Phase II Study of Nicotinamide in Early Onset Preeclampsia
Phase: PHASE2
Conditions: Pre-Eclampsia, Pregnancy Related
Sponsor: University of North Carolina, Chapel Hill

 
A PHASE II STUDY OF NICOTINAMIDE (VITAMIN B3 AMIDE) 
SUPPLEMENTATION IN WOMEN WITH EARLY ONSET PREECLAMPSIA  
 
 
 
NCT number NCT03419364 
Document Date 10/03/2019 
 

 
CONFIDENTIAL 
PROTOCOL AMENDMENT: NEW PROTOCOL 
 
 
 
  
 
 
 
A PHASE II STUDY OF  
VITAMIN B3 AMIDE SUPPLEMENTATION  
IN WOMEN WITH EARLY ONSET PREECLAMPSIA 
 
 
 
 
 
Coordinating Investigator: 
Kim Boggess MD 
Dept of Obstetrics and Gynecology 
Maternal Fetal Medicine 
University of North Carolina School of Medicine 
CB 7570 
3010 Old Clinic Bldg 
919-966-1601 
 
Co-Investigators: 
Noboyo Maeda PhD 
Dept of Pathology and Laboratory Medicine 
University of North Carolina School of Medicine 
 
S. Ananth Karumanchi MD 
Dept of Medicine 
Harvard University  
 
Matthew Laughon MD, PhD 
Dept of Pediatrics 
Neonatal-Perinatal Medicine 
University of North Carolina School of Medicine 
 
Craig Lee Pharm D 
Division of Pharmacotherapy and Experimental Therapeutics 
University of North Carolina School of Pharmacy 
Study Product: 
 
Nicotinamide, the amide form of vitamin B3 
Protocol Number: 
NicPhaseIIv.7 
IND Number: 
118832 
Confidential and Proprietary 
This document contains confidential information and is intended solely for use by the specified 
clinical investigator and must not be disclosed to any other party. Acceptance of this document 
constitutes agreement that no unpublished information contained herein will be disclosed 
without prior written approval of the coordinating investigator, except that this document may be 

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disclosed to the appropriate Human Ethics Committees who will agree to maintain 
confidentiality.  
Version Date: October 3, 2019 
 

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Table of Contents 
 
STUDY SUMMARY ................................................................................................................... 6 
1 
INTRODUCTION ................................................................................................................ 8 
1.1 
BACKGROUND .............................................................................................................. 8 
1.2 
INVESTIGATIONAL AGENT .............................................................................................. 9 
1.3 
PRECLINICAL DATA ......................................................................................................10 
1.4 
CLINICAL DATA TO DATE ............................................................................................... 6 
1.5 
DOSE RATIONALE AND RISK/BENEFITS .......................................................................... 6 
2 
STUDY OBJECTIVES ......................................................................................................13 
3 
STUDY DESIGN ...............................................................................................................11 
3.1 
GENERAL DESIGN .......................................................................................................14 
3.2 
PRIMARY STUDY ENDPOINT .........................................................................................11 
4 
SUBJECT SELECTION AND WITHDRAWAL .........ERROR! BOOKMARK NOT DEFINED. 
4.1 
INCLUSION CRITERIA ...................................................................................................15 
4.2 
EXCLUSION CRITERIA ..................................................................................................16 
4.3 
SUBJECT RECRUITMENT AND SCREENING .....................................................................17 
4.4 
EARLY WITHDRAWAL OF SUBJECTS ..............................................................................17 
4.4.1 
When and How to Withdraw Subjects ....................................................................17 
4.4.2 
Data Collection and Follow-up for Withdrawn Subjects ..........................................13 
5 
INVESTIGATIONAL AGENT ............................................................................................13 
5.1 
DESCRIPTION ..............................................................................................................13 
5.2 
TREATMENT REGIMEN .................................................................................................18 
5.3 
PREPARATION AND ADMINISTRATION OF STUDY AGENT .................................................18 
5.4 
SUBJECT COMPLIANCE MONITORING ............................................................................18 
5.5 
PRIOR AND CONCOMITANT THERAPY ............................................................................18 
5.6 
RECEIVING, STORAGE, DISPENSING AND RETURN .........................................................19 
5.6.1 
Receipt of Supplies ................................................................................................19 
5.6.2 
Storage ..................................................................................................................14 
5.6.3 
Dispensing of Investigational Agent .......................................................................14 
5.6.4 
Return or Destruction of Investigational Agent .......................................................14 
6 
STUDY PROCEDURES ....................................................................................................19 
6.1 
ELIGIBILITY .................................................................................................................15 
6.2 
STUDY INTERVENTION AND PROCEDURES .....................................................................15 
6.3 
LABORATORY SPECIMEN HANDLING AND PROCEDURES. ................................................15 
7 
STATISTICAL PLAN ........................................................................................................16 
7.1 
STATISTICAL METHODS ................................................................................................16 
7.2 
SUBJECT POPULATION(S) FOR ANALYSIS ......................................................................16 
8 
SAFETY AND ADVERSE EVENTS ..................................................................................17 
8.1 
DEFINITIONS ...............................................................................................................17 
8.2 
RECORDING OF ADVERSE EVENTS ...............................................................................18 
8.3 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS .................19 
8.3.1 
Investigator reporting .............................................................................................20 
8.3.2 
Investigator reporting: notifying the FDA ................................................................20 

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8.4 
Stopping Rules ......................................................................................................21 
8.5 
MEDICAL 
MONITORING…………………………………………………………………………………...21 
8.6 
INDEPENDENT DATA AND SAFETY MONITORING 
BOARD………………………………………………..21 
9 
DATA HANDLING AND RECORD KEEPING ...................................................................21 
9.1 
CONFIDENTIALITY ........................................................................................................21 
9.2 
SOURCE DOCUMENTS .................................................................................................21 
9.3 
CASE REPORT FORMS .................................................................................................21 
9.4 
RECORDS RETENTION .................................................................................................22 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ...................................................22 
10.1 
STUDY MONITORING PLAN ...........................................................................................22 
10.2 
AUDITING AND INSPECTING ..........................................................................................22 
11 
ETHICAL CONSIDERATIONS ..........................................................................................22 
12 
STUDY FINANCES ...........................................................................................................22 
12.1 
FUNDING SOURCE .......................................................................................................22 
12.2 
CONFLICT OF INTEREST ...............................................................................................23 
12.3 
SUBJECT STIPENDS OR PAYMENTS ...............................................................................23 
13 
REFERENCES ..................................................................................................................24 
 
 
 

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List of Abbreviations  
 
 
 
 
ACRONYM DESCRIPTION 
ACOG 
American College of Obstetrics and Gynecology 
AE 
Adverse event 
ALT 
Alanine aminotransferase 
ANOVA 
Analysis of variance 
APGAR 
APGAR score 
AST 
Aspartate amniotransferase 
B3A 
B3-amide 
BP 
Blood pressure 
BPP 
Biophysical profile 
CBC 
Complete blood count 
CRF 
Case report form 
CT 
Computerized tomography 
CTCA v3.0 
Common terminology criteria for adverse events v3.0 
DSMB 
Data Safety and Monitoring Board 
EOP 
Early onset preeclampsia 
EFW 
Estimated fetal weight 
ET 
Endothelin  
GI 
Gastrointestinal 
HELLP 
Hemolysis, elevated liver enzymes, low platelets 
HIV 
Human immunodeficiency virus 
INH 
Isoniazid 
LFTs 
Liver function tests (includes AST and ALT) 
MRI 
Magnetic resonance imaging 
MVP 
Maximum vertical pocket 
MWF 
Monday, Wednesday, Friday  
NIH 
National institutes of health 
PHI 
Personal health information 
NICU 
Neonatal intensive care unit 
NIH 
National institutes of health 
NST 
Non-stress test 
PHI 
Protected health information 
pK 
Pharmacokinetics 
PlGF 
Placental growth factor 
PI 
Principal investigator 
P/C 
Protein to creatinine ratio 
RDA 
Recommended daily allowance 
sFlt-1 
Soluble fms-like tyrosine kinase-1 
SD 
Standard deviation 
TID 
Three times per day 
UA 
Umbilical artery 
ULN 
Upper limit of normal 
VEGF 
Vascular endothelial growth factor 
WHO 
World Health Organization 

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Study Summary 
Title 
A PHASE II STUDY OF VITAMIN B3 AMIDE DIETARY 
SUPPLEMENTATION IN WOMEN WITH EARLY CONSET 
PREECLAMPSIA 
Short Title 
NicPreDose 
Protocol Number 
001v7 
Phase 
Phase II 
Methodology 
Open label 
Study Duration 
24 months 
Study Center(s) 
University of North Carolina Women’s Clinic/Hospital 
Objectives 
1. To test the effects of a novel oral agent, nicotinamide, on 
mean arterial pressure (MAP) after 48 hours and 7 days of 
treatment; 
2. To measure safety of nicotinamide in women with early-onset 
preeclampsia (n=25). Safety defined as development of 
maternal liver toxicity, defined as > 3x ULN of ALT or AST 
while on treatment, defined as within 24 hours of dose; 
3. To determine maternal tolerability of nicotinamide 2.5 gm/day, 
administered as 1000mg at 8AM and 12MN; 500mg at 4PM 
4. To measure pharmacokinetics (pK) of nicotinamide 1000 mg in 
normal healthy reproductive age women (n=6) and healthy, 
normotensive pregnant women (n=6). 
Number of Subjects 
37 (25 preeclamptic; 6 non-pregnant; 6 healthy, normotensive, 
pregnant) 

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Diagnosis and Main 
Inclusion/Exclusion 
Criteria 
Diagnosis and Inclusion Criteria for women with severe preeclampsia 
• 
Maternal age 18-45 years 
• 
Singleton or twin pregnancy with no known fetal anomalies 
• 
Early-onset preeclampsia defined as: 
o Early-onset: between 24 weeks 0 days and -33 weeks 3 
days, based on menstrual dating confirmed by first or 
second trimester ultrasound OR second trimester 
ultrasound if menstrual dating unavailable; 
o Preeclampsia:  
 
New onset hypertension and proteinuria, with 
systolic BP > 140 mm Hg and/or diastolic BP > 90 
mm Hg on two occasions 6 hours apart and > 300 
mg proteinuria on 24 hour urine collection OR urine 
P/C ratio >0.3; 
 
New onset hypertension and NO proteinuria, with 
systolic BP > 140 mm Hg and/or diastolic BP > 90 
mm Hg on two occasions 6 hours apart and one or 
more of the following: serum creatinine >1.1 mg/dL 
or doubling from baseline ,or central nervous 
system symptoms or visual changes 
 
Severe gestational hypertension defined as new 
onset systolic BP > 160 mm Hg and/or diastolic BP 
> 105. 
o Candidate for expectant management for at least 48 hours 
o Deemed clinically stable by primary clinician and candidate 
for expectant management (delayed delivery) for at least 
48 hours; 
• 
Maternal liver function tests < 2x ULN 
• 
Maternal platelet count > 100,000 mm3 
• 
Planned expectant management  
• 
Pre-existing medical diseases such as hypertension, diabetes, 
endocrine disorders, gastrointestinal diseases, are well controlled 
• 
Fetal well-being established by estimated fetal weight > 5th %tile; 
normal amniotic fluid volume (MVP > 2 cm); normal UA Dopplers; 
or reactive NST or BPP > 6 
• 
Delivery not anticipated within 48 hours of enrollment 
 
Exclusion Criteria for women with severe preeclampsia 
• 
Pre-existing renal disease (creatinine > 1.5 mg/dL) 
• 
Any pre-existing medical condition that would increase risk for liver 
toxicity (e.g. hepatitis B or C; HIV; INH use) 
• 
Eclampsia; cerebral edema on CT/MRI; headache unrelieved by 
analgesics 
• 
Evidence of liver dysfunction (LFTs > 2x ULN) 
• 
Thrombocytopenia (platelets < 100,000 mm3) 
• 
Pulmonary edema 
• 
HELLP syndrome 
• 
Evidence of fetal compromise: EFW < 5th percentile; or BPP < 6; 
or absent or reverse diastolic UA blood flow; or oligohydramnios 
(MVP < 2 cm) 

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• 
Placental abruption defined as unexplained vaginal bleeding 
• 
Preterm labor defined as regular contractions and cervical change 
• 
Any condition deemed by the investigator to be a risk to mother or 
fetus in completion of the study  
• 
Any condition deemed by the investigator to require delivery within 
48 hours 
Inclusion Criteria for healthy, normotensive, pregnant women  
• 
Maternal age 18-45 years 
• 
Singleton or twin pregnancy with no known fetal anomalies (24 
weeks to 33 weeks 3 days) 
• 
No known medical complications 
 
Exclusion Criteria for healthy, normotensive, pregnant women 
• 
Current cigarette smoker 
• 
Hypertension requiring medical treatment 
• 
Diabetes requiring medical treatment 
• 
Pre-existing renal disease (creatinine > 1.5 mg/dL) 
• 
Any pre-existing medical condition that would increase risk for liver 
toxicity (e.g. hepatitis B or C; HIV; INH use) 
• 
Currently taking medication for a chronic medical condition 
• 
Currently taking an oral or IV antibiotic or antifungal medication 
 
Diagnosis and Inclusion Criteria for healthy nonpregnant women  
• 
Age 18-45 years 
• 
No known medical complications or disease (eg hypertension, 
diabetes, liver or kidney disease) 
 
Exclusion Criteria for healthy nonpregnant women 
• 
Current cigarette smoker 
• 
Hypertension requiring medical treatment 
• 
Diabetes requiring medical treatment 
• 
Pre-existing renal disease (creatinine > 1.5 mg/dL) 
• 
Any pre-existing medical condition that would increase risk for liver 
toxicity (e.g. hepatitis B or C; HIV; INH use) 
• 
Currently taking medication for a chronic medical condition 
(excluding oral contraceptives) 
• 
Currently taking an oral or IV antibiotic or antifungal medication 
 
 
 

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Study Product, 
Dose, Route, 
Regimen 
Vitamin B3-amide; 2.5 mg daily, administered as 1000mg at 8AM and 
12MN; 500mg at 4PM, provided by Major Pharmaceuticals  
 
Wendy Ernst 
Advisor, Contracts and Billing 
17177 N Laurel Park Dr., Suite 233 
Livonia, MI 48152 
Office: (734) 743-6232 | Fax: (734) 743-7232 
Email: wernst@major-pharm.com 
 
Duration of 
administration 
Until delivery or 34 weeks’ gestation 
Statistical 
Methodology 
Primary Outcome 
• 
Mean arterial blood pressure before, 48 hours, and 7 days 
after daily dosing 
Secondary Outcomes 
• 
Maternal liver toxicity: the proportion of women who develop 
elevated liver function tests (ALT and/or AST > 3x ULN within 
24 hours of study drug) will be determined and compared to 
expected proportion of 20%  
• 
Maternal side effects (nausea, vomiting, rash, headache) 
• 
Optional: Plasma nicotinamide and 2-pyridone levels; sFlt-1 
and PlGF levels 

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1. Introduction 
 
This document is a protocol for a human research study. This study is to be conducted 
according to US and international standards of Good Clinical Practice (FDA Title 21 part 312 
and International Conference on Harmonization guidelines), applicable government regulations 
and Institutional research policies and procedures.  
1.1 
Background 
 
Preeclampsia is a hypertensive disorder unique to pregnancy that occurs in approximately 5 
– 8% of pregnancies in the United States.1 The disease is mild in 75% of cases, and 10% of 
cases occur before 34 weeks’ gestation.2 Despite its relatively rare prevalence, preeclampsia is 
the leading cause of maternal morbidity and mortality in the United States. Worldwide, 10 to 
15% of direct maternal deaths (i.e., resulting from obstetric complications of pregnancy) are 
associated with preeclampsia/eclampsia.3 Women who develop preeclampsia are at risk for 
pulmonary edema 4, coagulation defects, hepatic and/or renal failure, seizures, cerebral 
hemorrhage, and blindness.5-7 
 
In 2013 ACOG published an Executive Summary from the Task Force on Hypertension in 
Pregnancy. They proposed the following for the diagnosis of preeclampsia: 
• 
Blood pressure greater than or equal to 140 mm Hg systolic or greater than or equal to 
90 mm Hg diastolic on two occasions at least 4 hours apart after 20 weeks of gestation 
in a woman with a previously normal blood pressure; or greater than or equal to 160 mm 
Hg systolic or greater than or equal to 110 mm Hg diastolic, within a short interval 
(minutes) to facilitate timely antihypertensive therapy  
AND 
• 
Proteinuria, defined as > to 300 mg per 24-hour collection (or this amount extrapolated 
from a timed collection) or protein/creatinine ratio > 0.3, or urine dipstick reading of 1+ (if 
other quantitative methods not available)  
OR 
• 
New-onset hypertension and no proteinuria with the new onset of any of the following: 
platelet count less than 100,000/microliter, creatinine > 1.1 mg/dL or doubling from 
baseline, elevated LFTs > 2xULN, pulmonary edema, CNS symptoms, or visual 
changes. 
 
Preeclampsia is also a significant contributor to neonatal morbidity and mortality. Fetal 
complications are not uncommon and include poor fetal growth from chronic placental 
hypoperfusion8, especially in cases of early-onset preeclampsia.9, 10 Placental abruption, 
premature separation of the placenta with disruption of blood flow to the fetus, is an uncommon 
but life-threatening complication that occurs in up to 3% of pregnancies complicated by severe 
preeclampsia.11  
 
There are no proven measures to treat preeclampsia; resolution occurs only with delivery. In 
early onset preeclampsia (< 34 weeks), delaying delivery and prolongation of pregnancy is of 
benefit to the fetus but potentially detrimental to the mother. Medically indicated preterm birth as 
a secondary result of fetal or maternal complications contributes significantly to neonatal 
morbidity and mortality associated with preeclampsia.12 As shown in Figure 1, preeclampsia is 

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one of the leading causes of medically indicated preterm birth. Conservatively estimated, > 
20,000 preterm births < 34 weeks occur annually in the United States due to complications of 
preeclampsia. A therapeutic approach to early-onset preeclampsia to prolong pregnancy that 
will do no harm to both the mother and fetus is an important and unmet med.  
 
The pathophysiology of preeclampsia 
is complex and incompletely understood.  
Activation of several different pathways is 
thought to be operative in the development 
of preeclampsia. Evidence exists to 
support excessive maternal inflammation13 
maternal immunologic responses 14, 
placental hypoxia and oxidative stress15, 
generalized vasospasm, and alteration of 
growth factor production, as part of the 
pathophysiologic process in preeclampsia. 
The sentinel paper by Roberts et. al.16 
implicated angiogenic imbalance with 
endothelial activation and generalized maternal endothelial dysfunction as the explanation for 
most of the clinical aspects of preeclampsia. These pathways are all believed to culminate in 
endothelial activation and dysfunction17, characterized by an imbalance between circulating pro- 
and anti-angiogenic factors. 
 
Angiogenesis requires the complex interplay between vascular endothelial growth factor 
(VEGF), placental growth factor (PlGF), and their receptors, soluble fms-like tyrosine kinase-1 
(sFlt-1) and VEGFR-1. The placenta is a rich source of these factors, and in addition to 
regulating vascular homeostasis, VEGF, PlGF, and sFlt-1 are key components in regulating 
trophoblast cell function and survival.18-20 sFlt-1 acts as an anti-angiogenic factor by neutralizing 
PlGF and VEGF.21  
 
Animal and laboratory data exist to support the theory of angiogenesis imbalance as the root 
cause of preeclampsia. Overexpression of sFlt-1 induces hypertension and fetal growth 
restriction in pregnant mice, and the time course of blood pressure increase mirrors the increase 
in sFlt-1.22 The preeclampsia-like clinical phenotype associated with sFlt-1 expression occurs 
via activation of the endothelin (ET) system.23, 24 In humans, low plasma vascular endothelial 
growth factor (VEGF) is the first trimester of pregnancy is a predictive marker for preeclampsia.  
In addition, sFlt-1/PlGF ratios are increased in women who subsequently develop preeclampsia 
compared to normotensive women.25 ~90% of women with EOP have elevated sFlt-1.26 An sFlt-
1/PlGF ratio >0.85 is associated with adverse pregnancy outcomes: placental abruption, 
elevated liver enzymes and/or low platelets, and small-for-gestational-age birth weight and/or 
absent/reversed umbilical artery Doppler, and significantly shorter latency period, among 
women with EOP. 75% of women with sFlt-1/PlGF >0.85 deliver within one week and 85% 
within two weeks, compared to only 10% and 15% of women with sFlt-1/PlGF <0.85. sFlt-
1/PlGF is a useful discriminator for women with EOP who are at risk for adverse outcome and 
need for delivery prior to 34 weeks.27  The natural history of circulating sFlt-1 levels among 
women with preeclampsia has been described in several longitudinal studies.28, 29 sFlt-1 levels 
are elevated prior to the development of clinical symptoms of preeclamspsia, and remain 
elevated until delivery.17 Based on this data, we believe that elevated circulating sFlt-1 levels 
identify those women at greatest risk for adverse outcome, particularly if managed expectantly, 
and thus the women most likely to yield benefit from treatments that allow for longer latency.  
 
To address the angiogenic imbalance believed to be in the pathophysiology of 
preeclampsia, we24 and others30-33 have demonstrated that ET receptor antagonists greatly 
ameliorate the preeclampsia-like phenotypes induced by sFlt-1 in animal models. While this 
data is promising, ET receptor antagonists are teratogenic and contraindicated in pregnant 
0
10
20
30
PEX
Distress
SGA
Abruption
Percent
Medically indicated PTB < 35 weeks
Figure 1. Percent of medically indicated preterm birth (PTB) 
due to preeclampsia (PEX), fetal distress, small for 
gestational age (SGA), and abruption 

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women. However, this does not preclude the use of substances that block the action of factors 
downstream of the ET receptor that would mediate sFlt-1 expression and action.   
  
Following this reasoning, 
we tested the effects of 
nicotinamide, the amide of 
vitamin B3 (B3A) a potent 
inhibitor of ADP ribosyl 
cyclase (ADPR cyclase). 
ADPR cyclase is activated by 
endothelin, and mediates an 
increase in cytosolic Ca2+ 
and vasoconstriction. Using 
our mouse model of sFlt-1 
overexpression, we found that 
nicotinamide ameliorates the 
increased BP and urinary 
albumin excretion induced by 
increased sFlt-1. In our mouse 
studies we used 500mg/kg/day, equivalent to 41mg/kg/day in humans, which would be 2.7g/day 
for an average adult with a weight of 60kg. As shown in the Figure on the following page,we 
found a significant lowering of urinary albumin excretion, increase in open capillary volume on 
renal histopathology, and lowering of blood pressure, when vitamin B3A was given to mice as 
preventive (Nic (d0) group) or as therapeutic (Nic (d7) group) treatment. Panel a shows urinary 
excretion of albumin normalized to urinary creatinine concentration. Panel b shows open 
capillary volume on renal histopathology. Panel c shows systolic blood pressure (SBP) 
measured by telemetry.    
 
 
1.2  Investigational Agent 
 
The investigational agent for this protocol is Vitamin B3 Amide (B3A; Nicotinamide) 
Chemical Formula: C6-H6-N2-O. Metabolites include N1-methylnicotinamide and its oxidation 
products.   
 
Niacin (nicotinic acid, vitamin B3) is an essential vitamin.  Vitamin B3 and the amide form 
have identical vitamin functions, but vitamin B3-amide does not have the same pharmacological 
and toxic effects as vitamin B3. Thus it does not reduce cholesterol or induce flushing.34 In cells, 
vitamin B3 is incorporated into nicotinamide adenine dinucleotide (NAD) and NAD-phospate, 
which are coenzymes in a wide variety of oxidation-reduction reactions.35   
 
The U.S. Recommended Daily Allowance (RDA) for niacin is 18 mg/day during pregnancy 
and 17 mg/day during lactation. The recommended upper limits for pregnant and lactating 
women are 30 – 35 mg/day. 36 Prenatal vitamins contain 14-18 mg of niacin. 
1.3 Preclinical Data 
 
The LD50 of vitamin B3-amide in rodents is 3-7g/kg when given orally37, and its therapeutic 
index is correspondingly wide. 
 
Ieraci et al.38 have shown that a single high dose of vitamin B3-amide protects mice from 
developing the neurological damage and behavioral abnormalities that occur in adults that were 
exposed to high doses of alcohol perinatally at the time when the developing nervous system is 
most susceptible to chemical damage. The control mice given vitamin B3-amide but no alcohol 
were indistinguishable neurologically and in behavior from the mice given saline. Thus vitamin 
B3-amide is harmless to mice exposed to it at a dose level and at a time when it is highly 
protective against damage from alcohol.38 
Legend: [control]: mice receiving neither virus nor vitamin B3. [sFlt-1]: 
mice receiving sFlt-1 virus but not given vitamin B3 (n=5); [sFlt-1 + Nic 
(d0)]: mice given vitamin B3 daily starting on the same day as they 
received the virus (n=6); [sFlt-1 + Nic (d7)]: mice treated with vitamin 
B3 starting 7 days after they received the virus. 

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Vitamin B3-amide has also been shown to protect rat pups from long-term neurologic effects 
of perinatal asphyxia.39  
1.4 
Clinical Data to Date 
 
Vitamin B3-amide has several properties that may be of clinical benefit to patients. Vitamin 
B3-amide has been used clinically to treat acne vulgaris40, anxiety and schizophrenia41, 
Alzheimer’s disease42, 43 and cancer.44 Vitamin B3A has been used for long periods without 
significant side effects at doses of 50mg/kg/day for a variety of conditions, including type 1 
diabetes and schizophrenia.45, 46 Use of high dose vitamin B3-amide to treat schizophrenia was 
not associated with any embryonic or fetal toxicity among women who experienced pregnancy 
while on treatment46, based on exposure of 3 pregnant women. Human data demonstrate a risk 
for jaundice of 1 in 2000 following high dose vitamin B3-amide treatment for psychosis.47 
 
Studies in children have been conducted to prevent insulin-dependent diabetes. In a 
population-based diabetes prevention trial, 173 school age children with islet cell antibodies 
received vitamin B3-amide treatment (500 mg BID) for 2.7 years. Side effects, liver function 
abnormalities, and growth were recorded. There were no reactions or toxicity ascribed to 
vitamin B3-amide treatment.48 In another study, vitamin B3-amide at a dose of 1.2 g/m2/day or 
placebo was given to children age 3-12 years who were at risk for Type I diabetes. While 
vitamin B3-amide failed to reduce the cumulative diabetes incidence at 3 years, no side effects 
were observed in the children receiving vitamin B3-amide. Body growth was compared and 
decrease in growth was not observed in children receiving vitamin B3-amide compared to 
placebo.49  
 
In a clinical trial of vitamin B3-amide versus placebo for diabetes prevention, 276 subjects 
were randomized to 1.2 g/m2 per day of vitamin B3-amide.50 Regular safety analyses done 
throughout the trial showed no differences between the treatment groups with respect to 
adverse events. 35 serious adverse events were reported in 18 participants in the active 
treatment group and 15 in the placebo group. Increased LFTs (> 3x ULN) were noted in nine 
participants during the trial. Of these, five were taking active treatment group and four were on 
placebo. Six women became pregnant during the trial, four in the vitamin B3A group and two in 
placebo. Trial medication was stopped as soon as pregnancy was confirmed. No congenital 
abnormalities were reported in the offspring.50 
 
According to Reprotox®, possible pregnancy effects of pharmaceutical doses of vitamin B3-
amide have not been studied51, and the WHO Working Group on Human Lactation did not find 
available data on vitamin B3A excretion in human milk to be sufficient to comment on its 
safety.52 
 
We recently completed a Phase I study of 10 women receiving nicotinamide 
supplementation. Five women received 500 mg/day for up to two weeks; 5 women received 
1000 mg/day for up to two weeks. One subject (#5, on 500 mg/day) experienced an adverse 
event, acute renal failure, which was not believed to be related to study medication or 
procedures. There were no cases of liver toxicity. All subjects tolerated nicotinamide without 
significant side effects. 
Nicotinamide pharmacokinetics (pK) are well described in healthy, predominantly male, 
adults. 53-55 However, metabolite levels following our dosing regimen, and metabolite pK have 
not been reported and directly compared in healthy female adults or healthy pregnant women. 
We will address these gaps by enrolling six nonpregnant healthy and six pregnant healthy 
women and measuring pK of the main and secondary metabolites following a single 1000 mg 
dose.  
Dose Rationale and Risk/Benefits 
 
Overall, vitamin B3A rarely causes side effects, and the FDA labels it Generally Regarded as 
Safe (GRAS) when used as a direct food additive and nutrient and/or dietary supplement. 56  
This means that there is no evidence in the available information on vitamin B3A that 

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demonstrates, or suggests reasonable grounds to suspect that it is a hazard when used at 
levels that are now current or that might reasonably be expected in the future, which the FDA 
places as 3-9 gm/day. We propose 2.5 gm/day which is below the dose expected to result in 
significant toxicity (3 gm/day). 
 
2 Study Objectives 
 
The objectives of this phase II study are to 1) study the effect of vitamin B3 amide dietary 
supplementation on mean arterial pressure during expectant management of early-onset 
preeclampsia; and 2) further evaluate its safety in this context. We also aim to measure 
pharmacokinetics (pK) of nicotinamide 1000 mg in normal healthy reproductive age women and 
healthy, normotensive pregnant women. 
3 
Study Design 
3.1 
General Design 
 
This is an open labeled phase II study of vitamin B3-amide dietary supplementation in 
pregnant women with early-onset preeclampsia, per ACOG guidelines. We will enroll 24 
pregnant women at 24-33 weeks 3 days with EOP and anticipated treatment by expectant 
observation. If the woman is anticipated to remain undelivered for 48 hours after diagnosis she 
will receive vitamin B3-amide, 2.5 mg/day dosed in the following manner: administered as 
1000mg at 8AM and 12MN; 500mg at 4PM, continuing until delivery or 34 weeks, whichever 
occurs first. Optional research blood samples will be collected at times of clinically indicated 
blood draws (baseline and 2-3 times per week) to measure nicotinamide and its metabolite 2-
pyridone, sFlt-1 and PlGF. A sample of cord blood will be collected (6ml) following delivery. 
 
All study subjects will receive standard surveillance and treatment for expectant 
management of EOP, which may include but is not limited to:  
• 
Daily prenatal vitamin 
• 
24-hr urine collection for protein excretion at admission 
• 
Blood sampling for hematologic, liver, and kidney function at time of diagnosis and every 
2-3 days thereafter 
• 
Magnesium sulfate for seizure prophylaxis  
• 
Betamethasone to accelerate fetal lung maturity 
• 
Antihypertensive agents 
• 
Twice weekly fetal surveillance by NST (30 minutes of continuous fetal heart rate 
monitoring) or BPP (30 minutes of ultrasound to monitor for fetal breathing, movement, 
fluid) 
• 
Weekly ultrasound to measure amniotic fluid and UA Dopplers 
 
In addition to above standard care for EOP, subjects will receive surveillance and treatment 
solely for study purposes, including: 
• 
Daily administration of vitamin B3-amide, 2.5 Gm/day in 3 divided doses; “on treatment” 
is defined as within 24 hours of dose 
• 
Daily (M-F) study staff visit to query side effects if in-patient; with each outpatient visit 
(typically twice a week) if discharged from the hospital 
• 
Optional blood sampling to coincide with clinical blood draws to measure sFlt-1, 
nicotinamide and 2-pyridone levels; chart abstraction to review liver function testing 
results (done clinically) 
• 
Chart abstraction for maternal and delivery data (up until maternal discharge) and 
neonatal data (until 30 days of age or until discharge, whichever occurs first). We will 

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also perform a phone call at 30 days post stopping the study medication and 30 days 
following infant delivery to determine the occurrence of any adverse events. 
In addition to enrolling women with early-onset severe preeclampsia we will enroll 12 healthy 
control women (6 non pregnant, and 6 pregnant between 24-33 weeks 3 days). Study staff will 
interview control women and confirm medical history consistent with no exclusions. Once 
enrolled, healthy participants will have a baseline blood sampling for nicotinamide levels and 
LFTs. They will then ingest 1000 mg nicotinamide, and have blood drawn 2, 8 and 24 hours 
following the dose of nicotinamide. Urine samples will also be collected at baseline, and at 8 
and 24 hours following the dose of nicotinamide. Participants will be given the option to remain 
in the clinic for the 2- and 8-hour blood collection and then return the following day for the 24 
hour blood collection, or to be admitted to the UNC Clinical and Translational Research Center 
for all blood collection. 
3.2 
Study Outcomes 
PRIMARY 
• 
Maternal mean arterial blood pressure, defined as the highest MAP within 24 hour period 
 
SECONDARY-SAFETY AND TOLERABILITY 
• 
Liver toxicity, defined as 3x ULN of ALT or AST within 24 hours of study drug 
• 
Maternal report of side effects 
• 
Clinical parameters of maternal and fetal well being  
• 
Composite neonatal outcome 
 
Maternal or Fetal Parameter Safety Endpoint 
History 
Headache unrelieved by oral analgesics 
Physical examination 
Abdominal tenderness, (right upper quadrant or epigastric) 
Vaginal bleeding 
Fall in hematocrit of > 3% 
Urine output 
Oliguria (< 500 cc/24 hr) 
Serum LFTs 
AST and/or ALT > 3x ULN within 24 hours of study drug 
Fetal NST (or BPP) 
 
Category III (or < 6) 
 
 
SECONDARY-PHARMACOKINETICS 
• 
Nicotinamide and metabolite concentrations in plasma at baseline, 2, 8, and 24 hours 
• 
Peak plasma drug and metabolite concentration and time to reach peak 
• 
Nicotinamide and metabolite elimination half-life 
• 
Nicotinamide and metabolite area under the curve (integral of the plasma concentration-
time curve) 
• 
Nicotinamide and metabolite concentrations in urine at baseline, 8 and 24 hours 
4 
Subject Selection and Withdrawal  
4.1 
Inclusion Criteria for participants with early-onset preeclampsia 
1. Maternal age 18-45 years 
2. Singleton or twin pregnancy with no known fetal anomalies 
3. Early-onset preeclampsia OR early-onset severe gestational hypertension 
a. Early onset defined as 24-33 weeks 3 days gestation 
b. Preeclampsia defined as new onset hypertension and proteinuria: systolic BP > 
140 mm Hg and/or diastolic BP > 90 mm Hg on two occasions 6 hours apart and 
> 300 mg proteinuria on 24 hour urine collection OR urine P/C ratio >0.3; 

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c. Or BP > 160 mm Hg and/or diastolic BP > 105  
d. Dating criteria based on menstrual dating confirmed by first or second trimester 
ultrasound OR second trimester ultrasound if menstrual dating unavailable; 
e. Deemed clinically stable by primary clinician and candidate for expectant 
management (delayed delivery) for at least 48 hours; 
f. Dating criteria based on menstrual dating confirmed by first or second trimester 
ultrasound OR second trimester ultrasound if menstrual dating unavailable; 
4. Deemed clinically stable by primary clinician and candidate for expectant management 
(delayed delivery); 
5. Pre-existing medical diseases such as hypertension, diabetes, endocrine disorders, 
gastrointestinal diseases, are well controlled 
6. Maternal liver function tests < 2x ULN 
7. Maternal platelet count > 100,000 mm3 
8. Fetal well-being established by estimated fetal weight > 5th %tile; normal amniotic fluid 
volume (MVP > 2 cm); normal UA Dopplers; AND reactive NST or BPP > 6 
9. Plan for expectant management until delivery  
10. Delivery not anticipated within first 48 hours 
4.2 
Exclusion Criteria for participants with early-onset preeclampsia 
1. Preeclampsia < 24 or > 33 weeks 4 days gestation; 
2. Multiple gestation; 
3. Suspected fetal structural or chromosomal abnormality;  
4. Pre-existing renal disease (creatinine > 1.5 mg/dL) 
5. Plan for delivery within 48 hours  
6. Any pre-existing medical condition that would increase risk for liver toxicity (e.g. hepatitis 
B or C; HIV) 
7. Eclampsia; cerebral edema on CT/MRI; headache unresolved with analgesics 
8. Pulmonary edema 
9. HELLP syndrome  
10. Evidence of liver dysfunction (LFTs > 2x ULN) 
11. Thrombocytopenia (platelets < 100,000 mm3) 
12. Evidence of fetal compromise: EFW < 5th percentile; BPP < 6; absent or reverse diastolic 
UA blood flow; oligohydramnios (MVP < 2 cm) 
13. Placental abruption defined as unexplained vaginal bleeding 
14. Preterm labor defined as regular contractions and cervical change 
15. Any condition deemed by the investigator to be a risk to mother or fetus in completion of 
the study  
16. Any condition deemed by the investigator to require delivery within 48 hours 
 
4.1a  Inclusion Criteria for healthy, normotensive, pregnant women  
• 
Maternal age 18-45 years 
• 
Singleton or twin pregnancy with no known fetal anomalies (24 weeks to 33 weeks 3 days) 
• 
No known medical complications 
 
4.2a  Exclusion Criteria for healthy, normotensive, pregnant women 
• 
Current cigarette smoker 
• 
Hypertension requiring medical treatment 
• 
Diabetes requiring medical treatment 
• 
Pre-existing renal disease (creatinine > 1.5 mg/dL) 

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• 
Any pre-existing medical condition that would increase risk for liver toxicity (e.g. hepatitis B 
or C; HIV; INH use) 
• 
Currently taking medication for a chronic medical condition 
• 
Currently taking an oral or IV antibiotic or antifungal medication 
 
4.1b Diagnosis and Inclusion Criteria for healthy nonpregnant women  
• 
Age 18-45 years 
• 
No known medical complications or disease (eg hypertension, diabetes, liver or kidney 
disease) 
 
4.2b Exclusion Criteria for healthy nonpregnant women 
• 
Current cigarette smoker 
• 
Hypertension requiring medical treatment 
• 
Diabetes requiring medical treatment 
• 
Pre-existing renal disease (creatinine > 1.5 mg/dL) 
• 
Any pre-existing medical condition that would increase risk for liver toxicity (e.g. hepatitis B 
or C; HIV; INH use).  
• 
Currently taking medication for a chronic medical condition (excluding oral contraceptives) 
• 
Currently taking an oral or IV antibiotic or antifungal medication 
 
4.3 
Subject Recruitment and Screening 
 
Study personnel will review in-patient records or prenatal records under a limited waiver of 
HIPAA granted by the Institutional Review Board to determine if a patient meets eligibility 
requirements. If eligible, study personnel will approach medical provider to determine 
appropriateness of patient to serve as a study subject.  If appropriate, study personnel will invite 
the patient to serve as a study subject.  
 
Study personnel will describe the study in detail and review the study protocol with the 
patient.  Women agreeing to participate will sign a consent form; one copy will be placed in their 
medical record, and a copy will be given to the patient for her records. 
4.4 
Early Withdrawal of Subjects 
4.4.1 When and How to Withdraw Subjects 
 
Subjects may withdraw at any time and for any reason. Subjects may be withdrawn if they 
no longer meet eligibility criteria; or if in the opinion of the investigator it is not in the subject’s 
best interest to continue. A subject may also be withdrawn if she experiences an unmanageable 
or irreversible adverse Grade 3 or 4 adverse event using the CTCA v3.0 criteria as defined in 
section on safety monitoring. The date of withdrawal from study participation will be recorded in 
the CRF. Subjects who either complete or are removed from the treatment phase at any time 
will have complete data chart abstracted and recorded for study purposes. 
 
Specific study stopping rules include: 
• 
Any maternal or fetal death deemed to be related or possibly related to study 
participation 
• 
More than expected prevalence of liver toxicity within 24 hours of study drug, thus > 20% 
of subjects experience liver toxicity (more than 1 subject for every 5 subjects enrolled) 
• 
More than expected prevalence of fetal side effects (defined as BPP < 6 OR UA 
Dopplers show absence or reversal of diastolic blood flow), (more than 1 delivery for 
fetal reasons per every 5subjects enrolled) 

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Specific rules to stop study intervention for individual subject 
• 
Delivery, or two weeks of treatment (“on-treatment” defined as within 24 hours of study 
drug) 
• 
Liver toxicity (LFTs > 3x ULN within 24 hours of study drug) 
• 
Maternal side effects that cannot be managed with oral medication 
4.4.2 Data Collection and Follow-up for Withdrawn Subjects 
 
Withdrawn subjects will have data collected through delivery events. The full data set will 
include subjects who enroll and receive at least 72 hours of vitamin B3A dietary 
supplementation, as the primary outcome will be measured at 72 hours. Every effort will be 
made to obtain data on all enrolled subjects, even if they are withdrawn and deliver elsewhere. 
5 
Study Agent  
5.1 
Description 
The investigational agent is  
Vitamin B3-amide; 2.5 Gm daily, provided as 500mg oral capsules in three divided doses:  
administered as 1000mg at 8AM and 12MN; 500mg at 4PM, provided by Major Pharmaceuticals  
 
Wendy Ernst 
Advisor, Contracts and Billing 
17177 N Laurel Park Dr., Suite 233 
Livonia, MI 48152 
Office: (734) 743-6232 | Fax: (734) 743-7232 
Email: wernst@major-pharm.com 
5.2 
Treatment Regimen 
Subjects will receive vitamin B3-amide dietary supplementation, 2.5Gm/day daily until 
delivery or 34 weeks’ gestation whichever occurs first. “On-treatment” is defined as 24 hours of 
study drug. 
5.3 
Preparation and Administration of Study Agent 
 
Major Pharmaceuticals will supply the vitamin B3-amide (study agent). The study agent will 
be stored by either the UNC or the WakeMed pharmacy and dispensed via pharmacy services 
following enrollment.  
5.4 
Subject Compliance Monitoring  
 
Medication admission records will be examined by study staff to confirm dispensing of the 
study agent. Subjects will be queried daily by study staff regarding compliance with study 
regimen. If the patient goes home on therapy, she will be given a weeks’ supply of the study 
medication and her compliance monitored by study staff. 
5.5 
Prior and Concomitant Therapy 
 
Subjects will have clinical treatment decisions made by the primary physician, independent 
of study participation. All subjects will receive standard care as noted below: 
• 
Daily prenatal vitamin 
• 
Blood sampling for hematologic, liver, and kidney function at enrollment and every 2-7 

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days thereafter 
• 
Magnesium sulfate for seizure prophylaxis 
• 
Betamethasone to accelerate fetal lung maturity 
• 
Antihypertensive agents as needed, determined by primary clinician 
• 
At least biweekly fetal surveillance by NST (30 minutes of continuous fetal heart rate 
monitoring) or BPP (30 minutes of ultrasound to monitor for fetal breathing, movement, 
fluid) 
• 
Weekly ultrasound to measure amniotic fluid and UA Dopplers  
5.6 
Receiving, Storage, Dispensing and Return 
5.6.1 Receipt of Supplies 
 
Triangle Compounding Pharmacy will ship the vitamin B3-amide directly to the Pharmacy. 
Upon receipt, an inventory will be performed and an investigational agent receipt log filled out 
and signed by the person accepting the shipment. Designated study staff will count and verify 
that the shipment contains all the items noted in the shipment inventory.  Any damaged or 
unusable study agent in a given shipment will be documented in the study files.   
5.6.2 Storage 
 
The study agent will be stored in a cool, well-ventilated area at the Pharmacy. The vitamin 
B3-amide should be kept away from heat, sources of ignition, and from incompatibles such as 
oxidizing agents, moisture. Vitamin B3-amide is hydroscopic, air and light sensitive and should 
be stored in light-resistant containers. 
5.6.3 Dispensing of Study Agent 
 
The Pharmacy will dispense vitamin B3-amide. Regular reconciliation will be performed to 
document study agent assigned, consumed, and remaining. This reconciliation will be logged on 
the study log. 
5.6.4 Return or Destruction of Study Agent 
 
At the completion of the study, there will be a final reconciliation of study agent shipped, 
consumed, and remaining.  This reconciliation will be logged on the reconciliation form, signed 
and dated.  Any discrepancies noted will be investigated, resolved, and documented prior to 
return or destruction of unused investigational agent.  Vitamin B3-amide destroyed on site will be 
documented in the study files. 
6 
Study Procedures 
6.1 
Eligibility  
 
All study procedures will be conducted in the UNC Women’s Clinic or Hospital. Study staff 
will review records on a daily basis. Eligibility for participation is outlined above. Briefly, women 
with suspected hypertensive complications of pregnancy at 24-33 3/7 weeks’ gestation and no 
exclusion criteria are eligible. Eligible women will be approached after study staff obtains verbal 
consent to do so from the primary provider (study staff will confirm with primary provider that the 
woman is a candidate for expectant management/delayed delivery and there is a viable fetus).  
 
Women who agree to participate will sign written consent and be assigned a unique study ID 
that will be used to identify all study data collection forms and research specimens. The master 

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list linking the unique study ID with subject PHI will be kept on a locked computer file in a 
password protected file. 
 
Healthy women will be recruited from the UNC Women’s Clinic at the time of a routine 
prenatal appointment or well-woman gynecologic visit. Eligible women will be approached after 
study staff obtains verbal consent to do so from the primary provider. Women who agree to 
participate will sign written consent and be assigned a unique study ID that will be used to 
identify all study data collection forms and research specimens. The master list linking the 
unique study ID with subject PHI will be kept on a locked computer file in a password protected 
file. 
6.2 
 Study intervention and procedures for participants with early onset severe 
preeclampsia 
 
The respective pharmacy will dispense vitamin B3-amide, which will be administered given 
to the subject by study staff if out-patient or by in-patient nursing staff if in-patient. Study staff 
will meet with subjects at each prenatal visit or daily [(M-F) if in the hospital] to discuss 
compliance and side effects.  
 
Clinical care will continue per recommendations of primary obstetrician caring for the patient. 
Standard procedures may include: 
• 
24-hr urine collection for protein excretion at admission 
• 
Blood sampling for hematologic, liver, and kidney function at enrollment and every 2-3 
days thereafter 
• 
Physical examination by primary clinical provider 
• 
Weight and intake/output measurement as ordered by primary clinical provider 
• 
Magnesium sulfate for seizure prophylaxis 
• 
Betamethasone to accelerate fetal lung maturity 
• 
Antihypertensive agents 
• 
Daily fetal surveillance by NST (30 minutes of continuous fetal heart rate monitoring) or 
BPP (30 minutes of ultrasound to monitor for fetal breathing, movement, fluid) 
• 
Weekly ultrasound to measure amniotic fluid and UA Dopplers 
 
The primary obstetrician will make decisions regarding indication and timing of delivery. 
Clinical management of the infant after delivery will be per standard treatment dictated by the 
neonatologist caring for the baby. 
 
Study procedures include: 
• 
Daily administration of vitamin B3-amide, 2.5Gm given as administered as 1000mg at 
8AM and 12MN; 500mg at 4PM 
• 
Daily (if in-patient) or with each prenatal visit (if out-patient) study nurse visit to query 
side effects 
• 
Optional blood sampling to coincide with clinical blood draws to measure nicotinamide 
and 2-pyridone, sFlt-1 and PlGF levels 
• 
Optional blood sampling for Nicotinamide levels at the following times:  
o Day 1 - Baseline – pre 1st dose; Peak – 2 hrs post 1st dose; Trough – pre 2nd 
dose 
o Day 3 – Trough – pre AM dose; Peak – 2 hrs post AM dose 
o Day 7 -  Trough – pre AM dose; Peak – 2 hrs post AM dose 
o Cord blood following delivery. 
• 
Chart abstraction to review maternal liver function testing results, delivery data (up until 
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first) 
6.2a  Study intervention and procedures for healthy pregnant and non-pregnant controls 
• 
Administration of a single dose (1000mg) of Nicotinamide at 8AM. 
• 
Blood sampling at baseline (pre-dose), 2 hours post dose, 8 hours post dose and 24 
hours post dose. 
• 
Urine sample at baseline (pre-dose), 8 hours post dose and 24 hours post dose. 
• 
This will be done either in the clinic or the CTRC 
6.3 
 Laboratory specimen handling procedures 
 
Blood for research purposes will be collected at the time of clinically indicated blood draws. 
Specimens will be labeled with the subject’s unique study ID and processed.  
 
Specimens to be tested for circulating sFlt-1 and PlGF levels will be stored and shipped as a 
single batch on dry ice to the research laboratory at Harvard University. The interassay 
coefficient of variance for sFlt1 and PlGF immunoassays ranges from 2.6% to 3.0%.  
 
Specimens collected for nicotinamide and 2-pyridone measurements will be sent to the UNC 
School of Pharmacy Lab (Dr. Craig Lee). Dr. Lee developed a LC-MS/MS method using protein 
precipitation (acetonitrile) to measure nicotinamide and 2-pyridone during our previous phase I 
study. 
7 
Statistical Plan 
7.1 
Statistical Methods 
 
 
Sample size: The study sample size was calculated to the primary outcome of MAP. We 
stipulated a priori that α =.05 and β = 0.2. Using the highest BP measured within each 24-hr period 
and applying the following formula we will calculate daily MAP:  
 
𝒎𝒎𝒎𝒎𝒎𝒎𝒎𝒎 𝒂𝒂𝒂𝒂𝒂𝒂𝒂𝒂𝒂𝒂𝒂𝒂𝒂𝒂𝒂𝒂 𝑩𝑩𝑩𝑩= [𝟐𝟐(𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅𝒅 𝑩𝑩𝑩𝑩) +  𝒔𝒔𝒔𝒔𝒔𝒔𝒔𝒔𝒔𝒔𝒔𝒔𝒔𝒔𝒔𝒔 𝑩𝑩𝑩𝑩] ÷ 𝟑𝟑 
 
Assuming that the mean (±sd) MAP at enrollment of our subjects is 107 (±10) mm Hg, to detect 
a difference from enrollment to 48 hours after treatment of 7 mm Hg in MAP requires that 20 
subjects be enrolled. We will enroll 24 to allow for 20% attrition due to delivery prior to 48 hours 
of treatment.  
 
• 
We will use a repeated measurement ANOVA to compare baseline MAP to MAP at 48 
hours, 7 days and weekly thereafter until delivery or 34 weeks. 
• 
Maternal liver toxicity: the proportion of women who develop elevated liver function tests 
(ALT and/or AST > 3x ULN within 24 hours of study drug) will be determined and 
compared to expected proportion of 20%.  
• 
Descriptive report of proportion of women with 
o Side effects 
o Fetal effects  
7.2 
Subject Population(s) for Analysis 
 
All subjects will be included in the analysis, regardless of whether they received 
investigational agent. Subject demographic and baseline characteristics will be summarized.  
Descriptive summaries will include the number of subjects, mean, standard deviation, median, 
minimum and maximum for continuous parameters, frequency and percentages for categorical 
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8 
Safety and Adverse Events 
 
The PI and/or study staff will conduct daily medical monitoring for unanticipated problems, 
AEs, and serious AEs and record and report them to the UNC or WakeMed (respectively- 
dependent on where they are cared for) IRB and FDA as outlined below (Sections 8.2, 8.3, 8.5). 
The FDA will be notified after 1 case of liver toxicity and after every 1 case of delivery within 48 
hours of enrollment, and will conduct ad-hoc review as they deem appropriate.  
 
Study stopping rules and subject withdrawal for safety reasons are described previously 
(Section 4.4) and below (Section 8.4).  
8.1 
Definitions 
Unanticipated Problems Involving Risk to Subjects or Others 
Any incident, experience, or outcome that meets all of the following criteria:  
• Unexpected in nature, severity, or frequency  (i.e. not described in study-related 
documents such as the IRB-approved protocol or consent form, the investigators 
brochure, etc) 
• Related or possibly related to participation in the research (i.e. 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, 
 
Adverse Event 
 
An adverse event (AE) is any symptom, sign, illness or experience that develops or 
worsens in severity during the course of the study.  Intercurrent illnesses or injuries should be 
regarded as adverse events.  Abnormal results of diagnostic procedures are considered to be 
adverse events if the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse event 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
 
Adverse Event Grading 
 
Adverse events will be graded using the Common Terminology for Criteria for Adverse Events 
(CTCAE) version 4.03 (published June 14, 2010). 
 
Grade 1:  Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; 
intervention not indicated; limiting. (e.g., GI distress, nausea, vomiting; flushing) 
 
Grade 2: Moderate; minimal, local or noninvasive intervention indicated. (e.g. GI distress 
requiring IV therapy) 
 
Grade 3: Severe or medically significant but no immediately life-threatening; hospitalization 
or prolongation of hospitalization indicated; disabling.  
 
Grade 4: Life-threatening consequences; urgent intervention indicated. 
 
Grade 5: Death related to AE. 
 
Adverse Event Reporting Period 
 
The study period during which adverse events must be reported is defined as the period 
from the initiation of any study procedures to the end of the study treatment follow-up.  For this 
study, the study treatment follow-up for the mother is defined as until discharge from the 
hospital and the infant as until discharge or 30 days of life, whichever occurs first. 
 
Preexisting Condition 

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A preexisting condition is one that is present at the start of the study.  A preexisting 
condition will be recorded as an adverse event if the frequency, intensity, or the character of the 
condition worsens during the study period. 
 
General Physical Examination Findings 
 
At screening, any clinically significant abnormality will be recorded as a preexisting 
condition.  At the end of the study, any new clinically significant findings/abnormalities that meet 
the definition of an adverse event will also be recorded and documented as an adverse event.  
 
Post-study Adverse Event 
 
The investigator will follow all unresolved adverse events until the events are resolved, the 
subject is lost to follow-up, or the adverse event is otherwise explained.  At the last scheduled 
visit, the investigator will instruct each subject to report any subsequent event(s) that the 
subject, or the subject’s personal physician, believes might reasonably be related to 
participation in this study.  The investigator will notify the IRB of any death or adverse event 
occurring at any time after a subject has discontinued or terminated study participation that may 
reasonably be related to this study.  The IRB will also be notified if the investigator becomes 
aware of the development of cancer or of a congenital anomaly in a subsequently conceived 
offspring of a subject that has participated in this study.  
 
Abnormal Laboratory Values 
A clinical laboratory abnormality will be documented as an adverse event if any one of the 
following conditions is met:  
• The laboratory abnormality is not otherwise refuted by a repeat test to confirm the 
abnormality 
• The abnormality suggests a disease and/or organ toxicity 
• The abnormality is of a degree that requires active management; e.g. discontinuation of 
the study agent, more frequent follow-up assessments, further diagnostic investigation, 
etc. 
 
Hospitalization, Prolonged Hospitalization or Surgery 
 
Any adverse event that results in hospitalization or prolonged hospitalization will be 
documented and reported as a serious adverse event unless specifically instructed otherwise in 
this protocol.  Any condition responsible for surgery will be documented as an adverse event if 
the condition meets the criteria for and adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as 
an adverse event in the following circumstances: 
• Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures 
for a preexisting condition.  Surgery should not be reported as an outcome of an adverse 
event if the purpose of the surgery was elective or diagnostic and the outcome was 
uneventful. 
• Hospitalization or prolonged hospitalization required for an efficacy measurement for the 
study. 
• Hospitalization or prolonged hospitalization for therapy of the target disease of the study, 
unless it is a worsening or increase in frequency of hospital admissions as judged by the 
clinical investigator. 
• Surgery is undertaken for delivery of the infant (cesarean section). 
 
Potential Risks and/or Toxicities of Study Agent 
 
The most serious risk of vitamin B3-amide is liver toxicity. Potential risks of vitamin B3-amide 
at doses < 3 gm/day include: 

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Rare (< 1%)  
Liver toxicity 
Facial erythema 
Hives 
Sore mouth 
Dry hair  
 
Fatigue 
 
 
Infrequent (1-10%) 
Flushing 
(< 2%) 
Headache  
(1%) 
Nausea  
(< 2%) 
Heartburn 
(< 2%) 
8.2 
Recording of Adverse Events 
 
At each contact with the subject, the investigator will seek information on adverse events by 
specific questioning and, as appropriate, by examination.  Information on all adverse events will 
be recorded immediately in the source document, and also in the appropriate adverse event 
module of the case report form (CRF).  All clearly related signs, symptoms, and abnormal 
diagnostic procedures results will be recorded in the source document, grouped under one 
diagnosis. 
 
All adverse events occurring during the study period will be recorded.  The clinical course of 
each event will be followed until resolution, stabilization, or until it has been determined that the 
study treatment or participation is not the cause.  Serious adverse events that are still ongoing 
at the end of the study period will be followed up to determine the final outcome.  Any serious 
adverse event that occurs after the study period and is considered to be possibly related to the 
study treatment or study participation will be recorded and reported immediately. 
8.3 
Reporting of Serious Adverse Events and Unanticipated Problems 
 
Investigators will conform to the adverse event reporting timelines, formats and 
requirements of the various entities to which they are responsible, but at a minimum those 
events that must be reported are those that are: 
• related to study participation, 
• unexpected, and  
• serious or involve risks to subjects or others  
If the report is supplied as a narrative, the minimum necessary information to be provided 
includes 
Study Identifier 
Current status 
Study Center 
Whether study treatment was discontinued 
Subject number 
Reason why event classified as serious 
Date and description of the event  
Investigator determination of association 
between event and treatment 
Investigator reporting:  
 
For reportable deaths, the initial submission to the UNC IRB may be made by contacting the 
IRB Director or Associate Director. The AE/Unanticipated Problem Form is required as a follow 
up to the initial submission. AEs are reported to the IRB if they are unexpected in nature, 
severity or frequency and related or possibly related to administration of study intervention.  
 

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Other Reportable events: 
For clinical drug trials, the following events are also reportable to the UNC IRB: 
• Any adverse experience that, even without detailed analysis, represents a serious 
unexpected adverse event that is rare in the absence of exposure (such as agranulocytosis, 
hepatic necrosis, Stevens-Johnson syndrome). 
• Any adverse event that would cause the PI to modify the investigators brochure, protocol or 
informed consent form, or would prompt other action by the IRB to assure protection of 
human subjects. 
• Information that indicates a change to the risks or potential benefits of the research, in terms 
of severity or frequency. For example:  
– Safety monitoring indicates that a particular side effect is more severe, or more 
frequent than initially expected. 
– A paper is published from another study that shows that your research study is of no 
therapeutic value. 
• Change in FDA safety labeling or withdrawal from marketing of a drug, device, or biologic 
used in a research protocol. 
• Breach of confidentiality 
• Change to the protocol taken without prior IRB review to eliminate apparent immediate 
hazard to a research participant. 
• Incarceration of a participant when the research was not previously approved under 
Subpart C and the investigator believes it is in the best interest of the subject to remain on 
the study. 
• Complaint of a participant when the complaint indicates unexpected risks or the 
complaint cannot be resolved by the research team. 
• Protocol violation (meaning an accidental or unintentional deviation from the IRB 
approved protocol) that in the opinion of the investigator placed one or more participants 
at increased risk, or affects the rights or welfare of subjects. 
8.3.1 Sponsor reporting: Notifying the FDA 
 
The study sponsor (in this case, the PI) is required to report certain study events in an 
expedited fashion to the FDA.  These written notifications of adverse events are referred to as 
IND safety reports. The following describes the safety reporting requirements by timeline for 
reporting and associated type of event: 
 
• Within 7 calendar days 
Any study event that is: 
– associated with the use of the study agent 
– unexpected,  
– fatal or life-threatening, and  
 
• Within 15 calendar days 
Any study event that is: 
– associated with the use of the study agent, 
– unexpected, and 
– serious, but not fatal or life-threatening 
-or- 

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– a previous adverse event that was not initially deemed reportable but is later found to 
fit the criteria for reporting (reporting within 15 calendar days from when event was 
deemed reportable). 
Any finding from tests in laboratory animals that:  
– suggest a significant risk for human subjects including reports of mutagenicity, 
teratogenicity, or carcinogenicity. 
 
Additional reporting requirements 
 
Sponsors are also required to identify in IND safety reports all previous reports concerning 
similar adverse events and to analyze the significance of the current event in light of the previous 
reports. 
 
Reporting Process 
 
Adverse events may be submitted on FDA Form 3500A or in a narrative format. If supplied as 
in a narrative format, the minimum information to be supplied is noted above at the beginning of 
section 8.3. The contact information for submitting IND safety reports is noted below: 
 
Charlene Williamson at Charlene.Williamson@fda.hhs.gov 
8.4 
Stopping Rules  
The study will be stopped under the following circumstances: 
• 
Any maternal or fetal death deemed to be related or possibly related to study participation 
• 
>20% subjects experience liver toxicity (defined as AST or ALT > 3x ULN within 24 hours of 
study drug) 
  
Specific rules to stop study intervention for individual subject 
• 
Delivery, or 34 weeks, which ever occurs first 
• 
Liver toxicity (LFTs > 3x ULN within 24 hours of study drug) 
• 
Maternal side effects that cannot be managed with oral medication 
8.5 
Medical Monitoring 
 
The PI will oversee the safety of the study at her site.  This safety monitoring will include 
careful assessment and appropriate reporting of AEs as noted above, as well as the 
construction and implementation of a site data and safety-monitoring plan (see section 10 
Auditing, Monitoring and Inspecting).  Medical monitoring will include a regular assessment of 
the number and type of serious AEs. 
 
The PI will monitor subject data for safety concerns. Laboratory data will be reviewed daily 
to determine if abnormalities occur.  
8.6 
Data Safety Monitoring Board 
 
The NC TraCS Data and Safety Monitoring Board with serve as the DSMB of record for this 
single center clinical study. The master protocol has been reviewed and approved. The DSMB 
monitor safety using a priori defined study stopping rules and rules for withdrawal of subjects. 
The DSMB will review data after every 6 enrolled subjects; the PI will notify the DSMB after 
every 2 cases of liver toxicity and after every 2 cases of delivery within 48 hours of beginning 
nicotinamide. The NC TraCS DSMB Charter is available for review. 

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9 
Data Handling and Record Keeping 
9.1 
Confidentiality 
 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Those 
regulations require a signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization.  For subjects that have revoked authorization to collect or use PHI, attempts 
should be made to obtain permission to collect at least vital status (i.e. that the subject is alive) 
at the end of their scheduled study period. 
9.2 
Source Documents 
 
Source data is all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial.  Source 
data are contained in source documents.  Examples of these original documents, and data 
records include: hospital records, clinical and office charts, laboratory notes, memoranda, 
subjects’ diaries or evaluation checklists, pharmacy dispensing records, recorded data from 
automated instruments, copies or transcriptions certified after verification as being accurate and 
complete, microfiches, photographic negatives, microfilm or magnetic media, x-rays, subject 
files, and records kept at the pharmacy, at the laboratories, and at medico-technical 
departments involved in the clinical trial. 
9.3 
Case Report Forms 
 
The study case report form (CRF) will be the primary data collection instrument for the 
study.  All data requested on the CRF will be recorded and all missing data will be explained. If 
a space on the CRF is left blank because the procedure was not done or the question was not 
asked, “N/D” will be filled.  If the item is not applicable to the individual case, “N/A” will be filled.  
All entries will be printed legibly in black ink.  If any entry error has been made, to correct such 
an error, we will draw a single straight line through the incorrect entry and enter the correct data 
above it.  All such changes will be initialed and dated. To clarify illegible or uncertain entries, the 
clarification will be printed above the item, initialed and dated. 
9.4 
Records Retention 
 
The investigator will retain study essential documents and specimens for up to 10 years 
following study completion.  
10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
 
The PI will monitor the study to ensure quality and integrity of data collected. She will review 
study files, regulatory documents, and consent forms.  The PI will allocate adequate time for 
such monitoring activities.  The PI will also ensure that the monitor or other compliance or 
quality assurance reviewer is given access to all the above noted study-related documents and 
study related facilities (e.g. pharmacy, diagnostic laboratory, etc.), and has adequate space to 
conduct the monitoring visit. 

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10.2 Auditing and Inspecting 
 
The PI will permit study-related monitoring, audits, and inspections by the IRB, government 
regulatory bodies, and University compliance and quality assurance groups of all study related 
documents (e.g. source documents, regulatory documents, data collection instruments, study 
data etc.).  The investigator will ensure the capability for inspections of applicable study-related 
facilities (e.g. pharmacy, diagnostic laboratory, etc.). Participation as an investigator in this study 
implies acceptance of potential inspection by government regulatory authorities and applicable 
University compliance and quality assurance offices. 
11 Ethical Considerations 
 
This study is to be conducted according to US and international standards of Good Clinical 
Practice (FDA Title 21 part 312 and International Conference on Harmonization guidelines), 
applicable government regulations and Institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted independent 
Ethics Committee (EC) or Institutional Review Board (IRB), in agreement with local legal 
prescriptions, for formal approval of the study conduct.  The decision of the EC/IRB concerning 
the conduct of the study will be made in writing to the investigator and a copy of this decision 
will be provided to the sponsor before commencement of this study.  The investigator should 
provide a list of EC/IRB members and their affiliate to the sponsor. 
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in this 
study.  See Attachment  for a copy of the Subject Informed Consent Form.  This consent form 
will be submitted with the protocol for review and approval by the EC/IRB for the study.  The 
formal consent of a subject, using the EC/IRB-approved consent form, will be obtained before 
that subject undergoes any study procedure.  The subject will sign the consent form, and the 
investigator-designated research professional obtaining the consent.  
12 Study Finances 
12.1 Funding Source 
 
The funding source is NIH. 
12.2 Conflict of Interest 
 
All investigators will follow the University conflict of interest policy. None of the investigators 
have a conflict of interest. 
12.3 Subject Incentives 
 
Subjects will be provided compensation for participation. Each subject will receive $20 for 
the enrollment and baseline blood draw  and $20 for each subsequent study blood draw (up to 
3) then $20 for each week (or part of a week) of participation following the 2nd week which will 
include taking daily vitamin B3-amide dietary supplement, up to 10 weeks ($240 maximum total) 
 
Baseline (includes blood draw)  $20 
 
Day 3 trough 
 
 
$20 
 
Day 3 Peak 
 
 
 
$20 
 
Day 7 blood draw and start of wk 2 
$20 
 
Week 3-10 
 
 
$20 each week on study med 

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