Conditions: Cardiac Steatosis Hepatic Steatosis
Keywords: Hepatic Steatosis Cardiac Steatosis Aldosterone Eplerenone Mineralcorticoid Receptor
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 5
Healthy volunteers: no

Brief summary:
Background:

People with human immunodeficiency virus (HIV) are at a high risk of getting visceral or deep belly fat. Visceral fat can cause health problems like heart or liver disease. Researchers want to see if a blood pressure drug can help by blocking a hormone in the body.

Objective:

To see if eplerenone reduces fat stored in the heart muscle and liver in people with HIV and increased visceral fat.

Eligibility:

Adults ages 18 75 with HIV and increased waist circumference. Increased waist circumference is defined as more than 40 inches in men and more than 35 inches in women.

Design:

Participants will be screened with:

Physical exam

Medical history

Blood tests

Measurements of hips, waist, legs, arms, shoulders, and neck

Magnetic resonance imaging (MRI) scan. They will lie on a table that slides into a machine.

Electrocardiogram (EKG) to measure heart electrical activity

Transient elastography, a special ultrasound to measure liver tissue stiffness

A small piece their liver collected (optional)

Participants will have a baseline visit:

Physical exam

Medical history

Blood tests

DEXA scan to measure body fat, muscle mass, and bone density. Participants will lie on a table while a very small dose of x-rays goes through the body.

Resting energy expenditure (REE). This measures the amount of oxygen breathed in and carbon dioxide breathed out.

Participants will get a 1-week supply of eplerenone. They will take one pill per day.

Participants will have a follow-up visit 1 week later. They will have:

Physical exam

Medical history

Blood tests

23-week supply of eplerenone

Participants will have 5 more follow-up visits.

Participants will have a final study visit, repeating many of the screening and baseline tests.

Detailed description:
HIV-infected individuals are at higher risk than uninfected people for developing cardiovascular disease. Visceral adipose tissue is also increased in HIV-infected people compared to uninfected individuals. Animal studies suggest that blockade of the mineralocorticoid receptor (MR) may have beneficial effects on cardiovascular and metabolic parameters via inhibition of adipocyte differentiation and triglyceride accumulation. We will examine the effects of the MR antagonist eplerenone (50 mg daily) on HIV-infected adults with abdominal fat accumulation in a 24-week, open-label, proof-of-concept study. Magnetic resonance imaging will be conducted at screening and the final study visit to evaluate cardiac and hepatic steatosis. We anticipate that blocking the effects of increased aldosterone secretion with eplerenone will significantly reduce intramyocardial lipid content and hepatic steatosis in this population. These effects may be accompanied by decreases in visceral adipose tissue, and improvements in dyslipidemia and inflammation, thereby improving cardiovascular health.

Arms:
arm 1: Intervention: Eplerenone will be administered for 6 months as follows: 25 mg once daily for 1 week and then 50 mg once daily for the remainder of the study.

Interventions: intervention 1: Inspra /Eplerenone
Intervention descriptions: intervention 1: Eplerenone is provided as 25- or 50-mg tablets that are to be taken orally. Subjects will be dosed at 25 mg daily for 1 week, and then 50 mg daily for 23 weeks. The total duration of dosing for each subject is 24 weeks.

Protocol document:
Prot_SAP_000.pdf: 
 
Cardiometabolic Effects of Eplerenone in HIV Infection 
 
NIAID Protocol Number: TBD 
 
Sponsored by: 
 
NIAID 
 
Principal Investigator: 
Colleen Hadigan, MD, MPH 
 
Laboratory of Immunoregulation, NIAID 
 
301-594-5754 
 
 
 
 
Version Number: 3.0 
 
25 January 2017 


Eplerenone for HIV Patients
Protocol Version3.0
25 Jan 2017
Study Staff Roster 
Study Coordinator: 
Julia Purdy, MSN, CPNP 
Clinical Center (CC) 
301-451-9109
Associate Investigators: 
Dr. David Bluemke, MD, PhD 
CC 
301-402-1854
Dr. Chia-Ying Liu, MD 
CC 
301-402-6278
Dr. Caryn Morse, MD 
CC 
301-496-6028
Julia Purdy, MSN, RN 
CC 
301-451-9109
Biostatistician: 
Michael Proschan, PhD 
Biostatistics Research Branch (NIAID) 
 
240-669-5245 
 
Collaborating Institutions: 
 
Dr. Steven Grinspoon, MD 
Massachusetts General Hospital 
55 Fruit Street 
 
Boston, MA 02114 
Tel: 617-726-3890 
Email: sgrinspoon@mgh.harvard.edu 
 
Dr. Takara Stanley, MD 
Massachusetts General Hospital 
55 Fruit Street 
Boston, MA 02114 
 
Tel: 617-726-2909 
Email: tstanley@partners.org 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Table of Contents 
Study Staff Roster ........................................................................................................................... 2
Table of Contents ............................................................................................................................ 3
List of Abbreviations ...................................................................................................................... 5
Protocol Summary .......................................................................................................................... 6
Précis ............................................................................................................................................... 
7
1. 
Background Information and Scientific Rationale.................................................................. 8
1.1. 
Background Information ................................................................................................. 8
1.1.1. 
Adiposity in HIV-Infected Individuals ................................................................... 8
1.1.2. 
Rationale for Studying the Mineralocorticoid Receptor ......................................... 9
1.2. 
Rationale .......................................................................................................................11
2. 
Study Objectives ................................................................................................................... 11
2.1. 
Primary Objectives........................................................................................................11
2.2. 
Secondary Objectives.................................................................................................... 11
3. 
Study Design ......................................................................................................................... 11
3.1. 
Description of the Study Design ................................................................................... 11
3.2. 
Study Endpoints ............................................................................................................12
3.2.1. 
Primary Endpoint ..................................................................................................12
3.2.2. 
Secondary Endpoint ..............................................................................................12
4. 
Study Population ................................................................................................................... 12
4.1. 
Recruitment Plan ........................................................................................................... 12
4.2. 
Subject Inclusion Criteria ............................................................................................. 13
4.3. 
Subject Exclusion Criteria ............................................................................................ 13
4.4. 
Justification for Exclusion of Special Populations ....................................................... 14
5. 
Study Agent/Interventions .................................................................................................... 15
5.1. 
Disposition and Dispensation ....................................................................................... 15
5.1.1. 
Formulation, Packaging, and Labeling .................................................................15
5.2. 
Study Agent Storage and Stability ................................................................................ 15
5.3. 
Preparation, Administration, and Dosage of Study Agent ............................................15
5.4. 
Study Product Accountability Procedures .................................................................... 15
5.5. 
Assessment of Subject Compliance with Study Agent/Intervention ............................ 15
5.6. 
Concomitant Medications and Procedures.................................................................... 16
5.7. 
Prohibited Medications ................................................................................................. 16
6. 
Study Schedule and Procedures ............................................................................................ 16
6.1. 
Screening.......................................................................................................................16
6.2. 
Baseline ( Day 0) .......................................................................................................... 17
6.3. 
Study Phase (Weeks 1 to Week 24) .............................................................................. 17
6.4. 
Final Study Visit (Week 24) ......................................................................................... 18
6.5. 
Follow-up End of Study visit ( optional) .....................................................................19
6.6. 
Early Termination Visit ................................................................................................ 19
6.7. 
Pregnancy and Follow-up Visit .................................................................................... 19
7.   Potential Risks and Benefits ................................................................................................. 19
 
 
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7.1. Potential Risks ..............................................................................................................
19
7.2. Potential Benefits ..........................................................................................................
21
8.   Research Use of Stored Human Samples, Specimens, or Data ............................................ 
22
9.   Remuneration Plan for Subjects ............................................................................................ 
22
10. 
Assessment of Safety ........................................................................................................
23
10.1. 
Toxicity Scale ...........................................................................................................
23
10.2. 
Recording/Documentation ........................................................................................
24
10.3. 
Definitions.................................................................................................................
24
10.4. 
Reporting Procedures ................................................................................................
26
10.4.1.   Expedited Reporting to the NIAID IRB ............................................................... 
26
10.4.2. 
Waiver of Reporting Anticipated Protocol Deviations, Expected non-UP AEs, and
Deaths 
26 
10.4.3.   Annual Reporting to the NIAID IRB .................................................................... 
26
10.5. 
Reporting of Pregnancy ............................................................................................
27
10.6. 
Type and Duration of the Follow-up of Subjects after Adverse Events ...................
27
10.7. 
Pausing Rules for an Individual Subject ...................................................................
27
10.7.1.   Resumption Following a Pause for a Single Subject ............................................ 
27
10.8. 
Halting Rules for the Protocol ..................................................................................
28
10.8.1.   Reporting a Study Halt.......................................................................................... 
28
10.8.2.   Resumption of a Halted Study .............................................................................. 
28
10.9. 
Withdrawal of an Individual Subject ........................................................................
29
10.10. 
Replacement of a Subject Who Discontinues Study Treatment ...............................
29
10.11. 
Safety Monitoring Plan .............................................................................................
29
11. 
Statistical Considerations ..................................................................................................
29
11.1. 
Statistical Analysis Plan ............................................................................................
29
12. 
Ethics/Protection of Human Subjects ...............................................................................
30
12.1. 
Informed Consent Process ........................................................................................
30
12.1.1. Non–English-Speaking Subjects ...........................................................................
30
12.2. 
Subject Confidentiality .............................................................................................
31
13. 
Data Handling and Record Keeping .................................................................................
31
13.1. 
Data Capture and Management .................................................................................
31
13.2. 
Record Retention ......................................................................................................
31
Appendix A: Scientific References ............................................................................................... 
32
Appendix B: Schedule of Procedures/Evaluations ....................................................................... 
35
Appendix C: Prohibited Medications............................................................................................ 
36
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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List of Abbreviations 
ACE 
angiotensin converting enzyme 
AE 
adverse event 
ARB 
angiotensin reporter blocker 
BMI 
body mass index 
cART 
combination antiretroviral therapy 
CBC 
complete blood count 
CYP 
cytochrome P450 isozyme 
DEXA 
dual-energy x-ray absorptiometry 
eGFR 
estimated glomerular filtration rate 
FSH 
follicle-stimulating hormone 
GCP 
Good Clinical Practice 
Hgb 
hemoglobin 
HIV 
Human Immunodeficiency Virus 
HRPP 
Human Research Protections Program 
ICH 
International Conference on Harmonisation 
IRB 
Institutional Review Board 
LH 
luteinizing hormone 
MI 
myocardial infarction 
MR 
mineralocorticoid receptor 
MRI 
magnetic resonance imaging 
OHRP 
Office for Human Research Protections 
PT/PTT 
prothrombin time/partial thromboplastin time 
SAE 
serious adverse event 
SHBG 
sex hormone-binding globulin 
UP 
unanticipated problem 
UPnonAE 
unanticipated problem that is not an adverse event 
VAT 
visceral adipose tissue 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Protocol Summary 
 
Short Title: 
 
ECHO 
 
Sample Size: 
 
n = 20 
 
Accrual Ceiling: 
 
50 
 
Study Population: 
 
HIV-infected men and women between 20 and 75 years-old 
 
Study Duration: 
 
December 2015-February 2018 
 
Total length of individual patient participation: ~7 months 
 
Study Design: 
 
Open-label pilot study 
 
Study Agent/ 
 
Intervention Description: 
 
Inspra®/Eplerenone (Pfizer Inc [New York City, NY, 
USA]), 25 mg/day for 1 week, then 50 mg/day for 23 weeks 
 
Primary Objective: 
 
To evaluate the effects of eplerenone on cardiac and hepatic 
steatosis in people with HIV infection who have high 
central adiposity. 
 
Secondary Objectives: 
 
To evaluate the effects of eplerenone treatment on biomarkers of 
inflammation and immune activation. 
 
Primary Endpoints: 
 
1. Improvement of cardiac steatosis as measured by magnetic 
 
resonance imaging (MRI) of the intraventricular septum 
 
2. Improvement of hepatic steatosis as measured by MRI of the 
liver and histopathologic examination of liver biopsy. 
 
Secondary Endpoint: 
 
Reduction of biomarkers of inflammation and immune activation. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Précis 
 
HIV-infected individuals are at higher risk than uninfected people for developing cardiovascular 
disease. Visceral adipose tissue is also increased in HIV-infected people compared to uninfected 
individuals. Animal studies suggest that blockade of the mineralocorticoid receptor (MR) may 
have beneficial effects on cardiovascular and metabolic parameters via inhibition of adipocyte 
differentiation and triglyceride accumulation. We will examine the effects of the MR antagonist 
eplerenone (50 mg daily) on HIV-infected adults with abdominal fat accumulation in a 24-week, 
open-label, proof-of-concept study. Magnetic resonance imaging will be conducted at screening 
and the final study visit to evaluate cardiac and hepatic steatosis. We anticipate that blocking the 
effects of increased aldosterone secretion with eplerenone will significantly reduce 
intramyocardial lipid content and hepatic steatosis in this population. These effects may be 
accompanied by decreases in visceral adipose tissue, and improvements in dyslipidemia and 
inflammation, thereby improving cardiovascular health. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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1. 
Background Information and Scientific Rationale 
 
1.1. Background Information 
 
Metabolic, cardiovascular, and body composition abnormalities are associated with combination 
antiretroviral therapy (cART) and chronic HIV infection. Recent studies have shown that 
hypertension,1 impaired glucose tolerance,2 type 2 diabetes,3,4 increased carotid intima-media 
thickness,5 coronary atherosclerosis,6 and myocardial infarction7 are more prevalent in HIV-
infected individuals than in non-infected controls. Visceral adipose tissue (VAT) is increased in 
HIV-infected patients compared to non-infected controls8 and is associated with cardiac risk 
factors such as decreased insulin sensitivity,9,10 hypertriglyceridemia and low high-density 
lipoprotein,11 increased systemic inflammatory markers,12-14 increased subclinical 
atherosclerosis,15,16 and steatohepatitis. At this time there is no standard of care to adequately 
treat these abnormalities. 
 
1.1.1. Adiposity in HIV-Infected Individuals 
 
Cardiometabolic disturbances persist in the current era of HIV infection and in the context of 
contemporary cART practices. We recently conducted a detailed cross-sectional study of 
HIV-infected adults without known cardiovascular disease (n = 95) and age-, race-, and sex-
matched controls (n = 30).17 Using state-of-the-art magnetic resonance imaging (MRI) 
techniques, we identified significant increases in intramyocardial lipid content in HIV-infected 
subjects (HIV-infected = 1.5% ± 1.2%, control = 1.0% ± 1.0%, p = 0.04). In addition, HIV-
infected subjects demonstrated significant subclinical impairment in cardiac function as 
measured by myocardial strain (HIV-infected = 21.7% ± 8.6%, control = 30.5% ± 14.2%, p = 
0.004). 
 
Further, the marker of immune activation MCP-1 was markedly elevated in HIV-infected 
 
subjects compared to controls (HIV-infected = 473 ± 249 pg/mL, control = 321 ± 221 pg/mL, 
 
p = 0.003) and was correlated with the degree of impaired cardiac strain (r = −0.43, p < 0.0001). 
 
MCP-1 is a chemokine important in the regulation of monocyte and macrophage migration. In 
 
HIV-infected subjects, increased levels of MCP-1 was strongly associated with impairment in 
 
cardiac function, similar to patients with chronic heart failure. These data highlight the 
 
importance of and potential underlying relationship between dysregulation in lipid 
 
metabolism/storage, immune activation, and downstream organ function. Of note, we also found 
 
 
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that increased VAT was a strong independent predictor of both cardiac and hepatic steatosis in 
HIV-infected individuals, which further supports the pathophysiologic role of central adiposity in 
the process of cardiometabolic disturbances in HIV infection. 
 
While VAT appears important, the causes of body composition changes, metabolic 
abnormalities, and increased cardiovascular risk are multifactorial in HIV infection and likely 
include perturbation of multiple endocrine axes. In non–HIV-infected individuals, recent data 
have shown that aldosterone, a mineralocorticoid hormone, is increased in association with 
increased VAT18 and decreased insulin sensitivity.19 Our collaborators, led by Dr. Steven 
Grinspoon, demonstrated increased 24-hour urine aldosterone in HIV-infected women with 
increased visceral fat accumulation, compared to age- and body mass index (BMI)–matched 
healthy controls.20 In this study, urinary aldosterone secretion was strongly related to VAT. 
Furthermore, emerging animal and human studies have suggested effects of mineralocorticoid 
blockade on insulin sensitivity, inflammation, and cardiac and hepatic steatosis, all of which 
are metabolic problems enriched in persons living with chronic HIV infection.21-24 
 
1.1.2. Rationale for Studying the Mineralocorticoid Receptor 
 
The renin-angiotensin-aldosterone system represents a hormonal cascade that maintains blood 
pressure and salt water balance. Recent data suggest mineralocorticoid receptor (MR) activation 
also plays a role in promotion of fibrosis and inflammation in various tissues including the 
vasculature, cardiac muscle, and the liver. Reports speculate that MR activation by aldosterone 
may play a role in cardiovascular and metabolic disease, as well, which is further supported by 
animal models.25,26 For example, in vitro and in vivo data from a mouse model of 
steatohepatitis suggest that an MR antagonist ameliorates hepatic steatosis and fibrosis,23 
whereas the same approach attenuates cardiac steatosis and diastolic dysfunction in a rat model 
of type 2 diabetes.24 
 
There are reports of increased systemic aldosterone levels associated with high body fat. 
Twenty-four-hour urine aldosterone/creatinine concentrations were higher in an animal model of 
obesity (db/db mice) compared to lean (db/+) mice.21 In another study, non–HIV-infected 
overweight and obese normotensive adults exhibited higher concentrations of both 24-hour urine 
aldosterone and angiotensin II-stimulated aldosterone than lean controls.27 Some reports suggest 
that the relationship of aldosterone and body fat may be largely mediated by increased VAT. 
Goodfriend and colleagues demonstrated that plasma aldosterone correlated with VAT in 
normotensive women,18 and as described above, we have demonstrated a positive relationship 
of 24-hour urinary aldosterone with VAT in HIV-infected women.20 
 
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These observations are supported by in vivo models of ob/ob and db/db mice, in which MR 
blockade with the aldosterone antagonist eplerenone markedly decreased the number of 
hypertrophic adipocytes in epididymal fat.28 There is also evidence to suggest that MR blockade 
may reduce hepatic steatosis, which is prevalent in HIV-infected individuals and is associated 
with increased visceral abdominal adiposity.15,29 Wada and colleagues designed a murine 
model of metabolic syndrome and non-alcoholic steatohepatitis using transgenic mice that 
overexpressed liver-specific SREBP-1 and were fed a high-fat diet.23 They showed that MR 
blockade with eplerenone resulted in improvements in hepatic triglyceride content, liver 
transaminase levels, circulating triglycerides, and measures of insulin resistance. Fallo and 
colleagues demonstrated an increased prevalence of hepatic steatosis in human patients with 
primary aldosteronism compared to normotensive controls.30 Together, these observations 
provide compelling evidence to support investigation of the role of MR blockade in the context 
of hepatic steatosis and increased visceral adiposity in people with HIV infection. Further 
studies are clearly needed to determine whether mineralocorticoid activity affects myocardial 
and hepatic triglyceride accumulation. 
 
HIV infection is accompanied by increased markers of systemic inflammation.12-14 Levels of 
inflammatory cytokines predict atherosclerosis6,31 and myocardial infarction32 in HIV-infected 
individuals. As noted in our preliminary data, subclinical impairment in regional cardiac 
function in adults with HIV infection is associated with markers of inflammation and immune 
activation such as MCP-1. Recent studies suggest that MR activation may play a distinct role in 
both cardiovascular and systemic inflammation. In Sprague-Dawley rats, aldosterone 
administration for 4 weeks resulted in increased medial thickening of coronary arteries as well as 
perivascular leukocyte infiltration and, in some animals, significant leukocyte infiltration into 
cardiac tissue with subsequent cardiomyocyte degeneration and necrosis.33 These changes were 
accompanied by increased gene expression of COX-2, MCP-1, osteopontin, and ICAM-1. 
Concomitant eplerenone treatment significantly ameliorated inflammatory changes and 
attenuated alterations in gene expression. 
 
Although a role of hypertension cannot be excluded in this model, a model of atherosclerosis-
prone apolipoprotein E-deficient mice supports the association between MR activation and 
vascular inflammation, independent of blood pressure.34 Six weeks of high-cholesterol diet in 
these mice led to formation of atherosclerotic lesions in the aorta, with increased superoxide 
production and increased vascular expression of NADPH oxidase, TNF-α, and MCP-1. 
Eplerenone treatment did not alter total cholesterol levels or blood pressure, but significantly 
reduced atherosclerotic lesion area, superoxide production, and expression of 
 
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NADPH oxidase, TNF-α and MCP-1.34 Further, in ob/ob mice, eplerenone reduced mRNA 
expression of MCP-1, IL-6, and TNF-α.28 Finally, using the non-hypertensive Zucker diabetic 
rat model, Ramirez and colleagues showed benefits of 16 weeks of eplerenone treatment to 
attenuate cardiac steatosis, apoptosis, and diastolic dysfunction as measured by E/A ratio, 
without any untoward effects of hyperkalemia, or renal or hepatic injury.24 While animal models 
in mice and rats may suggest a physiologic role for eplerenone in cardiometabolic conditions, 
these models may not be directly applicable in human conditions of hyperaldosteronism and the 
benefits of this approach remain to be determined. 
 
1.2. Rationale 
 
Research is needed into the effects of aldosterone and MR blockade on systemic and local 
inflammation and cardiometabolic parameters in humans. Eplerenone is a MR antagonist which 
has benefit for patients with aldosterone related hypertension and heart failure, but with 
considerably greater receptor specificity than spironolactone. Therefore eplerenone is associated 
with fewer undesirable progestin-like side effects, i.e. mastodynia and disturbance of the 
menstrual cycle in women. In this study we will carefully study the effects of MR blockade on 
lipid deposition in the myocardium and liver as well as systemic inflammation and immune 
activation in HIV-infected individuals. 
 
2. 
Study Objectives 
 
2.1. 
Primary Objectives 
 
To evaluate the effects of eplerenone (Inspra®, Pfizer Inc [New York City, NY, USA] or generic) on 
cardiac and hepatic steatosis in people with HIV infection who have high central adiposity. 
 
2.2. Secondary Objectives 
 
To evaluate the effects of eplerenone treatment on biomarkers of inflammation and 
immune activation. 
 
3. 
Study Design 
 
3.1. 
Description of the Study Design 
 
 
 
 
 
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This is an open-label pilot study of the effects of eplerenone on 20 HIV-infected subjects who 
have increased central adiposity and evidence of hepatic steatosis. Eplerenone will be 
administered for 6 months as follows: 25 mg once daily for 1 week and then 50 mg once daily 
for the remainder of the study. This is a proof of concept study and therefore the sample size 
will be relatively small and there will be no control arm. If there is a signal for a beneficial 
effect of eplerenone, then we will consider design of a larger controlled trial in the future. 
 
3.2. 
Study Endpoints 
 
3.2.1. Primary Endpoint 
 
1. Improvement of cardiac steatosis as measured by MRI of the intraventricular septum 
 
2. Improvement of hepatic steatosis as measured by MRI of the liver and histopathologic 
examination of liver biopsy 
 
3.2.2. Secondary Endpoint 
 
Reduction of biomarkers of inflammation and immune activation. 
 
4. 
Study Population 
 
4.1. 
Recruitment Plan 
 
We will recruit patients with HIV infection from existing NIH cohorts as well as HIV 
healthcare clinics in the greater Washington, DC community. In addition, we will use the OP8 
Clinic recruitment strategies that are in place and include a full-time patient recruiter and 
community-based outreach within local area clinics specializing in HIV. 
 
Recruitment of NIH Employees 
 
NIH employees and members of their immediate families may participate in this protocol. We 
will follow the Guidelines for the Inclusion of Employees in NIH Research Studies and will 
give each employee a copy of the “NIH information sheet on Employee Research Participation.” 
 
For NIH employees: 
 
• 
Neither participation nor refusal to participate will have an effect, either beneficial 
or adverse, on the subject’s employment or work situation. 
 
 
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• 
The NIH information sheet regarding NIH employee research participation will 
be distributed to all potential subjects who are NIH employees. 
 
• 
The employee subject’s privacy and confidentiality will be preserved in accordance with 
 
NIH CC and NIAID policies, which define the scope and limitations of the protections. 
 
• 
For NIH employee subjects, consent will be obtained by an individual independent of 
the employee’s team. Those in a supervisory position to any employee and co-workers 
of the employee will not obtain consent. 
 
• 
The importance of maintaining confidentiality when obtaining potentially sensitive and 
private information from co-workers or subordinates will be reviewed with the study 
staff at least annually and more often if warranted. 
 
4.2. Subject Inclusion Criteria 
 
1. Increased waist circumference on the basis of National Cholesterol Education 
Program guidelines (> 102 cm in men and > 88 cm in women) 
 
2. Hepatic steatosis established by hepatic MRI > 5% and/or liver biopsy within the 
last 12 months 
 
3. HIV-infected, HIV viral load < 50 copies/mL and no change in ART regimen for at least 
3 months 
 
4. Age ≥ 18 and ≤ 75 years 
 
5. Agree to have samples stored for future research 
 
4.3. Subject Exclusion Criteria 
 
1. Estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2, 
serum creatinine > 1.5 mg/dL 
 
2. Serum potassium > 5.5 mEq/L, alanine aminotransferase > 2.5 times the upper limit 
of normal, hemoglobin (Hgb) < 11 g/dL 
 
3. Uncontrolled hypertension: systolic blood pressure ≥ 160 mm Hg or diastolic 
blood pressure ≥ 100 mm Hg 
 
4. A blood pressure < 90mmHg systolic or < 50mm Hg diastolic . 
 
5. Screening EKG with a significant heart block (e.g. PR > 300 ms) will trigger a 
cardiology consult before proceeding with the study. Based on the cardiology consult 
findings, the participants eligibility will be determined. 
 
6. Current hepatitis C infection, unless there has been a sustained virologic response for at 
least 12 months 
 
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7. Type 2 diabetes with microalbuminuria 
 
8. Current or prior steroid use within past 6 months (except short-course or single-
dose administration). Stable use of inhaled or nasal steroids are allowed. 
 
9. Use of angiotensin converting enzyme (ACE) inhibitors, angiotensin reporter blockers 
(ARBs), potassium-sparing diuretics, and other medications that may increase the risk 
of hyperkalemia 
 
10. Use of potassium supplementation or other medications known to increase potassium (see 
Appendix C) 
 
11. Concomitant use of strong inhibitors and/or inducers of cytochrome P450 
isozyme (CYP)3A4 (see Appendix C) 
 
12. If receiving testosterone, estrogen or progesterone therapy, must be on a stable dose for 
at least 3 months 
 
13. Current use of growth hormone or growth hormone-releasing hormone 
 
14. Current serious viral, bacterial, or other infection (excluding HIV) 
 
15. Current active substance abuse/dependence 
 
16. Substantial history of cardiovascular disease, including prior myocardial infarction 
(MI), congestive heart failure, or stroke 
 
17. Contraindication to MRI 
 
18. Pregnant or planning to become pregnant 
 
19. Breastfeeding 
 
20. Any condition that, in the opinion of the PI, may substantially increase the risk 
of participation 
 
Co-enrollment Guidelines: Co-enrollment on observational studies or those evaluating the 
use of a licensed medication are allowed. Study staff should be notified of co-enrollment as it 
may require the approval of the Investigator. 
 
4.4. Justification for Exclusion of Special Populations 
 
Exclusion of Women: 
 
• 
Pregnancy: Pregnant subjects are excluded from this study because the effects 
of eplerenone on the developing human fetus are unknown. 
 
• 
Breastfeeding: Because there is an unknown but potential risk for adverse events in 
nursing infants secondary to treatment of the mother with eplerenone. 
 
Exclusion of Subjects ≤ 18 years-old and ≥ 75 years-old 
 
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Minors are excluded from this study because there are insufficient data regarding dosing 
or adverse events (AEs) in patients younger than 18 years-old. The incidence of 
laboratory-documented hyperkalemia was increased in patients 75 and older as a result of 
age-related decreases in creatinine clearance. 
 
5. 
Study Agent/Interventions 
 
5.1. Disposition and Dispensation 
 
Study agent will be distributed via the NIH Pharmacy according to standard 
pharmacy procedures. 
 
5.1.1. Formulation, Packaging, and Labeling 
 
Each bottle will be individually labeled with the patient ID number, dosing instructions, 
recommended storage conditions, the name and address of the manufacturer, and that the 
agent should be kept out of reach of children. 
 
5.2. Study Agent Storage and Stability 
 
Eplerenone tablets should be stored at room temperature (15°C-30°C). 
 
5.3. Preparation, Administration, and Dosage of Study Agent 
 
Eplerenone is provided as 25- or 50-mg tablets that are to be taken orally. Eplerenone can be 
taken with or without food. Subjects will be dosed at 25 mg daily for 1 week, and then 50 mg 
daily for 23 weeks. The total duration of dosing for each subject is 24 weeks. Subjects who 
develop hyperkalemia (potassium > 5.5 mEq/L), eGFR< 60 mL/min/1.73 m2, or serum 
creatinine > 1.5 mg/dL will have eplerenone withheld, and will only resume treatment if an 
alternative cause for these lab abnormalities is identified and the abnormality resolves. Unused 
study drug will be returned to the NIH Pharmacy at the end of the dosing period. 
 
5.4. 
Study Product Accountability Procedures 
 
Study agent accountability will be maintained by the pharmacy per standard procedures. 
 
5.5. Assessment of Subject Compliance with Study Agent/Intervention 
 
 
 
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Medication compliance will be assessed at each visit by assessing pill count. 
 
5.6. Concomitant Medications and Procedures 
 
All concomitant prescription medications taken during study participation will be recorded. 
 
5.7. Prohibited Medications 
 
A member of the study team will screen the medication lists of eligible subjects before they 
enroll in the study. Subjects are prohibited from taking the following medications while they 
are taking eplerenone (see Appendix C): 
 
• 
Strong CYP3A4 inhibitors or inducers 
 
• 
ACE inhibitors and/or an ARB 
 
• 
Potassium-sparing diuretics 
 
• 
Medications that may cause hyperkalemia 
 
• 
Steroids (other than a single dose or restricted short course) 
 
• 
Potassium supplementation 
 
6. 
Study Schedule and Procedures 
 
A table of the study schedule is provided in Appendix B. 
 
6.1. 
Screening 
 
The following procedures will be conducted at the NIH Clinical Center (CC) to determine if a 
volunteer is eligible to participate in this study and may occur over a period of several days 
due to scheduling: 
 
1. Physical exam, medical history, and vital signs, including measurements of 
blood pressure, height, weight, and BMI 
 
2. Bionutrition: anthropometric measurements, Whole-body dual-energy x-ray 
absorptiometry (DEXA) 
 
3. Urine pregnancy test (for subjects of childbearing potential only) 
 
4. Blood collection for acute care, hepatic, and mineral panels; complete blood count 
(CBC); prothrombin time/partial thromboplastin time (PT/PTT); CD4 count and HIV 
viral load count; hepatitis serology 
 
 
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5. Urine studies: Urinalysis, urine protein/creatinine ratio and albumin/creatinine ratio. 
 
6. Resting electrocardiogram 
 
7. Non-contrast MRI for cardiac and hepatic steatosis and visceral fat volume 
 
8. Transient elastography (FibroScan®, Echosens [Paris, France]) to measure liver 
tissue stiffness 
 
9. Liver biopsy will be performed according to standard procedures by an experienced 
interventional radiologist (optional). Patients unwilling to undergo liver biopsy or for 
whom it is contraindicated (eg, platelets < 75,000) will not have a liver biopsy. 
Biopsies will be evaluated for biomarkers of inflammation and immune activation. 
 
6.2. Baseline ( Day 0) 
 
The following procedures will be conducted at baseline at the NIH CC: 
 
1. Interval medical history and physical exam, including blood pressure check 
 
2. Research blood collection (fasted overnight) for acute care, hepatic, and mineral panels, 
CBC, fasting lipid profile; HgbA1c, CD4/8 count, HIV viral load, aldosterone, plasma 
renin activity, inflammatory markers and adipokines (MCP-1, CRP, adiponectin, PAI-1, 
resistin, TNF-α, TNFR2, IL-6), sex hormone-binding globulin (SHBG), total and free 
testosterone, luteinizing hormone (LH, female only), follicle-stimulating hormone (FSH, 
females only), estradiol (females only), and serum, plasma and peripheral blood 
mononuclear cells (PBMCs) for storage 
 
3. Urine pregnancy test for subjects of childbearing potential 
 
4. Subjects will receive a 1-week supply of eplerenone and instructions for use. Subjects 
will be dosed with 25 mg once daily for 1 week, and then 50 mg once daily for 23 weeks. 
 
6.3. Study Phase (Weeks 1 to Week 24) 
 
Interim safety visits will be scheduled for Weeks 1, 2, 4, and 8. Subjects will visit the NIH CC 
as outpatients and the following procedures will be conducted: 
 
1. Physical exam and interval medical history, including blood pressure check 
 
2. Research blood collection (fasted overnight) for acute care, hepatic, and mineral panels, , 
and serum, plasma, and PBMCs for storage. CD4/8 and HIV viral load counts will be 
done at week 4. 
 
3. Urine pregnancy test for subjects of childbearing potential 
 
4. Pill count of unused study drug to assess adherence 
 
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Another outpatient visit to the NIH CC will be scheduled for Week 12. The following 
procedures will be conducted: 
 
1. Physical exam, including blood pressure check, and interval medical history 
 
2. Research blood collection (fasted overnight) for acute care, hepatic, and mineral panels, 
lipid profile, CBC, HgbA1c, CD4/8 count, HIV viral load, aldosterone, plasma renin 
activity, inflammatory markers and adipokines (MCP-1, CRP, adiponectin, PAI-1, resistin, 
TNF-α, TNFR2, IL-6), SHBG, total and free testosterone, LH (female only), FSH (females 
only), estradiol (females only), and serum, plasma and PBMCs for storage 
3. Urine pregnancy test for subjects of childbearing potential 
 
At week 18, subjects will return to the NIH CC or can choose to go to their local medical 
provider (if this does not incur additional burden), for the following procedures: 
 
1. Interval medical history, including blood pressure check 
 
2. Research blood collection (fasted overnight) for acute care, hepatic, and mineral panels. 
 
3. If this visit is done by their local medical provider , we will request the results to 
include in the patient’s NIH record. 
 
6.4. Final Study Visit (Week 24) 
 
Subjects will return to the NIH CC for a final study visit at Week 24, after the full regimen 
of eplerenone has been completed. The following procedures will be conducted: 
 
1. Interval medical history and physical exam, including blood pressure check 
 
2. Bionutrition: DEXA, anthropometric measurements 
 
3. Research blood collection (fasted overnight) for acute care, hepatic, and mineral panels, 
CBC, lipid profile; HgbA1c, CD4/8 count, HIV viral load, aldosterone, plasma renin 
activity, inflammatory markers and adipokines (MCP-1, CRP, adiponectin, PAI-1, 
resistin, TNF-α, TNFR2, IL-6), SHBG, total and free testosterone, LH (female only), 
FSH (females only), estradiol (females only), and serum, plasma, and PBMCs for 
storage 
 
4. Urine pregnancy test for subjects of childbearing potential 
 
5. MRI for cardiac and hepatic steatosis and visceral fat volume 
 
6. FibroScan transient elastography 
 
7. Liver biopsy (optional) 
 
 
 
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6.5. Follow-up End of Study visit ( optional) 
 
Subjects may be asked to return for assessments following their week 24 to determine if there 
are changes in their health status after withdrawal of study medication. These follow up 
evaluations could include: 
 
1. Interval medical history, including blood pressure check 
 
2. Research blood collection (fasted overnight) for acute care, hepatic, and mineral 
panels, CBC, lipid profile; HgbA1c, CD4/8 count, HIV viral load, aldosterone, 
plasma renin activity, inflammatory markers and adipokines (MCP-1, CRP, 
adiponectin, PAI-1, resistin, TNF-α, TNFR2, IL-6), SHBG, total and free 
testosterone, LH (female only), FSH (females only), estradiol (females only), 
and serum, plasma, and PBMCs for storage 
 
3. Urine pregnancy test for subjects of childbearing potential 
 
4. MRI for cardiac and hepatic steatosis and visceral fat volume 
 
5. FibroScan transient elastography 
 
6.6. Early Termination Visit 
 
If a subject’s participation is terminated before the end of the study, then they will be asked to 
come to the NIH CC for a Termination Visit. Laboratory tests and study evaluations to be 
conducted at that visit will be determined on the basis of the subject’s health, their 
willingness, and the appropriateness of the test at that time point. 
 
6.7. Pregnancy and Follow-up Visit 
 
If a subject becomes pregnant during the course of participation, then their participation in 
the study will be stopped. The study team will ask the subject to notify them of the pregnancy 
outcome. 
 
7. 
Potential Risks and Benefits 
 
7.1. Potential Risks 
 
Eplerenone: In one clinical trial, the overall incidence of AEs reported in patients treated with 
eplerenone was similar to those treated with placebo.35 The AEs that occurred more frequently 
in eplerenone-treated patients were hyperkalemia (3.4% with eplerenone vs. 2.0% with placebo) 
and increased creatinine (2.4% with eplerenone vs. 1.5% with placebo). Discontinuation of 
 
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treatment as a result of hyperkalemia or abnormal renal function was less than 1.0% in both 
groups. 
 
In another clinical trial, the overall incidence of AEs reported in patients treated with eplerenone 
was also similar to those treated with placebo.35 The AEs occurred at a similar rate in both 
groups regardless of age, gender, or race. Therapy was discontinued as the result of an AE in 
3% of patients treated with eplerenone and 3% of patients given placebo. The most common 
reasons for discontinuation of eplerenone were headache, dizziness, angina pectoris/MI, and 
increased concentration of gamma glutamyl transferase. Gynecomastia, mastodynia and 
abnormal vaginal bleeding were reported with eplerenone but not with placebo. The rates 
increased slightly with increasing duration of therapy. 
 
Angioneurotic edema and rash have been reported from post-approval use of Inspra.35 
 
There may be additional risks of eplerenone that are currently unknown. 
 
DEXA Scan: The total amount of radiation exposure from 2 DEXA scans is 0.00006 rem. The 
radiation exposure in this study is below the limit of 5 rem per year allowed for adult research 
subjects by the NIH Radiation Safety Committee. There is no direct evidence that radiation 
exposure at this level is harmful, but, as with all radiation exposure, there may be a very slight 
increase in the risk of cancer. 
 
The average person in the United States receives a radiation exposure of 0.3 rem per year from 
natural sources, such as the sun, outer space, and the earth's air and soil. A copy of the 
pamphlet, “An Introduction to Radiation for NIH Research Subjects,” will be provided to 
subjects by request. 
 
Liver Biopsy: Ultrasound-guided percutaneous liver biopsy will be performed by trained 
interventional radiologists who specialize in gastrointestinal procedures at the NIH. Subjects will 
be observed as outpatients following liver biopsy per standard of care for liver biopsy and 
conscious sedation when used. The risks associated with liver biopsy include pain, transient 
hypotension (vasovagal response), bleeding, and transient bacteremia. Subjects with any 
contraindication to liver biopsy, including platelets < 75,000, elevated PT or PTT, (except 
patients with known lupus anticoagulant antibody and aPTT mixing study that is normal at one 
hour ), or chronic aspirin use that cannot be suspended will not undergo biopsy. Individuals on 
aspirin for primary prevention of MI may undergo biopsy after discontinuation of aspirin for ≥ 7 
 
 
 
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days. Subjects will receive teaching and instructions for post-biopsy care and will be asked to 
call or return to clinic with persistent pain or other concerning symptoms. 
 
Conscious Sedation: Conscious sedation will be used in subjects undergoing liver biopsy. 
Sedative drugs will be provided by experienced physicians of the NIH CC. Side effects from 
sedative medications include cardiovascular and respiratory depression manifested by 
bradycardia, hypotension, respiratory acidosis, and apnea. Additional adverse reactions 
reported with these drugs are stinging or pain at the injection site, hiccoughs, nausea, vomiting, 
postoperative drowsiness and headache, and hypersensitivity reactions. Patients will be closely 
monitored and appropriate countermeasures will be taken as necessary. 
 
MRI: For most subjects, the primary risk associated with MRI is discomfort as subjects will be 
asked to lie still for a long period of time. Additionally, subjects may find the clicking sound 
caused by the MRI disturbing. Subjects with pacemakers, aneurysm clips, metallic prostheses, 
shrapnel fragments, welders and metal workers are at risk for injury and will be excluded from 
the study. 
 
Blood Draw: Collection of blood may be associated with discomfort, bruising, local hematoma 
formation and, on rare occasions, infections, lightheadedness, and fainting. The amount of 
blood drawn for research purposes will be within the limits allowed for adult subjects by the 
NIH CC (Medical Administrative Policy 95-9: Guidelines for Limits of Blood Drawn for 
Research Purposes in the Clinical Center: http://cc-internal.cc.nih.gov/policies/PDF/M95-9.pdf. 
 
Electrocardiogram: There are no foreseeable risks associated with this procedure. 
 
Transient Elastography: There are no foreseeable risks to these procedures. 
 
7.2. 
Potential Benefits 
 
Subjects may not receive any benefit from this study. However, there is the potential that a 6-
month treatment regimen of eplerenone may result in reductions of intramyocardial lipid 
content, hepatic steatosis, and visceral adipose tissue, thereby improving overall cardiovascular 
health. If this study is successful, then we will develop a larger trial to evaluate the clinical 
utility of eplerenone in HIV-infected individuals with steatosis. 
 
 
 
 
 
 
 
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8. 
Research Use of Stored Human Samples, Specimens, or Data 
 
• 
Intended Use: Samples and data collected under this protocol may be used to study 
HIV infection and related disorders. No genetic testing will be performed. 
 
• 
Storage: Access to stored samples will be limited using either a locked room or a locked 
freezer. Samples and data will be stored using codes assigned by the investigators. Data 
will be kept in password-protected computers. Only investigators will have access to the 
samples and data. 
 
• 
Tracking: Samples and data acquired as part of this protocol will be tracked using the 
CRIMSON database system. 
 
• 
Disposition at the Completion of the Protocol: 
 
• 
In the future, other investigators (both at NIH and outside) may wish to study these 
samples and/or data. In that case, Institutional Review Board (IRB) approval must be 
sought prior to any sharing of samples and/or data. Any clinical information shared 
about the sample would similarly require prior IRB approval. 
 
• 
At the completion of the protocol (termination), samples and data will either be 
destroyed, or after IRB approval, transferred to another existing protocol. 
 
• 
Reporting the Loss or Destruction of Samples/Specimens/Data to the IRB: 
 
• 
Any loss or unanticipated destruction of samples or data (for example, as a result of 
freezer malfunction) that meets the definition of Protocol Deviation and/or 
compromises the scientific integrity of the data collected for the study, will be 
reported to the NIAID IRB. 
 
• 
Additionally, subjects may decide at any point not to have their samples stored. In 
this case, the principal investigator will destroy all known remaining samples and 
report what was done to both the subject and to the IRB. This decision will not 
affect the subject’s participation in this protocol or any other protocols at NIH. 
 
9. 
Remuneration Plan for Subjects 
 
Eligible subjects will receive partial remuneration from the NIH for immediate costs associated with 
study-related expenses (eg, transportation and lodging) according to established NIH/NIAID 
guidelines. Subjects will also be compensated for the time and inconvenience of study participation 
according to the attached schedule (see Table 1). Thus, compensation may be up to $1280 for 
completion of the entire study, commensurate with the time and inconvenience of study 
participation including blood draws, liver biopsy, and scans. If a subject returns for 
 
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additional study related procedures as noted in section 6.5, they will be compensated at a rate 
consistent with the remuneration table. 
 
 
Table 1 
Remuneration 
Visit/Procedure 
Hours per Visit 
Inconvenience Units 
Total Compensation 
(Compensation) 
(Compensation) 
per Visit 
Screening visit(s): Screening labs, 
history/physical, MRI,(brief), 
anthropometrics transient, elastography 
4 ($50) 
8 ($80) 
$130 
Screening visit 2: MRI ( full) and 
DEXA 
4($50) 
7($70) 
$120 
Screening optional liver biopsy 
7 ($80) 
22 ($220) 
$300 
Day 0: History/physical, labs, education 
start eplerenone 
3 ($30) 
2($20) 
$50 
Weeks 1, 2, 4, 8, 12, 18: 
2 ($20) per visit 
1 ($10) per visit 
$30 per visit 
History/physical, adherence, labs 
10 ($100) total 
5 ($50) total 
$180 total 
Week 24: History/physical and labs, 
DEXA, MRI, elastography, 
anthropometrics 
5 ($60) 
12($140) 
$200 
Week 24 optional liver biopsy 
7 ($80) 
22 ($220) 
$300 
TOTAL COMPENSATION FOR COMPLETE STUDY PARTICIPATION 
$1280 
DEXA = dual-energy x-ray absorptiometry; MRI = magnetic resonance imaging;. 
 
Note: Screening visit and final visit at week 24 may be scheduled over multiple days for subject’s convenience. 
 
 
 
 
10. Assessment of Safety 
 
10.1.  Toxicity Scale 
 
The Investigator will grade the severity of each AE according to the “Division of Aids Table for 
 
Grading the Severity of Adult and Pediatric Adverse Events” Version 2.0, November 2014, 
 
which can be found at: 
 
http://rsc.techres.com/Document/safetyandpharmacovigilance/DAIDS_AE_GRADING_TABLE 
 
_v2_NOV2014.pdf 
 
Some grade 1 lab parameters on the DAIDS Toxicity Table (fibrinogen, potassium [low], uric 
acid [males only, elevated]) fall within the NIH lab reference range for normal values. These 
normal values will not be reported as grade 1 AEs. The grade 1 values for these tests will be 
reported as follows: 
 
• 
Fibrinogen: 100-176 mg/dL 
 
• 
Potassium (low): 3.0-3.3 mmol/L 
 
 
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• 
Uric acid (males): 8.7-10.0 mg/dL 
 
• 
Magnesium (low): 0.60-0.65 mmol/L 
 
10.2.  Recording/Documentation 
 
At each contact with the subject, information regarding AEs will be elicited by appropriate 
questioning and examinations. All AEs, both expected/unexpected and related/unrelated will 
be recorded on a source document. 
 
Source documents will include progress notes, laboratory reports, consult notes, phone call 
summaries, survey tools, and data collection tools. Source documents will be reviewed in a 
timely manner by the research team. All reportable AEs that are identified will be recorded in 
CRIMSON. The start date, the stop date, the severity of each reportable event, and the PI’s 
judgment of the AE’s relationship and expectedness to the study agent/intervention will also be 
recorded in CRIMSON. 
 
10.3.  Definitions 
 
Adverse Event: Any untoward medical occurrence in a human subject, including any abnormal 
sign, symptom, or disease, temporally associated with the subject’s participation in research, 
whether or not considered related to the research. 
 
Serious adverse event (SAE): Any AE that results in one or more of the following outcomes: 
 
• 
death; 
 
• 
a life-threatening event (places the subject at immediate risk of death from the event as 
it occurred); 
 
• 
an inpatient hospitalization or prolongation of existing hospitalization; 
 
• 
a persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions; 
 
• 
a congenital anomaly/birth defect; 
 
• 
on the basis of appropriate medical judgment, may jeopardize the subject’s health and 
may require medical or surgical intervention to prevent one of the other outcomes listed 
in this definition. (Examples of such events include allergic bronchospasm requiring 
intensive treatment in the emergency room or at home, blood dyscrasias or convulsions 
that do not result in inpatient hospitalization, or the development of drug dependency or 
drug abuse) 
 
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Protocol Deviation: Any change, divergence, or departure from the IRB-approved study 
procedures in a research protocol. Protocol deviations are designated as serious or non-
serious and further characterized as 
 
1. Those that occur because a member of the research team deviates from the protocol 
 
2. Those that are identified before they occur, but cannot be prevented 
 
3. Those that are discovered after they occur 
 
Serious Protocol Deviation: A deviation that meets the definition of an SAE or 
compromises the safety, welfare, or rights of subjects or others. 
 
Non-compliance: The failure to comply with applicable NIH Human Research Protections 
Program (HRPP) policies, IRB requirements, or regulatory requirements for the protection of 
human subjects. Non-compliance is further characterized as 
 
1. Serious: Non-compliance that 
 
a. Increases risks, or causes harm, to subjects 
 
b. Decreases potential benefits to subjects 
 
c. Compromises the integrity of the NIH-HRPP 
 
d. Invalidates the study data 
 
2. Continuing: Non-compliance that is recurring 
 
3. Minor: Non-compliance that, is neither serious nor continuing. 
 
Unanticipated Problem (UP): Any incident, experience, or outcome that meets all three of the 
following criteria would be considered a serious UP: 
 
1. unexpected in terms of nature, severity, or frequency in relation to 
 
a. the research risks that are described in the IRB-approved research protocol, 
informed consent document, package insert, or other study documents; and 
 
b. the characteristics of the subject population being studied 
 
2. possibly, probably, or definitely related to participation in the research 
 
3. suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized. 
 
Unanticipated problem that is not an Adverse Event (UPnonAE): An unanticipated problem 
that does not fit the definition of an AE, but that may, in the opinion of the investigator, involve risk 
to the subject, affect others in the research study, or substantially impact the integrity of 
 
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research data. These events may involve a greater risk of social or economic harm to subjects or 
others rather than physical/psychological harm. Such events would be considered a non-serious 
UP. Examples of a UPnonAE include a breach of confidentiality, accidental destruction of study 
records, or unaccounted-for study drug. 
 
10.4.  Reporting Procedures 
 
10.4.1. Expedited Reporting to the NIAID IRB 
 
Serious and non-serious UPs, deaths, serious deviations, and serious or continuing non-
compliance will be reported within 7 calendar days of investigator awareness. SAEs that are 
possibly, probably, or definitely related to the research will be reported to the NIAID IRB 
within 7 calendar days of investigator’s awareness, regardless of expectedness. 
 
10.4.2. Waiver of Reporting Anticipated Protocol Deviations, Expected non-UP AEs, and 
Deaths 
 
Anticipated deviations in the conduct of the protocol will not be reported to the IRB unless they 
occur at a rate greater than anticipated by the study team. Expected AEs will not be reported to 
the IRB unless they occur at a rate greater than that known to occur in HIV-infected patients. If 
the rate of these events exceeds the rate expected by the study team, then the events will be 
classified and reported as though they are UPs. Deaths related to the natural history of HIV 
infection will be reported at the time of continuing review. 
 
10.4.3. Annual Reporting to the NIAID IRB 
 
The following items will be reported to the NIAID IRB in summary at the time of 
Continuing Review: 
 
• 
Serious and non-serious unanticipated problems 
 
• 
Expected SAEs that are possibly, probably, or definitely related to the research 
 
• 
SAEs that are not related to the research 
 
• 
All AEs, except expected AEs granted a waiver of reporting 
 
• 
Serious and non-serious protocol deviations 
 
• 
Serious, continuing, and minor non-compliance 
 
• 
Any trends or events which in the opinion of the investigator should be reported 
 
 
 
 
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10.5.  Reporting of Pregnancy 
 
In the event of pregnancy: 
 
• 
Discontinue the study agent and procedures but continue to follow-up over the phone 
for safety and outcomes 
 
• 
Report to the IRB 
 
• 
Advise research subject to notify the obstetrician of study participation and study 
agent exposure 
 
10.6.  Type and Duration of the Follow-up of Subjects after Adverse Events 
 
AEs that occur from the time of enrollment of the subject are followed until the final outcome 
is known or until the end of the study follow-up period. 
 
SAEs that have not resolved by the end of the follow-up period are followed until final 
outcome is known. If it is not possible to obtain a final outcome for an SAE (eg, the subject is 
lost to follow-up), then the reason a final outcome could not be obtained will be recorded by the 
investigator. 
 
10.7.  Pausing Rules for an Individual Subject 
 
Pausing is the suspension of administration of study agent to a single subject until a decision 
is made whether or not to resume administration of the study agent. 
 
The pausing criteria for a single subject in this study include any of the following: 
 
• 
A subject experiences an SAE that is unexpected and possibly, probably, or definitely 
related to eplerenone 
 
• 
A subject develops a potassium level > 5.5 meq/L, eGFR< 60 mL/min/1.73 m2, or 
serum creatinine > 1.5 mg/dL 
 
• 
Any safety issue that the investigator determines should pause administration of a 
study agent to a single subject 
 
10.7.1. Resumption Following a Pause for a Single Subject 
 
The PI will determine whether or not it is safe to resume administration of the study agent to 
the subject. 
 
 
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• 
Subjects who develop a potassium level > 5.5 meq/L, eGFR< 60 mL/min/1.73 m2, or 
serum creatinine > 1.5 mg/dL will be asked to return to clinic in 24-48 hours for repeat 
lab testing. 
 
• 
Subjects will only continue/resume treatment if an alternative cause for these 
lab abnormalities is identified and the abnormality resolves. 
 
A subject who does not resume eplerenone will continue to be followed for safety. 
 
10.8.  Halting Rules for the Protocol 
 
Halting the study requires immediate discontinuation of study agent administered for all 
subjects and suspension of enrollment until a decision is made whether or not to continue 
enrollment and study agent administration. 
 
The halting rules are: 
 
• 
Two or more subjects experience the same or similar SAEs that are unexpected and 
are possibly, probably, or definitely related to eplerenone 
 
OR 
 
• 
any safety issue that the PI determines should halt the study 
 
The PI will determine if the study should be halted. The NIAID IRB may also halt the study. 
 
10.8.1. Reporting a Study Halt 
 
If a halting rule is met, then a description of the AE(s) or safety issue must be reported by the 
PI, within one business day, to the IRB by fax or email. 
 
10.8.2. Resumption of a Halted Study 
 
The PI will determine if it is safe to resume the study. The PI will notify the IRB of the decision 
on resumption of the study. 
 
 
 
 
 
 
 
 
 
 
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10.9.  Withdrawal of an Individual Subject 
 
An individual subject will be withdrawn for any of the following: 
 
• 
An individual subject’s decision (the investigator will attempt to determine the reason 
for the subject’s decision.) 
 
• 
Non-compliance with study procedures to the extent that it is potentially harmful to 
the subject or to the integrity of the study data. 
 
• 
The investigator determines that continued participation in the study would not be in 
the best interest of the subject. 
 
10.10. Replacement of a Subject Who Discontinues Study Treatment 
 
If a subject withdrawals after fewer than 12 weeks of study treatment, then they will be replaced. 
 
If a subject is replaced, then all of the data will still be included for the safety assessment. 
 
10.11. Safety Monitoring Plan 
 
The data gathered during this study will be monitored by the PI for safety and compliance with 
protocol-specified requirements. 
 
11. Statistical Considerations 
 
The proposed study is designed as a proof-of-concept study and will employ paired comparison 
of each subject pre- and post-treatment. With a total of 20 subjects we will have 90% power to 
detect a 0.1% unit change in intramyocardial lipid content based on an estimated within subject 
standard deviation of MRS intramyocardial lipid of 0.07% reported by O’Connor and 
colleagues36. In our prior work, HIV-infected subjects had a mean intramyocardial lipid content 
of 1.5% whereas controls were 1.0%. Therefore, with this sample size we will have ample 
power to detect a minimal clinically relevant reduction of 0.3% units or greater following 
eplerenone therapy. 
 
11.1.  Statistical Analysis Plan 
 
As previously stated, the primary endpoints for this study will be change in cardiac and hepatic 
steatosis from initial measurement (pre-treatment) to end of study measurement. This will be 
tested using a paired t-test, and a two sided p value of < 0.05 will be used for detection of 
 
 
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significance. In addition, we will conduct exploratory analyses to determine if eplerenone 
therapy is associated with changes in biomarkers of inflammation (eg, MCP-1 and IL-6). We 
also plan to evaluate potential changes in visceral fat volume with treatment, but these will be 
exploratory analyses, primarily descript, and which may not be sufficiently powered in this 
small preliminary trial. Finally we will construct descriptive tables summarizing reported side 
effects and any observed lab abnormalities observed during the course of study participation in 
all subjects. 
 
12. Ethics/Protection of Human Subjects 
 
12.1.  Informed Consent Process 
 
Informed consent is a process where information is presented to enable persons to voluntarily 
decide whether or not to participate as a research subject. It is an ongoing conversation between 
the human research subject and the researchers which begins before consent is given and 
continues until the end of the subject's involvement in the research. Discussions about the 
research will provide essential information about the study and include: purpose, duration, 
experimental procedures, alternatives, risks and benefits. Subjects will be given the opportunity 
to ask questions and have them answered. 
 
The subjects will sign the informed consent document prior to undergoing any research 
procedures. The subjects may withdraw consent at any time throughout the course of the trial. 
A copy of the informed consent document will be given to the subjects for their records. The 
researcher will document the signing of the consent form in the subject’s medical record. The 
rights and welfare of the subjects will be protected by emphasizing to them that the quality of 
their medical care will not be adversely affected if they decline to participate in this study. 
 
12.1.1. Non–English-Speaking Subjects 
 
If a non–English-speaking subject is unexpectedly eligible for enrollment, the subject will be 
provided with the CC Short Written Consent Form for Non–English-Speaking Research 
Subjects in the subject’s native language and a verbal explanation of the purpose, procedures, 
and risks of the study as described in MAS Policy M77-2, NIH HRPP SOP 12, and 45 CFR 
46.117(b)(2). If the CC Short Written Consent Form is used three times or more for the same 
language, this will be reported to the IRB immediately. 
 
 
 
 
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12.2.  Subject Confidentiality 
 
All records will be kept confidential to the extent provided by federal, state and local law. The 
study monitors and other authorized representatives of the Sponsor may inspect all documents 
and records required to be maintained by the Investigator, including but not limited to, medical 
records. Records will be kept locked and all computer entry and networking programs will be 
done with coded numbers only. Clinical information will not be released without written 
permission of the subject, except as necessary for review by IRB or the OHRP. 
 
13. Data Handling and Record Keeping 
 
13.1.  Data Capture and Management 
 
Study data will be maintained in CRIMSON and collected directly from subjects during study 
visits and telephone calls, or will be abstracted from subjects’ medical records. Source 
documents include all recordings of observations or notations of clinical activities and all 
reports and records necessary to confirm the data abstracted for this study. Data entry into 
CRIMSON will be performed by authorized individuals. The Investigator is responsible for 
assuring that the data collected are complete, accurate, and recorded in a timely manner. 
 
13.2.  Record Retention 
 
The investigator is responsible for retaining all essential documents listed in the ICH GCP 
Guideline. Study records will be maintained by the PI for a minimum of 5 years and in 
compliance with institutional, IRB, state, and federal medical records retention 
requirements, whichever is longest. All stored records will be kept confidential to the extent 
required by federal, state, and local law. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Appendix A: Scientific References 
 
1. 
Seaberg EC, Munoz A, Lu M, et al. Association between highly active antiretroviral 
therapy and hypertension in a large cohort of men followed from 1984 to 2003. Aids. 
2005;19(9):953-960. 
 
2. 
Hadigan C, Meigs JB, Corcoran C, et al. Metabolic abnormalities and 
cardiovascular disease risk factors in adults with human immunodeficiency virus 
infection and lipodystrophy. Clinical infectious diseases : an official publication of 
the Infectious Diseases Society of America. 2001;32(1):130-139. 
 
3. 
Brown TT, Cole SR, Li X, et al. Antiretroviral therapy and the prevalence and incidence 
of diabetes mellitus in the multicenter AIDS cohort study. Archives of internal medicine. 
2005;165(10):1179-1184. 
 
4. 
Carr A, Samaras K, Thorisdottir A, Kaufmann GR, Chisholm DJ, Cooper DA. 
Diagnosis, prediction, and natural course of HIV-1 protease-inhibitor-associated 
lipodystrophy, hyperlipidaemia, and diabetes mellitus: a cohort study. Lancet. 
1999;353(9170):2093-2099. 
 
5. 
Hsue PY, Lo JC, Franklin A, et al. Progression of atherosclerosis as assessed by carotid 
intima-media 
thickness 
in 
patients 
with 
HIV 
infection. 
Circulation. 
2004;109(13):1603-1608. 
 
6. 
Lo J, Abbara S, Shturman L, et al. Increased prevalence of subclinical coronary 
atherosclerosis detected by coronary computed tomography angiography in HIV-
infected men. Aids. 2010;24(2):243-253. 
 
7. 
Triant VA, Lee H, Hadigan C, Grinspoon SK. Increased acute myocardial infarction 
rates and cardiovascular risk factors among patients with human immunodeficiency virus 
disease. The Journal of clinical endocrinology and metabolism. 2007;92(7):2506-2512. 
 
8. 
Joy T, Keogh HM, Hadigan C, et al. Relation of body composition to body mass index 
in HIV-infected patients with metabolic abnormalities. Journal of acquired immune 
deficiency syndromes. 2008;47(2):174-184. 
 
9. 
Grunfeld C, Rimland D, Gibert CL, et al. Association of upper trunk and visceral 
adipose tissue volume with insulin resistance in control and HIV-infected subjects in the 
FRAM study. Journal of acquired immune deficiency syndromes. 2007;46(3):283-290. 
 
10. 
He Q, Engelson ES, Ionescu G, Glesby MJ, Albu JB, Kotler DP. Insulin resistance, 
hepatic lipid and adipose tissue distribution in HIV-infected men. Antiviral 
therapy. 2008;13(3):423-428. 
 
11. 
Wohl D, Scherzer R, Heymsfield S, et al. The associations of regional adipose tissue 
with lipid and lipoprotein levels in HIV-infected men. Journal of acquired immune 
deficiency syndromes. 2008;48(1):44-52. 
 
12. 
Dolan SE, Hadigan C, Killilea KM, et al. Increased cardiovascular disease risk indices in 
HIV-infected 
women. 
Journal 
of 
acquired 
immune 
deficiency 
syndromes. 
2005;39(1):44-54. 
 
 
 
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Eplerenone for HIV Patients 
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13. 
Samaras K, Gan SK, Peake PW, Carr A, Campbell LV. Proinflammatory markers, 
insulin sensitivity, and cardiometabolic risk factors in treated HIV infection. Obesity. 
2009;17(1):53-59. 
 
14. 
Reingold J, Wanke C, Kotler D, et al. Association of HIV infection and HIV/HCV 
coinfection with C-reactive protein levels: the fat redistribution and metabolic change 
in HIV infection (FRAM) study. Journal of acquired immune deficiency syndromes. 
2008;48(2):142-148. 
 
15. 
Guaraldi G, Squillace N, Stentarelli C, et al. Nonalcoholic fatty liver disease in HIV-
infected patients referred to a metabolic clinic: prevalence, characteristics, and predictors. 
Clinical infectious diseases : an official publication of the Infectious Diseases Society of 
America. 2008;47(2):250-257. 
 
16. 
Guaraldi G, Stentarelli C, Zona S, et al. Lipodystrophy and anti-retroviral therapy 
as predictors of sub-clinical atherosclerosis in human immunodeficiency virus 
infected subjects. Atherosclerosis. 2010;208(1):222-227. 
 
17. 
Thiara DK, Liu CY, Raman F, et al. Abnormal Myocardial Function Is Related to 
Myocardial Steatosis and Diffuse Myocardial Fibrosis in HIV-Infected Adults. 
The Journal of Infectious Diseases. 2015 [epub]. 
 
18. 
Goodfriend TL, Kelley DE, Goodpaster BH, Winters SJ. Visceral obesity and insulin 
resistance are associated with plasma aldosterone levels in women. Obesity 
research. 1999;7(4):355-362. 
 
19. 
Garg R, Hurwitz S, Williams GH, Hopkins PN, Adler GK. Aldosterone production 
and insulin resistance in healthy adults. The Journal of clinical endocrinology and 
metabolism. 2010;95(4):1986-1990. 
 
20. 
Lo J, Looby SE, Wei J, Adler GK, Grinspoon SK. Increased aldosterone among HIV-
infected women with visceral fat accumulation. Aids. 2009;23(17):2366-2370. 
 
21. 
Guo C, Ricchiuti V, Lian BQ, et al. Mineralocorticoid receptor blockade reverses 
obesity-related changes in expression of adiponectin, peroxisome proliferator-
activated receptor-gamma, and proinflammatory adipokines. Circulation. 
2008;117(17):2253-2261. 
 
22. 
Wada T, Kenmochi H, Miyashita Y, et al. Spironolactone improves glucose and lipid 
metabolism by ameliorating hepatic steatosis and inflammation and suppressing 
enhanced gluconeogenesis induced by high-fat and high-fructose diet. 
Endocrinology. 2010;151(5):2040-2049. 
 
23. 
Wada T, Miyashita Y, Sasaki M, et al. Eplerenone ameliorates the phenotypes of 
metabolic syndrome with NASH in liver-specific SREBP-1c Tg mice fed high-fat 
and high-fructose diet. American journal of physiology. Endocrinology and 
metabolism. 2013;305(11):E1415-1425. 
 
24. 
Ramirez E, Klett-Mingo M, Ares-Carrasco S, et al. Eplerenone attenuated 
cardiac steatosis, apoptosis and diastolic dysfunction in experimental type-II 
diabetes. Cardiovascular diabetology. 2013;12:172. 
 
 
 
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25. 
Sowers JR, Whaley-Connell A, Epstein M. Narrative review: the emerging 
clinical implications of the role of aldosterone in the metabolic syndrome and 
resistant hypertension. Annals of internal medicine. 2009;150(11):776-783. 
 
26. 
Rossi GP, Sechi LA, Giacchetti G, Ronconi V, Strazzullo P, Funder JW. Primary 
aldosteronism: cardiovascular, renal and metabolic implications. Trends in 
endocrinology and metabolism: TEM. 2008;19(3):88-90. 
 
27. 
Bentley-Lewis R, Adler GK, Perlstein T, et al. Body mass index predicts aldosterone 
production in normotensive adults on a high-salt diet. The Journal of clinical 
endocrinology and metabolism. 2007;92(11):4472-4475. 
 
28. 
Hirata A, Maeda N, Hiuge A, et al. Blockade of mineralocorticoid receptor reverses 
adipocyte dysfunction and insulin resistance in obese mice. Cardiovascular research. 
2009;84(1):164-172. 
 
29. 
Hadigan C, Liebau J, Andersen R, Holalkere NS, Sahani DV. Magnetic resonance 
spectroscopy of hepatic lipid content and associated risk factors in HIV infection. Journal 
of acquired immune deficiency syndromes. 2007;46(3):312-317. 
 
30. 
Fallo F, Dalla Pozza A, Tecchio M, et al. Nonalcoholic fatty liver disease in primary 
aldosteronism: a pilot study. American journal of hypertension. 2010;23(1):2-5. 
 
31. 
Floris-Moore M, Fayad ZA, Berman JW, et al. Association of HIV viral load with 
monocyte chemoattractant protein-1 and atherosclerosis burden measured by magnetic 
resonance imaging. Aids. 2009;23(8):941-949. 
 
32. 
Triant VA, Meigs JB, Grinspoon SK. Association of C-reactive protein and HIV 
infection with acute myocardial infarction. Journal of acquired immune deficiency 
syndromes. 2009;51(3):268-273. 
 
33. 
Rocha R, Rudolph AE, Frierdich GE, et al. Aldosterone induces a vascular 
inflammatory phenotype in the rat heart. American journal of physiology. Heart and 
circulatory physiology. 2002;283(5):H1802-1810. 
 
34. 
Suzuki J, Iwai M, Mogi M, et al. Eplerenone with valsartan effectively reduces 
atherosclerotic lesion by attenuation of oxidative stress and inflammation. 
Arteriosclerosis, thrombosis, and vascular biology. 2006;26(4):917-921. 
 
35. 
Inspra(R) [package insert]. Pfizer Inc., New York City, NY; May 2013. 
http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/021437s011lbl.pdf. Accessed 
March 5, 2015. 
 
36. 
O'Connor RD, Xu J, Ewald GA, et al. Intramyocardial triglyceride quantification by 
magnetic resonance spectroscopy: In vivo and ex vivo correlation in human subjects. 
Magnetic resonance in medicine : official journal of the Society of Magnetic Resonance 
in Medicine / Society of Magnetic Resonance in Medicine. 2011;65(5):1234-1238. 
 
 
 
 
 
 
 
 
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Appendix B: Schedule of Procedures/Evaluations 
Evaluation 
Screening 
Baseline 
Safety Visits 
Interim 
Final Study 
Day 0 
(Weeks 1, 2, 
Visit (Week 
Visit (Week 
4, 8, 18) 
12) 
24) 
Physical exam, 
Xa 
X 
X 
X 
X 
medical history 
Vital signsb 
X 
X 
X 
X 
X 
Urine 
X 
X 
X 
X 
X 
pregnancy testc 
Research blood 
X 
X 
X 
X 
X 
collection 
Urine collection 
X 
Cardiac and 
X 
X 
hepatic MRI 
Transient 
X 
X 
elastographyd 
Liver biopsye 
X 
X 
Bionutritionf 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Appendix C: Prohibited Medications 
  
• Boceprevir 
• Lopinavir/ritonavir 
• Saquinavir 
• Clarithromycin 
• Mibefradil 
• Seville oranges 
Strong CYP3A4 
• Conivaptan 
• Nefazodone 
• Suboxone 
• Grapefruit juice 
• Nelfinavir 
• Telaprevir 
Inhibitors 
• Indinavir 
• Posaconazole 
• Telithromycin 
• Itraconazole 
• Ritonavir 
• Voriconazole 
• Ketoconazole 
Strong CYP3A4 
• Avasimibe 
• Rifampin 
• Rifapentine 
• Carbamazepine 
• Rifabutin 
• St. John’s wort 
Inducers 
• Phenytoin 
Potassium- 
• Amiloride 
• Spironolactone 
Sparing Diuretics 
• Triameterene 
Agents that May 
• Aliskerin 
• Penicillin G 
• Tacrolimus 
Cause 
• Cyclosporine 
• Pentamidine 
• Verapamil 
Hyperkalemia 
• Digoxin 
CYP = cytochrome P450 isozyme; NSAID = nonsteroidal anti-inflammatory drug. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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