ABI, at the point that is 67% of the distance between the medial malleolus and the medial 
aspect of the proximal tibia. If for some reason the leg with the lowest ABI cannot be biopsied 
(for example, not enough muscle available or if the participant or study team prefers not to 
biopsy the leg with the lowest ABI), then the other leg may undergo biopsy. Anesthesia is 
achieved with subcutaneous lidocaine. Subcutaneous and adipose tissue are dissected. 
Approximately 250 mgs of muscle is removed and immediately prepared for long term storage 
at -70 degrees Celsius.  Approximately 100 to 150 mgs of fat may be removed from the 
subcutaneous fat and approximately 100 to 150 mgs of fat may be removed from below the 
fascial line during the muscle biopsy. In patients with more fat tissue, up to approximately 250 
mgs of fat will be removed from the subcutaneous fat and from below the fascial line, 
respectively, at the discretion of the physician performing the muscle biopsy.  Muscle tissue is 
frozen directly in liquid nitrogen for protein analyses and also mounted in trigacanth gum on cork 
and snap frozen in liquid nitrogencooled isopentane for histochemical analysis. At six-month 
follow-up, we will repeat the biopsy adjacent to the original biopsy, identifiable by the scar.   
 
All calf muscle measures will be compared between baseline and six-month follow-up.  To 
measure NAD+, frozen muscle will be analyzed using High-Performance liquid chromatography 
(HPLC) (81).  Satellite cell number will be measured in the muscle specimens before and after 
study interventions in Dr. Peterson’s lab at the University of Kentucky.  Immunohistochemical 
detection of Pax7, a satellite cell-specific transcription factor will be performed on 7 µm frozen 
muscle cross-sections.  Pax7+ DAPI+ nuclei will be counted and expressed per fiber type (82).  


STU00206660 
Because NR reduces senescence markers in aged mouse muscle (32), the frequency of p16+ 
nuclei, an indicator of senescence, will also be determined, as well as co-localization of p16 and 
Pax7.  Muscle fiber type and size will be quantified with myosin heavy chain-specific antibodies 
as described (75), to assess overall muscle fiber phenotype in response to the interventions. 
The frequency of regenerating muscle fibers will also be determined using an antibody against 
embryonic myosin heavy chain.  Additional muscle measures not specified here may be 
performed in Dr. Peterson’s and in Dr. Leeuwenburgh’s laboratory, based on findings in other 
ongoing studies of calf skeletal muscle dysfunction in people with PAD. Measures of 
senescence, including P16+ cells, may be performed in fat tissue obtained during the muscle 
biopsy in the laboratory of Dr. Peterson and/or Dr. Tchkonia at Mayo clinic. 
 
Other measures. Body mass index (BMI) will be assessed at baseline and follow-up by 
objectively measuring height and weight. A four-meter walk test will be administered at usual 
and fastest pace at the baseline and follow-up visits. Participants will be asked to perform the 
usual paced four-meter walk at usual pace and the “fast paced” four meter walk at their fastest 
pace. Each of these short walks will be performed twice. Participants will be asked to complete 
a series of standing balance tests and chair stands. Names and doses of participants’ 
medications will be systematically recorded at baseline and at follow-up.  
 
Microbiome. Study participants may be asked to provide a stool sample. Participants who 
agree to this optional element will be given supplies to swab the toilet paper after a bowel 
movement, place the swab into a tube labeled with their study ID number, and mail back the 
tube in a pre-stamped envelope within 48 hours of collection. Alternatively, the participant may 
be asked to bring the swab to a study visit to return in person, depending on their appointment 
schedule. This sample will be used to identify specific bacterial species whose relative 
abundance is either negatively or positively correlated with PAD and other patient 
characteristics, such as body mass index and PAD severity. Participants will be asked to 
complete a short diet and lifestyle questionnaire (self-administered or verbally completed in 
person or over the phone with a research study coordinator) during the week when the stool is 
collected. The stool sample will be mailed for analysis to the laboratory of Dr. Jack Gilbert, a 
Professor of Pediatrics and a Professor in the Center for Microbiome Innovation at the 
University of California San Diego. Some of the serum that is already collected as part of study 
blood collection procedures may be mailed to Dr. Gilbert’s laboratory for analyses of microbial 
metabolites.  
 
 
DATA AND SPECIMEN BANKING 
Muscle specimens and blood specimens for long-term storage will be stored in a freezer 
belonging to Dr. McDermott's research program at Northwestern University, in the freezer farm 
in the basement of Olson Pavilion. Specimens will be stored for up to 70 years, after which they 
will be destroyed. 
 
Specimens will be coded; meaning that a key will exist that can link the codes back to the direct 
subject identifiers. Each participant will be assigned a unique study ID number that can be 
traced back to the study participant. The muscle specimens and the blood samples that are 
stored will be labeled with this unique identifier and the date and time of the blood collection. 
 
Only Dr. McDermott has control over release of study data or specimens. Any investigators 
seeking to analyze blood or muscle specimens must contact Dr. McDermott for permission. 
Each request, if it occurs, will be considered on a case-by-case basis. Dr. McDermott will obtain 
IRB approval prior to releasing any blood or muscle specimens for analysis, other than those 
tests specifically named in this application. 


STU00206660 
 
SHARING RESULTS WITH PARTICIPANTS 
Participants will receive results of their ankle brachial index (ABI) test and will be provided with a 
“result letter” at the end of their baseline visit. ABI and stress test results will be mailed to the 
participant’s physician upon request. They will not be provided with other study results routinely. 
However, participants will be notified of medically significant stress test, blood, or blood 
pressure results identified in the stress test or ABI. 
 
STUDY TIMELINES 
Each participant will participate in the study for approximately six months after randomization. 
We plan to enroll 90 participants over an approximately three-year period. Primary analyses are 
anticipated to be completed by approximately April 2022.  
 
INCLUSION AND EXCLUSION CRITERIA 
Inclusion criteria. All participants will have PAD. PAD will be defined as the following: 1) An 
ankle-brachial index (ABI) <0.90 at the baseline study visit or 2) Vascular laboratory evidence or 
angiographic evidence of PAD. Inclusion based on prior vascular laboratory evidence will be 
determined by the study principal investigator and includes, for example, a toe brachial index 
(TBI) < 0.70, Duplex measure showing 70% stenosis or great, a post heel-rise or post-exercise 
ABI drop of 20% or greater, or ABI values < 0.90. Angiographic evidence of PAD consists of a 
stenosis of 70% or greater in a lower extremity artery.  
 
Exclusion criteria. 
1. Above- or below-knee amputation. 
2. Critical limb ischemia. 
3. Wheelchair-bound or requiring a walker to ambulate. 
4. Walking is limited by a symptom other than PAD. 
5. Current foot ulcer on bottom of foot. 
6. End stage renal disease defined as a GFR less than 20 ml/min/1.73 M2. 
7. Significant liver impairment defined as two or more hepatic function enzymes >3.0 times the 
upper limit of normal. [NOTE: participants who meet this criterion may undergo a re-test of 
hepatic function tests to determine whether initially elevated hepatic enzymes represented a 
transient or spurious phenomenon.] 
8. Failure to successfully complete the 2-week study run-in. 
9. Planned lower extremity revascularization, orthopedic surgery, or other major surgery during 
the next six months. 
10. Lower extremity revascularization, orthopedic surgery, cardiovascular event, coronary 
revascularization, or other major surgery in the previous three months. 
11. Participation in supervised treadmill exercise during the previous six months. 
12. Major medical illness including renal disease requiring dialysis, lung disease requiring 
oxygen, Parkinson’s disease, a life-threatening illness with life expectancy less than six months, 
or cancer requiring treatment in the previous two years. [NOTE: potential participants may still 
qualify if they have had treatment for an early stage cancer in the past two years and the 
prognosis is excellent. Participants who only use oxygen at night may still qualify.]  
13. Mini-Mental Status Examination (MMSE) score <23 or dementia. 
14. Participation in or completion of a clinical trial in the previous three months. [NOTE: after 
completing a stem cell or gene therapy intervention, participants will become eligible after the 
final study follow-up visit of the stem cell or gene therapy study so long as at least six months 
have passed since the final intervention administration. After completing a supplement or drug 
therapy (other than stem cell or gene therapy), participants will be eligible after the final study 


STU00206660 
follow-up visit as long as at least three months have passed since the final intervention of the 
trial.] 
15. Currently taking a dose of 250 mg or more of nicotinomide riboside, vitamin B3, niacin. 
Currently taking a slow-release form of niacin. Currently taking resveratrol or has taken any 
these drug(s) in past six months. Participants taking a multi-vitamin will not be excluded if the 
dose of vitamin B3 is less than 250 mgs.   
16. Increase in angina or angina at rest 
17. Non-English speaking. 
18. Visual impairment that limits walking ability. 
19. Women who are pregnant or who are pre-menopausal will not be eligible. 
20.  In addition to the above criteria, investigator discretion will be used to determine if the trial is 
unsafe or not a good fit for the potential participant. 
 
Potentially eligible participants will be advised that Medicare coverage for 12 weeks of 
supervised treadmill exercise is now available.  Potential participants who have not participated 
in supervised treadmill exercise covered by Medicare and who desire to participate will be 
referred back to their physician for follow-up.  These individuals may become eligible six months 
after they complete supervised treadmill exercise.   
  
Vulnerable populations (fetuses, pregnant women, children, prisoners, and institutionalized 
persons) and adults unable to consent will not be included in the study. 
 
PARTICIPANT POPULATION(S) 
Accrual 
Number: 
Category/Group: 
(Adults/Children 
Special/Vulnerable 
Populations) 
Consented: 
Maximum Number to be 
Consented or 
Reviewed/Collected/Screened 
Enrolled: 
Number to Complete 
the Study or Needed 
to Address the 
Research Question 
Local 
Adults 18 and older 
1000 
90 
Study-wide 
N/A 
 
 
Total: 
 
1000 
90 
 
 
RECRUITMENT METHODS 
Participants will be identified from among individuals with PAD who have participated previously 
in research conducted by Dr. McDermott and/or who have expressed an interest in participating 
in future studies conducted by Dr. McDermott. Participants who we screen for ongoing studies 
who may have PAD but are ineligible for that study and interested participating in a study may 
be screened for this study. 
 
In addition, PAD participants may be identified from among consecutive patients diagnosed with 
PAD in the non-invasive vascular laboratory at Northwestern Medical Group (NMG). Dr. Mark 
Eskandari is medical director of the non-invasive vascular laboratory at NMG and will assist with 
identifying potential participants from the non-invasive vascular laboratory. As director of the 
vascular laboratory at NMG, Dr. Eskandari formally reads many of the non-invasive vascular 
laboratory tests. He maintains all non-invasive vascular test results in his vascular laboratory. 


STU00206660 
As director of the vascular laboratory, Dr. Eskandari could conceivably contact the patients 
whose test results are maintained in his laboratory. However, Dr. Eskandari prefers that the 
contact of potential participants in studies come from the physicians referring him for testing. 
Lists of patients who have undergone lower extremity arterial testing in the non-invasive 
vascular laboratory are generated monthly and e-mailed from NMG to Dr. McDermott. A 
research assistant will contact referring physicians of potential participants identified from the 
vascular laboratory via fax, phone, page, or electronic message (EPIC or e-mail), to ask for 
permission to contact their patient about the study. If a reply is not received within three weeks, 
up to five letters are mailed from Dr. McDermott about the research study. We have substantial 
experience with our recruitment methods for our previous or ongoing studies. 
 
We will also obtain lists of consecutive patients with a diagnosis of lower extremity peripheral 
arterial disease and individuals at high risk for peripheral artery disease from Northwestern’s 
Enterprise Data Warehouse (EDW). EDW lists will be provided by an individual who is 
employed by the Division of General Internal Medicine who has received training and 
permission to obtain the lists from the EDW. 
 
Similar methods will be used as those described above, in which the patient’s physician will be 
contacted via fax, telephone, page, or electronic message (EPIC or email) to ask for permission 
to contact their patient about the study. If a reply is not received within three weeks, up to five 
letters are mailed from Dr. McDermott about the research study. In the recruitment letters, 
recipients are asked to call us if they are interested in participation or if they do not want to be 
contacted further. Potential participants who do not call us within three weeks of the first mailed 
recruitment letter may be telephoned by study staff and invited to participate. 
 
In addition, we may use newspaper, television, and radio advertising to identify potential 
participants for this study. We will also use brochures, flyers, or posters that we will post in 
relevant office practices and public areas. We may use advertising on public transportation (i.e. 
Chicago Transit Authority) or online advertisements. 
 
We will obtain a list of patients who live in the Chicago area from a mass mailing company. 
Using this, we will send postcards to those individuals on the list. The postcards will instruct 
people to call a study number if they are interested. 
 
Recruitment materials for methods referenced above will be submitted to the IRB for approval 
prior to their use.  
 
We may also use CAPriCORN for recruitment. CAPriCORN is a PCORI-funded network of 
institutions in the Chicago area. The purpose of CAPriCORN is to assist investigators with 
recruitment for clinical trials. CAPriCORN has its own IRB (Chicago Area Institutional Review 
board - CHAIRb) and uses ICD-9 codes and the electronic health record to identify potential 
participants who have PAD. These patients with PAD will be mailed a recruitment letter that 
describes the trial and invites the patient to participate. 
 
We may also obtain IRB approval at the University of Chicago and/or the Jesse Brown VA 
Medical Center to recruit patients from these medical centers. If IRB approval is obtained from U 
of C and JBVAMC, letters will be mailed by an approved staff member to potential patients with 
known PAD. Participants recruited through these methods at JBVAMC will sign a VA consent 
document and will undergo some study testing on-site at the VA. Study tests include 
questionnaires and functional performance measures. 


STU00206660 
 
COMPENSATION FOR PARTICIPATION IN RESEARCH ACTIVITIES 
Participants will receive $25 for completing six-month follow-up testing. 
 
If the participant undergoes the optional muscle biopsy portion of the study, they will receive 
$100 per muscle biopsy. 
 
Participants will be given assistance and/or reimbursement for expenses related to travel such 
as parking, bus/train fare, taxi or rideshare (i.e. Uber/Lyft) fare, and mileage, if requested. A 
receipt will be required for reimbursement above $40. Participants will be provided up to $90 per 
visit for travel reimbursement. If they require the use of our taxi or rideshare service, we will 
estimate the fare on www.taxifarefinder.com or on the rideshare website. A one-way fare 
estimate must be less than or equal to $45 (i.e. round trip of $90) in order for the study to 
provide taxi service. In some instances, a participant’s travel estimate may be within the $90 
limit for their first visit, but may unexpectedly increase at a later visit due to price fluctuations 
with Uber/Lyft. In these instances, the study will continue to provide travel to participants and 
pay the increased travel fare. In addition, if after randomization, a participant becomes unable to 
attend study visits and requires transportation such as a shared ride service in order to continue 
participation, then the travel service will be provided, using investigator discretion, so that the 
randomized participant can continue in the trial. In these cases, the amount of travel using our 
taxi or rideshare service may exceed $90.   
 
WITHDRAWAL OF PARTICIPANTS 
We anticipate that participant withdrawal from the research without their consent will be 
infrequent. However, a potential example is if a participant develops symptoms during the study 
and the principal investigator feels that the symptoms could make the study unsafe for the 
participant to continue. In this circumstance, the participant would be advised to follow-up with 
his or her physician. If the participant refuses to follow-up with their physician, it may be 
necessary for the participant to be withdrawn without their consent. 
 
Some participants may decide they no longer want to participate in the study intervention. 
These participants will still be asked to return for follow-up testing.  
 
Participants may withdraw from the research at any time. If they decide to leave the research, 
they should contact the principal investigator, Dr. Mary McDermott. If they stop being in the 
research, already collected data may not be removed from the study database. 
 
RISKS TO PARTICIPANTS 
Risks associated with NR and resveratrol. NR has been studied in humans and no serious 
adverse events have been reported (19,65). Resveratrol has been tested in multiple studies of 
humans (44,66,76). A systematic review reported that resveratrol is generally safe with only 
gastrointestinal symptoms reported at high doses (i.e. > 1,000 mgs) (76). Participants will be 
administered questionnaires monthly to obtain data regarding any potential side effects.  Safety 
will also be monitored by our DSMB. 
 
Risks associated with the muscle biopsy. The muscle biopsy is associated with several 
potential risks. These include discomfort during the muscle biopsy procedure and for 1-2 days 
afterward, scarring from the muscle biopsy skin incision, bleeding (including a hematoma), and 
infection. Adverse effects of Lidocaine administered prior to the biopsy include pain at the 
injection site, allergic reaction (including swelling of the tongue or throat, wheezing, difficulty 


STU00206660 
breathing, or death), emotional excitement, and a temporarily lowered heart rate and blood 
pressure. However, these adverse effects of lidocaine are rare. In addition, potential participants 
who are asked to hold their anti-platelet therapy during the week leading up to the muscle 
biopsy procedure may experience a cardiovascular event related to the temporary 
discontinuation of the anti-platelet therapy. First, to minimize risk related to muscle biopsy, all 
participants undergoing muscle biopsy will receive a written handout regarding signs to watch 
for that may indicate wound infection. They will also be verbally instructed in this. Each 
participant will be instructed to call Dr. McDermott immediately if any signs of infection occur. 
Second, permission from the participant’s physician will be required before participants are 
asked to discontinue anti-platelet therapy. Participants will be telephoned approximately seven 
days after the muscle biopsy. Participants who report any complaints about their biopsy site 
(such as significant pain or redness) will be scheduled for an evaluation of their biopsy site by a 
study physician.  
 
Risks associated with the six-minute walk test, treadmill stress test, four-meter walks, 
balance, and chair stands. The physical functioning tests may be associated with muscle 
fatigue or soreness. These symptoms typically resolve with rest. These tests may be associated 
with the risk of falling, irregular heartbeat, heart attack, or coronary ischemia or dyspnea due to 
heart failure or lung disease. Rarely, falling may result in a fracture. However, the research 
assistant who will collect these data has been trained to prevent falling. The risk of a fracture 
secondary to a fall during the testing is less than 1 in 8,000. If a participant experiences chest 
pain, research assistants are trained to page Dr. McDermott immediately. If the chest discomfort 
does not immediately resolve with rest, participants are escorted to Northwestern’s Emergency 
Department, which is located in the same building as the location of the tests. Dr. McDermott 
facilitates follow-up as appropriate, by contacting participants’ physicians, for those who 
experience new chest discomfort during testing, for example. In our experience, the risk of chest 
discomfort is approximately 1 in 750. Symptoms or results from the treadmill stress test may 
lead to further testing or hospitalization or recommendations for procedures to improve blood 
flow to the heart. 
 
Risks associated with ABI measurement. The ankle brachial index measurement consists of 
measuring systolic blood pressure in each extremity using a hand-held Doppler. The 
ABI is non-invasive, safe and does not have any known lasting side effects. During the ankle-
brachial index test, participants may experience discomfort from the inflated blood pressure cuff. 
However, this discomfort resolves immediately when the cuff is released. 
 
Risks associated with questionnaire administration. Participation includes a risk of loss of 
confidentiality regarding personal health information. However, all research staff have 
undergone formal human subjects training. They are trained to protect the privacy of research 
subject participants. 
 
Risks associated with drawing blood. The potential risks of drawing blood include a bruise at 
the site of vein puncture, inflammation of the vein, and infection. Participants undergoing a 
blood draw may experience lightheadedness, dizziness, or fainting. 
In addition to these risks, this research may cause harm in ways that are unknown. These may 
be a minor inconvenience or may be so severe as to cause death. 
 
POTENTIAL BENEFITS TO PARTICIPANTS 
Participants who are randomized to receive nicotinamide riboside could experience improved 
functional performance or less decline in functional performance, if our hypotheses are correct.  


STU00206660 
 
DATA MANAGEMENT AND CONFIDENTIALITY 
Data is recorded using preprogrammed instruments and an electronic case report form using 
secure, HIPAA-compliant REDCap database software on servers maintained by Northwestern’s 
Clinical and Translational Sciences Institute. We have substantial experience with REDCap. 
 
Power and Sample Size Estimation.  We will enroll 30 patients per group. Based on our 
experience with randomized trials in PAD, we anticipate that 27 participants in each group will 
complete 6-month follow-up and provide outcomes for the statistical analysis (44,74).  For 
Primary Aim 1, we will use a two-sample t-test to compare the 6-month decline in six-minute 
walk distance between NR alone and placebo.  Twenty-seven participants per group provides 
80% power for detecting a difference of 0.69 standard deviation (SD) of the decline at the one-
sided significance level of 0.1. Based on our GOALS Trial results (74), a 0.58 SD represents a 
difference of 30 meters in six-minute walk distance.  Similarly, for Primary Aim 2, we will have 
80% power for detecting a difference of 30 meters between NR combined with resveratrol vs. 
placebo. For Secondary Aim #1 and Secondary Aim #2, we will have 80% statistical power for 
detecting a difference of 30 meters between the NR alone vs. placebo group (Secondary Aim 
#1) and between the NR combined with resveratrol group vs. the placebo group (Secondary 
Aim #2) at 3-month follow-up.  In our Secondary Aim #3, we will have 80% statistical power for 
detecting a difference of 30 meters between the NR combined with resveratrol group and the 
NR alone group at 3-month and at 6-month follow-up.  Most prior studies have defined clinically 
meaningful changes in the six-minute walk as 20-50 meters (77-80). Thus, the study has 
sufficient statistical power for detecting a clinically meaningful difference under the same 
assumptions.  The NICE Trial is a proof of principle study intended to collect evidence for a 
large randomized trial.  For Secondary Aim #4, we will compare changes in maximal treadmill 
walking distance, the WIQ distance score and physical activity between NR alone vs. placebo. 
The study provides 80% power for detecting a difference of 0.58 SD. Similarly, in Secondary 
Aim #5, we will compare changes in maximal treadmill walking distance, the WIQ distance score 
and physical activity between NR + resveratrol and placebo.  In our GOALS trial, 0.69 SD of 6-
month decline in WIQ represented a difference of 14 points for the WIQ distance score (74).   
The difference in reported cut-off values in WIQ scores between high and low PAD performers 
is 76 minus 43, or 33 points (83).  Therefore, the study should have sufficient statistical power 
for detecting clinically important differences in the WIQ distance score. For Secondary Aim 6, 
we will compare 6-month changes in maximal treadmill walking distance, the WIQ distance 
score, and physical activity between people randomized to NR combined with resveratrol, 
compared to NR alone.  For Secondary Aim 7, we will compare 3-month and 6-month changes 
in six-minute walk distance between all people randomized to an NR group (i.e. those 
randomized to NR combined with resveratrol and those randomized to NR alone) and those 
randomized to placebo. For Secondary Aim 8, we will compare 6-month changes in maximal 
treadmill walking time, the WIQ distance score, and physical activity between all people 
randomized to an NR group (i.e. those randomized to NR combined with resveratrol and those 
randomized to NR alone) and those randomized to placebo. In Secondary Aims #7 and #8, we 
have 80% power for detecting a difference of 0.50 SD. The proposed mixed effects regression 
analysis has a higher power than the two-sample t-test and thus can detect even smaller 
differences. 
 
Statistical Analyses. Analyses will be performed using the intention to treat principle.  Prior to 
the analyses, the distributions of the variables (changes) will be examined. For our Primary Aim 
#1, we will use a mixed effects repeated measurements (MMRM) regression to compare 
changes in six-minute walk performance at 6-month follow-up between the NR alone vs. 
placebo groups, adjusting for age, sex, race, and baseline six-minute walk distance.  Age, sex, 


STU00206660 
and race will be adjusted for because of their association with change in six-minute walk 
distance (see below). Similar analyses will be performed for Secondary Aims #1, #2, #3, and #7.   
For our Primary Aim #2, we will use a one-tailed t-test based on MMRM to compared changes 
in six-minute walk between NR combined with resveratrol vs. placebo. We will perform MMRM 
regression analysis with the change in six-minute walk distance at month 3 and month 6 as the 
correlated response variable with an unstructured covariance matrix to evaluate differences in 
change in six-minute walk distance between the two groups in each comparison, adjusting for 
potential baseline confounders specified as following: baseline six-minute walk performance, 
age, sex, and race.  The mixed effect regression would include patients missing the 6 month 
follow-up visit, assuming missing at random. If either primary aim is positive, the clinical trial will 
be considered positive. A one-sided P value at P<0.10 will be considered statistically significant.  
We are selecting this P value because of the preliminary (pilot) nature of this work. For 
Secondary Aims #4, #5, #6, #8 and Exploratory Aims, we will use the analysis of covariance to 
compare the 6-month change of each outcome, separately. In each specific comparison, the 
baseline value for the outcome of interest (i.e. WIQ score, treadmill, physical activity) will be 
adjusted for (rather than the six-minute walk) in addition to age, sex and race. For the 
Secondary Aims #7 and #8, the NR + placebo groups will be combined with NR + resveratrol 
into one group and compared to the placebo group and the MMRM regression or analysis of 
covariance will additionally adjust for the resveratrol usage.   
For all of the analyses, The MMRM regression includes treatment indicator, visit time (month 3 
and month 6 as categorical factors), the interactions between treatment and visit time, baseline 
six minute walking distance (for all aims in which six-minute walk is the outcome), age, sex and 
race. For comparisons of other endpoints not measured longitudinally, the conventional analysis 
of covariance will be used adjusting for the baseline level of the corresponding outcome, age, 
sex, and race. We will adjust for baseline six-minute walk, age, sex, and race, because these 
variables have been correlated significantly with either change in six-minute walk or with six-
minute walk at follow-up in our prior studies. For example, in the combined data from the control 
groups of our GOALS, LITE, PROPEL, and TELEX randomized clinical trials of exercise 
interventions for people with PAD, six-minute walk at baseline was correlated with six minute 
walk distance at six-month follow-up (Pearson correlation coefficient= 0.812, P<0.001). In 
addition, participants who were Black had significantly poorer six-minute walk, compared to 
those who were not Black, at six-month follow-up (320.9 meters (SD: 104.5) vs. 359.8 meters 
(102.5), P=0.0035). Women had significantly poorer six-minute walk, compared to men, at six-
month follow-up (309.6 (SD: 103.2) vs. 358.7 (SD: 102.1), P<0.001). In our observational 
WALCS cohort of men and women with PAD, older age was associated significantly with 
greater decline in six-minute walk distance at one-year follow-up (correlation= -0.236, P<0.001). 
In a sensitivity analysis, we will repeat all comparisons additionally adjusting for baseline 
covariates that show major imbalances between relevant treatment groups, where the major 
imbalance is defined as Cohen’s effect size being greater than 0.5. The MMRM analysis for 
comparing the change in six-minute walking distance will be based on all participants who have 
their six minute walking distance measured at least once during follow-up (i.e. at least at month 
3 or month 6).    
 
Quality Control. Ten percent of participants are randomly identified for quality control.  They 
will have their ABI measured twice by independent examiners.  They will have a split sample of 
muscle tissue (i.e. two samples from one participant) sent for analyses.  The second muscle 
sample is designated an arbitrary identification number to which the technician is blinded. Using 
these methods, quality control is monitored continuously.   
 


STU00206660 
PROVISIONS TO MONITOR THE DATA TO ENSURE THE SAFETY OF PARTICIPANTS 
A Data and Safety Monitoring Board (DSMB) will monitor safety throughout the study. The 
DSMB consists of three internationally recognized scientists including:  Dr. Thomas Pearson 
MD, FAHA Professor of Epidemiology, Dr. Joe Ix, Professor and Chief of the Division of 
Nephrology at University of California San Diego, and Dr. Michael Miller, Professor of 
Biostatistics at Wake Forest Baptist Medical Center.   The DSMB will meet at least every six 
months during the study. The DSMB will review and approve the protocol prior to beginning data 
collection. They will decide on stopping criteria for the study. On July 13, 2108 during their initial 
meeting the DSMB decided that stopping criteria would be only for safety.  The biostatisticians 
will work with the DSMB to perform interim analyses regarding safety only.  
 
Hospitalizations will be reported to the DSMB within seven days of investigators learning 
of the event, if the hospitalizations are unexpected and may be related to study participation.  All 
deaths will be reported to the DSMB within 24 hours.  All new injuries or illness causing serious, 
chronic disability that are unexpected and that may be related to study participation will be 
reported to the DSMB within seven days of investigators learning of the event.   At the DSMB 
meetings, held approximately every six months, a report of all hospitalizations by study group 
will be presented to the DSMB.  
 
Laboratory testing will be performed at Northwestern Hospital and results will be e-mailed 
directly to Dr. McDermott through the Electronic Health Record.  In addition, the laboratory 
pages Dr. McDermott with any serious alert values, according to the laboratory’s criteria.  Dr. 
McDermott will follow-up with study participants and arrange appropriate follow-up, depending 
on the alert value.  If Dr. McDermott is not available, the physician covering for her will receive 
the telephone calls from the laboratory and arrange for appropriate follow-up. 
  
PROVISIONS TO PROTECT THE PRIVACY INTERESTS OF PARTICIPANTS 
Research staff undergo training (human subjects training) in the protection of participant 
confidentiality and privacy. Research staff have access to medical records only for the purpose 
of conducting research that is approved by the IRB. Research procedures will be conducted in 
an enclosed space by a trained and certified research assistant. Dr. McDermott certifies 
research assistants in data collection to help ensure that participants are treated with the 
highest level of professionalism. 
 
COMPENSATION FOR RESEARCH-RELATED INJURY 
If the participant needs medical care because of taking part in this research study, they should 
contact the investigator and medical care will be made available. This care will be billed to the 
participant, their insurance, or other third party. Northwestern University has no program to pay 
for medical care for research-related injury. 
 
ECONOMIC BURDEN TO PARTICIPANTS 
Describe any costs that participants may be responsible for because of participation in the 
research.  All of the study procedures and measures are paid for by the investigative team. 
 
CONSENT PROCESS 
Written informed consent will be obtained from the participant prior to study procedures. 
Participants will be consented by a research assistant who has been trained and certified by Dr. 
McDermott in obtaining informed consent. A research assistant will explain the study to potential 
participants by telephone prior to their first study visit. When a potential participant arrives to the 
medical center for study participation, the research assistant will explain the full details of the 


STU00206660 
research study. The informed consent process will take place at the initial baseline study visit in 
a private area on Northwestern’s medical campus. Potential participants will be provided plenty 
of time to read the consent form. The research assistant will answer questions and Dr. 
McDermott or another study investigator at Northwestern is also available to answer any 
questions that participants may have about the research. If the participant would like more time 
to discuss the research study with their physician or family member before signing the consent 
document, they will be allowed to do so and the study visit will be rescheduled for a later date. 
Potential participants who do not speak English, subjects who are not yet adults, cognitively 
impaired adults, and adults unable to provide written consent will not be eligible for study 
participation. 
 
PROTECTED HEALTH INFORMATION (PHI AND HIPAA) 
HIPAA Authorization will be obtained from all participants as part of the informed consent 
process. 
 
QUALIFICATIONS TO CONDUCT RESEARCH AND RESOURCES AVAILABLE 
The multidisciplinary investigative team for this randomized trial includes internationally 
recognized and leading experts in PAD, mitochondrial activity, skeletal muscle, functional 
performance, and randomized trial design and statistical analyses. Members of the investigative 
team have been working together for up to 20 years on NIH-funded and PCORI funded studies 
to identify clinical characteristics associated with functional decline in PAD and more recently to 
identify novel therapies to improve functional performance and prevent functional decline in 
people with PAD.   
 
The investigative team is internationally recognized for its experience and expertise successfully 
completing randomized clinical trials.  Since 2009, the investigative team, led by Dr. McDermott, 
has completed enrollment for six randomized trials of participants with PAD that were funded by 
NIH or PCORI.   
 
The investigative team has substantial experience with the recruitment methods described 
above.  Between January 1, 2015 and July 31, 2017, we randomized 466 eligible participants 
with PAD into our randomized clinical trials at Northwestern: an average of 14.6 participants per 
month.  
 
Health interviewers will be trained by a senior coordinator and certified by Dr. McDermott in 
each data collection element, using a detailed checklist developed for the NICE Trial.  Health 
interviewers are re-certified approximately every six months.  When deficiencies are identified, 
interviewers undergo additional training and re-assessment. 
 
Baseline and follow-up data collection will take place at Northwestern Memorial Hospital in the 
Division of General Internal Medicine space located on the 11th and 18th floors of the Galter 
Pavilion (675 N. St. Clair) or at 750 N. Lake Shore. Treadmill stress testing will be performed by 
Northwestern Medicine on the 8th floor of the Feinberg Pavilion (251 E. Huron).  
 
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