Nutritional Impact of Orkambi Treatment in 2 to 5 Year Old Children Homozygous for F508del Mutations
Conditions: Cystic Fibrosis
Sponsor: Children's Hospital of Philadelphia

 
  
 
 
i
Title: 
Nutritional Impact of Orkambi treatment in 2 to 5 Year Old 
Children Homozygous for F508del Mutations  
Short Title 
Orkambi in 2 to 5 Year Old Children with CF  
Regulatory Sponsor: 
 
eIRB Number 
18-015669 
Protocol Version Date: 
10/28/2019 
Amendment 1 Date:  
Amendment 3 Date:  
Amendment 2 Date: 
Amendment 4 Date: 
 
Sponsor 
Vertex Pharmaceuticals 
50 Northern Ave. 
Boston, MA 02210 
 
Principal Investigator 
Virginia A. Stallings, MD 
2716 South Street, Room 14473 
Philadelphia, PA, 19146 
Phone: 267.425.1633 
email: stallingsv@email.chop.edu 
 
 
 
 
 
 
 
 
 
 
 
 

 
  
 
 
ii
TABLE OF CONTENTS 
Table of Contents............................................................................................................ ii 
Abbreviations and Definitions of Terms ......................................................................... iv 
Abstract .......................................................................................................................... v 
Protocol Synopsis .......................................................................................................... vi 
1 
BACKGROUND INFORMATION AND RATIONALE ..................................................................................... 1 
1.1 
INTRODUCTION ............................................................................................................................................ 1 
1.2 
COMPLIANCE STATEMENT .............................................................................................................................. 3 
2 
STUDY OBJECTIVES .................................................................................................................................. 3 
2.1 
PRIMARY OBJECTIVE (OR AIM) ....................................................................................................................... 3 
2.2 
SECONDARY OBJECTIVES (OR AIM) .................................................................................................................. 3 
2.3  
EXPLORATORY AIMS…………………………………………………………………………………………………………………………………4 
3 
INVESTIGATIONAL PLAN.......................................................................................................................... 4 
3.1 
GENERAL SCHEMA OF STUDY DESIGN .............................................................................................................. 4 
3.1.1 
Screening Phase ............................................................................................................................... 4 
3.1.2 
Study Enrollment Phase ................................................................................................................... 4 
3.1.3 
Follow-up Phase ............................................................................................................................... 4 
3.2 
STUDY DURATION, ENROLLMENT AND NUMBER OF SITES .................................................................................... 5 
3.2.1 
Duration of Study Participation ....................................................................................................... 5 
3.2.2 
Total Number of Study Sites/Total Number of Subjects Projected .................................................. 5 
3.3 
STUDY POPULATION ..................................................................................................................................... 5 
3.3.1 
Inclusion Criteria .............................................................................................................................. 5 
3.3.2 
Exclusion Criteria ............................................................................................................................. 5 
4 
STUDY PROCEDURES ............................................................................................................................... 5 
4.1 
SCREENING ................................................................................................................................................. 5 
4.2 
OBSERVATIONAL PERIOD ................................................................................................................................ 6 
4.2.1 
Visit 1 ............................................................................................................................................... 6 
4.2.2 
Visit 2 ............................................................................................................................................... 7 
4.2.3 
Visit 3……………………………………………………………………………………………………………………………………….…8 
4.3 
UNSCHEDULED VISITS ................................................................................................................................... 8 
4.4 
SUBJECT COMPLETION/WITHDRAWAL ............................................................................................................. 9 
5 
STUDY EVALUATIONS AND MEASUREMENTS .......................................................................................... 9 
5.1 
SCREENING AND MONITORING EVALUATIONS AND MEASUREMENTS ...................................................................... 9 
5.1.1 
Medical Record Review .................................................................................................................... 9 
5.1.2 
Laboratory Evaluations .................................................................................................................... 9 
5.1.3 
Study Assessments ........................................................................................................................... 9 
5.3 
SAFETY EVALUATION................................................................................................................................... 11 
6 
STATISTICAL CONSIDERATIONS ............................................................................................................. 11 
6.1 
STATISTICAL METHODS ................................................................................................................................ 11 
6.1.1 ANALYSIS OF PRIMARY AND SECONDARY AIMS .................................................................................................. 11 
6.2 
SAMPLE SIZE AND POWER ........................................................................................................................... 12 
7 
STUDY MEDICATION (STUDY DEVICE OR OTHER STUDY INTERVENTION) ............................................ 123 
7.1 
DESCRIPTION .......................................................................................................................................... 133 

 
  
 
 
iii
8 
SAFETY MANAGEMENT ......................................................................................................................... 13 
8.1 
CLINICAL ADVERSE EVENTS .......................................................................................................................... 13 
8.2 
ADVERSE EVENT REPORTING ........................................................................................................................ 13 
9 
STUDY ADMINISTRATION ...................................................................................................................... 13 
9.1 
DATA COLLECTION AND MANAGEMENT ......................................................................................................... 13 
9.2 
CONFIDENTIALITY ....................................................................................................................................... 14 
9.3 
REGULATORY AND ETHICAL CONSIDERATIONS .................................................................................................. 14 
9.3.1 
Data and Safety Monitoring Plan .................................................................................................. 14 
9.3.2 
Risk Assessment ............................................................................................................................. 15 
9.3.3 
Potential Benefits of Study Participation ....................................................................................... 15 
9.3.4 
Risk-Benefit Assessment ................................................................................................................ 16 
9.4 
RECRUITMENT STRATEGY ............................................................................................................................. 16 
9.5 
INFORMED CONSENT/ASSENT AND HIPAA AUTHORIZATION .............................................................................. 16 
9.5.1 
Waiver of Documentation of Consent/Assent and Alteration of HIPAA Authorization ................. 17 
9.6 
PAYMENT TO SUBJECTS/FAMILIES ................................................................................................................. 17 
10 
PUBLICATION ...................................................................................................................................... 18 
11 
REFERENCES ........................................................................................................................................ 19 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
  
 
 
iv
ABBREVIATIONS AND DEFINITIONS OF TERMS 
AE 
 
Adverse event 
BMI 
 
Body mass index 
BMIZ 
 
BMI Z score 
CF 
 
Cystic fibrosis 
CFTR 
 
Cystic fibrosis transmembrane conductance regulator 
CHPS 
 
Center for Human Phenomic Science 
CYP 
 
Cytochrome P450 
 
 
 
FFM 
 
Fat free mass 
FM 
 
Fat mass 
HAZ 
 
Height Z score 
LAZ 
 
Length Z score 
NDS  
 
Nutrition data system 
Orkambi 
 
Lumacaftor (VX-809) and Ivacaftor (VX-770) 
PHI  
 
Personal health information 
REE 
 
Resting energy expenditure 
SAE  
 
Serious adverse event 
SEE 
 
Sleeping energy expenditure 
ucOC% 
 
Undercarboxylated osteocalcin 
WAZ 
 
Weight Z score 

 
 
 
 
 
 
 
v
ABSTRACT 
Context: Orkambi is a novel FDA approved (August, 2018) therapy for use in patients with 
cystic fibrosis (CF) who are 2 to 5 years of age and homozygous for F508del mutations in 
the CFTR gene. It is a combination of lumacaftor and ivacaftor that addresses both the 
processing and gating defects of the F508del mutation. Our Investigator Initiated Study is 
designed to evaluate the nutritional, growth and GI impact of Orkambi treatment for this 
unique younger (2 to 5 years) patient cohort. This proposal extends our previous highly 
informative nutrition and weight gain investigation of ivacaftor treatment in people with CF 
gating mutations to another CFTR modulator treatment (Orkambi) in people homozygous 
for F508del mutations. 
Objectives: The primary aims of the study are to evaluate the impact of 24 weeks of 
Orkambi treatment in 2 to 5 year old subjects with CF homozygous for F508del mutations 
on sleeping or resting energy expenditure, growth status and gut health and function in 
n=32 children ages 2.0 to 5.9 years of age.  Protocol evaluations will occur at baseline (pre-
treatment) and 12 and 24 weeks after clinically prescribed Orkambi treatment has begun. 
Other outcomes of significant clinical interest in young subjects with CF will be explored. All 
subjects will be evaluated as outpatient at The Children's Hospital of Philadelphia, and will 
be recruited both regionally and nationally to ensure timely enrollment.  
Study Design: Observational prospective study with evaluations before and after 24 weeks 
of Orkambi treatment.  An interim assessment at 12 weeks will also be included. 
Setting/Participants: Thirty-two subjects ages 2 to 5 years of age with CF homozygous for 
F508del mutations who are in a general state of good health from CF centers in US and 
Canada.  
Study Interventions and Measures: Subjects will be evaluated before and after Orkambi 
treatment for sleeping or resting energy expenditure, weight and BMI, BMI Z score, gut 
health and function as indicated by plasma fatty acids, fecal elastase and fecal calprotectin.  
Dietary intake, growth status for stature (length/height), body composition, and serum fat 
soluble vitamins, bile acids and calprotectin will also be assessed.   
 

 
 
 
 
 
 
 
vi
PROTOCOL SYNOPSIS 
Study Title 
Nutritional Impact of Orkambi Treatment in 2 to 5 Year Old Children 
Homozygous for F508del Mutations  
Funder 
Vertex Pharmaceutical, Inc. and CHOP Center for Human 
Phenomic Science and Nutrition Center 
Study Rationale 
     Cystic fibrosis (CF) is a genetic disease caused by mutations in 
the gene encoding the CF transmembrane conductance regulator 
(CFTR), a chloride channel in many types of cells. Most CF 
mutations either reduce the number of CFTR channels at the cell 
surface (synthesis and processing mutations) or impair channel 
function (gating or conductance mutations). Orkambi is a novel 
approved therapy for use in people homozygous for the F508del 
mutation in the CFTR gene.  It is a combination of lumacaftor (VX-
809) and ivacaftor( VX-770)  that addresses both the processing 
and gating defects of the F508del mutation. The small-molecule 
corrector lumacaftor corrects the F508del processing defect and 
increases epithelial delivery of CFTR protein1. Ivacaftor is a CFTR 
potentiator that increases the channel open probability in F508del-
mutant CFTRs that undergo epithelial delivery in vitro and has an 
additive effect with lumacaftor on chloride transport2-4.  In a 
randomized, doubled-blind, placebo-controlled trial of 1108 subjects 
homozygous for F508del CFTR mutation (12 years of age and 
older), Wainwright et al5 demonstrated that 24 weeks of Orkambi 
treatment was safe and significantly improved pulmonary function, 
with both increase in FEV1 % predicted and a reduction in 
pulmonary exacerbations, and also BMI. In an open label phase 3 
study of 58 children ages 6-11 homozygous for F508del CFTR 
mutation, Milla et al4 demonstrated significant improvements over 
24 weeks in sweat chloride, BMI Z score, Cystic Fibrosis 
Questionnaire Revised Respiratory Domain Score, and lung 
clearance index6,7. In an open-label trial of 57 children ages 2-5 
years old, significant improvement in sweat chloride and BMI Z 
score of 0.29 (95% CI 0.14, 0.45) was found after 24 weeks of 
Orkambi treatment8. 
    Ivacaftor (Kalydeco®, Vertex Pharmaceuticals Inc.) was the first 
of a new class of drugs that improved CFTR gating dysfunction3,9,10. 
In randomized, double-blind, placebo controlled trials, ivacaftor 
treatment in individuals (ages 6 to adulthood) with at least one 
G551D mutation resulted in clinically significant improvements in 
weight and body mass index (BMI), pulmonary function, and patient 
reported quality of life outcomes (QOL)10,11.  Lung function and 
weight changes occurred over eight weeks, then plateaued and 
were sustained over 48 weeks.  Ivacaftor has shown similar benefit 
in younger children and has been approved for use in 2 to 5 year 
old children.  Ivacaftor was found to be safe and effective in 33 
children in the KIWI study completed 24 weeks of treatment in the 
KIWI study, with significant reductions in sweat chloride 

 
 
 
 
 
 
 
vii
concentration, and an average increase in weight Z score of 
0.2±0.3 and BMI z score of 0.4±0.412.  Some exocrine pancreatic 
function restoration was demonstrated in these young children, as 
Davies et al.12 noted an increase in fecal elastase concentrations in 
a small sample of children after 24 weeks ivacaftor treatment.  Prior 
to treatment, 93% were PI with fecal elastase concentrations of <50 
µg/g, and after treatment this increased 100 µg/g on average.  
Furthermore, in the KLIMB study, a long-term follow-up to the KIWI 
study, the increased fecal elastase concentrations were sustained 
with mean increase of 129 µg/g after 84 weeks of treatment13.  
These results suggest that exocrine pancreatic function early in life 
may be partially restored with ivacaftor12,14.  
     In our recent longitudinal observational study of 23 subjects 
(ages 5 to 61 years), we identified several mechanisms for weight 
gain with 3-month ivacaftor treatment including decreased resting 
energy expenditure (REE), gut inflammation and dietary fat 
malabsorption, resulting in a positive energy balance and weight 
gain. Weight gain in this study was 2.5 kg and associated with a 
significant decrease in REE percent predicted of 5.5%, and in fecal 
calprotectin of 30 ug/g stool, a measure of gut inflammation15-17. 
   A phase 3 study of the safety and efficacy of two different dose 
levels of Orkambi in children ages 2 to 5 years homozygous for 
F508del CFTR mutations has recently been completed, and FDA 
approval for this age group obtained in August, 2018. The 
improvements in growth status for BMI and BMI Z score in the 
youngest children was significant with 24 weeks of Orkambi 
treatment8. Changes in energy expenditure with Orkambi treatment 
in these young children has also not yet been explored. This 
current application will directly address gaps in knowledge related 
to the important non-pulmonary outcomes that are clinically very 
important in very youngest children. Whether Orkambi treatment 
will improve sleeping or resting energy expenditure (SEE/REE), 
growth status and gut health and function related to improved fat 
absorption in young children is not known. 
   Several outcomes related to improved energy balance are 
considered in this proposal. We will focus on the importance of 
determining the effect of treatment on clinically important non-
pulmonary outcomes. Our primary aim in this study of young 2.0 to 
5.9 year old children is to determine if 24-week Orkambi treatment 
results in decreased SEE/REE and improved growth status as 
indicated by weight, BMI and BMI Z score. Our secondary aim is to 
determine improvement in gut health related to fat digestion, 
including increased total plasma fatty acids and decreased fecal 
calprotectin (gut inflammation).  Exploratory aim includes 
investigating the impact of Orkambi treatment on dietary intake, 
height status, on serum fat soluble vitamins, bile acids and 
calprotectin, and on fecal elastase.   
 

 
 
 
 
 
 
 
viii
Study Objective(s) 
     We propose a longitudinal study design to determine whether 24 
weeks of treatment with Orkambi results in improvement in SEE or 
REE depending on age of the subject, weight and BMI, BMI Z 
score, and gut health related to fat digestion in 32 children ages 2.0 
to 5.9 years homozygous for F508del CFTR mutation. We 
anticipate that these changes will accompany meaningful 
improvements in dietary intake, growth status, body composition, 
serum fat soluble vitamins, bile acids and calprotectin, and fecal 
elastase in these young children.       
PRIMARY AIMS 
H1:  Orkambi treatment will result in a significant reduction in 
SEE/REE as percent predicted over 24 weeks compared to 
baseline, thereby increasing the energy available for weight gain 
and physical activity. 
H2:  Orkambi treatment will result in significantly increased weight 
and BMI Z score over 24 weeks compared to baseline. 
SECONDARY AIMS 
H3:  Orkambi treatment will result in significantly improved gut 
health and function resulting in better dietary fat absorption as 
indicated by increased total plasma fatty acids and decreased fecal 
calprotectin over 24 weeks compared to baseline. 
EXPLORATORY AIMS 
To determine the impact of Orkambi treatment over 24 weeks 
compared to baseline in: 
 
Dietary intake of calories and percent calories from fat 
 
Growth status for stature (length/height), and measures of 
body composition (fat free mass [FFM] and fat mass [FM] 
from skin fold measures) 
 
Serum fat soluble vitamins A, D, E and K, bile acids and 
calprotectin, and fecal elastase 
Study Design 
 
We propose a longitudinal study design to determine whether 24 
weeks of clinically prescribed treatment with Orkambi results in 
improvement in SEE or REE, depending on if the subject typically 
takes daily naps or not. growth status as BMI Z score, and gut 
health related to fat digestion in 32 children ages 2.0 to 5.9 years 
homozygous for F508del mutation. There will be a mid-treatment 
evaluation after 12 weeks of Orkambi treatment to explore the pace 
of the change in the primary and secondary outcomes. 
Inclusion and 
Exclusion: 
Inclusion Criteria 
 
Cystic fibrosis and homozygous for F508del mutations,  
approved for treatment 
 
Age: 2.0 to 5.9 years   
 
In usual state of good health  
 
A clinical decision has been made for subject to begin 
Orkambi treatment 

 
 
 
 
 
 
 
ix
 
Family committed to the 6 to 8 month study protocol with visits 
to CHOP that will last 1-2 days for the baseline visit (Visit 1) 
prior to Orkambi and the 24 week visit (Visit 3) after clinically 
prescribed Orkambi treatment has begun, and will last 1 day 
for the 12 week visit (Visit 2) after Orkambi treatment has 
begun. 
Exclusion Criteria 
 
On parenteral nutrition 
 
Use of any inhibitors or inducers of cytochrome P450 (CYP) 
3A 
 
Liver function tests elevated above 3x the reference range for 
age and sex 
 
Lung disease considered severe by home CF Center based on 
clinical impression 
 
Other illness affecting growth or nutritional status 
 
Other contraindications described for Orkambi therapy 
Number Of Subjects  
32 
Study Duration 
Each subject’s participation will last approximately 6 to 8 months 
The entire study is expected to last 24 months 
Study Phases  
Screening: screening for eligibility and obtaining consent  
Baseline: baseline study visit at CHOP 
Follow up: 12 week visit at CHOP after confirmation of timing of the 
start of clinically prescribed Orkambi treatment (±2 week window) 
Follow up: 24 week visit at CHOP after confirmation of timing of the 
start of clinically prescribed Orkambi treatment (±2 week window) 
Safety Evaluations 
As part of safety assessment, a serum comprehensive metabolic 
panel including the ALT and AST liver enzymes, and complete 
blood count will be assessed (CHOP Clinical Laboratory). 
Dosing will likely be interrupted by the CF clinical care team in 
subjects with ALT or AST of greater than 5 times the upper limit of 
normal (ULN).  
Subjects will be asked about all adverse events at the 12 and 24 
week protocol visits and during the monthly phone calls, and rated 
by intensity (mild, moderate, severe). Serious adverse events will 
be reported as per various policies in a timely manner to CHOP IRB 
and CHPS. 
Statistical And 
Analytic Plan 
Analysis will begin with descriptive analyses of the study sample 
using means, standard deviations, medians, and ranges for 
continuous variables, and frequency distributions for categorical 
variables. Descriptive statistics and exploratory graphing such as 
frequencies, means, standard deviations, box plots, and scatter 
plots will be used to assess the normality of the data in terms of the 
presence of skew and/or outliers. Primary Aims: The goals of the 
primary aims of this study are to determine whether Orkambi 
treatment improves SEE/REE, weight and BMI Z score. Secondary 
Aims:  The goal of the secondary aim is to determine whether 

 
 
 
 
 
 
 
x
Orkambi improves gut health and function as measured by total 
plasma fatty acids and fecal calprotectin. Analysis of efficacy for the 
primary and secondary outcomes will be based on change from 
baseline (before treatment) in SEE/REE% predicted (Schofield), 
weight and BMI Z scores, total plasma fatty acids, and fecal 
calprotectin. The differences between baseline and 24 weeks 
continuous outcomes will initially be compared using paired-t-tests 
if continuous variables are normally distributed and nonparametric 
tests (Wilcoxon sign rank) if they are not. Subsequently, mixed 
effects longitudinal models will be performed to assess change over 
all three time points (baseline, 12 and 24 weeks), adjusting for 
potential covariates such as age, sex, and adherence to treatment. 
Chi-squared tests will be used for comparison of categorical 
variables before and after Orkambi treatment. Using similar 
methods, exploratory analyses will examine improvement in dietary 
intake of calories and fat, in growth status (length/height-for-age), 
serum fat soluble vitamins, bile acids, and calprotectin, and fecal 
elastase.   
DATA AND SAFETY 
MONITORING PLAN 
Safety will be formerly monitored weekly by the study team. The 
study protocol will be carried out in accordance with OHRP 
guidelines and requirements. SAEs that are unanticipated, serious, 
and possibly related to the study intervention will be reported to the 
study sponsor, IRB, CHPS, and members of the research and 
clinical teams in accordance with requirements. Anticipated SAEs 
or those unrelated to the study intervention will be reported to the 
same individuals/entities in accordance with requirements. There 
will be ongoing collection of data on adverse events and 
compliance to the treatment protocol throughout the study by 
research staff and which will be summarized and reviewed monthly 
by the study Principal Investigator and the Study Team.  Out of 
range laboratory values will be reviewed continually by the PI and 
the study team. 

 
  
 
 
xi
 
 
SCHEDULE OF STUDY PROCEDURES & STUDY TIMELINE 
 
 
 
 
 
 
 
 
Study Timeline (n=32)
 
Visit
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Total
Start-up
X
X
X
X
Visit 1: Pre-treatment
 
 
 
3
3
3
3
3
3
3
3
3
3
2
32
Visit 2: 12 wk Post-treatment
 
 
 
 
3
3
3
3
3
3
3
3
3
3
2
32
Visit 3: 24 wk Post-treatment
 
       
3
3
3
3
3
3
3
3
3
3
2
32
 
  
Visit Total
 
 
 
3
3
3
6
6
6
9
9
9
9
8
6
6
5
3
3
2
 
96
Sample and Data Analysis
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Year 2  (2019-2020)
Year 1  (2018-19)

 
  
 
  
1
 
1 BACKGROUND INFORMATION AND RATIONALE 
1.1 Introduction 
     Cystic fibrosis (CF) is a genetic disease caused by mutations in the gene encoding the 
CF transmembrane conductance regulator (CFTR), a chloride channel in many types of 
cells. Most CF mutations either reduce the number of CFTR channels at the cell surface 
(synthesis and processing mutations) or impair channel function (gating or conductance 
mutations). Orkambi is a novel approved therapy for use in people homozygous for the 
F508del mutation in the CFTR gene.  It is a combination of lumacaftor (VX-809) and 
ivacaftor( VX-770)  that addresses both the processing and gating defects of the F508del 
mutation. The small-molecule corrector lumacaftor corrects the F508del processing defect 
and increases epithelial delivery of CFTR protein1. Ivacaftor is a CFTR potentiator that 
increases the channel open probability in F508del-mutant CFTRs that undergo epithelial 
delivery in vitro and has an additive effect with lumacaftor on chloride transport2-4.  In a 
randomized, doubled-blind, placebo-controlled trial of 1108 subjects homozygous for 
F508del CFTR mutation (12 years of age and older), Wainwright et al5 demonstrated that 
24 weeks of Orkambi treatment was safe and significantly improved pulmonary function, 
with both increase in FEV1 % predicted and a reduction in pulmonary exacerbations, and 
also BMI. In an open label phase 3 study of 58 children ages 6-11 homozygous for F508del 
CFTR mutation, Milla et al4 demonstrated significant improvements over 24 weeks in sweat 
chloride, BMI Z score, Cystic Fibrosis Questionnaire Revised Respiratory Domain Score, 
and lung clearance index6,7. In an open-label trial of 57 children ages 2-5 years old, 
significant improvement in sweat chloride and BMI Z score of 0.29 (95% CI 0.14, 0.45) was 
found after 24 weeks of Orkambi treatment8. 
    Ivacaftor (Kalydeco®, Vertex Pharmaceuticals Inc.) was the first of a new class of drugs 
that improved CFTR gating dysfunction3,9,10. In randomized, double-blind, placebo 
controlled trials, ivacaftor treatment in individuals (ages 6 to adulthood) with at least one 
G551D mutation resulted in clinically significant improvements in weight and body mass 
index (BMI), pulmonary function, and patient reported quality of life outcomes (QOL)10,11.  
Lung function and weight changes occurred over eight weeks, then plateaued and were 
sustained over 48 weeks.  Ivacaftor has shown similar benefit in younger children and has 
been approved for use in 2 to 5 year old children.  Ivacaftor was found to be safe and 
effective in 33 children in the KIWI study completed 24 weeks of treatment in the KIWI 
study, with significant reductions in sweat chloride concentration, and an average increase 
in weight Z score of 0.2±0.3 and BMI z score of 0.4±0.412.  Some exocrine pancreatic 
function restoration was demonstrated in these young children, as Davies et al.12 noted an 
increase in fecal elastase concentrations in a small sample of children after 24 weeks 
ivacaftor treatment.  Prior to treatment, 93% were PI with fecal elastase concentrations of 
<50 µg/g, and after treatment this increased 100 µg/g on average.  Furthermore, in the 
KLIMB study, a long-term follow-up to the KIWI study, the increased fecal elastase 
concentrations were sustained with mean increase of 129 µg/g after 84 weeks of 
treatment13.  These results suggest that exocrine pancreatic function early in life may be 
partially restored with ivacaftor12,14.  
      In our recent longitudinal observational study of 23 subjects (ages 5 to 61 years), we 
identified several mechanisms for weight gain with 3-month ivacaftor treatment including 
decreased resting energy expenditure (REE), gut inflammation and dietary fat 
malabsorption, resulting in a positive energy balance and weight gain. Weight gain in this 

 
  
 
  
2
study was 2.5 kg and was associated with a significant decrease in REE percent predicted 
of 5.5%, and in fecal calprotectin of 30 ug/g stool, a measure of gut inflammation15-17.      
      A phase 3 study of the safety and efficacy of two different dose levels of Orkambi in 
children ages 2 to 5 years homozygous for F508del CFTR mutations has recently been 
completed, and FDA approval for this age group obtained in August, 2018. The 
improvements in growth status for BMI and BMI Z score in the youngest children was 
significant with 24 weeks of Orkambi treatment. Changes in energy expenditure with 
Orkambi treatment in these young children has also not yet been explored. This current 
application will directly address gaps in knowledge related to the important non-pulmonary 
outcomes that are clinically very important in very youngest children. Whether Orkambi 
treatment will improve SEE or REE, growth status and gut health and function related to 
improved fat absorption in young children is not known. 
   Several outcomes related to improved energy balance are considered in this proposal. 
We will focus on the importance of determining the effect of treatment on clinically important 
non-pulmonary outcomes. Our primary aim in this study of young 2.0 to 5.9 year old 
children is to determine if 24-week Orkambi treatment results in decreased SEE/REE and 
improved growth status as indicated by by weight, BMI and BMI Z score. Our secondary 
aim is to determine improvement in gut health related to fat digestion, including increased 
total plasma fatty acids and decreased fecal calprotectin (gut inflammation).  Exploratory 
aim includes investigating the impact of Orkambi treatment on dietary intake, length/height 
status, on serum fat soluble vitamins, bile acids and calprotectin, and on fecal elastase.   
     In addition to reduced dietary fat absorption, altered fatty acid metabolism has been 
shown in CF and PI18,19, and may be linked to CFTR dysfunction, and little is known of 
changes with CFTR modulator treatment. In the GOAL study, change in serum fatty acid 
concentrations with ivacaftor treatment were explored. Serum arachidonic acid levels 
decreased while linoleic and docosahexenoic acid levels did not change in 40 subjects with 
G551D CFTR mutation20. We previously demonstrated a significant increase in total plasma 
fatty acids from 8.5±1.6 to 10.2±3.6 mmol/L (P<0.01) with 3-month treatment of a structured 
lipid-based nutritional supplement: linoleic, lauric, palmitoleic, oleic and docosatetraenoic 
acids all significantly increased as well18. We propose to assess a plasma fatty acid panel 
that includes concentrations for 22 individual fatty acids as well as total fatty acids, as an 
indicator of change in fat absorption.  
     Serum calprotectin is a marker for whole body inflammation including lung and gut 
inflammation in CF, and other chronic inflammatory diseases21-23, and will be assessed 
along with fecal calprotectin. Improvements in growth status will likely result from a 
reduction in SEE/REE in these children which may be associated with Orkambi treatment. 
Furthermore, comparisons of metabolic profiles in children with CF and their healthy 
counterparts, showed that the children with CF had profiles indicating bile acid processing 
abnormalities24.  Whether Orkambi treatment results in improved plasma fatty acid profiles, 
gut and systemic inflammation (fecal and serum calprotectin), bile acids and fat soluble 
vitamin status as markers of improved fat absorption in young children homozygous for 
F508del CFTR mutations is not known and represent novel and clinically meaningful 
outcomes in young children with CF. 
We propose a longitudinal study design to determine whether 24 weeks of clinically 
prescribed treatment with Orkambi results in improvement in SEE or REE, depending on 
age of the subject, growth status as BMI Z score, and gut health related to fat digestion in 
32 children ages 2.0 to 5.9 years homozygous for F508del mutation. There will be a mid-
treatment evaluation after 12 weeks of Orkambi treatment to explore the pace of the 
change in the primary and secondary outcomes. To plan the study, we assume that 1/3 of 

 
  
 
  
3
subjects will be recruited locally within a 150 mile radius of Philadelphia and the remaining 
2/3 from other CF Centers in North America and will travel to Children’s Hospital of 
Philadelphia (CHOP) for three protocol visits, each visit lasting 2 or 3 days, conducted at 
our Center for Human Phenomic Science (CHPS) and Nutrition and Growth Laboratory. 
The primary aims of this study are to determine whether 24 weeks of clinically prescribed 
Orkambi treatment reduces SEE/REE and increases BMI Z score. Secondary aims are to 
determine if Orkambi treatment improves gut health and function resulting in better fat 
absorption as indicated by increased total plasma fatty acids and decreased fecal 
calprotectin over 24 weeks compared to baseline. Exploratory aims are to examine the 
impact on dietary intake, growth status for stature (length/height) and measures of body 
composition, serum fat soluble vitamins, bile acids, and calprotectin as a measure of 
systemic inflammation, and on fecal elastase.   
 
1.2 Compliance Statement 
This study will be conducted in full accordance all applicable Children’s Hospital of 
Philadelphia Research Policies and Procedures and all applicable Federal and state laws 
and regulations including 45 CFR 46.  All episodes of noncompliance will be documented. 
The investigators will perform the study in accordance with this protocol, will obtain consent 
and will report unanticipated problems involving risks to subjects or others in accordance 
with The Children’s Hospital of Philadelphia IRB Policies and Procedures and all federal 
requirements. Collection, recording, and reporting of data will be accurate and will ensure 
the privacy, health, and welfare of research subjects during and after the study. 
2 
STUDY OBJECTIVES 
We propose a longitudinal study design to determine whether 24 weeks of treatment with 
Orkambi results in improvement in SEE or REE depending on if the subject typically takes 
daily naps, weight and BMI, BMI Z score, and gut health related to fat digestion in 32 
children ages 2.0 to 5.9 years homozygous for F508del CFTR mutation. We anticipate that 
these changes will accompany meaningful improvements in dietary intake, growth status, 
body composition, serum fat soluble vitamins, bile acids and calprotectin, and fecal elastase 
in these young children.       
2.1 
Primary Aims 
H1:  Orkambi treatment will result in a significant reduction in SEE/REE as percent 
predicted over 24 weeks compared to baseline, thereby increasing the energy available for 
weight gain and physical activity. 
H2:  Orkambi treatment will result in significantly increased weight and BMI Z score over 24 
weeks compared to baseline. 
2.2 
Secondary Aims 
H3:  Orkambi treatment will result in significantly improved gut health and function resulting 
in better dietary fat absorption as indicated by increased total plasma fatty acids and 
decreased fecal calprotectin over 24 weeks compared to baseline. 
 

 
  
 
  
4
2.3 Exploratory Aims 
To determine the impact of Orkambi treatment over 24 weeks compared to baseline in: 
 
Dietary intake of calories and percent calories from fat 
 
Growth status for stature (length/height), and measures of body composition (fat 
free mass [FFM] and fat mass [FM] from skin fold measures) 
 
Serum fat soluble vitamins A, D, E and K, bile acids and calprotectin, and fecal 
elastase 
3 
INVESTIGATIONAL PLAN 
3.1 General Schema of Study Design 
3.1.1 Screening Phase 
Subjects (n=32) will be recruited to participate in the study from a pool of subjects 
homozygous for F508del mutations.  Given our previous success in enrolling subjects with 
CF from both CHOP and regional CF Centers and more distant Centers who traveled 
considerable distances to participate in our research protocols, we expect that enrollment 
will be achieved in a timely fashion. The plan to initiate treatment and the clinical eligibility 
for treatment is determined by the subject’s family and the CF care team. 
Potential subjects will be screened using the protocol inclusion and exclusion criteria.  The 
CF Centers around the country and Canada will provide the study with resources that will 
aide in recruitment efforts (i.e. to help to identify subjects 2 to 5 years of age homozygous 
for F508del mutations and eligible to receive Orkambi treatment). The subject’s CF care 
team will be contacted to confirm eligibility for the study and this will include obtaining 
medical information from the team and subject’s medical record. To collect medical data for 
screening purposes, a verbal or in person consent from parents/guardians will be obtained. 
Parental/guardian permission (informed consent) will be obtained prior to any study related 
procedures being performed.  
3.1.2 Study Enrollment Phase  
Eligible subjects will be enrolled into the study and come to CHOP for the study visits. Refer 
to Table 1 for list of assessments and the study timeline for the pace of recruitment.  
3.1.3 Follow-up Phase 
Their initial baseline visit (Visit 1) will occur before clinically prescribed Orkambi treatment 
has begun. The exact date of the start of medication will vary for families as they obtain 
their medication. Subjects will return to CHOP for the 12 week visit (Visit 2) and the 24 
week visit (Visit 3 and final) after subject/family has confirmed the timing of the start of 
Orkambi treatment. There may be a delay between the baseline visit and the 12 week visit 
based upon when treatment begins. For most families, the total duration of the study will be 
from 6 to 8 months. The duration of the study from start of Orkambi treatment until last 
study visit will be 24 weeks.  For each of the 12 and 24 week visits following the start of 
Orkambi treatment, there will be a window of ±2 weeks for the visit to occur (i.e. 12 week 
visit may occur between 10 and 14 weeks, and 24 week visit between 22 and 26 weeks 
post Orkambi treatment).  
Refer to Table 1 for list of assessments and the study timeline for the visit schedule.  

 
  
 
  
5
3.2 Study Duration, Enrollment and Number of Sites 
3.2.1 Duration of Study Participation 
The study duration for subject participation from enrollment to the last study visit will range 
from 6 to 8 months. The baseline visit will occur prior to the start of Orkambi treatment. 
From the start of the clinically prescribed Orkambi treatment to the last study visit will be 24 
weeks with a window of ±2 weeks. 
3.2.2 Total Number of Study Sites/Total Number of Subjects Projected 
The study will be conducted at one investigative site in the United States. 
Recruitment will stop when 32 subjects are enrolled. It is expected that 32 subjects will be 
enrolled to produce 26 evaluable subjects.  
3.3 Study Population 
3.3.1 Inclusion Criteria 
 
Cystic fibrosis and homozygous for F508del mutations, approved for treatment 
 
Age: 2.0 to 5.9 years  
 
In usual state of good health  
 
A clinical decision has been made for subject to begin Orkambi treatment 
 
Family committed to the 6 to 8 month study protocol with visits to CHOP that will 
last 2-3 days for the baseline visit (Visit 1) prior to Orkambi and the 24 week visit 
(Visit 3) after clinically prescribed Orkambi treatment has begun, and will last up to 
2 days for the 12 week visit (Visit 2) after Orkambi treatment has begun. 
3.3.2 Exclusion Criteria 
 
On parenteral nutrition 
 
Use of any inhibitor or inducer medications of cytochrome P450 (CYP) 3A 
 
Liver function tests elevated above 3x the reference range for age and sex 
 
Lung disease considered severe by home CF Center based on clinical impression 
 
Other illness affecting growth or nutritional status 
 
Other contraindications described for Orkambi therapy 
4 STUDY PROCEDURES 
4.1 Screening  
Subjects will be screened using the protocol inclusion and exclusion criteria.  Written (in 
person) or verbal (via phone) parental/guardian permission will be obtained prior to 
scheduling any study screening related procedures. Informed written consent will be 
obtained at the baseline visit prior to conducting any research procedures.  
All subjects will be enrolled in their usual state of good health defined as no 
hospitalizations, emergency room or unscheduled acute illness clinic visits, and with activity 
levels and food intake considered typical by the subject and their care provider for two or 
four weeks prior to the baseline visit.    

 
  
 
  
6
4.2 Observational Period  
Many of the protocol assessments could occur on any of the visit days (i.e. questionnaires, 
spot stool sample). Below is the best estimate of how each day will proceed.The baseline 
(Visit 1) and the 24 week (Visit 3) visit after Orkambi treatment has begun are nearly 
identical with the exception of obtaining informed consent which will occur at Visit 1 Day 1 
prior to any assessments being done or specimens being collected.  For the 12 week (Visit 
2) and 24 week (Visit 3) visits that will occur after confirmation of the timing of the start of 
clinically prescribed Orkambi treatment, there will be a ±2 week window for the visit. (i.e. 12 
week visit may occur between 10 and 14 weeks, and 24 week visit between 22 and 26 
weeks post Orkambi treatment).  
The description provided here applies to subjects who are not local to CHOP and who will 
be traveling to Philadelphia from other regions of the US and Canada and staying at a local 
hotel for one or two nights depending on the time of their scheduled research procedures. 
For non-regional families, Day 1 of each Visit is the day of arrival to CHOP and first night of 
their hotel stay.  
If the subject is local to CHOP, we will still require a Day 1 visit for in-person written consent 
for Visit 1, however, for Visits 2 and 3, Days 1 and 2 can be combined to complete study 
protocol procedures, and they will come in to CHOP from home for the major study protocol 
days: Day 2 for Visit 2 and Day 2 and again on Day 3 (if needed) for Visit 3.   
 
4.2.1 Baseline visit (Visit 1)
 
Day 1 
 
 
Informed Consent/Assent will be completed in at CHOP Main CHPS  
 
Instructions in preparation for study procedures will be given 
 
Spot stool sample will be collected for fecal elastase I and fecal calprotectin 
(collected anytime) 
 
Questionnaires may occur on this day (see Day 2 for details) 
 
Day 2 
 
 
Sleeping energy expenditure usually for children who typically take daily 
naps, during their morning nap (or afternoon nap if necessary). Time and 
amount of food intake will be recoded prior to the procedure. 
 
Resting energy expenditure usually for children who do not typically take 
daily naps in early morning (7:00 to 10:00 am), preceded by minimal physical 
activity. Time and amount of food and beverage intake will be recorded prior 
to this procedure.  
 
Blood draw for CBC, CMP, pre-albumin, bile acids, fatty acids, serum 
calprotectin, vitamin A (retinol), vitamin D (25(OH)D), vitamin E (a-
tocopherol) and  vitamin K (ucOC) 
 
Spot stool sample for fecal elastase and fecal calprotectin (if not collected on 
Day 1) 
 
Questionnaires: Health History 

 
  
 
  
7
 
Anthropometry: Stature (length/height), weight, head circumference, 
skinfolds, circumferences   
 
 
 
Day 3 (if needed and expected for half of subjects)  
 
 
Sleeping energy expenditure or resting energy expenditure– if it was not 
performed on Day 2 
 
Post Visit Follow Up 
 
 
3-day weighed food records  
 
Begin clinically prescribed Orkambi treatment after food records have been 
completed, and document the date that Orkambi treatment was started 
 
 
In Between Visits 1 & 2 
 
 
Maintain adverse events calendar 
 
 
4.2.2 12 week visit (Visit 2) after Orkambi treatment has begun
 
Day 1 
 
 
Instructions in preparation for study procedures will be given 
 
Spot stool sample will be collected for fecal calprotectin (collected anytime) 
 
Questionnaires may occur on this day 
 
Day 2 
 
 
Sleeping energy expenditure usually for children who typically take daily 
naps, during their morning nap (or afternoon nap if necessary).  Time and 
amount of food and beverage intake will be recorded prior to this procedure. 
 
 
Resting energy expenditure usually for children who do not typically take 
daily naps in early morning (7:00 to 10:00 am), preceded by minimal physical 
activity. Time and amount of food and beverage intake will be recorded prior 
to this procedure. 
 
   
 
Anthropometry: Stature (length/height), weight, head circumference, 
skinfolds, circumferences   
 
Blood draw for fatty acids and serum calprotectin 
 
Spot stool sample for fecal calprotectin (if not collected on Day 1) 

 
  
 
  
8
 
Questionnaires regarding interval health history, Adherence to Orkambi, 
enzymes, medications, and Adverse events  
 
Post Visit Follow Up 
 
 
3-day weighed food records  
 
Maintain adverse events calendar 
 
In Between Visits 2 & 3 
 
 
Maintain adverse events calendar  
. 
  
4.2.3 24 week visit (Visit 3) after Orkambi treatment has begun
 
Day 1 
 
 
Instructions in preparation for study procedures will be given 
 
Spot stool sample will be collected for fecal elastase I and fecal calprotectin 
(collected anytime) 
 
Questionnaires may occur on this day 
 
Day 2 
 
 
Sleeping energy expenditure usually for children who typically take daily 
naps, during their morning nap (or afternoon nap if necessary). Time and 
amount of food and beverage intake will be recorded prior to this procedure. 
 
Resting energy expenditure usually for children who do not typically take 
daily naps  in early morning (7:00 to 10:00 am), preceded by minimal 
physical activity. Time and amount of food and beverage intake will be 
recorded prior to this procedure. 
 
Blood draw for CBC, CMP, pre-albumin, bile acids, fatty acids, serum 
calprotectin, vitamin A (retinol), vitamin D (25(OH)D), vitamin E (a-
tocopherol) and  vitamin K (ucOC) 
 
Spot stool sample for fecal elastase and fecal calprotectin (if not collected on 
Day 1) 
 
Questionnaires about interval health history, Adherence to Orkambi, 
enzymes, medications, and Adverse events  
 
Anthropometry: Stature (length/height), weight, head circumference, 
skinfolds, circumferences   
 
 
 
Day 3 (if needed and expected for half of subjects)  

 
  
 
  
9
 
 
Sleeping energy expenditure or Resting energy expenditure – if it was not 
performed on Day 2 
 
Post Visit Follow Up 
 
 
3-day weighed food records  
 
Maintain adverse events calendar until 3-day food records are completed 
 
4.3 Unscheduled Visits 
Due to the complexity of the study, no unscheduled visits will be permitted. 
4.4 Subject Completion/Withdrawal 
Subjects may withdraw from the study at any time without prejudice to their care.  They may 
also be discontinued from the study at the discretion of the Investigator for lack of 
adherence to study treatment or visit schedules, or AEs. The Investigator or the Sponsor 
may also withdraw subjects who violate the study plan, or to protect the subject for reasons 
of safety or for administrative reasons.  It will be documented whether or not each subject 
completes the clinical study. If the Investigator becomes aware of any serious, related 
adverse events after the subject completes or withdraws from the study, they will be 
recorded in the source documents and on the CRF.  
5 STUDY EVALUATIONS AND MEASUREMENTS 
5.1.1 Medical Record Review 
Variables that may be abstracted from the medical chart (paper or electronic): 
 
Date of birth 
 
Sex 
 
CF genotype 
 
Medications 
 
History of liver disease, CF related diabetes, GI disease or abdominal surgery  
5.1.2 Laboratory Evaluations 
Plasma Total Fatty Acids: A total plasma fatty acid panel will be assessed (ARUP 
Laboratories) to measure change in status of 22 fatty acids. 
Serum Fat Soluble Vitamins: Serum vitamin A and vitamin E assessed at Craft 
Technologies Laboratories. Serum vitamin D determined using Liquid Chromatography-
Tandem Mass Spectrometry (CHOP).  As a measure of vitamin K status, % 
undercarboxylated osteocalcin (Gundberg Lab, Yale University) will be assessed.  
Serum prealbumin: A serum pre-albumin will be assessed (CHOP clinical Laboratory) 
Serum Bile Acids: Total serum bile acids and 14 bile acid concentrations will be assessed 
by liquid chromatography tandem mass spectrometry (ARUP Laboratories) 
Serum Calprotectin: Serum calprotectin will be obtained as a marker of lung and gut 
inflammation21,22 using a Buhlmann MRP8/14 ELISA kit (Alpco, Salem, NH)).  

 
  
 
  
10
Safety Assessment: As part of safety assessment, a comprehensive metabolic panel 
including the ALT and AST liver enzymes, and complete blood count will be assessed 
(CHOP Clinical Laboratory). 
5.1.3 Study Assessments 
Sleeping or Resting Energy Expenditure: The primary outcome for the assessment of 
energy expenditure is sleeping or resting energy expenditure (SEE or REE). Using indirect 
calorimetry, SEE or REE and respiratory quotient will be assessed using a computerized 
metabolic cart Vmax ENCORE at each protocol visit while the child is asleep (SEE) for  
children who typically take daily naps. SEE will be assessed in the morning if possible 
whether SEE or REE and the time of the day of the testing will be replicated at all study 
visits. For children who do not typically take daily naps,  REE will be assessed in the early 
morning after an overnight stay nearby. Subjects will fast from food and medication for 8 
hours prior and have minimal physical activity before the test is performed between 7:00 
and 10:00 AM.  SEE/REE is compared to predicted values derived from the World Health 
Organization that adjust for age, sex and weight25 and Schofield equations that adjust for 
age, sex, weight and stature (length/height)26.  SEE/REE as kcal/d will also be assessed by 
adjusting for both fat free mass (FFM) and fat mass (FM) obtained from skinfold 
measurements (see below). 
Anthropometric Assessment: The outcomes for weight gain, growth and nutritional status 
will be stature (length/height), weight, BMI, and head circumference Z scores. Measures of 
body composition will also be conducted to determine relative muscle and fat stores. All 
anthropometric techniques will follow those described by Lohman et al27. Weight (0.1 kg) 
will be measured on a digital electronic scale (Seca, Munich, Germany), height (0.1 cm) on 
a stadiometer (Holtain, Crymych, UK), length (0.1 cm) on an infantometer, (Holtain, 
Crymych, UK), and head circumference (0.1 cm) using an insertion tape. Skinfold thickness 
will be measured (0.1 mm) at the triceps, biceps, subscapular, and supra-iliac sites with a 
skinfold caliper (Holtain, Crymych, UK) to assess subcutaneous fat stores. Mid upper arm 
circumference measured with a non-stretchable fiberglass tape (0.1 cm) (McCoy, Maryland 
Heights, MO). All measurements will be used to generate age-sex-specific Z scores for 
height, weight, BMI, head circumference, arm circumference, triceps and subscapular 
skinfolds using WHO reference data28,29.  CDC reference data will also be used to generate 
age- sex-specific Z scores for length, height, weight and BMI (2.0-5.9 yrs)30. 
Body Composition: Total body composition, total FFM and FM and percent body fat (%FAT) 
and regional fat deposition, will be assessed byskinfold measurements.   .   
Fecal Elastase I:  Pancreatic function will be assessed by obtaining spot stool samples with 
fecal elastase 1 to determine the level of pancreatic enzyme activity31,32. Subjects will be 
provided with the stool collection kit and proper instructions and supplies, and will bring a 
stool sample back the next day. The stool sample will be stored at -20oC, and analyzed with 
an enzyme-linked immunosorbent assay kit sent to ARUP Laboratory (Salt Lake City, UT). 
Fecal Calprotectin: Spot stool samples will be obtained to determine fecal calprotectin, a 
marker for gut inflammation (CHOP Laboratories), determined using a QUANTA Lite® 
ELISA kit. 
Dietary Intake: Three day weighed food record will be obtained and calories, macro- and 
micro-nutrient content averaged over the three days. Families will be trained by staff and 
provided with scales, spoons and all supplies necessary for the collection of the dietary 
data.  Detailed verbal and written instructions will be provided to ensure that the recording 
procedures are clearly understood. Also assisting with this will come from the CHPS staff 
and Bionutrition Unit system33,34. Dietary intake of all nutrients will be analyzed using 

 
  
 
  
11
Nutrition Data System for Research software version 2012 developed by the National 
Coordinating Center (NCC, University of Minnesota. Minneapolis, MN)35.   
Health Questionnaire: The questionnaire will be administered by interview by the research 
staff, and will consist of two sections. The Health History section has general questions 
about the subject’s health history including documentation of medical history, recent 
hospital admissions and illnesses, medications, and nutrient supplement use. A section 
describes aspects of environment such household size, insurance for child and whether on 
Medicaid. In addition to family contact information (name, address, phone numbers), 
contact information from two non-household contacts will be collected to maintain contact 
with the subject in the event that the family cannot be contacted at their primary residence. 
Adherence: Questionnaire at the 24 week in-person visit regarding adherence to treatment 
will be administered.  Four phone calls will be made to all families at the 4 (± 4 days), 8 (± 
4 days), 16 (± 4 days), and 20 (± 4 days) week time points and in person at the 12- and 
24-week visits after Orkambi treatment has begun to assess adherence to treatment, to 
trouble-shoot any barriers to adherence, and also to collect information on adverse events 
experienced within the past four weeks.  Adherence to treatment with Orkambi treatment, 
pancreatic enzyme medication use, and vitamin use (CF-specific and other vitamin 
supplements) will be assessed. 
Adverse Events Diary: Families will be asked about all adverse events for their child at the 
12 and 24 week protocol visits and during the monthly phone calls, and rate by intensity 
(mild, moderate, severe). Serious adverse events will be reported as per various policies in 
a timely manner to CHOP IRB, and CHPS.  
5.2 Safety Evaluation 
As part of safety assessment, a comprehensive metabolic panel including the ALT and AST 
liver enzymes, and complete blood count will be assessed (CHOP Clinical Laboratory). 
Dosing will likely be interrupted by the CF clinical care team in subjects with ALT or AST of 
greater than 5 times the upper limit of normal (ULN).  
Subjects will be asked about all adverse events at the 12 and 24 week protocol visits and 
during the monthly phone calls, and rate by intensity (mild, moderate, severe). Serious 
adverse events will be reported as per various policies in a timely manner to CHOP IRB, 
and CHPS. For adverse events relating to subject’s Orkambi treatment, all events will be 
managed by the subject’s CF clinical care team.  
6 STATISTICAL CONSIDERATIONS 
6.1 Statistical Methods 
Analysis will begin with descriptive analyses of the study sample using means, standard 
deviations, medians, and ranges for continuous variables, and frequency distributions for 
categorical variables. Descriptive statistics and exploratory graphing such as frequencies, 
means, standard deviations, box plots, and scatter plots will be used to assess the 
normality of the data in terms of the presence of skew and/or outliers.  
6.1.1 Analysis of Primary & Secondary Aims 
Data Analysis:  Analysis will begin with descriptive analyses of the study sample using 
means, standard deviations, medians, and ranges for continuous variables, and frequency 
distributions for categorical variables. Descriptive statistics and exploratory graphing such 
as frequencies, means, standard deviations, box plots, and scatter plots will be used to 

 
  
 
  
12
assess the normality of the data in terms of the presence of skew and/or outliers. Primary 
Aims: The goals of the primary aims of this study are to determine whether Orkambi 
treatment improves SEE/REE, weight and BMI Z score. Secondary Aims:  The goal of the 
secondary aim is to determine whether Orkambi improves gut health and function as 
measured by total plasma fatty acids and fecal calprotectin. Analysis of efficacy for the 
primary and secondary outcomes will be based on change from baseline (before treatment) 
in SEE/REE% predicted (Schofield), weight and BMI Z scores, total plasma fatty acids, and 
fecal calprotectin. The differences between baseline and 24 weeks continuous outcomes 
will initially be compared using paired-t-tests if continuous variables are normally distributed 
and nonparametric tests (Wilcoxon sign rank) if they are not. Subsequently, mixed effects 
longitudinal models will be performed to assess change over all three time points (baseline, 
12 and 24 weeks), adjusting for potential covariates such as age, sex, and adherence to 
treatment. Chi-squared tests will be used for comparison of categorical variables before and 
after Orkambi treatment. Using similar methods, exploratory analyses will examine 
improvement in dietary intake of calories and fat, in growth status (height-for-age), serum 
fat soluble vitamins, bile acids, and calprotectin, and fecal elastase.   
6.2 Sample Size and Power 
Sample Size and Power: This is a longitudinal study of the effects of Orkambi treatment on 
outcomes before and after 24-week treatment.  The sample size of 32 subjects has been 
planned as adequate to have the power to test the primary outcomes of decrease in 
SEE/REE percent predicted value (5% change), and increase in weight (1.8 kg) and BMI Z 
score (0.15). Using STATA, power calculations were generated, with an α=0.05, for paired 
data (n=32) within the same sample (before and after 24 weeks of treatment with Orkambi) 
using the changes described above for the primary outcomes. 
Primary outcomes:  A sample size of 26 subjects results in 80% power to see a decrease of 
5% in SEE/REE (i.e. from 115 to 110) with a standard deviation of the change of 9%, using 
a paired t-test with α=0.05 two-sided significance level. We demonstrated a change of this 
magnitude in REE in 24 subjects with CF gating mutation after 3-mo treatment with 
ivacaftor17. For the weight and BMI status outcomes, we have used the outcomes 
reported by Milla et al4 for 6-11 year old children homozygous for F508del, and the more 
recent data for BMI Z score for younger children ages 2 to 5 years, after 24 months of 
Orkambi treatment. A sample of 26 subjects will provide 82% power with α=0.05 to detect 
an increase in weight of 1.8 kgs over 24 weeks compared to the 1.0 kgs expected 6-month 
increase for children of this age group28, an increase of 0.8 ± 1.4 kgs more than expected.  
A sample of 26 will also provide 81% power with α=0.05 to detect an increase in BMI Z 
score of 0.15±0.27, using a paired t-test and two-sided significance level.  
Secondary outcomes: A sample of 16 subjects will provide 80% power to detect an 
increase in total plasma fatty acids from 8.5 to 10.5 mmol/L with a standard deviation of 
2.8, and will provide 85% power to detect a decrease in fecal calprotectin of 30 ug/g stool 
with a standard deviation of the change of 40 ug/g stool.  We previously demonstrated a 3-
month increase in plasma total fatty acids of this magnitude in subjects with CF receiving a 
structured lipid-based nutritional supplement18. We have previously demonstrated a 3-
month decrease of 30 ug/g stool in fecal calprotectin with ivacaftor treatment in 5 to 61 year 
old people with CFTR gating mutations15.  
The standard deviations of 9% for REE, 0.3 for BMI Z score, 40 ug/g stool for fecal 
calprotectin, and 2.8 mmol/L for total plasma fatty acids are reasonable estimates of the 
variability expected in changes for these variables from our experience with 3-12 month 
changes in these measures in previous longitudinal clinical trials we have conducted for 

 
  
 
  
13
changes in children and adults with CF15,18,36-38.  In addition, our recent experience with 
SEE measures in 1 year old healthy children showed a standard deviation of 8% in SEE 
percent predicted values39. 
     We plan for up to 20% attrition over the 24 weeks. By enrolling 32 subjects we can 
account for attrition and also allow for the possibility of greater variability in the SEE/REE, 
weight and BMI Z scores, and gut health and fat absorption measures in these youngest 
children. 
7 STUDY MEDICATION (STUDY DEVICE OR OTHER STUDY INTERVENTION) 
7.1 
Description 
This is an observational study of subjects who will be assessed before and after Orkambi 
use.  The study will not provide the Orkambi to the subjects.  It will be clinically prescribed 
by the subject’s home CF care provider and the subject will not begin the Orkambi 
treatment until after all Baseline (Visit 1) study visit procedures have been completed.  
8 SAFETY MANAGEMENT 
8.1 
Clinical Adverse Events 
Clinical adverse events (AEs) will be monitored throughout the study.  
8.2 
Adverse Event Reporting 
Since the study procedures are not greater than minimal risk, SAEs are not expected. If any 
unanticipated problems related to the research involving risks to subjects or others happen 
during the course of this study (including SAEs) these will be reported to the IRB in 
accordance with CHOP IRB SOP 408: Unanticipated Problems Involving Risks to Subjects. 
AEs that are not serious but that are notable and could involve risks to subjects will be 
summarized in narrative or other format and submitted to the IRB at the time of continuing 
review. 
9 
STUDY ADMINISTRATION 
9.1 Data Collection and Management 
Data Management: The CHPS will work with the study team to create case report forms, 
set up REDcap database, and provide training for data entry and quality assurance. 
REDcap, a secure, web-based database, provides real time calculations, error detection 
and an automated export procedure for seamless data downloads to Excel, SAS and Stata. 
REDcap and all study computers are password protected and allow for storage of direct 
identifiers and de-identified data in a single database. Subjects will be assigned a unique 
identification number to insure confidentiality. Biological specimens are stored, identified 
using unique numbers in locked CHPS freezer. Routine backup to a secure server, 
including images of forms, the main study database, and files created for analysis, and 
analysis programs will be archived daily. Source documents will be stored in locked 
cabinets in secure research facilities with locked doors and security alarm with 24 hour 
security guard response. For any samples that need to be shipped to outside laboratories 
will also be coded with a study ID number. 

 
  
 
  
14
We will establish a database to store study data using standard software (e.g. RedCap). 
The database will be designed to perform automatic computations, such as exact age 
based upon birth date and date of exam, and averaging anthropometric measures, which 
are recorded in triplicate. Reports containing the number of subjects enrolled and data 
entered for each subject are generated and reviewed each month by the PI.  The PI, or 
study staff, will review all data collection forms on an ongoing basis for data completeness 
and accuracy as well as protocol compliance. Following data entry, all primary and 
secondary endpoint data will be verified against original source documents.  Data 
verification will be performed by someone other than the individual originally collecting and 
entering the data.  
All subjects will be assigned a unique identification number that will be used to insure strict 
confidentiality. The databases are secured with password protection to insure 
confidentiality and security. The informatics manager receives only coded information 
which is entered into the database under those identification numbers. Electronic 
communication with outside collaborators involves only unidentifiable information.  A 
master list containing PHI and subject ID number will be kept separate from the data forms 
and the database that will only have a study ID number. The master list will be on a 
separate password protected file on CHOP’s secured server. All source documents 
including case report forms, laboratory results, and subject study binders will be kept in 
secured locations on the 14th floor of the Roberts Center for Pediatric Research.  The file 
cabinets and the study-specific room will be locked with access to study personnel only, 
and the outer hallway is also locked with limited access to CHOP research personnel. 
Routine backup to the main study database, files created for analyses, and analysis 
programs will be completed. The main study database will be archived on a daily basis and 
stored on a CHOP secured server. The Informatics Core of the CHPS will create case 
report forms, set up the database in RedCap, and provide oversight for data entry and 
quality assurance for this study. 
There is no set time for destroying the information that will be collected for this study.  
9.2 Confidentiality 
Medical history information will be obtained at baseline.  All of the materials collected are 
for research purposes only, and data will be kept in strict confidence. No information will be 
given to anyone without permission from the subject or parent/guardian of the subject. This 
will be stated in the consent form.  Confidentiality is assured by use of identification codes. 
All data, whether generated in the laboratory or at the bedside, will be identified with a 
identification code unique to the subject.  
To maintain confidentiality, private health information will be collected, accessed and stored 
in accordance with Institutional policies and HIPAA guidelines, including the use of 
multilevel password protection and enforcement of system user privileges on the database. 
To minimize the risk of disclosure, all direct identifiers will be removed as soon as possible 
and codes will be substituted for personal identifiers. Records of individuals are stored with 
ID numbers and a code with no discernible personal identifiers. Code lists and data files will 
be stored in separate, secure locations. Data will be accessed and stored on password-
protected computers on the CHOP network. To maintain confidentiality, codes will be used 
in the database, presentations and publications. The Investigator and other site personnel 
will not use such data and records for any purpose other than conducting the study. 

 
  
 
  
15
9.3 Regulatory and Ethical Considerations 
9.3.1 Data and Safety Monitoring Plan 
Safety will be formerly monitored weekly by the study team and PI. The study protocol will 
be carried out in accordance with OHRP guidelines and requirements. SAEs that are 
unanticipated, serious, and possibly related to the study will be reported to the IRB, CHPS, 
all members of the research team, the clinical care team, and sponsor in accordance with 
requirements.  
9.3.2 Risk Assessment 
There is minimal risk to the subject associated with delaying clinically prescribed Orkambi 
treatment until all procedures for the baseline visit (Visit 1) have been completed. 
The procedures in this study involve the potential risks related to the drawing of blood.  
The risks of drawing blood are rare, and minimal. There is a small risk of pain, infection 
and local irritation associated with the blood draw. However, this is considered a minimal 
risk and skilled pediatric research nursing staff will perform phlebotomy. Each subject will 
have approximately 18cc (approximately 1.2 tablespoons) of blood drawn at baseline (Visit 
1) and 24 week (Visit 3) study visit, and 5 cc( 1 teaspoon) at the 12 week visit (Visit 2), and 
no more than 5mL/kg over an eight week period.   
The sleeping or resting energy expenditure assessment using the metabolic cart poses 
minimal risk to the subjects. Children will be able to drink beverages and eat prior to this 
procedure.  Study staff will record amount and type of liquid and solid food prior to the 
procedure.  This will also be used as a reference to repeat same conditions at each 
subsequent visit.  
There is minimal risk associated with anthropometric measurements, sharing dietary 
intake, demographic information, health history and medical information.   
Collection and storage of stool is associated with a small risk of fecal contamination. 
However, for safety and convenience, subjects will be provided with proper stool collection 
instructions and supplies (gloves, disposable collection containers, storage freezer 
container). 
Private health information will be collected, accessed and stored according to HIPAA 
guidelines, including the use of multilevel password protection and enforcement of system 
user privileges on the database. To minimize the risk of disclosure, all direct identifiers will 
be removed as soon as possible and codes will be substituted for personal identifiers. 
Records of individuals are stored with ID numbers and a code with no discernible personal 
identifiers. Code lists and data files will be stored in separate, secure locations. Data will 
be accessed and stored on password-protected computers. To maintain confidentiality, 
codes will be used in the database, presentations and publications.  
If clinically significant results are found as a results of this research study, subjects/families 
will be informed and consent to share findings with their clinical care team will be obtained.  
Once consent to share medical information is obtained, the subject’s clinical care team will 
be contacted by the study team and the results transferred for appropriate follow-up. 
In the event of a serious adverse event during the study protocol, it will be reported to Dr. 
Stallings (Principal Investigator), the IRB and CHPS, all study team members and sponsor 
as directed by policies and procedures and in accordance with requirements. With the 
approval of families, the information will be provided to their care providers as directed. 

 
  
 
  
16
9.3.3 Potential Benefits of Study Participation 
There is no direct benefit to study participation. Participants and their families may 
indirectly benefit from knowing that they will contribute to a clinical research study that is 
important to the health of people with CF in the U.S. and around the world. 
9.3.4 Risk-Benefit Assessment 
The research we propose is justified, considering that the risk associated with participation 
is minimal compared to the potential and anticipated benefits. The benefits of participation 
clearly outweigh the risks, in view of the positive and long-lasting benefits of the study to 
the larger population of people living with CF. 
9.4 Recruitment Strategy 
It is expected that all subjects will be recruited by word of mouth and at the 
recommendation of the subjects’ CF Care Team. The CF Foundation, CF Centers and CF 
support organizations around the country and Canada will provide the study with resources 
that will aide in recruitment efforts (i.e. to help to identify young 2 to 5 year old subjects 
homozygous for F508del mutations and eligible to receive Orkambi treatment). Subjects will 
be recruited after introduction by the subject’s CF Care Team. Once a family has expressed 
interest in participating a CHOP-based research team member will contact the family via 
telephone or in person and continue the introduction of the study to families. Written (in 
person) or verbal (via phone) consent will be acquired to collect medical information to 
determine eligibility. For verbal screening consent, a waiver of documentation of consent, a 
waiver of assent and an alteration of HIPAA to obtain verbal consent and HIPAA 
authorization for screening over the phone will be in place.  A waiver of verbal assent is 
requested due to the fact that the child is too young to provide it. 
In the event that a non-English speaking family is approached for screening, an interpreter 
will be used either by phone or in person depending upon whether the screening takes 
place verbally over the phone or in person to present the study in a language 
understandable to the subjects/families. The interpreter can be conferenced into the phone 
call for the consent process. The screening consent will include the Study Summary 
Document for interpreter documentation attesting to statements on the summary document. 
This document will be faxed or emailed (using secure email) to the interpreter to sign and 
sent back electronically if the process takes place by phone. All members of the team will 
be available to discuss the details and answer any study related questions as they arise. 
Once interest and eligibility are determined, procedures to set up enrollment will begin. 
9.5 Informed Consent/Assent and HIPAA Authorization 
At entry into the study, parent(s) or legal guardian of the subjects will be asked to review 
the study informed consent form (ICF).  The Project Coordinator or other member of the 
clinical research team will meet with the family on Day 1 of Visit 1 to review the form, to 
confirm the subject understands the study, and to answer any questions that the subject or 
parent/guardian might have.  After all study-related questions are answered and subjects 
and families have had time to consider their decision, the Project Coordinator or member of 
the clinical research team will obtain fully informed, written consent from parent(s) or legal 
guardian of the subjects. Again, in the event of enrollment of a non-English speaking 
subject/family, an interpreter will be used to present the study and the consent document in 
a language understandable to the family. The main ICF will include a Study Summary 
Document for interpreter documentation attesting to statements on the summary document,  

 
  
 
  
17
If the interpreter is not in person but is instead conferenced in by phone, then a copy of this 
attestation document will be faxed or emailed (using secure email) to the interpreter to sign 
and return to the team electronically. The consent will be signed in the presence of a team 
member. The families will be given a printed copy of the signed, informed consent.  The 
subjects will be too young to assent to this study. 
9.5.1 Waiver of Documentation of Consent/Assent and Alteration of HIPAA 
Authorization 
The Principal Investigator will be requesting a waiver of documentation to consent/parental 
permission and alteration of HIPAA authorization to obtain verbal authorization. The rights 
and welfare of the subject will not be adversely affected because during the verbal consent 
process it is explained to the subject that we are recording their health information to 
determine eligibility for the study. Study staff stress during the verbal consent that the 
screening is voluntary, but necessary if they wish to participate, and that they can decline 
and stop the process at any point. A written informed consent will be obtained upon study 
entry before any study procedures are performed. 
9.6 Payment to Subjects/Families 
We will compensate subjects/families via bank card (ClinCard) at a standard rate of $150 
per research visit day to offset incurred expenses, including compensation for time, food, 
and babysitting expenses. The baseline and 24-week visits will require 2 or 3 days and one 
or two overnight stays to complete the protocol. For the baseline (Visit 1) and 24 week (Visit 
3) visits, we have assumed that half the families will receive $150 to complete the visit and 
study protocol procedures for a one day visit and half will require an additional day to 
complete procedures and will receive $300. For the 12-week visit (Visit 2), all families will 
receive $150 as an additional day will not be an option. The average compensation to 
complete the study is $600, with a minimum of $450 and maximum compensation of $750. 
If the subject/family total compensation exceeds $600 in one calendar year, they will be 
provided with a W9 form. 
 
 

 
  
 
  
18
 
Summary of Range of Payment 
 
              Each Visit  
If Additional day required 
Visit 1 (Baseline) 
$150 
$300 
Visit 2 (12-weeks)* 
$150* 
$150* 
Visit 3 (24 weeks) 
$150 
$300 
 
           $450 (minimum) 
            $750 (maximum) 
*The compensation for Visit 2 (12 weeks) will always be $150 as there is no additional 
research procedure day option.  
Subjects/Families will be compensated $150 for each visit for time and effort associated 
with the study protocol procedures. Since oneimportant tests (SEE or REE) for this 
Baseline Visit 1 require subjects to be very still, these are planned to be conducted during a 
nap (with children who typically take daily naps)  or while child is awake lying very still (with 
children who do not typically take daily naps). If the SEE/REE is not completed in one day 
than an additional day may be needed.  
If subjects are not local to CHOP, they will stay in a nearby hotel for either 1 or 2 nights 
depending upon time of research procedures and whether a Day 3 is needed to complete 
the SEE/REE.   Subjects will also be reimbursed to cover the costs of travel and parking. 
Subjects/families will provide official receipts for these items. The 24-week Visit 3 plan is 
the same as Visit 1. The 12-week Visit 2 requires one day of research study procedures. . 
Subjects traveling regionally by car will be reimbursed at the completion of the study visit for 
mileage/gas/parking. For all subjects not from the Philadelphia area, we have assumed that 
the cost of travel will paid for the subject and one family member to accompany the subject. 
The overnight stays will also be paid for the family at a hotel nearby to CHOP.  
Travel expenses that are considered reimbursable are: miles to/from CHOP for subjects 
who are traveling regionally by car, miles to/from the airport or train station (at a rate of 
$20/day), parking at the airport or train station, cab to and from the airport or train station, 
checked bags.  All expenses will be reimbursed with receipts by ClinCard payment request. 
All subjects will be informed prior to participation of all travel arrangements and what costs 
are reimbursable and that receipts will be needed for ClinCard payment requests.  
 
10 PUBLICATION 
The research data obtained through the study outlined in this protocol will be shared with 
the research community, both through oral presentation at scientific meetings, and in 
written form, as published manuscripts.  Reported factual material (primary data on which 
summary statistics and tables are based), commonly accepted in the scientific community 
as necessary to document and support research findings, will be provided in a timely 
fashion upon request by members of the scientific community to the principal investigator 
for a period of 3 years following acceptance for publication. The CHOP investigators will 
have access to the complete study data.  
 

 
  
 
  
19
REFERENCES 
 
1. 
Van Goor F, Hadida S, Grootenhuis PD, et al. Correction of the F508del-CFTR 
protein processing defect in vitro by the investigational drug VX-809. 
Proc.Natl.Acad.Sci.U.S.A. 2011;108(46):18843-18848. 
2. 
Flume PA, Liou TG, Borowitz DS, et al. Ivacaftor in subjects with cystic fibrosis who 
are homozygous for the F508del-CFTR mutation. Chest. 2012;142(3):718-724. 
3. 
Van Goor F, Hadida S, Grootenhuis PD, et al. Rescue of CF airway epithelial cell 
function in vitro by a CFTR potentiator, VX-770. Proc Natl Acad Sci U.S.A. 
2009;106(44):18825-18830. 
4. 
Milla CE, Ratjen F, Marigowda G, et al. Lumacaftor/Ivacaftor in Patients Aged 6-11 
Years With Cystic Fibrosis Homozygous for F508del-CFTR. Am J Respir Crit Care 
Med. 2016;195(7):912-920. 
5. 
Wainwright CE, Elborn JS, Ramsey BW, et al. Lumacaftor-Ivacaftor in Patients with 
Cystic Fibrosis Homozygous for Phe508del CFTR. N Engl J Med. 2015;373(3):220-
231. 
6. 
Vertex Pharmaceuticals Inc. Lumacaftor/Ivacaftor: Phase 3 studies in patients with 
cystic fibrosis aged 6 through 11 years homozygous for F508del-CFTR. VXM-HQ-
04-00124(1). 2016. 
7. 
Vertex Pharmaceuticals Inc. ORKAMBI (lumacaftor/ivacaftor): Highlights of 
Prescribing Information. 2016. 
8. 
Vertex Pharmaceuticals Inc. ORKAMBI (lumacaftor/ivacaftor) was studied in 
patients ages 2 through 5 years. https://www.orkambihcp.com/clinical-data-trial-6. 
2018;accessed Oct. 3, 2018. 
9. 
Accurso FJ, Rowe SM, Clancy JP, et al. Effect of VX-770 in persons with cystic 
fibrosis and the G551D-CFTR mutation. N Engl J Med. 2010;363(21):1991-2003. 
10. 
Ramsey BW, Davies J, McElvaney NG, et al. A CFTR potentiator in patients with 
cystic fibrosis and the G551D mutation. N Engl J Med. 2011;365(18):1663-1672. 
11. 
Davies JC, Wainwright CE, Canny GJ, et al. Efficacy and safety of ivacaftor in 
patients aged 6 to 11 years with cystic fibrosis with a G551D mutation. Am J Respir 
Crit Care Med. 2013;187(11):1219-1225. 
12. 
Davies JC, Cunningham S, Harris WT, et al. Safety, pharmacokinetics, and 
pharmacodynamics of ivacaftor in patients aged 2-5 years with cystic fibrosis and a 
CFTR gating mutation (KIWI): an open-label, single-arm study. Lancet Respir Med. 
2016;4(2):107-115. 
13. 
Rosenfeld M, Robertson S, Cooke J, Higgins MN, Davies JC. Long-term safety and 
efficacy of ivacaftor in pediatric patients aged 2-5 years with CF and CFTR gating 
mutation. Pediatr Pulmonol. 2016;Suppl. 45 (abstract). 
14. 
Bodewes FA, Verkade HJ, Wilschanski M. Gastroenterological endpoints in drug 
trials for cystic fibrosis. Pediatr Pulmonol. 2016;51(S44):S18-S22. 
15. 
Stallings VA, Sainath NN, Oberle M, Bertolaso C, Schall JI. Energy balance and 
mechanisms of weight gain with ivacaftor treatment of cystic fibrosis gating 
mutations. J. Pediatr. 2018;201:229-237. 
16. 
Sainath NN, Schall JI, Bertolaso C, McAnlis C, Stallings VA. Italian and North 
American dietary intake after ivacaftor treatment for cystic fibrosis gating mutations. 
J Cystic Fibrosis. 2018;(in press). 

 
  
 
  
20
17. 
Schall JI, Sainath NN, McAnlis C, Hess OM, Bertolaso C, Stallings V. 3-Month 
Ivacaftor treatment resulted in weight gain, improved pulmonary function and growth 
status, and reduced energy expenditure and gut inflammation in people with cystic 
fibrosis gating mutations. Pediatr Pulmonol. 2016 Suppl 45:422. 
18. 
Stallings VA, Schall JI, Maqbool A, et al. Effect of oral lipid matrix supplementation 
on fat absorption in cystic fibrosis: a randomized placebo-controlled trial. J Pediatr 
Gastroenterol Nutr. 2016 63(6):676-680. 
19. 
Maqbool A, Schall JI, Garcia-Espana JF, Zemel BS, Strandvik B, Stallings VA. 
Serum linoleic acid status as a clinical indicator of essential fatty acid status in 
children with cystic fibrosis. J Pediatr Gastroenterol Nutr. 2008;47(5):635-644. 
20. 
O'Connor MG, Seegmiller A. The effects of ivacaftor on CF fatty acid metabolism: 
An analysis from the GOAL study. J Cyst Fibros. 2017;16(1):132-138. 
21. 
Mariani A, Marsili M, Nozzi M, Faricelli R, Chiarelli F, Breda L. Serum calprotectin: 
review of its usefulness and validity in paediatric rheumatic diseases. Clin Exp 
Rheumatol. 2015;33(1):109-114. 
22. 
Gray RD, Imrie M, Boyd AC, Porteous D, Innes JA, Greening AP. Sputum and 
serum calprotectin are useful biomarkers during CF exacerbation. J Cyst Fibros. 
2010;9(3):193-198. 
23. 
Reid PA, McAllister DA, Boyd AC, et al. Measurement of serum calprotectin in 
stable patients predicts exacerbation and lung function decline in cystic fibrosis. Am 
J Respir Crit Care Med. 2015;191(2):233-236. 
24. 
Joseloff E, Sha W, Bell SC, et al. Serum metabolomics indicate altered cellular 
energy metabolism in children with cystic fibrosis. Pediatr Pulmonol. 
2014;49(5):463-472. 
25. 
FAO / WHO / UNU Expert Consultation. Energy and protein requirements: technical 
report series.  1985 1985. 724. 
26. 
Schofield WN. Predicting basal metabolic rate, new standards and review of 
previous work. Hum Nutr Clin Nutr. 1985;39 Suppl 1:5-41. 
27. 
Lohman T, Roche A, Martorell R. Anthropometric Standardization Reference 
Manual. Champaign, IL: Human Kinetics; 1988. 
28. 
World Health Organization. WHO Child Growth Standards: Length/height-for-age, 
weight-for-age, weight-for-length, weight-for-height, and body mass index-for-age. 
Geneva, Switzerland: WHO Press, World Health Organization; 2006. 
29. 
World Health Organization. WHO Child Growth Standards: Head circumference-for-
age, arm circumference-for-age, triceps skinfold-for-age, and subscapular skinfold-
for-age. Geneva, Switzerland: WHO Press, World Health Organization; 2007. 
30. 
Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United 
States. Adv Data. 2000(314):1-27. 
31. 
Borowitz D, Baker SS, Duffy L, et al. Use of fecal elastase-1 to classify pancreatic 
status in patients with cystic fibrosis. J Pediatr. 2004;145(3):322-326. 
32. 
Borowitz D, Lin R, Baker SS. Comparison of monoclonal and polyclonal ELISAs for 
fecal elastase in patients with cystic fibrosis and pancreatic insufficiency. J Pediatr 
Gastroenterol Nutr. 2007;44(2):219-223. 
33. 
Derr JA, Mitchell DC, Brannon D, Smiciklaswright H, Dixon LB, Shannon BM. Time 
and Cost-Analysis of A Computer-Assisted Telephone Interview System to Collect 
Dietary Recalls. Am J Epidemiol. 1992;136(11):1386-1392. 

 
  
 
  
21
34. 
Copeland T, Grosvenor M, Mitchell DC, et al. Designing a quality assurance system 
for dietary data in a multicenter clinical trial: Women's Intervention Nutrition Study. J 
Am Diet Assoc. 2000;100(10):1186-1190. 
35. 
Feskanich D, Sielaff BH, Chong K, Buzzard IM. Computerized collection and 
analysis of dietary intake information. Comput Methods Programs Biomed. 
1989;30(1):47-57. 
36. 
Groleau V, Schall JI, Dougherty KA, et al. Effect of a dietary intervention on growth 
and energy expenditure in children with cystic fibrosis. J Cyst Fibros. 
2014;13(5):768-771. 
37. 
Schall JI, Mascarenhas MR, Maqbool A, et al. Choline supplementation with a 
structured lipid in children with cystic fibrosis: a randomized placebo-controlled trial. 
J Pediatr Gastroenterol Nutr. 2016;62(4):618-626. 
38. 
Sainath NN, Schall JI, McAnlis C, Hess O, Bertolaso C, Stallings VA. Improvement 
in weight, pulmonary function and other outcomes with 3-month Ivacaftor treatment 
differed by exocrine pancreatic status in people with cystic fibrosis gating mutations. 
Pediatr Pulmonol. 2016 Suppl 45:418. 
39. 
Mennella JA, Inamdar L, Pressman N, et al. Type of infant formula increases early 
weight gain and impacts energy balance: an RCT. Am J Clin Nutr. 2018;(in press).