A Pilot Study Evaluating Single, High-dose Pharmacokinetics/Pharmacodynamics of Vitamin D3 in CF
Phase: NA
Conditions: Vitamin D Deficiency, Cystic Fibrosis
Sponsor: University of Southern California

 
 
 
1
 
 
 
PROTOCOL NUMBER: HS-18-00737 
 
 
 
TITLE: A pilot study evaluating single, high-dose pharmacokinetics/pharmacodynamics of vitamin D3 
in CF 
 
PRINCIPAL INVESTIGATOR(S): 
Paul Beringer, Pharm.D. 
 
USC School of Pharmacy 
 
1985 Zonal Avenue, Los Angeles CA 90033 
 
TEL: 323-442-1402 
 
FAX: 626-628-3024 
 
CO-INVESTIGATOR(S):                      Adupa Rao, M.D.  
 
 
PARTICIPANTS/LOCATONS:             University of Southern California  
 
 
AMENDMENTS/REVISIONS: 
Version 5, Jan 22nd 2019 
 
 
 
 
 
 
 

 
 
 
2
TABLE OF CONTENTS 
 
 
SCHEMA, SYNOPSIS, OR STUDY SUMMARY 
 
 
 
 
 
PAGE 
 
1.0 
BACKGROUND AND HYPOTHESES  
__3___ 
 
2.0 
OBJECTIVES AND PURPOSE 
__4___ 
 
3.0 
STUDY DESIGN  
__4___ 
 
4.0 
DRUG/DEVICE INFORMATION 
__4___ 
 
5.0  
SELECTION AND WITHDRAWAL OF SUBJECTS 
__5___ 
 
6.0 
DESCRIPTIVE FACTORS/STRATIFICATION/RANDOMIZATION SCHEME
 
__5___ 
 
7.0  
STUDY AGENT ADMINISTRATION OR INTERVENTION AND TOXICITY     
MANAGEMENT PLAN 
__5___
 
 
 
 
8.0 
ASSESSMENT OF EFFICACY AND SAFETY 
__6___
 
 
 
9.0 
CLINICAL AND LABORATORY EVALUATIONS 
__7___ 
 
10.0 
CRITERIA FOR EVALUATION AND ENDPOINT DEFINITIONS  
__7___  
 
11.0 
SPECIAL INSTRUCTIONS 
 
 
 
 
 
 
__7___ 
 
12.0 
DATA COLLECTION AND MONITORING 
__7___ 
 
13.0 
STATISTICAL CONSIDERATIONS  
__7___ 
 
14.0 
REGISTRATION GUIDELINES  
__8___ 
 
15.0 
BIOHAZARD CONTAINMENT 
__8___ 
 
16.0 
ETHICAL AND REGULATORY CONSIDERATIONS 
__8___ 
 
17.0 
REFERENCES 
 
 
 
 
 
 
 
 
__8___ 
 
APPENDICES 
 
 

 
 
 
3
 1.0 
BACKGROUND AND HYPOTHESES 
 
Background 
 
Vitamin D is a fat-soluble vitamin that plays an important role in immune modulation in 
addition to its classical roles in regulation of calcium homeostasis and bone health (1). Vitamin D 
undergoes two subsequent hydroxylation reactions to form the active metabolite, 1,25(OH)2D. 
25(OH)D, which is an intermediate inactive metabolite, is the major circulating form of vitamin D, and 
its total serum concentration is used to assess the overall vitamin D status of an individual. Vitamin D 
insufficiency is defined as a serum 25(OH)D level between 29 and 20 ng/mL, while vitamin D 
deficiency is defined as a serum 25(OH)D levels below 20 ng/mL. Identification of vitamin D 
receptors and vitamin D-metabolizing enzymes (CYP27B1, CYP24A1) in immune cells revealed the 
immune-modulating activity of vitamin D. There is a plethora of evidence of anti-inflammatory effect 
for vitamin D through inhibition of pro-inflammatory cytokine expressions (2-4).  
 
Current recommended threshold for vitamin D adequacy has been controversial. According to 
the Endocrine Society, target 25(OH)D level of 30 ng/mL (or 75 nmol/L) is based on the finding that it 
is the minimal concentration required for optimal bone health while maximally suppressing 
parathyroid hormone productions in adults (5-7). However, in vitro study revealed that concentrations 
greater than 30 ng/mL may be required to have maximal anti-inflammatory effect (8). Clinical 
consequences of vitamin D inadequacy go well beyond osteoporosis; vitamin D deficiency is 
associated with increased risks of several diseases, including diabetes, cancer and inflammatory 
diseases (9-13). Accordingly, several studies demonstrated a positive effect of vitamin D 
supplementation on inflammatory markers indicating that correcting vitamin D status may serve as an 
effective anti-inflammatory therapy (14-16). 
 
Cystic Fibrosis and Vitamin D deficiency 
 
Cystic fibrosis (CF) is a lethal autosomal recessive disorder characterized by chronic airway 
infections, inflammation and obstruction, leading to progressive loss of lung function and ultimately 
respiratory failure. Vitamin D deficiency is highly prevalent in CF patients, affecting approximately 
90% of patients with CF (17, 18). Malabsorption of fat-soluble vitamins, which is a result of exocrine 
pancreatic enzyme insufficiency, likely play a role in vitamin D deficiency (19). Over 85% of CF 
patients are affected by pancreatic insufficiency, which causes intestinal malabsorption of nutrients, 
such as vitamin D (20). In addition to malabsorption, other factors may also contribute to suboptimal 
vitamin D status, including reduced exposure to sunlight, reduced levels of vitamin D binding proteins 
and poor adherence to daily dosing (20-22). Inadequate vitamin D level is of particular concern for 
patients with CF as vitamin D deficiency has been associated with increased risk of respiratory 
infection and worsened pulmonary function (21).  
 
Study Rationale 
Despite the extensive literatures on adverse clinical outcomes associated with vitamin D 
deficiency and beneficial effects of vitamin D supplementation in the treatment of various 
inflammatory and infectious diseases , there are currently no proven treatment strategy that effectively 
achieves and maintains optimal serum vitamin D status in CF patients (23). For the treatment of 
vitamin D deficiency in CF, CF Foundation currently recommends 2,000 IU daily (24). However, 
because achieving adequate serum 25(OH)D levels is a challenge in CF, higher doses of vitamin D 
may be necessary to reach and maintain vitamin D sufficiency (25, 26). A pilot study of vitamin D 
supplementation in adults with CF experiencing pulmonary exacerbation revealed that high dose of 
vitamin D (250,000 IU) raised 25(OH)D levels while it did not cause hypercalcemia or significant 
changes in PTH concentrations (26), which indicates that this mega-dose of vitamin D3 is safe in CF 
patients. In addition, several studies in non-CF population have demonstrated that high single doses of 
vitamin D3 did not significantly alter the PTH or calcium levels (27-29). In a retrospective chart 

 
 
 
4
review of pediatric CF patients, majority of patients (79%) rapidly and safely achieved and sustained 
optimal 25OHD levels over a 12 month period with a single high-dose oral vitamin D3 (300,000 IU – 
600,000 IU), also known as stoss therapy (25). However, approximately 20% of patients still could not 
achieve levels above 30 ng/mL. Wide inter-individual variability in response to vitamin D treatment 
has been previously reported in non-CF population, suggesting that fixed-dose approach to 
replacement therapy may not be effective in improving 25(OH)D status in CF (30). Poor oral 
bioavailability of ergocalciferol has been demonstrated in CF patients (31), which suggests that CF 
patients may potentially exhibit low absorption of cholecalciferol. Therefore, based on the degree of 
malabsorption of vitamin D and basal vitamin D status, supplementation should be tailored to 
individuals. In order to optimize the treatment of deficiency in CF, kinetic disposition of vitamin D 
must be well understood. However, there are very few data currently available describing the kinetics 
of both vitamin D and 25-hydroxyvitamin D, and to the investigator’s knowledge, no studies have yet 
characterized the pharmacokinetic disposition of vitamin D in cystic fibrosis. Addressing this issue is 
crucial in effectively and safely correcting vitamin D deficiency in CF.  
 
Our study hypothesis is that CF patients with vitamin D deficiency exhibit altered pharmacokinetics of 
vitamin D and 25(OH)D when compared to non-CF subjects with vitamin D insufficiency or 
deficiency. 
 
2.0 
OBJECTIVES AND PURPOSE 
2.1 Primary Objective: 
Characterize the pharmacokinetics of vitamin D3 and 25(OH)D3 with a single, high-
dose of vitamin D3 in adults with CF. 
 
Compare the pharmacokinetics of vitamin D3 and its metabolites between non-cystic 
fibrosis controls with low vitamin D levels and adults with cystic fibrosis  
 
2.2 Secondary Objective:  
Assess the anti-inflammatory effects of high dose vitamin D therapy in adults with CF. 
 
3.0 
STUDY DESIGN 
 
This is a pilot study to determine the pharmacokinetics-pharmacodynamics of vitamin D3 in 
CF patients. Clinically stable CF patients with a history of pancreatic insufficiency (n=6) and 
matching non-CF subjects (n=6) will be recruited in this study. The presence of pancreatic 
insufficiency will be based on a known CF genotype associated with pancreatic insufficiency. 
All subjects will be pre-screened for 25(OH)D status to include those with 25(OH)D levels 
below 30 ng/mL. The subjects will receive a single oral dose of vitamin D3, known as stoss 
therapy. The dose of stoss therapy will be based on patient’s baseline serum 25-hydroxyvitamin 
D3 level. For CF patients, the dose will be administered with food and pancreatic enzyme 
supplement to maintain nutritional status. This dose was chosen because previous studies in 
pediatric CF patients demonstrated that a large single dose of up to 600,000 IU vitamin D3 
raised and maintained sufficient 25(OH)D concentrations over 12 weeks without any signs of 
adverse events (25, 26).  
 
4.0 
DRUG/DEVICE INFORMATION 
 
 
4.1 
Vitamin D3 (Cholecalciferol)  

 
 
 
5
 
 
Currently, best approach to treat vitamin D deficiency is vitamin D supplementation. 
Cholecalciferol has shown to be effective in raising serum 25(OH)D concentrations in 
adult CF patients (32). Each patient will be given vitamin D3 50,000 IU capsules from 
BioTech Pharmacal Inc. Vitamin D3 is considered a dietary supplement and therefore 
is not part of FDA-regulated drugs.   
 
5.0  
SELECTION AND WITHDRAWAL OF SUBJECTS 
 
 
5.1 
Inclusion Criteria (CF) :   
 
 
Diagnosis of CF based on positive sweat chloride or known CF mutation 
 
 
 
Patients with pancreatic insufficiency 
 
 
 
Age ≥ 18 years 
 
 
 
Serum 25(OH)D concentrations below 30 ng/mL (75 nmol/L) 
 
 
 
Inclusion Criteria (non-CF) :   
 
 
 
Age ≥ 18 years 
 
 
 
Serum 25(OH)D concentrations below 30 ng/mL (75 nmol/L) 
 
5.2 Exclusion Criteria 
Pregnancy 
History of lung transplant,  
Severe anemia (hemoglobin concentration < 7 g/dL),  
Liver disease (AST/ALT > 3x ULN), kidney disease (GFR ≤ 40 mL/min), or 
granulomatous conditions 
Patients taking steroids, cholesterol-lowering drug (cholestyramine), weight-loss 
drugs (Orlistat) , statins, anti-tuberculosis drugs (rifampin and isoniazid), 
phenobarbital, phenytoin, carbamazepine, immunosuppressant (cyclosporine, 
tacrolimus) (33, 34) 
5.3 
Withdrawal Criteria 
 
 
Subject can be discontinued from the study for any of the following reasons: 
 
 
 
Subject’s personal reasons 
 
 
 
Other significant study related adverse events 
 
6.0 
 STRATIFICATION/DESCRIPTIVE FACTORS/RANDOMIZATION SCHEME 
 
 
6.1 
Stratification factors: Not applicable 
 
 
6.2 
Descriptive factors. Not applicable   
 
7.0 
STUDY AGENT ADMINISTRATION OR INTERVENTION AND TOXICITY 
MANAGEMENT PLAN 
 
 
7.1 
Patients will be given a single dose, oral capsule of vitamin D3 based on measured 25-
(OH) vitamin D level (25). 
 
 
 
 
7.2 
Drug studies:   
 

 
 
 
6
AGENT 
DOSE 
ROUTE 
DAYS 
ReRx 
NOTES 
Cholecalciferol
600,000 IU 
PO 
1 
Once 
25-(OH) vitamin D ≤ 25 nmol/L  
(≤ 10 ng/mL) 
Cholecalciferol
500,000 IU 
PO 
1 
Once 
25-(OH) vitamin D 25-50 nmol/L 
(10-20 ng/mL) 
Cholecalciferol
300,000 IU 
PO 
1 
Once 
25-(OH) vitamin D 50-75 nmol/L 
(20-30 ng/mL) 
 
 
 
7.3 
Criteria for removal from treatment  
 
 
 
 
 
7.31 
A patient may always be removed from treatment whenever he/she wishes. 
 
 
7.4 
Ancillary treatments. 
 
 
Patients will not be allowed to take supplements containing vitamin D3 during the trial.  
 
8.0 
ASSESSMENT OF EFFICACY AND SAFETY 
 
 
8.1 
Side effects/Toxicities to be monitored. 
 
 
 
 
8.11 
Possible side effects of vitamin D include: hypercalcemia, nausea, appetite, 
thirst, frequent urination, constipation, vomiting, abdominal pain, muscle 
weakness, muscle and joint pain, confusion, lethargy and fatigue (14, 35, 36). To 
ensure safety of high dose vitamin D in CF patients, we will be assessing the 
patients’ calcium, magnesium, phosphate, albumin and alkaline phosphatases 
levels, at screening and day 7.  
 
 
 
 
 
 
 
 
 
8.12 
Long-term toxicities to be monitored after completion of therapy.  List side 
effects/toxicities and define levels. 
 
 
 
 
Long-term vitamin D toxicities have not been determined. Single high 
intramuscular dose (600,000 IU) of vitamin D3 was shown to be safe in patients 
with osteoporosis (37), and accidental mega-dose of 2,000,000 IU was well 

 
 
 
7
tolerated, with slightly elevated calcium levels in the first two weeks, in two 
nursing home patients (38), suggesting that high bolus dose of cholecalciferol is 
safe.  
 
 
 
8.2 
Dosage change based on toxicity.  Not applicable.  
 
 
8.3 
Adverse Event Reporting: Procedures for reporting unexpected and fatal toxicity should 
be explained. 
 
 
 
 
 
8.31 
Any significant adverse events that occurs during the course of the study will be 
documented and reported. The types of event to be reported include Type of 
event to be reported and timing of reports. 
 
8.32 
Places for submitting reports:  IRB 
 
 
 
8.4 
Data Monitoring Committee (if applicable): Not Applicable 
 
9.0 
CLINICAL AND LABORATORY EVALUATIONS AND STUDY CALENDAR 
 
 
 
See Appendix I 
 
10.0 
CRITERIA FOR EVALUATION AND ENDPOINT DEFINITIONS 
 
Primary Outcome Measure 
1. Peak plasma concentrations (Cmax)  
2. Time taken to reach the maximum concentration (Tmax)  
3. Area under the plasma concentration versus time curve (AUC)  
 
Secondary Outcome Measure 
1. Levels of serum inflammatory biomarkers  
- 
Changes in IL-6, IL-8, TNF-α, IL-1β, C-reactive protein  
 
11.0 
SPECIAL INSTRUCTIONS: 
 
Blood samples will be taken at baseline (0 h) and at 2, 4, 6, 8 hours and 1, 7, 28, 56 and 70 days 
after intervention. At each defined time points, 5 mL of venous blood will be collected in serum 
separator tubes (BD Vacutainer) with clot activator (39) to measure serum vitamin D3 and 
25(OH)D3 concentrations. Samples will be handled with care to minimize sunlight exposure 
during the time of collection. Samples will be immediately placed on ice and stored in aliquots 
at -80 °C until analysis. Serum levels of vitamin D3 and its metabolites will be determined 
using LC/MS-MS. Levels of inflammatory biomarkers will also be determined at each defined 
time points.  
 
12.0 
DATA COLLECTION AND MONITORING 
 
Data will be collected on case report forms, which will be retained for the duration of the study. 
Data will include subject demographics, clinical characteristics, laboratory data, and results of 
pharmacokinetic analyses. Data will be coded and stored on a password protected electronic 
database.  
 

 
 
 
8
13.0 
STATISTICAL CONSIDERATIONS 
 
 
 
13.1 
Pharmacokinetic Analysis  
 
 
 
Population pharmacokinetic analysis will be performed using the maximum likelihood 
estimation via the EM algorithm (MLEM) as implemented in ADAPT 5 (Biomedical 
Simulations Resource, University of Southern California). Multiple candidate models 
will be evaluated to identify the model that best describes the observed plasma 
concentration data for vitamin D3 and 25(OH)D3. The maximum concentration and 
time to maximum concentration will be determined from the observed data.  
 
 
 
 
 
Patient demographics, clinical characteristics, and pharmacokinetic parameters will be 
summarized using descriptive statistics.  
 
Differences in the pharmacokinetic parameters between non-CF controls and CF 
patients will be determined by non-parametric Wilcoxon-Mann Whitney test. 
 
 
13.2 Comparison of mean serum and plasma concentrations of inflammatory markers at 
baseline and 10 weeks post intervention   
 
Mean serum/plasma concentrations of inflammatory biomarkers will be compared 
between CF and non-CF, as well as within groups. Differences in the mean 
concentrations of inflammatory markers will be determined by non-parametric 
Wilcoxon-Mann Whitney test.  
 
 
13.3 Pharmacodynamic model of vitamin D3 
 
 
 
 
Time course of inflammatory responses to vitamin D3 treatment will be used to develop 
the pharmacodynamics model of vitamin D3.  
 
 
14.0 
REGISTRATION GUIDELINE 
 
 
14.1 
Subjects will be registered into the study through submission of the research order form, 
informed consent, and patient bill of rights to the Clinical Trials Office (CTO) at USC. 
 
15.0 
BIOHAZARD COMTAINMENT 
 
 
 
Not Applicable 
 
16.0 
ETHICAL AND REGULATORY CONSIDERATIONS 
 
 
All institutional and Federal regulations concerning the Informed Consent form will be 
fulfilled.  The study will be conducted in adherence to ICH Good Clinical Practice. 
 
 
17.0 
REFERENCES 
 
1. 
Goldsmith JR. Vitamin D as an Immunomodulator: Risks with Deficiencies and Benefits of 
Supplementation. Healthcare (Basel). 2015;3(2):219-32. 

 
 
 
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2. 
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Zhang Y, Leung DY, Richers BN, Liu Y, Remigio LK, Riches DW, et al. Vitamin D inhibits 
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Upala S, Sanguankeo A, Permpalung N. Significant association between vitamin D deficiency 
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Grossmann RE, Zughaier SM, Liu S, Lyles RH, Tangpricha V. Impact of vitamin D 
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Wang Q, Zhu Z, Liu Y, Tu X, He J. Relationship between serum vitamin D levels and 
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American journal of clinical nutrition. 2007;86(6):1694-9. 
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Boyle MP, Noschese ML, Watts SL, Davis ME, Stenner SE, Lechtzin N. Failure of high-dose 
ergocalciferol to correct vitamin D deficiency in adults with cystic fibrosis. American journal of 
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Rey E, Tréluyer J-M, Pons G. Drug Disposition in Cystic Fibrosis. Clinical Pharmacokinetics. 
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20. 
Hall WB, Sparks AA, Aris RM. Vitamin d deficiency in cystic fibrosis. Int J Endocrinol. 
2010;2010:218691. 
21. 
Chesdachai S, Tangpricha V. Treatment of vitamin D deficiency in cystic fibrosis. J Steroid 
Biochem Mol Biol. 2016;164:36-9. 

 
 
 
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22. 
Lee MJ, Kearns MD, Smith EM, Hao L, Ziegler TR, Alvarez JA, et al. Free 25-
Hydroxyvitamin D Concentrations in Cystic Fibrosis. Am J Med Sci. 2015;350(5):374-9. 
23. 
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Grossmann RE, Zughaier SM, Kumari M, Seydafkan S, Lyles RH, Liu S, et al. Pilot study of 
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Sanders KM, Stuart AL, Williamson EJ, Simpson JA, Kotowicz MA, Young D, et al. Annual 
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and erratic absorption of ergocalciferol in adult cystic fibrosis patients. The American journal of 
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11 
APPENDICES 
 
 
 
Appendix I: 
Study Calendar 
 
 
 

 
 
 
12 
Appendix I 
 
 
Screening 
Day 0  
Day 1 
Day 7 
Day 28 
Day 56 
Day 70 
Informed Consent 
X 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
Medication History 
X 
 
 
 
 
 
 
Height, weight 
X 
 
 
 
 
 
 
Vital signsA 
X 
X 
X 
X 
X 
X 
X 
Safety labsB 
X 
 
 
X 
 
 
 
Pre-screening of 
25OHD status  
X 
 
 
 
 
 
 
PO drug administration 
 
X 
 
 
 
 
 
Blood 
Pharmacokinetics 
(PK)C 
 
X 
X 
X 
X 
X 
X 
Blood inflammatory 
biomarkers 
 
X 
X 
X 
X 
X 
X 
Adverse Events 
 
X 
X 
X 
X 
X 
X 
A. Vital signs to include blood pressure, heart rate, temperature, respiratory rate. 
B. Safety labs to include comprehensive metabolic panel  
C. All subjects will have a pre dose blood PK levels, 2, 4, 6, 8 hours and 1, 7, 28, 56, 70 days post 
dose of cholecalciferol. A 5mL serum separator tube will be used to collect the blood sample.