Conditions: Parkinson Disease Cerebrospinal Fluid
Keywords: 5-S-Cysteinyldopamine Cerebrospinal Fluid PARKINSONS DISEASE MONOAMINE OXIDASE INHIBITOR
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 6
Healthy volunteers: yes

Brief summary:
Background:

Parkinsons disease (PD) causes slow movement, stiffness, and poor balance. Many symptoms are due to the loss of brain cells that make the brain chemical dopamine. The cells may be damaged by the breakdown of dopamine by a process called oxidation. The drug N-acetylcysteine (NAC) can act as an antioxidant. Researchers want to test if NAC can decrease the oxidation of brain dopamine in people with PD.

Objective:

To look at the effect of NAC on brain chemistry in people with PD.

Eligibility:

People ages 18 and older with PD that were diagnosed within the past 5 years. They must be taking a monoamine oxidase inhibitor.

Healthy volunteer participants ages 18 and older.

Design:

Participants will be screened with:

Medical history

Physical exam

Blood and urine tests

Participants will be hospitalized for 4 to 8 days.

On day 1, participants will have blood and urine tests. For several hours, they cannot eat or drink anything but water and their medications. Late in the morning they will have a meal.

About 2 hours later they will have a spinal tap (lumbar puncture). For this, a numbing medicine is injected into the back. A needle is inserted between the bones in the back to remove a small amount of fluid. The spinal tap may use x-rays to see inside the body.

After the spinal tap, they will start taking NAC by mouth.

They will take NAC twice a day for 2 more days.

On the next day, they will not eat until a meal in the late morning. They will take a final NAC dose.

About 2 hours later they will have a second spinal tap.

Healthy Volunteer (HV) participants will receive a spinal tap on day one, followed by a second spinal tap 48 hours after the first spinal tap. HV participants will not receive NAC.

Detailed description:
Objective:

This study is to test whether N-acetylcysteine (NAC) inhibits the spontaneous oxidation of central neural dopamine as indicated by the cerebrospinal fluid (CSF) concentration of 5-S-cysteinyl-dopamine (Cys-DA) in patients with Parkinsons disease (PD).

Study population:

The study population comprises up to 35 participants with early (less than or equal to 5 years from diagnosis), mild, levodopa-untreated PD and up to 6 healthy volunteer participants. The PD participants will be on an inhibitor of monoamine oxidase (MAO) that is prescribed for their disease.

Design:

The study has a two groups employing a pretest-posttest design. Each participant undergoes a lumbar puncture (LP) as an inpatient at the NIH Clinical Center to obtain cerebrospinal fluid (CSF) for assays of Cys-DA, 3,4-dihydroxyphenylacetic acid (DOPAC), and related biochemicals. For PD participants, the second LP is done after the participant has taken at least 5 doses of NAC (2 grams orally twice per day). The LP takes place about 2 hours after the last NAC dose. For HV participants the second LP takes place approximately 48 hours after the first LP.

Outcome measures:

The main outcome measure is the CSF concentration of Cys-DA. Other outcome measures are levels of other catecholamine-related neurochemicals or of indices of oxidative stress. Depending on the results, an exploratory study may be done involving NAC at 1 gram orally twice per day.

Arms:
arm 1: HVs who undergo 2 LPs as inpatients, with 48 hours between LPs and no NAC treatment arm 2: Patient undergoes a lumbar puncture (LP) as an inpatient at the NIH Clinical Center to obtain cerebrospinal fluid (CSF) for assays of Cys-DA, 3,4- dihydroxyphenylacetic acid (DOPAC), and related biochemicals. The second LP is done after the patient has taken at least 5 doses of NAC (2 grams orally twice per day).

Interventions: intervention 1: N-Acetylcysteine intervention 2: Lumbar Puncture intervention 3: Fluoroscopy
Intervention descriptions: intervention 1: Oral intervention 2: Each participant undergoes a baseline lumbar puncture (LP 1) as an inpatient at the NIH Clinical Center to obtain cerebrospinal fluid (CSF) for assays of Cys-DA, 3,4-dihydroxyphenylacetic acid (DOPAC), and related biochemicals. The second LP (LP 2) is completed after the PD participant has taken at least 5 doses of NAC (2 grams orally twice per day) and approximately 2 hours after the last NAC dose. For the HV participant, LP 2 occurs approximately 48 hours after LP 1 (no NAC administered). intervention 3: If needed for lumbar puncture

Protocol document:
Prot_SAP_000.pdf: 
CNS IRB Protocol Template (12.15.15 rev2)
 
Protocol Title: Does N-Acetylcysteine Decrease Spontaneous Oxidation of Central 
Neural Dopamine in Parkinson’s Disease?
Abbreviated Title: NAC Protocol
Protocol Number: 17-N-0076
Date of This Submission/Version: January 11, 2019April 30, 2018
Principal Investigator
Name, 
Degree
David S. 
Goldstein, 
MD PhD
Branch/Institute
CNCS/NINDS
Bldg/Rm
10/5N220
Phone
301-
496-
2103
E-mail
goldsteind@ninds.nih.gov
Associate Investigators
Name, 
Degree
Branch/Institute
Bldg/Rm
Phone
E-mail
Jamie 
Cherup, 
CRNP
CNCS/NINDS
CRC 7-3657
SW
301-
802-
1476
jamie.cherup@nih.gov
Irene 
Dustin, 
PhD, CRNP
HMCS/NINDS
CRC 5-1473
301-
402-
4479
id30d@nih.gov
Debra 
Ehrlich, MD
OCD/NINDS
10/7D37
301-
443-
7888
debra.ehrlich@nih.gov
Janna 
Gelsomino, 
RN
CNCS/NINDS
CRC 7-5653
301-
435-
5166
Janna.Gelsomino@nih.gov
Codrin
Lungu, MD
DCR/NINDS
6001 
Executive 
Blvd./2188
301-
402-
0976
lunguci@ninds.nih.gov
Patti 
Sullivan, 
CMT
CNCS/NINDS
10/5N220
301-
402-
2052
psullivan1@ninds.nih.gov
Tianxia Wu,
PhD
OCD/NINDS
10/5N230
301-
496-
5763
wuti@mail.nih.gov
Referral Contact 
Janna 
Gelsomino, 
RN
CNCS/NINDS
CRC 7-
5653
301-435-
5166
Janna.Gelsomino@nih.gov


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Accountable Investigator
David S. 
Goldstein, 
MD PhD
CNCS/NINDS
10/5N220
301-496-
2103
goldsteind@ninds.nih.gov
Medical Advisory Investigator 
David S. 
Goldstein, 
MD PhD
CNCS/NINDS
10/5N220
301-496-
2103
goldsteind@ninds.nih.gov
Human Research Protections Program Investigator and Staff Training: For this 
protocol, the following “Just in time” human subjects protection training courses are 
required for investigators and staff: None.
Total requested accrual  
35 Patients      
6   Healthy Volunteers 
 
Project Uses Ionizing Radiation: 
   No 
   Yes 
 Medically-indicated only
 Research-related only
 Both
IND/IDE
 No 
Yes
Durable Power of Attorney 
 No 
 Yes 
Multi-institutional Project
 No 
 Yes
Data and Safety Monitoring Board  No 
 Yes 
Technology Transfer Agreement 
 No  
 Yes 
 
Samples are being stored 
 No  
 Yes 
Flesch-Kincaid reading level of consent form: 8.8 


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Précis:
Objective: This study is to test whether N-acetylcysteine (NAC) inhibits the spontaneous 
oxidation of central neural dopamine as indicated by the cerebrospinal fluid (CSF) 
concentration of 5-S-cysteinyl-dopamine (Cys-DA) in patients with Parkinson’s disease 
(PD).
Study population: The study population comprises up to 35 patients with early (≤ 5 
years from diagnosis), mild, levodopa-untreated PD. The patients will be on an inhibitor 
of monoamine oxidase (MAO) that is prescribed for their disease. There is also a pilot 
study of healthy volunteers (HVs), to measure biological variability of CSF Cys-DA 
levels.
Design: The study has a one group, pretest-posttest design. Each patient undergoes a 
lumbar puncture (LP) as an inpatient at the NIH Clinical Center to obtain cerebrospinal 
fluid (CSF) for assays of Cys-DA, 3,4-dihydroxyphenylacetic acid (DOPAC), and related 
biochemicals. The second LP is done after the patient has taken at least 5 doses of NAC 
(2 grams orally twice per day). The LP takes place about 2 hours after the last NAC dose. 
For the purpose of establishing biological variance and thereby carrying out a meaningful 
power analysis, we will study up to 6 HVs who undergo 2 LPs as inpatients, with 48 
hours between LPs and no NAC treatment. In the study of HVs the main outcome 
measure is the biological variation of CSF Cys-DA between the 2 LPs. 
Outcome measures: The main outcome measure is the CSF concentration of Cys-DA. 
Other outcome measures are levels of other catecholamine-related neurochemicals or of 
indices of oxidative stress. Depending on the results, an exploratory study may be done 
involving NAC at 1 gram orally twice per day. In the pilot study of HVs the main 
outcome measure is the biological variation of CSF Cys-DA between the 2 LPs.


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Table of Contents:
 
Précis:.........................................................................................................................................................3
List of Abbreviations.............................................................................................................................5
1. Introduction and Background.......................................................................................................6
2. Study Objectives ..............................................................................................................................12
3. Subjects...............................................................................................................................................13
4. Study Design and Methods...........................................................................................................14
5. Management of Data and Samples ............................................................................................20
6. Additional Considerations ...........................................................................................................21
7. Risks and Discomforts...................................................................................................................22
8. Subject Safety Monitoring ............................................................................................................23
9. Outcome Measures .........................................................................................................................24
10. Statistical Analysis .......................................................................................................................25
11. Human Subjects Protection.......................................................................................................26
12. Anticipated Benefit ......................................................................................................................27
13. Classification of Risk  (for the study as a whole) ...............................................................28
14. Consent Documents and Process ............................................................................................29
15. Data and Safety Monitoring.......................................................................................................30
16. Quality Assurance.........................................................................................................................31
17. Reporting of Unanticipated Problems, Adverse Events and Protocol Deviations..32
18. Alternatives to Participation....................................................................................................33
19. Privacy..............................................................................................................................................34
20. Confidentiality...............................................................................................................................35
21. Conflict of Interest........................................................................................................................36
22. Technology Transfer ...................................................................................................................37
23. Research and Travel Compensation ......................................................................................37
24. References ......................................................................................................................................38
25. Attachments/ Appendices.........................................................................................................41
26. Consent Forms...............................................................................................................................42


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List of Abbreviations
ALDH = aldehyde dehydrogenase
AR = aldehyde/aldose reductase
CC =  NIH Clinical Center
CSF = cerebrospinal fluid
DA = dopamine
DAT = cell membrane dopamine transporter
Cys-DA = 5-S-cysteinyldopamine
Cys-DOPA = 5-S-cysteinylDOPA
DOPAC = 3,4-dihydroxyphenylacetic acid
DOPAL = 3,4-dihydroxyphenylacetaldehyde
IT = Information Technology
IRB = Institutional Review Board
LAAAD = L-aromatic-amino-acid decarboxylase
LP = lumbar puncture
MAO = monoamine oxidase
MTA = Material Transfer Agreement
NAC = N-acetylcysteine
PD = Parkinson’s disease
VMAT2 = Type 2 vesicular monoamine transporter


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1. Introduction and Background
PD is a major public health burden. Parkinson’s disease (PD) is one of the most 
prevalent neurodegenerative diseases, affecting about a million people in the United 
States. PD is aging related, and the incidence of PD is likely to increase as the population 
ages. PD therefore poses a public health burden that likely will grow over time. Mortality 
ratios in PD are about twice those in the general population. 
Dopamine deficiency causes the movement disorder in PD. The proximate cause of the 
movement disorder that characterizes PD results from deficiency of the catecholamine, 
dopamine, in the nigrostriatal system—especially in the putamen (1). Effective 
symptomatic treatments for PD work directly or indirectly by countering the effects of 
nigrostriatal dopamine deficiency. Levodopa, the precursor of dopamine, combined with 
a peripheral inhibitor of L-aromatic-amino-acid decarboxylase to attenuate conversion of 
levodopa to dopamine outside the central nervous system, is the mainstay of treatment.   
There is no known means to slow the catecholaminergic neurodegeneration in PD. The 
mechanisms of nigrostriatal dopamine depletion PD are incompletely understood, and 
there is no proven treatment or prevention strategy. 
The catecholamine autotoxicity theory proposes a third determinant of catecholaminergic 
neurodegeneration besides genes and environment. It is widely presumed that PD is 
caused by complex interactions between genes and environment. An additional element 
may be catecholamine “autotoxicity” (Figure 1). According to the autotoxicity theory, 
catecholamines can be turned into “suicide chemicals” that kill the neurons that contain 
them (2).
There are two general proposed mechanisms of autotoxicity. Autotoxicity as applied to 
dopaminergic neurons in PD occurs by two routes (Figure 1). The first is via spontaneous 
oxidation of cytoplasmic dopamine to form reactive oxygen species and dopamine-
quinone (DA-quinone). DA-quinone can undergo rearrangement to form aminochrome 
and can bind covalently with glutathione or cysteine to form 5-S-cysteinyl-DA (Cys-
DA); both aminochrome and Cys-DA are toxic (3, 4).
 
The second—and likely predominant—route of autotoxicity is via enzymatic oxidation of 
cytoplasmic dopamine, catalyzed by monoamine oxidase (MAO), to form hydrogen 
peroxide and 3,4-dihydroxyphenylacetaldehyde (DOPAL). DOPAL can bind covalently 
to DA to form tetrahydropapaveroline (5), react with hydrogen peroxide and divalent 
metal cations to produce hydroxyl radicals (6) ,or oxidize spontaneously to form reactive 
oxygen species and DOPAL-quinone (7). DOPAL-quinone, in turn, readily forms 
adducts with lysine residues in proteins, thereby altering their functions (8) or causing 
them to oligomerize (9).
The catecholaldehyde hypothesis is a derivative of the autotoxicity theory. All of the 
enzymatic metabolism of intra-neuronal dopamine passes through DOPAL. DOPAL, like 


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other intracellular aldehydes, is extremely toxic but is detoxified by ALDH to form the 
non-toxic acid, 3,4-dihydroxyphenylacetic acid (DOPAC), which is actively pumped out 
of the neuron. Post-mortem neurochemical studies have shown that patients with PD have 
decreased ALDH activity and DOPAL buildup in the putamen (10). The 
catecholaldehyde hypothesis proposes that DOPAL buildup causes or contributes to the 
death of the nigrostriatal dopaminergic neurons in PD (11).
 
 
Figure 1: Overview of the catecholamine autotoxicity theory. The theory explains PD in 
terms of toxic effects of products of enzymatic and spontaneous oxidation of cytoplasmic 
dopamine. Levels of 3,4-dihydroxyphenylacetic acid (DOPAC) and 5-S-
cysteinyldopamine (Cys-DA) in cerebrospinal fluid reflect these processes. 
DOPAL toxicity depends on its spontaneous oxidation. Accumulating evidence indicates 
that DOPAL toxicity depends importantly on its spontaneous oxidation to DOPAL-
quinone (9, 12). Inhibiting DOPAL formation, in series with inhibiting DOPAL 
oxidation, would then be expected to decrease catecholamine autotoxicity and slow the 
loss of catecholaminergic neurons.
MAO inhibition decreases DOPAL formation. Examination of the concept diagram in 
Figure 1 leads straightforwardly to the prediction that inhibiting MAO should decrease 
DOPAL formation, and this is the case (13). There are two isoforms of MAO, MAO-A 
and MAO-B, and dopaminergic neurons exclusively express MAO-A. At first glance, 
testing the catecholaldehyde hypothesis would seem to require an MAO-A inhibitor. We 
wish to avoid using MAO-A inhibitors, because these drugs predispose to paroxysmal 


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hypertension upon ingestion of common tyramine-containing dietary constituents such as 
red wine and hard cheese (the “cheese effect”).  
MAO-B-inhibitors decrease MAO-A activity in humans. The MAO-B inhibitors selegiline 
and rasagiline are not associated with the cheese effect (14). These drugs decrease plasma 
levels of DOPAC and 3,4-dihydroxyphenylglycol, consistent with MAO-A inhibition in 
sympathetic nerves (13, 15). Selegiline also decreases CSF levels of DOPAC (16), and 
when administered clinically as a transdermal patch or effervescent tablet, selegiline 
decreases brain MAO-A activity in humans (17). We have found preliminarily that 
rasagiline decreases CSF DOPAC (unpublished observations). Therefore, a clinical trial 
to test the catecholaldehyde hypothesis could be based on MAO-B inhibition. 
Treatment with an MAO inhibitor alone might trade off one form of toxicity for another. 
Large multi-center clinical trials of MAO-B inhibitors have failed to show convincing 
evidence that this treatment slows the progression of symptomatic PD (18). A variety of 
explanations have been offered for this failure (19). A relatively recent one is based on 
our finding that MAO inhibition, while decreasing DOPAL formation, increases 
spontaneous oxidation of dopamine (13). Treatment with an MAO inhibitor alone might 
be ineffective because of concurrently decreased enzymatic oxidation and increased 
spontaneous oxidation of cytoplasmic dopamine.
N-Acetylcysteine (NAC) is promising as an anti-oxidant that may be bioavailable to 
central dopamine neurons. NAC is a glutathione precursor and well established anti-
oxidant.  NAC is an FDA approved drug to treat acetaminophen overdose and is 
marketed in the United States as a dietary supplement. Clinical trials of NAC in PD are 
under way (20). In humans NAC increases glutathione levels in the brain (21), and orally 
administered NAC appears unchanged in the cerebrospinal fluid (CSF) (22). Basic 
cellular studies have shown that NAC or glutathione attenuates DOPAL-induced protein 
reactivity (12) and virtually prevents DOPAL-induced oligomerization of alpha-synuclein 
(9). A small clinical trial of NAC in PD has preliminarily noted clinical and laboratory 
improvement (20).
NAC could mitigate dopamine autotoxicity (Figure 2). NAC should decrease the toxicity 
of DOPAL by inhibiting formation of DOPAL-quinone. Moreover, NAC should 
attenuate the increase in spontaneous oxidation of dopamine to form Cys-DA and 
increase availability of DOPA to form dopamine.  
Whether NAC is bioavailable to central dopaminergic neurons in humans and exerts 
an anti-oxidant effect in those neurons is unknown. This “proof of concept” study is 
designed to test the hypothesis that NAC decreases spontaneous oxidation of central 
neural dopamine in patients with PD. 
Testing the main hypothesis of this study requires a means to assess spontaneous 
oxidation of dopamine in vivo in the human brain.
 


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Figure 2: Possible effects of NAC-related anti-oxidation in central dopaminergic 
neurons. N-Acetylcysteine (NAC) should inhibit the spontaneous oxidation of DOPA to 
DOPA-quinone (DOPA-Q), dopamine to dopamine-quinone (DA-Q), and DOPAL to 
DOPAL-quinone (DOPAL-Q). DOPA-Q is converted to 5-S-cysteinyldopa (Cys-DOPA), 
and DA-Q is converted to 5-S-cysteinyldopamine (Cys-DA). The level of Cys-DA in 
cerebrospinal fluid provides a biomarker of spontaneous oxidation of dopamine in the 
brain.
Cys-DA in cerebrospinal fluid (CSF) provides a biomarker of spontaneous oxidation of 
central neural dopamine. Cys-DA is produced from the spontaneous oxidation of 
cytoplasmic dopamine. We have found that Cys-DA is present in the CSF of healthy 
humans and patients with PD (23). Our laboratory has the unique capability of 
simultaneously measuring CSF levels of Cys-DA and of DOPAC. Since DOPAC is 
produced by the action of MAO on cytoplasmic DA, measuring CSF Cys-DA and 
DOPAC enables a way to track both spontaneous and enzymatic oxidation of DA. Cys-
DA in CSF is probably not derived from released DA, because released DA is highly 
efficiently metabolized by catechol-O-methyltransferase. Since the vast preponderance of 
DA production in the brain is in the striatum, most of the Cys-DA in CSF probably 
reflects a basal ganglia source. Measurement of Cys-DOPA/DOPA is another way to 
examine oxidative stress in central catecholaminergic neurons. 
 
In this study we will test whether NAC at a dose of 4,000 mg per day decreases CSF Cys-
DA levels. The following information is provided as background to justify the chosen 
dosing regimen of NAC. 


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NAC is available in different forms and doses. Effervescent and liquid forms of NAC 
have equivalent plasma bioavailability (24); however, liquid forms have a bad odor and 
are less well tolerated. 
Cetylev™ (500 mg and 2.5 grams), a brand of effervescent, quick-dissolving, flavored 
tablets, is a trademark of Arbor Pharmaceuticals (Atlanta, GA). Cetylev is FDA approved 
as an antidote for acetaminophen overdose. Since Cetylev is FDA approved, the company 
manufactures the drug according to Good Manufacturing Practices (GMP), and Arbor can 
provide a Certificate of Analysis to verify the identity and potency of the drug. For the 
clinical indication of acetaminophen overdose, a loading oral dose of 140 mg/kg is given, 
followed by maintenance doses of 70 mg/kg every 4 hours for a total of 17 doses. Cetylev 
is available as 500 mg and 2.5 g tablets.
An alternative source is PharmaNAC™ (900 mg), another brand of effervescent, quick-
dissolving, flavored tablets. PharmaNAC™is a trademark of BioAdvantex Pharma 
(Mississauga, Canada). BioAdvantex Pharma voluntarily complies with essential 
elements of GMP, from the production of raw materials to the packaging of supplements 
for distribution. BioAdvantex Pharma has a warehouse in Buffalo, NY. 
In the study by Katz et al. (22), the FDA approved liquid form of NAC (20% solution, 
USP verified) was purchased from a contracting pharmaceutical distributor. A capsule 
form was compounded by UCSF Medical Center’s Drug Product Services Laboratory in 
the Department of Clinical Pharmacy, with NAC active ingredient purchased in powder 
form (USP verified) from Professional Compounding Centers of America (the PCCA 
Baltimore Distribution Center is in Elkridge, MD). Oral NAC doses of 7 mg/kg, 35 
mg/kg, or 70 mg/kg for two days, twice each day, were given to PD patients (22).
In the study by Monti et al. (20), both IV and oral NAC was given to PD patients for 3 
months. The oral dose was 600 mg tablets twice per day on the days that patients did not 
receive IV NAC.
In the clinical trial, “N-Acetylcysteine for Neuroprotection in Parkinson's Disease (NAC 
for PD) by Shungu et al. (ClinicalTrials.gov NCT01470027), 1,800 or 3,600 mg doses of 
effervescent NAC tablets are given for 30 days.
A recent review and meta-analysis summarized dosing regimens in clinical trials using 
NAC for a variety of conditions such as schizophrenia, bipolar disorder, attention deficit 
hyperactivity disorder, post-traumatic stress disorder, amyotrophic lateral sclerosis, 
impulse control disorder, and Alzheimer’s disease (but not PD) (25). A wide range of 
NAC doses have been given, over periods from several days to more than 2 years. All the 
clinical trials have used doses far less than those used for acetaminophen toxicity. Some 
clinical trials have given NAC on a per kg basis; most have given a constant dose 
regardless of body mass. Of 50 clinical trials, 8 used <1 gram of NAC per day, 12 1-2 
grams/d, 17 2-3 grams/d, 7 3-4 grams/d, and 6 ≥4 grams/d. 


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The study by Hoffer et al. (26) used a 4 gram load, then 2 grams bid for 4 days. Since we 
want to use a relatively high dose to minimize the chance of false negative results, we 
will use the regimen as in Hoffer et al., except without the 4 gram loading dose.
The biological variabiity of CSF Cys-DA is unknown. An estimate of test-retest variation 
in CSF Cys-DA is needed in order to carry out an informed power analysis.
Preliminary information: CSF Cys-DA data from 2 patients treated with NAC and 4 
HVs who underwent LPs on 2 different occasions under a different protocol are shown in 
Figure 3. Across the 6 subjects, the correlation coefficient (r value) for the scatter plot 
relating CSF Cys-DA for the second LP vs. CSF Cys-DA for the first LP was 0.99 
(p=0.0002). We predict that in the present study the r value will be even closer to 1 
because of the more tightly controlled situation for the 2 LPs. Based on this preliminary 
information, the reproducibility of CSF Cys-DA is excellent.  
Figure 3: Scatter plot relating CSF Cys-DA in a second LP to that in a first LP in 2 PD 
patients (red) and in 4 HVs studied under a different protocol (gray). The linear 
regression equation for the line of best fit, r value, and p value are shown. Note excellent 
reproducibility of CSF Cys-DA. 
PD
HV
y = 12 + 0.793x, r=0.99, p=0.0002


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2. Study Objectives 
This study is designed to test whether NAC decreases spontaneous oxidation of central 
neural dopamine in patients with PD. 
2.A.
Primary objective: The primary objective is to test whether NAC at a dose of 
4,000 mg per day decreases CSF Cys-DA levels.  
2.B.
Secondary objectives: A secondary objective is to evaluate levels of CSF Cys-
DA and other catecholamine-related compounds or indices of oxidative stress in CSF or 
plasma before and after NAC administration. We will also explore whether at a lower 
dose (2,000 mg per day) NAC produces similar results to those seen with the 4,000 mg 
per day dose. In a pilot study of HVs we will assess the test-retest variability of CSF Cys-
DA.


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3. Subjects
3.A.
Description of study populations: The study population is patients with PD who 
are taking an MAO inhibitor for their disease and are not on levodopa. The Planned 
Enrollment Report for this small study takes into account demographic differences in the 
prevalence of the disease under study. 
The pilot study includes adult HVs.
3.A1. Accrual ceiling: 41.
3.A2. Target number of completers: 10 patients, 6 HVs. Withdrawals/dropouts 
will be replaced.
3.A3. NIH employees may participate. NIH employees who are 
subordinates/relatives/co-workers of investigators may not participate.
3.B.  Inclusion criteria:
3.B.a. Inclusion criteria for PD Patients
o
PD diagnosed within the past 5 years
o
Taking a monoamine oxidase (MAO) inhibitor
o
Able to provide consent
o
At least18 years old
3.B.b. Inclusion criteria for Healthy Volunteers
o
Able to provide consent
o
At least18 years old
3.C.  Exclusion criteria:
3.C.a. Exclusion criteria for PD Patients
o
Taking levodopa in any form
o
Known allergy to NAC
o
A condition that would increase risk from a lumbar puncture (e.g., symptomatic 
spinal stenosis or myoclonus)
o
History of a post-spinal headache that required treatment with a blood patch
o
On a prescribed anti-coagulant (e.g., Coumadin, Plavix)
o
Pregnant or breast-feeding
o
History of alcohol or drug abuse
o
Any medical condition that could put subjects at increased risk. Potential 
participants are excluded who have evidence of bone marrow, liver, or kidney failure 
based on abnormal screening lab results.
o
On a medication that could interfere with the scientific results. An example of an 
exclusionary drug is the catechol-O-methyltransferase inhibitor Entacapone, Tricyclic 
anti-depressants are another type of exclusionary drug.


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3.C.b. Exclusion criteria for Healthy Volunteers
 o
A condition that would increase risk from a lumbar puncture (e.g., symptomatic 
spinal stenosis or myoclonus)
o
History of a post-spinal headache that required treatment with a blood patch
o
On a prescribed anti-coagulant (e.g., Coumadin, Plavix)
o
Pregnant or breast-feeding
o
History of alcohol or drug abuse
o
Any medical condition that could put subjects at increased risk. Potential 
participants are excluded who have evidence of bone marrow, liver, or kidney failure 
based on abnormal screening lab results.
3.D.  Eligibility Checklists: Eligibility Checklists for Patients and for HVs based on the 
inclusion/exclusion criteria are attached (25.B.). The checklists will be used by 
investigators at the time of pre-screening communications by phone or secure e-mail or at 
the time of screening for admission to the protocol. E-mail correspondence with potential 
participants for pre-screening will be via a secure system.
4. Study Design and Methods
4.A. Study overview: The site is the NIH Clinical Center. 
4.A.1. Study overview for patients: There is a screening visit and a single inpatient stay. 
Subjects are studied as inpatients, while on a prescribed MAO inhibitor. Each patient 
undergoes a lumbar puncture (LP) as an inpatient. A second LP is done after the patient 
has taken at least 5 doses of NAC over at least 48 hours. The inpatient stay is for up to 8 
days. The inpatient stay is less than 8 days if the participant does not develop a post-
spinal headache after the second LP. The patient continues his or her MAO inhibitor 
treatment throughout the hospital stay. The same dose and regimen of MAO inhibitor are 
used throughout the study in a given patient. This study is not related to other protocols. 
Subjects are not required to participate in another protocol. There are no follow-up visits 
under this protocol.
4.A.2. Study overview for HVs: There is a screening visit and an inpatient stay. Each 
HV undergoes a lumbar puncture (LP) as an inpatient, followed 2 days later by a second 
LP as an inpatient. While on study, HV subjects are not allowed to participate in another 
protocol outside the protocols of the Clinical Neurocardiology Section. There are no 
follow-up visits under this protocol.  
 
4.B. Recruitment: Accruing sufficient patients to meet the Primary Objective within 1 
year of initiation of the study will require an effective recruitment plan.
4.B.1. NINDS PD Clinic: The first source of participants will be patients who are 
in the NINDS PD Clinic database. Personnel of the NINDS PD Clinic will contact 


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possibly eligible patients to determine whether the patients are interested in participating 
in the study.
4.B.2. PRPL: The Patient Recruitment and Public Liaison Office (PRPL) will be 
used for recruitment. The PRPL will distribute recruitment information via the internet to 
neurology clinics, patient support groups, relevant websites, or other institutions or 
individuals. A protocol description for lay people is appended (Appendix 25.C.). A 
screening questionnaire is appended (Appendix 25.D.). Recruitment strategies to be 
utilized by the PRPL will include flyers, a Public Service Announcement (PSA), NIH 
newsletters, ResearchMatch, Clinical Center Facebook, Twitter, CC News/NIH Record, 
and LISTSERVs. The recruitment flyer is appended (Appendix 25.K). 
4.B.3. Recruitment ad: A sample recruitment ad is appended (Appendix 25.E.). 
The ad may be mailed or transmitted electronically to patient support groups, academic 
medical centers, local neurology practices, or other institutions or individuals. Flyers 
containing the ad may be posted or handed out at public events or places. 
4.B.4. Recruitment video: Recruitment may be done via a video ad. The script of 
the video ad is attached (Appendix 25.F.). The ad may be modified based on 
recommendations by the PRPL, without amending the protocol. The video ad may be 
disseminated via YouTube or any of the strategies in the section on Recruitment (4.B.). 
The link to the YouTube video is https://www.youtube.com/watch?v=bbUcuxtVo6o.      
4.B.5. Weblink ad: Non-NIH website(s) may link to information for this 
protocol. The weblink ad is appended (Appendix 25.G.). The planned placements of the 
link include pdtrials.org, the National Parkinson Foundation at www.parkinson.org, the 
Michael J. Fox Foundation for Parkinson’s Research at www.michaeljfox.org, the 
American Parkinson Disease Association at www.apdaparkinson.org, the Parkinson’s 
Disease Foundation at pdf.org, the Parkinson Foundation of the National Capital Area at 
parkinsonfoundation.org, and the Parkinson’s Pipeline Project at pdpipeline.org. 
4.B.6. List-Serv ad: For e-mail announcements sent to an individual’s e-mail 
address, the use of a listserv for solicitation will be approved in advance by the listserv 
manager. We will abide by any listserv rules. The text of the List-Serv ad is appended 
(Appendix 25.H). We do not plan to mail solicitation letters to those on commercial 
mailing lists for recruitment.
4.B.7 NINDS Office of Communications and Public Liaison: The NINDS 
Office of Communications and Public Liaison will be used for recruitment, including via 
the NINDS Spotlights. The text for carrying the protocol in the NINDS Spotlights is 
appended (Appendix 25.L).   
4.B.8. Pre-Screening: Candidate participants are pre-screened by phone, secure 
e-mail, or during attendance at the NINDS PD Clinic. Pre-screening questions for PRPL 
or other recruiters are appended (Appendix 25.D.).


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4.B.8.a. Steps to minimize confounding by antioxidant drugs and 
supplements on study measurements: Many antioxidant drugs and supplements are 
available over the counter, and their effects on levels of neurochemicals in CSF are 
unknown. If a patient is taking an antioxidant drug or supplement and is willing to stop it 
temporarily, then the first LP will be done after the antioxidant drug or supplement has 
been held for at least 7 days. If a patient wishes to continue the antioxidant drug or 
supplement, then the patient will take the antioxidant drug or supplement at the same 
dose and time of day for both LPs.
 
4.B.9. No Direct Solicitation: There will be no direct solicitation by supervisors 
or coworkers.
4.B.10. Google AdWords: Google AdWords may be used to enhance 
recruitment, via a text ad or image ad. (Appendices 25.M. and 25.N.). An image ad 
contains an image and text. The image in an image ad can be animated (up to 30 
seconds). The image may be animated, using a clip from the IRB-approved video ad for 
the study. The image may be colorized rather than black and white as in the video ad. The 
colors will be the same as in the image for the image ad.
In terms of the strategy, we are granting Google AdWords permission to place the text ad 
or image ad at any of the websites related to Parkinson’s Disease. Initially the placement 
will be based on keywords and target organizations that we supply. Text ads appear with 
the search results when keywords are used. We may add keywords and target websites as 
experience with the Google AdWords campaign proceeds.
Regarding how the ads appear on websites, when someone does a search and goes to one 
of the websites listed by us or chosen by Google AdWords for placement, the text ad or 
image ad appears on the person’s computer desktop. This is called an “impression.” The 
frequency and location of impressions depend on payment to Google AdWords. Clicking 
on the text ad or image ad will bring the person to either the IRB-approved YouTube 
video or to the NIH CC webpage that describes the study ((https://go.usa.gov/xXSsQ). 
The written advertisements (and the images within the video ad) will be used in color as 
submitted or may be printed in black and white. The color of the ads may vary. Color 
changes will not be used to change the emphasis of an ad. The size of the ads (including 
images in the video ads) may vary, but all parts of the ads, including fonts and pictures, 
will be changed proportionately to the rest of that ad. Disproportionate changes in size 
will not be used to change the emphasis of an ad. 
4.C. Screening: Consent is obtained before any study procedures, including screening 
procedures, are done. Each subject gives written informed consent and is accrued at the 
time of on-site screening. The location of screening is the 5th floor clinic, the Patient 
Testing Room in CRC 7-5653, or other room in the NIH Clinical Center. Screening will 
be done by the Principal Investigator or by clinical staff of the Clinical Neurocardiology 
Section who are authorized to obtain informed consent. The screening is to confirm 
eligibility criteria, by records review and history and physical examination. A Uniform 


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Parkinson’s Disease Rating Scale (UPDRS), University of Pennsylvania Smell 
Identification Test (UPSIT) or Montreal Cognitive Assessment (MoCA) may be done. 
Screening labs may include a complete blood count, electrolytes, glucose, BUN and 
creatinine, liver function testing, mineral panel, or urinalysis.  
Flow Diagram (Screening): The main purposes of the screening are to confirm 
eligibility, obtain consent, and carry out screening tests such as a medical history and 
physical examination. Rating scales or clinical pathology labs may be done.
4.D. Study procedures (see Flow Diagrams) 
4.D.1 History and physical examination: An admission history and physical 
examination are done.
4.D.2. Venipuncture: Venipuncture is done to obtain blood via a needle or 
catheter.
4.D.3. Blood drawing: Blood is drawn for screening laboratory tests. 
 
4.D.4. Lumbar puncture: In this study, lumbar puncture (LP) is done for 
research purposes, in order to obtain cerebrospinal fluid (CSF). The LP is done 
independently of other protocols. 
On the day of a LP, the patient may receive a pre-arranged breakfast. The patient receives 
a pre-arranged lunch in the late morning, to be finished by about 2 hours before the LP. 
On the day of a LP the patient should have no other oral intake except for medications 
and water before the LP. When the patient is on NAC, as soon as the lunch is finished, 
the patient takes 2,000 mg of NAC in water.
At about 2 hours after the pre-arranged lunch meal, a LP for research purposes is done to 
obtain CSF. For the LP, the subject sits upright (alternatively the subject may be lying 
sideway with knees curled up toward the chest). The lower back will be cleansed. For 
local anesthesia, lidocaine without epinephrine will be injected into and through the skin 
of the back. A needle will be inserted through the anesthetized skin between two lumbar 
vertebral processes. A total of 6 1-mL aliquots of CSF will be obtained. Each aliquot will 
be placed immediately on dry ice. It usually takes 5 to 10 minutes to collect the CSF. 
After the fluid is collected, the needle will be removed. 


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Flow Diagram (Inpatient Visit): A lumbar puncture (LP) is performed before and after 5 
doses of N-acetylcysteine (NAC). The length of the inpatient stay at the NIH Clinical 
Center will depend on when during the week the patient is admitted and whether the 
patient has a post-spinal headache. After the second LP, the patient is observed at least 
overnight (discharge on Day 4). The inpatient visit may last up to 8 days, for insertion of 
a blood patch and observation in the event of a post-spinal headache after the second LP.
After 5 NAC doses and about 48 hours of NAC administration, the LP for research 
purposes is repeated. Again, the patient receives a pre-determined lunch at about 12 noon. 
After the second LP, the subject is observed overnight and is discharged the next day if 
there is no post-spinal headache.
As noted below, the lumbar puncture may be done under fluoroscopic guidance by a 
neuroradiologist in the X-ray department.
In HVs, LPs are done also at about 2 hours after ingestion of a pre-determined meal. 
NAC is not given.
4.D.5. N-Acetylcysteine: In patients, beginning after the first LP, N-
acetylcysteine (NAC) is begun at a 2,000 mg by mouth twice daily. HVs do not receive 
NAC.  
4.D.6. Radiation (fluoroscopy): If technical difficulty is experienced or 
anticipated, the LP may be done under fluoroscopic guidance by a neuroradiologist, for 
research purposes. The anticipated Effective Dose is 0.023 rem per fluoroscopy (up to 2 
fluoroscopies). The radiation exposure is for research purposes only.  


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In the event of a post-spinal headache after the first LP, a blood patch is inserted by an 
anesthesiologist, the patient is observed as an inpatient as needed until the headache is 
resolved, and the patient is then discharged and withdrawn from the study. 
In the event of a post-spinal headache after the second LP, a blood patch is inserted by an 
anesthesiologist, the patient is observed as an inpatient as needed until the headache is 
resolved, and the patient is then discharged from the study.
  
4.E. 
End of participation: At the end of study participation the patient is transferred 
to the care of his or her primary physician or neurologist. There is no medical care 
offered at completion of study procedures. There are no follow-up visits under this 
protocol 
  
After completing study participation, the patient will receive a letter summarizing the 
results of the research tests they underwent and their interpretation, recognizing that the 
data should not be used for clinical diagnosis or management purposes. The patient will 
be free to share the letter with health care providers; however, the letter will be mailed 
only to the patient. HVs do not receive summary letters describing their research results.


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5. Management of Data and Samples
Data from this study will be entered in spreadsheets of the Clinical Neurocardiology 
Section (CNCS) or onto the Section’s clinical research FileMaker Pro database, until the 
planned CTDB database under construction for the CNCS is active.
5.A 
Storage: In this study, CSF samples are obtained and stored for neurochemical 
assays. The sample tubes are labeled coded without personal identifying information. The 
coded samples are stored in locked freezers of the Clinical Neurocardiology Section 
(CNCS). Residual samples will continue to be stored, so that groups of samples can be 
re-analyzed as needed. 
5.A.1. Future use: The Consent Forms state that the subject allows future use of 
his/her data and samples by the Clinical Neurocardiology Section (CNCS) or other 
components of intramural NIH. If the subject does not wish to have his/her data and 
samples used in future studies, the subject should not participate.  
5.A.2. Transfer to Repository Protocol 08-N-N090: Upon termination of this 
protocol data and samples will be transferred to repository protocol No. 08-N-N090. Data 
without personal identifying information will continue to be stored on secured computers, 
on encrypted electronic media, or in notebooks of the CNCS. Coded samples will 
continue be stored in locked freezers of the CNCS. Personnel of the CNCS will have 
access to the stored samples and data. Any loss or destruction of stored data or samples 
will be reported to the IRB.
5.B. Data and sample sharing plan
This protocol is not subject to the Genomic Data Sharing (GDS) policy.
The Consent Forms state that the samples and data will not be shared with those outside 
NIH or a non-NIH repository.


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6. Additional Considerations
6.A. 
Research with investigational drugs or devices: This study does not involve an 
investigational drug or device.
6.A.1. N-Acetylcysteine (NAC): will be obtained from a commercial supplier of 
NAC. The obtained NAC will be assayed and a Certificate of Analysis obtained before 
the NAC is administered. NAC will be dispensed through the NIH Clinical Center 
Pharmacy Department.
6.A.2. MAO inhibitor: The prescribed MAO inhibitor the patient takes will be 
identified by the NIH Clinical Center Pharmacy Department and dispensed by inpatient 
nursing personnel. 
6.B. 
Gene therapy: This study does not involve gene therapy.


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7. Risks and Discomforts An admission history and physical examination are 
done. This does not involve risk.
7.A. 
History and physical examination: Having a history and physical examination 
done does not involve increased medical risk.
7.B.
Venipuncture: There may be some discomfort and bruising from the needle 
insertion. Some people feel light-headed or faint.
7.C.
Blood drawing: The amount of blood to be drawn for laboratory tests (up to 
about 30 mL) should not involve increased medical risk.  
7.B.
 Lumbar puncture: Lumbar puncture may produce brief pain or a tingling 
sensation in the legs if the needle brushes against a nerve. If this happens, the needle will 
be adjusted. There may be a mild backache at the site of needle insertion. About one-third 
of people have a headache for a few days after a lumbar puncture. In the event of a post-
spinal headache a blood patch will be inserted by an anesthesiologist.  
7.C. 
N-Acetylcysteine: NAC is likely safe for most adults, when used as a prescription 
medication. It can cause gastrointestinal side effects such as nausea or abdominal pain, as 
well as headache and hypersensitivity reactions. Based on the mechanism of anti-oxidant 
effects of NAC, no potential drug interactions would be anticipated in PD patients on an 
MAO inhibitor. 
We anticipate that gastrointestinal side effects will be dose-related. If these symptoms 
occur at the initial dose, they will be considered to be expected non-serious adverse 
events and reported as such, and the dose will be decreased by one-half. If the symptoms 
occur at the lower dose, then the NAC will be stopped, the patient will be withdrawn 
from the study, and the patient will observed as an inpatient until the symptoms resolve. 
Rarely, NAC can cause rashes, fever, headache, drowsiness, low blood pressure, or liver 
problems. If a patient experiences these symptoms or signs or others that in the opinion of 
the Principal Investigator are the result of NAC, the patient will be withdrawn from the 
study.
7.D.
Radiation (fluoroscopy): This research study involves exposure to radiation 
from fluoroscopy if technical difficulty is anticipated or experienced with the lumbar 
puncture. This radiation exposure is not required for medical care and is for research 
purposes only. The estimated Effective Dose, 0.05 rem (2 fluoroscopy procedures), is 
below the guideline of 5 rem per year allowed for research subjects by the NIH Radiation 
Safety Committee. 
There is no direct evidence that the amount of exposure received from participating in 
this study is harmful. Pregnancy or lactation are exclusionary in this study.   


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8. Subject Safety Monitoring
8A. 
Identify monitors during participation in study procedures: In this study the 
monitors during participation in study procedures are the Principal Investigator, Research 
Nurse, or Nurse Practitioner.
8.B. 
Parameters to be monitored: The parameters to be monitored include symptoms 
and signs. During all study procedures, subjects are monitored by clinically credentialed 
personnel of the Clinical Neurocardiology Section (Physician, Registered Nurse, or Nurse 
Practitioner) or authorized personnel of the NIH Clinical Center (e.g., neuroradiologist).
8.C. 
Toxicity criteria to be used: The Protocol requires monitoring of procedures and 
possible symptomatic side effects of NAC or the development of a post-spinal headache. 
The NIH’s Common Terminology Criteria for Adverse Events (version 4.0) will be used. 
The patient is queried about any new symptoms at morning rounds on Day 2 and Day 3 
during NAC treatment. If the patient reports gastrointestinal side effects at the initial 
dose, the dose will be halved. All procedures involving more than minimal anticipated 
risk are administered only by experienced, qualified personnel or personnel.
8.D. 
Criteria for stopping individual procedures: The PI has the discretion of 
stopping individual procedures if the medical or psychological risk outweighs the 
anticipated scientific benefit. 
8.E. 
Criteria for individual subject withdrawal: If a patient develops a post-spinal 
headache requiring a blood patch, the subject is withdrawn. Subjects may refuse certain 
tests or procedures, or may withdraw from participation early, without loss of benefits to 
which they were previously entitled. The Principal Investigator may also exclude a 
subject from further participation, such as in the event of known or suspect falsification 
of medical history information or refusal to undergo planned tests or procedures, without 
loss of benefits to which the subject was previously entitled. If NAC at the initial dose 
produces gastrointestinal symptoms, the dose will be halved; and if the gastrointestinal 
symptoms persist after decreasing the NAC dose, then the patient will be withdrawn from 
the study. If a patient experiences other symptoms that in the opinion of the Principal 
Investigator are the result of NAC, the patient may be withdrawn from the study. If a 
woman becomes pregnant while on study, she will be withdrawn.  
8.E.1. Withdrawal definition: For record-keeping purposes, “withdrawal” refers 
to cessation from any further participation in the study, based on the decision of the 
participant or the Principal Investigator, before the endpoint for participation has been 
reached. The endpoint for participation is after obtaining CSF while the patient is on N-
acetylcysteine. Reaching the study endpoint for participation does not constitute 
withdrawal.


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9. Outcome Measures
In this study outcome is not related to measures of symptoms or signs or a disease but to 
CSF neurochemical findings.
9.A. 
Primary outcome measure
The primary outcome measure is the relative change in CSF Cys-DA levels between pre 
and post-NAC treatment, which is calculated as: the difference of (CSF Cys-DA at pre-
treatment – CSF Cys-DA at post-treatment) divided by CSF Cys-DA at pre-treatment. 
The change will be dichotomized as decrease vs. no decrease with a threshold decrease to 
be determined based on the pilot study of HVs. 
9.B. 
Secondary outcome measures
9.B.1. CSF levels of other biochemicals besides Cys-DA. For instance, CSF Cys-
DOPA/DOPA ratios may provide an index of oxidative stress in central 
catecholaminergic neurons.
9.B.2. Percent decrease in CSF Cys-DA expressed as a continuous variable.
9.B.3. In an exploratory study, NAC may be given at 2,000 mg per day.
9.B.4. In a pilot study, reproducibility of CSF Cys-DA will be assessed in a group 
of HVs studied as inpatients. In this group 2 LPs will be done, separated by 2 days, 
without NAC treatment prior to either LP. The LPs will be done at about the same time of 
day, after ingestion of the same pre-determined meal.   


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10. Statistical Analysis
10.A. Analysis of data/ study outcomes: 
For the primary objective, a one-sample t-test (t-test for dependent means) or Wilcoxon 
signed rank test will be performed to evaluate the difference between pre- and post-NAC 
treatment for CSF Cys-DA. The proportion of the patients with decreased CSF Cys-DA 
levels between pre- and post-NAC treatment will be evaluated by the exact binomial test.
For the secondary objectives, one-sample t-tests (t-tests for dependent means) or 
Wilcoxon signed rank tests will be performed to evaluate the differences between pre- 
and post-NAC treatment for each secondary outcome.
10.B. Power analysis: Based on the results of the study of HVs, a power analysis will 
be outlined and approved by the PIRC. The power analysis will be used to justify altering 
the accrual ceiling for PD patients. The power analysis will be performed using the 
primary outcome, the difference in CSF Cys-DA between pre- and post-NAC treatment. 
A one-sample t-test will be applied to estimate the sample size using the standard 
deviation of the difference calculated from the data in the HVs.  
10.C. Accrual ceiling: Based on power analysis, 10-11 patients with complete datasets 
would be required to achieve the Primary Objective. Considering the possibility of 
withdrawals, 15 subjects would undergo inpatient testing. In the exploratory study, up to 
20 subjects may be needed to test whether NAC at a 2,000 mg per day decreases CSF 
Cys-DA levels. Therefore, the accrual ceiling for patients in the study as a whole is 35.
The pilot study about biological variability of CSF Cys-DA levels in HVs will include up 
to 6 HVs with complete datasets. Dropouts will be replaced. 
Therefore, the total accrual ceiling under the protocol is 35 + 6 = 41 participants. 


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11. Human Subjects Protection
11.A. Subject selection:
11.A.1. Equitability: Participation in this study is offered to eligible subjects, 
without regard to race, ethnicity, sex, disability, nationality, religion, handedness, age, or 
English-language ability. Non-English speakers may be included. In this situation, the 
short-form consent process will be used.
 
11.B. Justification for exclusion of children: PD is a disease of middle aged or elderly 
people.
11.C. Justification for exclusion of other vulnerable subjects: This study does not 
involve pregnant or lactating women, due to the risks involved. Since this research study 
involves more than minimal risk without direct benefit, those who are unable to provide 
informed consent are excluded.
 
11.D. Justification for sensitive procedures: This study does not involve a placebo, 
medication withdrawal, provocative testing, or deception.
11.E. Safeguards for vulnerable populations:
11.E.1. NIH staff employee protections: NIH staff and members of their 
immediate families may participate in this NIH intramural research unless prohibited by 
the NINDS or excluded by the criteria of the study. 
Protections for employees and staff participating in this study include 1) assuring that the 
participation or refusal to participate will have no effect, either beneficial or adverse, on 
the subject’s employment or position at the NIH, 2) giving employees and staff who are 
interested in participating the “NIH Information Sheet on Employee Research 
Participation” prior to obtaining consent, and 3) assuring that there will be no direct 
solicitation of employees or staff. Independent consent monitoring will be provided by 
the NIH HSPU.
The research will be conducted consistent with the Guidelines for the Inclusion of in NIH 
Intramural Research Studies (March, 2012) and the requirements of NIH Policy Manual 
2300-630-3 – Leave Policy for NIH Employees Participating in NIH Medical Research 
Studies https://oma1.od.nih.gov/manualchapters/person/2300-630-3, as set forth in SOP 
14F of the Intramural NIH Human Research Protection Program (HRPP), website 
https://ohsr.od.nih.gov/OHSR/pnppublic.php. 
 
11.E.2. Pregnancy testing: Pregnancy testing is done in all women of child-
bearing potential. 
11.F. Qualifications of investigators


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David S. Goldstein, MD PhD, is the Principal Investigator. He directs the Clinical 
Neurocardiology Section (CNCS) in intramural NINDS. He has been a tenured Senior 
Investigator since 1984 and will be active in all aspects of this study. He obtains consent.
Jamie Cherup, DNP, CRNP, USPHS, is the CRNP of the CNCS. She carries out histories and 
physical examinations, places orders, manages patients, generates notes for medical records, 
and carries out procedures for clinical research protocols of the CNCS. She has substantial 
experience in lumbar puncture to obtain CSF and will be doing this as part of this study. She 
obtains consent.
Irene Dustin, PhD CRNP, USPHS, is a CRNP in the NINDS PD Clinic. She assists with 
recruitment. She does not obtain consent. 
Debra Ehrlich, MD, directs the NINDS PD Clinic. She assists with recruitment. She does not 
obtain consent.
Janna Gelsomino, RN, is the Research Nurse of the CNCS. She is in charge of the Patient 
Observation Room of the CNCS. She assesses protocol eligibility, arranges travel, enters data 
into the CNCS research database, and carries out procedures. She obtains consent.
Codrin Lungu, MD, Staff Clinician, has been the director of the NINDS PD Clinic. He is a 
neurologist with expertise in movement disorders. He knows the workings and patients of the 
PD Clinic and will help recruit patients into this study. He does not obtain consent.
Tianxia Wu, PhD, is a statistician in the Clinical Trials Unit, OCD/DIR/NINDS. She has 
expertise and experience in experimental design and statistics. She will help analyze the data 
from this study. She does not obtain consent.
The Principal Investigator has verified that all individuals working on this protocol 
required to take HRPP training under OHSRP SOP 25 (Training requirements for the 
NIH Human Research Protections Program) have completed all required training.
12. Anticipated Benefit
Protocol subjects benefit indirectly, in that the study is likely to yield generalizable 
knowledge.


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13. Classification of Risk  (for the study as a whole)
13.A. For adults: More than minimal risk.
13.B. For adults without consent capacity: This study does not involve adults without 
consent capacity. 
13.C. For children: This study does not involve children.
13.D. Overall risk and benefit consideration: The risks are reasonable in relation to 
anticipated benefit.


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14. Consent Documents and Process
14.A. Designation of those obtaining consent: Study investigators designated as able 
to obtain consent in section 11.F. above, will obtain informed consent. All study 
investigators obtaining informed consent have completed the NIMH HSPU ‘Elements of 
Successful Informed Consent’ training. 
14.B. Consent procedures: All participants will receive a verbal explanation in terms 
suited to their comprehension of the purposes, procedures, and potential risks of the study 
and of their rights as research participants. Participants will have the opportunity to 
review carefully the written consent form and ask questions regarding this study prior to 
signing. Coworkers will not consent one another.   
14.C. Consent document: The consent form contains all required elements. the consent 
document submitted with this protocol is for patients.
14.D. Short form process for non-English speaking participants: If a non-English 
speaking participant is unexpectedly eligible for enrollment, the NIH Clinical Center 
standard short written consent form in the appropriate language and a written summary of 
what the investigator will say to the participant will be used as part of an oral consent 
process.  The IRB approved English written consent form will serve as the written 
summary if the short form process is used. The investigator will obtain an interpreter 
unless the investigator is fluent in the prospective participant’s language. Preferably, the 
interpreter will be someone who is independent of the participant (i.e., not a family 
member). Interpreters provided by the NIH Clinical Center will be used whenever 
possible. The interpreters will translate the current IRB-approved English version of the 
consent verbatim and facilitate discussion between the participant and investigator. 
The written summary will be signed by the investigator obtaining consent and a witness 
to the oral presentation.  The short written consent form will be signed by the participant 
and a witness who observed the presentation of information.  The interpreter may sign the 
consent document as the witness and, in this case, will note “Interpreter” under the 
signature line. A copy of the signed form will be provided to the participant to take home.
The investigator obtaining consent will document the consent process in the participant’s 
medical record, including the name of the interpreter. Further, all instances of use of the 
short form process will be reported to the IRB at the time of continuing review. If the 
Clinical Center Short Written Consent form is used three times or more for the same 
language within an IRB approval period, this will be reported to the IRB immediately.
Interpreters will also be present for the other protocol procedures as necessary.


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15. Data and Safety Monitoring
15. 
Data and Safety Monitoring
15.A. Data and safety monitor: Data and safety will be monitored by the PI. 
15.B. Data and safety monitoring plan: Parameters to be monitored are those in the 
appended Clinical Investigation Monitoring Form (Appendix 25.I.). At the end of 
study participation, for each protocol participant, the Clinical Investigation Monitoring 
Form is completed and signed by the PI. Data and safety monitoring is conducted at the 
time of de-briefing of each protocol subject prior to discharge. Data and safety 
monitoring for the entire study is conducted via review by the PI of the notebook 
containing the Clinical Investigation Monitoring Forms at 6-month intervals beginning 
from the date of de-briefing of the first protocol participant.  
 
15.C. Criteria for stopping the study or suspending enrollment or procedures: The 
study will be stopped if 2 of the same Serious Adverse Events occur related to NAC 
administration. 


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16. Quality Assurance (QA)
16.A. Quality assurance monitor: The PI and NINDS Quality Assurance Audit 
Committee will monitor the study.
16.B. Quality assurance plan: This protocol will undergo periodic review by the 
NINDS Quality Assurance (QA) Audit Committee as outlined in the NINDS QA 
Standard Operating Procedure (SOP). The purpose of the QA audit is to assess 
compliance with applicable regulatory requirement, good clinical practice guidelines, and 
NINDS policy, as well as to provide recommendations for improving the management of 
clinical research data. The protocol will be audited according to the decision algorithm as 
described in the NINDS SOP. Since the study involves more than minimal risk, the 
protocol will undergo an audit during the first year and then a minimum of every 3 years 
thereafter.


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17. Reporting of Unanticipated Problems, Adverse Events and 
Protocol Deviations
The Principal Investigator is responsible for detecting, documenting, and reporting 
unanticipated problems, adverse events (AEs), including serious adverse events (SAEs), 
and deviations in accordance with NIH policy, IRB requirements, and federal regulations. 
Relatedness to the research of all serious adverse events will be determined by the PI in 
consultation with the CD.
Serious unanticipated problems and serious protocol deviations will be reported to the 
IRB and CD as soon as possible and in writing not more than 7 days after the PI first 
learns of the event. Not serious unanticipated problems and not serious deviations will be 
reported to the IRB and CD as soon as possible and in writing not more than 14 days after 
the PI first learns of the event. Written reports will be submitted in PTMS.
Deaths will be reported to the Clinical Director within 7 days after the PI first learns of 
the event. 
All adverse events, deviations, and unanticipated problems will be summarized and 
reported at the time of Continuing Review.
For reporting purposes, toxicity criteria in the Common Terminology Criteria for Adverse 
Events (CTCAE) will be used.


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18. Alternatives to Participation
In this study, subjects do not receive any treatment to treat symptoms of PD or forego any 
treatment in order to participate in this study. The alternative, therefore, is not to 
participate.
The patients will be taking an MAO inhibitor under the care of their own physicians.
NAC is marketed in the United States as a dietary supplement. Patients can take NAC on 
their own. 
 


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19. Privacy
All research activities will be conducted in as private a setting as possible.


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20. Confidentiality
20.A. For research data and investigator medical records: Procedure notes, medical 
histories and physical examinations, and results of clinical laboratory tests will be kept in 
the subject’s NIH medical chart and handled according to policies and procedures of the 
Medical Records Department, CC, NIH. Data from this protocol will be kept in 
password-protected computers or on electronic media or in data notebooks in offices or 
laboratories of the CNCS that are locked when unoccupied.
20.A.1. De-identified results from this study will be posted on cctrials.gov.
20.B. For stored samples: Samples and data will be stored using codes that assigned 
by the PI or personnel of the CNCS. Data will be kept in password-protected computers. 
Samples will be kept in locked storage. Only study investigators will have access to the 
samples and data.
20.C. Special precautions: Research staff will be trained to respect the privacy and 
confidentiality of NIH employees/staff. Such training may be accomplished through the 
Collaborative Institutional Training Initiative (CITI) course, “Vulnerable Subjects - 
Research Involving Workers/Employees.”


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21. Conflict of Interest
21.A Distribution of NIH guidelines: NIH guidelines on conflict of interest have been 
distributed to all investigators. 
21.B. Conflict of interest: There are no conflicts-of-interest to report for NIH 
investigators. Non-NIH investigators will abide by the conflict-of-interest policies of 
their own institutions.  
21.C. Role of a commercial company or sponsor: There is no commercial sponsor for 
this study.   


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22. Technology Transfer
No technology transfer agreement is in place for this protocol. 
Arbor Pharmaceuticals, LLC may provide NAC for this study under a Material Transfer 
Agreement (MTA), pending review of the IRB-approved protocol. 
23. Research and Travel Compensation
Patients in this study will be paid for time and research-related inconveniences.  
Otherwise eligible patients would likely not participate unless reimbursed, due to the 
demanding protocol regimen and lack of anticipated personal benefit. Although PD is a 
common disease, a rare specific subgroup is required (recent onset, levodopa-untreated, 
MAO inhibitor-treated). 
23.A. Amount of compensation: The maximum total compensation for a given subject 
is $500. A planned Payment Schedule is appended (Appendix 25.J). There is no 
payment for the screening visit. Compensation will be prorated for parts completed if 
subjects do not complete the study. Payment is sent at the end of the study. 
Travel/lodging compensation will be provided. Travel/lodging compensation for a 
medical escort may be provided if deemed necessary for safety by the PI.  
23.B.
NIH employees/staff participants: NIH employees or staff who participate 
during work hours must have permission from their supervisor. NIH employees or staff 
must either participate outside of work hours or take leave in order to receive 
compensation. 


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24. References
(1)
Kish, S.J., Shannak, K. & Hornykiewicz, O. Uneven pattern of dopamine loss in 
the striatum of patients with idiopathic Parkinson's disease. Pathophysiologic and 
clinical implications. N Engl J  Med  318, 876-80 (1988).
(2)
Goldstein, D.S., Kopin, I.J. & Sharabi, Y. Catecholamine autotoxicity. 
Implications for pharmacology and therapeutics of Parkinson disease and related 
disorders. Pharmacol Ther  144, 268-82 (2014).
(3)
Montine, T.J., Picklo, M.J., Amarnath, V., Whetsell, W.O., Jr. & Graham, D.G. 
Neurotoxicity of endogenous cysteinylcatechols. Exp Neurol  148, 26-33 (1997).
(4)
Linsenbardt, A.J., Wilken, G.H., Westfall, T.C. & Macarthur, H. Cytotoxicity of 
dopaminochrome in the mesencephalic cell line, MN9D, is dependent upon 
oxidative stress. Neurotoxicology  30, 1030-5 (2009).
(5)
Kobayashi, H., Oikawa, S. & Kawanishi, S. Mechanism of DNA damage and 
apoptosis induced by tetrahydropapaveroline, a metabolite of dopamine. 
Neurochem Res  31, 523-32 (2006).
(6)
Li, S.W., Lin, T.S., Minteer, S. & Burke, W.J. 3,4-Dihydroxyphenylacetaldehyde 
and hydrogen peroxide generate a hydroxyl radical: possible role in Parkinson's 
disease pathogenesis. Brain Res Mol Brain Res  93, 1-7 (2001).
(7)
Anderson, D.G., Mariappan, S.V., Buettner, G.R. & Doorn, J.A. Oxidation of 3,4-
dihydroxyphenylacetaldehyde, a toxic dopaminergic metabolite, to a semiquinone 
radical and an ortho-quinone. J Biol Chem  286, 26978-86 (2011).
(8)
Jinsmaa, Y. et al. Dopamine-derived biological reactive intermediates and protein 
modifications: Implications for Parkinson's disease. Chem Biol Interact  192, 118-
21 (2011).
(9)
Follmer, C. et al. Oligomerization and membrane-binding properties of covalent 
adducts formed by the interaction of alpha-synuclein with the toxic dopamine 
metabolite 3,4-dihydroxyphenylacetaldehyde (DOPAL). J Biol Chem  290, 
27660-79 (2015).
(10)
Goldstein, D.S. et al. Determinants of buildup of the toxic dopamine metabolite 
DOPAL in Parkinson's disease. J Neurochem  126, 591-603 (2013).
(11)
Burke, W.J., Li, S.W., Williams, E.A., Nonneman, R. & Zahm, D.S. 3,4-
Dihydroxyphenylacetaldehyde is the toxic dopamine metabolite in vivo: 
implications for Parkinson's disease pathogenesis. Brain Res  989, 205-13 (2003).
(12)
Anderson, D.G., Florang, V.R., Schamp, J.H., Buettner, G.R. & Doorn, J.A. 


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Antioxidant-mediated modulation of protein reactivity for 3,4-
dihydroxyphenylacetaldehyde, a toxic dopamine metabolite. Chem Res Toxicol  
29, 1098-107 (2016).
(13)
Goldstein, D.S., Jinsmaa, Y., Sullivan, P., Holmes, C., Kopin, I.J. & Sharabi, Y. 
Comparison of monoamine oxidase inhibitors in decreasing production of the 
autotoxic dopamine metabolite 3,4-dihydroxyphenylacetaldehyde in PC12 cells. J 
Pharmacol Exp Ther  356, 484-93 (2016).
(14)
Elsworth, J.D. et al. Deprenyl administration in man: a selective monoamine 
oxidase B inhibitor without the 'cheese effect'. Psychopharmacology  57, 33-8 
(1978).
(15)
Eisenhofer, G. et al. Simultaneous liquid-chromatographic determination of 3,4-
dihydroxyphenylglycol, catecholamines, and 3,4-dihydroxyphenylalanine in 
plasma, and their responses to inhibition of monoamine oxidase. Clin Chem  32, 
2030-3 (1986).
(16)
Heinonen, E.H., Savijarvi, M., Kotila, M., Hajba, A. & Scheinin, M. Effects of 
monoamine oxidase inhibition by selegiline on concentrations of noradrenaline 
and monoamine metabolites in CSF of patients with Alzheimer's disease. J Neural 
Transm  5, 193-202 (1993).
(17)
Fowler, J.S. et al. Evidence that formulations of the selective MAO-B inhibitor, 
selegiline, which bypass first-pass metabolism, also inhibit MAO-A in the human 
brain. Neuropsychopharmacology  40, 650-7 (2015).
(18)
de la Fuente-Fernandez, R., Schulzer, M., Mak, E. & Sossi, V. Trials of 
neuroprotective therapies for Parkinson's disease: problems and limitations. 
Parkinsonism Relat Disord  16, 365-9 (2010).
(19)
de la Fuente-Fernandez, R., Schulzer, M., Mak, E. & Sossi, V. Trials of 
neuroprotective therapies for Parkinson's disease: problems and limitations. 
Parkinsonism Relat Disord  16, 365-9 (2010).
(20)
Monti, D.A. et al. N-Acetyl Cysteine May Support Dopamine Neurons in 
Parkinson's Disease: Preliminary Clinical and Cell Line Data. PLoS One  11, 
e0157602 (2016).
(21)
Holmay, M.J. et al. N-Acetylcysteine boosts brain and blood glutathione in 
Gaucher and Parkinson diseases. Clin Neuropharmacol  36, 103-6 (2013).
(22)
Katz, M. et al. Cerebrospinal fluid concentrations of N-acetylcysteine after oral 
administration in Parkinson's disease. Parkinsonism Relat Disord  21, 500-3 
(2015).


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(23)
Goldstein, D.S., Holmes, C., Sullivan, P., Jinsmaa, Y., Kopin, I.J. & Sharabi, Y. 
Elevated cerebrospinal fluid ratios of cysteinyl-dopamine/3,4-
dihydroxyphenylacetic acid in parkinsonian synucleinopathies. Parkinsonism 
Relat Disord  31, 79-86 (2016).
(24)
Greene, S.C., Noonan, P.K., Sanabria, C. & Peacock, W.F. Effervescent N-
Acetylcysteine Tablets versus Oral Solution N-Acetylcysteine in Fasting Healthy 
Adults: An Open-Label, Randomized, Single-Dose, Crossover, Relative 
Bioavailability Study. Curr Ther Res Clin Exp  83, 1-7 (2016).
(25)
Deepmala et al. Clinical trials of N-acetylcysteine in psychiatry and neurology: A 
systematic review. Neurosci Biobehav Rev  55, 294-321 (2015).
(26)
Hoffer, M.E., Balaban, C., Slade, M.D., Tsao, J.W. & Hoffer, B. Amelioration of 
acute sequelae of blast induced mild traumatic brain injury by N-acetyl cysteine: a 
double-blind, placebo controlled study. PLoS One  8, e54163 (2013).


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25. Attachments/ Appendices
25.A. Flow Diagrams
25.B.
Eligibility Checklists
25.C. Protocol description for lay people
25.D. Screening questionnaire for Patient Recruitment Office (PRPL)
25.E.
Recruitment ad
25.F.
Recruitment video script
25.G. Weblink ad
25.H. List-Serv ad
25.I.
Clinical Investigation Monitoring Form
25.J.
Payment schedule
25.K. Recruitment flyer
25. L. Text for NINDS Spotlights
25.M
Text for Google AdWords
25.N. Image for Google AdWords


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26. Consent Form (Adult Patient, Adult Volunteer)