A Randomized Controlled Trial of Vitamin D Supplementation in Multiple Sclerosis
Phase: PHASE3
Conditions: Relapsing Remitting Multiple Sclerosis
Sponsor: Johns Hopkins University

Official Title: A Randomized Controlled Trial of Vitamin D Supplementation in Multiple 
Sclerosis 
 
Principal Investigator: Ellen M. Mowry, MD, MCR 
 
NCT01490502 
 
March 29, 2022 

1 
 
Protocol Title: A randomized controlled trial of vitamin D in multiple sclerosis 
 
Date: 03/29/2022 
 
Version: 2.0 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

2 
 
Synopsis 
Protocol Title: A randomized controlled trial of vitamin D in multiple sclerosis 
Rationale: Vitamin D insufficiency is a risk factor for multiple sclerosis (MS),1  but it is 
uncertain if it also influences the prognosis of those with established disease.  While vitamin D 
supplementation improves outcomes in an animal model of MS,2, 3 human studies are limited.  A 
vitamin D response element was recently identified in the promoter region of HLA-DRB1*15, a 
gene believed to be critical to MS risk, and 1, 25-dihydroxyvitamin D3 increases its expression 
in vitro.10 As such, vitamin D supplementation could even be harmful in established MS.4, 5   
Our observational data show that vitamin D levels are inversely associated with subsequent 
relapse rate.  However, other supplements that appeared to be helpful for other health conditions 
in observational studies had null or harmful effects in randomized trials.12-14  We propose a 
randomized controlled trial of high- versus low-dose vitamin D3 as an add-on to glatiramer 
acetate in patients with relapsing-remitting (RR) MS. 
Study Design: Multicenter, randomized controlled, double-blind study of vitamin D3 as add-on 
therapy to glatiramer acetate 
Study Location: University of California, San Francisco; Johns Hopkins University; University 
of Pennsylvania; Washington University St. Louis; Oregon Health & Science University; Mt. 
Sinai School of Medicine; Cleveland Clinic; Yale University; Columbia University; Swedish 
Medical Center; University of Virginia; University of Rochester; Stanford University; Anne 
Arundel Medical Center; University of Massachusetts, Worcester and Dignity Health Medical 
Foundation.  
Study Objectives: 
• To determine if high-dose versus low-dose vitamin D3 supplementation as an add-on to 
first-line therapy for RRMS is associated with a decrease in the proportion of patients 
who experience a relapse. 
• To determine if high-dose vitamin D3 as an add-on to first-line therapy for MS is 
associated with a decrease in new T2 lesions in patients with RRMS.   
• To determine if high-dose vitamin D3 supplementation as an add-on to first-line therapy 
for MS is associated with a reduced rate of neurodegeneration. 
Number of Planned Subjects: 172 
Study Population: RRMS subjects (MAGNIMS criteria) 9, aged 18 to 50 years, with a baseline 
Expanded Disability Status score between 0.0 and 4.0 (and disease duration  ≤ 10 years if 
MAGNIMS and McDonald RRMS, or ≤ 1 year if McDonald CIS meeting MAGNIMS RRMS 
criteria based on brain MRI).  Patients who meet the McDonald RRMS criteria (rather than 
McDonald CIS that is now classified as MAGNIMS MS): must have had one clinical attack in 

3 
 
past two years AND at least one new silent T2 or gadolinium-enhancing lesion on brain MRI 
within the past year, or have had two clinical attacks in past two years, one of which occurred in 
the past year.  Patients must have no prior history of treatment with rituximab, any 
chemotherapeutic agent, or total lymphoid irradiation.  No treatment in the past six months with 
natalizumab, fingolimod, or fumarate.  If patient has received glatiramer acetate, they have not 
been exposed to more than three months of treatment, and most recent treatment occurred greater 
than one month ago.  Patients have received no treatment with other investigational therapies for 
MS and can’t be receiving regular corticosteroids (e.g. scheduled pulse steroids or daily oral 
steroids).  Patients must not have used interferon beta therapy or steroids for one month prior to 
screening and can’t have used more than 1,000 IU supplemental vitamin D3 (in addition to 
multivitamin) daily in the three months prior to screening.  The 25-hydroxyvitamin D level must 
be ≥ 15 ng/mL within 30 days of screening; if not available, this will be added to the screening 
visit labs.  Patients who have a level < 15 ng/mL may be referred back to their neurologist for 
appropriate repletion.  Such patients may be rescreened for the vitamin D trial and enrolled 
successfully if all eligibility criteria are met at that time. 
Treatment Groups: There will be a one-month run-in in which eligible subjects after screening 
will initiate subcutaneous glatiramer acetate 20 mg daily for one month.  Those who are 
compliant (≤ 3 missed doses in one month, assessed at the baseline visit) will be randomized 
(1:1) to high (5000 IU/day) or low (600 IU/day) dose oral vitamin D3.  Randomization will be 
stratified by center and schedule for each center will be based on randomly permuted blocks of 
varied size to ensure proper balance of treatment assignments within each center. Subjects will 
receive 1 tablet of vitamin D3 daily and will also receive subcutaneous glatiramer acetate 20 mg 
daily:  
 
vitamin D3 600 

4 
 
Subjects who experience excessive activity (clinically, on MRI, or both) may be offered a switch 
from glatiramer acetate to another disease-modifying therapy for MS at the discretion of the 
treating physician but will remain in the study.  This treatment will not be covered by the study.   
Visit Schedule: 
1st Year of Study 
• Screening Visit 
• Run-In Visit 
• Baseline Visit  
• Visits 1 through 4 
• Premature Study Withdrawal Visit (if necessary) 
• Unscheduled Relapse Visit (if necessary; within 5 days of onset of suspected 
relapse) 
2nd Year of Study 
• Visits 5 through 8 
• Premature Study Withdrawal Visit (if necessary) 
• Unscheduled Relapse Visit (if necessary; within 5 days of onset of suspected 
relapse) 
Additional Subject Contact 
Patients will be contacted by the study coordinator at months 1 and 2, six weeks after the 
month 3 visit and every three months thereafter (alternating with study visits) to assess 
for potential new symptoms and encourage compliance, using a standardized transcript.   
Study Visit Window 
All study visits will occur within 10 days of the scheduled visit.  Visits that occur outside 
of the window will be recorded. 
After we re-open from the COVID-19 pandemic, we will continuously assess whether there 
appear to be any impending COVID-19-related shutdowns or serious concerns that may prevent 
in-person study visits. During and after the COVID-19 pandemic, investigators will, at their 
discretion, be allowed to relax study windows as much as is needed in order to minimize risk to 
participants while also securing outcomes needed for the trial, such as end-of-study assessments. 
Questionnaires, although quite short, may be administered remotely at the discretion of the site 
PI. 
In order to minimize the need for research-only in-person visits, telemedicine visits may be 
substituted for in-person clinical trial visits or portions of clinical trial visits where determined to 

5 
 
be appropriate and where determined by the investigator not to increase the participant’s risks. 
Prior to initiating telemedicine for study visits the study team will explain to the participant, what 
a telemedicine visit entails and confirm that the study participant is in agreement and able to 
proceed with this method. Telemedicine acknowledgement will be obtained in accordance with 
the Guidance for Use of Telemedicine in Research. In the event telemedicine is not deemed 
feasible, the study visit will proceed as an in-person visit. Telemedicine visits will be conducted 
using HIPAA compliant method approved by the Health System and within licensing 
restrictions.  
Efficacy Assessments:  Clinical relapse assessments, EDSS, MSFC, MRI brain with and 
without gadolinium, low-contrast visual acuity (2.5% Sloan chart, measured binocularly), health-
related quality of life (FAMS) 
Safety Assessments: Patients will have screening laboratory tests (BUN, creatinine, calcium, 
AST, ALT, and urine pregnancy).  Calcium and pregnancy tests will occur during the study.  
Suicidality assessment will occur every 3 months, per the FDA. 
Assessment of last menstrual period and ordering of urine pregnancy tests for unexplained gaps 
will take the place of urine pregnancy tests during and after the COVID-19 pandemic.  
Additional Assessments: 25-hydroxyvitamin D levels will be measured from samples at 
baseline and at months 3, 6, 12, and 24 (Heartland Laboratories, Ames, IA) as a batch at the end 
of the study to ensure the best possibility reproducibility.  Serum will also be stored for use in 
immunologic studies as well as genetic studies. 
Co-Consent for Genetics Study: All subjects will be asked at the screening visit to participate 
in a parallel study in which genotyping and gene expression analyses will be conducted using 
samples provided at study visits, as described in a related protocol.  Participation in this study 
will be optional. 
Statistical Analysis: 
Primary Outcome: The proportion of subjects in each group who have had a relapse at 
two years 
Secondary Outcomes 
Clinical: annualized relapse rate; number of relapses requiring treatment with 
high-dose steroids; time to first on-study relapse; occurrence of sustained clinical 
disease progression on EDSS; change in MSFC score; change in low-contrast 
letter acuity; change in Functional Assessment in MS score  

6 
 
MRI: number of new or enlarging T2-weighted hyperintense MRI lesions; change 
in T2 lesion volume, percentage brain volume, normalized gray matter volume, 
and cortical thickness 
Primary Predictor: Treatment group (high- versus low-dose vitamin D3) 
Secondary Predictor: Change in 25-hydroxyvitamin D level (baseline to month 24) 
Study Activities: 
 
Screen 
Run-
In 
Baseline Months 
3, 9, 
15, 21 
Months 
6, 12, 
18 
Month 
24 
Relapse 
Visit 
Informed consent 
X 
 
 
 
 
 
 
Co-enrollment in 
genetics study 
X 
 
 
 
 
 
 
Medical history and 
medication check 
X 
X 
X 
X 
X 
X 
X 
Clinical exam 
X 
 
 
 
 
X 
X§§ 
Vital signs 
 
 
X 
 
X*** 
X 
X§§ 
EDSS 
X 
 
X 
 
X*** 
X 
X 
MSFC 
X 
X 
X 
 
X 
X 
 
MRI 
 
 
X 
 
X*** 
X 
 
Suicidality assessment 
X 
X 
X 
X 
X 
X 
X 
Low-contrast acuity 
 
 
X 
 
X 
X 
 
FAMS 
 
 
X 
 
X 
X 
 
Sun exposure survey 
 
 
X 
X 
X 
X 
 
Skin tone card 
 
 
X 
 
 
 
 
Fitzpatrick skin tone 
survey^ 
 
 
X 
 
 
X 
 
Sodium screener 
 
 
 
 
X*** 
X 
 
Screening labs 
X 
 
 
 
 
 
 
Urine pregnancy test 
 
 
X 
X 
X 
 
 
Calcium 
 
 
 
X* 
X 
X 
 
Vitamin D level  
X 
 
X 
X** 
X 
X 
 
Blood storage 
 
 
X 
 
X*** 
X 
 
Dispensing study drug  
 
 
X 
X 
X 
 
 
Compliance check  
 
 
X 
X 
X 
X 
 
Relapse verification 
 
X 
X 
X 
X 
X 
X 
Evaluation of blind 
 
 
 
 
 
X 
 
*months 3 and 9; **month 3; ***month 12; §§ if clinically indicated; ^ slightly different version 
given at baseline and at final study visit; please consult the MOP 
 
 

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INTRODUCTION 
Vitamin D deficiency is associated with a greater risk of MS.  MS prevalence increases as 
distance from the equator increases,10, 11 and those who migrate adopt the risk of the new area. 10, 
12-14  Ultraviolet radiation (the main source of vitamin D) and skin cancer are inversely correlated 
with MS risk.11, 16-20  In a nested case-control study, higher vitamin D levels conferred a lower 
subsequent risk of MS.1  In experimental autoimmune encephalomyelitis (EAE), a mouse model 
of MS, ultraviolet radiation or 1, 25-dihydroxyvitamin D3 prevents the onset of the disease.2, 3, 21 
Vitamin D is a potent immunomodulator.  1, 25-dihydroxyvitamin D3 downregulates dendritic 
cells.22, 23  It prevents the proliferation of and enhances apoptosis of activated B cells.24  In mice, 
vitamin D receptor agonists reduce IL-17,25 a modulator of EAE,26 and inhibit proinflammatory 
TH1 cells.23  Vitamin D receptor agonists also promote CD4+CD25+TREG cells.27, 28  These data 
suggest that vitamin D plays key roles in innate and acquired immunity.29  In EAE, giving 
vitamin D improves recovery 2, 3, 30-32 and reduces inflammation.30, 33   
It is not known if vitamin D supplementation modifies the course of MS.  Our preliminary 
data show a strong inverse association between vitamin D levels and subsequent relapse rates; 
these results were recently replicated in an adult MS cohort.34, 35  Older pilot studies did not 
confirm the effect of vitamin D in MS, perhaps because they were small or non-randomized.36-38  
A recent pilot study randomized 49 MS patients to very high-dose versus discretionary vitamin 
D3 (up to 4,000 IU/day) for one year and found a trend for better outcomes in the intervention 
group.  However, subjects were not blinded or otherwise treated identically (limited follow-up of 
controls; actual control use of vitamin D not recorded).39  Vitamin D increased the expression of 
HLA-DRB1*15 in vitro, presumably by acting on the concomitantly-reported vitamin D response 
element in the gene’s promoter, suggesting that vitamin D could even worsen MS.4  Moreover, 
other supplements that seemed beneficial for other diseases in observational studies had a null or 
negative impact in randomized trials.6-8 
Vitamin D may be neuroprotective.  As the duration of RRMS increases, many patients 
develop insidious disability progression, thought to be caused by neurodegeneration (the likely 
cause of volume loss, or atrophy, on brain MRI).40, 41-48  Loss of normalized gray matter volume 
is associated with later disability, making it an attractive outcome measure for trials.40, 49-54 
Vitamin D and its receptor are widespread in the central nervous system.55, 56  In cell culture 
excitotoxicity models, vitamin D was neuroprotective.57-61  While there are no published data in 
MS, 1, 25 dihydroxyvitamin D3 reduces activated T cell-mediated axonal damage in EAE.62 
 
 
 

8 
 
OBJECTIVES 
Primary Objective 
• To determine if high-dose versus low-dose vitamin D3 supplementation as an add-on to 
first-line therapy for RRMS is associated with a decrease in the proportion of patients 
who experience a relapse. 
Secondary Objectives 
The secondary objectives of the study are to determine if high-dose vitamin D3 as an add-on to   
first-line therapy for MS, as compared to low-dose vitamin D3, is associated with: 
• a decrease in new T2 lesions in patients with RRMS.   
• a reduction in the loss of brain volume (whole brain; normalized gray matter; cortical 
thickness) 
• a lower annualized relapse rate in the two-year study 
• a reduction in the number of relapses requiring intravenous steroid therapy 
• a prolongation of the time to the first relapse 
• a reduction in the occurrence of sustained EDSS progression 
• less worsening of disability as assessed by the MSFC  
• less worsening of low-contrast letter acuity 
• better health-related quality of life 
We will also determine if high-dose vitamin D3 as an add-on to first-line therapy for MS, as 
compared to low-dose vitamin D3, is associated with the same effects as a function of time 
except for EDSS endpoint, as progression can only be confirmed after two years. 
 
STUDY DESIGN 
Overview 
This is a prospective, double-blind, randomized multi-center trial of high- versus low-dose 
vitamin D3 as add-on therapy to a standard therapy for RRMS, glatiramer acetate.  Subjects will 
be randomized (1:1 ratio) to 600 IU or 5000 IU of oral vitamin D3 daily for two years. The 
primary outcome will be the proportion of patients that experiences a clinical relapse during the 
study.   
All study staff will be blinded to the treatment assignment; only in an emergency will unblinding 
occur.  The study drug packages will be identical.  Continental Vitamin Company (Los Angeles, 
CA) will manufacture capsules identical in size, color, odor, and taste.  At the end of the study, 
subjects and coordinators will be asked to guess which group they were in. 

9 
 
Subjects who experience two or more relapses or who have excessive brain MRI activity at year 
1 (or a combination; see “Study Treatment” section) may be offered a switch from glatiramer 
acetate to another disease-modifying therapy for MS at the discretion of the treating physician 
but will remain in the study.  This treatment will not be covered by the study.   For confirmed 
relapses, subjects may be offered a three-day course of high-dose intravenous 
methylprednisolone if deemed necessary by the treating physician.  The cost of steroid treatment 
will not be covered by the study.    
Overall Study Duration and Follow-Up 
For the first year, the study will consist of the screening, run-in, and baseline visits, followed by 
visits at months 3, 6, 9, and 12 (visits 1-4).  The second year will consist of visits at months 15, 
18, 21, and 24 (visits 5-8).  Visits 1, 3, 5, and 7 will be abbreviated visits at which the treating 
physician and examining physician do not need to perform any assessments.  Premature 
withdrawal visits and unscheduled relapse visits will be conducted as needed.  The unscheduled 
relapse visit may be merged with a scheduled visit if the two visits coincide and neither visit will 
fall out of window. 
Efficacy Measures 
Relapse: Relapses are new or recurring symptoms referable to the central nervous system lasting 
for at least 24 hours after a remission of 30 days or more since the prior event.  Pseudo-
exacerbations (worsening in the context of a fever/infection) will be excluded.  Relapses must be 
accompanied by worsening of the EDSS (≥ 0.5 points) or in the Functional Systems (FS) scales 
(2 points on at least one FS scale or 1 point ≥ 2 FS scales), as determined by the examining 
neurologist.63  Patients will be asked to report new symptoms within 48 hours of onset.  Those 
with suspected relapses will be assessed within five days of onset.  For confirmed relapses, 
subjects may be offered a three-day course of high-dose steroids if deemed necessary by the 
treating physician.  The cost of steroid treatment will not be covered by the study.  MRIs will be 
delayed for one month after the last date of steroid use. 
We will also document probable relapses.  These relapses include new or recurring symptoms 
referable to the central nervous system lasting for at least 24 hours after a remission of 30 days or 
more since the prior event.  Pseudo-exacerbations (worsening in the context of a fever/infection) 
will be excluded.  However, there will not be a requirement for an accompanying change on 
EDSS or FS scales.  While relapse criteria are very stringent for many drug trials, relapses in 
practice may not involve a new examination finding (e.g. mild optic neuritis; sensory changes) 
Disability Progression: A patient will be considered to have had sustained progression of 
disability if there is an increase in the EDSS score at month 12 by at least 1.0 point that is 
confirmed on the final examination, as performed by the examining neurologist, one year later. 

10 
 
MS Functional Composite (MSFC): The MSFC will be done by a research coordinator at the 
screening, run-in, and baseline visits and then every six months until month 24.  The MSFC will 
also be performed at visits for relapses.64   
Vision: Binocular low contrast letter acuity will be assessed by 2.5% Sloan charts.65   
MRI: MRI scans will be performed at 3T and processed at baseline, month 12, and month 24. 
Since they are considered standard of care, the MRI scans will be read locally by the attending 
radiologist at each study site, and the local readings will be used for making decisions about 
changing therapy if disease activity is judged to be excessive, as detailed above, as well as for 
identifying and acting on incidental findings, as detailed in the IRB application.  Prior to June 1, 
2015, MRIs will be sent to Dr. Daniel Pelletier’s laboratory at Yale University, which will 
perform MRI post-processing and analysis; laboratory members will be blinded to treatment 
group and disease course.  In order to ensure the MRI scan quality is sufficient, each site will do 
a dry-run MRI scan on one individual.  Since the MRI protocol being used is a standard clinical 
MS scan, the dry-run MRI may be conducted on a patient in the MS clinic who is already 
planning to have a follow-up scan as part of their routine clinical care.  The scan will be loaded 
on a CD and sent to Yale University for approval.    The dry-run MRI will be de-identified.  For 
routine study participants, at Johns Hopkins, the study scans will be de-identified.  If other sites 
do not wish to de-identify their scans, then the sites must provide proof to the study managers 
and to the Yale IRB that both their IRB-approved protocol and the IRB-approved patient consent 
form state that identifiers will remain on the CD and images.   The discs will be stored in a 
secure facility and not used for any purpose other than this research study. 
As of June 1, 2015, Dr. Pelletier’s laboratory and all stored MRI study materials will move to 
University of Southern California (USC).  Local IRBs will need to be updated that MRIs will be 
sent to USC for the remainder of the trial.  
Brain lesions will be identified on simultaneously-viewed, high-resolution T1-weighted, T2-
weighted, and proton density-weighted images.  Regions of interest will be drawn based on a 
semi-automated threshold with manual editing utilizing in-house software, and T1- and T2-lesion 
masks will be created.66  Intra- and inter-observer variability analyses will performed to ensure 
accuracy.  T2-lesion volumes will be calculated by multiplying the area of the lesion by the slice 
thickness and the number of slices penetrated using in-house software.  For atrophy, brain 
segmentation and normalization will be performed using SIENAX (Oxford, UK).  Whole brain 
volume change will be calculated from high-resolution 3D T1-weighted images by SIENA.67  
Output will be converted into percentage brain volume change. Novel measures, such as cortical 
thickness, will also be assessed.  The MRI endpoints will be evaluated as soon as the final 
subject completes the month 24 visit.  
Health-related Quality of Life: The Functional Assessment in MS (FAMS) Version 4.0 will be 
administered at the beginning of each study visit at which it is scheduled.68   

11 
 
   
STUDY POPULATION 
Inclusion Criteria: 
1. Must meet MAGNIMS criteria for relapsing-remitting MS 
2. Age 18 to 50 years 
3. EDSS score ≤ 4.0 
4. MS disease duration ≤ 10 years if McDonald RRMS; ≤ 1 year if meets MAGNIMS 
RRMS criteria but not McDonald RRMS criteria 
5. If the patient meets the McDonald RRMS criteria (rather than McDonald CIS that is now 
classified as MAGNIMS MS):  
- 
Must have had one clinical attack in past two years AND at least one new 
silent T2 or gadolinium-enhancing lesion on brain MRI within the past year 
OR 
- 
Must have had two clinical attacks in past two years, one of which occurred in 
the past year 
6. Females of child-bearing age must be willing to use at least one form of pregnancy 
prevention throughout the study. 
7. Must have had a 25-hydroxyvitamin D level of ≥ 15 ng/mL within past 30 days 
8. Must be willing to stop taking additional supplemental vitamin D, except as part of a 
multivitamin (can contain up to 600 IU), and must be willing to not take cod liver oil.  
 
Exclusion Criteria: 
1. Pregnant or nursing 
2. Ongoing renal or liver disease 
3. Known history of nephrolithiasis, hypercalcemia (non-spurious), sarcoidosis or other 
serious chronic illness including cancer (other than basal cell or squamous cell carcinoma 
of the skin), clinically relevant (non-benign) cardiac disease, or HIV. 
4. Ongoing hyperthyroidism or active infection with Mycobacterium species 
5. Known gastrointestinal disease (ulcerative colitis, Crohn’s disease, celiac disease/gluten 
intolerance) or use of medications associated with malabsorption. 
6. History of self-reported alcohol or substance abuse in past six months. 
7. Prior history of treatment with rituximab, any chemotherapeutic agent, or total lymphoid 
irradiation.  Treatment in the past six months with natalizumab, fingolimod, or fumarate 
is prohibited.  If patient has received glatiramer acetate, exposure to more than three 
months of treatment is prohibited.  No glatiramer acetate for one month prior to 
screening.Treatment with other unapproved therapies for MS is prohibited. 
8. Use of interferon beta therapy for one month prior to screening 
9. Use of more than 1,000 IU vitamin D daily (average) in the three months prior to 
screening 
10. Condition that would limit the likelihood of completing the MRI procedures 
11. Use of thiazide diuretics, digoxin, diltiazem, verapamil, cimetidine, heparin, low-
molecular weight heparin, certain anticonvulsants (carbamazepine, phenytoin, or 

12 
 
phenobarbital), routine corticosteroids (eg scheduled monthly steroids, daily, etc), 
rifampin, or cholestyramine.   
12. Steroids within a month of screening. 
13. Recent active suicidal ideation in past 6 months (no “yes” answers to questions 2-5 on the 
screening Columbia Suicide Severity Rating Scale [C-SSRS]);  no passive suicidal 
ideation in the past 2 months (answers “yes” to question 1 on the C-SSRS); suicidal 
attempts or preparatory attempts in the past 5 years (answers “yes” to any of the suicide 
attempt questions when referencing the past 5 years).  Serum calcium.> 0.2 mg/dL above 
the upper limit of normal. 
 
ENROLLMENT AND RANDOMIZATION 
Patients who meet inclusion criteria and want to participate in the study will initiate therapy with 
glatiramer acetate for a one month run-in period.  Those who successfully complete the run-in 
period and remain compliant with glatiramer acetate (compliance defined by no more than three 
missed doses in the run-in period) will then be randomized (stratified by site) in a 1:1 fashion to 
receive either 5,000 IU daily or 600 IU daily of oral vitamin D3.  The run-in was chosen so that it 
will reduce the risk of randomizing non-compliant individuals. 
For subjects who have successfully completed the run-in, the study statistician will generate the 
randomization schedule (which will be stratified by site in order to account for differences in 
ultraviolet light in each location and will be based on randomly permuted blocks of varying sizes 
to ensure proper balance of treatment assignments within each center) in conjunction with the 
Investigational Drug Services (IDS) group at Johns Hopkins; the site coordinator (or study 
pharmacist, if necessitated by the site IRB) will distribute the study drug after confirming 
eligibility to the IDS.  Each subject will be assigned a unique identification number, which will 
be used on all of the subject’s Case Report Forms.  In order to inform other providers and 
prevent unblinding, the subjects’ primary care physician and regular neurologist will be informed 
that the subject is in the trial and will be asked not to check vitamin D levels during the trial in 
order to prevent unblinding. 
STUDY TREATMENT: DESCRIPTION AND ALLOCATION 
Subjects will be randomized to oral vitamin D3 5,000 IU or 600 IU once daily in a 1:1 fashion.  
All patients will be treated with subcutaneous glatiramer acetate 20 mg daily throughout the 
course of the study.  Subjects who experience two or more relapses or excessive MRI activity 
(more than 3 new T2 lesions on the year 1 brain MRI) or one relapse plus more than 2 new T2 
lesions on the year 1 MRI, may be offered a switch from glatiramer acetate to another disease-
modifying therapy for MS at the discretion of the treating physician but will remain in the study.  
This treatment will not be covered by the study.  The rules for discontinuing study treatment are 
described below.  A subject may withdraw from the study if they choose to do so.  The treating 
physician may also terminate a subject due to poor compliance, safety, or other issues. 

13 
 
Dose Rationale for Study Drug: The ideal serum level of 25-hydroxyvitamin D is still debated.  
Several experts have suggested that 30 ng/mL (75nmol/L; conversion factor from ng/mL to 
nmol/L is 2.496) is the minimum desired 25-hydroxyvitamin D level;69 however, levels above 40 
ng/mL were protective against MS.1 Further, in our pediatric-onset MS study, there was no 
evidence of a threshold above which vitamin D was not important (up to 60 ng/mL, the highest 
level measured);34 no threshold was determined in the Australian study either.35  Many experts 
consider 10,000 IU the tolerable upper dose limit; in the most systematic pharmacokinetic study, 
this dose produced a final 25-hydroxyvitamin D level that approached 100 ng/mL (see Figure).70, 
71  
It thus seems likely that the appropriate target level is between 40 ng/mL and 100 ng/mL.  In the 
Heaney vitamin D3 pharmacokinetic study,70 healthy subjects with a mean baseline level of 28 
ng/mL were treated with vitamin D3 5,000 IU daily for 20 weeks and had a final 25-
hydroxyvitamin D level of 60 ng/mL.  From our preliminary data, the mean 25-hydroxyvitamin 
D level in MS subjects was 22 ng/mL.  We propose that 5,000 IU daily is a justifiable dose for 
the target 25-hydroxyvitamin D level of 60 ng/mL. 
The control dose of 600 IU vitamin D3, the current recommended daily allowance (RDA), was 
chosen for equipoise; however, this dose should produce little change in serum 25-
hydroxyvitamin D levels (see Figure).70 
 
Intervention Group: 86 subjects will receive glatiramer acetate 20 mg subcutaneously once a 
day, which will be given for one month prior to randomization, as described above.  After 
randomization, subjects in this group will take 5,000 IU (125 mcg) of oral vitamin D3 daily. 
 Control Group: 86 subjects will take glatiramer acetate 20 mg subcutaneously once daily.  After 
one month, subjects randomized to this group will take 600 IU (15 mcg) of oral vitamin D3 
daily. 
10,000 IU/day 
 
5,000 IU/day 
 
1,000 IU/day 
Placebo 

14 
 
Methods for Maximizing Adherence and Compliance: The run-in period will allow investigators 
to assess compliance with glatiramer acetate.  Patients who report missing more than three doses 
of glatiramer acetate during the run-in will not be eligible for randomization.  Patients will be 
encouraged to take glatiramer acetate and the study drug together at the same time each day to 
minimize the chance that they will be forgotten.  Patients will be instructed to take the 
medication within an hour of a meal, since oral vitamin D is fat-absorbed.  A study coordinator 
will contact all subjects (texting or emailing, or phone call if preferred) to query about new 
symptoms and assess compliance.   Subjects will be asked to complete an online or telephone 
survey if they are having new symptoms.  Compliance will be assessed at each three-month visit 
by pill count.     
Drug Accountability: The site principal investigator will maintain adequate records of the 
disposition of the study drug, including receipt, storage, dates, quantity of drug received, to 
whom dispensed, and accounts of any study drug accidentally or deliberately destroyed. A drug-
dispensing log will be kept current for each participant and should contain the identification 
number of each participant and the date and quantity of drug dispensed.  
Treatment Acquisition and Storage: All vitamin D will be stored in a secure location and will be 
dispensed by the study coordinator.  The Johns Hopkins Investigational Drug Services will 
distribute the vitamin D capsules to each site to ensure study medication blinding. Vitamin D 
will be provided by Continental Vitamin Company; Teva Pharmaceuticals will provide 
glatiramer acetate. 
 
SCHEDULE OF EVENTS 
Study Personnel  
At each site, the following personnel will participate in the study: 
Treating physician: This person will be responsible for informed consent (a designee can consent 
e.g. the study coordinator), patient monitoring, adverse event assessment, physical examination 
and identifying possible relapses.  The treating physician will remain blinded to treatment 
assignment. 
Examining physician: This physician will perform the Expanded Disability Status Scale for 
scheduled and unscheduled visits for possible relapses. The examining physician will remain 
blinded to treatment assignment and to any details about a subject’s course. 
Pharmacist: If a site is unable to store and dispense the vitamin D and glatiramer acetate, a site 
pharmacy will store and distribute study medications.   

15 
 
Study coordinator: The coordinator will be responsible for administrative duties associated with 
study and will remain blinded to treatment assignment.   
Injection training nurse: Injection training may be done by each site’s nurse or referred to Teva, 
as determined by the site training physician. 
Study technician:  An examining technician will conduct the health-related quality of life, 
MSFC, and low-contrast letter acuity testing.   
MRI technician: Each site technician will conduct the MRI protocol.  This person will be blinded 
to treatment assignment and disease course. 
Schedule of Events 
 
Screening Visit 
Treating physician 
 Informed consent (can also be done by study coordinator) 
 Consent for genetics study 
 Eligibility criteria/verification 
 Medical history 
 Medication history 
 Physical examination 
 Suicidality assessment 
 
Study coordinator 
 Collection of blood for screening labs and vitamin D level (if not done within past  
month), and urine for pregnancy test (in women of childbearing potential) 
 
 
Examining physician 
 Expanded Disability Status Scale 
 
Study technician 
 MS Functional Composite 
 
Run-in Visit  
Study coordinator 
 Suicidality assessment 

16 
 
 Instructions to start glatiramer acetate (training by nurse at each site/injection nurse) 
 
Study technician 
 
 MS Functional Composite 
 
Baseline Visit (Day 0) 
Treating physician 
 Verification of compliance with glatiramer acetate injections 
 Updating medical record (medical history, medications, contraceptive use) 
 Adverse effect evaluation 
 Documentation of relapses 
 Suicidality assessment 
 
Study coordinator 
 Vital signs 
 Collection of urine for pregnancy test 
 Collection of blood for storage (for baseline 25-hydroxyvitamin D levels and future 
studies, including immunologic studies) 
 Randomization  
 Dispense study drug and glatiramer acetate 
 Inform primary care doctor and neurologist of participation in study 
 
Examining physician 
 Expanded Disability Status Scale 
 
Study technician 
 MS Functional Composite 
 Health-related quality of life (FAMS) 
 Low-contrast visual acuity testing 
 Sun Exposure Questionnaire 
 Skin tone measurement (skin tone card, longer Fitzpatrick) 
 
MRI technician 
 Conducting the baseline brain MRI  
 
 

17 
 
Month 3, 9, 15, 21 Visits 
Study coordinator 
 Verification of compliance with glatiramer acetate injections and study drug 
 Collection of blood for safety labs (months 3 and 9 only) and urine for pregnancy test 
 Storage of blood for vitamin D levels (only at month 3) 
 Updating medical record (medical history, medications, contraceptive use) 
 Dispensing study drug and glatiramer acetate 
 Suicidality assessment 
 
Study technician 
 Sun Exposure Questionnaire 
 
 
Month 6, 12, 18 Visits 
Treating physician 
 Adverse event evaluation 
 Suicidality assessment 
 
Study coordinator 
 Vital signs (month 12 only) 
 Collection of blood for safety labs and urine for pregnancy test 
 Collection of blood for storage for vitamin D levels  
 Collection of blood for storage for future studies (month 12 only) 
 Updating medical record (medical history, medications, contraceptive use) 
 Verifying compliance with glatiramer acetate injections and study drug 
 Dispensing study drug and glatiramer acetate 
 
Examining physician 
 Expanded Disability Status Scale (month 12 only) 
 
Study technician 
 MS Functional Composite 
 Health-related quality of life (FAMS) 
 Sodium Screener (month 12 only) 

18 
 
 Low-contrast visual acuity testing (binocular, 2.5%) 
 Sun Exposure Questionnaire 
 
MRI technician 
 Conducting the brain MRI (month 12 only) 
 
 
Month 24/End of Study Visit 
Treating physician 
 Physical examination including adverse event evaluation 
 Suicidality assessment 
 
Study coordinator 
 Vital signs 
 Collection of blood for safety labs (calcium only) 
 Collection of blood for 25-hydroxyvitamin D levels 
 Collection of blood for storage for future studies 
 Updating medical record (medical history, medications, contraceptive use) 
 Verifying compliance with glatiramer acetate injections and study drug 
 Evaluation of the blind (patients, treating physician, examining physician, study 
technician) 
 
Examining physician 
 Expanded Disability Status Scale 
 
Study technician 
 MS Functional Composite 
 Health-related quality of life (FAMS) 
 Low-contrast visual acuity testing 
 Sun Exposure Questionnaire 
 Sodium screener 
 Skin tone measurement (Fitzpatrick short version) 
 
MRI technician 
 Conducting the brain MRI  
 
 

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Unscheduled Relapse Visit 
Treating physician 
 Physical examination, if indicated, including adverse event evaluation 
 Verification of relapse 
 Determination of need for intravenous methylprednisolone 
 Suicidality assessment 
 
Study coordinator 
 Vital signs, if indicated 
 Urinalysis, urine culture and/or complete blood count (as needed, per the treating 
physician) 
 Updating medication record 
 
Examining physician 
 Expanded Disability Status Scale 
 
Additional Patient Contact 
Between study visits, patients will be contacted by the study coordinator (months 1, 2, 4.5, 7.5, 
10.5, 13.5, 16.5, 19.5, 22.5) to ask about new symptoms and encourage compliance, as well as to 
set up study visits. 
 
Study Visit Windows 
All study visits will occur within 10 days of the scheduled visit.  Visits that occur outside of the 
window will be recorded. 
During and after the COVID-19 pandemic, investigators will, at their discretion, be allowed to 
relax study windows as much as is needed in order to minimize risk to participants while also 
securing outcomes needed for the trial, such as end-of-study assessments. 
 
SAFETY AND ADVERSE EVENT MONITORING 
Screening will include blood (BUN, creatinine, AST, ALT, calcium), and urine pregnancy tests.  
Urine pregnancy testing will occur at baseline and every three months thereafter; serum calcium 
will be repeated at months 3, 6, 9, 12, 18, and 24.  All safety data will be recorded; serious 

20 
 
adverse events will be reported on a serious adverse event form and in the chart.  This algorithm 
will be used if hypercalcemia is detected during the study: 
 Serum calcium level ≥1 mg/dL above the upper limit of normal: discontinue the study drug, 
and repeat labs in one week.  If it normalizes, the drug will be restarted, and the level will be 
checked every other week for six weeks.  If the level again is ≥1 mg/dL above the upper limit of 
normal, the patient will stop the drug for the rest of the study.  If the repeat level is > 0.5 mg/dL 
above the upper limit of normal but is <1 mg/dL above the upper limit of normal, the patient will 
decrease the dose to one tablet every other day and will have serum calcium checked monthly for 
the rest of the study.   
 Serum calcium is >0.5 mg/dL above the upper limit of normal but is <1 mg/dL above the 
upper limit of normal: labs repeated in one week; if the level continues to be in this range, 
patients will take only one tablet every other day for the remainder of the study and will have 
levels checked monthly until they normalize.   
 Patients will be educated about symptoms of nephrolithiasis, will be instructed to call if they 
occur, and will be evaluated within 24 hours by the treating physician or by the Emergency 
Department.  If nephrolithiasis is confirmed, the study drug will be stopped.   
 
In compliance with the FDA regulations on assessing for suicidality in prospective trials 
(http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/
UCM225130.pdf), the treating physician will administer the Columbia Classification Algorithm 
for Suicide Assessment at the screening visit, at baseline, and every three months as well as at 
unscheduled visits. 
 
Adverse Event: An adverse event is any occurrence or worsening of an undesirable or unintended 
sign, symptom (or abnormal laboratory test), or disease temporally associated with the use of a 
medicinal product, whether or not it is considered related to the medicinal product.  The 
investigator will record all study adverse events in the chart and will treat participants with 
adverse events appropriately, observing them until they resolve or stabilize.  Adverse events will 
be collected from the start of the study until a participant terminates from the study; those that 
are unresolved at the time of termination will be followed until they resolve or up to 30 days. 
 
Unexpected Adverse Event An adverse event is considered unexpected when its nature 
or severity is not consistent with the product information (e.g. package insert safety information, 
the investigational plan, the investigator’s brochure, the protocol, or the informed consent form). 
 
Serious Adverse Event: A serious adverse event (any adverse event that suggests a significant 
hazard, contraindication, side effect, or precaution) must be reported. This includes, but may not 
be limited to, death, a life-threatening event, inpatient hospitalization or prolongation of existing 
hospitalization, persistent or significant disability/ incapacity, congenital anomaly/ birth defect, 
other protocol-specified conditions, or an event that requires intervention to prevent permanent 
impairment or damage.  Serious adverse events will be collected from informed consent signing 
until 30 days after study completion or until 30 days after a participant withdraws from the study. 
 
 
 

21 
 
Grading of Adverse Events 
We will use the National Cancer Institute’s Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0 to report and grade all adverse events, whether or not they are related to 
disease progression or treatment.  The relationship between an adverse event and the study drug 
will be determined by the site investigator and recorded on the appropriate form.  
 
Serious Adverse Event Reporting The following process for reporting a serious adverse event 
will ensure compliance with the International Conference on Harmonisation guidelines: 
1. The Institutional Review Board will be notified in one business day of a serious adverse event. 
2.  Standard reporting will occur if the event is serious, expected and drug-related, serious, 
expected and not drug-related, or serious, unexpected and not drug-related. 
3. Expedited reporting is required if the event is serious, unexpected and drug-related. This type 
of event must be reported to the appropriate authorities within 15 days unless it is fatal or life-
threatening; a fatal or life-threatening event must be reported within 7 days.  
 
Pregnancy (Serious Adverse Event Reporting Requirements): Any pregnancy that occurs during 
a clinical study with an investigational drug will be reported as a serious adverse event, and 
pregnancies will be followed to their conclusion.  Female participants should immediately 
inform the investigator of pregnancies and will stop taking the study medications. The 
investigator will report pregnancies to the Institutional Review board within one business day. 
The investigator will counsel the participant about the risks of continuing the pregnancy.  
 
Criteria for Discontinuing Study Drug or Terminating the Study The study drug will be 
discontinued if the participant becomes pregnant or develops nephrolithiasis or persistently 
elevated serum calcium levels (as above), if it is in the participant’s best interest (decided by the 
treating physician), if the participant experiences an adverse event grade 3 or higher that is at 
least possibly related to the study drug, or if the subject cannot tolerate the study drug or wants to 
discontinue treatment.  Any death that is at least possibly related to the study will put the study 
on hold.  The Data and Safety Monitoring Board will determine if it is safe to resume the study.  
Subjects who become suicidal during the study (codes 1-4, 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/U
CM225130.pdf) will be referred to a psychiatrist or to a psychiatric emergency room for 
evaluation at the discretion of the site treating physician. 
Data and Safety Monitoring Board (DSMB) 
The independent DSMB consists of two neurologists (Amy Waldman, M.D., Children’s Hospital 
of Philadelphia; Jill Conway, M.D., Carolinas Health Care) and one statistician (Ciprian 
Crainiceanu, Ph.D., Johns Hopkins University).  The DSMB will meet, in person, or by 
teleconference, two times per year and will convene by teleconference or through e-mail any 
time a serious adverse event occurs.   

22 
 
For suicide, if there are more than three suicides or deaths in the study, the DSMB will be 
unblinded to treatment assignment.  If the statistician deems this to be related to vitamin D 
dosage, the DSMB will be asked to make a recommendation about how to proceed.  If more than 
5 patients develop severe hypercalcemia (serum calcium ≥1 mg/dL above the upper limit of 
normal), a similar procedure will occur, with unblinding of the DSMB, the determination of 
whether this is likely related to vitamin D dose, and any recommendations for modification of 
the protocol.  All serious adverse events will be reported to the DSMB members within one 
business day of the event’s documentation.  A recommendation from the DSMB when the 
thresholds above have been reached will be expected within three business days of the receipt of 
the report. 
MRI and glatiramer acetate are part of the standard of care for MS patients, so adverse events 
will be reported to the DSMB, but the plan of care will be adjudicated and determined by the site 
PI, in consultation with the overall study PI, Dr. Mowry, as needed. 
STATISTICAL ANALYSIS 
Primary Outcome: The proportion of subjects in each group who have had a relapse at two years 
Secondary Outcomes 
Clinical: annualized relapse rate; number of relapses requiring treatment with high-dose steroids; 
time to first on-study relapse; proportion with probable relapse; annualized probable relapse rate; 
occurrence of sustained clinical disease progression on EDSS; change in MSFC score; change in 
low-contrast letter acuity over two years; change in Functional Assessment in MS score over two 
years 
MRI: number of new or enlarging T2-weighted hyperintense MRI lesions; percentage of patients 
with a new T2 lesion; change in T2 lesion volume, percentage brain volume, normalized gray 
matter volume, and cortical thickness 
Primary Predictor: Treatment group (high- versus low-dose vitamin D3) 
Secondary Predictor: Change in 25-hydroxyvitamin D level (baseline to month 24) 
Statistical Analyses 
Efficacy Outcomes: All statistical tests will be considered significant at a two-sided alpha of 
0.05.  Intention-to-treat will be used for all analyses. 
The primary outcome is the proportion of individuals with a relapse during the two years of 
follow-up.  Parameter estimates will be calculated using generalized estimating equations (GEE) 
with robust standard errors.  A longitudinal logistic regression model with a saturated cell means 
model (including indicators for each visit and each visit by treatment interaction) and an 
unstructured covariance matrix will be used.  The interaction term for the two-year visit 

23 
 
represents the comparison of the odds of relapse at two years for the two dose levels.  Negative 
binomial regression will be used to compare the annual relapse rates and a Cox proportional 
hazards model will be used to compare the time to first relapse. 
The occurrence of sustained EDSS progression will be assessed using the techniques described 
for the primary outcome.  Longitudinal linear regression models will be used to evaluate changes 
in continuous outcomes (MS function composite score, T2 lesion volume, percentage brain 
volume, normalized gray matter volume, cortical thickness, low-contrast letter acuity, and 
Function Assessment in MS score).  GEE with saturated mean models and unstructured 
covariance matrices will be applied.  For all analyses, we will explore the potential effects of co-
intervention (e.g. sun exposure;72 use of multivitamin) and of baseline skin tone (using Skin 
Tone measurement card and Fitzpatrick scale) by adjusting for these variables in the models 
described above. 
Adverse Event Outcomes: All participants who receive any vitamin D3 will be included in the 
analysis of safety.  Adverse events occurring before baseline, but not worsening or not related to 
study therapy during study, will not be considered as treatment-emergent adverse events.   
Summary: The principal features of the design of this study and of the plan for statistical analysis 
of the data are outlined in this protocol. Any changes in these principal features will require a 
protocol amendment that will then be subject to review by the study sponsor. 
 
Role of Johns Hopkins as Coordinating Center 
Dr. Mowry, the coordinating center PI, has the contact information for all centers.  The study 
managers, Sandra Cassard and Susan Emrich, will assist Dr. Mowry in the oversight of the trial 
conduct.  Dr. Mowry and/or the study managers will assist the participating centers in the 
submission of their IRB approval documents and consent forms and in drafting any response 
letters to the IRBs.  All approved IRB applications and consent forms will be submitted to the 
coordinating center prior to starting the study at each site for review by Dr. Mowry/overall study 
managers to ensure modifications will not threaten the integrity of the study or the safety of the 
patients. 
When modifications to the protocol are initiated by the coordinating center, the study managers 
will disseminate those modifications to each participating site.  The managers will follow up 
within 10 days to ensure that the modifications have been submitted by each site to their IRB and 
will check in every three weeks after submission until written confirmation acknowledging the 
protocol modifications are provided from each site’s IRB.  The study managers will also be 
responsible for training study coordinators at participating sites in data entry.  REDCap, a web-
based database, will be used for data collection.  The study managers will do spot checks of all 
data, using faxed data entry sheets (coded to maintain confidentiality) to assess for data entry 

24 
 
errors.  The study managers will monitor data entry on an ongoing basis to ensure data are 
entered efficiently and within an expected window of subjects’ study visits. 
Protocol events and deviations will be reported directly to the study PI (Dr. Mowry) and to the 
study managers within 5 business days; serious adverse events must be reported immediately by 
e-mail and phone to Dr. Mowry and the study managers. 
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