Vitamin D Oral Replacement in Asthma
Phase: NA
Conditions: Asthma, Vitamin D Deficiency, Pediatric Obesity
Sponsor: IDeA States Pediatric Clinical Trials Network

 
 
 
 
 
 
 
 
 
Vitamin D Oral Replacement in Asthma 
 
NCT03686150 
 
Protocol Document 
 
December 14, 2020 
 
 

Vitamin D Oral Replacement in Asthma (VDORA1) 
UAMS IRB Protocol Number: 228446 
Version Number: 07 
14 December 2020 
 
Sponsor: ISPCTN DCOC 
 
 
Operational Principal Investigators:  
 
Jessica Snowden, MD 
(ISPCTN DCOC at UAMS) 
 
Jason Lang, MD, MPH 
Duke Clinical Research Institute 
 
Protocol Chairs:  
Brian O’Sullivan, MD  
(Geisel School of Medicine at Dartmouth College)  
 
J. Marc Majure, MD  
(University of Mississippi Medical Center) 
 
Laura James, MD, FAAP  
(Arkansas Children’s Research Institute) 
 
 
Funded by: The National Institutes of Health (NIH) 
 
 
 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
 
 
IRB # 228446 Version # 07 
Date: 14 December 2020                                                                                                      Page 2 of 89 
 
Summary of Changes from Version 01 to 02: 
Affected 
Section(s) 
Summary of Revisions Made (01 to 02) 
Rationale 
1.1 
Schedule of 
Activities 
Corrected footnote “h” in Schedule of Activities so that the 
footnote matched the table.  Specifically changed 
“screening” to “baseline.” 
Inadvertent oversight during 
proofreading. 
6.5 
Concomitant 
Therapy 
Added information about allowable Vitamin D dosage in 
over-the-counter vitamins that the participants may take. 
Requested in UAMS IRB 
contingency letter of 09/13/2018 
8.1.2  
Laboratory 
Evaluations 
Corrected “complete blood count” to “platelet” where the 
change was not made prior to initial IRB submission. 
Prior to initial IRB submission, a 
decision was made to change 
one of the lab tests from 
“complete blood count” to 
“platelet count.”  This change 
was inadvertently not made 
consistently throughout the 
protocol. 
10.1.9.1 
Data Collection 
& Management 
Responsibilities 
 
Added paragraph noting that data will not be de-identified 
by the sites, but will be de-identified before it is shared 
outside of the network. 
Requested in UAMS IRB 
contingency letter of 09/13/2018 
 
 
Summary of Changes from Version 02 to 03: 
Affected 
Section(s) 
Summary of Revisions Made (02 to 03) 
Rationale 
Title page 
and section 
10.1.5 
Added Jason Lang, MD, PhD to title page and corrected 
affiliation 
Simple correction. 
Title page 
and section 
10.1.5 
Removed Dr. Greg Kearns name from protocol. 
Dr. Kearns is no longer working 
on protocol. 
Sections 1 
and 4.1,  
Increase number of participants that can be randomized in 
part 1 of the study.  Increased from 32 to 50. 
This is to ensure adequate 
numbers in each group for 
pharmacokinetic analyses. 
Sections 1; 
1.1;  3; 
8.1.2; and  
9.4.10  
Made specimen collection optional for platelets. 
Specimens for platelet analysis 
cannot be frozen or held for 
extended periods. This will allow 
sites to schedule participants for 
Friday and Saturday visits 
Sections 
1.1; 4.1; 
4.4; 6.1.2;  
8.1.1.1; and 
8.2    
Corrected/clarified timeframes for scheduling visits to make it 
clear that all visits are in relation to baseline visit (Visit 2). 
 
There were inconsistencies within 
the protocol regarding scheduling 
of visits. 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
 
 
IRB # 228446 Version # 07 
Date: 14 December 2020                                                                                                      Page 3 of 89 
 
Affected 
Section(s) 
Summary of Revisions Made (02 to 03) 
Rationale 
Section 1.1; 
8.1.1.1 
(screening 
and 
baseline 
visits)  
Removed requirement to do a focused physical examination 
as a routine part of the study. 
 
 
Not essential to protocol. 
Sections 
2.3.3; 4.1; 
and  5.2,  
Corrected use of terminology for randomization and 
enrollment. 
Technical correction/clarification. 
Section 5.1 
Annotated “abnormal liver function” to indicate values need to 
also be clinically significant (per site investigator). 
Clarification. 
Sections 5.2 
Clarified/revised used of “restricted” and “excluded” with 
regard to medication.  Noted that excluded medication cannot 
be used, not only within 30 days prior to enrollment, but also 
at any time during the run-in period.   
Clarification. 
Section 5.2 
and  8.1.1.1 
(Visit 2)  
Changed “return greater than or equal to 75% of diary cards” 
to “return diary cards with a completion rate greater than or 
equal to 75%.” 
Clarification/correction. 
Section 5.4 
Inserted “Participants who were terminated due to a screen 
fail must sign new consent/assent documents prior to 
rescreening.” 
Clarification. 
Section 5.5, 
(Recruit-
ment) 
Added paragraph to allow for collection of information about 
why potential participants decline to be in the study. 
New. 
Sections 
6.1.2; 6.4; 
and  8.1.1.1 
Added that diary cards will be used for follow-up visits in 
addition to Visits 1-6. These diary cards will not have a line for 
recording if vitamin D pills were taken. Concomitantly, diary 
cards for visits in which Vitamin D is dispensed will be “diary 
cards for dosing visits.” 
New. 
Section 6.5 
Clarified what is a study deviation with regard to use of 
excluded medication.  
Clarification. 
Section 6.5 
In excluded medication list, the “calcifediol (vitamin D2)” was 
changed to “Vitamin D2.” 
Technical correction. 
Sections 
7.1;  and  
8.2 
Deleted “calcium and creatinine” each measured in mg/ml” 
Phrase was causing confusion at 
sites. 
Section 7.2 
Add “at the discretion of the site investigator” to 
discontinuation due to non-compliance. 
Clarification. 
Section 
8.1.1.1 
(Visit 1) 
Revised daily diary cards for visit 1. Cards for visit 1 will no 
longer have a line to collect information about taking 
Vitamin D pills. 
Correction made to diary cards. 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
 
 
IRB # 228446 Version # 07 
Date: 14 December 2020                                                                                                      Page 4 of 89 
 
Affected 
Section(s) 
Summary of Revisions Made (02 to 03) 
Rationale 
Section 
8.1.1.1 
(Visit 1) 
Added that participants whose safety laboratory values 
exceed thresholds will be referred to primary care physician. 
Clarification for safety. 
Section 
8.1.1.1 
(Visit 2). 
Clarified that sites must verify participants continue to meet 
inclusion/exclusion criteria at baseline (visit 2). 
Clarification/reinforcement of 
requirement. 
Section 
8.1.2. 
Referenced lab manual for specimen collection methods for 
central lab; deleted specifications for collection methods that 
were in this protocol. 
Some specification in protocol 
were not accurate.   
Section 
8.1.2 
Revised inclusion criteria in later part of protocol to include the 
specification that Vitamin D level must be greater than 10 
ng/ml, as well as less than 30 ng/ml, to meet inclusion criteria. 
Corrected within protocol 
inconsistency. 
Section 8.2.  
Deleted “…or they may proceed to a total serum calcium 
measurement (if preferred in order to obviate a return visit).”  
A second urine calcium/creatinine is required prior to getting a 
specimen for blood calcium.   
Corrected within protocol 
inconsistency. A second urine 
calcium/creatinine is required prior 
to collecting blood for a blood 
calcium level.  
Section 
8.3.3.3 
Added list of expected AEs 
Clarification. 
Section 
8.3.9 
“Reporting of Pregnancy” section re-written 
Clarification and to eliminate the 
requirement to follow infants for 
“up to 2 months.” 
Section 
9.4.3 
Corrected “…25(OH)D greater than or equal to 0 ng/ml during 
a desired time period..”  to “…25(OH)D greater than or equal 
to 40 ng/ml during a desired time period..” 
Typographical error. 
Section 
10.2 
Deleted unused abbreviations (GLP and IDE) from table. 
Correction of inconsistency. 
 
 
Summary of Changes from Version 03 to 04:  
(primarily addressing contingencies from version 03 but also removing requirement to collect specimens 
for platelets and allowing for more than weekly contact between visits.) 
 
Affected 
Section(s) 
Summary of Revisions Made (03 to 04) 
Rationale 
Sections 1;   
1.1;  2.2;  3;  
8.1.1.1; 
8.1.2;  and 
9.4.10 
Deleted requirement/option to collect platelets from entire 
protocol.  Specimens for platelets shall no longer be collected. 
Study team (chairs/PIs) 
determined this was not an 
essential part of the protocol. 
Requirement to collect platelets 
had potential to cause undue 
noncompliance issues related to 
scheduling problems, which were 
secondary to the limited stability 
of platelet samples. 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
 
 
IRB # 228446 Version # 07 
Date: 14 December 2020                                                                                                      Page 5 of 89 
 
Affected 
Section(s) 
Summary of Revisions Made (03 to 04) 
Rationale 
Section 1 
and 5.5 
Changed total randomized for entire study to 107 and total 
enrolled for entire study to 321. 
Change to total enrollment 
because enrollment in part 1 of 
the study was increased. 
Sections 
1.1;  4.1; 
4.4;  
8.1.1.1; 
8.1.2;  8.2;  
9.4.7;  
Noted that weeks 20, 24, and 28 are visits 7, 8, and 9, 
respectively. 
Contingency response: clarified to 
match informed consent.  
Sections 
1.1;  6.4;   
8.1.1;  
8.1.1.1;     
Changed weekly calls to “at least weekly.” 
This will allow sites to be able to 
have additional contact and send 
additional reminders to 
participants. 
Sections 
1.1;  8.1.1;  
8.1.1.1;  
and  8.1.2 
Clarified what was optional with regard to venipuncture and 
collection of blood for inflammatory markers.  Collection of 
blood for inflammatory markers is not optional if blood 
obtained by venipuncture.  Method of blood collection 
(venipuncture vs fingerstick) is, however, optional for most 
visits. 
Contingency response: 
clarification. 
Section 4.1 
Changed number of participants to be enrolled in part I to 150.  
This is to match the 3:1 ratio used 
to estimate 
enrollment:randomization for part 
II of the study 
Section 
8.1.1.1 
Added requirement for source documentation of participants’ 
choice of venipuncture or fingerstick for each visit. 
Ensure adequate documentation 
of study conduct. 
Section 
8.1.2. 
Changed statement FROM “25(OH) vitamin D level by liquid 
chromatography/tandem mass spectrometry (specimen 
collection per laboratory manual) to be done at Baseline and 
study Visits 3, 4, 5, and 6 and optionally at Follow-up and 
between Week 1 and 3 if the participant volunteers for this..” 
TO 25(OH) vitamin D level by liquid chromatography/tandem 
mass spectrometry (specimen collection per laboratory 
manual) to be done at Baseline (visit 2) and study Visits 3, 4, 
5, and 6 as well as Follow-up (visits 7, 8, and 9). There is an 
optional visit between Week 1 and 3, if the participant 
volunteers for this. 
Corrected internal inconsistency.  
Vitamin D central laboratory 
assays are required for all visits 2 
through 9, inclusive. 
 
 
Summary of Key Changes from Version 04 to 05:  
Affected 
Section(s) 
Summary of Key Revisions Made (04 to 05) 
Rationale 
Title Page, 
Header, 
protocol 
summary 
and section 
10.2  
Changed Protocol Name to “Vitamin D Oral Replacement in 
Asthma” 
Study team decided the name 
change would be useful in 
reducing the stigma associated 
with obesity language for 
potential participants 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
 
 
IRB # 228446 Version # 07 
Date: 14 December 2020                                                                                                      Page 6 of 89 
 
Affected 
Section(s) 
Summary of Key Revisions Made (04 to 05) 
Rationale 
Sections 1.1;  
6.4;   8.1.1;  
8.1.1.1;     
Changed weekly calls to “at least biweekly” (meaning every 2 
weeks). 
Reduce the required burden on 
coordinators and participants  
Protocol 
Summary 
Changed study duration to 34 months and Part 1 duration to 
17 months 
Correction 
Protocol 
Summary 
and section 
4.3 
Changed the names of Part 2 Cohorts 1 and 2 to Cohorts A 
and B, respectively  
Changed to keep Part 1 and Part 
2 Cohorts separate 
Protocol 
Summary 
and section 
4.3 
Changed “recommended dose based on Part 1 PK analysis” 
to Single 50,000 IU loading dose + 8,000 IU daily dose 
Specified recommended dose for 
Part 2  
Section 4.1 
Added actual enrollment start date 
Update 
Section 4.3 
Added Justification for Part 2 dosing 
New 
Schedule of 
Assessments 
and section 
8.1.1.1 
Increased the number of days between clinic visits from 28 ± 
3 days to 28 ± 7 days 
Extended visit window per study 
team recommendation 
Schedule of 
Assessments 
Updated the footnote concerning requirement of focused 
physical examination.  
Updated per protocol revision 
Schedule of 
Assessments 
Instruction added to safety lab footnote: 
“If urine Ca++/Cr sample is not obtained at the scheduled 
visit, the sample must be obtained within 2 business days 
since it is a safety assessment.” 
Clarification  
Section 5.2 
Added clarifying language for spot urine calcium creatinine 
ratio exclusion criteria 
Clarification 
Section 5.5 
Rewording in recruitment section  
Clarification 
Section 6.1.2 
Added the recommended dose for Part 2 
New 
Section 6.2.3 
Added information from drug vendor concerning drug stability 
at certain temperatures  
Clarification 
Section 6.4  
Added a requirement for pharmacists/designees to perform a 
pill count prior to dispensing study drug to participants.   
New 
Section 6.4  
Added the instruction that study staff will be trained to review 
the diary cards with the participants  
New 
Section 
6.5/6.5.1 
Added clarifying language concerning steroid use   
Clarification 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
 
 
IRB # 228446 Version # 07 
Date: 14 December 2020                                                                                                      Page 7 of 89 
 
Affected 
Section(s) 
Summary of Key Revisions Made (04 to 05) 
Rationale 
Section 7.1  
Added verbiage for an intended termination visit for 
unplanned study termination and outlined what the visit will 
include. 
New 
Section 7.1 
Clarified the “Rules for Halting of Study Drug” to indicate that 
serum calcium and 25(OH) D are collected locally to 
determine if a participant develops elevated serum calcium 
greater than or equal to 1.5×ULN or 25(OH)D level greater 
than 100 ng/ml [following elevated urine calcium/creatinine 
ratio > 0.37 on repeat test] 
Clarification 
Section 
10.1.1 
Added that unemancipated minors who are 7 years old or 
older will sign the separate assent form 
 
 
Summary of Key Changes from Version 05 to 06:  
Affected 
Section(s) 
Summary of Revisions Made (05 to 06) 
Rationale 
Section 1.1. 
Schedule of 
Activities 
In footnote “b” changed “an unplanned study termination visit 
occurs” to “the participant is asked to stop taking vitamin D 
and terminates from the study.”  
Clarification. 
Section 4.4 
Changed “day 196 ±3” to “day 196 ±7.” 
Simple correction for internal 
consistency. 
Section 
6.2.2.  
Specified that the loading doses would not be sent home with 
participants; added that loading doses will be given to 
participants during visit 2. 
Simple correction for internal 
consistency and clarification 
regarding dispensing of loading 
doses. 
Section 
6.2.3.  
Deleted “According to the study drug vendor, vitamin D3 
should be stable for months at 45 oC.” 
Data not provided by company. 
Section 
6.2.4 
Added second sentence regarding counting of pills for 
confirmation of number prior to dispensing. 
To be consistent with pharmacy 
manual.  
Section 7.1 
Deleted reference to an unplanned study termination.  
Replaced with “If a participant who has been asked to stop 
taking study drug terminates (for any reason) from the 
study…” 
Terminology (i.e., “unplanned 
study termination”) was not 
defined. Clarification of when a 
focused physical exam would be 
done. 
Section 
8.1.1.1, Visit 
3 and 
throughout 
Corrected “weekly” to “biweekly” in section “weeks 5-7” of 
Study Visit 3 section and indicated that “biweekly” means 
every 2 weeks 
Simply correction and clarification 
because biweekly has more than 
one definition.  
Section 
10.1.5 
Corrected address and phone number for Jessica Snowden, 
MD 
Change of office location. 
Section 
10.1.7 
Added that monitoring visits can be conducted remotely as 
well as at the site 
Personnel safety accommodation 
due to COVID-19 pandemic. 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
 
 
IRB # 228446 Version # 07 
Date: 14 December 2020                                                                                                      Page 8 of 89 
 
 
Summary of Key Changes from Version 06 to 07:  
Affected Section(s) 
Summary of Revisions Made  
(06 to 07) 
Rationale 
Protocol Summary Table (1);  
4.1, Overall design;  
4.3, Justification for Dose;  
4.4 End of Study Definition;  
9.2, Sample size determination 
Randomization maximum changed:  
FROM 57 TO 63. 
DSMB-approved increase due to 
potential increase in dropout rate 
secondary to COVID-19 
pandemic. 
 
 
 
 
 
 
 
 
 
 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
IRB # 228446  Version # 07 
Date: 14 December 2020                                                                                                     Page 9 of 89  
Table of Contents 
STATEMENT OF COMPLIANCE ..................................................................................................................................... 12 
1 
PROTOCOL SUMMARY ............................................................................................................................. 12 
Signature Page ............................................................................................................................................................. 16 
1.1 
Schedule of Activities (SoA) .................................................................................................................. 17 
2 
INTRODUCTION ............................................................................................................................................... 19 
2.1 
Study Rationale .................................................................................................................................... 19 
2.2 
Background ........................................................................................................................................... 21 
2.3 
Risk/Benefit Assessment ...................................................................................................................... 30 
2.3.1 
Known Potential Risks ....................................................................................................... 30 
2.3.2 
Known Potential Benefits ................................................................................................. 31 
2.3.3 
Assessment of Potential Risks and Benefits ..................................................................... 32 
3 
OBJECTIVES AND ENDPOINTS ......................................................................................................................... 32 
4 
STUDY DESIGN ................................................................................................................................................. 33 
4.1 
Overall Design ...................................................................................................................................... 33 
4.2 
Scientific Rationale for Study Design .................................................................................................... 34 
4.3 
Justification for Dose ............................................................................................................................ 35 
4.4 
End of Study Definition......................................................................................................................... 36 
5 
STUDY POPULATION ....................................................................................................................................... 37 
5.1 
Inclusion Criteria................................................................................................................................... 37 
5.2 
Exclusion Criteria .................................................................................................................................. 37 
5.3 
Lifestyle Considerations ....................................................................................................................... 38 
5.4 
Screen Failures ..................................................................................................................................... 38 
5.5 
Strategies for Recruitment and Retention ........................................................................................... 39 
5.6 
Clinical Help Line .................................................................................................................................. 40 
6 
STUDY INTERVENTION .................................................................................................................................... 40 
6.1 
Study Intervention(s) Administration ................................................................................................... 40 
6.1.1 
Study Intervention Description ......................................................................................... 40 
6.1.2 
Dosing and Administration ............................................................................................... 40 
6.2 
Preparation/Handling/Storage/Accountability .................................................................................... 41 
6.2.1 
Acquisition and Accountability ......................................................................................... 41 
6.2.2 
Formulation, Appearance, Packaging, and Labeling ......................................................... 41 
6.2.3 
Product Storage and Stability ........................................................................................... 41 
6.2.4 
PREPARATION ................................................................................................................... 42 
6.3 
Measures to Minimize Bias: Randomization and Blinding ................................................................... 42 
6.4 
Study Intervention Compliance ............................................................................................................ 42 
6.5 
Concomitant Therapy ........................................................................................................................... 43 
6.5.1 
Rescue Medicine ............................................................................................................... 44 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT DISCONTINUATION/WITHDRAWAL ............. 45 
7.1 
Discontinuation of Study Intervention ................................................................................................. 45 
7.2 
Participant Discontinuation/Withdrawal from the Study .................................................................... 46 
7.3 
Lost to Follow-Up ................................................................................................................................. 47 
8 
STUDY ASSESSMENTS AND PROCEDURES ....................................................................................................... 47 
8.1 
Study Assessments ............................................................................................................................... 47 
8.1.1 
Clinical Assessments ......................................................................................................... 47 
8.1.2 
Laboratory evaluations ..................................................................................................... 56 
8.2 
Safety and Other Assessments ............................................................................................................. 57 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
IRB # 228446  Version # 07 
Date: 14 December 2020                                                                                                     Page 10 of 89  
8.3 
Adverse Events and Serious Adverse Events and Adverse Reactions .................................................. 58 
8.3.1 
Definition of Adverse Events and Adverse Reactions ....................................................... 58 
8.3.2 
Definition of Serious Adverse Events or Reactions ........................................................... 58 
8.3.3 
Classification of an Adverse Event .................................................................................... 59 
8.3.4 
Time Period and Frequency for Event Assessment and Follow-Up .................................. 61 
8.3.5 
Adverse Event and Reaction Reporting ............................................................................ 61 
8.3.6 
Serious Adverse Event and REaction Reporting ................................................................ 61 
8.3.7 
Reporting Events to Participants ...................................................................................... 62 
8.3.8 
Events of Special Interest.................................................................................................. 62 
8.3.9 
Reporting of Pregnancy .................................................................................................... 62 
8.4 
Unanticipated Problems ....................................................................................................................... 63 
8.4.1 
Definition of Unanticipated Problems .............................................................................. 63 
8.4.2 
Unanticipated Problem Reporting .................................................................................... 63 
8.4.3 
Reporting Unanticipated Problems to Participants .......................................................... 64 
9 
STATISTICAL CONSIDERATIONS ....................................................................................................................... 65 
9.1 
Statistical Hypotheses .......................................................................................................................... 65 
9.2 
Sample Size Determination .................................................................................................................. 65 
9.3 
Populations for Analyses ...................................................................................................................... 65 
9.4 
Statistical Analyses ............................................................................................................................... 66 
9.4.1 
General Approach ............................................................................................................. 66 
9.4.2 
Analysis of the Study Endpoint ......................................................................................... 66 
9.4.3 
Analysis of the Part 1 Endpoint ......................................................................................... 67 
9.4.4 
ANAYLSIS OF PART 2 ENDPOINTS ..................................................................................... 67 
9.4.5 
Safety Analyses ................................................................................................................. 67 
9.4.6 
Baseline Descriptive Statistics .......................................................................................... 68 
9.4.7 
Planned Interim Analyses ................................................................................................. 68 
9.4.8 
Subgroup Analyses ............................................................................................................ 68 
9.4.9 
Tabulation of Individual Participant Data ......................................................................... 68 
9.4.10  
Exploratory Analyses ........................................................................................................ 68 
9.5 
Missing Data ......................................................................................................................................... 69 
10 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS ...................................................... 69 
10.1 
Regulatory, Ethical, and Study Oversight Considerations .................................................................... 69 
10.1.1 
Informed Consent Process ................................................................................................ 69 
10.1.2 
Study Discontinuation and Closure ................................................................................... 71 
10.1.3 
Confidentiality and Privacy ............................................................................................... 72 
10.1.4 
Future Use of Stored Specimens and Data ....................................................................... 73 
10.1.5 
Key Roles and Study Governance ..................................................................................... 73 
10.1.6 
Safety Oversight ................................................................................................................ 75 
10.1.7 
Clinical Monitoring ............................................................................................................ 75 
10.1.8 
Quality Assurance and Quality Control ............................................................................. 76 
10.1.9 
Data Handling and Record Keeping .................................................................................. 77 
10.1.10 
Protocol Deviations ........................................................................................................... 78 
10.1.11 
Publication and Data Sharing Policy ................................................................................. 78 
10.1.12 
Conflict of Interest Policy .................................................................................................. 78 
10.2 
Abbreviations ....................................................................................................................................... 79 
11 
REFERENCE ...................................................................................................................................................... 81 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
IRB # 228446  Version # 07 
Date: 14 December 2020                                                                                                     Page 11 of 89  
 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
IRB # 228446  Version # 07 
Date: 14 December 2020                                                                                                     Page 12 of 89  
STATEMENT OF COMPLIANCE 
The trial will be carried out in accordance with International Council on Harmonisation 
(ICH) Good Clinical Practice (GCP) guidelines and the United States (US) Code of 
Federal Regulations (CFR) applicable to clinical studies (45 CFR Part 46, 21 CFR Part 
50, and 21 CFR Part 56). 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who 
are responsible for the conduct, management, or oversight of NIH-funded clinical trials 
have completed Human Subjects Protection and ICH GCP Training. 
The protocol, informed consent form(s), recruitment materials, and all participant 
materials will be submitted to the Institutional Review Board (IRB) for review and 
approval. Approval of both the protocol and the consent form must be obtained before 
any participant is enrolled. Any amendment to the protocol will require review and 
approval by the IRB before the changes are implemented to the study. In addition, all 
changes to the consent form will be IRB-approved; a determination will be made 
regarding whether a new consent needs to be obtained from current participants who 
have provided consent using a previously approved consent form. 
1 
 
PROTOCOL SUMMARY 
Title: 
Vitamin D Oral Replacement in Asthma (VDORA1) 
Study Description: 
Multi-center, randomized, open-label, pharmacokinetic (PK) 
and safety study of oral vitamin D3 supplementation. This will 
be performed in two parts. The data from both parts will be 
combined for PK calculations. 
Objectives: 
Study objective: The overall objective of the study is to 
determine the pharmacokinetics of Vitamin D supplementation 
in children who have asthma and are overweight or obese. 
Part 1 objective: Identify dosing to use in Part 2 using PK 
analysis on a subset of participants. 
Part 2 objective: Determine the effectiveness of a 
recommended 16-week dosing regimen to achieve a serum 
level of 25(OH)D greater than or equal to 40 ng/ml in vitamin D 
insufficient or deficient children who have asthma and are 
overweight or obese. 
Safety objective: Assess the safety and tolerability of oral 
vitamin D3 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
IRB # 228446  Version # 07 
Date: 14 December 2020                                                                                                     Page 13 of 89  
Exploratory objectives: 
1. Characterize selected inflammatory markers in children 
receiving vitamin D3 supplementation. 
2. Characterize asthma symptoms in children receiving 
vitamin D3 supplementation.  
3. Compare the proportion of participants randomized to 
receive an optimal dose of vitamin D based on PK data 
versus those who are exposed to standard of care doses 
that achieve serum 25(OH)D greater than or equal to 40 
ng/ml. 
Endpoints: 
Study endpoint: Pharmacokinetic analysis of vitamin D 
supplementation in children who have asthma and are 
overweight/obese. 
Part 1 endpoint: Serum 25(OH)D will be evaluated at baseline 
and various times including post-dose elimination to determine 
preliminary PK analysis for the best dose for increasing vitamin 
D levels above 40 ng/ml in children with asthma who are 
overweight or obese. 
Part 2 endpoint: Did participants in the Part 2 active dosing 
cohort achieve a serum 25(OH)D of greater than or equal to 
40 ng/ml at 16 weeks? 
Safety endpoints: Adverse events (AEs), serious adverse 
events (SAEs), adverse reactions (ARs), and serious adverse 
reactions (SARs) 
Exploratory endpoints: 
1. Inflammatory biomarker panel to include serum leptin as 
well as tumor necrosis factor alpha (TNFα), interleukin-2 
(IL-2), IL-6, IL-10 and IL-17 (cytokine panel) 
2. Asthma exacerbations 
3. Asthma Symptom Days (ASDs) 
4. Asthma Control Test (ACT) (or Childhood Asthma Control 
Test [c-ACT] for participants less than12 years of age) 
5. Differences in the proportion of participants that achieve 
serum 25(OH)D levels greater than or equal to 40 ng/ml 

Title: Vitamin D Oral Replacement in Asthma 
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Study Population: 
Approximately 107 participants randomized (321 enrolled), 
ages 6 to less than18 years of age at enrollment, body mass 
index (BMI) greater than or equal to 85% for age and sex, with 
physician-diagnosed asthma and baseline serum 25(OH)D 
level less than 30 ng/ml and greater than 10 ng/ml 
Phase: 
PK / dose finding study 
Description of 
Sites/Facilities 
Enrolling 
Participants: 
Open to sites of the IDeA States Pediatric Clinical Trials 
Network (ISPCTN) 
Description of 
Study Intervention: 
Part 1: (Dose Finding) 
A total of 50 participants were randomized (1:1:1:1) into one of 
four 16-week vitamin D3 oral regimens: 
Cohort 1: Single 50,000 IU loading dose + 6000 IU daily dose 
Cohort 2: Single 50,000 IU loading dose + 10,000 IU daily 
dose 
Cohort 3: 6000 IU daily dose 
Cohort 4: 600 IU daily dose (standard of care comparator 
[SoC] group) 
After a minimum of 16 participants (4 in each group) completed 
PK sampling at Week 20, we performed an interim analysis to 
determine the recommended dose for use in Cohort A for 
Part 2 of the study. 
Part 2: (Dose Confirming) 
Up to 63 additional participants will be randomized into one of 
two 16-week vitamin D3 oral regimens in a 2:1 ratio: 
Cohort A: Single 50,000 IU loading dose + 8,000 IU daily dose  
Cohort B: 600 IU daily dose (SoC)  
Study Duration: 
42 months 
Part 1: 17 months (assumes 6 randomizations/month) 
Interim Analysis period: 2 months 
Part 2: 17 months (assumes 6 randomizations/month) 
Final Analysis period: 6 months 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
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Participant 
Duration: 
30 weeks (2-week screening/run-in, 16-week intervention, 
12-week follow-up period) 

Title: Vitamin D Oral Replacement in Asthma 
Sponsor: ISPCTN DCOC 
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SIGNATURE PAGE 
The signature below documents my review and approval of this protocol, including all 
appendices and product information. I agree to personally oversee the conduct of this 
study as described herein and to follow this protocol version as approved by the 
Institutional Review Board. I agree that this clinical study will be conducted according to 
all stipulations of the protocol, including all statements regarding confidentiality and 
according to local legal and regulatory requirements and to the principles outlined in 
applicable US federal regulations and ICH guidelines. 
 
Operational Principal Investigator 
 
               Jessica Snowden, MD 
                   Printed name 
 
                   Signature                                                                                  Date 
 
 
 
 
 
 
 
12/14/2020

Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
Sponsor: ISPCTN DCOC 
 
 
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1.1 SCHEDULE OF ACTIVITIES (SOA) 
A summary of the study procedures is provided in Table 1. An illustration of the study design is provided in Figure 1. 
Table 1. 
Schedule of Assessments and Procedures 
 
Schedule of Assessments and Procedures 
Activities 
Screening 
 
Dosing Phase 
Follow-Up 
Screening 
(Visit 1) 
Baseline 
(Visit 2) 
Optional 
Blood 
Draw 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visits 7, 8, 
and 9 
 
Day -14 a 
Day 0 
Day 7- 21 
Day 28 a 
Day 56 a 
Day 84 a 
Day 112 a 
 
 
Week 1 
Week 1 to 
Week 3 
Week 4 
Week 8 
Week 12 
Week 16 
Weeks 20, 
24, and 28a 
Informed consent/assent 
X 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
Inclusion/exclusion criteria 
X 
X 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
Focused physical examinationb 
 
 
 
 
 
 
 
 
Collection of height and weight 
X 
X 
 
X 
X 
X 
X 
 
Urine pregnancy testc 
X 
 
 
 
X 
 
X 
 
Begin run-in periodd 
X 
 
 
 
 
 
 
 
Dispense and explain/review diary 
cards 
X 
X 
 
X 
X 
X 
X 
X 
Randomize to dose group 
 
X 
 
 
 
 
 
 
Dispense study drug 
 
X 
 
X 
X 
X 
 
 
Collect unused study drug 
 
 
 
X 
X 
X 
X 
 
Assess adherencee 
 
X 
 
X 
X 
X 
X 
 
Adherence communicationf 
 
X 
 
X 
X 
X 
X 
X 
Urine calcium/creatinine ratiog 
X 
 
 
X 
X 
X 
X 
 
Blood inflammatory markersh 
 
X 
 
Xi 
Xi 
Xi 
X 
Xi 
Serum 25(OH) vitamin D (local 
laboratory) 
X 
 
 
 
 
 
 
Xj 

Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
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Schedule of Assessments and Procedures 
Activities 
Screening 
 
Dosing Phase 
Follow-Up 
Screening 
(Visit 1) 
Baseline 
(Visit 2) 
Optional 
Blood 
Draw 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visits 7, 8, 
and 9 
 
Day -14 a 
Day 0 
Day 7- 21 
Day 28 a 
Day 56 a 
Day 84 a 
Day 112 a 
 
 
 
Week 1 
Week 1 to 
Week 3 
Week 4 
Week 8 
Week 12 
Week 16 
Weeks 20, 
24, and 28a 
Serum 25(OH) vitamin D (central 
laboratory)k 
 
X 
Xl 
X 
X 
X 
X 
X 
Asthma assessments (ACT, c-ACT) 
X 
X 
 
X 
X 
X 
X 
 
Concomitant medications review 
X 
X 
 
X 
X 
X 
X 
X 
Adverse event assessment 
X 
X 
 
X 
X 
X 
X 
X 
 
a 
Screening is 14 (±7) days PRIOR to baseline.  Except for Optional Blood Draw and Baseline, days are ±7.   
b 
a focused physical examination will only be done if the participant is asked to stop taking vitamin D and terminates from the 
study.. 
c 
for females of child-bearing potential only; a pregnancy test will also be done if a female participant does not remain in the study 
through Visit 6. 
d 
start of daily diary cards 
e 
weekly adherence will be assessed by diary cards and pill count at visits.  
f 
periodic communication may be via phone, text, or email as participant prefers. Communication will occur at least every other 
week in weeks without a study visit between Visits 2 and 6, and then contact will be made, minimally, during the week prior to 
each Follow-up Visit (visits 7, 8 and 9) 
g 
performed locally; if urine Ca++/Cr ratio is greater than 0.37 on repeat testing [after adequate hydration and within 2 business 
days of initial test], the patient will return for a local serum calcium and 25(OH)D. If urine Ca++/Cr sample is not obtained at the 
scheduled visit, the sample must be obtained within 2 business days. This is necessary because Ca++/Cr is a safety 
assessment. 
h 
leptin plus TNFα, IL-2, IL-6, IL-10, and IL-17 (cytokine panel). These will be drawn by venipuncture at baseline and Visit 6. If 
blood for vitamin D level is drawn by venipuncture (vs fingerstick) at other times, sufficient blood will be collected for inflammatory 
marker determination.  
i 
for participants having venipuncture (vs fingerstick) blood draw 
j 
local laboratory determination of serum 25(OH)D will be performed at week 28 (visit 9). 
k 
blood for central laboratory vitamin D determination can be collected by venipuncture or by fingerstick using a microtainer 
collection tube  
l 
an optional blood draw (fingerstick or venipuncture) can occur any time between week 1 and 3 (from day 7 to day 21, inclusive). 
 
 

Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
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Figure 1.Study Design 
 
 
2 
 
INTRODUCTION 
2.1 STUDY RATIONALE  
Obesity and asthma are epidemic in the United States. Low vitamin D levels have been 
recognized as a common denominator in both inflammatory diseases, making vitamin D 
supplementation a potential low cost, readily available way to ameliorate the shared 
inflammatory aberration in these 2 conditions. A premise of the current study is that 
raising low 25(OH)D levels to greater than or equal to 40 ng/ml will achieve 
immunomodulatory effects beneficial to asthma control among children who are obese. 
Optimal dosing to achieve levels greater than or equal to 40 ng/ml is not known, and 
there is no recommended dose for vitamin D supplementation in this population that will 
reliably achieve a serum 25(OH)D level sufficient to affect inflammation. 
This PK study is being conducted in a population of children with obesity and asthma to 
obtain dosing and safety data to inform the design of a future interventional trial. Since 
the intervention trial will be performed in children with obesity-related asthma, it is 

Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
Sponsor: ISPCTN DCOC 
 
 
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important that this PK study be performed in an identical population. The PK of vitamin 
D are considerably more complex than a standard pharmacological agent because of 
the required stepwise hydroxylation into the active form, 1,25(OH)2 D, and the presence 
of vitamin D and its metabolites in the circulation and tissues. Vitamin D’s binding to the 
vitamin D-binding protein influences the properties of vitamin D metabolites.(1) In fact, 
data from large community-based health maintenance programs predict that 
supplemental vitamin D intake for individuals who are obese should be 2 to 3 times 
higher than for those of normal weight.(2) Therefore, it is imperative that the PK of 
vitamin D supplementation in the target population of  children with asthma and obesity 
be well-studied prior to the design of any intervention study in this population. 
There are confounding variables between asthma, obesity, and vitamin D deficiency. 
We believe studying a group with all 3 variables is important to achieve our goal of 
determining the most appropriate dose for a randomized, controlled intervention trial at 
a later date. Children who are overweight/obese represent an understudied population 
in asthma treatment and the data obtained through this trial will contribute to the 
network’s future studies and to other pediatric studies involving lipophilic compounds. 
The IDeA States Pediatric Clinical Trials Network (ISPCTN) is part of the Environmental 
Influences on Child Health Outcomes (ECHO) program with a focus on the ECHO 
priority areas: upper and lower airway disease; pediatric obesity; neurodevelopment; 
and pre-, peri-, and post-natal outcomes. Its purpose is to provide an opportunity for 
children in IDeA states to participate in clinical trials and to build clinical trial research 
capacity in the IDeA states. The ISPCTN is perfectly suited for this study given the 
prevalence of both asthma and obesity in rural areas (Figure 2) and the inclusion of 
both of these issues in the ECHO portfolio. ISPTCN sites have developed a close 
working relationship with each other and with the central coordinating center. This PK 
study is ideal as a “first in network” trial to build capacity, experience, and to help the 
coordinating center gain experience running a multi-center trial. It will inform us as to the 
ability of this network to recruit participants into future PK and intervention trials. 

Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
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Figure 2. 
Percent of Asthma Patients in Each State Who Are Also Obese 
 
Source: Centers for Disease Control and Prevention Asthma States, CDC.gov 
2.2 BACKGROUND  
Asthma is one of the most common chronic illnesses in childhood and a major cause of 
hospitalization. The incidence and prevalence of asthma have increased since 2000.(3) 
The disease burden of asthma in children includes missed school days, parental work 
absence, limitation of activities of daily living, Emergency Department (ED) visits, and 
hospitalizations. 
Similarly, obesity is a burgeoning problem throughout the United States, particularly in 
rural areas.(4) There is a growing body of literature regarding the effect that obesity has 
on asthma control. The Centers for Disease Control and Prevention report 39% of 
adults with asthma in the United States are obese.(5) There are several aspects of 
obesity that contribute to more severe asthma symptoms including mass loading on the 
chest wall, airway stiffness, and inflammation. Childhood obesity-related asthma likely 
differs from adult-onset obesity-related asthma in that the pro-inflammatory nature of 
adipose tissue may be more critical for children.(6, 7, 8) Supporting this, a study in 
young children with asthma and obesity suggested that obese children are more 
responsive to inhaled corticosteroid therapy than their adult counterparts.(9) 
Vitamin D plays a role in modulating inflammation, and deficiency of this pro-hormone 
may exacerbate poor asthma control. Vitamin D insufficiency/deficiency is common in 
children who are overweight or obese (10) and studies have suggested a relationship 

Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
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between low serum 25(OH)D and asthma symptoms.(11, 12) It is possible that vitamin 
D supplementation could improve asthma control through its anti-inflammatory 
mechanisms. A Cochrane review published in 2016 supported this assertion, although 
noted that better studies, particularly in subpopulations, were needed.(13) A 
meta-analysis of studies in children showed a trend toward fewer asthma exacerbations 
in children given relatively small amounts of supplemental vitamin D.(14) Greater 
supplementation, which is considered to be very safe, may have even more salubrious 
effects.  
The conversion of vitamin D3 to 25(OH)D has been well studied. (15) It is noted that the 
vitamin D-25-hydroxylase operates well below its Vmax in most individuals due to a lack 
of substrate. The Vmax of the conversion of D3 to 25(OH)D occurs when the 2 are in 
equimolar concentrations, which occurs with a 25(OH)D level of approximately 
40 ng/ml. Unfortunately, as the authors state, “…it is very difficult and costly to measure 
circulating vitamin D3 and relate it to circulating 25(OH)D.” As D3 will not be measured, 
the conversion of D3 to 25(OH)D will be considered with absorption of D3 and 
incorporated in the model as extravascular input for 25(OH)D. This approach has been 
used in a previously developed model for vitamin D by Foissac et al.(16) 
The level of 25(OH)D needed to ameliorate asthma symptoms is not known, but is 
believed to be greater than that recommended for bone health, 30 ng/ml. It has been 
suggested that a level of approximately 40 ng/ml is necessary to achieve anti-infective 
and anti-inflammatory activity in cells critical to asthma control.(17, 18) It is unknown 
how much vitamin D (as vitamin D3) should be given to  children who are 
overweight/obese to attain a level of greater than or equal to 40 ng/ml. It is likely a much 
larger dose is needed given the large volume of distribution that excess adipose tissue 
poses (a potential vitamin D sink). A study that combines PK modeling with exploratory 
asthma and inflammatory mediator endpoints is of particular interest given the 
uncertainty regarding an appropriate dose of vitamin D necessary to achieve adequate 
serum levels of 25(OH)D and the need to verify that reaching a level greater than or 
equal to 40 ng/ml will in fact lead to decreased inflammation. We propose this study to 
determine an appropriate regimen for vitamin D supplementation to achieve consistent 
serum 25(OH)D levels greater than or equal to 40 ng/ml, and we will explore its effect 
on markers of inflammation and asthma control. 
Obesity Worsens Asthma Severity in Children 
Uncontrolled asthma is a major public health problem. Each year asthma is a leading 
cause of ED visits, hospitalization, and missed school for children. Obesity in children 
increases the risk for the development of asthma,(19, 20) through unknown means. 
Although there are many mechanical reasons why obesity may cause a predisposition 
to asthma-like symptoms, it is probable that the pro-inflammatory nature of excess 
adipose tissue is a predisposing factor.(6, 21) A recent Expert Panel proposed that 
obesity-mediated metabolic and inflammatory dysregulation contributes to the 
pathogenesis of asthma.(7) Specifically, analysis of data from over 17,000 children 
demonstrated a link between asthma, body mass index, and dyslipidemia.(22) Obesity 
is associated with elevated levels of circulating adipokines and cytokines, including 
leptin, tumor necrosis factor alpha (TNF-α), and numerous interleukins (ILs), all of which 

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can contribute to airway inflammation and asthma.(21, 23) In one study, serum leptin 
levels were found to be elevated in asthmatic children who were obese and higher leptin 
levels were associated with worse airflow through peripheral airways.(24) Several 
studies have demonstrated that obesity in children is associated with worse asthma 
symptom control, reduced lung function, and greater health care utilization.(25, 26, 27). 
Thus, improved asthma control in this high-morbidity group is a leading public health 
need. 
Vitamin D Levels are Lower in Obese Children and Are Associated With Worse 
Asthma Symptoms 
Correcting low vitamin D levels may be critically important for improving asthma control 
in children who are obese. Low vitamin D levels are associated both with obesity in 
children and with difficult-to-treat asthma.(10,12) Turer, et al. observed that 79% of 
overweight children (BMI 85th%-95th%) and 86% of obese children (BMI greater than or 
equal to 95th percentile) met the diagnosis of vitamin D insufficiency (less than 
30 ng/ml).(10) In addition, low 25(OH)D levels are associated with increased markers of 
oxidative stress and inflammation in children who are severely obese.(28) Vitamin D 
has been demonstrated to down-regulate production of pro-inflammatory cytokines such 
as TNFα and IL-6 and inhibit NFĸB activation,(29) processes important to asthma 
control. Polymorphisms in the vitamin D receptor that decrease vitamin D action have 
been associated with the presence of asthma in children and adults.(30) Decreased 
platelet counts have been noted anecdotally in those increasing their vitamin D 
consumption (Scott Weiss, personal communication) and platelets play an important 
role in recruiting effector cells into the lungs of people with asthma .(31) 
Children With Asthma Have Lower Vitamin D Levels 
Low vitamin D levels are found in children with asthma irrespective of body weight. 
There is an association between low vitamin D levels and obesity in childhood. 
However, even children who are not obese but have asthma are at increased risk of 
having low serum 25(OH)D levels. In the Childhood Asthma Management Program 
(CAMP) vitamin D levels were obtained on 1,024 children aged 5 to 12 years who were 
known to have asthma. Thirty-five percent of these children were vitamin D insufficient 
(less than 30 ng/ml).(12) A nationwide study using National Health and Nutrition 
Examination Survey (NHANES) data saw a positive correlation between vitamin D 
insufficiency defined as serum 25(OH)D level less than 30 ng/ml and current asthma or 
current wheeze in children.(32) An examination of data from the Childhood Asthma 
Study from Australia found that 25(OH)D deficiency (less than 20 ng/ml) early in 
childhood is associated with an increased risk for persistent asthma.(33) These lower 
levels may be due to increase exposure to oral and inhaled corticosteroids used to treat 
asthma, decreased sun exposure due to exercise induced symptoms limiting outdoor 
activities, or a primary effect of asthma on vitamin D metabolism.(34) It will be 
important, therefore, to evaluate the relationship between asthma, obesity, and vitamin 
D pharmacokinetics as a whole since the target population for an intervention trial will 
be  children who have both asthma and weight-related issues.. 

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Low vitamin D levels put people at risk for a multitude of inflammatory disorders 
including asthma.(35) (Figure 3) Several high quality controlled trials have shown that 
low vitamin D levels place asthmatic children at high risk for severe 
exacerbations.(12, 36) Gupta and collaborators found lower vitamin D levels in children 
who had difficult-to-treat asthma or poor asthma control,(37) and vitamin D deficiency 
has been associated with lower pulmonary function in obese children.(38) 
In a longitudinal study, Hollams and colleagues found that the number of times a child 
was found to be deficient in vitamin D (defined as a level of less than 20 ng/ml) was 
positively associated with the risk for asthma and wheezing at 10 years of age, 
suggesting that low vitamin D is instrumental in the inception of asthma.(33) In addition, 
several studies have concluded that higher 25(OH)D levels appear to protect against 
respiratory infections, a key trigger for asthma exacerbations.(39, 40) 
 
Figure 3. 
 Role of Vitamin D in the Immune System 
 
Source: Lin Z, Li W. Vitamin D and Inflammatory Diseases. Current Top Med Chem. 
2016; 16(11), 1242-61 
The Optimal 25(OH)D Level for Treating Asthma 
Obesity among adults with asthma is associated with more severe symptoms and a 
reduced response to conventional anti-inflammatory asthma treatments. The Endocrine 
Society states that vitamin D deficiency occurs at levels less than 20 ng/ml and vitamin 
D insufficiency is present when levels are 21 to 29 ng/ml. (59) Vitamin D insufficiency 
and deficiency are generally defined in terms of calcium metabolism and bone health. 
Non-calcemic effects of vitamin D are well known, but the Endocrine Society does not 
recommend specific levels to achieve effects outside of bone health and fall prevention. 
The precise level one needs to achieve to have an effect on infection and inflammation 

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is not known. However, several studies indicate that this is likely greater than or equal to 
40 ng/ml.(33, 29) 
The anti-infective and anti-inflammatory effects of vitamin D appear to occur when 
serum levels are high enough to achieve adequate cellular levels of 1,25 hydroxy-
vitamin D3 (1,25D3). The expression of many genes in inflammatory cells including 
macrophages, dendritic cells, T helper cells, and B cells is regulated by 1,25D3 through 
the vitamin D receptor. Despite levels of 25(OH)D greater than 30 ng/ml being adequate 
for bone health, higher levels may be necessary to achieve maximal extra-orthopedic 
vitamin D effects. Hollis, et al. showed that optimal conversion of vitamin D3 to 25(OH)D 
occurs when serum levels of 25(OH)D are greater than or equal to 40 ng/ml.(15) 
Further, Ginde et al. reviewed NHANES 2003 to 2006 data and found that optimal 
vitamin D status, defined by estimated maximum parathyroid hormone (PTH) 
suppression, does not occur until 25(OH)D levels are greater than or equal to 40 ng/ml. 
(41) This study included nearly 6000 children between 6 and 19 years old. In a 
prospective study, Sabetta et al. (40) found that maintaining a serum 25(OH)D level 
above 38 ng/ml could reduce the risk of acute viral respiratory tract infections in adults. 
Another study found that pre-eclampsia did not occur in women who had 25(OH)D 
levels greater than 37 ng/ml early in pregnancy.(42) These studies imply that higher 
levels of 25(OH)D are necessary to achieve the desired effects beyond bone health. 
Indeed, a small number of asthma studies support this target. In the Childhood Asthma 
Management Program (CAMP) study, the risk of exacerbations was inversely 
associated with 25(OH)D with the lowest risk seen with levels greater than or equal to 
40 ng/ml.(12) Similarly, the large Vitamin D Add-on Therapy Enhances Corticosteroid 
Responsiveness in Asthma (VIDA) study reported trends toward improved asthma 
control in a population of adults who achieved a mean 25(OH)D level of 41.9 ng/ml at 
12 weeks of treatment.(43) The 95% confidence interval around this mean was quite 
small, implying that benefit begins to be seen at this level. Some studies of 
supplementation of vitamin D have not shown a positive effect on asthma control; 
however, serum 25(OH)D levels greater than or equal to 40 ng/ml were not achieved 
routinely. Due to these uncertain findings, a 2016 Cochrane review of vitamin D 
supplementation in asthma noted that the optimum circulating level is as yet 
undetermined.(13) They note that there is a need for primary trials in under-represented 
populations to determine this goal. We hope to fill this knowledge gap by aiming to 
achieve a level that will provide supporting evidence for anti-inflammatory benefits at an 
appropriate serum level. 
Vitamin D Trials in Children with Asthma Are Few but Encouraging 
Few controlled trials involving vitamin D supplementation have been conducted in 
children with asthma. Those that have been done have been small but encouraging. A 
recent meta-analysis of vitamin D supplementation trials in children found that 
supplementation is likely to reduce the risk of asthma exacerbations.(14) The analysis 
included 8 randomized trials of greater than 570 children treated for 1 to 12 months with 
a dose that ranged from 1000 IU per day to 60,000 IU per month. The authors 
concluded that children receiving vitamin D had reduced odds of exacerbation 

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compared to placebo treated children, although the evidence was weak. It should be 
noted that few children achieved a serum 25(OH)D level of greater than or equal to 
40 ng/ml, and serum levels were not reported for most studies. None of the trials were 
designed to achieve a target 25(OH)D level greater than or equal to 40 mg/ml. 
A similar meta-analysis was performed in adults taking vitamin D supplementation and 
showed a significant reduction in asthma attacks requiring ED visits in those 
supplemented.(44) Again, serum levels greater than or equal to 40 ng/ml were not 
necessarily reached. Kerley and colleagues evaluated 17 intervention trials of vitamin D 
supplementation involving 1578 asthmatic adults and children.(45) Study size, vitamin D 
dose, age of participants, and study lengths differed, making comparisons among these 
17 trials difficult. Results were generally supportive of supplementation, including 
decreased exacerbations in newly diagnosed children (46) and decreased airway 
eosinophilia.(47) The Cochrane review of 7 trials involving 435 children and 2 trials of 
658 adults concluded that improved vitamin D levels reduced the risk of asthma 
exacerbations; however, vitamin D supplementation had no effect on lung function as 
assessed by Forced Expiratory Volume in 1 Second.(13) Spirometry does not appear to 
be an important endpoint for a vitamin D-asthma study. 
Determining Optimal Supplemental Dose Needed to Achieve 25(OH)D Levels 
Above 40 ng/ml 
Scott Weiss and Augusto Litonjua have studied the asthma-vitamin D link extensively. 
As they state, “The biology of vitamin D is complex…we feel there is much more to 
uncover, such as the dose and timing of supplementation and the level that maximizes 
protection.”(18) 
We have examined previous studies of vitamin D supplementation in adults and children 
in order to try to determine the best way to achieve adequate serum 25(OH)D levels in 
children who are overweight or obese. Two months of treatment with vitamin D at a 
dose of 5000 IU daily increased mean 25(OH)D levels from 15 to 40 ng/ml in a small 
study of children who were obese  (n=14).(48) 
A vitamin D3 supplementation trial of 4000 IU daily for 6 months was conducted in 
adolescents with diabetes and obesity.(49) After 3 months, levels increased from an 
average of 19 ng/ml to roughly 35 ng/ml (mean increase at 3 and 6 months was 
15 ng/ml and 19.5 ng/ml, respectively). Treatment was well tolerated. Importantly, this 
study did not include a loading dose, yet yielded a substantial increase in 25(OH)D in 
just 3 months in adolescents who were obese. Maximum levels were not achieved until 
6 months, consistent with the long half-life of vitamin D. 
A loading dose is the amount of drug designed to fill the central volume of distribution 
for a drug to a concentration that matches the final plateau concentration achieved with 
the maintenance dose.(50) Loading doses are used in order to achieve this final plateau 
sooner than the four half-lives required if the drug is simply administered at the 
maintenance dose rate.(51) The functional half-life for vitamin D3 is extremely long and 
ranges from 2 to 3 months (52, 53) or longer (54), largely due to the lipophilic nature of 
the drug and its distribution into adipose tissue. The clinical effect of this long 

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elimination half-life and high volume of distribution is that dose adjustments require 4 to 
5 half-lives to reach steady-state conditions. Thus, achieving target concentrations 
through a loading dose strategy should allow individuals to achieve target 
concentrations more quickly (51) and have a more rapid therapeutic effect. 
Limited studies have examined the benefit of a loading dose of vitamin D on obtaining 
the desired 25(OH)D concentration.(50) Luger examined 2 dose regimens in adults with 
morbid obesity following gastric by-pass surgery; a loading dose (up to 300,000 IU over 
4 weeks, divided into 3 doses) achieved the desired vitamin D concentration more 
rapidly than the standard regimen. Radhakishun examined weekly vitamin D treatment 
with 25,000 IU in 109 multi-ethnic obese children, 8 to 18 years of age, with vitamin D 
insufficiency/deficiency.(55) In 84.4% of the children, the vitamin D status improved 
from deficiency (less than 20 ng/ml) to insufficiency/sufficiency (greater than or equal to 
20 ng/ml). No side effects were reported, and the highest level reached was far below 
the threshold for toxicity.(55) Van Groningen evaluated 3 loading dose strategies in 208 
vitamin D deficient adults (ages 18-77 years). This study found that greater responses 
in vitamin D status were observed as a function of increasing loading dose.(56) A study 
by Alansari, et al. gave 6 to 14 year-olds 600,000 IU by intramuscular injection as a 
loading dose followed by just 400 IU daily.(57) Participants who received the loading 
dose demonstrated a 7 ng/ml greater increase in 25(OH)D than participants who did not 
receive the loading dose. 
In the VIDA trial, a large-scale vitamin D supplementation trial in mainly 
overweight/obese adults with asthma and vitamin D deficiency (mean BMI = 30, mean 
25(OH)D less than 20 ng/ml), participants received a single oral vitamin D3 loading 
dose of 100,000 IU and 4000 IU daily. This resulted in a mean 25(OH)D level of 
41.9 ng/ml at 12 weeks (43), highlighting the benefit of a large loading dose in this 
population. 
Of concern is that most of these studies did not achieve a level over the presumed 
threshold of 40 ng/ml needed to achieve an anti-inflammatory effect in a majority of their 
participants. Discussions with endocrinologists, pulmonologists caring for patients with 
cystic fibrosis, and colleagues in Lipid and Weight Management clinics have raised 
concerns about achieving our desired goal even with doses similar to those used above. 
It is likely that even higher doses will be needed to achieve a level greater than or equal 
to 40 ng/ml in a large proportion (75%) of participants who have large lipid stores. To 
obviate this concern, we will use a dose approximating that used by Benechia, et al (49) 
and a higher dose of 10,000 IU/day. The use of a loading dose in 2 groups and the lack 
of such a dose in another treatment group and the standard of care group will allow PK 
modeling to determine an optimal dose to get 25(OH)D levels greater than or equal to 
40 ng/ml consistently. 
 
 

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Inclusion of Children With Both Asthma and Obesity 
It is the intention of this study to serve as a dose finding study for a large, randomized, 
controlled intervention trial in overweight/obese children with asthma in the future.  
It is self-evident that to determine the best dose of vitamin D to use in a study of 
children who are obese and have asthma, we should study the PK of vitamin D in 
children who are obese and have asthma. 
There are several reasons that children with both asthma and obesity should be 
included in this study: 
1. Children with asthma and obesity may differ in vitamin D status and response to 
supplementation compared to children who are only obese. 
2. Most children with persistent asthma symptoms are currently treated with inhaled 
corticosteroids. Both inhaled and oral corticosteroids can affect vitamin D levels.(34) 
3. Previous studies of vitamin D levels in non-obese children with asthma have 
demonstrated the presence of low levels of 25(OH)D in many, which raises the 
possibility of direct asthma-vitamin D metabolism interactions. 
4. Children with asthma may spend more time inside and have decreased exposure to 
sunlight due to exercise-induced asthma symptoms. 
5. In contrast to children with asthma, where there is at least a theoretical benefit to 
high vitamin D levels, there is no evidence to support the need for 25(OH)D levels 
greater than equal to 40 ng/ml in children who are obese and do not have asthma. 
Exposing children with no potential for benefit to higher doses of vitamin D raises 
ethical concerns. 
6. Including children with asthma allows for collection of preliminary data on the effect 
of vitamin D supplementation on inflammatory markers in a group of children 
suffering from an inflammatory disease.  
7. Including children with asthma in the PK study is important to help develop research 
capacity in this nascent network. By asking sites to collect diary cards and 
administer the ACT and record results on case report forms (CRFs) we will build 
infrastructure and test feasibility for a more sophisticated and intricate asthma study 
at a later date.  
8. Review of the literature reveals that there are few data available on the effects of 
vitamin D administration in specific patient groups, such as obese children with 
asthma.   
We believe this PK pilot study will be most applicable to our final target population if it 
includes children with both asthma and obesity. 

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Pharmacokinetic Considerations 
Ekawaru evaluated 17,614 patients receiving vitamin D and characterized the resulting 
vitamin D concentrations.(2) The relationship between dose and 25(OH)D appeared to 
be a non-linear, exponential curve, whereby dose adjustments increased vitamin D 
concentrations to a point, at which levels began to plateau. BMI, rather than absolute 
body weight, was found to be the better determinant of the 25(OH)D level. Obese and 
overweight participants had serum 25(OH)D levels that were 8 ng/ml and 3.2 ng/ml 
lower, respectively (p<0.001), than normal weight participants. Due to the long half-life 
of 25(OH)D a minimum of 3 months of daily administration is required to attain steady-
state concentrations of 25(OH)D.(58) 
Safety of Vitamin D Supplementation 
Vitamin D supplementation is extremely safe.(2) Accepted normal serum values for 
25(OH)D levels range widely. Some expert groups feel that values less than 30 ng/ml 
are abnormal, whereas others feel that 20 ng/ml is the lower limit of normal. The upper 
bound of normal serum 25(OH)D in most laboratories is 100 ng/ml, however toxicity is 
unlikely to occur at levels less than 150 ng/ml.(59) No published supplementation trials 
to our knowledge (including those with loading and daily doses far exceeding our 
proposed dosing) have experienced levels exceeding this safe level. Numerous 
published trials have demonstrated that the doses we will evaluate are well within a safe 
dosing range. Recent published dosing regimens including 4000 IU daily for 6 months 
(49) and repeated 600,000 IU intramuscular loading doses every 3 months over a 
6 month period were well tolerated with no untoward effects.(57) Young adults with 
vitamin D deficiency have been treated with 50,000 IU weekly for 8 weeks and then 
continued on 50,000 IU every other week for up to 6 years without serious side effects 
or changes in serum calcium levels.(60) Doses as high as 55,000 IU daily have been 
administered to obese adults without causing hypercalcemia,(2) and loading doses of 
200,000 IU administered to normal weight adults were not associated with 
hypercalcemia.(51) Celedon and colleagues are currently conducting an NIH-funded 
trial in 4 to 12-year-olds (61) giving 4000 IU daily for 48 weeks. From personal 
communication with the study team, we understand there have been no SAEs. 
Some drugs interfere with vitamin D absorption or metabolism.(62) These include 
glucocorticoids, some anti-epileptics, orlistat, and cholestyramine, which have been 
shown to lower 25(OH)D levels. There is a theoretical concern for hypercalcemia when 
vitamin D is taken with thiazide diuretics and supplemental calcium. Only 3 such cases 
of hypercalcemia have been reported. These reports were from 2 studies, both involving 
elderly patients, and the cases of hypercalcemia were mild and reversible.(63) 
Evaluation of Inflammatory Mediators 
Obesity is a pro-inflammatory state characterized by increased circulating levels of 
adipokines including leptin. It is postulated that the inflammation caused by increased 
leptin is a contributing factor to the asthma-obesity dyad in children. It will be useful to 
examine the anti-inflammatory effects of vitamin D on certain biomarkers. Leptin 

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promotes the release of TNF-α and IL-6 from endotoxin-treated macrophages and 
lymphocytes.(64) In a study of adults, TNF-α, IL-6, and leptin levels were higher in 
obese asthma patients compared to non-obese asthma patients.(65) IL-17 is another 
proinflammatory mediator that regulates tissue inflammation in asthma.(66) Its activity 
can be inhibited by vitamin D.(67) 
Conversely, IL-10 is an anti-inflammatory cytokine. In a mouse model of allergic 
asthma, 1,25 vitamin D3 has been shown to induce IL-10 release and enhance the 
effect of immunotherapy.(68) 
Examining the effect of vitamin D on leptin plus IL-2, IL-6, IL-10, IL-17, TNF-α (cytokine 
panel) will help assess its anti-inflammatory role in obesity-related asthma. This will be 
important to support the benefit of achieving a high level of vitamin D (greater than or 
equal to 40 ng/ml) in an intervention trial. 
2.3 RISK/BENEFIT ASSESSMENT  
2.3.1 KNOWN POTENTIAL RISKS  
Compared to most medications, there are few risks to vitamin D supplements. No 
adverse reactions are listed in the manufacturer’s labeling (69). Levels greater than 
100 ng/ml have been well tolerated without significant side effects.(70) The Endocrine 
Society’s practice guidelines on vitamin D state that vitamin D intoxication is usually not 
observed until serum 25(OH)D levels are greater than 150 ng/ml.(59) Vitamin D 
intoxication associated with hypercalcemia, hyperphosphatemia, and suppressed 
parathyroid hormone level may occur, but is typically only seen in patients who are 
receiving massive doses of vitamin D (50,000 to 1 million IU per day for several months 
to years).(70) Symptoms of vitamin D intoxication may include nausea, vomiting, loss of 
appetite, constipation, dehydration, fatigue, irritability, confusion, weakness, and/or 
weight loss(69). Hypersensitivity reactions to vitamin D supplementation are rare but 
possible. Vitamin D3 is a weak inhibitor of CYP2C9 and may cause drug interactions, 
although this is considered very rare. 
Multiple studies have demonstrated the safety of vitamin D supplementation in 
pregnancy. Hollis et al. showed that giving pregnant women 4,000 IU/day was safe (71), 
and another study demonstrated the safety of a single dose of 70,000 IU in pregnant 
women.(72) In fact, several studies have explicitly looked for the potential benefit of 
vitamin D supplementation to the mother and fetus and found no harms.(73, 74, 75) 
However, we will not enroll pregnant women in this study and will ask all females of 
child-bearing potential to utilize some form of birth control (abstinence qualifies). 
Risks of blood draws are minimal and include fainting, bruising, and mild pain. There 
are small risks to blood sampling, such as pain/discomfort due to the collection process 
or blood loss. Local pressure will be applied at blood drawing sites to minimize the risk 
of bruising, and participants who become light-headed will be placed in a supine 
position. The maximum amount of blood that could be collected per participant over the 
course of the study is approximately 76.4 ml, and the largest amount of blood drawn in 

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a single day is 10.6 ml. Both amounts are well below the daily and sustained limits for 
blood collection in pediatric participants. These amounts will be even lower if 
microtainer collection of fingerstick samples is used and participants opt out of optional 
measures – the minimum required amount of blood drawn per participant over the 
complete course of the study is approximately 23.6 ml.  
Protocol elements to mitigate risk include the exclusion of participants with known 
hypercalcemia, kidney stones, significant renal or parathyroid disease, and/or known 
diseases complicated by elevated 25(OH)D levels, including sarcoidosis, William 
Syndrome, and granulomatous diseases. Kidney stones are a known complication of 
hypercalcemia and hypercalcuria. Spot urine calcium/creatinine ratios will be monitored, 
and serum calcium levels will be obtained in any participant with elevated urine 
calcium/creatinine ratios.  
2.3.2 KNOWN POTENTIAL BENEFITS  
Participant Impact 
Because inclusion criteria include a serum 25(OH)D less than 30 ng/ml —a level 
considered to be vitamin D insufficient (59) — participating in this study may increase a 
participant’s serum 25(OH)D into the normal range, which potentially could improve 
bone health. The comparator group will be provided the Institute of Medicine’s 
recommended daily allowance of vitamin D – 600 IU/day.(76) Prior research has shown 
a trend toward improved asthma control or fewer symptoms in children who have higher 
levels of vitamin D. It is possible that children in this study may experience fewer and 
less severe asthma exacerbations with increased serum 25(OH)D levels; however, this 
cannot be guaranteed. The participants may learn basic information about nutrition and 
asthma by taking part in this study, potentially resulting in additional health benefits. 
Public Health Impact 
Both asthma and obesity are major public health problems, each contributing 
significantly to the burden on healthcare systems, patients, and families. Asthma and 
obesity are particularly prevalent in lower socioeconomic, underserved populations. The 
Centers for Disease Control and Prevention reports that up to 39% of individuals with 
asthma are obese, giving a comorbid condition of obesity-related asthma. Notably, 
obesity is more common in rural areas than in urban areas according to the US 
Department of Health and Human Services.(77) Vitamin D is an inexpensive nutritional 
supplement. A low-cost, readily available intervention that could decrease the burden of 
asthma in the obese asthma pediatric population could have major public health 
implications. Although speculative at this time, the proposed intervention has the 
capacity to improve public health in an underserved population with little expense if the 
correct dose can be determined and shown to be beneficial.  

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2.3.3 ASSESSMENT OF POTENTIAL RISKS AND BENEFITS  
All participants randomized will have vitamin D insufficiency and participation in this 
study will lead to appropriate supplementation. Benefits may be related to improved 
25(OH)D level effects on bone health with a potential for a positive effect on asthma 
control. Risks of blood draws are minimal and not outside those encountered in daily 
living. We will provide the option for fingerstick collection of small volumes of blood for 
vitamin D level determination in order to lessen the anxiety of venipuncture in children. 
Risks will be mitigated by implementation of inclusion and exclusion criteria that 
decrease the chance of any hypercalcemia-associated problems and by monitoring 
urine calcium/creatinine ratios. 
3 
OBJECTIVES AND ENDPOINTS 
 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR 
ENDPOINTS 
Study 
 
 
The overall objective of the 
study is to determine the 
pharmacokinetics of vitamin 
D supplementation in children 
who have asthma and are 
overweight or obese. 
Pharmacokinetic analysis of 
vitamin D supplementation 
in children who have 
asthma and are overweight 
or obese 
PK characteristics of 
25(OH)D following 
vitamin D3 
supplementation are 
not known in this 
population. 
Part 1 
Identify dosing to use in Part 
2 using PK analysis on a 
subset of participants 
Serum 25(OH)D will be 
evaluated at Baseline and 
various times including 
post-dose elimination to 
determine preliminary PK 
analysis for the best dose 
for increasing vitamin D 
levels above 40 ng/ml in 
children with asthma who 
are overweight or obese 
PK characteristics of 
25(OH)D following 
vitamin D3 
supplementation are 
not known in this 
population. 
Part 2 
Determine the effectiveness 
of a recommended 16-week 
dosing regimen to achieve a 
serum level of 25(OH)D 
greater than or equal to 40 
ng/ml in vitamin D insufficient 
or deficient children who have 
asthma and are overweight or 
obese.  
Did participants in the Part 
2 active dosing cohort 
achieve a serum 25(OH)D 
of greater than or equal to 
40 ng/ml at 16 weeks 
 
Serum 25(OH)D level 
greater than or equal to 
40 ng/ml has been 
implicated to be 
anti-inflammatory. 

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OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR 
ENDPOINTS 
Safety 
Assess the safety and 
tolerability of oral vitamin D3 
Adverse events (AEs), 
serious adverse events 
(SAEs), adverse reactions 
(ARs), and serious adverse 
reactions (SARs) 
Assessing safety is 
important to 
determining tolerability 
of vitamin D in this 
study population. 
Exploratory 
 
 
1. Characterize selected 
inflammatory markers in 
children receiving vitamin 
D3 supplementation. 
2. Characterize asthma 
symptoms in children 
receiving vitamin D3 
supplementation.  
3. Compare the proportion of 
participants randomized to 
receive an optimal dose of 
vitamin D based on PK 
data versus those who are 
exposed to standard of 
care doses that achieve 
serum 25(OH)D greater 
than or equal to 40 ng/ml. 
1. Inflammatory biomarker 
panel including serum 
leptin plus TNFα, IL-2, 
IL-6, IL-10 and IL-17 
(cytokine panel) 
2. Asthma exacerbations 
3. Asthma symptom days 
(ASDs) 
4. Asthma control test 
(ACT) (or childhood 
asthma control test [c-
ACT] for participants 
less than 12 years of 
age) 
5. Differences in the 
proportion of 
participants that achieve 
serum 25(OH)D levels 
greater than or equal to 
40 ng/ml 
Vitamin D levels are 
negatively associated 
with asthma symptoms, 
and supplementation 
has improved asthma 
outcomes in children. 
The anti-inflammatory 
effect of vitamin D may 
underlie its utility in 
asthma. Assure that 
any increases in 
vitamin D levels in the 
experimental group are 
not solely the impact of 
unmeasured factors. 
4 
STUDY DESIGN  
4.1 OVERALL DESIGN 
The trial will comprise a Dose Finding part (Part 1) and a Dose Confirming part (Part 2). 
A total of 50 children age 6 years to less than 18 years were randomized to 4 cohorts 
(1:1:1:1) (Table 2) during Part 1. An interim PK analysis was performed when at least 
4 participants in each cohort had completed PK sampling at Week 20 (visit 7; 
days 137-143). Interim PK analysis yielded PK parameters, and a recommended dosing 
regimen to achieve 25(OH)D greater than or equal to 40 ng/ml in greater than or equal 
to 75% of participants was determined. In Part 2, up to 63 children will be randomized to 

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the recommended dose (Single 50,000 IU loading dose + 8,000 IU daily dose) or a 
standard of care dose of 600 IU/day (2:1). 
The age range of 6 to less than 18 years encompasses the major population of children 
who have both clinical asthma and obesity. 
Table 2. 
Dosing Schemes for Vitamin D3 in Part 1 (Dose Finding) 
Cohort 
N 
Loading Dose (IU) 
Maintenance Dose (IU/day) 
1 
4-8 
50,000 
                      6,000 
2 
4-8 
50,000 
                    10,000 
3 
4-8 
0 
6,000 
4 
4-8 
0 
              600 (SoC) 
 
Participant Enrollment and Randomization 
There will be enrollment at ISPCTN sites with the goal of enrolling up to 150 participants 
and randomizing up to 50 for Part 1 and enrolling up to 171 participants and 
randomizing up to 63 participants for Part 2. During the interim analysis, enrollment 
continued, which explains the 50 participants randomized in Part 1. 
Study Timeline 
We anticipated initiating enrollment in the fourth quarter of 2018. Actual enrollment 
started in January 2019. 
4.2 SCIENTIFIC RATIONALE FOR STUDY DESIGN 
Low serum 25(OH)D levels are associated with both asthma and obesity in children. 
Obesity is associated with greater asthma severity. A premise of the current study is 
that raising low 25(OH)D levels to greater than or equal to 40 ng/ml will achieve 
immunomodulatory effects beneficial to asthma control among obese children. The 
optimal dosing strategy of vitamin D for obese and overweight adolescents with asthma 
and vitamin D insufficiency is unknown. Identifying the appropriate dosing regimen for 
this population lays the foundation for future efficacy trials, which may be of great public 
health benefit. 
The nonlinear PK of vitamin D3 has been reported in adults, but it is not well studied in 
children. The multi-level dosing strategy in this study will result in sufficient PK data to 
better characterize the dose-response relationship of 25(OH)D after vitamin D3 
administration. The PK data will be used to model vitamin D dosing regimens that 
would, based upon the disposition characteristics of the compound, produce a degree of 
systemic exposure sufficient to produce plasma 25(OH)D concentrations greater than or 
equal to 40 ng/ml (the putative therapeutic target concentration). 

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4.3 JUSTIFICATION FOR DOSE 
Based on published data involving children with obesity, the optimal dosing regimen to 
achieve serum levels greater than or equal to 40 ng/ml will likely be within the range of 
doses of vitamin D3 evaluated in Part 1. Based on PK models of vitamin D in adults, the 
increase in 25(OH)D after vitamin D3 dosing is not linear, but is influenced by the 
baseline value. A study in obese adults with vitamin D deficiency reported that mean 
(SD) measured increments in 25(OH)D at Week 21 were 12.4 (9.7) ng/ml, 27.8 (10.2) 
ng/ml, and 48.1 (19.6) ng/ml following vitamin D3 treatment at 1000 IU/day, 
5000 IU/day, and 10,000 IU/day, respectively. Assuming a median baseline of 
~20 ng/ml, 5000 IU/day would lead to greater than 50% of participants with 25(OH)D 
greater than or equal to 40 ng/ml and 10,000 IU/day would lead to greater than 75% 
participants with 25(OH)D greater than or equal to 40 ng/ml after 21 weeks. To ensure 
the appropriate exposure of vitamin D in obese children with asthma and in anticipation 
of a future intervention study, the present study will examine the effect of a loading dose 
regimen, followed by daily dosing. 
Belenchia et al. found that giving obese adolescents with diabetes 4000 IU/day vitamin 
D3 led to a mean increase in serum 25(OH)D of 19.5 ng/ml at 6 months.(49) That study 
did not use a loading dose. Assuming our cohort has a similar mean baseline 25(OH)D 
concentration, we anticipate that we will need more than 4000 IU/day to get 75% of 
participants above the desired goal of 25(OH)D level of greater than or equal to 
40 ng/ml. This is also supported by a study in obese children with vitamin D deficiency, 
which reported a mean serum 25(OH)D increasing from 15 to 40 ng/ml after 
5000 IU/day orally for just 2 months (48). Our group of children, which will include some 
participants greater than 99th% BMI for age and sex, may require even greater amounts 
of vitamin D3. 
Vitamin D dosing arms for a PK study 
We explored 3 dosing arms and a SoC arm in Part 1 of this PK trial. Nutrient studies 
cannot have a true placebo arm since all participants are exposed to some level of 
vitamin D. An SoC arm has been included to allow for evaluation of changes in 
25(OH)D over 16 weeks in a population of participants who are not exposed to high 
levels of vitamin D. A placebo arm is not appropriate because it is unethical to identify a 
treatable metabolic deficiency and not intervene.(78) Although the Endocrine Society 
recommends higher doses for replenishment, the Institute of Medicine recommends 
600 IU/day for vitamin D supplementation as SoC.(76) We used this for the comparator 
group. Given that it is a log-order less than the lowest dose in our treatment arm, it 
should still act as a reasonable control group. This low dose supplementation also 
enriched the PK modeling. 
 
 

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This is a randomized study with Part 1 randomization being 1:1:1:1. 
Part 1: 
• Cohort 1: Single 50,000 IU loading dose + 6,000 IU daily dose 
• Cohort 2: Single 50,000 IU loading dose + 10,000 IU daily dose 
• Cohort 3: no loading dose + 6,000 IU daily dose 
• Cohort 4: no loading dose + 600 IU daily dose (SoC) 
We performed interim analysis when a minimum of 4 participants in each group had 
completed 16 weeks of therapy and had a 20-week serum level drawn. Participants 
continued to be randomized to one of these 4 groups while the analysis took place. 
Their data will be collected and utilized in the end-of-study PK modeling.  
Following the interim analysis (see statistical methods below), we determined the dose 
most likely to achieve the Part 2 endpoint of greater than 75% of participants achieving 
a serum 25(OH)D level greater than or equal to 40 ng/ml. The selection was based on 
the interim PK analysis as well as safety and tolerability data. This dose is not any of the 
pre-determined arms used in Part 1.  
The DCOC submitted data from Part 1 to the pharmacokinetic analysis team at Duke in 
November 2019.  Based on the PK data, the VDORA1 study team proposed that the 
dosing regimen that consisted of a single 50,000 IU loading dose + 8,000 IU daily dose 
be used for part 2.  The ECHO ISPCTN Data Safety and Monitoring Board (DSMB) met 
on February 13, 2020, to review the recommended dose along with a data report 
prepared by the DCOC.  The DSMB approved of the recommended dose. 
We will continue to recruit into the SoC arm. These SoC participants will serve as a 
control/comparator group to help us understand the effect of latitude, season, ethnicity, 
diet, and skin tone on vitamin D metabolism. This group will also be useful when 
assessing our ability to achieve serum level greater than or equal to 40 ng/ml in the 
Part 2 intervention group. 
Part 2 will randomize up to 63 additional participants into one of two 16-week regimens 
in a 2:1 ratio: 
Part 2: 
• Cohort A: Single 50,000 IU loading dose + 8,000 IU daily dose 
• Cohort B: 600 IU daily dose (SoC) 
4.4 END OF STUDY DEFINITION 
The end of the study will be at the completion of the study activities of the 
63 randomized participants in Part 2 of the study. For individual participants, the end of 
the study will be following the Week 28 (visit 9; day 196 ±7) follow-up visit, following 
participant withdrawal of consent or when the participant has met the protocol-defined 
criteria for study termination.  

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5 
STUDY POPULATION 
5.1 INCLUSION CRITERIA 
In order to be eligible to participate in this study, an individual must meet all of the 
following inclusion criteria: 
• Greater than or equal to 6 and less than 18 years of age at screening (Visit 1) 
• BMI greater than or equal to 85% for age and sex 
• Physician-diagnosed asthma 
• Ongoing relationship with asthma provider responsible for asthma care (can be 
specialist or primary care provider) 
• Serum 25(OH)D level greater than or equal to 10 ng/ml but less than 30 ng/ml at 
screening (Visit 1) based on local laboratory test 
• Ability to swallow pills similar in size to the vitamin D preparation to be used 
(Vitamin D supplements will be provided in the form of a size 2 capsule. See 
Section 6.2.2 for additional information.) 
• Signed consent from his or her parent, legal guardian, or caregiver and signed 
assent from participant (as appropriate) 
• Females of child-bearing potential must not be pregnant, must not be lactating, 
and must agree to practice adequate birth control method (abstinence, single 
barrier methods, combination barrier and spermicide, or hormonal) for the 
duration of the study 
• Child and parent, legal guardian, or caregiver must speak English or Spanish 
5.2 EXCLUSION CRITERIA 
An individual who meets any of the following exclusion criteria will be excluded from 
participation in the study: 
• Known diseases of calcium metabolism or the parathyroid 
• History of renal insufficiency or kidney stones 
• Known liver failure or history of abnormal liver function which is deemed by the 
site investigator to be clinically significant 
• History of Williams syndrome, sarcoidosis, or granulomatous disease 
• Active tuberculosis 

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• Spot urine calcium/creatinine ratio greater than 0.37 on 2 consecutive visits. If 
the ratio is greater than 0.37 on the first visit, this test must be repeated once - 
following adequate hydration, within 2 business days of the study team being 
notified of the initial lab results. 
• Clinical evidence of rickets  
• Taking supplemental vitamin D greater than 1000 IU per day 
• Administration of an excluded medication (systemic glucocorticoids, drugs 
affecting calcium metabolism, drug affecting fat absorption) within 30 days prior 
to study enrollment – at screening (Visit 1) or at any time during the run-in period. 
• Other medical issues that in the opinion of the investigator put the participant at 
risk or affect results of the study (e.g., fat malabsorption, cystic fibrosis, chronic 
lung disease of prematurity, congenital heart disease). Type 2 diabetes is not an 
exclusion criterion. 
• Plans to move out of the study area in the next 9 months 
• There is another child in the household enrolled in the study 
• Plans for significant lifestyle changes in the next 9 months (significant dietary 
changes while enrolled in the study) 
• Participants who are eligible for the run-in period will be ineligible for 
randomization if they do not demonstrate adherence to run-in procedures (return 
diary cards with a completion rate greater than or equal to 75%) 
5.3 LIFESTYLE CONSIDERATIONS 
Participants will be advised to not use a tanning bed and to not make significant lifestyle 
changes (significant dietary changes or changes in their use of sunscreen) while 
enrolled in the study. Study participants will receive basic health information about the 
risks of obesity. 
5.4 SCREEN FAILURES 
A screen failure will be defined as a participant who consents to participate in the 
clinical trial but does not enter the treatment phase of the study. A minimal set of 
information (demography, informed consent process, reason for screen failure, eligibility 
criteria, and any AEs) is required for documentation of screen failures to ensure 
transparent reporting to meet the Consolidated Standards of Reporting Trials 
(CONSORT) publishing requirements and to respond to queries from regulatory 
authorities. Individuals who do not initially meet eligibility criteria may be rescreened 
1 time at least 4 weeks later.  Participants who were terminated due to a screen fail 
must sign new consent/assent documents prior to rescreening.  Rescreened 
participants should be assigned the same participant number as for the initial screening. 

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5.5 STRATEGIES FOR RECRUITMENT AND RETENTION 
Though there are many children with both asthma and obesity, especially in the rural 
IDeA states, recruitment and retention of eligible participants will be critical to study 
success. We anticipate that we will need a large number of sites involved in this trial in 
order to recruit the necessary participants. This study will recruit (enroll) up to 321 
participants for a study lasting over 6 months. Although vitamin D supplementation is 
safe and easy to administer, there are several scheduled blood draws and the time 
commitment and child concern about blood tests may make it difficult for a small 
number of sites to recruit enough participants. It is very feasible that a large number of 
sites can recruit a small number of participants at each site leading to success of this 
study and success of the Network as a unit working cooperatively. 
Within a multi-center network, optimal recruitment approaches may vary from site to 
site, and network success may require sharing of best-practices between clinical sites. 
Though each clinical site is responsible for recruiting, enrolling, and retaining study 
participants, the Data Coordinating and Operations Center (DCOC) will assist each site 
in creating a site-specific recruitment and retention plan. The DCOC has a Recruitment 
and Retention Plan summarizing the most common best practices for recruitment and 
retention of pediatric and adolescent participants and will work with each site to 
establish their own customized recruitment and retention plan. Site initiation will include 
review of the individual site’s recruitment and retention plans. The trial is registered on 
www.ClinicalTrials.gov (NCT03686150).   
Recruitment  
FDA considers direct advertising (i.e., advertising intended to be seen or heard by 
prospective participants) to be part of the informed consent process as well as the 
participant-selection process. Therefore, IRB review and approval is required to ensure 
that the information is not misleading and that the ad is not coercive. Paper advertising 
products (flyers, small posters, handbills) and phone recruiting scripts will be created as 
needed by the DCOC as templates for sites to use. This approach is commonly used 
with success by pharmaceutical companies and large clinical research organizations.  
Following approval by the central (University of Arkansas for Medical Sciences [UAMS]) 
IRB, the material will be made available in template form to all sites for customization. 
Sites will be required to use the central (UAMS) IRB for this study. A site may customize 
recruitment templates and phone scripts – or create its own material - to fit its own 
community. All advertising and scripts must, however, have written cIRB approval prior 
to use. A general description of the study, including frequently asked questions and 
consent and assent forms will be provided to potential participants prior to their initial 
screening visit. If the potential participants are interested in attending a screening visit, 
they will meet with the study coordinator and the local physician co-investigators to 
review the study and answer questions.  
Another option for recruitment that local sites may use is a search of medical records for 
potential participants who may met the inclusion criteria.  This will be done in 

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accordance with their institutional policies and procedures. The cIRB serves as the 
privacy board as well as the IRB for this study and can grant partial HIPAA waivers to 
allow sites to use medical records. 
If a potential participant appears to meet eligibility requirements, i.e., based on pre-
screening assessment, but does not want to be in the study, the potential participant 
and/or parents/guardians will be asked why they do not want to participate.  These data 
will be recorded in a screening log without any identifiers that could link answers back to 
an individual or family. The individual/family will be told they do not have to answer any 
of the questions they do not want to answer. 
Retention 
Similar to recruitment, retention tactics should be tailored to the individual resources 
and challenges of each site These include the study being too long or burdensome, the 
participant feeling they are not benefitting from participation, unengaged or 
unenthusiastic study staff, and lack of physician involvement and attention. The study 
staff must recognize that the study participants (and caregivers) are providing a service 
to the study while undergoing risk and participants must feel appreciated.   
The target for completion is 80% of randomized participants. 
More details about recruitment and retention processes can be found in the Recruitment 
and Retention Plan in the Manual Operating Procedures (MOP), including detailed 
descriptions of best practices, strategies to be implemented, and metrics to be 
monitored.  
5.6 CLINICAL HELP LINE 
Sites can call the VDORA1 Clinical Help Line for specific protocol questions or to speak 
with one of the protocol PIs. The phone number can be found in the MOP. 
6 
STUDY INTERVENTION 
6.1 STUDY INTERVENTION(S) ADMINISTRATION 
6.1.1 STUDY INTERVENTION DESCRIPTION 
Participants in VDORA1 will receive oral vitamin D3 (cholecalciferol) at a dose 
determined by the randomized assignment to 1 of 4 dosing regimens in Part 1 or 1 of 2 
dosing regimens in Part 2. This product will be packaged and distributed to study sites 
for dispensing to the participant’s caregiver (parent or guardian). 
6.1.2 DOSING AND ADMINISTRATION 
Once the assigned dose of vitamin D3 is determined, it will be dispensed by the site to 
the participant’s caregiver at Visit 2 (baseline). The caregiver will be instructed to give 
the participant a loading dose of one 50,000 IU capsule orally on the day of the baseline 

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visit if the child is randomized to a loading dose cohort. Thereafter, participants will take 
their assigned vitamin D3 dose (600, 6000, or 10,000 IU (part 1) or 600 or 8,000 IU (part 
2)) orally each day, starting on the day after the baseline visit and continuing to Visit 6. 
Participants with no loading dose will start on their daily dose on the day of the baseline 
visit. A member of the study team will witness and document the initial dose for each 
participant during the baseline visit. Participants will be given a dosing diary for 
recording all doses of vitamin D3 taken through the 16-week dosing phase. Missed 
doses will also be noted in the daily diary cards for dosing visits. 
Following the interim analysis, an optimal dosing regimen was recommended for Part 2.  
6.2 PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY 
6.2.1 ACQUISITION AND ACCOUNTABILITY 
We will use a vitamin D3 supplement in this study because vitamin D2 is only 
approximately 30% as effective as vitamin D3 in maintaining serum 25(OH)D levels.(79) 
Bio-Tech Pharmacal, Inc. will package and supply all vitamin D3 products for use in this 
study. The products are licensed, approved drugs. Specific details of this product will be 
provided to study sites in the MOP. Capsule ingredients include vitamin D3 power 
(containing cholecalciferol 0.25% and polyethylene glycol 99.5%), microcrystalline 
cellulose, and gelatin capsule. Ingredients are free from microbiological content and 
meet USP specification. 
6.2.2 FORMULATION, APPEARANCE, PACKAGING, AND LABELING 
All vitamin D3 doses will be packed in blister packs or individually labeled bottles.  The 
loading doses will be packaged separately from the daily doses; loading doses will be 
given directly to participants to take during visit 2. Participants will take home the 
labeled bottles/packs for their daily (i.e., all but visit 2) doses. Vitamin D supplements 
will be provided in the form of a size 2 capsule, either gelatin or hypromellose 
(vegetable). The capsules used for all doses in Part 1 were gelatin. The D3 (4000 IU) 
capsules for Part 2 are vegetable capsules. Size 2 capsules are approximately 18 mm 
in length (0.71 inches) with an outside diameter of 6.3 mm (0.24 inches). 
6.2.3 PRODUCT STORAGE AND STABILITY 
This product is to be stored at room temperature approximately 20ºC), away from 
moisture and light.  All temperature excursions at sites must be appropriately recorded 
and reported to the study sponsor for further evaluation and follow-up.  
 
 

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6.2.4 PREPARATION 
The product will be kept ready for administration in a sealed bottle or blister packs. No 
additional preparation is required. However, either the pharmacist or designee will do a 
pill count prior to giving the bottle to the participant. For details on the pill count, refer to 
the pharmacy manual. 
6.3 MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING 
Randomization 
Randomization of participants will be done online using the randomization module of the 
DCOC electronic data capture system. For the first part of the study, participants were 
randomized using a 1:1:1:1 ratio to receive 1 of 4 dose regimens after providing consent 
and confirmation of eligibility on the study inclusion and exclusion criteria. Upon 
completion of the interim PK analysis, participants in the second part will be randomized 
using a 2:1 ratio to receive the treatment regimen or the SoC comparator. The 
randomization will use a stratified block scheme. Stratification will be by age (6-11 vs 
12- less than18 years of age) and BMI age and sex percentile at entrance (overweight = 
greater than or equal to 85th% to less than 95th% BMI, obese = greater than or equal to 
95th% BMI for age and sex, and obese = greater than or equal to 99th% BMI for age 
and sex).  
Masking 
Masking is not planned for this study. 
6.4 STUDY INTERVENTION COMPLIANCE 
Research assistants will call, email, or text families at least biweekly (every 2 weeks) to 
provide encouragement regarding adherence to taking the study supplement. The first 
dose will be witnessed by study staff at Visit 2. Several methods will be employed to 
optimize intervention compliance and document compliance. Participants will not initiate 
treatment unless they demonstrate daily diary card adherence during the run-in. This 
will minimize dropouts due to non-adherence. At Visit 1, participants will be given diary 
cards (without a line to record Vitamin D dosing) and taught to use them to document 
asthma medication use and asthma symptoms.  At visits 2 -5, diary cards for dosing 
visits will be given to the participant to use to document adherence to daily Vitamin D 
dosing as well as to document asthma medication use and asthma symptoms. 
Pharmacists/designees will perform pill count from sealed bottles prior to dispensing to 
subjects as outlined in the Drug Accountability memo (March 4, 2020) to pharmacists 
from the ISPCTN DCOC.  
At visits 6-8, participants will again be given daily dairy cards (without the line to record 
Vitamin D dosing) to document asthma medication use and asthma symptoms.  Similar 
diary cards have been used successfully in numerous large asthma studies to bolster 
adherence to study drug.(80, 81)  

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During monthly clinic visits for which Vitamin D was given (at the previous visit), sites 
are to measure participant dosing compliance by pill counts and by participant diary 
review, identifying non-compliance (taking less than 75% of vitamin D3). Study staff will 
be trained to review the diary cards at the visit with the participant to clarify any issues 
or questions, and to provide positive feedback to participants who demonstrate good 
adherence and ongoing encouragement when warranted at each visit. Sites are to 
make every effort to schedule participant clinic visits ±7 days of the scheduled visit, per 
the schedule of activities. Enrolling ISPCTN study sites will receive a minimum of 1 on-
site monitoring visit by a member of the DCOC or their designee, as described in the 
Clinical Monitoring Plan. During the monitoring visit, drug accountability will be 
performed. Sites are to maintain all shipment records and non-dispensed product 
received from Bio-Tech Pharmacal, Inc. 
6.5 CONCOMITANT THERAPY 
All drugs and/or treatments, other than specific excluded medications, are permitted 
while on study drug. Use of an undisclosed excluded medication will be a protocol 
deviation. Similarly, if a participant uses an excluded medication and the instructions in 
this section are not followed, the use of the excluded medication will be a study 
deviation.  Several medications can interfere with the absorption or metabolism of 
vitamin D and alter 25(OH)D levels. If a participant must start on an excluded 
medication during the trial period (i.e. after study drug starts), the participant will 
discontinue study drug but will continue with all other study procedures. New 
medications prescribed for the control of asthma (including systemic corticosteroids 
used for brief time periods [less than 14 days] or change in asthma controllers) will not 
result in withdrawal from study drug but will be recorded. Participants will be advised not 
to take additional supplements containing more than 1000 international units (IU) of 
vitamin D per day. All concomitant medications including dates of use, formulation, 
dose, and frequency will be documented during the study period.  
If a participant is taking over-the-counter vitamin supplement(s), study personnel will 
find out what supplement(s) are being taken. This will be done by showing the 
participants and caregivers pictures of supplements that are commonly used by the 
general public. If the supplement is not in the picture set, then the caregiver will be 
asked to bring in the bottle at the next visit. The caregiver will also be asked how 
frequently the supplement is taken. Once the supplement is identified, the study team 
can verify the dose of vitamin D that is being taken by the participant. Children will be 
allowed to participate if, at the initial visit, the daily dose of vitamin D is less than or 
equal to 1,000 IU per day.  
Concomitant medications will be verified at every visit; the study team will, therefore, be 
able to provide on-going guidance and counseling regarding participants’ daily intake of 
vitamin D from over-the-counter vitamins.  If a study participant changes over-the-
counter vitamins and the vitamin D dose changes to greater than 1,000 IU per day, the 
study team will ask the participant/caregiver to reduce the over-the-counter vitamin D 
dose to 1,000 IU per day or less. If the participant/caregiver does not follow the request 

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and the participant’s vitamin D dose remains greater than 1,000 IU per day, the 
participant will be removed from the study. 
Excluded medications 
• Oral or IV steroids (including prednisone and equivalent dexamethasone or other 
steroid dose) greater than 10 mg/day in the 30 days prior to the screening visit or 
during the run-in period.  
o Oral or parenteral steroids, including doses greater than 10 mg/day, may 
be used as an acute asthma control medicine during trial period as stated 
above. 
• Vitamin D2 within the 30 days prior to the screening visit or during the run-in 
period.  
• Vitamin D3 supplementation with a daily dosage of greater than 1000 IUs in an 
individual supplement form or as part of a multivitamin within the 30 days prior to 
the screening visit or during the run-in period. 
Concomitant Medications 
Notes: changes in the medications below while on study could alter PK of vitamin D and 
information regarding such changes must be captured. Participants would not 
necessarily have to be withdrawn from the study, but changes in dose for any drug in 
the following list must be documented. 
• Anti-epileptic drugs 
• Digoxin, calcium channel blockers  
• Statins 
• Calcium supplements 
6.5.1 RESCUE MEDICINE 
The study team will advise participants to have access to asthma rescue medications 
(typically albuterol sulfate) for exacerbations of asthma symptoms per standard of care. 
Management of asthma symptoms will be performed by the participant’s routine medical 
provider. Oral or parenteral steroids are allowed as rescue medicines for asthma 
exacerbations and should be recorded in the CRF. There is no anticipated need for a 
rescue medication for the study drug. 
 
 

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7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL 
7.1 DISCONTINUATION OF STUDY INTERVENTION 
Discontinuation from taking vitamin D supplements does not mean discontinuation from 
the study, and remaining study procedures should be completed as indicated by the 
study protocol. If a clinically significant finding is identified such as an elevated urine 
calcium/creatinine ratio (greater than 0.37 on 2 measurements), elevated serum calcium 
level (greater than 1.5×ULN), or 25(OH)D level greater than100 ng/ml after enrollment, 
the investigator or qualified designee will determine if any change in participant 
management is needed including discontinuation of vitamin D supplements. If a 
participant is discontinued from study drug (vitamin D supplement), he or she will be 
asked to complete any remaining study visits in order to assure his or her safety and for 
the sake of completeness of data collection. If a participant who has been asked to stop 
taking study drug terminates (for any reason) from the study, site coordinators will make 
reasonable efforts to complete a termination visit. The termination visit will include 
routine labs (safety labs at minimum) and a focused physical exam.  
Rules for halting of study drug: 
1. Spot urine calcium/creatinine ratio greater than 0.37 and subsequent serum 
calcium above 1.5×ULN for the local laboratory. Because dehydration can 
artificially inflate the calcium/creatinine ratio, participants will be counseled on 
consuming adequate fluids throughout the study. Participants who have an 
elevated spot urine calcium/creatinine ratio will be asked to consume 6 to 8 
eight-ounce glasses of water per day, and to return within 2 business days of the 
site team receiving initial lab results for a repeat calcium/creatinine ratio. If the 
repeat ratio is less than or equal to 0.37, study medication will be continued 
without interruption. If the ratio remains greater than 0.37, a local serum calcium 
level and local 25(OH)D will be checked. If the serum calcium is less than 
1.5×ULN and 25(OH)D is less than 100 ng/ml, the participant will continue study 
drug without interruption. 
If a participant develops elevated serum calcium greater than or equal to 
1.5×ULN or 25(OH)D level greater than 100 ng/ml by local lab, the participant will 
remain off study drug through the duration of the study, but will continue with all 
other study procedures. See Section 8.2 for further safety assessment 
information. 
2. Any documented adverse event, which in the opinion of the site investigator 
warrants halting of study drug for participant safety. 
 
 

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If a participant develops elevated serum calcium greater than or equal to 1.5×ULN or 
25(OH)D level greater than 100 ng/ml, the participant will remain off study drug through 
the duration of the study, but will continue with all other study procedures. 
The data to be collected at the time of study intervention discontinuation will include the 
following: 
• Reason for discontinuation 
• Serum 25(OH)D and serum calcium 
• Urine calcium/creatinine ratio 
• Concomitant medications (including vitamin D3 daily dose at screening in either 
individual supplement or as a part of a multivitamin) 
7.2 PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
An investigator may discontinue or withdraw a participant from the study for the 
following reasons: 
• Participant request. Participants are free to withdraw from participation in the 
study at any time for any reason. 
• New medical issues that would make continuing in the study dangerous for the 
participant 
• Pregnancy 
• Significant study intervention non-compliance at the discretion of the site 
investigator 
• At the discretion of the investigator 
The reason for participant discontinuation or withdrawal from the study will be recorded. 
Participants who sign the informed consent form (i.e., are enrolled) but do not receive 
the study intervention may be replaced. Participants who sign the informed consent 
form, receive the study intervention, and subsequently withdraw or are withdrawn or 
discontinued from the study will not be replaced. 
Participants who are withdrawn or who discontinue from the study for any reason are 
encouraged to return for final study procedures.  
 
 

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7.3 LOST TO FOLLOW-UP 
A participant will be considered lost to follow-up if he or she fails to return for more than 
2 consecutive scheduled visits and is unable to be contacted by the study site staff.  
The following actions must be taken if a participant fails to return to the clinic for a 
required study visit: 
• The site will attempt to contact the participant, reschedule the missed visit within 
7 days of the missed visit, counsel the participant on the importance of 
maintaining the assigned visit schedule and ascertain if the participant wishes to 
continue in the study. 
• Before a participant is deemed lost to follow-up, the investigator or designee will 
make every effort to regain contact with the participant (where possible, 
3 telephone calls followed by a certified letter to the participant’s last known 
mailing address or local equivalent methods). These contact attempts must be 
documented in the participant’s medical record or study file.  
Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up. 
8 
STUDY ASSESSMENTS AND PROCEDURES 
8.1 STUDY ASSESSMENTS  
8.1.1 CLINICAL ASSESSMENTS 
In the procedure sections below, it should be noted that PK blood samples can be 
collected by venipuncture or by fingerstick microtainer collection method. If the 
participant prefers venipuncture, then blood for inflammatory markers will also be 
drawn. Fingerstick is not an option for visits 2 and 6 since blood inflammatory markers 
must be assessed for those visits. 
Note phone calls will be made at least biweekly (every 2 weeks) from research team to 
participant/family to promote adherence to medication. 
 
 

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8.1.1.1 PROCEDURES BY STUDY VISIT 
Screening Visit (Visit 1, Days -7 to -21) 
The goal of this visit is to explain the study to potential participants, obtain informed 
consent/assent, and collect a brief medical history and laboratory studies to assess 
inclusion/exclusion criteria. After the Screening Visit is complete, eligible participants will 
begin the run-in period. 
1. Inclusion/exclusion criteria will be reviewed. This will include age, BMI, 
asthma diagnosis, and ability to swallow pills, confounding medical 
conditions, and concomitant medications per protocol. 
2. Informed consent/assent will be obtained for eligible participants (see Section 
10.1.1). Once consent and assent have been obtained, the participant is 
enrolled in the study. 
3. Demographic data will be recorded on the data collection form along with 
measured height and weight.  
4. Medical history, including history of asthma exacerbations, will be obtained.  
5. Participants (parent/guardian and child) will be asked to initial a form 
documenting whether they prefer to have this visit 1 blood sample taken from 
the child’s arm or taken from a fingerstick. 
6. Participants meeting all other eligibility criteria will have samples collected for 
local serum 25(OH) vitamin D assessment, urine pregnancy test (for female 
participants of child-bearing potential), and urine calcium/creatinine ratio. 
7. Local safety measures (as described in Section 8.2) will be reviewed by the 
study coordinator to determine eligibility for continued enrollment. If any 
safety laboratory value exceeds the thresholds defined by protocol, the 
participant will be referred to the participant’s primary care physician. 
8. Diary cards, (without the line to record Vitamin D dosing), will be given to the 
participant and instructions for completion of the diary will be reviewed. These 
diary cards will have the questions about asthma control and symptoms and 
asthma medications, but will not have the questions about vitamin D dosing. 
 
 

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Baseline (Visit 2, Day 0)  
Study Visit 2 must occur between 10 and 21 days, with a target of 14 days, after Study 
Visit 1. The goal of this visit is to review eligibility for continued enrollment, provide study 
procedure training, and randomize participants. 
1. Interval history (concomitant medications, asthma symptoms, healthcare 
utilization) and diary cards (without the line to record Vitamin D dosing) will be 
reviewed at Visit 2 to assess eligibility for study participation. 
a. Site must confirm that participant continues to meet inclusion/exclusion 
criteria except for age less than 18 years. 
b. To be randomized, participants must complete and return diary cards 
with a completion rate greater than or equal to 75%. Participants who 
do not meet this level of adherence will be removed from the study.  
2. An ACT or c-ACT will be completed by the caregiver and/or child, as 
appropriate. 
3. Height and weight measurements for calculation of BMI and BMI-percentile. 
4. Blood draw (by venipuncture) for central laboratory 25(OH)D level 
determination and inflammatory marker assays.  
5. Study drug will be dispensed and dosing explained to the participant and his 
or her parent, legal guardian, or caregiver. (See Section 6.1.2). 
6. Diary cards for dosing visits will be given to the participant and instructions for 
completion of the diary will be reviewed.  
7. Study Visit 3 will be scheduled for 28 days (±7) from Study Visit 2. 
Weeks 1-3 (no mandatory visits; optional visit for PK blood draw) 
Adherence communications will occur at least biweekly (every 2 weeks) between study 
Visits 2 and 3. The study coordinator will interact with the participants and his or her 
parent, legal guardian, or caregiver through text message, phone, or email to encourage 
continued participation in the study, monitor adherence to medications, and ask about 
interval asthma symptoms.  
Sites will ask participants to return for serum 25(OH)D level between 1-3 weeks (days 7 
to 21, inclusive) after the first dose of vitamin D. Every effort will be made to collect this 
sample, but this blood draw will be optional.  If the participant consents to the optional 
visit, the participant (parent/guardian and child) will be asked to initial a form 
documenting whether they prefer to have this visit’s blood sample taken by 
venipuncture or fingerstick. 

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Study Visit 3 (Week 4, Day 28 [±7]) 
1. Unused medication will be returned and the study coordinator will review the 
diary cards for dosing visits.  
2. ACT (or c-ACT) will be completed by the caregiver and/or child as 
appropriate.  
3. Interval history will be reviewed and recorded including asthma 
exacerbations, unplanned healthcare utilization, new or changes in 
concomitant medications (including asthma medications) and adverse events.  
4. Height and weight measurements for calculation of BMI and BMI-percentile. 
5. Urine will be obtained for calcium/creatinine ratio.  
6. Participants (parent/guardian and child) will be asked to initial a form 
documenting whether they prefer to have this visit’s blood sample taken by 
venipuncture or fingerstick. 
7. Blood for 25(OH)D level (required) and inflammatory markers (if blood drawn 
by venipuncture) will be obtained and sent to central laboratory. 
8. Study drug will be dispensed and dosing reviewed with the participant and his 
or her parent, legal guardian, or caregiver. (See Section 6.1.2)  
9. Diary cards for dosing visits will be given to the participant and instructions for 
completion of the diary will be reviewed.  
10. Study Visit 4 will be scheduled for 56 days (±7) from Study Visit 2 (baseline). 
11. If a participant is withdrawn from the study drug, he/she will be asked to 
continue to make any remaining study visits in order to assure his/her safety. 
(See Section 7.1) 
Weeks 5-7 (No Scheduled Visits) 
Adherence communications will occur at least biweekly (every 2 weeks) between study 
Visits 3 and 4. The study coordinator will interact with the participants and his or her 
parent, legal guardian, or caregiver through text message, phone, or email to encourage 
continued participation in the study, monitor adherence to medications, and ask about 
interval asthma symptoms. 
 
 

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Study Visit 4 (Week 8, Day 56 [±7]) 
1. Unused medication will be returned and the study coordinator will review the 
diary cards for dosing visits.  
2. ACT (or c-ACT) will be completed by the caregiver and/or child as 
appropriate.  
3. Interval history will be reviewed and recorded including asthma exacerbations 
and adverse events.  
4. Concomitant medications will be reviewed and recorded. 
5. Height and weight measurements for calculation of BMI and BMI-percentile. 
6. Urine will be obtained for calcium/creatinine ratio (all participants) and for 
pregnancy tests (for female participants of child-bearing potential). 
7. Participants (parent/guardian and child) will be asked to initial a form 
documenting whether they prefer to have this visit’s blood sample taken by 
venipuncture or fingerstick. 
8. Blood for 25(OH)D level (required) and inflammatory markers (if blood drawn 
by venipuncture) will be obtained and sent to central laboratory.  
9. Study drug will be dispensed and dosing reviewed with the participant and his 
or her parent, legal guardian, or caregiver. (See Section 6.1.2)  
10. Diary cards for dosing visits will be given to the participant and instructions for 
completion of the diary will be reviewed.  
11. Study Visit 5 will be scheduled for 84 days (+7) from Study Visit 2 (baseline).  
Weeks 9-11 (No Scheduled Visits) 
Adherence communications will occur at least biweekly (every 2 weeks) between study 
Visits 4 and 5. The study coordinator will interact with the participants and his or her 
parent, legal guardian, or caregiver through text message, phone, or email to encourage 
continued participation in the study, monitor adherence to medications, and ask about 
interval asthma symptoms. 
 
 

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Study Visit 5 (Week 12, Day 84 [±7]) 
1. Unused medication will be returned and the study coordinator will review the 
diary cards for dosing visits.  
2. ACT (or c-ACT) will be completed by the caregiver and/or child as 
appropriate.  
3. Interval history will be reviewed and recorded including asthma exacerbations 
and adverse events.  
4. Concomitant medications will be reviewed and recorded. 
5. Height and weight measurements for calculation of BMI and BMI-percentile. 
6. Urine will be obtained for calcium/creatinine ratio. 
7. Participants (parent/guardian and child) will be asked to initial a form 
documenting whether they prefer to have this visit’s blood sample taken by 
venipuncture or fingerstick. 
8. Blood for 25(OH)D level (required) and inflammatory markers (if blood drawn 
by venipuncture) will be obtained and sent to central laboratory. 
9. Study drug will be dispensed and dosing reviewed with the participant and his 
or her parent, legal guardian, or caregiver. (See Section 6.1.2).  
10. Diary cards for dosing visits will be given to the participant and instructions for 
completion of the diary will be reviewed.  
11. Study Visit 6 will be scheduled for 112 days (+7) from Study Visit 2 (baseline). 
Weeks 13-15 (No Scheduled Visits) 
Adherence communications will occur at least biweekly (every 2 weeks) between study 
Visits 5 and 6. The study coordinator will interact with the participants and his or her 
parent, legal guardian, or caregiver through text message, phone, or email to encourage 
continued participation in the study, monitor adherence to medications, and ask about 
interval asthma symptoms. 
 
 

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Study Visit 6 (Week 16, Day 112 [±7]) 
1. Unused medication will be returned and the study coordinator will review the 
diary cards for dosing visits. 
2. ACT (or c-ACT) will be completed by the caregiver and/or child as 
appropriate. 
3. Interval history will be reviewed and recorded including asthma exacerbations 
and adverse events. 
4. Concomitant medications will be reviewed and recorded. 
5. Height and weight measurements for calculation of BMI and BMI-percentile. 
6. Blood for 25(OH)D level and inflammatory marker assays will be drawn by 
venipuncture and sent to central laboratory. 
7. Urine will be obtained for calcium/creatinine ratio (all participants) and for 
pregnancy tests (for female participants of child-bearing potential). 
8. Diary cards without the line to record Vitamin D dosing will be given to the 
participant/parent/guardian.  These diary cards have the questions about 
asthma control and symptoms and asthma medications, but do not have the 
questions about vitamin D dosing. These will be the same cards as those 
given at Visit 1 (screening visit). 
9. Follow-up visit for week 20 (visit 7) will be scheduled for 140 days (±7 days) 
from Study Visit 2 (baseline). 
Follow-up Visits: Weeks 20 (visit 7), 24 (visit 8), and 28 (visit 9) [Days 140, 168, 
and 196, respectively, each ±7 days]  
1. Participants (parent/guardian and child) will be asked to initial a form 
documenting whether they prefer to have this visit’s blood sample taken by 
venipuncture or fingerstick. 
2. Post-dosing blood draw for 25(OH)D level (required) and inflammatory 
markers (if blood drawn by venipuncture) will be obtained and sent to central 
laboratory.  
3. At weeks 20 (visit 7; day 140 ±7) and 24 (visit 8; day168 ±7) only, diary cards 
without the line to record vitamin D dosing will be given to the 
participant/parents/guardian. Instructions for completion of the diary will be 
reviewed. These diary cards will have questions about asthma control and 
symptoms and asthma medications but will not have any questions about 
vitamin D. These will be the same cards as those given at Visit 1 (screening 
visit). 

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4. Diary cards from the previous visit, as well as additional interval history, will 
be reviewed. Information, including asthma exacerbations and adverse 
events, will be recorded.  
5. Follow-up visit for week 24 (visit 8) will be scheduled for 168 (±7) days from 
Visit 2 (baseline) and follow-up visit for week 28 (visit 9) will be schedule for 
196 (±7) days from Visit 2 (baseline). 
6. At week 28 (visit 9; day 196 ±7), local serum 25(OH)D level will be 
determined. This is in addition to the central lab. 
7. Coordinators will call, text, or email participants at least the week prior to their 
visit as a reminder. 
8.1.1.2 ASTHMA MEASURES 
Asthma Control Test (ACT) 
The ACT is a 4-week recall questionnaire that has been validated and addresses issues 
of asthma control, symptoms, and nocturnal awakenings for patients with asthma aged 
12 and above.(82) The ACT will be administered to 12 to 18-year-olds at all in-person 
clinic visits. 
Childhood Asthma Control Test (c-ACT) 
The c-ACT is a 4-week recall questionnaire that has been validated and addresses 
issues of asthma control, symptoms, activity limitation, and nocturnal awakenings for 
patients aged 4 to 11 years with asthma). The c-ACT will be administered to 6 to 
11- year- olds at all in-person visits. 
Participants that turn 12 during the course of the study will continue to use the c-ACT 
test for the duration of their participation. 
Asthma-related Events 
The presence of asthma-related events (ASDs, exacerbations, episodes of problematic 
asthma, respiratory infections) will be identified by participant documentation on daily 
diary cards (collected at all clinic visits) and by structured interviews at in-person clinic 
visits. 
1. ASDs:  
A diary card will be used to compile information about asthma symptoms. Though diary 
cards similar to those proposed for VDORA have been used successfully in large 
highly-controlled pediatric asthma trials, symptom diaries can be criticized for some 
participants having incomplete data. Symptom diaries however can be used 
successfully particularly in intervention trials less than 26 weeks (as with VDORA) and 
when participants are frequently reminded and supported closely by research staff. (76, 
77) 

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An ASD (83) will be defined as a day with any one of the following: 
a. Albuterol rescue use (pre-exercise treatment permitted)  
b. Use of additional asthma medications including oral steroids. In addition, the 
7 days immediately following the end of a course of oral steroids will be 
considered ASDs.  
c. Daytime or nighttime asthma symptoms (wheezing, coughing, phlegm/mucus, 
chest tightness, or shortness of breath)  
d. Unscheduled health care provider visits for asthma, emergency room visit or 
hospital admission for asthma, or missed work or school due to asthma 
Baseline frequency of ASDs will be documented for each participant using the 
participant’s run-in period and Week 1 (if needed) diary cards to explore changes in 
mean ASD/week longitudinally on treatment. 
2. Asthma Exacerbation 
In this study an asthma exacerbation will be defined according to the recommendation 
of the NIH Outcomes Workshop (84) as a worsening of asthma requiring the use of a 
systemic corticosteroid (at least 2 days of treatment) to prevent a serious outcome. In 
accordance with the Expert Panel recommendations, data will be captured on the 
following exacerbation-related outcomes:  
a. All worsening asthma events in which systemic corticosteroids were initiated 
to prevent a serious outcome, including use of systemic corticosteroids in 
association with any form of healthcare provider encounter  
b. All asthma-specific ED or urgent care visits that involved treatment with 
systemic corticosteroids  
c. All asthma-specific hospitalizations that involved treatment with systemic 
corticosteroids (also reported as an SAE)  
d. All asthma-specific intensive care unit admissions or intubations (also 
reported as an SAE)  
e. All deaths (all-cause and asthma-related; also reported as an SAE)  
 
 

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For the purpose of this study, 2 courses of systemic corticosteroids must be separated 
by at least 1 week to count as 2 exacerbations and to be documented as such. 
3. Episode of problematic asthma 
Any asthma-related unscheduled healthcare visit (outpatient, urgent care, ED). 
4. Respiratory tract infection 
Patient-reported episodes of upper respiratory tract infection (cold), sore throat, 
strep throat, bronchitis, pneumonia, ear infection, and acute sinusitis (sinus 
infection) will be documented from structured interviews occurring at each study 
visit and planned study phone call. This approach has been used successfully in 
large pediatric asthma trials. (80) 
8.1.2 LABORATORY EVALUATIONS 
Specimens for evaluation include: 
• Safety assessments (volumes to be determined by laboratory facility at local site; 
methodology to be determined by the laboratory facility at the local site) 
o Urine for pregnancy test for female participants of childbearing potential (done 
only at Visit 1, Visit 4, and Visit 6/Early Termination). 
o Blood for serum 25(OH)D level at Visit 1 (Screening) and Follow-up visit 9 
(week 28). 
o Urine for creatinine/calcium ratio to be done at Screening and study Visits 3, 
4, 5, and 6. Blood for serum calcium will be collected if indicated due to a high 
urine calcium/creatinine ratio. 
• Study assessments (to be performed by a College of American Pathologists 
[CAP] accredited and Clinical Laboratory Improvement Amendments [CLIA] 
certified central laboratory). 
o 25(OH) vitamin D level by liquid chromatography/tandem mass spectrometry 
(specimen collection per laboratory manual) to be done at Baseline (visit 2) 
and study Visits 3, 4, 5, and 6 as well as follow-up (visits 7, 8, and 9). There is 
an optional visit, with a blood draw for vitamin D analysis, between Week 1 
and 3, if the participant volunteers for this. 
o Cytokine panel (IL-2, IL-6, IL-10, IL-17, and TNF-alpha) by immunoassay as 
cytokine panel (specimen collection per laboratory manual) to be done at 
Baseline and at Visit 6 and, if the participant agrees to blood collection by 
venipuncture, at Visits 3, 4, and 5, and Follow-up (visits 7, 8, and 9). 

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o Leptin by electrochemiluminescence (specimen collection per laboratory 
manual) to be done at Baseline and at Visit 6 and, if the participant agrees to 
blood collection by venipuncture, at Visits 3, 4, and 5, and Follow-up (visits 7, 
8, and 9). 
Laboratory determinations of vitamin D levels 
25(OH)D levels for study endpoints will be determined at a CAP accredited and CLIA 
certified central laboratory. Vitamin D levels will be obtained at the local laboratory for 
determining inclusion criteria (25(OH)D level less than 30 ng/ml but great than 
10 ng/mL) and for safety measurements at the local investigator’s discretion, ensuring 
prompt turn around. 
8.2 SAFETY AND OTHER ASSESSMENTS 
Vitamin D is a very safe supplement with a large therapeutic index. Vitamin D 
sufficiency is considered to be greater than 30 ng/ml. Intoxication does not occur until 
serum 25(OH)D levels exceed 150 ng/ml (325 nmol/L).(85) However, most clinical 
laboratories consider 100 ng/ml to be the upper limit in order to maintain a wide safety 
margin. Reports of vitamin D toxicity are rare and virtually always related to faulty 
manufacturing or labeling of product such that individuals ingested hundreds to 
thousands of times the presumed dose.(86, 87) The consequence of vitamin D toxicity 
is hypercalcemia. Hypercalcemia only results when 25(OH)D concentrations have 
consistently been above 150-200 ng/ml (375-500 nmol/L).(85) 
To ensure safety in this study, spot urine calcium/creatinine levels will be measured at 
each visit as a screen for hypercalciuria. The study coordinator will instruct the 
participant and his or her parent, legal guardian, or caregiver to ensure that the child is 
well-hydrated prior to the study visit. If the urine calcium/creatinine level is greater than 
0.37 on a specimen, the participant will be asked again to ensure good hydration and 
return within 2 business days for a repeat spot urine calcium/creatinine measurement. If 
the ratio remains greater than 0.37, then a serum calcium level and 25(OH)D for the 
local laboratory will be obtained.(75) If serum calcium is greater than 1.5×ULN or the 
25(OH)D level is greater than 100 ng/ml, the participant will have supplementation 
stopped but will be asked to return for remaining study visits in order to obtain data on 
vitamin D clearance and for safety assessments. Vitamin D supplementation ends at 16 
weeks (day 112 ±7) for all participants. They will be followed for another twelve weeks 
for determination of elimination kinetics and for safety assessments. The half-life of 
vitamin D is variable but is felt to be approximately 2 months.(88) The 12-week follow-
up therefore consists of 1.5 half-lives. A serum 25(OH)D level will be drawn for the local 
laboratory safety measure at week 28 (visit 9; day 196 ±7). If a participant has a serum 
25(OH)D level greater than 80 ng/ml at that time, he/she will be asked to return 4 weeks 
later for a re-check to ensure that the level is not continuing to rise as vitamin D washes 
out of adipose tissue. If there are any ongoing concerns, further follow up will be 
determined by the local investigator in collaboration with the child’s primary care team 
and sub-specialists as necessary.  

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This is not an asthma treatment study. We will monitor asthma symptoms, however. 
Each participant is required to have an identified asthma-care provider at entry. This 
can be a specialist or a primary care provider. If it is found that a participant’s asthma is 
poorly controlled, he or she will be referred back to the primary asthma-care provider for 
reevaluation and further treatment. 
If any child is found to be in the midst of an asthma exacerbation at the time of a study 
visit, the study staff will notify the local PI and take appropriate action to guarantee 
safety of the child. This may include referral to an Urgent Care or Emergency facility or 
may involve the local PI treating the participant if he or she is the child’s asthma care 
provider. 
8.3 ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS AND ADVERSE 
REACTIONS 
8.3.1 DEFINITION OF ADVERSE EVENTS AND ADVERSE REACTIONS 
AE means any untoward medical occurrence associated with the use of an intervention 
in humans, whether or not considered intervention related.  
AR means any adverse event caused by a drug.  Adverse reactions are a subset of all 
suspected adverse events where there is reason conclude that the drug caused the 
event. 
8.3.2 DEFINITION OF SERIOUS ADVERSE EVENTS OR REACTIONS 
An AE or suspected AR is considered "serious" if, in the view of either the investigator 
or sponsor, it results in any of the following outcomes: 
• death 
• a life-threatening adverse event 
• inpatient hospitalization or prolongation of existing hospitalization 
• a persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions 
• a congenital anomaly/birth defect 
• important medical events that may not result in death, be life-threatening, or 
require hospitalization may be considered serious when, based upon appropriate 
medical judgment, they may jeopardize the participant and may require medical 
or surgical intervention to prevent one of the outcomes listed in this definition. 
Examples of such medical events include allergic bronchospasm requiring 
intensive treatment in an emergency room or at home, blood dyscrasias or 
convulsions that do not result in inpatient hospitalization, or the development of 
drug dependency or drug abuse. 

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8.3.3 CLASSIFICATION OF AN ADVERSE EVENT 
8.3.3.1 SEVERITY OF EVENT 
For AEs and ARs not included in the protocol-defined grading system, the following 
guidelines will be used to describe severity. The site investigator will determine severity. 
• Mild – Events require minimal or no treatment and do not interfere with the 
participant’s daily activities.  
• Moderate – Events result in a low level of inconvenience or concern with the 
therapeutic measures. Moderate events may cause some interference with 
functioning. 
• Severe – Events interrupt a participant’s usual daily activity and may require 
systemic drug therapy or other treatment. Severe events are usually potentially 
life-threatening or incapacitating. Of note, the term “severe” does not necessarily 
equate to “serious.” 
8.3.3.2 RELATIONSHIP TO STUDY INTERVENTION 
All AEs must have their relationship to study intervention assessed by the clinician who 
examines and evaluates the participant based on temporal relationship and his/her 
clinical judgment. The degree of certainty about causality will be graded using the 
categories below. In a clinical trial, the study product must always be suspect. 
• Definitely Related – There is clear evidence to suggest a causal relationship, 
and other possible contributing factors can be ruled out. The clinical event, 
including an abnormal laboratory test result, occurs in a plausible time 
relationship to study intervention administration and cannot be explained by 
concurrent disease or other drugs or chemicals. The response to withdrawal of 
the study intervention (dechallenge) should be clinically plausible. The event 
must be pharmacologically or phenomenologically definitive, with use of a 
satisfactory rechallenge procedure if necessary. 
• Probably Related – There is evidence to suggest a causal relationship, and the 
influence of other factors is unlikely. The clinical event, including an abnormal 
laboratory test result, occurs within a reasonable time after administration of the 
study intervention, is unlikely to be attributed to concurrent disease or other 
drugs or chemicals, and follows a clinically reasonable response on withdrawal 
(dechallenge). Rechallenge information is not required to fulfill this definition. 
 
 

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• Potentially Related – There is some evidence to suggest a causal relationship 
(e.g., the event occurred within a reasonable time after administration of the trial 
medication). However, other factors may have contributed to the event (e.g., the 
participant’s clinical condition, other concomitant events). Although an AE may 
rate only as “possibly related” soon after discovery, it can be flagged as requiring 
more information and later be upgraded to “probably related” or “definitely 
related,” as appropriate. 
• Unlikely to be related – A clinical event, including an abnormal laboratory test 
result, whose temporal relationship to study intervention administration makes a 
causal relationship improbable (e.g., the event did not occur within a reasonable 
time after administration of the study intervention) and in which other drugs or 
chemicals or underlying disease provides plausible explanations (e.g., the 
participant’s clinical condition, other concomitant treatments). 
• Not Related – The AE is completely independent of study intervention 
administration, and/or evidence exists that the event is definitely related to 
another etiology. There must be an alternative, definitive etiology documented by 
the clinician. 
8.3.3.3 EXPECTEDNESS  
The expectedness of an AE or suspected AR shall be determined according to the 
specified reference document containing safety information (e.g., most current product 
information or product label). Any AE that is not identified in nature, severity, or 
specificity in the current study drug reference document(s) (e.g., product information) is 
considered unexpected. Events that are mentioned in the product information as 
occurring with a class of drugs or as anticipated from the pharmacological properties of 
the drug, but not specifically mentioned as occurring with the particular drug in this 
study are considered unexpected. 
Expected AEs that could occur in this study are: bruising related to 
venipuncture/fingerstick, pain related to venipuncture/fingerstick, increase in calcium in 
the blood or urine, kidney stones, accidental vitamin D poisoning (associated nausea 
and increased levels of calcium in the blood), increased urination, decreased appetite, 
increased fatigue, hypersensitivity to vitamin D, or hypercalcemia (only expected when 
vitamin D blood level is above 150-200 ng/mL, but the intervention will be stopped if 
level reaches 100 ng/mL).    
If the capsule is ruptured or broken, the powder may cause the following:  irritation or 
burning of the eyes, skin, or respiratory system (if inhaled). 
 

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8.3.4 TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND 
FOLLOW-UP 
The occurrence of an AE or SAE may come to the attention of study personnel during 
study visits and interviews of a study participant presenting for medical care, or upon 
review by a study monitor. All AEs including local and systemic reactions will be 
captured on the appropriate CRF. Information to be collected includes event description, 
time of onset, clinician’s assessment of severity, relationship to study product (assessed 
only by those with the training and authority to make a diagnosis), and time of 
resolution/stabilization of the event. All AEs occurring while on study must be 
documented appropriately regardless of relationship. All AEs must be followed until 1 of 
the following criteria is met: resolution, the condition stabilizes, the event is otherwise 
explained or is judged by the PI to be no longer clinically significant, or the participant is 
lost to follow-up 
Any medical condition that is present at the time that the participant is screened will be 
considered as baseline and not reported as an AE. However, if the study participant’s 
condition deteriorates at any time during the study, it will be recorded as an AE. 
Changes in the severity of an AE will be documented to allow an assessment of the 
duration of the event at each level of severity to be performed. AEs characterized as 
intermittent require documentation of onset and duration of each episode. At each study 
visit, the investigator or study coordinator will inquire about the occurrence of AE/SAEs 
since the last visit. The site investigator will record all reportable events with start dates 
occurring any time after informed consent is obtained. Events will be followed for 
outcome information until resolution or stabilization or until 7 days (for non-serious AEs) 
or 30 days (for SAEs) after the last day of study participation.  
8.3.5 ADVERSE EVENT AND REACTION REPORTING  
All AEs and ARs that occur after informed consent is obtained until 7 days after the last 
day of study participation should be documented in the patient's source documents in 
accordance with the Investigator's normal clinical practice and in the AE section of the 
CRF. 
8.3.6 SERIOUS ADVERSE EVENT AND REACTION REPORTING  
The site investigator will report all SAEs and SARs occurring any time after informed 
consent is obtained until 30 days after the last day of study participation. The study 
clinician will immediately report to the sponsor any SAE, whether or not considered 
study intervention related, including those listed in the protocol or product information 
and must include an assessment of whether there is a reasonable possibility that the 
study intervention caused the event. Study endpoints that are SAEs (e.g., all-cause 
mortality) must be reported in accordance with the protocol unless there is evidence 
suggesting a causal relationship between the study intervention and the event (e.g., 
death from anaphylaxis). In that case, the investigator must immediately report the 
event to the sponsor. 

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The investigator/qualified designee will enter the required information regarding the SAE 
into the appropriate module of the electronic case report form (eCRF), which will 
automatically result in distribution of the information to the appropriate sponsor contact. 
If the eCRF system is temporarily unavailable, the event, including the investigator-
determined causality to study drug, must be reported via a paper back-up SAE form to 
the appropriate sponsor contact. Upon return of the availability of electronic data 
capture system, the SAE information must be entered into the eCRF. 
All SAEs will be followed until resolution or until the site investigator deems the event to 
be chronic, or until the participant is stable, or until 30 days after the last day of study 
participation. Other supporting documentation of the event may be requested by the 
DCOC/study sponsor and should be provided as soon as possible. 
8.3.7 REPORTING EVENTS TO PARTICIPANTS  
The participants will be notified of those study-related (or potentially study-related) 
SAEs, SARs and unanticipated problems (UPs) that may affect either the participants’ 
willingness to continue with the study or the future health of the child enrolled in the 
study. This determination can be made by any of the following: the IRB, the medical 
monitor, the DSMB, or the sponsor. The person or oversight body that makes the 
determination will inform the DCOC, which will instruct the site PIs/study coordinators to 
contact those participants enrolled through their site. Contacts with participants, if 
necessary, will be recorded on the appropriate CRF and/or study log. 
8.3.8 EVENTS OF SPECIAL INTEREST  
Not applicable. 
8.3.9 REPORTING OF PREGNANCY  
As noted above in Section 2.3.1, vitamin D supplementation is safe in pregnancy. 
However, to be extremely cautious, participants of childbearing potential will be 
counseled to use acceptable forms of birth control as well as condoms during the study 
period. Abstinence is considered an acceptable form of birth control. There are no 
known risks of vitamin D intake during pregnancy. 
We will follow standard pharmaceutical study practices in regards to pregnancy to make 
sure we account for the possibility of untoward and unexpected effects on a fetus. If a 
participant becomes pregnant during the study, dosing will be discontinued immediately.  
If a subject reports a pregnancy, we will use a specific pregnancy follow-up form to track 
the outcome of the pregnancy for the subject.  On this form, we will document how the 
pregnancy diagnosis was made, whether the subject has received a medical evaluation 
for the pregnancy (and where), and what the outcome of the pregnancy was (e.g., 
miscarriage, elective abortion, live birth or stillbirth). We will also record maternal history 
(including congenital abnormalities or pregnancy complications) and estimated date of 
conception. 

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The pregnant participant will be followed until delivery or until the end of pregnancy (in 
the case of miscarriage or pregnancy termination). This will occasionally require us to 
follow participants after they have completed this study.  
For all live births, we will document the mode of delivery, gestational delivery age, the 
birth weight, whether there were any health problems (infant and/or mother) at delivery, 
and whether the baby required a hospitalization beyond 2 days.  These data will all be 
self-reported by the participant.  We will monitor all pregnancy-related outcomes, and 
will request permission to obtain medical records for any participant in which adverse 
pregnancy-related outcomes are reported.    
Any associated AEs or SAEs that occur to the mother or fetus/child will be recorded in 
the AE or SAE eCRF. 
8.4 UNANTICIPATED PROBLEMS 
8.4.1 DEFINITION OF UNANTICIPATED PROBLEMS 
The Office for Human Research Protections (OHRP) considers unanticipated problems 
involving risks to participants or others to include, in general, any incident, experience, 
or outcome that meets all of the following criteria: 
• Unexpected in terms of nature, severity, or frequency given (a) the research 
procedures that are described in the protocol-related documents, such as the 
IRB-approved research protocol and informed consent document; and (b) the 
characteristics of the participant population being studied; 
• Related or possibly related to participation in the research (“possibly related” 
means there is a reasonable possibility that the incident, experience, or outcome 
may have been caused by the procedures involved in the research); and 
• Suggests that the research places participants or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized. 
An unanticipated problem is not necessarily an AE or SAE. Unanticipated problems that 
are neither an AE nor SAE, but which must be reported, are listed below in Section 
8.4.2. 
8.4.2  UNANTICIPATED PROBLEM REPORTING  
Unanticipated problems (per Section 8.4.1) must be reported to the reviewing IRB, the 
DCOC, the sponsor, and the NIH DSMB as well as any other persons or groups noted 
in the DSMB charter. These problems must be reported to the reviewing IRB according 
to the reviewing IRB’s policies and procedures and reported to local institutions 
according to the rules and regulations of the local institution. The reviewing IRB will 
report the issue to OHRP per the policies of the reviewing IRB. For the UAMS IRB, 
which will be the reviewing IRB for most of the sites for this study, the required reporting 
times are shown in the following table. 

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Table 3. 
Unanticipated Problem Reporting 
Unanticipated Problem 
Required Reporting Time to UAMS 
IRB 
Death or life-threatening 
Immediately to IRB office or IRB 
Chair 
All other events 
Within 10 days of event or notification 
of event if non-local 
 
Examples of unanticipated problems that are not an AE or SAE, but which would need 
to be reported include: 
• Breach of confidentiality 
• Change in product labeling, or withdrawal from marketing, of the vitamin D used 
in this protocol 
Typically, the report to the IRB et al. will include the following: 
• Protocol identification information (title, number, etc.) 
• PI name 
• Detailed description of event  
• Explanation of why the event is a UP 
• Description of changes needed (to protocol) and/or other corrective actions taken 
or needed 
Additional details are provided in the study-specific MOP. 
8.4.3 REPORTING UNANTICIPATED PROBLEMS TO PARTICIPANTS  
The participants will be notified only of those study-related (or potentially study-related) 
SAEs and unanticipated problems that may affect either the participants’ willingness to 
continue with the study or the future health of the participant enrolled in the study. This 
determination can be made by any of the following: the IRB, the medical monitor, the 
DSMB, or the sponsor. The person or oversight body that makes the determination will 
inform the DCOC, which will instruct the site PIs/study coordinators to contact those 
participants enrolled through their site. 
Contacts with participants, if necessary, will be recorded on the appropriate CRF and/or 
study log. 

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9 
STATISTICAL CONSIDERATIONS  
9.1 STATISTICAL HYPOTHESES 
Study objective: The overall objective of this study is to determine the PK of Vitamin D 
supplementation in children who have asthma and are overweight or obese and 
therefore no formal hypothesis testing will be performed. 
Part 1 Objective: Identify dosing to use in Part 2 using PK analysis on a subset of 
participants Part 2 Objective: Determine the effectiveness of a recommended 16-week 
dosing regimen to achieve a serum level of 25(OH)D greater than or equal to 40 ng/ml 
in vitamin D insufficient or deficient children who have asthma and are 
overweight/obese 
The hypothesis for Part 2 will be tested using the one-group Chi-square test at the 5% 
one-sided significance level. 
9.2 SAMPLE SIZE DETERMINATION 
Part 1: a sample size of greater than 50 participants will be powered (greater than 80%) 
to target a 95% confidence interval within 60% and 140% of the geometric mean 
estimates of 25(OH)D systemic clearance. The sample size assumes a coefficient of 
variation of 50% in 25(OH)D steady-state concentration.(48, 89) Based on prior 
experience (90, 91, 92, 93) a sample size of 16 participants in the interim analysis will 
suffice to determine a recommended dose for Part 2. 
Part 2: For the optimal dosing regimen defined by the interim PK-analysis, the null 
hypothesis that the proportion of children who achieve a vitamin D level of greater than 
or equal to 40 ng/ml is 50% or less at 16 weeks will be tested against the alternative 
hypothesis that the proportion is 75% or more at the one-sided 0.05 significance level 
with power of 0.90. Using the one group Chi-square test for testing a single proportion, 
the number of study participants required to complete Part 2 is 31 participants. To allow 
for an approximately 30% dropout rate (due, in part, to the COVID-19 pandemic), 
63 participants will be randomized to (A) the 8,000 IU daily dose (with a 50,000 IU 
loading dose) regimen or to (B) the standard of care (600 IU/day) dose. The allocation 
ratio will be 2:1 (A:B). 
9.3 POPULATIONS FOR ANALYSES 
PK analysis Population: All participants with at least 1 PK sample will be included in 
the population PK analysis. 
Intent-to-Treat (ITT) Population: This population includes all enrolled participants. 
Analysis of the ITT population will be used for all non-PK analyses. 
Safety Population: This analysis population includes all enrolled participants who 
received at least one dose of study treatment. 

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9.4 STATISTICAL ANALYSES 
9.4.1 GENERAL APPROACH 
Following finalization of the Protocol, but prior to 25% enrollment, a Statistical Analysis 
Plan (SAP) will be issued as a separate document, which will provide detailed analytical 
plans for the set of analyses outlined below. All statistical analyses will be conducted 
following the statistical principles for clinical trials as specified in International 
Conference on Harmonization Statistical Principles for Clinical Trials (ICH Topic E9). 
Any deviations from the planned analyses will be described and justified in the final 
integrated clinical study report. All study data and summary tables will be presented 
overall and by study sites. 
Descriptive statistics for continuous data will be summarized using mean and standard 
deviation or median and interquartile range, as appropriate. Categorical data will be 
summarized using frequency and percent. Any outliers detected during data review will 
be investigated and methods for handling outliers or data transformation will be defined 
in the SAP. 
9.4.2 ANALYSIS OF THE STUDY ENDPOINT 
The study does not include an efficacy endpoint. The primary objective is to conduct a 
population PK analysis.    
A population PK analysis will be performed to characterize the PK of vitamin D in 
overweight/obese children using the software Nonlinear Mixed Effects Modeling 
(NONMEM, version 7.2). Different structural PK models (e.g., 1 and 2 compartment) 
with linear or non-linear (e.g., Michaelis-Menten) kinetics will be fitted to the 
concentration-time data of 25(OH)D. Between-participant variability on model 
parameters and different residual error models will be tested. Model development will be 
guided by goodness of fit plots, plausibility of parameter estimates, and reduction in 
inter-individual variability for structural and residual error parameters, as well as 
objective function and shrinkage values.  
Covariate evaluation will be performed to examine the relationship between model 
parameters and demographic factors (e.g., age, weight status, ethnicity) and co-
administered medications, as applicable. More detail about the weight status measures 
used in the model will be included in the SAP. Appropriate covariates will be 
incorporated into the model using a standard forward inclusion-backward elimination 
approach. Standard model diagnostic plots and procedures will be used to evaluate 
model appropriateness. Model validation will be performed using visual predictive check 
and bootstrapping. 
Using the final PK model and parameter estimates, serum concentration-time profiles of 
25(OH)D will be simulated for each participant at varied dosing regimens. The 
percentage of participants with serum 25(OH)D greater than or equal to 40 ng/ml during 
a desired time period will be calculated. The best dosing regimen will be determined as 
the one resulted in serum 25(OH)D greater than or equal to 40 ng/ml in a majority (i.e. 

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75%) of participants. It is possible that the doses outlined and evaluated in this study 
will not end up being the dose chosen for a larger randomized, controlled, double-
masked intervention trial. Creation of a PK model will determine the optimal dosing 
strategy in Part 2 to achieve serum vitamin D levels greater than or equal to 40 ng/ml. 
9.4.3 ANALYSIS OF THE PART 1 ENDPOINT 
This analysis was done including participants randomized in part 1.  Dose finding was 
done using the PK model and parameter estimates, serum concentration-time profiles of 
25(OH)D was simulated for each participant at varied dosing regimens. The percentage 
of participants with serum 25(OH)D greater than or equal to 40 ng/ml during a desired 
time period was calculated. The best dosing regimen was determined as the one 
resulted in serum 25(OH)D greater than or equal to 40 ng/ml in a majority (i.e. 75%) of 
participants. It is possible that the doses outlined and evaluated in this study will not end 
up being the dose chosen for a larger randomized, controlled, double-masked 
intervention trial. Creation of a PK model determined the optimal dosing strategy in Part 
2 to achieve serum vitamin D levels greater than or equal to 40 ng/ml. The participants 
who achieved a vitamin D level of greater than or equal to 40 ng/ml were estimated 
along with the corresponding 95% confidence interval for each dose regimen in Part 1. 
A one-group test of proportion will be used to analyze the overall proportion of 
participants with 25(OH)D greater than or equal to 40 ng/ml at 16 weeks among 
participants treated with the final recommended dose in Part 2. 
9.4.4 ANAYLSIS OF PART 2 ENDPOINTS 
The participants who achieve a vitamin D level of greater than or equal to 40 ng/ml will 
be estimated along with the corresponding 95% confidence interval for each dose 
regimen in Part 1. A one-group test of proportion will be used to analyze the overall 
proportion of participants with 25(OH)D greater than or equal to 40 ng/ml at 16 weeks 
among participants treated with the final recommended dose in Part 2. 
9.4.5 SAFETY ANALYSES 
All AEs recorded during the study period will be coded with Medical Dictionary for 
Regulatory Activities (MedDRA) Version March 2018. All participants enrolled in the 
study will be evaluated for safety. Summaries of AE will be tabulated for the following 
types: 
• Number (%) of participants with any AE or AR 
• Number (%) of participants with any SAE or SAR 
• Number (%) of participants withdrawn from treatment due to AE 
All summaries will be reported overall and by study site. Additional analyses and 
summaries may be derived if deemed appropriate and will be further described in the 
SAP. 

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9.4.6 BASELINE DESCRIPTIVE STATISTICS 
Baseline and demographic characteristics will be summarized overall and by study site. 
Summary statistics will be applied for both continuous and categorical variables. For 
continuous measures, descriptive measures will include number of non-missing values, 
mean, standard deviation, median, minimum, and maximum. For categorical variables, 
descriptive statistics will include frequency counts and percentages by category. 
9.4.7 PLANNED INTERIM ANALYSES  
An interim PK analysis was performed after a minimum of 16 participants (at least 4 in 
each arm) completed PK sampling at Week 20 (visit 7) in Part 1 of the study. The 
interim PK analysis provided an optimal dosing regimen for Part 2. 
Results of the Part 1 analysis were presented to the DSMB along with the 
recommended new dose. Enrollments at the new dose will begin after DSMB approval. 
9.4.8 SUBGROUP ANALYSES 
Minimal subgroup analyses will be performed. 
9.4.9 TABULATION OF INDIVIDUAL PARTICIPANT DATA 
A detailed description of participant disposition will be provided. The number of enrolled 
participants will be tabulated overall and by study site and presented as counts and 
percentages. Additionally, the number of participants either completing or discontinuing 
the study will be summarized using counts and percentages. 
9.4.10 EXPLORATORY ANALYSES 
At each study visit, ACT (or c-ACT) and ASDs will be computed to monitor asthma 
control. The presence and number of severe asthma exacerbations (as defined by the 
need for oral or parenteral corticosteroids), unscheduled asthma-related healthcare 
utilizations, and asthma-related hospitalizations will be collected. General estimating 
equations will be used to assess changes in the number of exacerbations, ASDs and 
the ACT (or c-ACT) score over time.  
Baseline and 16-week inflammatory biomarkers (leptin plus TNFα, IL-2, IL-6, IL-10 and 
IL-17 (cytokine panel)) will be collected to assess changes on vitamin D 
supplementation. Participants who opt for venipuncture for vitamin D levels (rather than 
fingerstick) will have blood drawn for inflammatory markers at more times. Total 
25(OH)D, changes in 25(OH)D, changes in individual biomarkers, and asthma 
outcomes will be explored. 

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9.5 MISSING DATA  
To compare the proportion of participants that achieve the serum 25(OH)D levels 
greater than 40 ng/ml target among the standard of care group and the optimal PK dose 
group, differences in sample proportions will be evaluated by chi-square or Fisher’s 
exact test as appropriate. Additionally, proportion difference with the 95% confidence 
interval will be obtained. 
  
Participants will be defined as a responder or non-responder at the 16-week visit 
according to the serum level criteria (i.e., achieve a serum 25(OH)D of greater than or 
equal to 40 ng/ml at 16 weeks).  Participants who withdraw prematurely will be 
considered non-responders in the primary analysis.  
To investigate the effect of missing data on the proportion of response endpoint, a 
sensitivity analysis will be carried out using a multiple imputation approach.  Additionally, 
all participants who do not complete the recommended 16-weeks dosing regimen will be 
regarded be excluded from the per-protocol analysis population.   
 
10 SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS 
10.1 REGULATORY, ETHICAL, AND STUDY OVERSIGHT 
CONSIDERATIONS 
10.1.1 
INFORMED CONSENT PROCESS 
10.1.1.1 
CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS 
PROVIDED TO PARTICIPANTS 
Consent forms describing in detail the study intervention, study procedures, and risks 
are given to the participant and written documentation of informed consent is required 
prior to starting intervention/administering study intervention. The following consent 
materials will be submitted to the IRB with this protocol: 
• Product information 
• Diary card 
• Informational brochure/flyer for participants 
• Informed consent form (including the assent portion) 
 
 

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10.1.1.2 
CONSENT PROCEDURES AND DOCUMENTATION 
Informed consent is a process that starts before a participant agrees to be a part of a 
study and the process continues throughout the individual’s study participation. 
Parents/guardians of the participating children under the age of majority, participants 
that are at or over the age of majority, and emancipated minors will be asked to read 
and review the consent form. Children under the age of majority, but who are also 
7 years of age or older, will be provided with a separate assent form. Both the consent 
and assent forms will be approved by the IRB.  
The investigator or designee will explain the research study to the participant(s) (i.e., 
parents/guardians for children under the age of majority, children under the age of 
majority, participants at the age of majority, and emancipated minors). The investigator 
or designee will answer any questions that may arise. The verbal explanation will be 
provided in terms the participant(s) can understand. The explanation will state the 
purposes, procedures, and potential risks of the study and describe their rights as 
research participants. Participants will have the opportunity to carefully review the 
written forms and ask questions before signing. The participants will be given the 
opportunity to discuss the study with their family or surrogates or think about it prior to 
agreeing to participate. The parent/guardian of underage children, participants who 
have reached the age or majority, and emancipated minors will sign the informed 
consent document prior to any procedures being done specifically for the study. 
Unemancipated minors who are 7 years old or older will sign the separate assent form. 
Participants will be informed that participation is voluntary and that they may withdraw 
from the study at any time, without prejudice. They will be informed that their medical 
care and their children’s medical care will not be adversely affected if they decline to 
participate in the study. A copy of the informed consent and assent documents (if 
separate form used) will be given to the participants/parents/guardians for their records.  
Assent is a process for children who have not reached the age of majority. The age at 
which assent is required is dependent on central IRB (i.e., the UAMS IRB) and any local 
site requirements for relying sites. All sites will be using the UAMS IRB as the IRB of 
record; per the UAMS IRB, the age of assent is 7 years old. All children who are 7 years 
old or older must agree to be participants in the study. Simply not disagreeing does 
NOT constitute assent.  
The informed consent process, as well as the child’s assent, will be conducted and will 
be documented in the source documents (research or medical record of the participant). 
The documentation will include, but is not limited to: (a) the title of the study, (b) the date 
the participant entered into the study, (c) the name of the PI, (d) the name of the site 
investigator, (e) the name of the person(s) obtaining the informed consent and assent, 
and (e) a statement that the participant or legally authorized representative received a 
copy of the signed form. Additional documentation that is recommended, but not 
required, includes: (a) list of who else was present during the process, (b) type of 
questions asked by the participant, (c) details that demonstrate the participant 
understands the information, and (d) other specific details related to that case.  

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Both parental consent and the children(s)’ assent - as well as records of the process of 
obtaining the consent and assent - will be maintained in the source documents. 
10.1.2 
STUDY DISCONTINUATION AND CLOSURE 
This study may be temporarily suspended at 1 or more sites if the reviewing IRB does 
not authorize renewal at the time of continuing review. Potential problems include, but 
are not limited to, information not received in time for continuing review to occur before 
the 1-year authorization period is up or issues that need to be address prior to re-
authorization. The study may also be suspended or stopped per any 
stopping/suspension specifications in the DSMB charter. Early termination may be 
permanent if there is sufficient cause. Written notification, documenting the reason for 
study suspension or termination, will be provided, directly or indirectly, by the 
suspending or terminating party to the following as applicable: study participants, PI, 
site investigators, reviewing IRB, local IRBs, the NIH, the ISPCTN DCOC, and the 
OHRP. Persons and offices notified shall include those specified in the study MOP, the 
reviewing IRB’s policies and procedures, and the SMART IRB policies and procedures. 
When study participants are contacted, they shall be informed of any changes to the 
study visit schedule. 
Circumstances that may warrant termination or suspension include, but are not limited 
to: 
• Determination of unexpected, significant, or unacceptable risk to participants 
• Demonstration of efficacy that would warrant stopping  
• Insufficient compliance to protocol requirements 
• Data that are not sufficiently complete and/or evaluable 
• Determination that the primary endpoint has been met 
• Determination of futility 
If the study was temporarily suspended, the study may resume once concerns about 
safety, protocol compliance, and data quality are addressed, and satisfy the DSMB, the 
reviewing IRB, the local IRB(s) (when applicable), the funding agency, and/or the 
sponsor (ISPCTN DCOC). 
 
 

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10.1.3 
CONFIDENTIALITY AND PRIVACY  
Participant confidentiality is held strictly in trust by the participating investigators, their 
staff, and the sponsor(s) and their agents. This confidentiality is extended to cover 
testing of biological samples, in addition to the clinical information relating to 
participating participants.  
The study protocol, documentation, data, and all other information generated will be 
held in strict confidence. No information concerning the study or the data will be 
released to any unauthorized third party without prior written approval of the sponsor.  
The study monitor or other authorized representatives of the sponsor may inspect all 
documents and records required to be maintained by the investigator. This 
documentation includes, but is not limited to, medical records (office, clinic, or hospital) 
and pharmacy records for the participants in this study. Clinical study sites will permit 
access to such records.  
The PI will ensure that the use and disclosure of protected health information (PHI) 
obtained during this research study complies with the Federal Privacy Regulation. In the 
U.S., the Health Insurance and Portability and Accountability (HIPAA) Privacy Rule 
applies. The rule provides U.S. federal protection for the privacy of PHI sent to or 
collected in the U.S. for the purposes of this research by implementing standards to 
protect and guard against the misuse of individually identifiable health information of 
participants participating in clinical trials. “Authorization” is required from each research 
participant (i.e., specific permission granted by an individual to a covered entity for the 
use or disclosure of an individual’s PHI). A valid authorization must meet the 
implementation specifications under the applicable Federal Privacy Regulations. The 
relevant privacy authorization will either be combined with the informed consent form 
(ICF) or will be provided as a separate document. If the privacy authorization is 
presented as a separate form, a copy of the signed form will be given to the 
participant/participant’s legal guardian. The HIPAA authorization, in addition to the ICF, 
will be approved by the IRB of record. 
Records will be maintained as required by the privacy and security rules promulgated by 
HIPAA (Health Insurance Portability and Accountability Act; Title 45 of the Code of 
Federal Regulations Part 164). The following links direct the reader to the rules: 
https://www.hhs.gov/hipaa/for-professionals/security/index.html and 
https://www.hhs.gov/hipaa/for-professionals/privacy/index.html (accessed by KLS 
06/12/17).  
 
 

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Certain bodies/institutions may need to review information, including the participants, for 
any of the following reasons: to process information, to ensure compliance with the 
protocol and other applicable requirements (such as the policies and procedures of the 
reviewing IRB). Institutions/bodies that may have access to the participants’ information 
include:  
• UAMS IRB 
• the IRB for the site through which the participant is enrolled 
• OHRP 
• DCOC for the ISPCTN 
• NIH 
Individuals with access to study records will be: 
• overall-study PI 
• site investigators 
• research coordinators 
• data managers at participating site(s) 
10.1.4 
FUTURE USE OF STORED SPECIMENS AND DATA  
During the conduct of the study, an individual participant can choose to withdraw 
consent to have their data used.  
10.1.5 
KEY ROLES AND STUDY GOVERNANCE 
 
Protocol Co-Chair 
Name, degree, title 
Brian O’Sullivan, MD 
Professor, Pediatrics 
Institution 
Geisel School of Medicine at Dartmouth College 
Address 
100 Hitchcock Way, Manchester, NH 03104 
Phone 
603-695-2790 
Email 
osullivb@hitchcock.org 
Protocol Co-Chair 
Name, degree, title 
J. Marc Majure, MD 
Suzanne T. Miller Chair in Pediatric Pulmonology 
Institution 
University of Mississippi Medical Center 
Address 
2500 N. State St., Jackson, MS 39216 
Phone 
601-984-5205 
Email 
jmajure@umc.edu 
 
 

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Protocol Co-Chair 
Name, degree, title 
Laura James, MD, FAAP 
Associate Vice Chancellor for Clinical and Translational 
Research 
Institution 
Arkansas Children’s Research Institute  
Address 
1 Children’s Way, Little Rock, AR 72202 
Phone 
501-296-1100 
Email 
jameslaurap@uams.edu 
Statistician 
Name, degree, title 
Songthip Ounpraseuth, PhD 
Associate Professor, Biostatistics 
Institution 
University of Arkansas for Medical Sciences 
Address 
4301 W. Markham St., Little Rock, AR 72205 
Phone 
501-686-7233 
Email 
stounpraseuth@uams.edu 
Duke Coordinating Center (DCC) PI 
Name, degree, title 
Jason Lang, MD, MPH 
Associate Professor, Allergy, Immunology, and Pulmonary 
Medicine 
Institution  
Duke Clinical Research Institute 
Address 
203 Research Drive, Durham, NC 27710 
Phone Number 
919-684-9590 
Email 
jason.lang@duke.edu 
Data Coordinating and Operations Center (DCOC) PI 
Name, degree, title 
Jessica Snowden, MD 
Associate Professor, Pediatric Infectious Diseases 
Institution  
Arkansas Children’s Research Institute / 
University of Arkansas for Medical Sciences 
Address 
13 Children’s Way, ACRI Slot 512-35, Little Rock, AR 
72202 
Phone Number 
501-364-4693  
Email 
 jsnowden@uams.edu 
Medical Monitor 
Name, degree, title 
Rachel Greenberg, MD, MB, MHS 
Assistant Professor, Pediatrics 
Institution  
Duke University School of Medicine 
Address 
300 West Morgan St, Suite 800, Durham, NC 27701 
Phone Number 
(919) 668-4725 
Email 
rachel.greenberg@duke.edu  
 
 
 

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The clinical trial outlined in this protocol is part of the ISPCTN, a branch of the ECHO 
program supported by the NIH. The data coordination, technical instruction, data 
standards, quality control and assurance, and operational coordination for the clinical 
trial protocol outlined here (and for the ISPCTN overall) is provided by the DCOC. The 
work of ISPCTN is governed by the Steering Committee, which includes representatives 
from all 17 state awarded clinical trial sites, as well as representatives from the DCOC 
and the NIH. Overseeing the work of the Steering Committee is the NIH ECHO Office, 
as well as an executive Leadership Committee. This clinical trial protocol was 
completed by a team of content experts and DCOC staff and was reviewed by the 
members of the Airways Working Group within the ISPCTN. Further review was 
completed by the NIH Protocol Review Committee as well as a DSMB. 
10.1.6 
SAFETY OVERSIGHT 
Safety oversight will be under the direction of a DSMB composed of individuals with the 
appropriate expertise, including pediatrics, PK, and biostatistics. Members of the DSMB 
should be independent from the study conduct and free of conflict of interest, or 
measures should be in place to minimize perceived conflict of interest. The DSMB will 
meet on a regular basis, per the DSMB charter, to assess safety and efficacy data of 
the study. The DSMB will operate under the rules of an approved charter that will be 
written and reviewed at the organizational meeting of the DSMB. At this time, each data 
element that the DSMB needs to assess will be clearly defined. The DSMB will provide 
its input to the NIH and the IND/sponsor. 
The role of the Medical Monitor (MM) is to provide input on safety considerations, 
evaluate safety trends, and to provide oversight throughout the life cycle of the clinical 
research, in accordance with the approved protocol. This role includes review and 
monitoring of safety events on a regular basis, advising the protocol investigators on 
trial-related medical questions or problems, as needed, and to review cumulative 
participant safety data and make recommendations regarding the data to the Data 
Safety Monitoring Board. The Medical Monitor will remain blinded to treatment 
assignment during safety event review, unless unblinding is warranted to optimize 
management of an adverse event or for other safety reasons. 
10.1.7 
CLINICAL MONITORING 
Clinical site monitoring is conducted to ensure that the rights and well-being of trial 
participants are protected, that the reported trial data are accurate, complete, and 
verifiable, and that the conduct of the trial complies with the currently approved 
protocol/amendment(s), with ICH GCP, and with applicable regulatory requirement(s).  
• Monitoring for this study will be performed by a member of the DCOC clinical 
operations staff or their designee.  
• Monitoring will be planned to be conducted on site or remotely at least once 
during the course of the study and if needed for cause.  

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• Details of clinical site monitoring are documented in the Clinical Monitoring Plan, 
which will be included in the MOP. The plan describes in detail who will conduct 
the monitoring, at what frequency monitoring will be done, at what level of detail 
monitoring will be performed, and the distribution of monitoring reports. 
Independent audits of the monitoring system will not be conducted by the ISPCTN 
DCOC. 
10.1.8 
QUALITY ASSURANCE AND QUALITY CONTROL 
Each clinical site will perform internal quality management of study conduct, data and 
biological specimen collection (if applicable), documentation, and completion. Each site 
will follow the trial-specific MOP and any additional written site-specific processes, as 
applicable. These processes may include, but not necessarily be limited to: 
(a) procedures for recruitment, (b) data collection, entry, review and submission 
processes, (c) roles and responsibilities of site personnel, and (d) training methods for 
study staff. 
Following the DCOC specific processes on monitoring, the monitors will verify that the 
clinical trial is conducted and data are generated and biological specimens are 
collected, documented (recorded), and reported in compliance with the protocol, the 
trial-specific MOP, site-specific processes, the [ICH] E6(R2) Good Clinical Practice: 
Integrated Addendum to ICH E6(R1), and applicable regulatory requirements.  
Quality control (QC) procedures for the database and DCOC-maintained records will be 
implemented in accordance with the MOP, DSMB charter, and applicable DCOC and 
site-specific processes. Information about any data anomalies will be communicated to 
the site(s) for clarification/resolution. There will be electronic field checks, database 
listings, and quality control reports implemented to monitor data quality. 
The investigational site will provide direct access to all trial-related sites, source 
data/documents, and reports for the purpose of monitoring and auditing by the DCOC 
and inspection by local and regulatory authorities. Issues uncovered during Quality 
Assurance (QA), QC, or monitoring activities will be addressed by making simple 
corrections or doing a root cause analysis, followed by instituting Corrective and 
Preventative Action (CAPA), as appropriate and as described in the MOP. 
Vendors performing study activities, such as specimen processing, will also be 
evaluated prior to study start to ensure they have in place standard operating 
procedures. Quality checks will be implemented to ensure they are following the trial-
specific MOP, their standard operating procedures and the protocol.  
 
 

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10.1.9 
DATA HANDLING AND RECORD KEEPING  
 
10.1.9.1 
DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES  
The data and workflow for the study will be described and documented in a formal data 
management plan. The data management plan and associated documentation will 
specify all operations performed on data from origination to database lock, including 
detailed descriptions of source documentation, CRFs, instructions for completing forms, 
data handling and record keeping procedures, procedures for data monitoring, and 
reconciliation procedures and coding dictionaries to be used, if applicable. The data 
management plan will also describe the specific data collection and management 
responsibilities required of the sponsor, PI, the award site, clinical site(s), 
laboratory/laboratories (if applicable), and the DCOC The data management plan 
contents will be consistent with those described in the Good Clinical Data Management 
Practices (GCDMP). Components of the data management plan documenting 
operations performed on the data will be provided to the PI for review and approval prior 
to implementation. 
Data collection is the responsibility of the clinical trial staff at the individual sites under 
the supervision of the site investigator. The investigator is responsible for ensuring the 
accuracy, completeness, legibility, and timeliness of the data reported. All source 
documents must be completed using standard good documentation practices 
(attributable, legible, contemporaneous, original, and accurate). 
Hardcopies of any data recorded on paper CRFs or study visit worksheets/assessment 
forms will be provided for use as source documents for recording data for each 
participant enrolled in the study. Data recorded in eCRFs derived from source 
documents must be consistent with the data recorded on the source documents.  
Clinical data (including demographics, physical examinations, and intervention-specific 
questionnaires) and applicable clinical laboratory data will be entered into a 21 CFR 
Part 11-compliant data capture system provided by the ISPCTN DCOC at the UAMS. 
The data system includes password protection and internal quality checks, such as 
automatic range checks, to identify data that appear inconsistent, incomplete, or 
inaccurate. Clinical data will be entered directly from the source documents. 
Data submitted from sites to the DCOC will not be de-identified since the data will 
include date of birth and may include other information that could possibly be linked 
back to the participant. Data will be de-identified before sharing externally. 
10.1.9.2 
STUDY RECORDS RETENTION  
Throughout the course of the study, all sites will retain a copy of the source documents 
on site in accordance with current site-specific medical record storage procedures. All 
study documents must be retained in accordance with local and/or federal regulations, 
whichever is most stringent. No records will be destroyed without the written consent of 
the sponsor, if applicable. It is the responsibility of the sponsor to inform the investigator 
when these documents no longer need to be retained. 

Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
Sponsor: ISPCTN DCOC 
 
 
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10.1.10 
PROTOCOL DEVIATIONS  
Protocol deviations are any instances in which the protocol, or any applicable DCOC or 
site-specific processes or applicable regulations are not followed as written. Deviations 
are not allowed; all deviations shall, therefore, be recorded in the study source 
documents. Whenever a deviation occurs, there must be an assessment of the severity 
and risk of the deviation. Depending on the results of the assessment, either a 
corrective action or a simple, 1-time correction shall be implemented. A corrective action 
institutes a process designed to keep that specific problem from happening again. 
Typically, a determination of the root cause of the problem is completed in order to 
develop the most appropriate corrective action plan. 
The specific methods for handling protocol deviations will be provided in the study-
specific MOP and/or site-specific processes. 
10.1.11 
PUBLICATION AND DATA SHARING POLICY 
This study will be conducted in accordance with the following publication and data 
sharing policies and regulations: 
• NIH Public Access Policy, which ensures that the public has access to the 
published results of NIH-funded research. It requires scientists to submit final 
peer-reviewed journal manuscripts that arise from NIH funds to the digital archive 
PubMed Central upon acceptance for publication. 
• ISPCTN Publications and Presentations Policy, which ensures accurate, 
responsible, and efficient communication of findings from ISPCTN clinical trials. 
The ISPCTN Publications and Presentations Policy has been approved and 
ratified by the ISPCTN Steering Committee, which includes representatives from 
all awarded clinical trial sites, as well as representatives from the NIH and the 
DCOC.  
• This trial will be registered at ClinicalTrials.gov, and results information from this 
trial will be submitted to ClinicalTrials.gov. In addition, every attempt will be made 
to publish results in peer-reviewed journals. Data from this trial may be requested 
from other researchers by contacting Dr. Jeannette Lee at the DCOC. 
10.1.12 
CONFLICT OF INTEREST POLICY 
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons 
who have a role in the design, conduct, analysis, publication, or any aspect of this trial 
will be disclosed and managed. Furthermore, persons who have a perceived conflict of 
interest will be required to have such conflicts managed in a way that is appropriate to 
their participation in the design and conduct of this trial. The study leadership in 
conjunction with the NIH ECHO Office has established policies and procedures for all 
study group members to disclose all conflicts of interest and will establish a mechanism 
for the management of all reported dualities of interest. 

Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
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10.2 ABBREVIATIONS 
 
1,25D3 
1,25 hydroxy-vitamin D3 
25(OH)D 
25-hydroxy-vitamin D 
ACT 
Asthma Control Test 
AE 
Adverse Event 
AR 
Adverse Reaction 
ASD 
Asthma Symptom Days 
BMI 
Body Mass Index 
c-ACT 
Child-Asthma Control Test 
CAMP 
Childhood Asthma Management Program 
CAPA 
Corrective and Preventative Action 
CAP 
College of American Pathologists 
CBC 
Complete Blood Count 
CFR 
Code of Federal Regulations 
CLIA 
Clinical Laboratory Improvement Amendments 
CMP 
Clinical Monitoring Plan 
CONSORT 
Consolidated Standards of Reporting Trials 
CRF 
Case Report Form 
DCC 
Data Coordinating Center 
DCOC 
Data Coordinating and Operations Center 
DSMB  
 Data Safety Monitoring Board  
ECHO 
Environmental Influences on Child Health Outcomes 
eCRF 
Electronic Case Report Forms 
ED 
Emergency Department 
FDA 
Food and Drug Administration 
GCDMP 
Good Clinical Data Management Practices 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act  
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation  
ICS 
Inhaled Corticosteroid 
IL 
Interleukin 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISPTCN 
The IDeA States Pediatric Clinical Trials Network 
ITT 
Intention-To-Treat 
LABA 
Long-acting Beta-agonist 
LSMEANS 
Least-squares Means 
LTRA 
Leukotriene Receptor Antagonist 
MedDRA 
Medical Dictionary for Regulatory Activities 
MOP 
Manual of Procedures 
NCT 
National Clinical Trial 
NHANES 
National Health and Nutrition Examination Survey 

Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
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NIH  
National Institutes of Health 
OHRP 
Office for Human Research Protections 
PHI 
Protected Health Information 
PI 
Principal Investigator 
PK 
Pharmacokinetic(s) 
PTH 
Parathyroid Hormone 
QA 
Quality Assurance 
QC 
Quality Control 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SAR 
Serious Adverse Reaction 
SoC 
Standard of Care Comparator Group 
SMART IRB 
Streamlined, Multisite, Accelerated Resources for Trials IRB 
Reliance platform 
SOA 
Schedule of Activities 
TBD 
To Be Determined 
TNFα 
Tumor Necrosis Factor Alpha 
UAMS 
University of Arkansas for Medical Sciences 
ULN 
Upper Limit Normal 
UP 
Unanticipated Problem 
US 
United States 
USP 
United States Pharmacopeia 
VIDA 
Vitamin D Add-on Therapy Enhances Corticosteroid 
Responsiveness in Asthma 
VDORA 
Vitamin D Oral Replacement in Asthma 

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11 REFERENCE
1  
Schoenmakers I, Jones KS. (2018) Pharmacology and Pharmacokinetics. In D. 
Feldman, Vitamin D, Vol. 1: Biochemistry, Physiology, and Diagnostics (4th ed., pp. 635-
661).  London, England:  Elsevier. 
2  
Ekwaru JP, Zwicker JD, Holick MF, Giovannucci E., Veugelers PJ. The importance of 
body weight for the dose response relationship of oral vitamin D supplementation and 
serum 25-hydroxyvitamin D in healthy volunteers. PLoS One 2014;9(11):e111265 
3. 
Akinbami LJ, Simon AE, Rossen LM. Changing Trends in Asthma Prevalence Among 
Children. Pediatrics. 2016; 137(1). 
4. 
Ogden CL, Carroll MD, Flegal KM. Prevalence of Childhood and Adult Obesity in the 
United States, 2011-2012. JAMA. 2014;311(8), 806-814. 
5. 
https://www.cdc.gov/asthma/asthma_stats/asthma_obesity.htm (accessed 9-28-17) 
6. 
Dixon AE, Poynter ME. Mechanisms of Asthma in Obesity. Pleiotropic Aspects of 
Obesity Produce Distinct Asthma Phenotypes. Am J Respir Cell Mol Biol. 2016;54(5), 
601-8. 
7. 
Suratt BT, Ubags NDJ, Rastogi D, et al. An Official American Thoracic Society 
Workshop Report: Obesity and Metabolism. An Emerging Frontier in Lung Health and 
Disease. Ann Am Thorac Soc. 2017;14(6), 1050-9. 
8. 
Vijayakanthi N, Greally JM, Rastogi D. Pediatric Obesity-Related Asthma: The Role of 
Metabolic Dysregulation. Pediatrics. 2016;137(5): e20150812. 
9. 
Lang JE, Fitzpatrick AM, Mauger DT, Guilbert TW, Jackson DJ, Lemanske RF, et al. 
Overweight/obesity status in preschool children associates with worse asthma but robust 
improvement on inhaled corticosteroids. 2017 J Allergy Clin Immunol. Online prior to 
publication. https://doi.org/10.1016/j.jaci.2017.09.043] 
10. 
Turer CB, Lin H, Flores G. Prevalence of Vitamin D Deficiency Among Overweight and 
Obese US Children. Pediatrics. 2013;131:e152-e161. 
11. 
Luong KV, Nguyen LT. The Role of Vitamin D in Asthma. Pulm Pharmacol Ther. 25, 
137-143. 
12. 
Brehm JM, Schuemann B, Fuhlbrigge AL, et al. Serum Vitamin D Levels and Severe 
Asthma Exacerbations in the Childhood Asthma Management Program Study. J Allergy 
Clin Immunol. 126, 52-58 
13. 
Martineau AR, Cates CJ, Urashima M, et al. Vitamin D for the Management of Asthma. 
The Cochrane Database of Systematic Reviews. 2016. doi: 
10.1002/14651858.CD011511. 
14. 
Riverin BD, Maguire JL, Li P. Vitamin D Supplementation for Childhood Asthma: A 
Systematic Review and Meta-Analysis. PLoS One. 10(8), e0136841.  
15  
Hollis BW, Wagner, CL, Drezner MK, et al. Circulating Vitamin D3 and 25-
hydroxyvitamin D in Humans: An Important Tool to Define Adequate Nutritional Vitamin 
D Status. J Steroid Biochem Mol Biol. 2007;103, 631–634 
 
 

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16  
Foissac F, Meyzer C, Frange P, Chappuy H, Benboud S, Bouzza N, et al. Determination 
of optimal D3 dosing regimens in HIV-infected paediatric patients using a population 
pharmacokinetic approach. 2014;78(5):1113-21. 
17. 
Weiss ST, Litonjua AA. Vitamin D Dosing for Infectious and Immune Disorders. Thorax. 
2015;70(10), 919-20. 
18. 
Litonjua AA, Weiss ST. Vitamin D Status Through the First 10 Years of life: A Vital Piece 
of the Puzzle in Asthma Inception. J Allergy Clin Immunol. 2017;139(2), 459-61. 
19. 
Taveras EM, Rifas-Shiman SL, Camargo CA Jr, Gold DR, Litonjua AA, Oken E, et al. 
Higher Adiposity in Infancy Associated with Recurrent Wheeze in a Prospective Cohort 
of Children. J Allergy Clin Imunol. 2008 May;121(5), 1161-1166. 
20. 
Mannino DM, Mott J, Ferdinands JM, et al. Boys with High Body Masses Have an 
Increased Risk of Developing Asthma: Findings from the National Longitudinal Survey of 
Youth (NLSY). Int J Obes (Lond). 2006;30(1): 6-13. 
21. 
Hampton T. Studies Probe Links Between Childhood Asthma and Obesity. JAMA. 
2014;311(17), 1718-9. 
22  
Cottrell L, Neal WA, Ice C, Perez MK, Piedimonte G. Metabolic abnormalities in children 
with asthma. Am J Respir Crit Care Med 2011;183:441-8 
23. 
Pfeffer PE, Hawrylowicz CM. Vitamin D and Lung Disease. Thorax. 2012;67(11), 1018-
20. 
24  
Koksal BT, Ozbek OY, Bayraktar N, Kinik ST, Yazici AC. Evaluation of serum leptin and 
adiponectin levels in obese and lean asthmatic children. Pediatr Allergy Immunol 
Pulmonol 2015;28:96-101. 
25. 
Schatz M, Zeiger RS, Zhang F, et al. Overweight/Obesity and Risk of Seasonal Asthma 
Exacerbations. J Allergy Clin Immunol Pract. 2013 Nov-Dec;1(6), 618-22. 
26. 
Lang JE, Hossain J, Dixon AE, et al. Does Age Impact the Obese Asthma Phenotype? 
Longitudinal Asthma Control, Airway Function, and Airflow Perception Among Mild 
Persistent Asthmatics Chest. 2011 Dec;140(6), 1524-1533. 
27. 
Lang JE, Hossain MF, Lima JJ. Overweight Children Report Qualitatively Distinct 
Asthma Symptoms: Analysis of Validated Symptom Measures. J Allergy Clin Immunol. 
2015 Apr;135(4), 886-93. 
28. 
Codoner-Franch P, Tavarez-Alonso S, Simo-Jorda R, et al. Vitamin D Status is Linked to 
Biomarkers of Oxidative Stress, Inflammation, and Endothelial Activation in Obese 
Children. J Pediatr. 2012;161(5), 848-54. 
29. 
Kerley CP, Elnazir B, Faul J, et al. Vitamin D as an Adjunctive Therapy in Asthma. Part 
1: A Review of Potential Mechanisms. Pulm Pharmacol Ther. 2015;32,60-74. 
30. 
Raby BA, Lazarus R, Silverman EK, et al. Association of Vitamin D Receptor Gene 
Polymorphisms with Childhood and Adult Asthma. Am J Respir Crit Care Med. 
2004;170(10), 1057-65. 
31. 
O’Sullivan BP, Kerrigan SW. Platelets, Inflammation, and Respiratory Disease. In: The 
Non-Thrombotic Role of Platelets in Health and Disease.  Kerrigan SW, editor, In-Tech 
Press. 2015. 
 

Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
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32  
Han YY, Forno E, Celedon JC. Vitamin D insufficiency and asthma in a US nationwide 
study.  J Allerg Clin Immunol Practice 2017 May-Jun;5(3):790-796. 
33  
Hollams EM, Teo SM, Kusel M, et al. Vitamin D Over the First Decade and Susceptibility 
to Childhood Allergy and Asthma. J Allergy Clin Immunol. 2017 Feb;139(2), 472-481. 
34  
Searing DA, Zhang Y, Murphy JR, Hauk PJ, Goleva E, Leung DY. Decreased serum 
vitamin D levels in children with asthma are associated with increased corticosteroid 
use. J Allergy Clin Immunol 2010 May;125(5):995-1000 
35. 
Lin Z, Li W.  Vitamin D and Inflammatory Diseases Current Top Med Chem. 
2016;16(11), 1242-61. 
36. 
Brehm JM, Acosta-Perez E, Klei L, et al. Vitamin D Insufficiency and Severe Asthma 
Exacerbations in Puerto Rican Children. Am J Respir Crit Care Med. 2012 Jul 15;186(2), 
140-6. 
37. 
Gupta A, Sjoukes A, Richards D, et al. Relationship Between Serum Vitamin D, Disease 
Severity, and Airway Remodeling in Children with Asthma. Am J Respir Crit Care Med. 
2011;184(12), 1342-9. 
38. 
Lautenbacher LA, Jariwala SP, Markowitz ME, et al. Vitamin D and Pulmonary Function 
in Obese Asthmatic Children. Pediatr Pulmonol. 2016;51(12), 1276-83. 
39. 
Martineau AR, Jolliffe DA, Hooper RL, et al. Vitamin D Supplementation to Prevent 
Acute Respiratory Tract Infections: Systematic Review and Meta-Analysis of Individual 
Participant Data. BMJ. 2017 Feb 15;356, i6583. 
40. 
Sabetta JR, DePetrillo P, Cipriani RJ, et al. Serum 25-Hydroxyvitamin D and the 
Incidence of Acute Viral Respiratory Tract Infections in Healthy Adults. PLoS One. 2010 
Jun 14;5(6) e11088. 
41. 
Ginde AA, Wolfe P, Camargo CA, et al. Defining Vitamin D status by Secondary 
Hyperparathyroidism in the U.S. Population. J Endocrinol Invest. 2012 Jan;35(1), :42-8. 
42. 
Mirzakhani H, Litonjua AA, McElrath TF, et al. Early Pregnancy Vitamin D Status and 
Risk of Preeclampsia. J Clin Invest. 2016;126(12), 4702-4715. 
43. 
Castro M, King TS, Kunselman SJ, et al. Effect of Vitamin D3 on Asthma Treatment 
Failures in Adults with Symptomatic Asthma and Lower Vitamin D Levels: The VIDA 
Randomized Clinical Trial. JAMA. 2014;311(20), 2083-91. 
44. 
Jolliffe DA, Greenberg L, Hooper RL, et al. Vitamin D Supplementation to Prevent 
Asthma Exacerbations: a Systematic Review and Meta-Analysis of Individual Participant 
Data. Published online October 3, 2017 http://dx.doi.org/10.1016/S2213-2600(17)30306-
5. 
45. 
Kerley CP, Elnazir B, Faul J, et al. Vitamin D as an Adjunctive Therapy in Asthma. Part 
2: A Review of Human Studies. Pulm Pharmacol Ther. 2015;32, 75-92. 
46. 
Majak P, Olszowiec-Chlebna M, Smejda K, et al. Vitamin D Supplementation in Children 
May Prevent Asthma Exacerbation Triggered by Acute Respiratory Infection. J Allergy 
Clin Immunol. 2011;127(5), 1294-6. 
47. 
de Groot JC, van Roon EN, Storm H, et al. Vitamin D Reduces Eosinophilic Airway 
Inflammation in Nonatopic Asthma. J Allergy Clin Immunol. 2015;135(3), 670-5. 
 

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48. 
Elitsur Y, Preston DL. Randomized Vitamin D Supplementation in Vitamin D Deficient 
Obese Children from West Virginia. Archives of Clinical Gastroenterology. 2016;2(3), 65-
68. 
49. 
Belenchia AM, Tosh AK, Hillman LS, et al. Correcting Vitamin D Insufficiency Improves 
Insulin Sensitivity in Obese Adolescents: a Randomized Controlled Trial. The American 
Journal of Clinical Nutrition. 2013;97(4), 774-81. 
50. 
Luger M, Kruschitz R, Kienbacher C, et al. Vitamin D3 Loading Is Superior to 
Conventional Supplementation After Weight Loss Surgery in Vitamin D-Deficient 
Morbidly Obese Patients: a Double-Blind Randomized Placebo-Controlled Trial. Obes 
Surg. 2017;27(5), 1196-207. 
51. 
Schleck ML, Souberbielle JC, Jandrain B, et al. A Randomized, Double-Blind, Parallel 
Study to Evaluate the Dose-Response of Three Different Vitamin D Treatment Schemes 
on the 25-Hydroxyvitamin D Serum Concentration in Patients with Vitamin D Deficiency. 
Nutrients. 2015;7(7), 5413-22. 
52. 
Vieth R. Vitamin D Supplementation, 25-Hydroxyvitamin D Concentrations, and Safety. 
The American Journal of Clinical Nutrition. 1999;69(5), 842-56. 
53. 
Wu AC, Himes BE, Lasky-Su J, et al. Inhaled Corticosteroid Treatment Modulates 
ZNF432 Gene Variant's Effect on Bronchodilator Response in Asthmatics. J Allergy Clin 
Immunol. 2014;133(3), 723-8. 
54. 
Mocanu V, Vieth R. Three-Year Follow-Up of Serum 25-Hydroxyvitamin D, Parathyroid 
Hormone, and Bone Mineral Density in Nursing Home Residents Who Had Received 12 
Months of Daily Bread Fortification With 125 mug of Vitamin D(3). Nutrition Journal. 
2013;12, 137. 
55. 
Radhakishun NN, van Vliet M, Poland DC, et al. Efficacy and Tolerability of a High 
Loading Dose (25,000 IU weekly) Vitamin D3 Supplementation in Obese Children with 
Vitamin D Insufficiency/Deficiency. Horm Res Paediatr. 2014;82(2), 103-6. 
56. 
van Groningen L, Opdenoordt S, van Sorge A, et al. Cholecalciferol Loading Dose 
Guideline for Vitamin D-Deficient Adults. Eur J Endocrinol. 2010 Apr;162(4), 805-11. 
57. 
Alansari K, Davidson BL, Yousef KI, et al. Rapid vs Maintenance Vitamin D 
Supplementation in Deficient Children With Asthma to Prevent Exacerbations. Chest. 
2017. 152(3), 527-36. 
58. 
Heaney RP, Davies KM, Chen TC, et al. Human Serum 25-Hydroxycholecalciferol 
Response to Extended Oral Dosing with Cholecalciferol. Am J Clin Nutr. 2003 Jan;77(1), 
204-10. 
59. 
Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al. 
Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society 
clinical practice guideline. J Clin Endocrinol Metab 2011;96(7):1911-30 
60. 
Pietras SM, Obayan BK, Cai MH, et al. Vitamin D2 Treatment for Vitamin D Deficiency 
and Insufficiency for Up to 6 years. Arch Intern Med. 2009;169(19), 1806-8. 
61. 
https://clinicaltrials.gov/ct2/show/NCT02687815 
62. 
Mazahery H, von Hurst PR. Factors Affecting 25-Hydroxyvitamin D Concentration in 
Response to Vitamin D Supplementation. Nutrients. 2015 Jun 25;7(7), 5111-42. 
63. 
Robien K, Oppeneer SJ, Kelly JA, et al. Drug-Vitamin D Interactions: a Systematic 
Review of the Literature. Nutr Clin Pract. 2013 Apr;28(2), 194-208. 
 

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Sponsor: ISPCTN DCOC 
 
 
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64  
Weiss ST, Shore S. Obesity and asthma: direction for research. A. Am J Respir Crit 
Care Med. 2004 Apr 15;169(8):963–968. 
65  
Canoz M, Erdenen F, Uzun H, Muderrisoglu C, Aydin S. The relationship of inflammatory 
cytokines with asthma and obesity. Clin Invest Med 2008 Dec 1;31(6):e373-9. 
66  
Halwani R, Al-Kufaidy R, Vazquez-Tello A, et al. IL-17 enhances chemotaxis of primary 
human B-cells during asthma. PLoS One 2014;9(12):e114604. 
67  
Nanzer AM, Chambers ES, Ryanna K, et al. Enhanced production of IL-17A in patients 
with severe asthma is inhibited by 1α, 25-dihydroxyvitamin D3 in a glucocorticoid-
independent fashion. J Allergy Clin Immunol 2013;132:297-304. 
68  
Taher YA, van Esch BC, Hofman GA, Henricks PA, van Oosterhout AJ. 1aplha,25-
dihyroxyvitamin D3 potentiates the beneficial effects of allergen immunotherapy in a 
mouse model of allergic asthma: role for IL-10 and TGF0beta. J Immunol 
2008,180(8):5211–21 
69. 
Lexicomp Online® , Pediatric & Neonatal Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; 
accessed September 29, 2017. 
70. 
Holick MF. Vitamin D Is Not as Toxic as Was Once Thought: A Historical and an Up-to-
Date Perspective. Mayo Clin Proc. 2015;90(5), 561-4 
71.  
Hollis BW, Johnson D, Hulsey TC, Ebeling M, Wagner CL. Vitamin D supplementation 
during pregnancy: double-blind, randomized clinical trial of safety and effectiveness. J 
Bone Mineral Res 2011;26:2338-2340 
72.  
Roth DE, Al Mahmud A, Ragib R, Black RE, Baqui AH. Pharmacokinetics of a single oral 
dose of vitamin D3 (70,000 IU) in pregnant and non-pregnant women. Nutrition J 
2012;11:114. 
73. 
Hollis BW, Wagner CL. Vitamin D supplementation during pregnancy: Improvements in 
birth outcomes and complications through direct genomic alteration. Mol Cell Endocrinol 
2017;113-130. 
74.  
Chawes BL, Bonnelykke K, Stokholm J, Vissing NH, Bjarnadottir E, Schoos AM, et al. 
Effect of Vitamin D3 Supplementation During Pregnancy on Risk of Persistent Wheeze 
in the Offspring: A Randomized Clinical Trial. JAMA 2016;315:353-361 
75.  
Litonjua AA, Carey VJ, Laranjo N, et al. Effect of Prenatal Supplementation With Vitamin 
D on Asthma or Recurrent Wheezing in Offspring by Age 3 Years: The VDAART 
Randomized Clinical Trial. JAMA. 2016;315(4), 362-70. 
76.  
Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D 
and Calcium; Ross AC, Taylor CL, Yaktine AL, et al., editors. Dietary Reference Intakes 
for Calcium and Vitamin D. Washington (DC): National Academies Press (US); 2011. 
Available from: https://www.ncbi.nlm.nih.gov/books/NBK56070/ doi: 10.17226/13050. 
Accessed 01/26/2018 
77. 
U.S. Department of Health and Human Services, Health Resources and Services 
Administration, Maternal and Child Health Bureau, The Health and Well-Being of 
Children in Rural Areas: A Portrait of the Nation, 2011-2012. Rockville, Maryland: U.S. 
Department of Health and Human Services, 2015. 
78  
“Use of placebo on children in study draws researcher’s ire.” Boston Globe, Sunday, Feb 
11, 2018 https://www.bostonglobe.com/metro/2018/02/11/ethical-questions-arise-over-
 

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giving-young-asthma-patients-placebos-study-children-
hospital/Gc7X7SZ6Hsgu5zwtYCXtqL/story.html (accessed 2/14/18) 
79  
Holick MF. Vitamin D Deficiency. N Engl J Med. 2007 Jul 19;357(3):266-81. 
80. 
Writing Committee for the American Lung Association Asthma Clinical Research 
Centers. Lansoprazole for Children with Poorly Controlled Asthma: a Randomized 
Controlled Trial. JAMA. 2012 Jan 25;307(4), 373-81. 
81. 
American Lung Association Asthma Clinical Research Centers. Randomized 
Comparison of Strategies for Reducing Treatment in Mild Persistent Asthma. N Engl J 
Med. 2007 May 17;356(20), 2027-39. 
82. 
Schatz M, Sorkness CA, Li JT, et al. Asthma Control Test: Reliability, Validity, and 
Responsiveness in Patients Not Previously Followed by Asthma Specialists. J Allergy 
Clin Immunol. 2006 Mar;117(3), 549-56. 
83. 
Lemanske RF Jr, Mauger DT, Sorkness CA, et al. Step-Up Therapy for Children with 
Uncontrolled Asthma Receiving Inhaled Corticosteroids. N Engl J Med. 2010 Mar 
18;362(11), 975-85. 
84. 
Fuhlbrigge A, Peden D, Apter AJ, et al. Asthma Outcomes: Exacerbations. J Allergy Clin 
Immunol. 2012 Mar;129(3 Suppl), S34-48. 
85.  
Alshahrani F, Aljohani N. Vitamin D: Deficiency, Sufficiency and Toxicity. Nutrients. 
2013;5(9):3605-3616. doi:10.3390/nu5093605. 
86  
Marins TA, Galvão Tde F, Korkes F, et al. Vitamin D intoxication: case report. Einstein 
2014;12(2):242-4 
87  
Araki T, Holick, MF, Alfonso BD, et al. Vitamin D intoxication with severe hypercalcemia 
due to manufacturing and labeling errors of two dietary supplements made in the United 
States. J Clin Endocrinol Metab. 2011;96:3603-8. 
88  
Schoenmakers I, Jones KS. Pharmacology and Pharmacokinetics. In: Vitamin D, 4th 
Edition. Feldman D, editor. Academic Press, London, UK. Pages 636-662. 
89  
Wang Y, Jadhav PR, Lala M, Gobburu JV. Clarification on Precision Criteria to Derive 
Sample Size When Designing Pediatric Pharmacokinetic Studies. J Clin Pharmacol 
October 2012 52: 1601-1606. 
90  
Gonzalez D, Palazzi DL, Bhattacharya-Mithal L, Al-Uzri A, James LP, Bradley J, et al. 
Solithromycin pharmacokinetics in plasma and dried blood spots and safety in 
adolescents. 2016. Antimicrob Agents Chemother Mar 25;60(4):2572-6 
91  
Cohen-Wolkowiez M, Ouellet D, Smith PB, James LP, Ross A, Sullivan JE, et al.  
Population pharmacokinetics of metronidazole evaluated using scavenged samples from 
preterm infants. 2012 Antimicrob Agents Chemother Apr;56(4):1828-37. 
92  
Cohen-Wolkowiez M, Sampson M, Bloom BT, Arrieta A, Wynn JL, Martz K, et al. 
Determining population and developmental pharmacokinetics of metronidazole using 
plasma and dried blood spot samples from premature infants. Dediatr Infect Dis J 
2013;32(9):956-61. 
 

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93  
Horlick CP, Wu H, Edginton AN, Watt K, Cohen-Wolkowiez M, Gonzalez D. 
Development of a pediatric physiologically-based pharmacokinetic model of clindamycin 
using opportunistic pharmacokinetic data. Clin Pharmacokinet 2017 Nov;56(11):1343-
1353. 
 
 

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Title: Vitamin D Supplementation in Children With Obesity-Related Asthma 
Sponsor: ISPCTN DCOC 
 
 
IRB # 228446  Version # 07 
Date: 14 December 2020                                                                                                     Page 89 of 89  
 
 
 
 
 
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