Phase I/II Study of Inhaled Sodium Nitrite as an Antimicrobial for Pseudomonas Infection in Cystic Fibrosis
Phase: PHASE1
Conditions: Cystic Fibrosis
Sponsor: Schmidhofer, Mark, MD

 
 
 
 
 
 
Inhaled Sodium Nitrite for Cystic Fibrosis 
 
 
 
 
 
 
 
 
 
 
Joseph Pilewski, MD 
Principal Investigator 
 
 
 
 
 
 
 
 
University of Pittsburgh 
School of Medicine 
Division of Pulmonary, Allergy and Critical Care Medicine 
 
 
 
 
 
 
Version 6.0 
November 28, 2018 
 
 
 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
2 
Table of Contents 
OBJECTIVE, SPECIFIC AIMS, BACKGROUND, AND SIGNIFICANCE ......................... 7 
OBJECTIVE ......................................................................................................................................7 
SPECIFIC AIMS ................................................................................................................................7 
BACKGROUND ................................................................................................................................7 
Investigational Drug .......................................................................................................................8 
Rationale for Dose of Nitrite ...........................................................................................................8 
SIGNIFICANCE ................................................................................................................................9 
STUDY DESIGN AND METHODS.......................................................................................... 10 
CLASSIFICATION AND METHODOLOGICAL DESIGN ......................................................................... 10 
STUDY DESIGN AND METHODS ..................................................................................................... 10 
Study Design.......................................................................................................................... 10 
SAFETY MONITORING ................................................................................................................... 13 
STOPPING RULES .......................................................................................................................... 14 
STUDY INVESTIGATIONAL THERAPY SUPPLIES ............................................................................... 14 
Formulation and Packaging ................................................................................................... 14 
Availability ............................................................................................................................ 15 
Preparing and Dispensing ...................................................................................................... 15 
Drug Administration .............................................................................................................. 15 
STUDY INVESTIGATIONAL THERAPY ACCOUNTABILITY................................................................... 15 
HUMAN SUBJECTS .................................................................................................................. 23 
SUBJECT POPULATION: ................................................................................................................. 23 
Inclusion of Children ............................................................................................................. 23 
RECRUITMENT AND INFORMED CONSENT PROCEDURES ...................................... 24 
Risks and Benefits ....................................................................................................................... 25 
POTENTIAL RISKS ......................................................................................................................... 25 
PROTECTIONS AGAINST RISK ........................................................................................................ 27 
ALTERNATIVE TREATMENTS.......................................................................................................... 28 
POTENTIAL BENEFITS .................................................................................................................... 28 
DATA SAFETY MONITORING PLAN ................................................................................................ 28 
STUDY ADMINISTRATION ................................................................................................... 34 
QUALITY CONTROL AND QUALITY ASSURANCE .............................................................................. 34 
DATA HANDLING AND RECORD-KEEPING ...................................................................................... 34 
ETHICS ......................................................................................................................................... 35 
Institutional Review Board (IRB) Approval ......................................................................... 35 
Ethical and scientific conduct of the clinical study ............................................................... 36 
COSTS AND PAYMENTS ........................................................................................................ 36 
COSTS .......................................................................................................................................... 36 
PAYMENTS ................................................................................................................................... 36 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
3 
QUALIFICATIONS AND SOURCE OF SUPPORT .............................................................. 36 
QUALIFICATION OF INVESTIGATORS ............................................................................................. 36 
SOURCE OF SUPPORT ................................................................................................................... 37 
References .................................................................................................................................... 37 
 
 
 
 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
4 
PROTOCOL SYNOPSIS 
 
Protocol Title: 
Inhaled Sodium Nitrite for Cystic Fibrosis 
Protocol Number: 
PRO15040062 
NCT Number: 
NCT02694393 
Version # and Date: 
Version 5.0 /January 5, 2018 
Clinical Phase: 
 
Phase I/II clinical investigation 
Investigational Drug: 
Sodium Nitrite (nebulized) 
Trial Site: 
Single-Center Trial 
Sponsor: 
Mark Schmidhofer, MD 
Associate Professor of Medicine 
University of Pittsburgh 
Heart and Vascular Institute 
 
Investigator: 
 
Joseph Pilewski, MD 
Associate Professor of Medicine, Pediatrics, and Cell Biology 
University of Pittsburgh 
Division of Pulmonary, Allergy, and Critical Care Medicine 
 
Sub-Investigators: 
Michael Myerburg, MD       
Keven Robinson, MD 
Joel Weinberg, MD 
Anna Zemke, MD 
Study Monitor: 
Joseph Pilewski, MD 
Associate Professor of Medicine, Pediatrics, and Cell Biology 
University of Pittsburgh 
Division of Pulmonary, Allergy, and Critical Care Medicine 
 
Research Facilities: 
University of Pittsburgh Medical Center (UPMC) 
200 Lothrop Street 
Pittsburgh, PA. 15213 
 
Children’s Hospital of UPMC 
One Children’s Hospital Drive 
4401 Penn Avenue 
Pittsburgh, PA 15224 
 
Clinical Laboratories: 
UPMC CLSI Lab           
3477 Euler Way  
Pittsburgh, PA. 15213 
Automated Testing Laboratory 
Children’s Hospital of Pittsburgh 
UPMC 
One Children’s Hospital Drive 
Pittsburgh, PA 15224 
 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
5 
Manufacturer: 
Hope Pharmaceuticals. 
 
Study Rationale: 
Cystic fibrosis (CF) is the most common severely life-
shortening genetic disease of Caucasians. Tenacious mucus 
plugs the airways and allows for bacterial biofilms to grow. 
Ongoing infections lead to bronchiectasis and ultimately death 
from chronic respiratory failure (reviewed in (1–3)). The most 
common pathogen in adults with CF is Pseudomonas 
aeruginosa, which affects 80% of the CF population (4).  
Nebulized sodium nitrite may represent a new therapeutic 
approach for the treatment of P. aeruginosa infection. Sodium 
nitrite has in vitro antimicrobial activity against P. aeruginosa 
and other airway pathogens (5–7).  Nebulized sodium nitrite has 
an excellent safety profile from ongoing studies in pulmonary 
hypertension.  In CF, there is the potential for bronchospasm in 
subjects with CF-related airway hyperactivity, thus a safety 
study such as the one proposed is warranted.   
Study Objectives: 
The objective of this research study is to determine whether 
nebulized sodium nitrite is safe in adults with cystic fibrosis.  
Study Hypothesis: 
The hypothesis of this study is: 
Nebulized sodium nitrite will be well tolerated by adults with 
CF.  
Study Aims: 
Specific Aim: 
1. Determine the safety of nebulized sodium nitrite 
administered in two doses to patients with CF.  
2. Explore the effects of inhaled sodium nitrite on measures of 
lung function, exhaled airway nitric oxide, and bacterial 
burden as measured by quantitative sputum cultures. 
 
Study type 
This is an experimental study of a new inhalation solution for 
cystic fibrosis. The initial study is a Phase I/II open-label design 
enrolling a total of 35 subjects that meet all the eligibility 
criteria.  
 
Planned Sample Size: 
35 Subjects 
 
Duration of Treatment: 
56 days 
Inclusion Criteria: 
1. Subjects 18 years or older with CF as documented by 
clinical features of CF, and documentation of a positive 
sweat test or two diseasing causing mutations in the CF 
gene, will be eligible.  
 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
6 
Exclusion Criteria: 
1. Inability to provide consent 
2. Use of supplemental oxygen or non-invasive ventilatory 
support 
3. FEV1 < 40% 
4. Awaiting lung transplantation 
5. Pregnancy or unwilling to comply with birth control 
during the intervention period 
6. History of glucose-6-phosphate dehydrogenase (G6PD) 
deficiency or any contraindication to receiving 
methylene blue 
7. Hospitalization within the past 4 weeks prior to 
enrollment 
8. Subject requires additional antibiotics or steroids within 
the past 4 weeks prior to enrollment 
9. Change in maintenance CF therapies in the past 4 weeks 
prior to enrollment 
10. Baseline systemic hypotension (systolic BP < 90 mm 
Hg) 
11. History of orthostatic hypotension or syncope 
12. Chronic kidney disease (creatinine > 2.5 or requiring 
dialysis 
13. Severe anemia (Hgb <9 gm/dL in the last six months) 
14. History of portal hypertension or chronic liver disease, 
including hepatitis B and/or hepatitis C (with evidence 
of recent infection and/or active virus replication), 
defined as moderate to severe hepatic impairment 
(Child-Pugh Class B-C) 
15. History of abusing alcohol or illicit drugs within 28 days 
prior to study 
16. Severe pulmonary hypertension (mean PA pressure > 
25) 
17. Use of sildenafil or other pulmonary vasodilator 
18. History of any organ transplantation 
19. Participation in another interventional trial in the 
previous 28 days 
 
Study Endpoints: 
Primary endpoint: 
The primary safety and efficacy endpoint is FEV1.  A sustained 
decrease in FEV1 of >15% will be considered intolerable.  
Secondary endpoints include exhaled NO (FENO), sputum 
nitrite concentration, quantitative bacterial cultures, 
percutaneous methemoglobin levels, blood pressure, and 
subject symptoms as measured by the CF Questionnaire-R. 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
7 
1. 
OBJECTIVE, SPECIFIC AIMS, BACKGROUND, AND SIGNIFICANCE 
 
1.1 
OBJECTIVE 
The objective of this research study is to determine the safety of nebulized sodium nitrite  
administered in a dose escalation manner in adults with cystic. 
 
1.2 
SPECIFIC AIMS 
Hypotheses: 
(1) Nebulized sodium nitrite will be well tolerated by adults with CF.   
 
To determine the therapeutic potential of sodium nitrite for CF, we propose two specific aims: 
Specific Aims: 
Aim 1:  Determine the safety of nebulized sodium nitrite administered in two doses to patients 
with CF. 
Aim 2: Explore the effects of nebulized sodium nitrite on measures of lung function, exhaled 
airway nitric oxide, and bacterial burden. 
 
1.3 
BACKGROUND 
1.3.1 Cystic Fibrosis and Chronic Airway Infections 
Cystic fibrosis (CF) is the most common severely life-shortening genetic disease of Caucasians. 
Tenacious mucus plugs the airways and becomes chronically infected (reviewed in 1-3).  
Ongoing infections lead to bronchiectasis and ultimately death from chronic respiratory failure. 
The most common pathogen in adults with CF is Pseudomonas aeruginosa, which affects 80% 
of the CF population (4). Current treatment focuses on monthly cycled of inhaled antibiotics 
such as tobramycin and aztreonam(8). However, over decades bacteria become resistant to all 
existing antibiotics. There is an additional 10% of the CF population infected with organisms 
such as B. cepacia complex for which there are no existing inhaled antimicrobial therapies(4). 
Despite the magnitude of disease caused by P. aeruginosa and other airway pathogens, we do 
not have adequate antibiotic therapies to either keep colonization in check or eradicate the 
organism. This will continue to be an unmet therapeutic need as the CF population ages and is 
exposed to additional decades of antibiotics. 
Nebulized sodium nitrite may represent a new therapeutic approach for the treatment of P. 
aeruginosa infection. Previous work by Dr. Hassett demonstrated that nitrite has bactericidal 
activity against P. aeruginosa growing in liquid culture, with mucoid strains and anaerobically 
growing bacteria being 2-5 fold more sensitive(5, 6). We have extended this work and shown 
that nitrite prevents biofilm growth by P. aeruginosa growing on the surface of primary human 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
8 
airway epithelial cells(7). The effect ceiling is 50 mM, which is near the estimated airway 
concentration of nitrite after nebulization. In addition to anti-Pseudomonal activity, nitrite has 
antimicrobial activity against other CF pathogens including Staphylococcus aureus, 
Burkholderia spp and Achromobacter spp(5, 7, 9). The broad activity of nitrite is a unique 
strength of the agent as an antimicrobial agent.  
Within the lung, the chemistries of nitrite and nitric oxide (NO) are closely related. Nitrite is 
reduced to NO both enzymatically and nonenzymatically. NO is formed when nitrite reacts with 
metal containing proteins such as hemoglobin and cytochrome c oxidase (mitochondrial complex 
4)(10). These reactions are influenced by both pH and oxygen tension, and occur more rapidly 
under acidic conditions with a low oxygen tension, such as those found in the CF lung (6). NO 
has a biologic half-life of milliseconds and is the principle regulator of pulmonary vascular tone. 
With a half life of 51 minutes when delivered IV (and potentially longer when inhaled), nitrite 
can be viewed as a long acting source of NO(11, 12). In addition to its role as a vasodilator, 
nitrite plays a role in innate immunity. In the epithelium NO is produced by inducible nitric 
oxide synthetase (iNOS) from L-Arginine. In the healthy lung, both the airway epithelium and 
immune cells produce NO. However, in CF the airway epithelium expresses much less iNOS 
leading to decreased exhaled nitric oxide (13). Low exhaled nitric oxide levels are correlated 
with worse lung function as well as P. aeruginosa colonization in CF (14). Because NO has 
strong antimicrobial effects, low NO levels in the airway may contribute to the susceptibility to 
bacterial colonization in CF. Nitrite has the theoretical added benefit of restoring normal airway 
NO levels in patients, such as those with CF, who have an endogenous NO production defect. 
The antimicrobial activity of nitrite derives from its ability to inhibit bacterial respiration(7, 15). 
The precise molecular targets are an area of active investigation, but nitrite can inactivate heme-
containing proteins (such as cytochrome c oxidases), disrupt iron-sulfur containing proteins 
(such as NADH dehydrogenase and succinate dehydrogenase), and S-nitrosate redox active 
cysteine residues impairing protein function (16). Nitrite was initially proposed as an inhaled 
antimicrobial agent in 2006 by Dr. Hassett’s group, however compound to perform clinical trials 
was not available until recently and preclinical safety data was not previously available. 
1.3.2  Investigational Drug   
The study material (nebulized sodium nitrite) is sodium nitrite in a sterile aqueous solution.  It is 
FDA-approved for intravenous use.  We will be nebulizing the solution in the current study.  The 
solution is packaged at 30 mg/mL.  Thus 1.5 ml will be nebulized for a 45 mg dose and 3ml will 
be nebulized for a 90mg dose.   
1.3.3 Rationale for Dose of Nitrite 
The doses of nitrite proposed (45 mg and 90mg) were chosen based on existing human safety 
data and in-vitro antimicrobial data.  In healthy volunteers, the maximum tolerated dose of nitrite 
was 90 mg(12).  In the initial study CS01, 2/6 subjects experienced symptomatic hypotension 
and tachycardia at a dose of 176 mg. This effect occurred immediately after nebulization, and 
thus for CS01 the MTD was 125mg. In study CS04, 2/3 subjects had transient, but symptomatic, 
orthostasis with 120 mg, thus the MTD was lowered to 90mg. No other dose limiting toxicity 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
9 
was seen at 90 mg. This study included dosing subjects with mild hypoxia (such as might be seen 
in patients with end stage lung disease) and no interaction was seen between hypoxia and 
nebulized nitrite. Methemoglobin did not exceed 3% in these studies.  Subequently, in a study of 
36 participants with pulmonary hypertenions, no increase in methemoglobin was seen with 90 
mg doses (17).  Another study on heart failure with preserved ejection fraction found no increase 
in methemoglobin as compared to control (18).  Methemoglobin levels above 30% of total 
hemoglobin can cause shortness of breath due to the reduced oxygen carrying capacity, and 
levels above 50% can lead to seizures and death(19). In these studies, nebulized sodium nitrite 
was dosed up to every 8 hours for 6 days. Thus at doses up to 90mg, nebulized sodium nitrite 
appears safe in healthy subjects for dosing. Additional, unpublished safety data is available from 
Phase 2b clinical trials that were terminated with the sale of of the sponsor company.  More than 
30 subjects with pulmonary arterial hypertension have been treated for as long as 12 months with 
no treatment related serious adverse events.  In the recently completed studies of inhaled nitrite 
for pulmonary hypertension, doses of 46 or 80 mg four times daily were reportedly well tolerated 
for up to 16 weeks.  Since initial submission of this protocol, additional safety data in 36 patients 
with pulmonary hypertension and heart failure with preserved ejection fraction have been 
published.  In these studies, one subject was withdrawn due to asymptomatic hypotension, and 
the only side effect reported was occasional self-limited cough (17, 18).  Regarding the doses 
where nitrite may have antimicrobial activity, we estimate that with a dose of 46 mg in a high 
efficiency nebulizer no less than 50% of the dose will reach the lower airways. Assuming a 
volume of distribution in the airway surface liquid of at most 7 mL, we estimated that the initial 
sodium nitrite concentration in the airway after nebulization of a 46 mg dose will be 47 mM, and 
with 80 mg, 82 mM. In the CF airway, assuming surface liquid depletion, these are likely 
conservative estimates and the immediate post-deposition concentration may be higher. 
Importantly, these estimated concentrations are above the concentrations that we found reduce 
biofilm growth of P. aeruginosa (1 log reduction at 15 mM)(7). Based on these considerations, 
in this safety and proof of concept study, we will target dosing above the concentrations 
necessary for an anti-microbial effect and two fold below the maximal tolerated dose in normal 
volunteers. Dosing will be 45 mg (controlled by the nebulizer) for the first week to provide 
multiple day safety data prior to observed escalation to the target 90 mg dose for the remaining 
three weeks of the study 
1.4 
SIGNIFICANCE 
Chronic airway infections with multi-drug resistant Gram-negative organisms are common in 
patients with structural lung diseases, particularly CF but also including those with non-CF 
bronchiectasis, COPD, following lung transplant, and those with chronic airway hardware such 
as tracheostomies.  The current FDA approved inhaled antibiotics are limited to tobramycin and 
aztreonam, to which many organisms are resistant.  We hypothesize that inhaled nitrite provides 
an innovative therapeutic approach for patients with chronic airway infections because: 
1. 
Nitrite has broad antimicrobial activity against all organisms tested, including 
respiratory isolates of Burkholderia cepcacia complex, Staphylococcus aureus, 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
10 
Achromobacter complex, and Klebsiella pneumoniae(5, 9). This study will provide 
proof-of-concept efficacy data that nitrite inhibits bacterial growth. 
2. 
The antimicrobial activity of nitrite increases under anaerobic and acidotic conditions 
such as those found in the CF airway.  Both low pH and oxygen tension decrease the 
activity of many antibiotics. 
3. 
This study will provide evidence that nebulize nitrite can reconstitute the NO 
deficiency found in CF.   
4. 
The results obtained in this study will lay the groundwork for future large scale 
clinical trials needed to determine the efficacy of inhaled nitrite as an antibiotic in 
patients with cystic fibrosis and other patient populations with chronic airway 
infections. 
2. 
STUDY DESIGN AND METHODS 
2.1 
CLASSIFICATION AND METHODOLOGICAL DESIGN 
This is a single-center, open label phase I/II study to determine the safety of inhaled nitrite in 
adults with cystic fibrosis. 
2.2 
STUDY DESIGN AND METHODS 
2.2.1 Study Design 
A total of 35 subjects with a confirmed diagnosis of cystic fibrosis meeting all the eligibility 
criteria will receive the investigative drug, nebulized sodium nitrite.  The starting dose of 
nebulized sodium nitrite is 45 mg for the first week to provide multiple dose safety data and 
subject tolerability prior to the observed escalation target dose of 90 mg for the remaining three 
weeks of the study. 
Screening (day -28 to -2): Potential subjects will be recruited from the CF Center at Children’s 
Hospital of Pittsburgh and/or the UPMC Comprehensive Lung Center (CLC).  In these locations, 
individuals with CF are followed on a routine basis and are well known to the study 
investigators. Initial screening evaluations including urine pregnancy test (only on females of 
childbearing potential), physical examination, medical history, and clinical laboratory 
assessments will be conducted to determine study eligibilities during a routine clinic visit.  If a 
patient has had the required screening laboratory assessments within the past 6 months, results of 
those tests will be used for screening purposes and only repeated if clinically significant 
abnormalities were identified.  In addition, vital signs (pulse, non-invasive blood pressure 
measurement, temperature, respiratory rate and oxygen saturation) will be performed.  Subjects 
who meet the inclusion criteria and none of the exclusion criteria will be entered into the study 
and baseline spirometry will be obtained with the study spirometer.  If the participant is on 
inhaled antibiotics, Visit 1 will be scheduled 2-7 days after the participant initiates the next 
scheduled inhaled antibiotic.  Subjects are to remain on the same inhaled antibiotic through the 
end of Visit 5.  Remaining on the same inhaled antibiotic for more than one month is quite 
common in CF clnical care. 
 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
11 
Experimental Procedures (visit 1/day 0 (+/- 1day)): This visit will take approximately 5 hours.  
Subjects will arrive and complete the CFQ-R CF Questionnaire.  Vital signs will be recorded and 
a physical examination performed, subjects will provide a sputum sample if able, and complete 
an oral wash specimen. The fractional excretion of nitric oxide (FENO) will be measured using a 
NIOX device, and baseline spirometry will be obtained. If subjects are unable to spontaneously 
expectorate sputum, then sputum induction will be done, followed by at least a 30 minute 
observation period because sputum induction is associated with temporary bronchoconstriction 
which might confound further measurements. The observation period will be omitted in subjects 
that spontaneously expectorated sputum. Next, an electronic nebulizer will be used to deliver 45 
mg of nebulized sodium nitrite.  Subjects will be monitored closely for the next two hours, 
including percutaneous measurements of oxygen saturation and methemoglobin levels, recorded 
at minutes 15, 30, 60 and 120, and noninvasive systemic blood pressure measurements every 15 
minutes. Spirometry will be repeated at 30 and 120 minutes following nebulized sodium nitrite 
administration. If percutaneous methemoglobin measurements exceed 5%, they will be 
confirmed by venous blood measurement. If nebulized sodium nitrite is tolerated, then the 
subject will be dispensed an 8 day supply of 45 mg nebulized sodium nitrite dosed two times 
daily and discharged from the CTRC, CHP or the Emphysema Research Center in Montefiore.  
If the 45mg dose of nebulized sodium nitrite is not tolerated, the subject will be observed until 
stable and then discharged from the CTRC, CHP or the Emphysema Research Center in 
Montefiore. 
Experimental Procedure (visit 2/day 7 (+/- 1day)):  This visit will take approximately 5-7 hours.  
Subjects will arrive and complete the CFQ-R CF Questionnaire.  FENO will be measured as 
above.  If the subject had no serious adverse events for the first seven days of the 45 mg dose of 
nebulized sodium nitrite, and has stable systemic blood pressure and FEV1 on presentation to the 
Day 7 visit, an electronic nebulizer will be used to deliver 90 mg of nebulized sodium nitrite.  
Subjects will be monitored closely for the next two hours, including percutaneous measurements 
of oxygen saturation and methemoglobin levels, recorded at minutes 15, 30, 60 and 120, and 
noninvasive systemic blood pressure measurements every 15 minutes. If percutaneous 
methemoglobin measurements exceed 5%, they will be confirmed by venous blood 
measurement.  Spirometry will be repeated at 30 and 120 minutes following nebulized sodium 
nitrite administration.  If nebulized sodium nitrite is tolerated, then the subject will be dispensed 
an 8 day supply of 90 mg nebulized sodium nitrite dosed two times daily and discharged from 
the CTRC, CHP or the Emphysema Research Center in Montefiore.  If the 90 mg dose of 
nebulized sodium nitrite was not tolerated, the subject will be observed. If FEV1 returns to 
baseline in 4 hours and subject’s SaO2 is not greater than 5% drop from baseline and systolic BP 
is not greater than 40 mm Hg drop from pre-dose baseline, the subject will be re-challenged at 
this visit with a 45 mg dose of nebulized sodium nitrite and the observation protocol of blood 
pressure measurements, spirometry and percutaneous oxygen saturation measurement will be 
repeated. 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
12 
Experimental Procedures (visit 3/day 14(+/- 1day)):  This is a safety and tolerability visit and 
will take approximately 1 hour.  Subjects will complete the CFQ-R and spirometry. An oral wash 
will be collected, and then a sputum sample will be collected.  If the subject cannot 
spontaneously expectorate, then sputum induction will be done.  The subject will then be 
discharged with a 15 day supply of nebulized sodium nitrite. 
 
Experimental Procedures (visit 4/day 28(+/- 1day)):  This visit will take approximately 1.5 hours.  
Subjects will complete the CFQ-R and spirometry.  Expectorated or induced sputum will be 
collected, an oral wash will be collected, and FENO measured as above.  Sputum will be used to 
measure nitrite concentration and quantitative bacterial load.   
 
Experimental Procedure (visit 5/day 42(+/- 5day)):  This visit will take approximately 1 hour.  
Subjects will complete the CFQ-R and have spirometry, an oral wash will be collected, 
expectorated or induced sputum will be collected, physical exam, vital signs (pulse, non-invasive 
blood pressure measurement, temperature, respiratory rate and oxygen saturation) and interval 
history assessment will be performed.  
 
Subjects will be monitored carefully for adverse events, laboratory test abnormalities, and 
changes in vital signs.  Adverse experiences will be evaluated according to criteria outlined in 
the NCI Common Terminology Criteria for Adverse Events (CTCAE), version 4.0 
 
2.3 
STUDY TREATMENT 
The study treatment will be delivery of nebulized sodium nitrite by nebulization at the dose of 45 
or 90 mg. 
 
Table 1  Dose Limiting Toxicity Criteria 
Sign or Symptom 
Moderate 
Severe1 
Bronchospasm/ 
wheezing 
Symptomatic but not requiring 
therapy 
Symptomatic and requiring therapy 
Decrease in FEV1 
>15% 
>25% 
SBP2 
Systolic ≥ 20 mm Hg drop from 
pre-dose baseline AND 
symptomatic, or SBP <80 mm 
Hg AND symptomatic 
Systolic > 30  mm Hg drop from pre-
dose baseline  AND symptomatic or 
requiring fluid replacement or other 
therapy  
Dyspnea 
Causes more discomfort (than a 
mild, easily tolerated AE) and 
interrupts the subject’s usual 
daily activities  
Incapacitating and causes 
considerable interference with the 
subject’s usual daily activities 
Cough 
Causes more discomfort (than a 
mild, easily tolerated AE) and 
interrupts the subject’s usual 
daily activities 
Incapacitating and causes 
considerable interference with the 
subject’s usual daily activities 
Hypoxia3 
SaO2 > 5% drop from baseline 
AND symptomatic  
SaO2 ≥ 10% drop from baseline or 
SaO2< 88% AND symptomatic 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
13 
Percutaneous 
methemoglobin4,5 
>5% and <7% 
≥7% 
Other drug-related 
signs or symptoms6 
Causes more discomfort (than a 
mild, easily tolerated AE) and 
interrupts the subject’s usual 
daily activities 
OR 
CTCAE v.46 Grade 2 toxicity 
Incapacitating and causes 
considerable interference with the 
subject’s usual daily activities 
OR 
CTCAE v.46 Grade 3 or 4 toxicity 
AE = adverse event; CTCAE = Common Toxicity Criteria for Adverse Events; DLT = dose limiting toxicity; SBP = systolic 
blood pressure; SaO2 = oxygen saturation (hemoglobin) 
 
1. 
Severe DLT seen in any subject which is deemed to be study drug-related will preclude further dosing with nebulized 
sodium nitrite for that subject. 
2. 
Moderate or Severe SBP without symptoms will be continuously monitored with BP measurements every 5 minutes.  
Symptomatic refers to dizziness or fainting.  Discontinuation of further dosing or dose escalation will be based upon 
follow up blood pressure measurements, subject symptoms and physician-investigator discretion (see Stopping Rules). 
3. 
Moderate or Severe SaO2 without symptoms will be continuously monitored and recorded every 5 minutes until return 
of saturation > 92%. 
4. 
Elevated percutaneous methemoglobin levels measured by pulse co-oximeter will be continuously monitored and 
confirmed by venous methemoglobin level.  Follow up will be based upon the clinical decision of the operating 
physician and will be documented as such. 
5. 
A single occurrence of venous methemoglobin levels >5% in an individual subject will result in no further dosing for 
that individual subject for the remainder of the study period. 
6. 
Common Terminology Criteria for Adverse Events v. 4.0 (CTCAE). CTCAE criteria will be applied if considered related 
to study drug and confirmed on repeat testing. 
 
2.4 
DURATION OF FOLLOW-UP:  All subjects will be followed for 14 days +/- a 5 day 
window after completion of the study treatment. Subjects removed from study for unacceptable 
adverse events will be followed until resolution or stabilization of the adverse event. 
2.5 
SAFETY MONITORING 
Prior studies suggested that hypotension and methemoglobinemia may occur with the use of 
sodium nitrite. The study treatment of inhaled nitrite will be used safely with careful monitoring 
and prompt discontinuation of the study treatment in response to systemic hypotension with 
definitions of dose limiting toxicity. The presence of severe DLT deemed to be study-drug 
related will lead to a discontinuation of the study treatment.  
Following study drug treatment, subjects will be evaluated as an outpatient at the clinic on Day 
42 (+/- 5 day window). Interval study visits (days 7, 14 and 28) have been included in the study 
design to ensure subject safety. Subjects will be followed for evidence of acute or delayed 
adverse effects from the study treatment and to assess their clinical status. All adverse events 
experienced by subjects will be collected from beginning of visit 1 through final study visit.  
Study subjects will be routinely questioned about adverse events at study visits. The study 
investigators will evaluate all subject reported and observed AEs.  All untoward medical 
occurrences observed in subjects receiving the study drug will be recorded on the participants’ 
adverse event worksheets by the study coordinator under the supervision of the principal 
investigator.  AEs occurring pre-treatment, during active treatment and post-treatment will be 
summarized separately. Subjects continuing to experience toxicity at the off study visit may be 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
14 
contacted for additional assessments until the toxicity has resolved or is deemed irreversible. If 
possible, symptoms should be managed symptomatically. In the case of toxicity, appropriate 
medical treatment should be used. 
In addition to these formal evaluations, subjects will be encouraged to immediately contact the 
study investigator and/or the study coordinator with questions, concerns, or to report new 
symptoms that occur during their study participation. If appropriate, based upon the evaluation, 
medical treatments will be provided to subjects, including appropriate referral to physicians or 
other services at the UPMC.  
2.6 
STOPPING RULES 
Two distinct scenarios in which subjects must be removed from the study are anticipated. 
First, the subject experiences a CF respiratory exacerbation marked by a persistent drop in FEV1 
>15% that is not temporally associated with nebulized sodium nitrite administration. The drop in 
FEV1 would be seen on the first set of spirometry at a visit, prior to dosing of nebulized sodium 
nitrite for that day.  In this case, subjects will be removed from the study and referred to their 
pulmonologist for treatment of the CF respiratory exacerbation. 
Drop in FEV1 >15% on the first set of spirometry, prior to drug administration, on any study 
visit when compared with baseline spirometry collected at screening. 
In the second scenario, nebulized sodium nitrite is associated with a dose-dependent intolerance 
that will be seen at the dose escalation visit 2, or after receiving the first dose of drug on visit 1.  
Specific intolerances of concern are acute bronchospasm, hypotension or methemoglobinemia.  
In this case, if any one of the below occurs at the 45 mg dose, subject will be removed from the 
study; if any occur at the 90 mg dose, the subject will return to the previously tolerated dose of 
45 mg. 
Specific criteria for dose-dependent intolerance are: 
Decrease in FEV1 by >15% between measurements on an individual study visit.   
A decrease in systolic BP > 40 mmHg drop from pre-dose baseline or to <80mmHg and 
symptomatic. 
SaO2 drop below 88% and symptomatic or SaO2 desaturation > 5% from baseline and 
symptomatic  
A single occurrence of venous methemoglobin level >5% 
Any serious adverse event thought to be possibly related to the study treatment   
2.7 
STUDY INVESTIGATIONAL THERAPY SUPPLIES 
2.8.1 Formulation and Packaging 
Formulation: 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
15 
The active ingredient of the Sodium Nitrite Inhalation Solution (nebulized sodium nitrite 
Inhalation Solution) is sodium nitrite in a sterile aqueous solution approved for intravenous use.  
It is packaged at a 30 mg/mL in 10ml vials.   
 
Packaging: 
Vials will be purchased from Hope Pharmaceuticals and patients will withdraw the appropriate 
volume using a 3 mL sterile syringe with needle and place in nebulizer.  Study subjects have 
extensive experience administering maintenance CF medications using this technique. 
2.7.2 Availability 
Nebulized sodium nitrite will be purchased from Hope Pharmaceuticals.  We will ensure that 
enough compound is on site to complete the study prior to enrolling any individual subject 
2.7.3 Preparing and Dispensing 
The study drug will dispensed by the research pharmacist and the research coordinator will 
provide instructions for withdrawing the appropriate volume via a syringe with needle and 
delivering to the nebulizer device.    
2.7.4 Drug Administration 
The route of administration is by nebulization.   It is anticipated that each nebulization will take 
approximately 10 – 15 minutes to deliver the dose. All doses specified in the protocol are the 
amounts of nebulized sodium nitrite placed into the nebulizer cup. We will be using Aerogen 
Solo nebulizers, as was done in the study by Simon, et al (17). 
2.8 
STUDY INVESTIGATIONAL THERAPY STORAGE  
The investigational drug will be kept in its original packaging and stored in a locked, secure area 
at controlled room temperature (20 – 25º C) with the investigation drug services (IDS).  The 
temperature of the storage area must be monitored to ensure compliance with required 
temperatures. A temperature log will be maintained to make certain that the drug supplies are 
stored at the correct temperature at all times maintained by IDS. Access to and administration of 
the investigational drug will be limited to the study investigators and authorized research staff. 
Study drugs may only be dispensed to subjects enrolled in this study.  
 
2.9 
STUDY INVESTIGATIONAL THERAPY ACCOUNTABILITY 
The study investigators or the study coordinator will document the amount of study drugs 
dispensed and/or administered to subjects. The study drugs accountability records will be 
maintained throughout the course of the clinical trial by IDS.  Any discrepancies in drug supplies 
will be noted and explained. 
2.10 
STUDY PROCEDURES 
Screening: Potential subjects will be recruited from the CF Center at Children’s Hospital of 
Pittsburgh and/or the UPMC Comprehensive Lung Center (CLC).  In these locations, individuals 
with CF are followed on a routine basis, and well known to one or more of the study 
investigators. After informed consent is obtained, screening evaluations, including urine 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
16 
pregnancy test (only on females of childbearing potential), physical examination, medical 
history, and clinical laboratory assessments, will be conducted to determine study eligibilities 
during a routine clinic visit. In addition, vital signs (pulse, non-invasive blood pressure 
measurement, temperature, respiratory rate and oxygen saturation) will be performed and 
baseline spirometry will be obtained. Screening is further discussed in Section 2.2.1. 
Spirometry: FEV1 will be measured with a handheld spirometer as the primary endpoint. 
Spirometry is performed for patients with CF at every outpatient visit, thus the subjects will have 
had experience performing spirometry since they were children.  A baseline spirometry will be 
done as well as spirometry at 30 and 120 minutes following nebulization of nebulized sodium 
nitrite on days 0 and 7.  Spirometry will also be performed at subsequent visits on days 14, 28 
and 42. 
Sputum Induction: Sputum induction will be performed per the CF Foundation Therapeutic 
Development Network SOP.  See detailed protocol in appendix.  In brief, the Sputum Induction 
(SI) procedure consists of four 3-minute cycles during which the participant breathes aerosolized 
3% hypertonic saline and then expectorates sputum into a sample container. The participant’s 
peak flow is monitored at the end of each cycle. As long as the peak flow remains ≥80% of pre-
induction baseline, the cycle is repeated four (4) times. An optional fifth 3-minute cycle may be 
employed for those participants who have not yet expectorated an adequate sample and are 
tolerating the procedure. The complete procedure includes several preparatory steps, discharge 
monitoring, and clean up. For the participant, the entire sputum induction procedure from the 
time of initial assessment (vital signs and peak flow) to the end of the induction with associated 
monitoring is expected to last approximately 25-35 minutes. Total saline inhalation time should 
not exceed 15 minutes.   
If subjects spontaneously expectorate, then sputum induction will not be done.  After sputum 
induction, subjects will wait a minimum of 30 minutes prior to nebulization of nebulized sodium 
nitrite because sputum induction can cause temporary bronchoconstriction and this might 
confound the safety assessment of nebulized sodium nitrite.  The amount of wait time will be 
determined by the physician investigator at the time of visit.  Sputum induction will be done on 
Study days 0, 14, 28, and 42.  If no further administration of nebulized sodium nitrite is planned 
during the visit (Days 14, 28, and 42), subjects may leave after sputum induction if they are not 
symptomatic. 
Nebulization of Drug: nebulized sodium nitrite will be nebulized via electronic nebulizer with 
direct observation by a study physician or nurse coordinator on day 0, and at dose escalation by a 
study physician or nurse coordinator on day 7 in the CTRC, CHP or an Emphysema Research 
Center room in Montefiore.  Subsequent doses will be self-administered by the subjects two 
times daily at home.  

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
17 
CFQ-R Questionnaire: Subjects will complete this standard and validated questionnaire on paper.  
Results of the CFQ-R will be confidentially stored electronically.  Original paper will be 
maintained and stored in the locked Pulmonary Medicine Allergy and Immunology office. 
NIOX device: Subjects exhale slowly through the device as guided by a small video screen with 
a smiling cloud icon.  Disposable filters are used for each subject to minimize infection control 
concerns with the device.   NIOX data will be recorded on days 0, 7 and 28.   
Phlebotomy:  Blood will be drawn by trained personnel at the screening visit (and day 0 if labs 
require repeating).  Peripheral blood for confirmatory methemoglobin level will be obtained if 
percutaneous methemoglobin levels exceed 5%.   
Vital sign measurements: Pulse, systemic blood pressure, temperature, respiratory rate and pulse 
oximetry will be measured noninvasively by trained study personnel using standard clinical 
equipment.  All these values will be measured on screening visit and days 0, 7 and 42 (exit 
exam).  On days 0 and 7 when nebulized sodium nitrite is being administered with observation, 
percutaneous measurements of oxygen saturation and methemoglobin levels will be measured 
for two hours after delivery.  Noninvasive systemic blood pressure measurements will be taken 
every 15 minutes for the first two hours.  
Subjects will be monitored carefully for adverse events, laboratory test abnormalities, and 
changes in vital signs.  Adverse experiences will be evaluated according to criteria outlined in 
the NCI Common Terminology Criteria for Adverse Events (CTCAE), version 4.0 
 
 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
18 
2.11 
SCHEDULE OF ACTIVITIES  
Study Phase 
Screening 
Treatment 
Follow-Up 
Monitoring 
Visit Type 
Outpatient  
Outpatient  
Study Day                             
day -28 
to -2 
(visit 1) 
day 0 - 
+/- 1 day 
 
(visit 2) 
day 7 - 
+/- 1 day 
 
(visit 3) 
day 14 - 
+/- 1 day 
 
(visit 4) 
day 28 - 
+/- 1 day 
 
(visit 5) 
day 42 - 
+/- 5 day 
 
Informed Consent 
x 
 
 
 
 
 
Medical History and 
Demographics 
x 
 
 
 
 
 
I/E Criteria 
x 
 
 
 
 
 
Tolerability Determination for 
Dose Escalation 
 
 
x 
 
 
 
Physical Exam 
x 
x 
 
 
 
x 
Vital Signs (Pulse, systemic 
blood pressure, temperature, 
respiratory rate and pulse 
oximetry) 
x 
x 
x 
 
 
x 
Non-invasive blood pressure 
measurement  
 
x 
x 
 
 
 
Oxygen Saturation 
 
x 
x 
 
 
 
Laboratory Tests*** 
x 
 
 
 
 
 
Urine Pregnancy Test ∆ 
x 
 
 
 
 
 
Spirometry 
X 
x 
x 
x 
x 
x 
Sputum Collection 
 
x 
 
x 
x 
x 
FeNO 
 
x 
x 
 
x 
 
oral wash 
 
x 
 
x 
x 
X 
Percutaneous metHgb Level§ 
 
x 
x 
 
x 
 
CFQ-R symptom assessment 
 
x 
x 
x 
x 
x 
AE Assessment 
 
x 
x 
x 
x 
x 
Interval History Assessment 
 
 
 
 
 
x 
∆   Urine pregnancy test will be performed only on female of childbearing potential.  *** Clinical laboratory tests may be repeated on study visit 1 if 
screen lab results deemed clinically significant and warrant repeat testing or inadvertently not collected at screen visit   § Methemoglobin 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
19 
(metHgb) levels: will be measured and recorded at the following time points: pre-dose, approx. 5, 15, 30, 60, and 120 minutes post each dose of 
nebulized sodium nitrite. If percutaneous measurements exceed 5%, then a venous blood sample will be drawn for confirmation. Peripheral 
blood for confirmatory methemoglobin level will be obtained 60 minutes after nebulization on study days 0 and 7 and for a final methemoglobin 
level on day 28. 
2.12 
DESCRIPTION OF STUDY PROCEDURES 
2.12.1 Sputum Induction 
Please see description in 2.10 above and in the SOP in the appendix.  
2.12.2 Spirometry 
Spirometry will be used to measure FEV1.  All CF subjects undergo spirometry at every 
outpatient visit, and have extensive experience with the procedure.  A handheld spirometer will 
be used. 
2.12.3 Oral Washes 
Subjects will be asked to brush teeth with a clean, single use toothbrush.  Next subjects will be 
given 10 ml of 0.9% salt water solution and instructed to swish and gargle for 1 full minute 
before spitting the salt water solution into a sterile specimen cup. 
2.12.4 Percutaneous Oxygen Saturation and Methemoglobin:  The device (Masimo Rainbow 
SET® CO-Oximeter) selected for use in this clinical trial has been validated to provide accurate 
determinations of both SaO2 and methemoglobin levels under conditions of hypoxia and 
methemoglobinemia. SaO2 and methemoglobin monitoring will occur prior to study drug 
administration until 2 hours post-dose. Measurements will be recorded pre-dose, approx. 5, 15, 
30,60, and 120 minutes post each dose of nebulized sodium nitrite. 
2.12.5 CFQ-R Questionnaire  
Subject symptoms will be measured using the Cystic Fibrosis Questionnaire – Revised (CFQ-R), 
which is the best validated and most widely used disease specific instrument for measuring 
health-related quality of life in CF(20). The CFQ-R was used during evaluation of inhaled 
amikacin, inhaled aztreonam, and ivacaftor.  The Minimal Clinically Important Difference for 
CFQ-R is 4.0 for stable patients and 8.5 during an exacerbation, thus a threshold of 4.0 point 
change will be used to define a meaningful change(21). 
2.12.6 Exhaled NO measurements 
FENO measurement will be done with a NIOX MINO device.  This is a noninvasive test that 
involves the subject slowly exhaling through the measurement device for a 10-second period of 
time.  The device is in widespread clinical use for the assessment of asthma severity. 
 
2.12.7 Laboratory Testing Peripheral blood samples will be evaluated for evaluation of study 
eligibility and includes complete blood count with differential, platelets, electrolytes, glucose, 
BUN, serum creatinine, and liver function tests (total bilirubin, ALT, AST, alkaline 
phosphatase).  Urine pregnancy test may be performed only on female of child-bearing potential 
at screening.   Screening lab samples may be collected and analyzed at UPMC laboratories or at 
outlying facility of subject’s choice.  Lab results will be added to research chart for comparison.  
Except for urine pregnancy tests, baseline laboratory results within 6 months of screen visit may 
be used as baseline comparison and will not be repeated for research purposes.  Blood samples 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
20 
may be collected on study visit 1 if baseline screening results are deemed clinically significant 
and warrant repeat testing or inadvertently not collected at screen visit. 
2.12.8 Specimen collection and management 
Specimen Collection / Documentation:  
 
Oral washes: Washes will be collected as described, de-identified and frozen for future 
microbiome studies.    
 
Sputum Collection and Handling: Sputum will be collected by spontaneous expectoration if 
possible, or induction with hypertonic saline if needed as described above.  After de-
identification, sputum samples will be divided for nitrite measurements, microbiome studies, and 
quantitative CFU measurements.  Sputum for nitrite measurements and microbiome studies will 
be immediately frozen.  Sputum for CFU measurements will be packaged for shipping to the CF 
Foundation Microbiology Core Laboratory at University of Washington.   
 
Blood Collection and Handling:  Venous blood for screening labs and methemoglobin levels will 
be drawn by trained personnel.  Samples will be sent to the hospital laboratory for analysis. 
Remaining sample will be bar coded and stored.   
 
Specimen Handling and Labeling (De-Identification) 
Specimens collected will be properly labeled. All research biological specimens and all records 
associated with the samples will be labeled only with a unique code that contains no personal 
identifiers. The information linking these code numbers to the corresponding subject’s identity 
will be kept in a secure location in the investigator’s office, and will not be available to staff 
managing samples at the research laboratories.  
 
Immediately upon receipt of the biological specimens, all attempts will be made to process, 
isolate, collect, and store the specimens. The code number and date on which the specimen is 
frozen, all other information about the specimen, and subsequent processing will be entered on 
the specimen processing worksheet. 
 
Specimen Management and Storage 
Specimens in excess of immediate assay requirements may be stored indefinitely in a locked 
freezer under the control of the principal investigator. 
 
The blood, sputum and oral wash samples will be stored after appropriate coding to remove 
patient identifiers. The coding information linking patient identifiers to the stored samples will 
be maintained in a locked, secure area that will be accessible only to the study investigator. 
Subjects may request to have their samples destroyed at any time. These samples will be 
destroyed immediately upon receipt of the subjects’ written request to do so. Identification of 
which samples to destroy will be available from the coding information linking patient identifiers 
to the stored samples as described earlier in this paragraph.  
 
Restrictions to Direct Access of Specimens 
Specimens will be kept in the responsible study investigators’ laboratories indefinitely and will 
be under the control of the principal investigator.  Investigators or other personnel not involved 
with the management or operations of the study are not permitted direct access to the specimens.  

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
21 
 
2.13 
ENDPOINTS 
2.13.1 Primary endpoint:  The primary endpoint is FEV1 to assess for bronchoconstriction 
induced by the study compound.  We will compare FEV1 before and at 30, and 120 minutes after 
dosing on day 0 with 45 mg dose, and day 7 with 90 mg dose.  A sustained decrease in FEV1 > 
15% with the 45 mg dose will be considered intolerability and the study subject will be removed 
from the protocol. If a subject tolerates one week of the 45 mg dose but has a sustained decrease 
in FEV1 after getting the first  90 mg dose, the subject will remain on the 45 mg dose for the 
duration of the study.  If a subject experiences a CF respiratory exacerbation as defined by a drop 
in FEV1 >15% on the first set of spirometry at any visit compared with baseline spirometry, then 
the subject will be removed from the study. 
2.13.2 Secondary endpoints: 
• FENO (exhaled NO) 
• sputum nitrite concentrations 
• CF Questionnaire-R subsection 
• quantitative bacterial cultures for P. aeruginosa and/or S. aureus 
• methemoglobin levels measured both non invasively and in whole blood 
• systolic blood pressure 
2.14 
SUBJECT WITHDRAWAL  
A subject may voluntarily discontinue participation in this study at any time. The investigator 
may also, at his or her discretion, discontinue a subject from this study at any time. Every effort 
should be made by the investigator to keep the subject in the study.  Subjects may be withdrawn 
from the study prior to completion if any of the following criteria are observed: 
• Intercurrent illness or an unexpected fatal or life-threatening adverse event, which 
requires discontinuation of study treatment 
• Subject requires the use of new inhaled antibiotics between day -2 and study visit 4. 
• Pregnancy 
• Subject reached protocol-defined stopping criteria 
• Request by the subject to withdraw from the study 
• Protocol violations 
• Persistent non-compliance 
• Lost to follow-up 
• Investigator discretion 
• Study closed/terminated 
 
2.14.1. Dropouts and withdrawals 
To be considered complete, a subject must complete all study visits as specified in the protocol 
without violations of the protocol so significant as to obscure the response to study treatment. 
 
Subjects who fail to complete all study required visits will not be considered complete and may 
not enroll at a later date and will not be replaced. A record will be kept of all subjects who fail to 
complete all study visits and their primary reasons for discontinuation. 
 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
22 
In the event of subject withdrawal, subjects will be encouraged to continue all follow-up visits 
for safety monitoring or to continue follow up as directed by their personal primary physicians, 
unless the subject withdraws consent at any time (without having to justify the decision). All 
available data from subjects who discontinued during the study, for whatever reason, will be 
included in the safety analysis. 
 
2.14.2 WITHDRAWL CRITERIA  
Study treatment will be discontinued in individual subjects during the day 0 inhalation if any of 
the following occurs regardless of symptoms: 
• Decrease in FEV1 by >15% between measurements on an individual study visit.   
• A decrease in systolic BP > 40 mm Hg drop from pre-dose baseline or to <80mmHg and 
symptomatic; 
• SaO2 drop below 88% and symptomatic or SaO2 desaturation > 5% from baseline and 
symptomatic  
• A single occurrence of venous methemoglobin level >5%; 
• Any serious adverse event thought to be possibly related to the study treatment   
 
Any serious adverse event thought to be possibly related to the study treatment 
If a study subject tolerates the 45 mg dose but develops hypotension, sustained > 15% decrease 
in FEV1 (as measured at time points (30min and 120 min), or oxygen desaturation with the 90 
mg dose on day 7, the subject will be observed.  If after 4 hours of observation the subject’s 
FEV1 returns to baseline, the subject’s SaO2 is not greater than 5% drop from baseline, and the 
subject’s systolic BP is not greater than 40 mm Hg drop from pre-dose baseline, the subject will 
be re-challenged with the 45mg dose; if the lower dose is tolerated, the subject will remain in the 
study at the lower dose.  
 
Subjects will be withdrawn if at any time the investigator feels that it is not in the subject’s best 
interest to continue. 
 
2.15 
STATISTICAL ANALYSIS   
2.15.1 Power Analysis and Sample Size:  
The main adverse events reported in CF antibiotic trials are increased cough and change in 
respiratory symptoms. The overall subject driven discontinuation rate for these symptoms in both 
the placebo and treatment arms of recent antibiotics studies has ranged from 10-18%, although 
these symptoms do not necessarily correlate with bronchoconstriction (22, 23).  Hypertonic 
saline is the most osmotically similar agent in use, and it causes 4.5% of children with severe CF 
lung disease to have an acute drop in FEV1 of >15% (our stopping threshold) when used for 
sputum induction(24). Over a 4 week period, recent antibiotic studies have showed a decrease in 
FEV1 of 3 to 6.5% in the placebo arms (19, 20, 22), so we are unlikely to have subjects reach the 
FEV1 discontinuation threshold if nebulized sodium nitrite is safe but ineffective. Considering 
these data, we expect a 5-10% rate of discontinuation due to FEV1 drop >15%, and we would 
consider up to 20% discontinuation acceptable. At a significance level of 0.05, a sample size of 
33 is required to achieve 82% power to detect a difference of 0.14 using a one-sided binomial 
test, assuming that the population proportion under the null hypothesis is 0.06.   

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
23 
2.15.2  Safety Analysis 
Adverse events (AEs) will be grouped by body system. The number and percentage of subject 
experiencing at least one AE of any type, AEs within each body system and AEs within each 
preferred term will be tabulated and listed. Separate summaries will be provided for all AEs, AEs 
by maximum severity, drug related AEs, severe adverse events (SAEs), and for AEs leading to 
withdrawal. All adverse events experienced by subjects will be collected from beginning of visit 
1 through final study visit.  Study subjects will be routinely questioned about adverse events at 
study visits. The study investigators will evaluate all subject reported and observed AEs.  All 
untoward medical occurrences observed in subjects receiving the study drug will be recorded on 
the participants’ adverse event worksheets by the study coordinator under the supervision of the 
principal investigator.  AEs occurring pre-treatment, during active treatment and post-treatment 
will be summarized separately.   
2.15.3 Handling of missing data: 
Every effort will be made to collect complete data on each study day. With respect to safety 
evaluation, it is not planned to impute missing data. 
3. 
HUMAN SUBJECTS 
3.1 
SUBJECT POPULATION:   
The gender and ethnic characteristics of the proposed subject population in this research protocol 
shall reflect the demographics of the population of Pittsburgh and the surrounding area. No 
exclusion criteria shall be based on race, ethnicity or gender.  Because cystic fibrosis is largely a 
disease of Caucasians, our pool of potential subjects is >95% Caucasian reflecting the incidence 
of the disease across various ethnic and racial groups.   
3.1.1 Inclusion of Women and Minority 
Both men and women of all races and ethnic groups are eligible for this trial. Women who meet 
the inclusion criteria, and have none of the exclusion criteria, will be enrolled without restriction as 
dictated by the study protocols.  Because of the use of a study medication, woman of child bearing 
potential must meet specialized inclusion/exclusion criteria to minimize this risk.   
3.1.2 Inclusion of Children 
Children under the age of 18 will not be recruited for this protocol because of the need to explore 
potential adverse effects of the study treatment more fully in adults.  
 
3.2 
INCLUSION CRITERIA:   
Subjects 18 years or older with cystic fibrosis as documented by clinical features of CF, and 
documentation of a positive sweat test or two diseasing causing mutations in the CF gene, will be 
eligible.. 
 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
24 
3.3 
EXCLUSION CRITERIA:  
FEV1<40%, use of supplemental oxygen or non-invasive ventilatory support, awaiting lung 
transplant, pregnancy or unwilling to comply with birth control during the intervention period, 
history of glucose-6-phosphate dehydrogenase (G6PD) deficiency or any contraindication to 
receiving methylene blue, hospitalization within the past 4 weeks prior to enrollment, need for 
additional antibiotics or steroids within the past 4 weeks prior to enrollment, change in 
maintenance CF therapies in the prior 4 weeks, inability to provide consent, baseline systemic 
hypotension (systolic BP<90mm Hg), chronic kidney disease (Cr >2.5 or requiring dialysis), 
severe anemia (Hgb <9 gm/dL in the last six months), history of portal hypertension or chronic 
liver disease, including hepatitis B and/or hepatitis C (with evidence of recent infection and/or 
active virus replication), defined as moderate to severe hepatic impairment (Child-Pugh Class B-
C); history of abusing alcohol or illicit drugs within 28 days prior to study, severe pulmonary 
hypertension (mean PA pressure > 25), use of sildenafil or other pulmonary vasodilator, organ 
transplant of any kind, history of orthostatic hypotension or syncope, participation in another 
interventional trial in the previous 28 days. 
4. 
RECRUITMENT AND INFORMED CONSENT PROCEDURES 
4.1 
RECRUITEMENT METHODS:   
Patients will be recruited from the CF Center at Children’s Hospital of Pittsburgh and the 
University of Pittsburgh Medical Center. A list of eligible patients will be generated using a 
query of the Pittsburgh CF Center patient registry and patients who meet the lung function and 
bacterial pathogen criteria will be approached in clinic by one of the physicians or nurse 
coordinators to discuss the study and review the informed consent. A consent form will be given 
to the individual for review. The investigator and/or research coordinator will answer any 
questions and review study procedures and the potential risks and benefits of the study. The 
subject will be given a copy of the consent form to take home and read and may be called in 
approximately one week by the department research coordinator to answer questions and assess 
interest in participation. If the subject would like to enroll themselves, a visit will be arranged 
and written informed consent will be obtained by the investigator (pulmonologist) after any 
questions are answered and before any study procedures are performed. Patients meeting all 
inclusion/exclusion criteria and providing informed consent will be enrolled. 
4.2 
INFORMED CONSENT PROCEDURES:  
Subjects will be recruited from the cystic fibrosis clinics at Children’s Hospital of Pittsburgh and 
the Lung Center at Falk Clinic. Potential subjects will be identified by querying the CF Registry 
(IRB# 0405219). Patients must have given their consent for participation in the CF Registry to be 
included. The study will be introduced to eligible subjects by their primary pulmonologist or the 
research coordinator. The subject, if interested, will speak to the research coordinator. The 
subject will be given a copy of the consent form to take home and read and may be called in 
approximately one week by the department research coordinator to answer questions and assess 
interest in participation. If the subject is interested in participation, a visit will be arranged and 
written informed consent will be obtained by the investigator (pulmonologist) after any questions 
are answered and before any study procedures are performed.  
 
The subject will be told research is voluntary and they are not obligated to participate if they are 
not interested. The subject will be presented with information on all studies they may qualify for 
prior to assessing for interest in a particular study. 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
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If circumstances arise which necessitate that new information be provided to a subject, relevant 
subjects will be verbally notified by clinical staff as soon as possible. PI will be available to 
answer questions. Verbal notification will be documented in the subject's research chart. Upon 
approval of a revised consent, if applicable, all relevant subjects will be re-consented using the 
same process as outlined above as soon as possible. 
5. 
Risks and Benefits 
5.1 
POTENTIAL RISKS 
As with any experimental procedure, there may be adverse events or side effects that are 
currently unknown, and certain of these unknown risks could be permanent, severe or life 
threatening.  Every attempt will be taken to minimize these risks.   
5.1.1 Risks of Sodium Nitrite Inhalation Solution: 
The first-in-man clinical study of nebulized sodium nitrite Inhalation Solution, Study 
AIR001-CS01, was a dose escalation study designed to identify the dose limiting toxicity, the 
maximum tolerated dose, and the pharmacokinetics of nebulized sodium nitrite administered.  
The most important safety finding was a decline in systolic and diastolic blood pressure at the 
highest dose tested, 176 mg.  Dose-dependent asymptomatic increases in heart rate were noted at 
all doses, although at doses up to and including the maximum tolerated dose of 125 mg, the heart 
rate changes were well tolerated.  Increase in heart rate was not always associated with a change 
in blood pressure.  Significant levels of methemoglobin, or changes in pulmonary function, were 
not observed. Methemoglobin levels increased at the highest doses administered, but remained 
less than 3.5% in all subjects(12).   
 
As with any drug product administered via inhalation, it is possible that susceptible individuals, 
such as those with unrecognized asthma, will develop bronchospasm upon exposure to inhaled 
sodium nitrite solution.  There were no changes in pulmonary function noted in AIR001-CS01, 
which excluded subjects with asthma or abnormal baseline pulmonary function tests. 
 
In Study AIR001-CS02, inhaled nitrite was generally well tolerated under hypoxic conditions at 
doses up to and including 113 mg.  Additionally, a sustained reduction in hypoxia-induced 
pulmonary hypertension was demonstrated, suggesting that safely delivered doses of nebulized 
sodium nitrite result in clinically significant vasodilatation, presumably through a mechanism of 
intrapulmonary reduction of nitrite to NO. In this study, the significant treatment related adverse 
event was a decrease in blood pressure.  The magnitude of the change in blood pressure from the 
hypoxic baseline was less than from the normoxic baseline, suggesting that hypoxia itself has an 
effect on BP. 
 
The Hope Pharmaceuticals package insert includes the following warnings and precautions: 
hypotension, methemoglobin formation, risk for interaction with carbon monoxide (in the setting 
of smoke inhalation), use in the setting of known anemia (causing further decreased oxygen 
carrying capacity in the setting of methemoglobinemia), G6PD Deficiency, and use with PDE5 
inhibitors and diuretics.  Adverse reactions listed include syncope, hypotension, tachycardia, 
palpitations, dysrhythmia, methemoglobinemia, headache, dizziness, blurred vision, seizures, 
confusion, coma, nausea, vomiting, abdominal pain, tachypnea, dyspnea, anxiety, diaphoresis, 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
26 
lightheadedness, injection site tingling, cyanosis, acidosis, fatigue, weakness, urticaria, 
generalized body numbness and tingling.  Note that these reactions were reported with 
intravenous formulation of sodium nitrite being used to treat life-threating cyanide poisoning, the 
total dose of nitrite given is 3-6 fold higher than in our study, and that the intravenous route may 
have more abrupt onset of effects.  These adverse reactions are manifestations of systemic 
hypoperfusion or severe methemoglobinemia.   The severe hypotension, methemoglobinemia, 
cardiac dysrhythmias and coma were reported in patients without life-threatening cyanide 
poising that were treated with intravenous doses less than twice those recommended for 
treatment of cyanide poisoning. 
5.1.2 Risks of Blood Drawing: 
The amount of blood to be drawn over the course of this research study could be a maximum of 
5 tablespoons. To minimize the risks of blood tests, a licensed technician or registered nurse will 
draw blood.  Common risks include temporary discomfort, bruising which may last for several 
days, redness, swelling, lower hemoglobin level. Infrequent risks include a subject may feel 
lightheaded or faint when blood is drawn. This is usually due to nervousness and is not usually 
serious. Rare risks include infection, and bleeding.  
5.1.3 Risks of sputum induction 
Sputum induction has been a standard study intervention in patients with CF for almost ten years 
and is generally well tolerated.  Sputum induction may be associated with any of the following 
symptoms: You may experience: a salt water aftertaste, coughing, a need to swallow, sore throat, 
shortness of breath, wheeze, chest tightness, lightheadedness, nausea, and headache. Patients will 
be asked to report any symptoms during the procedure, and measures to assess symptoms will be 
taken as described in the Standard Operating Procedure for sputum induction (see Appendix).  
5.1.4 Risks of withholding medications:  
Participants will not be asked to withhold medications during the study. 
  
5.1.5 Reproductive Risks:   
It is not known if the study drug can affect an unborn baby. Therefore, subjects should not become 
pregnant or father a baby while on this study. If subjects are physically able to father a baby or 
become pregnant, subjects must use an effective method of birth control while on this study.  If 
subjects become aware that they or their sexual partner is pregnant during the course of their 
participation in this research study, subjects must contact, as soon as possible, the study 
investigator.  
5.1.6 Risks of Exhaled Nitric Oxide Measurement: 
Exhaled Nitric Oxide Measurement is a non-invasive test commonly performed on asthma 
patients. There are no significant risks.  Subjects may experience coughing during the test. 
 
5.1.7 Risks of Spirometry: 
Subjects may experience brief mild shortness of breath, wheezing, an increase in cough, or 
lightheadedness while doing spirometry. 
 
5.1.8 Risks of Breach of Confidentiality:  

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
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Participation in this study also exposes subjects to risks associated with medical record review, 
specimen banking, and the completion of the CF respiratory symptom questionnaire.  Some 
subjects may feel the questionnaire is too personal.  To minimize this risk, privacy will be 
assured during completion of the questionnaire.  Review of medical records and specimen 
banking are associated with the risk of loss of privacy or confidentiality There is the possibility 
that if results of the medical record were generally known, the information may impact future 
insurability, employability, reproductive planning, or have a negative impact on family 
relationships.  Note that the risk of breach of confidentiality exists during regular medical 
treatment.  To minimize the risk of breach of confidential patient information we will do the 
following: All study visits are conducted in a private room.  Samples will be bar coded as 
described above.  Only IRB-approved staff will have access to any samples or information that is 
not de-identified.  All research records will be kept in the locked office in the Pulmonary 
Medicine Allergy and Immunology office. Initials and identification number only will be used 
identify patients. All databases are password protected. 
 
5.2 
PROTECTIONS AGAINST RISK 
5.2.1 Protection Against Patient Risks Related to the Study Drug 
The study has been designed with a focus on protecting subjects against risk from the medication 
including: 
• Specific exclusion criteria to provide a stable population of subjects and non-enrollment 
of subjects with significant co-morbidities that might place them at excess risk (see 
exclusion criteria above). 
• Continuous monitoring by the DSMB. 
• Involvement by trained staff / investigators with experience in the administration of 
inhaled study medications. 
• Specific holding criteria related to study adverse events. 
• Frequent monitoring of vital signs and spirometry over the duration of the study. 
 
5.2.2 Protection Against General Risks of Study Procedures 
All research interventions/activities will be conducted in private patient care areas. The 
collection of sensitive information about subjects is limited to the amount necessary to achieve 
the aims of the research, so that no unneeded sensitive information is being collected. 
 
All demographic and clinical information about the subject will be stored on an electronic 
password-guarded study database under the supervision of the investigator for this protocol. The 
electronic database has not been validated to be in full compliance with the FDA regulations at 
21 CFR Part 11.  Use of this electronic database is, however, felt to be acceptable due to the 
limited scope of this research study and the extent of data that will be collected. The data will be 
stored anonymously with a subject number. Information linking subject identifiers with the 
coded subject number will be stored under password protection on computers in locked areas, 
with access only to the database manager. Maintaining records in locked files in locked offices 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
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will protect confidentiality of subjects.  Access to the database will be limited to the data 
manager and staff under the supervision of the PIs.  
 
To prevent excessive blood sampling, a single withdrawal of blood for a combination of 
clinically indicated and this research study will not exceed 5% of the circulating blood volume, 
and the cumulative withdrawal over 1 month will not exceed 10% of the circulating blood 
volume. In addition, careful attention will be made to cardiovascular status and hemoglobin 
evaluation. 
 
Specimens will be stripped of subject identifiers and stored securely according to a similar 
coding protocol as described above. These specimens will be stored safely in the custody of the 
Principal Investigator responsible for the individual assays. These Investigators will limit future 
access to any remaining sample to only those investigators with prior IRB approval for their 
studies. 
 
All staff involved in this study are properly credentialed and instructed in the areas of testing, 
confidentiality, and safety. To minimize the risks associated with the study procedures and/or 
collection of specimens, trained staff or experienced investigators will perform the study 
procedures.  
 
5.3 
ALTERNATIVE TREATMENTS 
If subjects choose not to participate in this study, they are to continue their medical care under 
the direction of their primary physicians. 
5.4 
POTENTIAL BENEFITS 
There will be no direct benefit to the subjects participating in this study, but the society at large 
may benefit from the increased knowledge gained from this study that will lead to new treatment 
for individuals diagnosed with cystic fibrosis in the future. 
5.5 
DATA SAFETY MONITORING PLAN 
5.5.1 Data Safety Monitoring Board 
A Data and Safety Monitoring Board (iDSMB) independent of the study investigators will 
monitor this clinical trial for additional measure of subject protection. The iDSMB consists of 
clinicians completely independent of the investigators who have no financial, scientific, or other 
conflict of interest with the trial.  The iDSMB will conduct interim monitoring of accumulating 
data from research activities to assure the continue safety of human subjects, relevance and 
appropriateness of the study, and the integrity of research data. 
5.5.2 Data Safety Monitoring Plan 
Assuring patient safety is an essential component of this protocol.  The study Principal 
Investigator has primary responsibility for the oversight of the data and safety monitoring.  All 
adverse events experienced by subjects will be collected from beginning of visit 1 through final 
study visit.  Study subjects will be routinely questioned about adverse events at study visits. The 
study investigators will evaluate all subject reported and observed AEs.  All subjects who have 
AEs, whether considered associated with the use of the study medication or not, must be 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
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monitored to determine the outcome.  The clinical course of the AE will be followed up 
according to accepted standards of medical practice, even after the end of the period of 
observation, until a satisfactory explanation is found or the Principal Investigator considers it 
medically justifiable to terminate follow-up. 
 
All untoward medical occurrences observed in subjects receiving the study drug will be recorded 
on the participants’ adverse event worksheets by the study coordinator under the supervision of 
the principal investigator. AEs occurring pre-treatment, during active treatment and post-
treatment will be summarized separately.  The worksheets will then be reviewed for 
completeness and internal consistency. In addition to internal safeguards built into a 
computerized system, external safeguards will be put in place to ensure that access to the 
computerized system and to the data is restricted to authorized personnel. Training conducted by 
qualified individuals on a continuing basis will be provided to individuals in the specific 
operations with regard to computerized systems that they are to perform during the course of the 
study.  
 
*Stopping Rule: 
Two distinct scenarios in which subjects must be removed from the study are anticipated. 
First, the subject experiences a CF respiratory exacerbation marked by a persistent drop in FEV1 
>15% that is not temporally associated with nebulized sodium nitrite administration. The drop in 
FEV1 would be seen on the first set of spirometry at a visit, prior to dosing of nebulized sodium 
nitrite for that day.  In this case, subjects will be removed from the study and referred to their 
pulmonologist for treatment of the CF respiratory exacerbation. 
• 
Drop in FEV1 >15% on the first set of spirometry, prior to drug administration, on any 
study visit when compared with baseline spirometry collected at screening. 
In the second scenario, nebulized sodium nitrite is associated with a dose-dependent intolerance 
that will be seen at the dose escalation visit 2, or after receiving the first dose of drug on visit 1.  
Specific intolerances of concern are acute bronchospasm, hypotension or methemoglobinemia.  In 
this case,  if any one of the below occurs at the 45 mg dose, subject will be removed from the 
study; if any occur at the 90 mg dose, the subject will return to the previously tolerated dose of 45 
mg. 
• Decrease in FEV1 by >15% between measurements on an individual study visit.   
• A decrease in systolic BP > 40 mmHg drop from pre-dose baseline or to <80mmHg and 
symptomatic 
• SaO2 drop below 88% and symptomatic or SaO2 desaturation > 5% from baseline and 
symptomatic  
• A single occurrence of venous methemoglobin level >5% 
• Any serious adverse event thought to be possibly related to the study treatment   
 
The Investigator will prepare a detailed written summary of serious, unexpected, and treatment 
related adverse events, and will compare, and contrast the event with prior events. The detailed 
written summary will be provided to the DSMB and the IRB.  

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
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In addition, the DSMB Report addressed the following information will be submitted to the IRB 
at the time of continuing review annually or more often as required: 
 
• A list of the research personnel who participated in the data and safety monitoring. 
• The frequency of monitoring that took place during the renewal intervals and/or the dates 
that data and safety monitoring was conducted. 
• A summary of cumulative data related to unanticipated problems (including adverse 
events) including a determination of causality and whether the risk to benefit assessment 
has changed. 
• If appropriate, a summary of pertinent scientific literature reports, therapeutic 
developments, or results of related studies that may have an impact on the safety of study 
participants or the ethics of the research study. 
• A summary of the outcome of reviews conducted to ensure subject privacy and research 
data confidentiality. 
• Final conclusions regarding changes to the anticipated benefit-to-risk assessment of the 
study participation and final recommendations related to continuing, changing, or 
terminating the study. 
• We will comply with the reporting of adverse events to the IRB per the Human Research 
Protection Office Policies and Procedures Manual. 
 
5.5.3 Parameters to be Monitored 
The following progress will be monitored throughout the course of the research to ensure the 
safety of subjects as well as the integrity and confidentiality of their data. 
• An evaluation of the progress of the research study, including subject recruitment and 
retention, and an assessment of the timeliness and quality of the data. 
• A review of collected data (including adverse events, unanticipated problems, and subject 
withdrawals) to determine whether there is a change to the anticipated benefit-to-risk 
assessment of study participation and whether the study should continue as originally 
designed, should be changed, or should be terminated. 
• An assessment of external factors or relevant information (eg. Pertinent scientific 
literature reports or therapeutic development, results of related studies) that may have an 
impact on the safety and study participants or the ethics of the research study. 
• A review of study procedures designed to protect the privacy of the research subjects and 
the confidentiality of their research data. 
 
5.5.4  Frequency of Monitoring 
The Investigator will review subject safety data as it generated. The Investigator and the research 
staff will meet on a quarterly interval to re-evaluate study goals, subject recruitment, data coding 
and retention, documentation and identification of adverse events, complaints and confidentiality 
of subjects. There will be an evaluation of the progress of the research study, including 
assessments of data quality, time lines, participant recruitment, accrual, and retention. The 
Investigator will also review the outcome and adverse event data to determine whether there is 
any change to the anticipated benefit-to-risk ratio of study participation and whether the study 
should continue as originally designed or should it be re-evaluated and changed. 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
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The iDSMB is expected to meet at least two times a year at the call of the Chairperson to review 
the progression of the study including patient enrollment, protocol compliance, and adverse 
event reports. An emergency meeting of the iDSMB may be called at any time by the Chair 
should participant safety questions or other unanticipated problems arise. 
 
5.5.5 Adverse Event Reporting: 
The study investigators will be responsible for detecting, documenting and reporting events that 
meet the following definition of an adverse event as define below: 
 
Adverse event. Any untoward medical occurrence in a clinical study; regardless of the causal 
relationship of the event with the investigational drug or study treatment(s). 
 
Associated with the use of the investigational drug or study treatment(s).  There is a reasonable 
possibility that the adverse event may have been caused by the investigational drug or study 
treatment(s). 
 
Disability.  A substantial disruption of a person’s ability to conduct normal life functions. 
 
Life-threatening adverse event.  Any adverse event that places the patient or subject, in the view 
of the investigator, at immediate risk of death from the event as it occurred (i.e., does not include 
an adverse event that, had it actually occurred in a more severe form, might have caused death). 
 
Serious adverse event. Any adverse event occurring at any dose that results in any of the 
following outcomes: death, a life-threatening adverse event, inpatient hospitalization or 
prolongation of existing hospitalization, a persistent or significant disability/incapacity, or a 
congenital anomaly/birth defect. 
 
Hospitalization shall include any initial admission (even if less than 24 hours) to a healthcare 
facility as a result of a precipitating clinical adverse event; to include transfer within the hospital 
to an intensive care unit.  Hospitalization or prolongation of hospitalization in the absence of a 
precipitating, clinical adverse event (e.g., for a preexisting condition not associated with a new 
adverse event or with a worsening of the preexisting condition; admission for a protocol-
specified procedure) is not, in itself, a serious adverse event.   
 
Unexpected adverse event.  Any adverse event, the frequency, specificity or severity of which is 
not consistent with the risk information described in the clinical protocol(s) or elsewhere in the 
current IND application, as amended. 
 
5.5.6 Recording/Reporting requirements  
5.5.6.1 Eliciting adverse event information 
All adverse events experienced by subjects will be collected from beginning of visit 1 through 
final study visit.  Clinical study subjects will be routinely questioned about adverse events at 
study visits.   

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
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5.5.6.2 Recording requirements 
All observed or volunteered adverse drug events (serious or non-serious) and abnormal test 
findings, regardless of treatment group or suspected causal relationship to the investigational 
drug or study treatment(s) will be recorded in the subjects’ case histories.  For all adverse events, 
sufficient information will be pursued and/or obtained so as to permit 1) an adequate 
determination of the outcome of the event (i.e., whether the event should be classified as a 
serious adverse event) and; 2) an assessment of the casual relationship between the adverse event 
and the investigational drug or study treatment(s).    
 
Adverse events or abnormal test findings felt to be associated with the investigational drug or 
study treatment(s) will be followed until the event (or its sequelae) or the abnormal test finding 
resolves or stabilizes at a level acceptable to the Investigator. 
5.5.6.3 Abnormal test findings 
An abnormal test finding will be classified as an adverse event if one or more of the following 
criteria are met: 
• The test finding is accompanied by clinical symptoms. 
• The test finding necessitates additional diagnostic evaluation(s) or medical/surgical 
intervention; including significant additional concomitant drug treatment or other therapy  
• The test finding leads to a change in study dosing or discontinuation of subject 
participation in the clinical study 
• The test finding is considered an adverse event by the investigator-sponsor of the IND 
application 
 
Note: simply repeating a test finding, in the absence of any of the other listed criteria, does not 
constitute an adverse event.   
5.5.6.4 Causality and severity assessment 
The investigator-sponsor of the IND application will promptly review documented adverse 
events and abnormal test findings to determine 1) if the abnormal test finding should be 
classified as an adverse event; 2) if there is a reasonable possibility that the adverse event was 
caused by the investigational drug or study treatment(s); and 3) if the adverse event meets the 
criteria for a serious adverse event. 
 
If the investigator-sponsor’s final determination of causality is “unknown and of questionable 
relationship to the investigational drug or study treatment(s)”, the adverse event will be classified 
as associated with the use of the investigational drug or study treatment(s) for reporting 
purposes.  If the investigator-sponsor’s final determination of causality is “unknown but not 
related to the investigational drug or study treatment(s)”, this determination and the rationale for 
the determination will be documented in the respective subject’s case history.  
 
5.6 
Reporting of adverse events 
5.6.1 Reporting of adverse events to the FDA 
5.6.1.1 Written IND Safety Reports:  The investigator-sponsor will submit a written IND Safety 
Report (i.e., completed FDA Form 3500 A) to the responsible new drug review division of the 
FDA for any observed or volunteered adverse event that is determined to be 1) associated with 
the investigational drug or study treatment(s); 2) serious; and 3) unexpected.  Each IND Safety 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
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Report will be prominently labeled, “IND Safety Report”, and a copy will be provided to all 
participating sub-investigators.   
 
Written IND Safety Reports will be submitted to the FDA as soon as possible and, in no event, 
later than 15 calendar days following the Sponsor’s receipt of the respective adverse event 
information. 
 
For each written IND Safety Report, the investigator-sponsor and Aires Pharmaceuticals, Inc. 
chief medical officer or designee will identify all previously submitted IND Safety Reports that 
addressed a similar adverse event experience and will provide an analysis of the significance of 
newly reported adverse event in light of the previous, similar report(s). 
 
Follow-up information to an IND Safety Report will be submitted to the applicable review 
division of the FDA as soon as the relevant information is available.  If the results of the 
sponsor-investigator’s follow-up investigation show that an adverse event that was initially 
determined to not require a written IND Safety Report does, in fact, meet the requirements for 
reporting; the investigator-sponsor will submit a written IND Safety Report as soon as possible, 
but in no event later than 15 calendar days, after the determination was made. 
5.6.1.2 Telephoned IND Safety Reports 
In addition to the subsequent submission of a written IND Safety Report (i.e., completed FDA 
Form 3500A), the investigator-sponsor will notify the responsible review division of the FDA by 
telephone or facsimile transmission of any observed or volunteered adverse event that is 1) 
associated with the use of the investigational drug or study treatment(s); 2 fatal or life-
threatening; and 3) unexpected. 
 
The telephone or facsimile transmission of applicable IND Safety Reports will be made as soon 
as possible but in no event later than 7 calendar days after the investigator-sponsor’s initial 
receipt of the respective human adverse event information. 
5.6.2 Reporting adverse events to the responsible IRB 
In accordance with applicable policies of the University of Pittsburgh Institutional Review Board 
(IRB), the Investigator will report, to the IRB, any observed or volunteered adverse event that is 
determined to be 1) associated with the investigational drug or study treatment(s); 2) serious; 
and 3) unexpected.  Adverse event reports will be submitted to the IRB in accordance with the 
respective IRB procedures.  
 
Applicable adverse events will be reported to the IRB as soon as possible and, in no event, later 
than 10 calendar days following the Investigator’s receipt of the respective information.  Adverse 
events which are 1) associated with the investigational drug or study treatment(s); 2) fatal or 
life-threatening; and 3) unexpected will be reported to the IRB within 24 hours of the 
Investigator’s receipt of the respective information.  
 
Follow-up information to reported adverse event will be submitted to the IRB as soon as the 
relevant information is available.  If the results of the sponsor-investigator’s follow-up 
investigation show that an adverse event that was initially determined to not require reporting to 
the IRB does, in fact, meet the requirements for reporting; the Investigator will report the adverse 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
Protocol v6.0/Nov. 28, 2018 
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event to the IRB as soon as possible, but in no event later than 10 calendar days, after the 
determination was made. 
6. 
STUDY ADMINISTRATION 
6.1 
QUALITY CONTROL AND QUALITY ASSURANCE 
Study worksheets will be completed for each subject enrolled into the clinical study.  The 
Investigator will review, sign and date completed worksheets; the Investigator’s signature 
serving as attestation of the Investigator’s responsibility for ensuring that all clinical and 
laboratory data are complete, accurate and authentic.   
Appropriate coded identifications (i.e. Subject ID number) will be used. Every effort will be 
made to collect complete data for each study visit. Causes of missing data will be fully 
documented. With respect to safety evaluation, it is not planned to impute missing data. 
6.2 
DATA HANDLING AND RECORD-KEEPING 
The Sponsor and Investigator will maintain records in accordance with Good Clinical Practice 
guidelines; to include: 
• FDA correspondence related to the IND and clinical protocol, including copies of 
submitted Safety Reports and Annual Reports  
• IRB correspondence (including approval notifications) related to the clinical protocol; 
including copies of adverse event reports and annual or interim reports 
• Current and past versions of the IRB-approved clinical protocol and corresponding IRB-
approved consent form(s) and, if applicable, subject recruitment advertisements 
• Signed FDA Form 1572 Statements of Investigator (i.e., for the Sponsor and all identified 
sub-investigators) 
• Financial disclosure information (Investigator-sponsor and clinical protocol sub-
investigators) 
• Curriculum vitae (Sponsor and clinical protocol sub-investigators) 
• Certificates of required training (e.g., human subject protections, Good Clinical Practice, 
etc.) for Sponsor and listed sub-investigators 
• Listing of printed names/signatures of Investigator-sponsor and listed sub-investigators 
• Normal value(s)/range(s) for medical/laboratory/technical procedures or tests included in 
the clinical protocol 
• Laboratory certification information 
• Instructions for on-site preparation and handling of the investigational drug(s), study 
treatment(s), and other study-related materials (i.e., if not addressed in the clinical 
protocol) 
• Decoding procedures for blinded trials (incorporate only if applicable) 
• Master randomization list (incorporate only if applicable) 
• Signed informed consent forms 
• Completed worksheets; signed and dated by Investigator 
• Source Documents or certified copies of Source Documents 
• Monitoring visit reports  

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
Confidential                                                                                                                                           
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• Copies of Sponsor communications to the Investigator and copies of Investigator 
communications to sub-investigators  
• Subject screening and enrollment logs 
• Subject identification code list 
• Investigational drug accountability records, including documentation of drug disposal. 
• Retained biological specimen log 
• Interim data analysis report(s)  
• Final clinical study report 
 
Subject-specific data and will be coded and the subject identification code list will be stored so 
as to protect the subjects’ confidentiality.  Subject names or other directly identifiable 
information will not appear on any reports, publications, or other disclosures of clinical study 
outcomes. 
The Investigator-sponsor will retain the specified records and reports for up to 2 years after the 
marketing application is approved for the investigational drug; or, if a marketing application is 
not submitted or approved for the investigational drug, until 2 years after investigations under the 
IND have been discontinued and the FDA so notified. 
6.3 
ETHICS 
6.3.1 Institutional Review Board (IRB) Approval 
The Investigator will obtain, from the University of Pittsburgh Institutional Review Board (IRB), 
prospective approval of the clinical protocol and corresponding informed consent form(s); 
modifications to the clinical protocol and corresponding informed consent forms, and brochures 
(i.e., directed at potential research subjects and clinical faculty/staff) for study recruitment.    
The only circumstance in which a deviation from the current IRB-approved clinical 
protocol/consent form(s) may be initiated in the absence of prospective IRB approval is to 
eliminate an apparent immediate hazard to the research subject(s).  In such circumstances, the 
Investigator will promptly notify the University of Pittsburgh IRB of the deviation.  
The University of Pittsburgh IRB operates in compliance with FDA regulations at 21 CFR Parts 
50 and 21 CFR 56, and in conformance with applicable International Conference on 
Harmonization (ICH) Guidelines on Good Clinical Practice (CGP).  
In the event that the University of Pittsburgh IRB requires, as a condition of approval, substantial 
changes to a clinical protocol submitted under an FDA-accepted IND application, or in the event 
of the Investigator’s decision to modify the previously accepted clinical protocol: 
The Investigator will submit (i.e., in advance of implementing the change) a Protocol 
Amendment to the IND describing any change to this Phase I/II clinical protocol that 
significantly affects the safety of the subjects.  For changes that do not affect critical safety 
assessments, the revisions to the clinical protocol will be addressed in the Annual Report to the 
IND.  

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6.3.2 Ethical and scientific conduct of the clinical study  
The clinical study will be conducted in accordance with the current IRB-approved clinical 
protocol; ICH Guidelines on GCP; and relevant policies, requirements, and regulations of the 
University of Pittsburgh IRB, University of Pittsburgh and UPMC, Commonwealth of 
Pennsylvania, and applicable federal agencies. 
The Investigator will make certain that appropriate processes and procedures are in place to 
ensure that ongoing questions and concerns of enrolled subjects are adequately addressed and 
that the subjects are informed of any new information that may affect their decision to continue 
participation in the clinical study.  In the event of substantial changes to the clinical study or the 
risk-to-benefit ratio of study participation, the Investigator will obtain the informed consent of 
enrolled subjects for continued participation in the clinical study. 
7. 
COSTS AND PAYMENTS 
7.1 
COSTS 
The study is jointly supported by the Cystic Fibrosis Foundation and NIH.  The Cystic Fibrosis 
Foundation supports the costs of subject payment, analysis of samples, procedures such as 
spirometry, and costs associated with use of the clinical research center.  No study related costs 
will be billed to patients or their insurance providers.  
7.1 
PAYMENTS 
Subjects will be paid as follows: 
Screening $30 
Visit 1 / Day 0 $150 
Visit 2 / Day 7 $150 
Visit 3 / Day 14 $50 
Visit 4 / Day 28 $75 
Visit 5 / Day 42 $50 
In addition, subjects will also be reimbursed for parking and travel for study visits at the standard 
government rate.   
8. 
QUALIFICATIONS AND SOURCE OF SUPPORT 
8.1 
QUALIFICATION OF INVESTIGATORS 
  
Sponsor: 
Mark Schmidhofer, MD is an Associate Professor of Medicine, at the University of Pittsburgh, 
Heart and Vascular Institute.  Dr. Schmidhofer is the Director of the Coronary Intensive Care 
Unit and Director of Quality Improvement, Division of Cardiology.  He has served as coauthor 
on several publications.  Dr. Schmidhofer will work closely with Dr. Simon in maintaining the 
necessary regulatory documents for this established IND. 

Study Short Title: Inhaled Nitrite for CF 
PI: Joseph Pilewski, MD 
PRO15040062 
 
  PI: Joseph Pilewski, MD 
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Protocol v6.0/Nov. 28, 2018 
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Principal Investigator 
Joseph Pilewski, MD is an Associate Professor of Medicine, Pediatrics, and Cell Biology, and 
Co-director of the Adult CF program in the CF Center at CHP, and has been principal 
investigator on numerous large clinical trials involving children and adults with CF as well as 
serving on the CF Foundation Therapeutics Development Network. Dr. Pilewski treats adult 
cystic fibrosis patients as part of his practice, and will aid with the recruitment and consenting 
process. He will also provide medical supervision for the studies being performed and will be 
extensively involved in the interpretation of the results of the study. 
 
Sub-investigators: 
Michael Myerburg, MD is an Assistant Professor in the Pulmonary, Allergy and Critical Care 
Medicine Division who has a clinical practice at the Cystic Fibrosis Center and conducts basic 
and clinical research related to CF. Dr. Myerburg sees adult CF patients as part of his practice, 
and he will aid with recruitment, consenting, and study execution.  
 
Keven Robinson, MD is an Assistant Professor of Medicine in Pulmonary, Allergy and Critical 
Care Medicine Division who has joined Dr. Pilewski in his clinical practice at the Cystic Fibrosis 
Center. Dr. Robinson sees adult CF patients as part of her practice, and she will aid with 
recruitment, consenting and study execution.  
Joel Weinberg, MD is Co-director of the CF Center and an adult CF clinician, and has 
experience as principal or co-investigator on numerous clinical trials for cystic fibrosis. He will 
aid with recruitment and consenting.  
Anna Zemke, MD. PhD. is Assistant Professor of Medicine in Pulmonary, Allergy and Critical 
Care Medicine Division. She currently practices ICU medicine at UPMC East and UPMC 
Presbyterian-Shadyside. 
 
8.2 
SOURCE OF SUPPORT 
Grant support from the Cystic Fibrosis Foundation and NIDDK P30 Core.  
 
9. 
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Pulm Med 19:251–8. 
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infection in cystic fibrosis lung disease and new perspectives of treatment: a review. Eur J Clin 
Microbiol Infect Dis 32:1231–52. 
3.  
Paranjape SM, Mogayzel PJ. 2014. Cystic fibrosis. Pediatr Rev 35:194–205. 
4.  
 2011. Patient Registry: Annual Data Report 2011. 
http://www.cff.org/UploadedFiles/research/ClinicalResearch/2011-Patient-Registry.pdf. 

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PRO15040062 
 
  PI: Joseph Pilewski, MD 
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5.  
Major TA, Panmanee W, Mortensen JE, Gray LD, Hoglen N, Hassett DJ. 2010. Sodium nitrite-
mediated killing of the major cystic fibrosis pathogens Pseudomonas aeruginosa, Staphylococcus 
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Agents Chemother2010/08/11. 54:4671–4677. 
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Anaerobic killing of mucoid Pseudomonas aeruginosa by acidified nitrite derivatives under cystic 
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7.  
Zemke AC, Shiva S, Burns JL, Moskowitz SM, Pilewski JM, Gladwin MT, Bomberger JM. 2014. 
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Safety, and Tolerability of Nebulized Sodium Nitrite (AIR001) Following Repeat-Dose Inhalation 
in Healthy Subjects. Clin Pharmacokinet. 
13.  
Meng QH, Springall DR, Bishop AE, Morgan K, Evans TJ, Habib S, Gruenert DC, Gyi KM, 
Hodson ME, Yacoub MH, Polak JM. 1998. Lack of inducible nitric oxide synthase in bronchial 
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Pathol1998/06/06. 184:323–331. 
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Keen C, Olin AC, Edentoft A, Gronowitz E, Strandvik B. 2007. Airway nitric oxide in patients 
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Rowe JJ, Yarborough JM, Rake JB, Eagon RG. 1979. Nitrite Inhibition of Aerobic Bacteria. Curr 
Microbiol 2:51–54. 
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Bowman LA, McLean S, Poole RK, Fukuto JM. 2011. The diversity of microbial responses to 
nitric oxide and agents of nitrosative stress close cousins but not identical twins. Adv Microb 
Physiol2011/11/26. 59:135–219. 
17.  
Simon MA, Vanderpool RR, Nouraie M, Bachman TN, White PM, Sugahara M, Gorcsan J, 
Parsley EL, Gladwin MT. 2016. Acute hemodynamic effects of inhaled sodium nitrite in 
pulmonary hypertension associated with heart failure with preserved ejection fraction. JCI Insight. 
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Borlaug BA, Koepp KE, Melenovsky V. 2015. Sodium Nitrite Improves Exercise Hemodynamics 
and Ventricular Performance in Heart Failure with Preserved Ejection Fraction. J Am Coll 
Cardiol. 
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Rehman HU. 2001. Methemoglobinemia. West J Med 175:193–6. 
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Quittner AL, Buu A, Messer MA, Modi AC, Watrous M. 2005. Development and validation of 
The Cystic Fibrosis Questionnaire in the United States: a health-related quality-of-life measure for 

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PRO15040062 
 
  PI: Joseph Pilewski, MD 
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cystic fibrosis. Chest2005/10/21. 128:2347–2354. 
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Quittner AL, Modi AC, Wainwright C, Otto K, Kirihara J, Montgomery AB. 2009. Determination 
of the minimal clinically important difference scores for the Cystic Fibrosis Questionnaire-Revised 
respiratory symptom scale in two populations of patients with cystic fibrosis and chronic 
Pseudomonas aeruginosa airway infection. Chest 135:1610–8. 
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Geller DE, Flume PA, Staab D, Fischer R, Loutit JS, Conrad DJ. 2011. Levofloxacin inhalation 
solution (MP-376) in patients with cystic fibrosis with Pseudomonas aeruginosa. Am J Respir Crit 
Care Med 183:1510–6. 
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Montgomery AB, Geller DE. 2012. Fosfomycin/tobramycin for inhalation in patients with cystic 
fibrosis with pseudomonas airway infection. Am J Respir Crit Care Med 185:171–8. 
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induction in children with cystic fibrosis. Pediatr Pulmonol 35:309–13. 
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