Conditions: Human Immunodeficiency Virus (HIV) Nonalcoholic Fatty Liver Disease (NAFLD) Nonalcoholic Steatohepatitis (NASH)
Keywords: Human immunodeficiency virus (HIV) Nonalcoholic fatty liver disease (NAFLD) Nonalcoholic steatohepatitis (NASH) Growth hormone releasing hormone tesamorelin
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 61
Healthy volunteers: no

Brief summary:
Liver disease is one of the leading co-morbidities of human immunodeficiency virus (HIV) infection, and nonalcoholic fatty liver disease (NAFLD) is present in approximately 30-40% of patients with HIV infection. Nonalcoholic steatohepatitis (NASH) is a more severe form of NAFLD in which increased liver fat is also accompanied by inflammation, cellular damage, and fibrosis.

NAFLD is most prevalent in patients who also have increased visceral adiposity, and our group has previously shown that HIV-infected individuals with increased visceral adiposity generally have decreased growth hormone secretion. Tesamorelin is a growth hormone releasing hormone (GHRH) analogue that increases endogenous growth hormone secretion. Tesamorelin is FDA-approved for the reduction of visceral fat in HIV-infected individuals. In a previous study, treatment with tesamorelin in HIV-infected individuals selected for abdominal adiposity reduced liver fat. The current study is designed to test the effect of tesamorelin on liver fat and steatohepatitis in HIV-infected individuals who have NAFLD. The investigators hypothesize that tesamorelin will reduce liver fat and will also ameliorate the inflammation, fibrosis, and hepatocellular damage seen in conjunction with NASH.

Detailed description:

Arms:
arm 1: tesamorelin 2mg subcutaneously daily x 12 months double-blind phase. At the end of 12 months, subjects enter open-label tesamorelin treatment phase for 6 months. arm 2: placebo subcutaneously daily x 12 months double-blind phase. At the end of 12 months, subjects enter open-label tesamorelin treatment phase for 6 months.

Interventions: intervention 1: tesamorelin intervention 2: Placebo
Intervention descriptions: intervention 1: None intervention 2: inactive substance that looks like tesamorelin

Protocol document:
Prot_SAP_000.pdf: 
 
FINAL DETAILED PROTOCOL 
 
Tesamorelin Effects on Liver Fat and Histology in HIV: A Collaborative UO1 Grant 
 
 
 
Protocol Version 6.2, Version Date 6/17/2019 
 
 
 
NCT02196831 
 
 
 


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1.  Title Page 
 
 
DETAILED PROTOCOL 
 
Full Title: 
 
Tesamorelin Effects on Liver Fat and Histology in HIV: A Collaborative UO1 Grant 
 
 
 
Clinical Trial Phase:  N/A 
 
Local Protocol Numbers: 
MGH 2014p-001502 
NIAID  15-I-0036 
 
DAIDS-ES Document Number:  12038 
 
NIAID Funding Mechanism and Principal Investigators: 
Principal Investigators: Steven Grinspoon, MD, and Colleen Hadigan, MD, MPH 
U01-AI115711-01 
 
Other Collaborators: 
Takara Stanley, MD (MGH) 
Martin Torriani, MD (MGH) 
Wendy Henderson, CRNP, PhD (NIH) 
Chia-Ying Liu, PhD (NIH) 
Theo Heller MD (NIH) 
David Kleiner, MD PhD (NIH) 
Joseph Kovacs, MD (NIH) 
 
Pharmaceutical and other Study Support Provided by: 
Study drug and matching placebo provided at discounted cost by Theratechnologies, Inc. 
 
IND Sponsor:  Steven Grinspoon, MD 
 
IND Number:  77,473 
 
Protocol Chair:  Steven Grinspoon, MD 
 
DAIDS Medical Officer/Medical Monitor: Beverly Alston Smith , MD (NIH) 
 
Version Number:  6.2 
 
Version Date:   06/17/2019 
 


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2.  SIGNATURE PAGE:  N/A 
3.  TABLE OF CONTENTS 
 
Table of Contents 
 
Page
4.  KEY ROLES 
3
5.  LIST OF ABBREVIATIONS 
5
6.  PROTOCOL SUMMARY 
7
7.  INTRODUCTION 
9
8.  OBJECTIVES AND STUDY ENDPOINTS
12
9.  STUDY DESIGN 
13
10.  STUDY POPULATION 
13
11.  INTERVENTIONS 
16
12. STUDY PROCEDURES/EVALUATIONS
18
13. ASSESSMENT OF SAFETY
24
14. CLINICAL MANAGEMENT 
29
15. STATISTICAL CONSIDERATIONS
32
16. DATA HANDLING AND RECORD KEEPING
37
17. CLINICAL SITE MONITORING
38
18. HUMAN SUBJECTS PROTECTION
38
19. ADMINISTRATIVE PROCEDURES
44
20. PUBLICATION POLICY 
44
21. REFERENCES
45
22. APPENDICES 
50
 
 


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4.  KEY ROLES   
Steven Grinspoon, MD 
Co-PI, Protocol Chair, and MGH Site PI.  Responsibilities 
include (1) coordinating all progress reports to the NIH; (2) 
maintaining the investigator-initiated IND, including 
submitting annual reports and Serious Adverse Events to 
the FDA as required; (3) registering the trial on 
clinicaltrials.gov, updating the entry as required, and 
reporting results upon completion of the trial; (4) 
supervising the performance of all activities at the MGH 
site, including the performance of clamp and isotope 
studies and liver biopsy, as well as the performance of 
IGF-1 and insulin assays at the MGH core laboratory; (5) 
procuring study drug from Theratechnologies and 
coordinate the shipping and labeling of the drug as well as 
shipping of labeled drug to the NIH pharmacy. 
Phone:  617-724-9109; Email:  sgrinspoon@partners.org 
Colleen Hadigan, MD, 
MPH 
Co-PI and NIH Site PI.  Responsibilities include (1) 
supervising the performance of all activities at the NIH 
site, including recruitment, liver biopsy procedures and 
MRI/MRS; (2) supervising shipping of all histology 
specimens to Dr. Kleiner; (3) supervising the shipment of 
samples to MGH for assay of IGF-1; (4) working with Dr. 
Kleiner to ensure timely completion of histological 
analyses. 
Phone:  301-594-5754; Email:  hadiganc@niaid.nih.gov
David Kleiner, MD, PhD 
Central pathologist for the study.  He will receive all liver 
biopsies and read them in a blinded manner. 
 
 
Takara Stanley, MD 
Co-investigator at MGH.  Responsibilities collaborating with 
Dr. Grinspoon in the recruitment, data collection, and 
performance of study procedures at MGH. In addition, under 
the supervision of Dr. Grinspoon, Dr. Stanley will take 
primary responsibility for monitoring data entry and for 
preparing monthly reports of accrual and retention, data 
integrity, and adverse events for monthly study meetings. 
Martin Torriani, MD 
Central radiologist for the study.  He will receive all liver 
MRS data and interpret the data in a blinded manner. 
Chia-Ying Liu, PhD 
NIH Special Volunteer and Investigator physicist who will 
oversee MRS/MRI acquisition of scans and de-identified 
coded data to MGH for interpretation. 
Hang Lee, PhD 
Study biostatistician (MGH).  Will prepare randomization 
lists, provide statistical consultation as needed throughout 
the study, and oversee analysis of study data per statistical 
analysis plan. 
Theo Heller, MD 
NIH Investigator with the Liver Disease Branch of NIDDK.  
Will serve as the liver expert for the study, available for 
consultation regarding complex liver-related issues. 
Wendy Henderson, PhD 
NIH Investigator with the Behavioral Branch of NINR.  Will 


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serve as the expert in transient elastography (FibroScan) at 
the NIH. 
Zana Blaku, PharmD  
NIH Protocol Pharmacist,  
John Vetrano, PharmD, 
RPh 
MGH Protocol Pharmacist 
Beverly Alston Smith,  
MD,TRP,Complications 
and Co-infections 
Research Branch 
DAIDS Medical Officer 
TRP, Complications and Co-Infections 
DAIDS, NIAID, NIH 
5601 Fishers Lane, 9F50 
Rockville, MD 20852 
Phone:  1-301-435-3773 
Email: balston@niaid.nih.gov 
 
 
 
 


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5.  LIST OF ABBREVIATIONS 
ACC 
Acetyl CoA Carboxylase 
AE 
Adverse Event 
ALT 
Alanine Aminotranferease 
AST 
Aspartate Aminotransferase 
BMI 
Body Mass Index 
CBC 
Complete Blood Count 
CD 
Cluster of Differentiation 
ChREBP 
Carbohydrate Response Element Binding Protein 
CK18 
Cytokeratin 18 
CPT-1 
Carnitine Palmitoyltransferase 1 
CRF 
Case Report Form 
CRP 
C-Reactive Protein 
CVD 
Cardiovascular Disease 
DEXA 
Dual Energy X-ray Absorptiometry 
DNL 
De Novo Lipogenesis 
DSMB 
Data Safety and Monitoring Board 
FAS 
Fatty Acid Synthase 
FATP 
Fatty Acid Transport Protein 
FBG 
Fasting Blood Glucose 
FDA 
Food and Drug Administration 
FFA 
Free Fatty Acid 
GCRC 
General Clinical Research Center 
GGT 
Gamma-Glutamyl Transferase 
GHRH 
Growth Hormone Releasing Hormone 
GHRLD 
Liver-specific Deletion of the Growth Hormone Receptor 
GPAT 
Glycerol-3-Phosphate Acyltransferase 
HbA1c 
Glycated Hemoglobin 
hCG 
Human Chorionic Gonadotropin 
HCV 
Hepatitis C Virus 
HepG2 
Human liver carcinoma cell line 
1H-MRS 
Proton Magnetic Resonance Spectroscopy 
HIV 
Human Immunodeficiency Virus 
HOMA-IR 
Homeostatic Model Assessment of Insulin Resistance 
IATA 
International Air Transport Authority 
IGF-1 
Insulin-like Growth Factor 1 
IL-6 
Interleukin 6 
IND 
Investigational New Drug 
INR 
International Normalized Ratio 
IR 
Insulin Resistance 
IRB 
Institutional Review Board 


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IU 
International Units 
IV 
Intravenous 
LDL 
Low-Density Lipoprotein 
MAQ 
Modifiable Activity Questionnaire 
MGH 
Massachusetts General Hospital 
MI 
Myocardial Infarction 
MRI 
Magnetic Resonance Imaging 
mRNA 
Messenger Ribonucleic Acid 
NAFLD 
Non-Alcoholic Fatty Liver Disease 
NAS 
NAFLD Activity Score 
NASH 
Non-Alcoholic Steatohepatitis 
NIAID 
National Institute of Allergy and Infectious Diseases 
NIH 
National Institutes of Health 
OGTT 
Oral Glucose Tolerance Test 
PAI-1 
Plasminogen Activator Inhibitor 1 
PBMC 
Peripheral Blood Mononuclear Cell 
PI 
Principal Investigator 
PO 
By Mouth 
PPARγ 
Peroxisome Proliferator-Activated Receptor Gamma 
PSA 
Prostate-Specific Antigen 
PT 
Prothrombin Time 
PTT 
Partial Thromboplastin Time 
QD 
Every Day 
RNA 
Ribonucleic Acid 
SAE 
Serious Adverse Event 
sAg 
Surface Antigen 
SC 
Subcutaneous 
SD 
Standard Deviation 
SDR 
Spontaneous Dwarf Rat 
SREBP1c 
Sterol Regulatory Element Binding Protein 1c 
TG 
Triglyceride 
tPA 
Tissue Plasminogen Activator 
TNFα 
Tumor Necrosis Factor Alpha 
TZD 
Thiazoledinedione 
VAT 
Visceral Adipose Tissue 
VLDL 
Very Low Density Lipoprotein 


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6.  PROTOCOL SUMMARY   
 
Full title:  Tesamorelin Effects on Liver Fat and Histology in HIV: A Collaborative UO1 Grant 
 
Short Title:  TESLA 
 
Sample Size:  60 (recruited at MGHand NIH) 
 
Study Population: HIV infected men and women, ages 18-70y, judged to have nonalcoholic 
fatty liver disease (NAFLD) on the basis of liver fat fraction ≥5% on 1H-MRS. 
 
Participating Sites:  Massachusetts General Hospital and National Institutes of Health Clinical 
Center 
 
Study Design:  12 month double-blind, randomized, placebo-controlled phase followed by 6 
month open-label phase. 
 
Study Schema: 
 
 
Schedule of Procedures/Evaluations 
 
Screen visit for eligibility assessment, including 1H-MRS/MRI for quantification of liver fat 
and visceral and subcutaneous abdominal fat area 
 
Baseline visit for laboratory evaluation, liver biopsy, DEXA, transient elastography 
(FibroScan), and, at MGH, stable isotopes for assessment of de novo lipogenesis and 
gluconeogenesis.  Study drug started at conclusion of baseline visit. 
 
Safety visits at 0.5, 3, 6, 9 months for measurement of IGF-1, fasting glucose, AST, and 
ALT.  1H-MRS/MRI also performed at 6 month visit. 
 
12 month visit identical to baseline, with addition of 1H-MRS/MRI.  Open label 
tesamorelin started at conclusion of 12 month visit. 


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 
Safety visits at 12.5 and 15 months for measurement of IGF-1, fasting glucose, AST, 
and ALT. 
 
18 month visit to consist of repeat 1H-MRS/MRI as well as laboratory evaluation and 
transient elastography. 
 
Study Duration:  1 month screening period, 12 month double-blind phase, 6 month open-label 
phase.  Total subject participation anticipated at 19 months from screen visit to conclusion of 18 
month visit. 
 
Study Regimen/Intervention:  Lifestyle counseling throughout for all participants.  First 12 
months:  tesamorelin vs. identical placebo, 2mg subcutaneously daily.  Final 6 months:  open-
label tesamorelin 2mg subcutaneously daily. 
 
Primary Objective:  To determine the effects of tesamorelin (vs. placebo) on liver fat quantity in 
HIV-infected individuals with NAFLD. 
 
Primary Endpoint:  Change in hepatic fat fraction as measured by 1H-MRS after 1 year of 
randomized, double-blind treatment with study drug. 


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7. INTRODUCTION 
7.1  Background Information 
Liver disease is one of the leading co-morbidities of HIV-infection, highly prevalent even 
in those without hepatitis B or C co-infection.  Studies of hepatitis B- and C-negative adults with 
treated HIV demonstrate 20-60% prevalence of elevated liver enzymes [1-4].  Among this 
group, 60-70% of HIV-monoinfected individuals with elevated liver enzymes have non-alcoholic 
fatty liver disease (NAFLD) [5, 6].  NAFLD may also be present in the absence of liver enzyme 
elevation, and, overall, it is estimated to occur in up to 30-40% of patients with HIV [7, 8].   
 
NAFLD is of significant concern in the context of HIV-infection for two reasons.  First, the 
disease spectrum of NAFLD encompasses not only steatosis but also inflammation, 
hepatocellular damage, and fibrosis, which are hallmarks of non-alcoholic steatohepatitis 
(NASH).  NASH, in turn, may progress to cirrhosis and eventual liver failure. NASH is also a 
significant risk factor for hepatocellular carcinoma [9].  Second, NAFLD is strongly associated 
with visceral adiposity and other cardiometabolic abnormalities, including insulin resistance (IR) 
and cardiovascular disease (CVD) [7]. Abundant evidence suggests a causal link between 
NAFLD and IR, and emerging data suggest that NAFLD may also be causal in CVD. Thus, 
understanding NAFLD in HIV and developing strategies to treat it are critical to reduce liver 
disease and ameliorate cardiometabolic risk in this population.    
Accumulation of triglyceride (TG) in the cytoplasm of hepatocytes is the sine qua non of 
NAFLD.  Sources of hepatic TG are (i) dietary fats; (ii) uptake of circulating free fatty acid (FFA), 
mediated by fatty acid transport proteins (primarily FATP2 and FATP5); and (iii) hepatic DNL 
whereby palmitate is synthesized from glucose, particularly during conditions of carbohydrate 
excess [10, 11].  Investigation with stable isotope tracers suggests that approximately 59% of 
hepatic TG are from uptake of circulating FFA, 25% from hepatic DNL, and 15% from the diet 
[10].  We hypothesize that both hepatic FFA flux – and therefore FFA uptake – and hepatic DNL 
are increased in HIV-infected individuals with NAFLD, and, further, that GHRH treatment may 
decrease these two processes and thereby reduce hepatic fat.   
 
Hepatic DNL is stimulated by glucose, acting through carbohydrate response element 
binding protein (ChREBP), and by insulin, acting through sterol regulatory element binding 
protein 1c (SREBP1c).  Activation of these transcription factors increases the expression of 
lipogenic genes, including acetyl CoA carboxylase (ACC) and fatty acid synthase (FAS), both of 
which encode enzymes in the pathway through which glucose is used as a precursor to produce 
palmitate.  Importantly, even in the context of significant hepatic IR, insulin retains the ability to 
promote lipogenesis in the liver [12-14].  This paradoxical preservation of hepatic DNL in the 
context of hepatic and whole body IR is a critical factor promoting NAFLD.  
 
DNL is increased in HIV-infection [15] and in NAFLD [16, 17]. Lambert et al. have 
recently shown that DNL is more than twice as high in those with high liver fat compared to 
controls [16].  Moreover, DNL is significantly positively associated with quantity of intrahepatic 
TG [16].  Importantly, GH administration suppresses hepatic DNL both in animal models [18-22] 
and in individuals with HIV-associated abdominal obesity [23].  The effects of tesamorelin per se 
on DNL have never been investigated.  We hypothesize that one of the mechanisms by which 
GHRH analogue will reduce liver fat is through reduction in hepatic DNL. 
 
Free fatty acids from the circulation comprise approximately 60% of hepatic TG 
accumulation in NAFLD [10], and increased FFA flux plays an important role in the development 
of NAFLD, because of both increased delivery of lipid substrate and the resulting increases in 
oxidative stress and mitochondrial dysfunction due to lipotoxicity [24-29]. Stable isotope studies 
show strong associations between increased adipocyte lipolysis – resulting from impaired 
insulin suppression of lipolysis due to IR – and increased liver TG content [25, 26].  Visceral 
adipose tissue (VAT), which is highly lipolytic and releases FFA directly to the portal circulation, 
may be particularly pathogenic. Quantity of VAT is strongly associated with NAFLD and NASH 


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in both the general population [30, 31] and HIV-infected individuals [7, 8].  In vitro lipolytic 
activity of visceral but not subcutaneous adipocytes is significantly associated with increased 
liver fat [32, 33].  Further, fatty acids derived from visceral fat comprise a significantly greater 
percent of very low density lipoprotein (VLDL) in individuals with fatty liver and IR than in 
controls, suggesting significantly greater hepatic flux of FFA derived from visceral fat in NAFLD 
[26, 34].  We have previously demonstrated that reductions in liver fat were significantly 
associated with reductions in VAT, and we hypothesize that reduction in visceral fat, resulting in 
decreased FFA flux to the liver, is another mechanism whereby GHRH reduces liver fat.   
The pathophysiological mechanisms distinguishing simple steatosis from NASH are not 
yet well understood, but one mechanism thought to play a central role in the development of 
steatohepatitis is alteration in adipokines and inflammatory cytokines consistent with a pro-
inflammatory milieu [27, 35, 36].  In particular, NASH appears to be closely linked to changes in 
adipose tissue production of adipokines and inflammatory cytokines.  In rodent models, a high 
fat diet leads to increased adipose tissue macrophage activation and pro-inflammatory gene 
expression within a few weeks, and the magnitude of these inflammatory changes in adipose 
tissue portends subsequent inflammatory changes in the liver and development of NASH 
several weeks later [37, 38].  In humans, adipose tissue expression of macrophage markers and 
inflammatory cytokines is increased in those with NAFLD, independent of obesity [39, 40].  
Conversely, expression of the insulin sensitizing hormone adiponectin is decreased in NAFLD, 
independent of obesity [40], and adiponectin levels are significantly inversely associated with 
steatosis and features of steatohepatitis [41, 42].  Measurement of circulating adipocytokines 
shows similar results, with elevated TNFα [43] and CRP [44] and decreased serum adiponectin 
in NAFLD and NASH.  In a cohort of 80 individuals with NASH and 29 with simple steatosis, 
adiponectin was significantly reduced in NASH as compared to simple steatosis, suggesting a 
role for adiponectin in preventing steatohepatitis as well as steatosis [43].  Further suggesting a 
role for adiponectin, a model of C57BL/6 mice fed high fat diet showed that treatment with 
adiponectin reverses steatosis and significantly improves inflammation [45].   
 
Its contribution to a pro-inflammatory milieu is another respect in which visceral fat is 
likely central in the etiology of NASH.  Visceral adipose tissue shows significantly higher 
monocyte/macrophage infiltration compared to subcutaneous adipose tissue [46-48], as well as 
significantly increased expression of pro-inflammatory cytokines and reduced expression of 
adiponectin [49-51].  As an example of the contribution of visceral cytokines to hepatic and 
systemic inflammation, Fontana et al. found that portal vein concentrations of IL-6 are 50% 
higher than those in the systemic circulation, presumably due to elevated visceral production of 
IL-6 [52].  In individuals with NAFLD, visceral adipose tissue volume is significantly associated 
with the extent of hepatic inflammation and fibrosis, even after adjusting for both IR and hepatic 
lipid content, suggesting a strong contribution of visceral fat to the pathogenesis of NAFLD [31]. 
Thus we anticipate that VAT reduction achieved with GHRH analogue will be accompanied by 
improvements in circulating adipokines.  We have previously shown that VAT reductions 
achieved with GHRH analogue are significantly associated with increases in adiponectin and 
improvements in fibrinolytic markers tissue plasminogen activator (tPA) and plasminogen 
activator inhibitor 1 (PAI-1) [53, 54].  In the current proposal, we will perform more 
comprehensive analysis of changes in circulating inflammatory cytokines as well as hepatic 
expression of pro-inflammatory genes to better assess changes in inflammation achieved with 
GHRH treatment and associated VAT reduction in a specific HIV population with NAFLD. 
Independent of its effects to decrease VAT, we expect that GHRH analogue will have 
direct effects on hepatic lipid metabolism and inflammation. Indeed, in the large Phase III 
studies leading to FDA approval of tesamorelin to reduce visceral fat, triglycerides levels 
significantly decreased in the tesamorelin vs. placebo-treated subjects (-37±139 vs. +6±112 
mg/dl, P<0.001; net difference 43mg/dL). Abundant data show the importance of the GH-IGF-1 
axis in hepatic lipid metabolism and suggest that deficiencies in this axis increase the risk of 


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hepatosteatosis.  IGF-1 levels are lower in individuals with NAFLD compared to controls [55], 
and, among those with NAFLD, IGF-1 levels are inversely associated with degree of steatosis 
and fibrosis [56-58]. Further, liver IGF-1 mRNA expression is inversely associated with 
histological Kleiner score [56]. Supporting these findings, adults with GH deficiency due to 
hypopituitarism have a significantly higher prevalence of NAFLD than controls, and GH 
replacement improves histological findings associated with NAFLD [59-61].   
 
In vitro and animal models also highlight the significance of the GH-IGF-1 axis in hepatic 
metabolism.  As discussed above, GH suppresses hepatic DNL, and GH and IGF-1 signaling 
may also affect hepatic lipid metabolism and inflammation in other respects.  Mice with liver-
specific GH-receptor knock-out (GHRLD) demonstrate severe hepatic steatosis, in conjunction 
with increased hepatic lipogenesis [62].  These changes are accompanied by upregulation of 
SREBP1c, peroxisome proliferator-activated receptor-γ (PPARγ), and CD36 fatty acid 
transporter, all of which promote hepatic lipogenesis [62].  Adenovirus-mediated rescue of GHR 
expression reverses these changes and normalizes hepatic triglyceride output [62].  In this 
model, IGF-1 treatment did not reverse the phenotype, suggesting important metabolic effects 
of GH independent of IGF-1.  Other studies, however, demonstrate that IGF-1 also plays a 
significant role in hepatic lipid metabolism.  The spontaneous dwarf rat (SDR), which has a 
truncated GH gene resulting in severe GH deficiency, also demonstrates hepatic steatosis and 
fibrosis.  In the SDR model, contrasting with the GHRLD model, treatment with either GH or 
IGF-1 reverses steatosis and fibrosis [63].  On a cellular level, hepatocyte mitochondria in the 
SDR rat are small and irregularly shaped, and mRNA expression of the rate-limiting enzyme for 
β-oxidation, carnitine palmitoyltransferase I (CPT-1), is significantly decreased, whereas hepatic 
expression of glycerol-3-phosphate acyltransferase (GPAT), which catalyzes the first step in TG 
synthesis, is increased, consistent with increased hepatic lipogenesis [63].  Treatment with 
either GH or IGF-1 restores normal mitochondrial morphology and reverses the observed 
changes in gene expression [63].  Further, in vitro data show that treatment of HepG2 cells with 
IGF-1 attenuates the pro-inflammatory effects of IL-6 exposure [56], and gene transfer of IGF-1 
to cirrhotic hepatic tissue decreases fibrosis and improves liver function [64].  Taken together, 
these data demonstrate potentially critical effects of GH and IGF-1 in hepatic metabolism and 
inflammation.  Whereas some of these effects appear to be unique to GH, acting independently 
of IGF-1, others may be IGF-1 mediated.   
 
 
7.2  Rationale  
 
There are currently no highly effective strategies to decrease liver fat in HIV-infected 
patients with NAFLD. In previous work, treatment with a growth hormone releasing hormone 
(GHRH) analogue in HIV-infected individuals with abdominal adiposity reduces liver fat as 
measured by 1H-MRS spectroscopy [65]. The current protocol builds upon these data, 
investigating GHRH analogue in a cohort specifically chosen for NAFLD.    The current protocol 
also investigates mechanisms by which GHRH may reduce liver fat. Mechanistic study is 
particularly critical in the HIV-infected population, as metabolic changes caused by HIV and its 
treatment may mediate the development of NAFLD and NASH in this population.  For example, 
hepatic de novo lipogenesis (DNL) is known to be increased in HIV infection [15] and is also a 
critical pathway underlying NAFLD. Further, many of the mechanisms thought to cause 
progression from NAFLD to NASH – including increased expression of inflammatory cytokines 
and impaired mitochondrial function – are also characteristics of HIV infection, such that HIV-
infection may alter the natural history of NAFLD and increase the risk of progression to NASH. 
The current protocol assesses the effects of GHRH on steatosis, inflammation, and fibrosis at a 
tissue level also assesses effects on mRNA expression of genes involved in substrate 
metabolism.   
 
7.3  Study Hypotheses 


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 
We hypothesize that GHRH analogue will reduce liver fat in patients with NAFLD and 
NASH (Specific Aim 1), and, in conjunction, will reduce inflammation and may improve 
indices of hepatocellular damage and fibrosis (Specific Aim 2).  
 
We hypothesize that GHRH analogue will reduce hepatic de novo lipogenesis and 
expression of pro-inflammatory and pro-lipogenic genes (Specific Aim 3a and 3c).  We 
further hypothesize that reductions in liver fat will result in improved hepatic and 
peripheral insulin sensitivity (Specific Aim 3b). 
 
8. OBJECTIVES  & STUDY ENDPOINTS 
8.1 Primary Objective:  To determine the whether tesamorelin treatment for 1 year reduces 
liver fat quantity compared to placebo treatment for 1 year.   
 
8.2 Secondary Objectives:  To compare the effects of tesamorelin treatment for 1 year 
compared to identical placebo on the following 
a) Hepatic enzymes (AST, ALT, GGT)  
b) histologic features of steatohepatitis (steatosis, inflammation, hepatocellular 
ballooning, and fibrosis) 
c) serum CK-18, a marker of hepatocellular inflammation 
d) hepatic glucose metabolism 
e) hepatic lipid metabolism 
 
8.3 Exploratory Objectives:  N/A 
 
8.4 Primary Endpoint:  Change in hepatic fat fraction, as measured by 1H-MRS, between 
baseline and 12 months.   
 
This primary endpoint is chosen based on known effects of growth hormone to increase 
lipolysis and reduce hepatic de novo lipogenesis and on previous data demonstrating an 
effect of tesamorelin to decrease liver fat as compared to placebo over 6 months of 
treatment.  We hypothesize that changes in liver fat may be associated with improvements 
in steatohepatitis and hepatic substrate metabolism, which will be assessed as secondary 
endpoints. 
 
8.5 Secondary Endpoints: 
a) Change in ALT, AST, and GGT over 12 months 
 
These are chosen as clinically relevant markers of hepatocellular inflammation, 
which we hypothesize will decrease with tesamorelin treatment as compared to 
placebo. 
 
b) Change in histologic scores for steatosis, inflammation, and hepatocellular ballooing, 
and change in histologic staging of fibrosis after 12 months 
 
Examination of histologic features of steatohepatitis is critical to determine the 
effects of tesamorelin on hepatocellular inflammation and fibrosis, beyond its effects 
to reduce liver fat per se.  NAFLD activity score (NAS) will be assessed using the 
sum of subscores for steatosis, inflammation, and hepatocyte ballooning.  Fibrosis 
stage will also be assessed.  These assessments are standard in studies of NAFLD 
and have been developed by Dr. Kleiner and others as tools to assess the effect of 
interventions for NAFLD.   
 


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c) Change in CK-18 after 12 months 
 
CK-18 is expressed by epithelial cells, including hepatocytes, and CK-18 cleavage 
fragments are released during apoptosis.  CK-18 is a well-validated marker of 
nonalcoholic steatohepatitis and will be assessed as a measure of apoptotic activity 
and NAFLD severity.   
 
d) Change in hepatic glucose metabolism as measured by endogenous glucose 
production (EGP) during the fasting state and suppressibility of EGP during low-dose 
insulin clamp (assessed at MGH only) 
 
NAFLD is strongly associated with insulin resistance, and we hypothesize that 
improvements in NAFLD may improve hepatic glucose metabolism, i.e., decrease 
hepatic insulin resistance.  This will be assessed through two measures, namely 
measurement of EGP in the fasting state using stable isotopes and subsequent 
assessment of the suppressibility of EGP in response to “low-dose” insulin clamp. 
 
e) Change in hepatic lipid metabolism as measured by stable isotope measurement of 
de novo lipogenesis, using deuterium incorporation into palmitate (assessed at MGH 
only) 
 
An etiologic contributor to NAFLD is increased hepatic de novo lipogenesis, which is 
increased in HIV infection and thought to be reduced by growth hormone.  We will 
assess whether treatment with tesamorelin decreases hepatic de novo lipogenesis 
using stable isotopes (deuterated water consumption, followed by assessment of 
deuterium enrichment of palmitate). 
 
 
9. STUDY DESIGN 
 
Overall design:  Randomized, placebo-controlled, double blind during first 12 months 
(“double-blind” phase), followed by a 6 month “open-label” phase during which all study 
participants receive tesamorelin.  Double-blind phase has 2 arms:  tesamorelin and 
placebo, with participants allocated in 1:1 ration 
 
Intervention:  tesamorelin 2mg subcutaneously daily vs. identical placebo.  One-time 
dose-reduction to 1mg built in for subjects whose IGF-1 level exceeds 3 standard 
deviations above the mean.  This will be determined by an independent endocrinologist 
who monitors IGF-1 levels of all participants and requests dose reduction if needed.  A 
“dummy” dose-adjustment will be requested for a placebo patient to maintain blinding. 
 
Randomization for double-blind phase is 1:1 allocation, using a permuted block 
algorithm with randomly varying block sizes.  Randomization will be stratified by site and 
use of Vitamin E ≥400 IU daily 
 
Sample size:  60 participants randomized  
 
Duration of each subject’s participation:  18 months  
 
Duration of study (study initiation until last patient, last visit):  36 months 
 
Number of sites:  2 
 
10. STUDY POPULATION 
10.1 
Inclusion/Exclusion Criteria 
10.1.1 60 HIV-infected subjects will be enrolled in this 18 month study. Inclusion criteria:   


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 
Men and women 18-70yo 
 
HIV-infection and treatment with a stable antiretroviral regimen for ≥ 3 months. HIV-
status will be documented with any one of the following: 
 
Documentation of HIV diagnosis in the medical record by a licensed health care 
provider; 
 
OR HIV-1 RNA detection by a licensed HIV-1 RNA assay demonstrating > 1000 
RNA copies/mL; 
 
OR any licensed HIV screening antibody and/or HIV antibody/antigen 
combination assay confirmed by a second licensed HIV assay such as a HIV-1 
Western blot confirmation or HIV rapid multispot antibody differentiation assay. 
NOTE:  A “licensed” assay refers to a US FDA-approved assay, which is required 
for all IND studies. 
 
Hepatic steatosis as demonstrated by liver fat fraction ≥5% on 1H-MRS 
 
Hepatitis C antibody negative, or, if Hepatitis C antibody positive, either:  a) known 
clinical disease, successful therapy ≥1 year prior to baseline and undetectable HCV 
RNA, or b) HCV resolved spontaneously and undetectable HCV RNA.  Hepatitis B 
surface antigen negative at screen visit 
 
For females ≥50yo, negative mammogram within 1 year of baseline visit 
 
If use of Vitamin E ≥400 IU daily (in any formulation), stable dose for ≥6 months prior to 
study. 
10.1.2 Exclusion criteria:   
 
Heavy alcohol use defined as consumption of more than 20g daily for women or more 
than 30g daily for men for at least 3 consecutive months over the past 5 years assessed 
using the Lifetime Drinking History Questionnaire [66, 67];  
 
Use of insulin or thiazoledinediones (TZDs), or HbA1c ≥7%.  Individuals with mild 
diabetes that is well-controlled with diet and/or oral anti-diabetic agents besides TZDs 
will be included.  Use of oral anti-diabetics must have been stable for ≥6 months prior to 
study entry.   
 
Known diabetic retinopathy. 
 
Known cirrhosis, or Child-Pugh score ≥7, stage 4 fibrosis on biopsy, or clinical evidence 
of cirrhosis or portal hypertension on imaging or exam.  If a subject is not known to be 
cirrhotic at screen but is found to be cirrhotic based on the results of liver biopsy at 
baseline, this subject will be referred to a hepatologist for clinical care and will be 
excluded from further participation in the study.  
 
Chronic corticosteroid use except intermittent use of topical steroid creams and/or prior 
short-term physiologic corticosteroid use in the ≤ 6 months prior to baseline visit 
 
Chronic use of methotrexate, amiodarone, or tamoxifen 
 
Known diagnosis of Alpha-1 antitrypsin deficiency, Wilson’s disease, hemochromatosis, 
or autoimmune hepatitis 
 
Use of GH or GHRH within the past 1 year 
 
Change in lipid lowering or anti-hypertensive regimen within 3 months of screening 


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 
HgB < 11.0 g/dL, CD4 < 100 th/mm3, or HIV viral load > 400 copies/mL 
 
Active malignancy   
 
For men, history of prostate cancer or evidence of prostate malignancy by PSA > 5 
ng/mL  
 
Severe chronic illness judged by the investigator to present a contraindication to 
participation 
 
History of hypopituitarism, head irradiation or any other condition known to affect the GH 
axis 
 
Use of physiologic testosterone (men) or estrogen or progesterone (women) unless 
stable use for a year or more prior to study entry 
 
Routine MRI exclusion criteria such as the presence of a pacemaker or cerebral 
aneurysm clip 
 
Weight loss surgery within 1 year before study entry.   
 
For women, positive pregnancy test performed in a CLIA certified laboratory using a test 
with a sensitivity of at least 25mIU/mL, or breastfeeding.  
 
Known hypersensitivity to tesamorelin or mannitol 
 
Unwillingness to abstain from the conception process during the study (i.e., must agree 
not to participate in an active attempt to become pregnant or impregnate, donate sperm, 
or participate in in vitro fertilization) 
 
Unwillingness to use one (for males) or two (for females) reliable methods of 
contraception while engaging in heterosexual intercourse during the study.  Acceptable 
methods for women include hormonal contraception (estrogen/progesterone or 
progesterone-only formulations) if stable for a year or more prior to study entry, 
intrauterine device, or barrier methods (condom, or diaphragm with spermicide).  
Acceptable methods for males include condom use.  This requirement does not apply to 
women who have been post-menopausal for at least 24 consecutive months or have 
undergone surgical sterilization, or to men who have undergone surgical sterilization or 
have documented azoospermia. 
 
Not willing or able to adhere to dose schedules and required procedures per protocol. 
 
Unwilling to agree to use of study samples for related research (criterion for NIH only) 
 
10.1.3 Co-Enrollment Criteria:   
Participants will be asked to inform the study team if they are enrolled in any other research 
studies to determine if it is safe and appropriate for them to enroll in this study. 
 
10.2 
Recruitment Process 
We will recruit patients with HIV infection and known or suspected fatty liver disease.   
 
At NIH, recruitment efforts will be based on existing NIH cohorts following patients with these 
conditions. In addition, NIH will utilize 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.   
 


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At MGH, subjects will be recruited from local primary care, infectious disease, and 
gastroenterology practices as well as community organizations and the MGH Clinical Research 
Program’s Research Subject Volunteer database (RSVP). We anticipate that some subjects will 
be known to have NAFLD or NASH and may already be followed by (and referred from) 
gastroenterologists, whereas other patients may not have a known diagnosis and will be either 
self-referred or referred from their primary care or infectious disease providers due to high 
likelihood of NAFLD or NASH based on clinical factors such as abdominal adiposity and 
elevated transaminases.  For self-referred patients, phone screening will be used to select 
volunteers for screening who have a high likelihood of qualifying for the study based on either 
history of elevated transaminases or significant abdominal adiposity and/or metabolic 
abnormalities. 
 
Participants who are interested in the study will be asked to contact us.  Flyers with our contact 
information will be provided to medical practices for distribution to appropriate patients, and 
flyers will also be sent to community organizations.  In addition, if a physician obtains 
permission from his/her patient for us to contact the patient, then we may contact the patient.   
 
Advertisement of the study in community organizations will increase participation of women and 
minorities.   
 
10.3 
Participant Retention   
Every effort will be made to maintain subject participation by calling participants approximately 
once per month between visits to ensure that they are feeling comfortable with the study drug 
and that they do not have any unanswered questions.  Subjects who wish to discontinue 
participation for any reason will be asked to discuss possible solutions that may allow them to 
continue participation, and subjects will also be reminded that their participation is voluntary and 
they are free to discontinue at any time. 
 
11. INTERVENTIONS 
11.1 
Biomedical Interventions (Study Drug) 
11.1.1 Regimen 
 
Double blind phase (first 12 months):  subjects will receive tesamorelin vs. identical 
placebo, formulated as described below, according to their randomization. 
 
Open label phase (last 6 months):  subjects will receive tesamorelin, formulated as 
described below 
 
Tesamorelin and identical placebo will be provided by Theratechnologies, Inc. (Montreal, 
Canada).  The dose of tesamorelin will be 2 mg SC QD, with provision for a dose 
adjustment to 1mg SC QD if subject’s IGF-1 is ≥3 (see below and Section 14.4.1).  All 
doses will be self-administered by the subject, after s/he receives instruction in 
reconstitution and administration and demonstrates competence in self-injection. Dosing 
is based on prior studies of this compound in HIV-infected patients with fat accumulation 
in which GHRH1-44 at 2mg significantly reduced visceral fat, improved lipid parameters, 
while achieving a generally physiologic increase in IGF-I of 80% vs. placebo over 6 
months [54].  
 
Dose adjustment:  If a subject who is receiving tesamorelin in either the double-blind 
phase or open-label phase has an IGF-1 z-score ≥3, a dose reduction to 1mg will be 
performed.  If the subject is in the double-blind phase, this will be accompanied by a 
dummy dose reduction for a placebo subject in order to maintain blinding, as described 
in 14.4.1.  If the subject’s next IGF-1 level shows z-score ≥3, s/he will be discontinued 
from the study.  If the next IGF-1 z-score is <3, the subject will continue in the study at 


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the 1mg dose.  Dose reductions will remain in place for the remainder of the subject’s 
participation in the study. 
 
11.1.2 Study Product Formulation and Preparation 
A three month supply of tesamorelin or identical-appearing placebo will be dispensed at each 
study visit. The dose of study drug is 2mg subcutaneous daily, which requires administration of 
two reconstituted vial of medication.  Each vial of tesamorelin contains 1.1mg, which are 
reconstituted to provide 1mg dose.  Each vial of placebo contains 55 mg of mannitol. Subjects 
will be instructed to refrigerate the vials between 36-46° F, and will be expected to dilute, mix, 
and administer daily injections of the study drug or placebo. Dr. Grinspoon holds an IND for the 
use of GHRH1-44 in HIV lipodystrophy (IND 77,473, S. Grinspoon) that has been amended to 
include this protocol.  GHRH1-44 (Tesamorelin) has been approved by the FDA for use in HIV 
lipodystrophy.  Medication adherence will be assessed by vial count and medication diary.   
 
Patients will receive detailed instruction regarding proper storage and self-administration of the 
study agent in accordance with the manufacturer’s product information. 
 
11.1.3 Device Studies:  N/A 
 
11.1.4 Study Product Supply and Accountability   
Tesamorelin and identical placebo will be procured from Theratechnologies, Inc. (Montreal, 
Canada).  Medication will be dispensed by the MGH and NIH Research Pharmacies.  A three 
month supply of medication will be dispensed to patients at the baseline, 3, 6, 9, 12, and 15 
month visits.  Medication and supplies dispensed will be as follows: 
 
190 vials of study drug, comprising a 95 day supply 
 
100 vials of sterile water, to be used to reconstitute study drug.  A total of 2.2 cc of sterile 
water is used for the reconstitution of the medication in both vials, and 2cc solution is 
withdrawn and administered. 
 
100 3cc syringes with 18 gauge, 1.5 inch needles.   
 
100 additional 18 gauge, 1.5 inch needles 
 
95 27 gauge, ½ inch needles 
 
Box of alcohol swabs 
 
Sharps container 
 
Cooler with 2 ice packs for transporting medication home 
 
Study drug diary 
At each dispensation, the subject’s identity will be confirmed using 2 identifiers that match the 
prescription labeling, and the randomization number will also be verified.  The number of vials 
provided will be recorded, along with the Lot # for the medication and, if applicable, kit and/or 
box #s as well.   
 
The MGH and NIH research pharmacies will receive vials of tesmorelin and placebo from 
Theratechnologies.  The pharmacies will be able to identify which vials are active vs. placebo, 
but this will not be apparent to investigators or subjects by inspecting the vials.       
 
Subjects will be asked to return used and unused medication at the 3, 6, 9, 12, 15, and 18 
month visits.  The number of used and unused vials will be recorded prior to destruction of used 
and unused drug. 
 


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Each site will keep track of study drug supply on hand, as well as study drug dispensed to each 
patient.  Overall accountability for this will be shared by the investigator and the research 
pharmacy, with specific responsibilities delegated by the investigator at each site. 
 
11.1.5 Assessment of Participant Adherence   
Participants will be asked to keep a study drug diary in which they record their daily injections 
and/or note if an injection was missed.  The number of missed injections will be tallied as a 
measure of adherence.  Independently, the count of used study drug vials, as compared to the 
expected number of used vials, will also be used as a measure of adherence.   
 
11.1.6 Concomitant Medications and Procedures  
All concomitant prescription medications taken during study participation will be documented in 
CRIMSON (NIH) or the written CRF (MGH). For this protocol, a prescription medication is 
defined as a medication that can be prescribed only by a properly authorized/licensed clinician. 
Medications to be reported in CRIMSON or the CRF are concomitant prescription medications, 
over-the-counter medications, and non-prescription medications taken at the time of adverse 
events (all grades). 
 
11.1.7 Permitted Medications and Procedures  
Subjects will be asked to discuss all new medications or procedures with study investigators.      
Unless specified below, medications and medical procedures will generally be permitted as long 
as there is no concern for participant safety.   
 
11.1.8 Precautionary Medications and Procedures  
Tesamorelin has not been shown to have significant drug-drug interactions in clinical studies to 
date. Theoretical interactions may affect the metabolism of other drugs that are metabolized by 
CYP450.  Concomitant medications will be recorded at each visit, and subjects will be carefully 
monitored.   
 
11.1.9 Prohibited Medications and Procedures  
Treatment with insulin or thiazoledinediones (TZDs); chronic corticosteroid use except 
intermittent use of topical steroid creams and/or prior short-term physiologic corticosteroid use 
in the ≤6 months prior to baseline visit; chronic use of methotrexate, amiodarone, or tamoxifen; 
use of GH or GHRH within the past 1 year; or use of physiologic testosterone (men) or estrogen 
or progesterone (women) unless stable for 1 year prior to study participation will not be 
permitted unless discussed with and approved by the study team.  
 
11.1.10 
Required Medications:  N/A   
 
11.1.11 
Rescue Medications:  N/A 
 
11.2 
 Behavioral Intervention 
All subjects will be counseled in standard lifestyle modification using standard recommendations 
for reduced dietary saturated fat (< 7%) and cholesterol intake (< 300 mg/day), and 150 minutes 
of activity equivalent to brisk walking a week [68, 69].  Please see Appendix A for the schedule 
of planned counseling sessions. 
 
12. STUDY PROCEDURES/EVALUATIONS 
 
12.1 
Clinical Procedures and Evaluation (Please also see Appendix A, Schedule of 
Events) 


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All subject encounters will take place at the MGH GCRC or the NIH Clinical Center. All female 
subjects will have a pregnancy test at each visit.  All subjects will receive standard nutrition 
counseling at baseline and every 6 months thereafter. 
 
12.1.1 Evaluation of Preliminary Eligibility 
Preliminary eligibility will be determined based on study staff interviews of interested subjects 
over the phone. Eligible subjects will then be scheduled for a screening visit.  
 
12.1.2 Informed Consent 
Written informed consent will be signed prior to screening evaluation and testing by a licensed 
physician investigator. Subjects will be informed that they may withdraw from participation in the 
study at any point. 
 
12.1.3 Screen Visit (to determine eligibility) 
 
Informed consent 
 
Detailed H&P and medications (past and current), Lifetime Drinking History assessment 
 
Blood sampling (AST, ALT, creatinine, total bilirubin, PT (and INR) and PTT, CBC, CD4, 
HbA1c, HIV viral load, Hepatitis B sAg, Hepatitis C antibody*, PSA (male subjects).  
*Positive Hep C antibody patients will be tested for HCV RNA.   
 
1H-MRS/MRI of abdomen for quantification of liver fat and to exclude abnormal liver 
lesions. (This scan will also be used to assess VAT for those eligible subjects 
participating in the baseline visit.)   
 
12.1.4 Randomization and Subsequent Visits    
Eligible subjects will return for 9 visits.  After signing consent and, prior to the baseline visit, 
subjects will be randomized in a 1:1 ration to receive GHRH1-44 2mg SC QD versus identical-
appearing placebo as above.  Randomization will be stratified by study site and vitamin E use 
≥400 IU daily of any formulation.  Permuted block randomization will be performed by an MGH 
biostatistician, with randomization lists distributed to the MGH and NIH pharmacies.  Study staff, 
investigators, and subjects will be blinded to assignment.  During the first 12-month treatment 
phase, subjects will have visits at baseline, 2 weeks, and months 3, 6, 9 and 12. After month 12, 
all patients will receive open label GHRH regardless of their original randomization. Subsequent 
visits will take place at months 12.5, 15 and 18 months.  Subjects seen at MGH will receive 
stable isotope study and euglycemic hyperinsulinemic clamp in addition to other study 
procedures.  
 
12.1.5 Baseline assessment:  The baseline assessment will be completed within 3 months of 
the screening visit.  In order to complete all of the procedures in the baseline 
assessment, subjects may come for up to 3 different visits, all of which should take place 
within a 2 week period.  Subjects will begin the study drug upon completion of the 
baseline assessment, and subsequent visits will be timed according to the day study 
drug is started. 
 
H&P 
 
Fasting labs:  IGF-I, AST, ALT, GGT, alkaline phosphatase, lipid panel including direct 
LDL, frozen serum for adiponectin, IL-6, CRP, CK18, and other relevant inflammatory 
biomarkers, as guided by the histological results 
 
Height, metabolic weight, anthropometrics 
 
Whole body DEXA scan for regional fat 
 
4-day food record and Modifiable Activity Questionnaire 
 
OGTT 


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 
Transient elastography (“FibroScan”) 
 
Liver biopsy. Biopsy will not be done if performed in the 6 months prior to baseline and, 
in the interval since biopsy, no new treatment initiated and no weight change ≥8% of 
baseline weight 
 
Peripheral blood mononuclear cells (PBMCs) will be processed and stored 
 
Subjects at MGH will receive stable isotopes and clamp for metabolic assessment (see 
below). 
 
12.1.6 Safety Visits  
At 0.5, 3, 6, 9, 12.5, and 15 months:  (1) interval H&P; (2) fasting glucose, AST, ALT, IGF-1.  At 
6 month only: 1H-MRS/MRI of abdomen for quantification of liver fat and VAT 
 
12.1.7 12-month visit  
Identical to baseline visit (including liver biopsy) but excluding (1) collection of PBMCs and 
including (1) HbA1c, CD4+, CBC, and HIV viral load; (2) 1H-MRS for quantification of liver fat 
and MRI of abdomen for quantification of VAT that were obtained at the screening visit  
 
12.1.8 18 month visit 
 
Interval history, H&P 
 
Fasting labs:  IGF-I, AST, ALT, GGT, alkaline phosphatase, lipid panel including direct 
LDL, HbA1c 
 
Height, weight, anthropometrics 
 
Whole body DEXA scan for regional fat 
 
1H-MRS for quantification of liver fat, MRI of the abdomen for quantification of VAT 
 
Transient elastography 
 
4-day food record and Modifiable Activity Questionnaire 
 
OGTT 
 
12.2 
Laboratory Evaluations  
12.2.1 Specimen Preparation, Handling, and Shipping  
Blood samples drawn during visits will have 1 of 3 possible dispositions:  (1) assay through 
NIH/MGH lab services; (2) central assay, for IGF-1 levels only, requiring sample shipment; (3) 
processing and frozen storage for later analysis.  Samples of liver tissue will be sent to Dr. 
David Kleiner at NIH; those samples gathered at MGH will require shipment.  Samples will be 
handled using universal precautions and only by individuals who have had biohazard training.  
Samples that require shipment will be shipped only by individuals who have IATA training in 
biohazard shipment, and shipment will follow all IATA regulations.  All protocol specimens will 
be shipped using packaging that meets requirements specified by the International Air Transport 
Association Dangerous Goods Regulations for UN 3373, Biological Substance, Category B, and 
Packing Instruction 650. Culture isolates, if obtained in this study, are to be shipped as specified 
for UN 2814 Category A Infectious Substances. 
 
12.2.2 Biohazard Containment   
Transmission of HIV and other blood borne pathogens can occur through contact with 
contaminated needles, blood, and blood products. Respiratory pathogens such Mycobacterium 
tuberculosis (MTB) are transmitted by inhalation of droplet nuclei. Appropriate blood, secretion, 
and respiratory precautions will be employed by all personnel in the collection of clinical 
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currently recommended by the Centers for Disease Control and Prevention in the United States, 
the WHO internationally and the National Institutes of Health.  
 
12.2.3 Total Blood Volume  
The total blood drawn for subjects completing the study is equivalent to approximately 730 cc 
over a period of 18 months for those subjects in the subset receiving euglycemic 
hyperinsulinemic clamp and stable isotopes at MGH, and approximately 540cc over 18 months 
for those at NIH (where clamp/isotope will not be performed).  The maximum amount of blood 
drawn at any given visit will be approximately 170cc, which will be drawn at the baseline and 12 
month visits.  A total of 730cc (less than 2 blood donations) over 18 months does not pose 
excessive risk to patients, nor does withdrawal of up to 170cc at a single timepoint.   
 
Patients with a hemoglobin < 11 g/dL will be excluded from the study.  
 
The amount of blood drawn for research purposes will be within the limits allowed for adult 
subjects at the NIH Clinical Center (Medical Administrative Series Policy M95-9 Guidelines for 
Limits of Blood Drawn for Research Purposes in the Clinical Center: http://cc-
internal.cc.nih.gov/policies/PDF/M95-9.pdf).  The amount is also within Partners Human 
Research Committee guidelines (MGH IRB). 
 
12.3 
Study Methods 
12.3.1 1H Magnetic Resonance Spectroscopy(MRS) & MRI 
After a 12-hour overnight fast subjects will undergo 1H -MRS of the liver.  A breath-hold true fast 
imaging with steady precession sequence will be obtained.  A voxel measuring 20 x 20 x 20 mm 
(8 ml) will be placed within the right lobe of the liver, avoiding vessels or artifact, and with 
position within the liver confirmed by 3 planes of view.  1H -MRS data will be acquired using 
point-resolved spatially localized spectroscopy pulse sequence without water suppression. For 
abdominal visceral and subcutaneous fat volumes, conventional MR images will be acquired 
and will serve as anatomic reference of 1H-MRS overlays. Image series will include Axial T1-
weighted localizers.  No intravenous contrast will be used.  The total amount of time in the 
magnet will be approximately 1 hour.  A subset of patients at the NIH (no more than 5) may be 
offered an opportunity for a repeat validation scan to establish test-retest reliability and will be 
compensated an additional $50 for this procedure.   Proton density fat fraction will be calculated 
from integral lipid and water peak areas as previously described [70, 71].  The imaging 
procedure will be identical at both the MGH and NIH sites. Dr. Torriani will read all the MRS 
scans centrally at MGH, including data sent from MRS scans obtained at NIH, to ensure 
uniformity in the assessment hepatic fat by MRS across both sites.  
 
12.3.2 Transient Elastography 
Liver stiffness will be determined using transient elastography.[72].  At least ten measurements 
will be made using the M-probe according to the manufacturer’s recommendations and the 
median will be expressed in kilopascal (kPa) units.  If measurements from the M-probe are 
unsuccessful at the baseline assessment, the XL probe may be used at the operator’s 
discretion.  Use of the XL probe at baseline will be noted, and the XL probe will also be used for 
subsequent assessment of that subject. 
 
12.3.3 Liver Biopsy  
Following MRS/MRI, a percutaneous liver biopsy will be performed under ultrasound guidance 
using an 18-gauge needle by experienced interventional radiologists.  Participants with any 
contraindication to liver biopsy, including platelets < 75,000, elevated PT or PTT, or chronic use 
of aspirin or other anti-platelet agents will not undergo biopsy.  Use of other anti-coagulants will 


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be considered and managed on a case-by-case basis by the site PI in conjunction with the 
physician performing the biopsy and the subject’s primary care physician.  Subjects will not be 
asked to discontinue necessary therapeutic medications such as warfarin in order to undergo 
biopsy.  Individuals on aspirin may undergo biopsy following discontinuation of aspirin for ≥7 
days.  Resumption of anti-coagulants will be under the direction of the interventional radiologist 
performing the procedure.  A maximum of 3 passes will be performed during the biopsy.  A 
biopsy fragment will be fixed in 10% formalin. These will be sent to the NIH for central review by 
Dr. David Kleiner using standard histopathologic techniques.  Semi-quantitative scoring will use 
validated scoring systems, including the modified Histologic Activity Index [73] and NASH 
Clinical Research Network scoring system [74].  If sufficient tissue exists, a second fragment will 
be placed in an RNA stabilization reagent (RNAlater, Qiagen) for gene expression analysis.  
Microarray of liver tissue will be used to study the expression of inflammation, fibrosis and 
metabolism related genes in liver tissue.   
 
12.3.4 Genetic Analysis   
PBMC’s will be stored and analyzed for single nucleotide polymorphisms that may affect liver fat 
content.  This analysis will be performed at the NIH. 
 
12.3.5 Oral Glucose Tolerance Test 
75 g Oral Glucose Tolerance Test will be performed with sampling for insulin and glucose at 0, 
30, 60, 90, and 120 min.  
 
12.3.6 Whole Body DEXA will be performed to determine total body and regional percent fat 
and lean body mass.  The technique has a precision error (1 SD) of 3% for fat and 1.5% for lean 
body mass[75]. Trunk, extremity and trunk to extremity ratio will also be assessed [76, 77].  
 
12.3.7 Nutritional Analysis  
Four day food record at baseline, 12 months, and 18 months will be analyzed for protein, 
carbohydrate, fat, micronutrient, dietary supplements and alcohol intake (Nutrition Data 
Systems).  
 
12.3.8 Anthropometric Measurements  
Measurements of waist to hip ratio, leg circumference, arm circumference, shoulders, back of 
neck, and neck circumference will be performed using a standardized technique [78]. 
 
12.3.9 Activity  
Modifiable Activity Questionnaire (MAQ) will be used to assess physical activity [79].   
 
12.3.10 
History and Physical Examination 
The initial history, performed at the screening visit, will consist of a comprehensive review of 
the subject’s medical history, including any previous surgical procedures and any previous 
significant medical conditions.  A comprehensive review of systems will also be performed.  A 
detailed medication history will be taken.  Subjects will specifically be asked about any previous 
use of growth hormone or growth hormone releasing hormone, as well as antiretroviral 
medication history.  Allergies and all current medications will be recorded.  Interval history, 
performed at all subsequent visits, will consist of questioning subjects about any new medical 
issues or any noted changes in health, as well as any symptoms of developing or worsening 
diabetic retinopathy.  The most recent medication list will be reviewed with subjects to assess 
for any changes in dosing, new medications, or medication discontinuation.  Physical 
examination will consist of a review of vital signs obtained by nursing staff as well as 
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abdomen (palpation and auscultation), and extremities (visualization and palpation).  Additional 
elements of the physical examination may be performed at the investigator’s discretion.     
 
12.3.11 Stable Isotopes and Clamp  Subjects who participate at the MGH will undergo stable 
isotope and euglycemic hyperinsulinemic clamp studies, in order to assess the following:  de 
novo lipogenesis (stable isotopes), hepatic insulin sensitivity (stable isotopes and low dose 
clamp to measure insulin suppression of gluconeogenesis), and peripheral insulin sensitivity 
(“full” dose clamp).  Assessment of hepatic gluconeogenesis and de novo lipogenesis will utilize 
6,6-2H-glucose and deuterium oxide stable isotopes, respectively.  Two intravenous (IV) 
catheters will be inserted:  (1) one placed in the hand when access is available, otherwise in the 
forearm or antecubital space, to be used for venous sampling; (2) one placed in the antecubital 
space or proximal forearm and used for administration of stable isotopes, insulin, and 20% 
dextrose as below.  Starting at 7am, 1g/kg of deuterated water will be consumed PO and a 
priming dose (3.0 mg/kg) of 6,6-2H-glucose will be administered intravenously, followed by a 
continuous infusion (0.03 mg/kg/min) of 6,6-2H-glucose until 11am.  Baseline fasting samples 
for isotopic analysis will be collected at -20, -10, and 0 minutes.  Samples will be collected at 60, 
100, 110, and 120 minutes for 6,6-2H-glucose enrichment for assessment of fasting 
gluconeogenesis. At 120 minutes, a “low dose” euglycemic hyperinsulinemic clamp will be 
performed with an insulin dose of 20 mU/m2/min to detect differential suppression of hepatic 
gluconeogenesis.  Blood will be sampled for isotopic enrichment of 6,6-2H-glucose at 180, 220, 
230, and 240 minutes.  At 240 minutes, a “full dose” insulin clamp will commence with an insulin 
infusion of 80mU/m2/min. Blood will be sampled for deuterium incorporation into palmitate at 
340, 350, and 360 minutes.  Samples for isotopic enrichment will be assayed by Metabolic 
Solutions.   Although DNL occurs in both liver and adipocytes, measured DNL will reflect largely 
hepatic DNL because DNL plays only a minor role in adipose tissue metabolism [17] and does 
not significantly contribute to circulating FFA.  Peripheral insulin sensitivity will be determined 
during the last 20 minutes of the full dose clamp using the DeFronzo method [80].   
Clamp procedure will be as follows.   
 
Insulin infusate will be prepared by the MGH pharmacy. 
 
The hand/forearm with the IV that will be used for venous sampling will be placed in a 
warming box for the duration of the clamp procedure, although it may be withdrawn if the 
subject finds the warmth uncomfortable.   
 
At time “120” (approximately 10am), a priming dose of 100mU/m2/min of insulin will be 
given for 2 minutes followed by a continuous infusion of 20mU/m2/min for the next 118 
minutes, comprising the “low dose” clamp.   
 
At 240 minutes (approximately 12pm), the dose of insulin will be increased to a priming 
dose of 400mU/m2/min for 2 minutes followed by a continuous infusion of 80mU/m2/min 
from 240-360 minutes, comprising the “full dose” clamp.   
 
From 0-240 minutes, a sample (≤ 0.5cc) of venous blood will be drawn every 5 minutes 
for assessment of glucose using a Hemocue glucose analyzer.  Each sample is run 
twice in the Hemocue analyzer, with an additional third run if the difference between the 
first two runs is ≥4mg/dL.  Samples for serum insulin concentration will be drawn at 
times 120, 200, 220, 240, 320, 340, 360. 
 
Starting at 125 minutes (5 minutes after commencing insulin infusion), a variable 20% 
dextrose infusion will be administered to achieve a target glucose of 90mg/dL (range 85-
95mg/dL).  The rate will be adjusted by the investigator, an MD or NP who is trained in 
clamp procedure.  The initial infusion rate of 20% dextrose will be 0-30cc/hr, with the 
exact rate determined by the investigator based on the subject’s fasting glucose, 
available clinical information, and, if available, data from the subject’s previous clamp 
procedure for the study.  (For example, a subject who is known clinically to be insulin 


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resistant and has a fasting glucose of 110mg/dL would be started at a rate of 0cc/hr, 
whereas a lean, muscular subject who exercises regularly and has a fasting glucose of 
70mg/dL would be started at 30cc/hr.) 
 
The rate of 20% dextrose infusion will be adjusted up or down for the duration of the 
clamp procedure by the investigator.  Rate changes of 0-40cc/hr will be made by the 
investigator every 5 minutes, based on the subject’s venous glucose and rate of change 
in glucose, to achieve target glucose of 90mg/dL.   
 
At 360 minutes, the insulin infusion will be discontinued, and the glucose infusion will 
continue for 30 more minutes.  During this time, subjects will be given a meal.  At 390 
minutes, venous glucose will be checked, and the glucose infusion will be discontinued if 
venous glucose ≥80mg/dL.  If glucose is <80mg/dL, the glucose infusion will be 
continued and will be weaned by the investigator at the bedside, with repeat venous 
glucose sampling every 10 minutes until the glucose is ≥80mg/dL and the infusion is 
stopped.   
 
After the clamp, all subjects are counseled concerning the symptoms of hypoglycemia 
and are asked to report immediately any symptoms.  Subjects are observed on the CRC 
for at least 20 minutes following discontinuation of glucose infusion.   
 
12.4 
Schedule of Procedures/Evaluations:  Timing and Definitions   
12.4.1 Screening:  The period that commences at the signing of informed consent and ends 
when subjects are either (1) informed that they are not eligible for participation; (2) informed that 
they are eligible but decline participation; or (3) informed that they are eligible, choose to 
participate, and are scheduled for a baseline assessment and randomized.   
 
12.4.2 Enrollment:  For IRB purposes, participants who sign a consent form are considered to 
be enrolled.  However, the sample size of 60 refers to the number of individuals who screen, are 
eligible, choose to participate, and are randomized to treatment. 
 
12.4.3 HIV Counseling and Testing:  Individuals will not be invited to screen for the study unless 
they are known to have HIV infection.  Thus HIV counseling and testing will not take place under 
this protocol. 
 
12.4.4 Follow-Up:  Please see description of follow-up visits in section 12.1 
 
12.4.5 Early Termination Visit:  Subjects who end the study early will be asked come for a study 
termination visit (please see Appendix A). 
 
12.4.6 Pregnancy Visit:  Every effort will be made, both through absolute eligibility criteria and 
ongoing counseling about contraception and risk for participating women of child-bearing age, to 
prevent pregnancy during the study.  Should pregnancy occur, a participant would be asked to 
discontinue the medication immediately and to come for a visit in order to discuss the situation 
with the Site PI.  Such participants would also be asked to remain in contact with the PI and 
study team through the completion of the pregnancy in order to document the outcome. 
 
12.4.7 Other Visits:  Aside from the visits described in this section and in 12.1, no other visits 
are anticipated. 
 
12.4.8 Final Study Visit:  Please see description of 18 month visit above.  Subjects who leave 
the study early will be asked to come for an early termination visit in lieu of their next scheduled 
study visit as discussed above. 


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13. ASSESSMENT OF SAFETY   
13.1 
Safety Assessment Overview 
Assessment of safety will be performed by a study investigator at each visit, with subjects asked 
to describe any changes or adverse effects that they have noted since the previous study visit.  
In addition, subjects will be repeatedly asked to call the study team if they experience any 
adverse effects, have any new medical conditions, start any new medications, have any 
procedures, or require hospitalization, such that safety can be monitored between study visits.  
All adverse events will be collected and reported as described below.  The Co-PI’s (Hadigan 
and Grinspoon) will periodically review adverse events, and the study will also be monitored by 
the NIAID and the FDA, as the protocol is conducted under an IND for tesamorelin (77,473 to 
S.Grinspoon). 
 
13.2 
Adverse Event Procedures and Reporting Requirements  
At each contact with the subject, information regarding adverse events will be elicited by 
appropriate questioning and examinations and will be:  
 
immediately documented in the subject’s medical record/source document, 
 
recorded on the Adverse Event Case Report Form (AE CRF) or electronic database, and 
 
reported as outlined below (e.g., IND Sponsor, IRB). 
 
13.2.1 Definitions 
Adverse Event (AE) 
An adverse event is any untoward or unfavorable medical occurrence in a human subject, 
including any abnormal sign (e.g., abnormal physical exam or laboratory finding), symptom, or 
disease, temporally associated with the subject’s participation in the research, whether or not 
considered related to the research. 
 
Adverse Reaction (AR) 
An adverse event that is caused by an investigational agent (drug or biologic). 
 
Suspected Adverse Reaction (SAR) 
An adverse event for which there is a reasonable possibility that the investigational agent 
caused the adverse event. ‘Reasonable possibility’ means that there is evidence to suggest a 
causal relationship between the drug and the adverse event. A suspected adverse reaction 
implies a lesser degree of certainty about causality than adverse reaction which implies a high 
degree of certainty. 
 
Serious Adverse Event (SAE) 
A Serious Adverse Event is an AE that results in one or more of the following outcomes: 
 
death 
 
a life threatening (i.e., an immediate threat to life) event 
 
an inpatient hospitalization or prolongation of an existing hospitalization 
 
a persistent or significant incapacity or substantial disruption of the ability to conduct normal 
life functions 
 
a congenital anomaly/birth defect 
 
a medically important event* 
 
* Medical and scientific judgment will be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately life 


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threatening or result in death or hospitalization but that may jeopardize the subject or may 
require intervention to prevent one of the other outcomes listed above.  
 
Unexpected Adverse Event 
An AE is unexpected if it is not listed in the Investigator’s Brochure or Package Insert (for 
marketed products) or is not listed at the specificity or severity that has been observed.  It is the 
responsibility of the IND Sponsor to make this determination. 
 
Serious and Unexpected Suspected Adverse Reaction (SUSAR) 
A SUSAR is a Suspected Adverse Reaction that is both Serious and Unexpected.   
 
Unanticipated Problem (UP) 
An Unanticipated Problem is any event, incident, experience, or outcome that is 
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 and 
informed consent document; Investigator’s Brochure or other study documents; and 
b. the characteristics of the subject population being studied; and 
2. possibly, probably, or definitely related to participation in the research; and 
3. places subjects or others at a greater risk of harm (including physical, psychological, 
economic, or social harm) than was previously known or recognized. (Per the IND Sponsor, 
an AE with a serious outcome will be considered increased risk.) 
 
Unanticipated Problem that is not an Adverse Event (UPnonAE) 
Unanticipated problem that is not an Adverse Event (UPnonAE): An unanticipated problem that 
does not fit the definition of an adverse event, but which may, in the opinion of the investigator, 
involve risk to the subject, affect others in the research study, or significantly impact the integrity 
of research data.  Such events would be considered a non-serious UP. For example, we will 
report occurrences of breaches of confidentiality, accidental destruction of study records, or 
unaccounted-for study drug. 
 
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 a Serious Adverse Event 
or compromises the safety, welfare or rights of subjects or others. 
 
Non-compliance: The failure to comply with applicable NIH 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 participants 
b. Decreases potential benefits to participants 
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. 


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13.2.2 Investigator Reporting Responsibilities to the IND Sponsor  
 
Adverse Events 
Line listings, frequency tables, and other summary AE data will be submitted to the IND 
Sponsor when needed for periodic safety assessments, review of IND annual reports, review of 
IND safety reports, and preparation of final study reports. 
 
Serious Adverse Events 
All SAEs (regardless of relationship and whether or not they are also UPs) must be reported to 
the IND Sponsor within 1 business day of site awareness. Any SAE submitted to the FDA will 
also be submitted to the DAIDS Clinical Representative within 24 hours of FDA notification.  
SAEs that are unexpected and deemed to be possibly related to the study drug will also be 
reported to both IRBs, regardless of the site at which they occur.   
 
Unanticipated Problems 
Unanticipated Problems that are also adverse events must be reported to the IND Sponsor and 
the DAIDS Clinical Representative no later than 7 calendar days of site awareness of the event. 
UPs that are not AEs are not reported to the IND Sponsor. 
 
Pregnancy 
Pregnancy itself is not an AE. However, complications of pregnancies are AEs and may be 
SAEs. Pertinent obstetrical information for all pregnancies will be reported to the IND Sponsor 
via fax or email within 3 business days from site awareness of the pregnancy.   
 
Pregnancy outcome data (e.g., delivery outcome, spontaneous or elective termination of the 
pregnancy) will be reported to the IND Sponsor within 3 business days of the site’s awareness. 
 
In the event of a pregnancy, the DSMB and the IRB will be notified. The participant will  
 
Discontinue the study agent 
 
Withdraw from the study but continue in follow-up for safety 
 
Be advised to notify her obstetrician of study agent exposure 
 
13.2.3 Reporting Procedures to the NIAID IRB  
 
Expedited Reporting to the NIAID IRB 
 
Serious and non-serious Unanticipated Problems, deaths, serious deviations, and serious or 
continuing non-compliance will be reported within 7 calendar days of investigator awareness. 
Serious Adverse Events 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. 
 
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 serious adverse events that are possibly, probably, or definitely related to 
the research 
- 
Serious adverse events that are not related to the research 
- 
All adverse events, except expected AEs and deaths granted a waiver of reporting.  
- 
Serious and Non-Serious Protocol deviations  


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- 
Serious, continuing, and minor non-compliance 
- 
Any trends or events which in the opinion of the investigator should be reported 
 
13.2.4 Reporting Procedures to the MGH IRB 
Partners Human Research Committee policy dictates the following reporting procedures. 
 
Expedited Reporting to the MGH IRB 
 
The following will be reported within 7 calendar days of investigator awareness: 
 
Internal adverse events that are unexpected, and related or possibly related to the 
research and that indicate there are new or increased risks to subjects 
 
External adverse events that are serious, unexpected, and related or possibly related to 
the research and that indicate there are new or increased risks to subjects that require 
some action (e.g., modification of the protocol, consent process, or informing subjects) 
 
Deviation from the approved research protocol or plan without IRB approval in order to 
eliminate apparent immediate hazard to subjects or harm to others 
 
Deviation from the approved research protocol or plan that placed subjects or others at 
an increased risk of harm regardless of whether there was actual harm to subjects or 
others 
 
Breach of confidentiality or violation of HIPAA (e.g., lost or stolen laptop) 
 
Medication, procedural or laboratory error (e.g., errors in drug administration or dosing, 
surgical or other procedure, or testing of samples or test results) regardless of whether 
subjects experienced any harm 
 
Interim analysis, safety monitoring report, publication in a peer-reviewed journal, or other 
finding that indicates that there are new or increased risks to subjects or others or that 
subjects are less likely to receive any direct benefits from the research 
 
Change in FDA labeling (e.g., black box warning), withdrawal from market, manufacturer 
alert from the sponsor, or recall of an FDA-approved drug, device, or biologic used in the 
research 
 
Complaint by/on behalf of a research subject that indicates that the rights, welfare, or 
 
safety of the subject have been adversely affected or that cannot be resolved by the 
 
investigator 
 
Incarceration of a research subject during participation in research that is not approved 
for involvement of prisoners as subjects 
 
Noncompliance with applicable regulations or requirements or determinations of the IRB 
identified by the research team or others (e.g., FDA Form 483 or Warning Letter) that 
indicates that the rights, welfare, or safety of subjects have been adversely affected 
 
Suspension or termination of the research, in whole or in part, based on information that 
indicates that the research places subjects at an increased risk of harm than previously 
known or recognized (e.g., FDA clinical hold) 
 
Suspension or disqualification of an investigator by FDA, sponsor, or others 
 
Scientific misconduct  
 
Any other problem that indicates that the research places subjects or others at an 
increased risk of harm or otherwise adversely affect the rights, welfare or safety of 
subjects or others.  
 
Annual Reporting to the MGH IRB  
The following items will be reported to the MGH IRB in summary at the time of Continuing 
Review: 
- 
Serious and non-serious unanticipated problems  


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- 
Expected serious adverse events that are possibly, probably, or definitely related to 
the research 
- 
Serious adverse events that are not related to the research 
- 
All adverse events 
- 
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 
 
13.2.5 Follow-up of Adverse Events and Serious Adverse Events 
AEs that occur following enrollment of the subject (by signing the informed consent) 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 (e.g., the subject is lost to 
follow-up), the reason a final outcome could not be obtained will be recorded by the investigator 
on the AE CRF (if the CRF is still open).  
 
SAEs that occur after the study follow-up period that are reported to and are assessed by the 
Investigator to be possibly, probably, or definitely related must be reported to the IND Sponsor, 
as described above. 
 
14. CLINICAL MANAGEMENT   
 
Clinical Management of Adverse Events 
If a diagnosis is clinically evident (or subsequently determined), the diagnosis rather than the 
individual signs and symptoms or lab abnormalities will be recorded as the AE. 
 
All AEs occurring from the time the informed consent is signed through the study follow-up 
period will be documented, recorded, and reported. 
 
The Investigator will evaluate all AEs with respect to Seriousness (criteria listed above), 
Severity (intensity or grade), and Causality (relationship to study agent and relationship to 
research) according to the following guidelines.  
 
Severity 
The Investigator will grade the severity of each AE according to the “Division of AIDS Table for 
Grading fhe Severity of Adult and Pediatric Adverse Events” Version 2.0, November, 2014, 
which can be found at:   
https://rsc.niaid.nih.gov/clinical-research-sites/daids-adverse-event-grading-tables   
   
 
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 adverse events. 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 
 
Uric Acid (males): 8.7-10.0 mg/dL  
 


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Causality    
Causality (likelihood that the event is related to the study agent)  will be assessed 
considering the factors listed under the following categories:  
 
Definitely Related 
   
 
reasonable temporal relationship 
 
follows a known response pattern 
 
clear evidence to suggest a causal relationship 
 
there is no alternative etiology 
 
Probably Related 
 
 
reasonable temporal relationship 
 
follows a suspected response pattern (based on similar agents) 
 
no evidence of a more likely alternative etiology 
 
Possibly Related 
 
 
reasonable temporal relationship 
 
little evidence for a more likely alternative etiology 
 
Unlikely Related 
 
 
does not have a reasonable temporal relationship  
OR 
 
good evidence for a more likely alternative etiology 
 
Not Related 
 
 
does not have a temporal relationship 
         
OR 
 
definitely due to an alternative etiology 
 
Note: Other factors (e.g., dechallenge, rechallenge) should also be considered for each 
causality category when appropriate. Causality assessment is based on available information at 
the time of the assessment of the AE. The investigator may revise the causality assessment as 
additional information becomes available. 
 
14.1 
Other Disease Events  
Occurrence of other disease events will be immediately brought to the attention of the Site PI.  
The participant’s clinical care providers will be contacted to discuss his/her participation in the 
study and to discuss whether or not the study drug should be discontinued, either temporarily or 
permanently, and whether or not the participant can safely continue in the protocol.  
   
14.2 
Pregnancy  
 Women able to bear children will be repeatedly counseled about the risks of pregnancy during 
the study and the importance of contraception, and women will be instructed to immediately 
discontinue the study drug if they suspect pregnancy.  If a participant becomes pregnant during 
the study, she will 
 
Discontinue the study agent 
 
Withdraw from the study but continue in follow-up for safety 
 
Be advised to notify her obstetrician of study agent exposure 
 
14.3 
Criteria for Discontinuation  


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14.3.1 Criteria for Permanent Intervention Discontinuation for an Individual Participant 
The criteria for permanent discontinuation of further study intervention for an individual 
participant are 
 
Fasting glucose >150mg/dL, or >180 mg/dL for individuals with known type 2 diabetes at 
study entry,  at any visit, confirmed by re-draw 
 
Erythema and/or pruritis extending ≥3cm beyond the immediate injection site, indicating 
allergic reaction 
 
Pregnancy 
 
Active malignancy 
 
Evolving medical condition (e.g., progressive liver disease, acute critical illness) such 
that continued participation in the study may incur risk will also be discontinued.   
 
Significant symptoms of GH excess felt to be related to the study drug 
 
IGF-1 level that remains ≥ 3 standard deviations above the mean following a dose 
adjustment 
 
Development or worsening of retinopathy 
 
Clinical conditions, which in the best judgment of the investigator are believed to be 
harmful or potentially life-threatening to the participant, even if not felt to be related to the 
study drug and/or not addressed in the AE management section of the protocol. 
 
Request by participant to terminate study product(s)/intervention(s) 
 
14.3.2 Criteria for Premature Study Discontinuation for an Individual Participant  
The criteria for premature discontinuation from the study for an individual participant are:  
 
Lost to follow up as evidenced by failure by the participant to attend a safety visit after 
multiple attempts at rescheduling, at the discretion of the site investigator  
 
Request by participant to withdraw  
 
Request of the primary care provider if s/he thinks the study is no longer in the best 
interest of the participant  
 
Participant judged by the investigator to be at significant risk of failing to comply with the 
provisions of the protocol as to cause harm to self or seriously interfere with the validity 
of study results  
 
14.4 
Toxicity Management 
In the event of noted side effects, treating physicians will provide whatever available treatment 
is considered best to protect patient safety and well-being; compliance with study requirements 
will not compromise such treatment.  Guidelines for the management of known side effects of 
tesamorelin that do not require immediate discontinuation of study drug are as follows. 
 
14.4.1 Elevated IGF-1:  IGF-1 will be checked at each visit, and results will be reviewed by an 
independent endocrinologist at MGH who has the randomization code for both study 
sites.  If a subject receiving tesamorelin has an IGF-1 z-score of ≥ 3, the endocrinologist 
will contact the site investigator to recommend a dose-decrease of study drug to 1mg 
daily.  If the subject is in the double-blind phase of treatment, the independent 
endocrinologist will simultaneously recommend a dose decrease for a placebo subject 
from the same site whose visit was temporally closest to the visit of the tesamorelin 
subject requiring dose reduction.  Dose reductions should be enacted within 1 month of 
the IGF-1 level being drawn.  Any dose reductions taking longer than this will be 
reported as protocol deviations.  If a tesamorelin subject continues to have IGF-1 z-
score ≥ 3 following dose reduction, the subject will be discontinued from the study.    
14.4.2 Injection site reaction:  A mild degree of non-pruritic swelling and mild erythema at the 
site of the injection that resolves within a few hours is relatively common with 


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tesamorelin and does not necessarily represent a hypersensitivity reaction.  Subjects 
who present with this reaction will be asked to monitor for resolution and to let the study 
investigator know of any spread beyond the injection site or any pruritis, either of which 
may represent hypersensitivity.  Erythema and pruritis extending >3cm beyond the 
injection site will be treated as a likely hypersensitivity reaction.  If this is accompanied 
by any systemic symptoms such as shortness of breath or swelling suggestive of 
anaphylaxis, subjects will be discontinued from the study immediately and will be 
directed to immediate care.  If the erythema and pruritis are not accompanied by any 
systemic symptoms, subjects will be asked to hold the study drug until resolution of the 
symptoms.  At the study investigator’s discretion, the subject may restart study drug 
once to determine if the reaction recurs.  With recurrence, subjects will be discontinued 
from the study. 
14.4.3 Joint pain:  Joint pain of varying severity is a possible side effect of tesamorelin.  For 
mild joint pain, subjects will be offered the choice of continuing the study drug or 
discontinuing the medication to see if the joint pain resolves.  If joint pain resolves with 
discontinuation and thus is presumably related to tesamorelin, the subject may elect to 
discontinue or to continue in the study with careful monitoring as long as the joint pain is 
mild.  Lack of resolution will prompt referral to the subject’s usual care providers for 
further evaluation.  For moderate to severe joint pain, i.e., pain that interferes with sleep 
or affects physical function, subjects will be asked to discontinue the study drug to 
determine if the joint pain resolves.  If the joint pain resolves and thus is presumably 
related to tesamorelin, subjects will be discontinued.  If joint pain does not resolve, 
subjects will continue to hold the study drug and will be referred to their usual care 
providers for evaluation.  If an alternate etiology is found, subjects may elect to resume 
study drug. 
14.4.4 Peripheral edema:  Peripheral edema will be carefully assessed at baseline, as many 
subjects may have some degree of edema.  If peripheral edema worsens during the 
study, subjects will be asked to have evaluation with their regular care provider for 
possible etiologies (cardiac, renal), with the understanding that an increase in edema 
may also be due to study drug.  If no other etiology is found and if the edema does not 
interfere with physical function, the subject may continue in the study with careful 
monitoring if s/he wishes.   
14.4.5 Hyperglycemia/glucose intolerance:  Fasting glucose will be checked at every visit.  For 
any fasting glucose of >150mg/dL, or >180 mg/dL for individuals with known type 2 
diabetes at study entry, subjects will be contacted to arrange a re-draw.  If fasting 
glucose persists >150mg/dL, or >180 mg/dL for individuals with known type 2 diabetes 
at study entry, subjects will be discontinued.  Subjects without diabetes at study entry 
who develop fasting glucose >126mg/dL but <150mg/dL during the study, or any 
subjects who are found to have increases in HbA1c or adverse changes in glucose 
tolerance, will be reminded that tesamorelin may contribute to increased blood sugar 
and will receive additional counseling regarding limiting caloric intake.  They will also be 
asked to discuss their glucose control with their regular care provider.  Such subjects 
may continue in the study if they wish, with continued monitoring of glucose per protocol.   
14.4.6 Malignancy:  There is no evidence linking tesamorelin to the development of or 
worsening of malignancy.  Nonetheless, there is theoretical concern that increasing 
growth hormone levels may promote tumor growth.  Consequently, subjects with active 
malignancy will not be allowed in the study, and subjects with any new malignancy 
discovered during the study will be discontinued from the study.        
 
15. STATISTICAL CONSIDERATIONS 
15.1 
Overview and General Design Issues  


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Examination of data from the double-blind study phase, comparing changes between 
tesamorelin and placebo groups after 12 months, will comprise the primary statistical analysis.  
The final 6 month open-label phase of the study is designed to improve subject retention and to 
gather longer-term safety data.   
 
15.2 
Study Endpoints 
15.2.1 Primary Endpoint:  change in hepatic fat fraction as measured by 1H-MRS after 1 year of 
randomized treatment.   
15.2.2 Secondary endpoints will include changes in the following:  overall NAS score; fibrosis 
stage and NAS scores for ballooning degeneration, inflammation, and steatosis;  
transient elastography measurement; AST and ALT; fasting lipids; fasting insulin, 
glucose, HOMA-IR; adiponectin and markers of inflammation and cellular injury including 
circulating CK-18 and hepatic mRNA expression of IL-6 and TNFα; and, in a subset, 
hepatic DNL and gluconeogenesis.   
15.2.3 Exploratory endpoints:  none 
 
15.3 
Study Aims and Hypotheses 
Specific Aim 1:  Tesamorelin will significantly decrease liver fat in HIV-infected 
patients with NAFLD.  We hypothesize that, after 12 months, compared to placebo 
a) tesamorelin will significantly decrease hepatic fat fraction as measured by 1H-MRS 
(primary endpoint). 
b) improvements in hepatic fat fraction will be reflected in reductions in steatosis as 
assessed by histological examination of liver biopsy. 
 
Specific Aim 2:  Tesamorelin will reduce inflammation and improve histological 
findings.  We hypothesize that a significant proportion of our patients will demonstrate 
histologically confirmed NASH on biopsy and that after 12 months, compared to placebo, 
a) tesamorelin will improve hepatocellular ballooning and reduce inflammation on liver 
biopsy. 
b) tesamorelin will reduce fibrosis on liver biopsy, and as measured by transient 
elastography (e.g. FibroScan®). 
c) expression of pro-inflammatory genes in the liver will be reduced, and adiponectin 
expression will increase. 
d) tesamorelin will significantly decrease AST and ALT. 
 
Specific Aim 3:  Reduction in liver fat with tesamorelin will be associated with 
beneficial changes in hepatic glucose and lipid metabolism. 
a) tesamorelin will decrease hepatic de novo lipogenesis as measured by stable isotopes. 
b) reduction in liver fat will be associated with improved hepatic insulin sensitivity, as 
measured by hepatic gluconeogenesis in the fasting and hyperinsulinemic states, and 
peripheral insulin sensitivity. 
c) hepatic expression of lipogenic genes will decrease. 
 
15.4 
Sample Size Considerations 
In our previous study of GHRH in HIV, the change in liver fat over 6 months among individuals 
who started with hepatic fat fraction >5% was -2.5 ± 11.9 lipid-to-water percent in placebo vs. -
9.1 ± 7.6 lipid-to-water percent in tesamorelin.  Based on the prior data, we assumed that the 
pooled standard deviation of the 1 year change is 11%. Using this data we estimate that an 
initial sample size of 60 will provide 82% power to detect a clinically relevant treatment 
difference of 9.4% or larger 1 year mean changes in liver fat (lipid to water %) at α = 0.05 if the 


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discontinuation rate is 20% (48 evaluable patients), or 80% power if the discontinuation rate is 
25%. For secondary variables collected at both sites, the sample size will provide 85% power to 
determine a 0.89 SD difference in 1 year mean changes between treatment groups at α = 0.05 
with 48 evaluable patients, which is considered a clinically meaningful effect size. For example, 
we will have 85% power to detect a change of 7 U/L in AST and 8 U/L in ALT.  Power will be 
lower for secondary assessment of insulin sensitivity assessed by euglycemic clamp and stable 
isotopes, performed only at MGH. 
 
15.5 
Stratification/Randomization/Blinding Procedures/Unblinding Procedures  
 
Randomization will be stratified by site (NIH or MGH) and vitamin E use (≥400 IU 
daily or not) 
 
Randomization lists will be prepared by an MGH biostatistician (Hang Lee, PhD) 
using 1:1 treatment allocation, using a permuted block algorithm with randomly 
varying block sizes 
 
Dr. Lee will send the site specific randomization lists to the NIH and MGH research 
pharmacies.   
 
Randomization procedure: 
o   Eligible participants who have a baseline visit scheduled will be randomized 
in the 1-2 weeks prior to the baseline visit, so that the research pharmacy can 
prepare their study drug.   
o At the time of randomization, study staff will assign the next randomization 
number in sequence and write this in the randomization form as well as on 
the prescription sent to pharmacy.  (e.g., numbers 101, 102, then 103 will be 
assigned sequentially for subjects at MGH who are not using Vitamin E.)   
o Upon receiving a prescription for a new participant, the pharmacy will record 
the participant’s name next to the appropriate randomization number on their 
list. 
o Randomization numbers will not be re-used, even if a participant is 
randomized and then fails to come for baseline assessment.  The next 
randomization number in sequence will always be assigned. 
 
Blinding will be maintained, as the only parties who will know the randomization 
assignment of subjects will be the research pharmacists and an independent 
endocrinologist at MGH who reviews IGF-1 levels.  Reports of IGF-1 levels will not 
be made available to study staff, as this would unblind the study.   
 
Should a situation arise in which a subject or subject’s medical provider needed to 
know their treatment assignment for medical reasons, the Site PI would contact the 
appropriate research pharmacy to obtain the randomization assignment.  The PI at 
the other site, as well as the DSMB, will be made aware of the unblinding.   
 
15.6 
Maintenance of Trial Treatment Randomization Codes  
As above, randomization codes will be held by each site’s research pharmacy, and pharmacy 
staff will record participant assignments.  These lists will be distributed to the PIs and other 
study staff only after every participant has completed the double-blind phase of the study, and 
all data have been entered, verified, and locked. 
 
15.7 
Participant Enrollment and Follow-up 
Please see Section 10 for details regarding recruitment and enrollment of participants, and 
please see section 12 for details regarding study visits, including all follow-up visits. 
 
15.8 
Data and Safety Monitoring  


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15.8.1 Planned Interim Analyses and Stopping Guidelines:  N/A 
 
15.8.2 Data and Safety Monitoring Board:   
 
Because this study will generate randomized, blinded data, NIAID intramural policy mandates 
that it be reviewed by the NIAID intramural DSMB.  The DSMB has been constituted to review 
the data and analysis plans of all intramural NIAID clinical studies that require DSMB oversight 
and consists of experts in infectious diseases, biostatistics, and clinical trials.  The DSMB is 
responsible for reviewing the IRB approved protocol, informed consent documents, the data and 
safety monitoring plan, and the stopping guidelines prior to initiation of the study, unless 
otherwise waived by the NIAID Clinical Director.   
  
During the course of the study, the DSMB will review cumulative study data twice per year to 
evaluate safety, efficacy, study conduct, and scientific validity and integrity of the trial.  As part 
of this responsibility, DSMB members must be satisfied that the timeliness, completeness, and 
accuracy of the data submitted to them for review are sufficient for evaluation of the safety and 
welfare of study subjects.  The DSMB will also assess the performance of overall study 
operations and any other relevant issues, as necessary.  The DSMB may also convene outside 
of the biannual meeting if other safety issues arise that the Principal Investigator would like the 
DSMB to address.   
 
Study Pause Criteria: There will be no predetermined stopping criteria based on efficacy or lack 
of efficacy, however if 3 or more similar grade 4 events that are possible, probably or definitely 
related to the study drug, or a single SAE that is possibly, probably or  definitely related to study 
drug are reported, the DSMB will be asked to convene to determine if early stopping is 
warranted.  
 
Items reviewed by the DSMB include:  
 
Interim/cumulative data for evidence of study-related adverse events; 
 
Data quality, completeness, and timeliness; 
 
Demographic information on study subjects; 
 
Site monitoring reports related to adherence to the protocol and applicable regulations; 
 
Factors that might affect the study outcome or compromise the confidentiality of the trial 
data (such as protocol violations, unblinding, etc.); and, 
 
Factors external to the study such as scientific or therapeutic developments that may 
impact subject safety or the ethics of the study. 
   
Prior to opening the study to enrollment, the statistician will provide the DSMB Executive 
Secretary with blinding codes in case the DSMB requires this information to make its 
recommendations.  If the DSMB decides to unblind the safety data, the DSMB Executive 
Secretary will inform the Principal Investigator of the decision in writing or via e-mail as soon as 
possible. 
 
The trial will be conducted in compliance with Title 21 Code of Federal Regulations, the 
International Conference on Harmonization (ICH) Guideline for Good Clinical Practice (GCP) 
and any applicable regulatory requirements.   
 
The Investigator is responsible for assuring that the data collected is complete, accurate, and 
recorded in a timely manner.  Source documentation (the point of initial recording of information) 
should support the data collected and must be signed and dated by the person recording and/or 


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reviewing the data.  Source documents include all recordings of observations or notations of 
clinical activities, and all reports and records necessary for the evaluation and reconstruction of 
the clinical trial.  Source documents include, but are not limited to, the subject's medical records, 
laboratory reports, radiologist's reports, subject's diaries, biopsy reports, progress notes, 
pharmacy records, and any other similar reports or records of procedures performed during the 
subject's participation in the study. 
 
15.8.3 Progress and Safety Monitoring:  Reports on subject accrual and toxicity will be provided 
to the Division of AIDS Clinical Representative every month (or more frequently if 
necessary). In addition, periodic reports of data pooled over arm will be provided to the 
team that details accrual, participant status, delinquency of forms and specimens, and 
toxicity.  
 
15.8.4 Analysis Plan 
The analysis will be based on intention to treat analysis population using all available data, 
including interim data on subjects not completing the study. Wilk-Shapiro test will be used to 
assess for normality of distribution of all variables. For variables measured at baseline, 6 and 12 
months in the study, including the primary endpoint of liver fat by MRS, we will analyze the 
longitudinal data including 0, 6, and 12 month data using general linear mixed effects modeling 
for which the subject level intercept will be random, and effects of treatment group, time, time x 
treatment group will be random, and a compound symmetry error covariance structure will be 
considered. The longitudinal treatment effect between tesamorelin and placebo will be 
examined by testing for time x treatment group interaction. The same statistical methods will be 
applied to the analyses of other endpoints performed at repeated time points in the study.  If 
there is evidence that any of the outcomes is not normally distributed, we will choose a proper 
transformation for normalization before the mixed effects model analyses. For variables 
assessed at baseline and 1 year in the study, including changes in DNL and gluconeogenesis, 
and liver histology, the effect of tesamorelin vs. placebo will be assessed first using a two-
sample t-test to compare the mean changes or Wilcoxon Rank Sum test if not normally 
distributed. Following primary analyses to assess treatment effect, we will perform adjusted 
analyses to assess whether covariates may have influenced apparent treatment effects.  We 
anticipate that some patients will have simple steatosis and some will have steatohepatitis on 
biopsy, and secondary stratified analyses will be performed for these subgroups.  We will also 
perform secondary stratified analyses by those with vs. without elevation in transaminases.  We 
also anticipate using gender, age, change in caloric intake, and change in BMI as covariates, as 
these may be potential confounders of hepatic steatosis. We will also carefully assess changes 
in physical activity, Vitamin E use, and macronutrient composition between the groups.  If any 
subject demonstrates dramatic changes in physical activity or diet during the course of the 
study, we will consider secondary sensitivity analyses excluding such subjects.  
We expect that the pattern of any missing data will be at random (MAR), and the 
longitudinal mixed effects model approach utilizing all available observation will provide 
unbiased effect size estimates. However, we will perform sensitivity analyses if the dropout rate 
is higher than expected or differs between groups. We will initially consider applying the last 
observation carried forward (LOCF) as a conservative approach. We will also consider multiple 
imputations (MI) based analysis. 
 
For the 6-month open-label extension, hepatic fat on MRS and relevant secondary 
endpoints including HOMA-IR and OGTT, fibrosis as assessed by transient elastography, and 
AST and ALT will be determined.  Although the primary purpose of the 6-month open label 
extension is to increase recruitment and retention, analysis of data from the group receiving 
tesamorelin for 18 months will provide information regarding whether reductions in liver fat 
translate into sustained longer-term improvements in transaminases, glucose homeostasis and 


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liver fibrosis as measured by transient elastography.  We will use paired t-test to compare data 
for subjects initially randomized to tesamorelin at 12 and 18 months, to assess whether there 
were additional changes beyond 12 months of continued treatment and, if so, if these changes 
represented continued benefit or reversal of benefit.  The extension will also provide longer-term 
safety data in this group. 
 
16. DATA HANDLING AND RECORDKEEPING 
16.1 
Data Management Responsibilities  
At NIH, Dr. Hadigan is responsible for assuring that the data collected are complete, accurate, 
and recorded in a timely manner.  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. Data entry into CRIMSON will be performed by authorized individuals.  
 
At MGH, Dr. Grinspoon is responsible for assuring that the data collected are complete, 
accurate, and recorded in a timely manner.  Study data will be maintained in a written CRF and 
collected directly from subjects during study visits and telephone calls, or will be abstracted from 
subjects’ medical records. MGH will also maintain a deidentified study database into which data 
from both MGH and NIH subjects will be entered.  Data entry will be performed by authorized 
individuals. The NIH site will enter data into REDCAP and periodically send de-identified data to 
MGH for maintenance of this database. 
 
16.2 
Essential/Source Documents and Access to Source Data/Documents  
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.  These will be kept 
at each site in subjects’ study binders, which will stored in a locked and secured location, or 
electronically in the form of scanned documents.  If stored electronically, access to the storage 
location will be protected by password. For regulatory purposes, individuals from the FDA, NIH, 
and each site’s IRB may access these documents for inspection.  The regulatory monitors will 
also access these documents for inspection (see Section 17). 
 
16.3 
Quality Control and Quality Assurance  
The Site PIs (Hadigan and Grinspoon) will audit study charts and review data collection 
periodically to check for completeness.  At monthly meetings with the PI’s, Dr. Stanley (Co-I, 
MGH) will report on the completeness of the de-identified database to ensure timely and 
complete entry and troubleshoot any issues.  
 
The investigator is responsible for retaining all essential documents listed in the ICH Good 
Clinical Practice Guideline. Study records will be maintained by the Investigator for a minimum 
of 3 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. Should the investigator wish to assign the study 
records to another party and/or move them to another location, the investigator must provide 
written notification of such intent to OCRPRO/NIAID with the name of the person who will 
accept responsibility for the transferred records and/or their new location. NIAID must be 
notified in writing and written NIAID/OCRPRO permission must be received by the site prior to 
destruction or relocation of research records. 


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17. CLINICAL SITE MONITORING  
As per ICH-GCP 5.18 and FDA 21 CFR 312.50, clinical protocols are required to be adequately 
monitored by the study sponsor. This study monitoring will be conducted according to the 
“NIAID Intramural Clinical Monitoring Guidelines.” Monitors under contract to the 
NIAID/OCRPRO and NIAID/DAIDS will visit the NIAID and MGH clinical research sites to 
monitor aspects of the study in accordance with the appropriate regulations and the approved 
protocol. The objectives of a monitoring visit will be: 1) to verify the existence of signed informed 
consent documents and documentation of the informed consent process for each monitored 
subject; 2) to verify the prompt and accurate recording of all monitored data points, and prompt 
reporting of all SAEs; 3) to compare CRIMSON data abstracts (NIH) or written CRF’s (MGH) 
with individual subjects’ records and source documents (subjects’ charts, laboratory analyses 
and test results, physicians’ progress notes, nurses’ notes, and any other relevant original 
subject information); and 4) to help ensure investigators’ are in compliance with the protocol. 
The monitors also will inspect the clinical site regulatory files to ensure that regulatory 
requirements (Office for Human Research Protections-OHRP, FDA) and applicable guidelines 
(ICH-GCP) are being followed. During the monitoring visits, the investigator (and/or designee) 
and other study personnel will be available to discuss the study progress and monitoring visit. 
 
The investigator (and/or designee) will make study documents (e.g., consent forms, CRIMSON 
data abstracts or CRFs) and pertinent hospital or clinical records readily available for inspection 
by the local IRB, the FDA, the site monitors, and the NIAID staff, for confirmation of the study 
data.  
 
A specific protocol monitoring plan will be discussed with the Principal Investigator(s) and study 
staff prior to enrollment. The plan will outline the frequency of monitoring visits based on such 
factors as study enrollment, data collection status, and regulatory obligations. 
 
18. HUMAN SUBJECTS PROTECTIONS 
18.1 
Institutional Review Board/Ethics Committee 
The protocol has been approved by the Partners Human Research Committee (MGH IRB) and 
the NIH NIAID IRB, and research will be conducted with oversight from these IRBs.  Each site 
PI will be responsible for reporting of study progress, AEs, protocol deviations, and other 
necessary reporting per the requirements of each site’s IRB.   
 
18.2 
Vulnerable Participants  
18.2.1 Pregnant women and fetuses are not included in this research. Pregnant women are 
excluded from this study because the effects of tesamorelin on the developing human 
fetus are unknown with the potential for teratogenic effects.   
18.2.2 Prisoners are not included in this research.  Should a study participant become newly 
incarcerated during participation in the study, the PIs will consult their IRBs for guidance. 
18.2.3 Children are not included in this research.  Because there are insufficient data regarding 
dosing or adverse events available in adults to judge the potential risk in children, 
children are excluded from participation in this study. 
 
18.3 
Informed Consent 
18.3.1 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 
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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.  
 
Written informed consent will be obtained by a physician investigator.  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.  
 
18.3.2 Assent Process:  N/A 
 
18.3.3 Documentation of Informed Consent 
The physician-investigator who obtains written informed consent will document this in the 
subject’s chart.  In addition, the consent form will be signed and dated by both the subject and 
the investigator, and the original signed/dated consent form will be kept in the subject’s study 
record.  A copy of the informed consent document will be given to the subject, and a copy may 
also be stored in the subject’s medical record, according to site-specific guidelines. 
 
18.3.4 Waiver of Informed Consent:  N/A 
 
18.3.5 Waiver of Documentation of Informed Consent:  N/A 
 
18.3.6 Stored Samples and Associated Data Considerations  
 
Subjects at both sites will be informed that de-identified tissue samples from liver biopsy 
will be sent to the NIH, where they will be analyzed and potentially banked.   
 
At MGH, subjects will be asked permission for researchers to also utilize their blood 
samples for future related research.  Consent or non-consent is noted by a check-box 
and initials section on the consent form.  Subjects who agree to have their blood 
samples used for related studies will have their samples used as described below, and 
will be informed that they can withdraw this consent in writing at any time for any 
remaining identifiable samples.  Subjects at MGH who do not agree will have any 
remaining blood samples discarded after their study participation and protocol-specified 
analyses of banked samples are complete. 
 
At NIH, subjects must agree to use of samples for related research as an inclusion 
criterion for study participation. 
 
Use of samples for related research is described as below: 
 
Intended Use: Samples and data collected under this protocol may be used to study 
the effects of tesamorelin on liver fat and liver histology and related health conditions 
in individuals with HIV. Genetic testing will be performed. Any other research or 
experimental treatments will be done under this or other protocols for which separate 
signed informed consent documents will be obtained. 
 
Storage: Access to stored samples will be limited using either a locked freezer or (at 
NIH) a secure repository facility in Frederick. 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.  


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 
Tracking: Samples and data acquired as part of this protocol will be tracked at NIH 
using the CRIMSON database system.  Samples acquired and stored at MGH will be 
tracked by Dr. Grinspoon. 
 
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, 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, due to 
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 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. 
Subjects at NIH will not be able to participate if they refuse to have samples 
stored but this decision will not affect the subject’s participation in other 
protocols at NIH. 
 
18.4 
Risks 
18.4.1 Radiation   
The total amount of radiation exposure from 3 DEXA scans is 0.00009 – 0.00015 rem (0.9 to 1.5 
microSeiverts). 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. 
 
18.4.2 Venipuncture/IV Catheter Placement 
There will be minimal risk and discomfort associated with blood drawing and IV placement. The 
risks of these procedures are minor bruising or bleeding at the site of the blood draw or IV 
catheter. 
 
18.4.3 Liver Biopsy 
Ultrasound-guided percutaneous liver biopsy will be performed by trained interventional 
radiologists who specialize in gastrointestinal procedures at both the NIH and the MGH.  
Subjects will be observed as outpatients following liver biopsy per standard interventional 
radiology procedure.  The risks associated with liver biopsy include pain, transient hypotension 
(vasovagal response), bleeding, and transient bacteremia.  Participants with known 
contraindication to liver biopsy, including platelets < 75,000, elevated PT or PTT, or chronic 
aspirin use will not undergo biopsy.  Individuals on aspirin for primary prevention of MI may 
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discharge will follow the site-specific policy for liver biopsy with and without sedation as 
appropriate. After discharge from interventional radiology following the procedure and outpatient 
observation, subjects will also be called the next day by study staff to ensure that any post-
procedure pain has resolved and that no new symptoms are present.  Subjects with persistent 
pain or other concerning symptoms will be asked to return for evaluation. 
 
18.4.4 Study Drug 
Administration of all medications will be overseen by the appropriate health care professional. A 
physician will be available on-call 24 hours/day, 7 days/week, to all study participants for any 
questions or concerns. Participants will self-administer the study drug at home, with the 
exception of observed administration at the clinical research center during baseline and 12 
month visits.  Please see the Intervention section above for more information regarding study 
drug risks and benefits. 
 
GHRH1-44 analogue (tesamorelin, Theratechnologies, Inc.) for treatment purposes has been 
used in a number of studies, including the protocol in a prior completed R-01 grant described in 
preliminary data, with minimal side effects.  In two large, Phase III studies conducted in 
individuals with HIV-infection and abdominal adiposity, adverse events that were more common 
in the treatment vs. placebo group were injection site erythema (8.5% in treated vs. 2.7% in 
placebo), injection site pruritis (7.6% of treated vs. 0.8% placebo), and peripheral edema (6.1% 
in treated vs. 2.3% in placebo).  With respect to serious adverse events (SAEs), prevalence was 
not statistically different (3.7% in treated vs. 4.2% in placebo).  Clinically significant changes 
were not observed for liver function (alanine transaminase), kidney function (creatinine), or 
blood pressure (diastolic and systolic). The majority of the reported side effects were mild in 
severity.  Tesamorelin is FDA approved for HIV-lipodystrophy and has now been prescribed to 
approximately 4000 patients with no additional signals of safety concern. 
 
With regard to injection site reactions, subjects will be informed to notify a study investigator of 
any sign of erythema, swelling, or pruritis.  Subjects will also be informed of theoretical risks 
associated with excess GH, including arthralgia, paresthesia, and hyperglycemia, although 
these were not seen frequently in previous studies of GHRH1-44.  In previous studies, there was 
no net effect of tesamorelin on glucose tolerance after 1 year of administration.  Although there 
is a theoretical risk of neoplasm with an agent that increases GH and IGF-I, there is no evidence 
of increased malignancy with GHRH1-44.  This risk is further minimized based on the data from 
previous studies showing achievement of physiologic, rather than pharmacologic, increases in 
IGF-1 SD scores. Nonetheless, subjects with active malignancy will be excluded from the study.  
For potential participants with previous malignancy that has been treated and cured, their health 
care providers will be contacted to discuss history and risk of recurrence. The study 
investigators, potential participant, and participants’ providers will work together to weigh the 
potential benefits of the study drug against the risk of recurrence; only if an agreement is 
reached that participation poses no increased risk of recurrence will subjects with previous 
history of cured malignancy be enrolled. 
 
IGF-1 Z-score ≥3 for subjects on tesamorelin will prompt a dose-decrease. IGF-1 levels will be 
monitored by an endocrinologist not otherwise involved in the study in order to maintain blinding 
of study physicians and study staff.  This endocrinologist will know the study drug assignment.  
If a subject receiving tesamorelin has an IGF-1 Z-score ≥3 (i.e., an IGF-1 level of 3 SD or more 
above the mean for age and gender), then the endocrinologist will contact the site investigator 
to request a dose decrease to 1mg.  If the subject is in the double-blind portion of the study (first 
12 months), a dummy dose decrease will also be requested for a placebo patient seen at the 
same site during the same time-frame in order to maintain blinding.  If the IGF-1 Z-score for the 


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tesamorelin subject remains ≥3 at the next visit, tesamorelin administration will be discontinued 
but the subject will continue to be followed for safety.   
 
18.4.5 Euglycemic Hyperinsulinemic Clamp/Insulin (MGH Only) 
Administration of insulin infusion can cause hypoglycemia. Blood sugar will be monitored every 
5 minutes during the insulin clamp, and 20% dextrose is infused per protocol to achieve target 
blood glucose of 90mg/dL. In the event of hypoglycemia, 50% dextrose is available at the 
bedside, and a physician or nurse practitioner is present throughout the insulin clamp 
procedure.  
 
18.4.6 Other Risks 
It is possible that incidental abnormal findings may be found during this study. In this case, the 
subject and his/her primary care physician will be notified. 
 
18.5 
Social Impact Events   
Individuals enrolled in this study may experience personal problems resulting from the study 
participation. Such problems are termed social impact events. Although study sites will make 
every effort to protect participant privacy and confidentiality, it is possible that participants' 
involvement in the study could become known to others, and that participants may experience 
stigmatization or discrimination as a result of being perceived as being HIV-infected or at risk for 
HIV infection. For example, participants could be treated unfairly, or could have problems being 
accepted by their families and/or communities. Problems may also occur in circumstances in 
which study participation is not disclosed, such as impact on employment related to time taken 
for study visits. In the event that a participant reports a social impact event, every effort will be 
made by study staff to provide appropriate assistance, and/or referrals to appropriate resources.  
 
Social impact events are documented and reviewed on a scheduled basis by the protocol team 
leadership with the goal of reducing their incidence and enhancing the ability of study staff to 
mitigate them when possible. 
 
Social impact events that are judged by study investigators to be serious, unexpected, or more 
severe or frequent than anticipated, will be reported to the responsible site’s IRB promptly, or 
otherwise in accordance with the IRB’s requirements. 
 
18.6 
Benefits 
There may be no benefit to participants from participation in this study. 
 
Participants will receive information about their nutritional and metabolic health.  In addition, 
subjects may experience benefits from the study drug, which half of subjects will receive from 
study onset and which all subjects will receive for at least 6 months during the final open-label 
extension.  Tesamorelin is established to reduce visceral fat in a majority of patients and to 
lower triglyceride, on average.  In addition, based on our preliminary data, subjects may 
experience reductions in liver fat, and potentially related improvements in metabolism and 
reductions in inflammation.  Further, the information obtained from this study will inform the use 
of GHRH analogue and possibly other strategies to treat NAFLD in HIV.  Therefore, the benefits 
are felt to outweigh the risks described above.  
 
18.7 
Compensation  
 
18.7.1 MGH Compensation Plan 


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Subjects will receive reimbursement for parking and for transportation to study visits from within 
the greater Boston area.  In addition, subjects will receive monetary compensation as below: 
Patient Stipend  
Amount
Screen 
$50 
Baseline 
$100 
Biopsy Stipend 
$100 
Clamp Stipend 
$50 
Safety visits (0.5, 3, 6, 9, 12.5, 15 
months) 
$25 
12 mo visit 
$150 
18mo visit 
$100 
 
Given these amounts, the maximum compensation amounts for each visit (including clamp 
stipend and/or biopsy stipend when applicable) are as follows: 
 
 
Screen visit -- $50 
 
Baseline visit -- $150, plus $100 if liver biopsy 
 
Safety visits -- $25 for each visit 
 
12 month visit -- $200, plus $100 if liver biopsy 
 
18 month visit -- $100 
 
18.7.2 NIH Compensation Plan 
Subjects will be reimbursed for their time and inconvenience according to the following and in 
keeping with NIH NIAID OP8 Clinic reimbursement practices in similar protocols.  
 
Screen visit -- $50 
 
Baseline visit -- $100, plus $300 if liver biopsy 
 
Safety visits -- $25 for each visit 
 
12 month visit -- $100, plus $300 if liver biopsy 
 
18 month visit -- $100 
 
18.8 
Participant Privacy and Confidentiality 
Data at each site will be stored securely, with access restricted to co-investigators and study 
staff. Binders with subject information will be labeled with coded enrollment number to protect 
confidentiality.  For regulatory purposes, individuals from the FDA, NIH, and each site’s IRB 
may access these documents for inspection.  The regulatory monitors will also access these 
documents for inspection (see 17 below). Electronic databases will be locked, and password-
protected, with access available only to study staff.  Data will not be saved on the hard drive of 
any laptop or desktop computers or on any removable data storage devices such as flash drives 
or CDs.  
 
Any data or samples shared between sites will be de-identified such that no protected health 
information is shared between sites. 
 
18.9 
Certificates of Confidentiality:  N/A 
 
18.10 Critical Event Reporting:  N/A 
 
18.11 Communicable Disease Reporting  


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Subjects will be tested for Hepatitis B and Hepatitis C at the screen visit.  Positive results will be 
communicated to the subject and, with the subject’s permission, his/her provider, and, if 
required by state law, will be reported to the Department of Public Health per their reporting 
requirements.  There are no plans to report Hepatitis B or C status except as required by the 
state law governing each site.  HIV testing will not be performed, and there are no plans to 
report HIV status. 
 
18.12 Incidental Findings  
Incidental findings discovered on imaging will be discussed with the radiologist and 
subsequently be reported to the subject and, with the subject’s permission, his/her provider.  
The possibility of incidental findings is discussed with subjects as part of the informed consent 
process. 
 
18.13 New Findings  
Any new scientific findings related to the research that affect the risk/benefit assessment of 
study participation, or that substantially affect the importance of the research question, will be 
reported to the IRBs overseeing the research and will be shared will any active and future 
research subjects. 
 
18.14 Study Discontinuation  
The study may be discontinued at any time by the IRB, NIAID, the FDA, or other government 
entities as part of their duties to ensure that research participants are protected.  
 
18.15 Ancillary Benefits:  N/A  
 
18.16 Community Advisory Board and Other Relevant Stakeholders:  N/A   
 
19. ADMINISTRATIVE PROCEDURES 
 
19.1 
Regulatory Oversight 
As above, the protocol will be monitored by the NIAID as well as the site IRB’s.  In addition, the 
protocol is being conducted under an IND (77,473 to Dr. Steven Grinspoon) and thus falls under 
FDA regulatory oversight. 
 
19.2 
ClinicalTrials.gov 
This protocol will be registered in ClinicalTrials.gov. 
 
20. PUBLICATION POLICY 
Drs. Grinspoon and Hadigan will share responsibility and decision making regarding publication 
of study results.   
 


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35. Vanni, E., et al., From the metabolic syndrome to NAFLD or vice versa? Dig Liver 
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38. Stanton, M.C., et al., Inflammatory Signals shift from adipose to liver during high 
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53. Stanley, T.L., et al., Effects of tesamorelin on inflammatory markers in HIV 
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54. Falutz, J., et al., Metabolic effects of a growth hormone-releasing factor in 
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22.  APPENDICES 
 
Appendix A:  Schedule of procedures/evaluations 
 
Test/Procedure 
screen 
Base-
line 
0.5 
mo 
3 
mo
6 
mo
9 
mo
12 
mo
12.5 
mo 
15 
mo 
18 
mo
ETV* 
Informed consent 
x 
  
  
  
 
Assessment of 
eligibility criteria 
x 
  
  
  
 
Pregnancy test** 
x 
x
x
x
x
x
x
x 
x 
x 
x
Review of medical 
history 
x 
  
  
  
 
Interval history 
  
x
x
x
x
x
x
x 
x 
x 
x
Review of 
concomitant 
medications 
x 
x
x
x
x
x
x
x 
x 
x 
x
Physical examination 
x 
x
x
x
x
x
x
x 
x 
x 
x
Nutrition Counseling 
 
x
x
x
 
 
x 
Vital Signs 
x 
x
x
x
x
x
x
x 
x 
x 
x
Body weight 
x 
x
x
x
x
x
x
x 
x 
x 
x
Anthropometrics 
  
x
x
  
  
x 
x
Assessment of 
adverse events 
  
x
x
x
x
x
x
x 
x 
x 
x
AST 
x 
x
x
x
x
x
x
x 
x 
x 
x
ALT 
x 
x
x
x
x
x
x
x 
x 
x 
x
Creatinine 
x 
  
  
  
 
total Bilirubin 
x 
  
  
  
 
PT and INR 
x 
  
  
  
 
PTT 
x 
  
  
  
 
CBC 
x 
x
  
  
  
 
CD4, HIV Viral Load 
x 
x
  
  
  
 
HbA1c 
x 
x
  
  
x 
 
Hepatitis B sAg 
x 
  
  
  
 


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Test/Procedure 
screen 
Base-
line 
0.5 
mo 
3 
mo
6 
mo
9 
mo
12 
mo
12.5 
mo 
15 
mo 
18 
mo
ETV* 
Hepatitis C antibody 
x 
  
  
  
 
PSA 
x 
  
  
  
 
HCV RNA 
x 
  
  
  
 
IGF-1 
  
x
x
x
x
x
x
x 
x 
x 
x
GGT 
  
x
x
  
  
x 
x
Alkaline Phosphatase 
  
x
x
  
  
x 
x
Lipid Panel 
  
x
x
  
  
x 
x
Fasting Glucose 
  
x
x
x
x
x 
x 
  
x
Glucose (OGTT) 
  
x 
x 
  
  
x 
Frozen serum: CK18, 
adiponectin, CRP, IL-
6, other 
  
x
x
  
  
  
 
1H-MRS/MRI 
x 
x
x
  
  
x 
x
Liver Biopsy 
  
x
x
  
  
  
 
DEXA 
  
x
x
  
  
x 
x
FibroScan 
  
x
x
  
  
x 
x
4-day food record 
  
x
x
  
  
x 
Modifiable Activity 
Questionnaire 
  
x
x
  
  
x 
x
Collection of 
Peripheral Blood 
Mononuclear Cells 
 
x
 
 
 
Stable Isotopes and 
Clamp (MGH only) 
 
x
x
 
 
 
*ETV:  Early termination visit. 
**A urine or serum pregnancy test with sensitivity of at least  25 mIU/ml will be used.