Safety, Efficacy, and Feasibility of High-dose Cholecalciferol in Pediatric Patients With Cystic Fibrosis
Phase: PHASE2
Conditions: Vitamin D Deficiency
Sponsor: Johns Hopkins All Children's Hospital

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
Page 1 of 18  
  
  
  
Study Title: Safety, Efficacy, and Feasibility of High-dose Cholecalciferol  in 
Pediatric Patients with Cystic Fibrosis  
 
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
Document: Protocol to accompany reported study results  
  
  
  
  
  
  
NCT02613884  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
Page 2 of 18  
JHM IRB - eForm A – Protocol  
  
Safety, Efficacy, and Feasibility of High-dose Cholecalciferol  in 
Pediatric Patients with Cystic Fibrosis  
  
  
*********************************************************************************************  
 
1.  
Abstract  
Children and adults with Cystic Fibrosis (CF) are at risk of developing a vitamin D deficiency or 
insufficiency, defined as a 25-hydroxyvitamin D (25OHD) serum blood level <30 ng/mL. 
Greater than 85% of people with CF have pancreatic insufficiency, which contributes to poor 
absorption of fat soluble vitamins and dietary fats. A 25OHD level greater than 30 ng/mL has 
been shown to provide improvements to markers of inflammation in adults with CF and is 
known to improve bone mineral density and prevent bone fractures in all populations, including 
CF. This study will assess the safety of a one-time high dose of cholecalciferol or vitamin D3 
along with efficacy and feasibility of providing this therapy.   
  
Children between the ages of 3 years and 18 years (inclusive), with a 25OHD level <30 ng/mL 
will be provided with a vitamin D3 supplement of 250,000 international units (IU) observed in 
our CF clinic. We hypothesize that this one-time, oral, high dose of vitamin D3 will safely and 
effectively raise the 25OHD level to above 30 ng/mL.   
  
Safety will be monitored using a tiered safety protocol. Within the first tier, a serum calcium 
level and a serum phosphorus level will be measured at 1 week and 3 months following the 
dosage. This timing is appropriate as cholecalciferol has a half-life of 2-3 weeks and these timed 
levels  would be at or near the middle of the 25-OHD range. A second tier safety evaluation will 
only be done if serum calcium levels or serum phosphorus levels are elevated. For this second 
tier, the participant will have a parathyroid hormone level measured (PTH) as well as a spot 
urine calcium to creatinine ratio.   
  
Feasibility is to be measured using a 10-question phone survey 1 week following the dosage (see 
appendix A - attached). Efficacy will be measured by the 25OHD level itself; if 25OHD levels 
are found to be between 30-100 ng/mL over the course of the study, the dose will have 
demonstrated effectiveness in achieving the study’s goal.   
  
The purpose of this study is to show that 25OHD levels can be safely corrected with a one-time 
dose of vitamin D3 and be feasibly provided in the outpatient setting to children with CF.  
  
 
2.  
Objectives (include all primary and secondary objectives)  
Primary   
1. Assess the safety of a single dose of oral vitamin D3 (250,000 IU) for the 
treatment of vitamin D insufficiency in pediatric cystic fibrosis patients.   
  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
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Secondary   
1. Assess the feasibility of undertaking a future large scale randomized 
controlled trial. Specifically, we will:  
(a) Assess the acceptability and timing of the selected outcome 
measures;   
(b) Obtain estimates needed to design a full-scale randomized trial design 
(if warranted), including: number of eligible participants, recruitment 
rate, retention rate, response rates to initial and follow up 
questionnaires.   
2. Determine the efficacy of a single dose of oral vitamin D3 (250,000 IU) for 
the treatment of vitamin D insufficiency in pediatric cystic fibrosis   
  
 
3.  
Background   
Cystic Fibrosis is an inherited disease that primarily affects the lungs but also can affect the 
pancreas, liver and gastrointestinal tract. Subsequently, the bone health of individuals is also 
compromised due to complications arising from malnutrition, malabsorption, and repeated 
pulmonary exacerbations.   
  
Greater than 85% of individuals with Cystic Fibrosis have pancreatic insufficiency, meaning that 
their pancreas does not produce digestive enzymes to chemically break down carbohydrates, fats, 
and proteins. It is known that a majority of digestion takes place in the duodenum of the small 
intestine where the digestive enzymes are secreted by the pancreas to the duodenum in 
preparation for the chyme that is released from the stomach. Without digestive enzymes, 
individuals with CF end up with large macronutrients passing through the small and large 
intestine undigested, unabsorbed and eventually excreted. Maldigestion and malabsorption 
results in steatorrhea or fatty stools. Therefore, individuals with CF are required to take 
porcinebased pancreatic replacement enzymes before each meal or snack to digest and absorb the 
carbohydrates, fats and proteins in their food.   
  
In addition to having difficulty digesting and absorbing macronutrients, individuals with CF also 
have difficulty absorbing fat soluble vitamins such as vitamin A, vitamin D, vitamin E and 
vitamin K . Therefore, individuals with CF are prescribed higher maintenance dosages of these 4 
micronutrients to ensure they have adequate absorption and do not become deficient. Individuals 
with CF require significantly more than the current recommendations vitamins, calories and 
protein. Recent literature has demonstrated that a substantial proportion of patients with CF are 
vitamin D  insufficient and the current guidelines in treating their clinical insufficiency are not 
adequate (1).Adequate vitamin D status is defined and measured by a 25OHD level of greater 
than or equal to 30 ng/mL. Vitamin D insufficiency is defined as a 25OHD level of between 
2029 ng/mL and vitamin D deficiency is defined as a 25OHD level of less than 20 ng/mL.   
  
Adequate vitamin D levels have been frequently linked to improving bone mass in those with 
and without CF. Low levels of vitamin D (25OHD) make it difficult for the body to produce 
sufficient osteoclasts, which are found in growing bone (1).  Lower than expected  bone mass of 
the spine and whole body has been potentially linked to suboptimal levels of vitamin D in 

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
Page 4 of 18  
pediatric patients with CF (2). In  adult CF populations, sufficient levels of vitamin D have also 
been linked to reductions in inflammatory markers such as tumor necrosis factor and interleukin6 
(3).   
  
The Cystic Fibrosis foundation currently outlines step-wise treatment for vitamin D insufficiency 
as well as for vitamin D deficiency (4). A Cochrane review describing vitamin D 
supplementation in cystic fibrosis was published in 2012. The authors reported that none of the 
studies in the review had closely examined bone mineral density relationship, nutritional status, 
or growth related to vitamin D. Lung function at baseline was reported in one of the studies; 
however, no data was collected in any of the reviewed studies indicating proportions of 
respiratory exacerbations and none of the reviewed studies assessed quality of life (5). Therefore, 
there is still extensive research needing to be performed with regards to CF and vitamin D 
insufficiency.   
  
Currently, our CF center at Johns Hopkins All Children’s Hospital are seeking to improve the 
administration of vitamin D to our insufficient  CF patients. We know that individuals with CF 
are burdened with multiple medications throughout the day. The current administration of 
vitamin D to our patients who have vitamin D insufficiency include a recommendation for the 
parent or caregiver to purchase vitamin D as cholecalciferol in the prescribed amount, at a local 
drug store, and to administer to the patient once daily with food and with enzymes (if 
applicable). After consistently providing this prescribed dose for 12 weeks, the patient is asked 
to have his/her 25OHD level re-drawn with a second venipuncture. Anecdotally we have 
discovered that parents and caregivers often do not obtain the prescribed amount of vitamin D by 
the next CF clinic visit 2-3 months later and will also delay the second episode of venipuncture 
due to anxiety surrounding this procedure.   
  
When we analyzed our center specific data on vitamin D levels and treatment, we discovered that 
our current efforts reveal approximately 87% of our population have vitamin D levels  within the 
past twelve months. Of those tested, 53 (40%) demonstrate levels between 30 ng/ml and 40 
ng/ml and 43 (33%) below 30 ng/ml (insufficient), the remaining 27% had levels below 20 
ng/mL (deficient). Current empirical and anecdotal data show a clear need for improvement in 
administration of vitamin D3 for the purpose of correcting vitamin D insufficiency and 
deficiency in this pediatric CF population.  
  
As evidenced by our recent analysis, we continue to face challenges in our efforts to improve 
vitamin D abnormalities. Insurance companies rarely, if ever, cover vitamin supplements, putting 
the financial burden on parents. Adding additional medication to already expansive chronic 
therapy increases the burden of care for everyone involved. Repeating vitamin D level tests 
several times a year results in significant patient and family stress for those with needle aversion, 
including additional costs to insurance and other financial entities.  
  
To address these challenges, we are exploring alternatives to our current treatment methods.  
These include increasing the daily maintenance dose of vitamin D3 across the board.  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
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Alternatively, we are evaluating  implementation of STOSS (single high-dose oral vitamin D3) 
therapy. Research has shown that a one-time high dosage of cholecalciferol (vitamin D3), 
increases 25OHD levels in the Cystic Fibrosis population as well as the non-CF population in 
both pediatric and adult individuals, without hypercalcemia and with reductions in parathyroid 
hormone (PTH) (6, 7, 8, 9).  If successful, changing the current route of correcting vitamin D 
insufficiency via STOSS therapy would provide financial relief related to medication access and 
a decrease in burden of care.   
  
Research has displayed that the human body’s response to vitamin D3 is biphasic, meaning it 
responds rapidly to low vitamin D3 doses and responds much slower to a larger vitamin D3 dose. 
Heaney et al. found that the low doses of vitamin D3 had a half-life of 20-30 days, but a high 
dose, such as 100,000 IU vitamin D3 had a half-life of 50 days (10). The authors hypothesized 
that perhaps at this higher dosage the vitamin D3 is being stored in fat and other body tissues and 
then slowly released; whereas the daily low doses of vitamin D3 provide an immediate increase 
or response that can sometimes be reflected in the blood sample.  
  
In children and adults without malabsorption disorders, the current recommended range of daily 
vitamin D intake ranges from 400 IU per day for children as recommended by the American 
Academy of Pediatrics (11). Whereas the Institute of Medicine or IOM recommends a range of  
600 IU to 4000 IU per day based on the age of the child. The IOM committee did increase its  
“upper level intake”.  That dose is 4,000 IU/day for adults, 3,000 IU/day for kids aged 4-8, 2,500 
IU/day for kids aged 1-3, 1,500 IU/day for infants aged 6-12 months, and 1,000 IU/day for 
infants aged 0-6 months. The Endocrine Society for Patients at risk for vitamin D deficiency 
recommend a daily requirement of 400 IU-1000 IU for children depending on age and their 
upper level intake is 2000-4000 IU per day depending on age as well (12, 13). However, these 
recommendations are not for children with absorption disorders such as Cystic Fibrosis.  
  
According to the National Institutes of Health, 25-OHD levels which are consistently greater 
than 200 ng/mL are "potentially toxic" (13). The IOM committee found no conclusive evidence 
that increased vitamin D levels confer increased health benefits, challenging the concept that 
“more is better". However, this was meant to be applied to healthy populations. A review of 
literature conducted in 2013 displayed that intoxication from vitamin D supplementation was 
rare in the pediatric setting. This same review also found that hypervitaminosis was “usually 
asymptomatic” and errors in formulation of the vitamin, manufacturing or prescription of the 
vitamin resulted in intoxication (13).  
  
Vitamin D toxicity or hypervitaminosis D is characterized by elevated serum calcium levels or 
hypercalcemia (14). Due to the hypercalcemia, acute symptoms of toxicity can include muscle 
weakness, confusion, vomiting, anorexia, polyuria and polydipsia. In addition, hypercalcemia 
can be chronic, and those symptoms of intoxication from hypervitaminosis D could include bone 
demineralization, pain, and nephrocalcinosis.   
  
Therefore, we believe STOSS therapy will efficaciously, safely and feasibly increase vitamin D 
levels to above 30 ng/mL in our pediatric CF population. We hypothesize that STOSS therapy 

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
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administered once in clinic as witnessed by a designated clinician, will maintain 25OHD levels 
greater than or equal to 30 ng/mL without instances of hypercalcemia (7).  
  
 
4.  
Study Procedures  
The study is a phase 2 single arm study that will assess the safety, feasibility and efficacy of a 
high dose of vitamin D3 as cholecalciferol in Cystic Fibrosis pediatric patients with a 25OHD 
level <30 ng/mL. The members of the study team will enroll 30 participants who have consented 
and meet eligibility criteria, including a baseline 25OHD level <30 ng/mL which is measured 
annually, at a minimum, as a part of the current standard of care. All patients with CF, will be 
consented to participate upon having his/her annual lab work collected.   
  
As patients present with a 25OHD level < 30 ng/mL they will be screened to see if they meet full 
eligibility criteria for enrollment. This will include a phosphorus level and spot urine calcium to 
creatinine ratio which will be collected at their CF visit (patients seen at the St. Petersburg 
office) or within 2 weeks prior to their visit if in Sarasota or Tampa. (See section 5 for complete 
inclusion/exclusion criteria). Screening will also consist of a urine pregnancy test to be 
completed the day of the administration of the high dose of vitamin D.   
  
After a patient meets full eligibility criteria, they will be enrolled in the study and we will 
administer the 250,000 IU vitamin D3 at that visit. Upon administration, each participant will be 
provided with an oral, one-time dosage of vitamin D3 (cholecalciferol) in the form of capsules 
that will be swallowed; the capsule cannot be crushed or dissolved in anything in order to be 
administered.   
  
Participants will be witnessed by a member of the study team to confirm 100% adherence. With 
this, they will also be provided with water and saltine crackers to take with the vitamin D by 
mouth. If the participant is on pancreatic enzymes, they will be required to take their prescribed 
snack dosage with this as outlined by their CF Physician. The participants will be notified to 
bring their own supply of pancreatic enzymes to this visit with them. If the participant forgets to 
bring pancreatic enzymes, enzymes will be provided to them at a dosage closest to the prescribed 
snack dosage.   
  
If the participant has an episode of emesis upon taking the high dose of vitamin D3 at any time 
following the dose, the participant will not be provided or required to take any additional high 
dose of vitamin D3 for study purposes. They will continue to be followed in the study. They will 
also continue to take their previously prescribed standard CF vitamins as dictated by standards of 
care throughout the study; this information will be kept in a secure study database. Information 
on the participant’s daily CF vitamin/mineral prescription, including total International Units of 
cholecalciferol they are receiving will be collected at each study visit. Additionally, information 
on the participant’s pancreatic function, i.e.: pancreatic insufficiency or pancreatic sufficiency 
will be collected at baseline, among other demographic data.  
  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
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As much as possible, we will try to have study visits coincide with clinic visits which usually 
occur every 3 months as a part of the current standard of care. A study calendar describing all 
study procedures is found at the end of this section.  
  
The following safety measures have been reviewed and approved by two Johns Hopkins All 
Children’s Hospital Endocrinologists: As additional measures of safety at 7 days to the next 
working business day of the administration of the 250,000 IU of vitamin D3, all participants will 
also have a serum calcium and serum phosphorus level measured. If any participant has a serum 
calcium above the upper limits of normal (ULN) for their age (appendix B), they will be 
contacted via telephone to be queried about symptoms of hypercalcemia such as muscle 
weakness, confusion, vomiting, anorexia, confusion, polyuria and polydipsia. If the patient has 
more than 1 symptom of hypercalcemia and an elevated serum calcium level, we will consider 
this an adverse event. During this communication, it will be decided if any type of treatment will 
be needed to remedy the complaint (see section on treatment of hypervitaminosis D from 
hypercalcemia).   
  
If any participant has a serum calcium level greater than the ULN for age or a serum phosphorus 
level greater than the ULN for age, a second tier of safety measures will be taken. This will 
include measuring a PTH with reflex calcium level as soon as possible, within approximately  7 
days (+ 3 days) of the serum calcium or phosphorus lab draw. In addition, we will obtain a spot 
urine calcium to creatinine ratio. Calcium levels and/or phosphorus levels will be repeated every 
2 weeks (+7 days) until normalized for age. If the spot urine calcium to creatinine ratio is > ULN 
for age (Appendix C) we will obtain an Endocrinology consult and if symptomatic be instructed 
to go to the Johns Hopkins All Children’s Hospital for evaluation . The urine calcium to 
creatinine ratio will be repeated in 1 week (+3 days) and then monthly (+7 days) until 
normalized for age. Proposed treatment for hyperphosphatemia will involve increased fluids and 
restriction of phosphorus loaded foods. Proposed treatment for hypercalcemia, as reflected by a 
serum calcium level, is detailed in another section of this protocol.   
  
To evaluate for feasibility, at 7 days to the next working business day after administration of the 
250,000 IU administration of Vitamin D3, participants will be contacted by a member of the 
study team via phone to answer a 10-item questionnaire which is included as an appendix at the 
end of this protocol. This questionnaire is to assess feasibility of the 250,000 IU Vitamin D3.  
  
Regardless of serum calcium level or other labs collected, if a participant does become ill after 
taking the high dose of vitamin D3 (e.g., muscle weakness, confusion, vomiting, anorexia,  
polyuria and polydipsia, etc.) they will be asked to call the CF office number, 727.767.3995. 
During this communication, it will be decided if any type of treatment will be needed to remedy 
the complaint (see section on treatment of hypervitaminosis D from hypercalcemia).  If their 
serum calcium level was within normal limits for age, but they have symptoms of those found 
with hypercalcemia, it will be noted in our study findings but not classified as an adverse event.  
  
At 12 weeks (+ 30 days) from the initial study visit, participants will be required to have another 
25OHD level measured via venipuncture as a part of standard of care. In addition, as a part of the 

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
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first tier of safety measures, a serum calcium and serum phosphorus level will be measured 
again. If either of these levels is elevated, a PTH level will be measured as soon as possible 
within approximately 14 days (+ 3 days) of this serum calcium lab draw.  If serum calcium level 
is above ULN a spot urine calcium to creatinine ratio will be ordered. At 26 weeks (+ 30 days) 
and 52 weeks (+ 30 days) the participants will have 25OHD levels measured again. No 
additional one-time  high dosage of vitamin D3 will be prescribed or provided during the study 
period for any reason to any of the participants. No additional measures of safety, in the forms of 
serum calcium labs, serum phosphorus, or PTH will be measured.  
  
Any participant with an elevated serum calcium level of anything above normal limits for age 
will be instructed to limit calcium containing foods in their diet, stop supplements with 
additional vitamin D and/or calcium. Since these participants will be called regarding their 
elevated serum calcium level to query about symptoms of hypercalcemia, we will be able to 
instruct them on this.   
  
If at any time after the study intervention has started and the participant has a 25OHD level less 
than 30 ng/mL, they will be placed on the current standard CF Foundation step-wise guidelines 
for treatment appropriate for their low vitamin D level.  
  
There will not be a placebo group, as the study design does not support this; providing a placebo 
is not ethical in this population for this condition.   
  
If a patient does not complete the study for any reason, meaning they do not get each set of lab 
work completed, their results up to that point in time will still be used in the study but their 
duration of participation will be noted in the results section. Every effort will be made to contact 
patients who are lost to follow up to ascertain the reason for withdrawal.  
  
  
 

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
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Study Procedures  
  
Study Time-points  
 
Screening/ 
Eligibility  
Base- 
line  
Week 1  
+/- 3 day  
Week 1  
B:***  
Week 1+/-  
14 days  
Week  
12    
+/- 30 
days  
Week 12  
B:***  
Week 12 +/-  
42 days  
Week 26  
+/- 30 
days  
Week 52  
+/- 30 days  
Informed Consent  
X  
  
  
  
  
  
  
  
25OHD Lab  
X  
  
  
  
X  
  
X  
X  
Screening /  
Eligibility  
Verification  
(including pregnancy  
test)  
X  
  
  
  
  
  
  
  
Eligibility screening:  
Spot Urine Calcium to 
Creatinine Ratio  
X  
  
  
  
  
  
  
  
Study Registration   
  
X  
  
  
  
  
  
  
Medication Review*  
  
X  
  
  
X  
  
X  
X  
STOSS Vitamin D3 
Administration  
  
X  
  
  
  
  
  
  
Serum Calcium Test  
& Hypercalcemia  
Monitoring  
  
  
X  
X  
X  
X  
  
  
Serum Phosphorus  
X  
  
X  
X  
X  
X  
  
  
Parathyroid Hormone  
(PTH) Level   
(2nd tier only)  
  
  
  
X  
  
X  
  
  
Spot Urine Calcium to 
Creatinine Ratio (2nd 
tier only)  
  
  
  
X  
  
X  
  
  
Administration of  
Appendix A  
Questionnaire   
  
  
X  
  
  
  
  
  
Adverse Event 
Assessment**  
  
X  
X  
X  
X  
X  
X  
X  
*  
Medication review will consist of surveying the patient’s current daily maintenance dosage for vitamin D as 
previously prescribed.   
** AEs and SAEs are defined per 21CFR312.32. All adverse events will be monitored and processed from study 
start until 30 days after study product administration. All adverse events deemed related to known vitamin D 
supplementation risks and/or study procedures will be monitored for 12 months post drug administration.  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
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*** 2nd tier safety assessment using PTH will only be performed in the event serum calcium levels or serum 
phosphorus levels are elevated greater than the upper limit of normal for age. A spot urine calcium to 
creatinine ratio will  be done.Repeat calcium and phosphorus will be provided every 2 weeks until normalized.  
 
5.  
Inclusion/Exclusion Criteria:  
1. Exclusion Criteria:  
a. Any history of kidney disease, kidney stones, or on dialysis  
b. Any history of hypercalcemia above upper limits of normal for age within the 
last six months (see appendix B for normal calcium levels).  
c. Elevated serum phosphorus level at screening  
d. Elevated spot urine calcium to creatinine ratio at screening  
e. Abnormal serum creatinine level 2 times the upper limit of normal for age 
within the last 6 months  
f. History of unresolved, abnormal liver function (ALT or AST>4times upper 
limit of normal (ULN)) or any history of portal hypertension.  
g. Pregnant or breast feeding adolescent females; upon enrollment, will test urine 
sample for pregnancy in females 8 years and older  
h. Any history of parathyroid disorders  
i. Inability to swallow pills by mouth 2.  Inclusion Criteria:  
a. Children with Cystic Fibrosis >36 months of age  
b. Serum/blood 25OHD level < 30 ng/mL  
c. Ability to provide valid informed consent to be a part of the study  
d. Negative urine pregnancy test upon enrollment  
  
 
6.  
Drugs/ Substances/ Devices  
This trial is being conducted under Investigational New Drug (IND) application # 128487 – IND 
Sponsor: Deanna Green, MD; all relevant FDA regulations will be followed.   
Cholecalciferol (Vitamin D3) capsules from Biotechpharmacal will be used. Each capsule has 
50,000 International Units of Vitamin D3. Each participant will be provided with 250,000 IU 
Vitamin D3 (5 capsules) regardless of age, sex or 25OHD level.  
  
The dosage of 250,000 IU Vitamin D3 has been shown to be safe and effective in raising the 
25OHD level in adult patients with CF and dosages higher than this have been shown to be safe 
and effective at raising 25OHD levels in pediatric patients as young as 36 months old with 
dosages of 100,000 IU Vitamin D3 in addition to pediatric patients 12 years old receiving 
400,000 IU Vitamin D3 as a one-time dosage without any adverse events, including 
hypercalcemia.   
  
The safety of high dose of Vitamin D3 has not been evaluated in pediatric CF patients in the U.S.  
  
 
7.  
Off-Treatment and Off-Study Criteria  
1. Off-Treatment Criteria: Any patient who requires high dose supplemental vitamin D 
prescribed outside the study.   
2. Off-Study Criteria:  
a. Refusal of further study follow-up by patient or legal guardian  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
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b. Lost to follow-up  
c. Death  
d. Completion of study requirements  
  
  
 
8.  
Reporting Mechanisms  
1. Study Registration  
a. All patients will be registered by the Research Coordinator. The following forms 
will be completed: Eligibility checklist, On-study form, and Concomitant 
information form.   
2. Toxicity and /or Adverse Reactions  
a. All adverse events will be monitored and processed from study start until 30 days 
after study product administration.   
b. All adverse events deemed related to known vitamin D supplementation risks 
and/or study procedures will be monitored for 12 months post drug 
administration. Serious adverse events will be defined by the criteria specified in 
21CFR312.32.   
c. All safety-related event meeting FDA’s expedited or annual reporting 
requirements as stated in 21 CFR 312.32 and 21 CFR 312.33, respectively, will 
be reported to the FDA.   
d. All safety-related events meeting the IRB’s reporting requirements will be 
submitted to the IRB.  
3. Informed Consent  
a. All patients and/or their legal guardian must sign a document of informed consent 
consistent with local institutional and federal guidelines stating that they are 
aware of the investigational nature of this protocol and of the possible side effects 
of treatment. Further, patients must be informed that no efficacy of this therapy is 
guaranteed and that unforeseen toxicities may occur. Patients have the right to 
withdraw from this protocol at any time. No patient will be accepted for treatment 
without such a document signed by him or his legal guardian. Full confidentiality 
of patients and patient records will be provided according to institutional 
guidelines.   
4. Clinical Trial Oversight and Monitoring   
a. This protocol will be monitored and evaluated in accordance with Johns Hopkins 
All Children’s Hospital CTRO’s quality assurance procedures.  
  
 
9.  
Statistical Analysis   
The primary safety endpoint will be serum calcium levels one-week after administration of the 
high dose of vitamin D3. Other variables related to safety include the frequency and severity of 
adverse events and early stopping rules.    
  
Serious Adverse Experiences (SAE): An SAE is defined as any AE that results in any of the 
following outcomes:  
• 
Death;  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
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• 
Life-threatening adverse experience;  
• 
In-patient hospitalization or prolongation of existing hospitalization;  
• 
Persistent or significant disability/incapacity;  
• 
Other important medical events may also be considered an SAE when, based on 
appropriate medical judgment, they jeopardize the participant or require intervention 
to prevent one of the outcomes listed.  
  
For this study, important medical events that will be reported as an SAE per protocol also 
include:  
If at any time >10% of the participants experience hypercalcemia, accrual will be held 
pending safety analysis and will be restarted only with the approval of the Data Safety 
Monitoring Board.  
A hypercalcemia level with serum calcium measure of > 13.5 mg/dL  requiring 
hospitalization and treatment.   
  
The following additional demographic and clinical information will be collected at baseline for 
each participant: Age, gender, pancreatic status (pancreatic insufficiency or pancreatic 
sufficiency), brand of daily vitamin, prescribed dosage and amount of vitamin D3 in prescribed 
daily dosage. Qualitative data on the appropriateness of study materials and reasons for 
nonparticipation and attrition will also be collected to inform future improvement in study 
materials and recruitment and retention strategies.  
  
Demographic and clinical characteristics of participants will be summarized using counts and 
percentages for categorical variables and mean and standard deviation or median and range for 
continuous variables. The mean and corresponding standard deviation of serum calcium level 
one-week after administration of the high dose of vitamin D3 as well as the proportion and 95% 
confidence interval of participants with elevated serum calcium levels for age will be calculated.   
  
Feasibility and efficacy parameters including recruitment rate, retention, response percentages to 
initial and follow up questionnaires and proportion of participants with serum 25OHD level >30 
ng/mL at the end of the study will be calculated with the corresponding  
95% confidence intervals. All adverse events and study related adverse events will be 
summarized using counts and percentages.  
  
The aim of the study is to determine safety and feasibility of a single high dose (250,000 IU) oral 
vitamin D3 for the treatment of vitamin D insufficiency/deficiency in pediatric cystic fibrosis 
patients. The study is therefore not powered to detect a difference in a clinically important 
endpoint. We intend to consecutively enroll 30 patients in the study. A sample size of 30 should 
be sufficient to determine the safety and feasibility and to also estimate the parameters needed to 
perform a definitive sample size and power estimation of a large-scale RCT if safety and 
feasibility are shown in the current study. An appropriate sample size and power calculation 
based on the parameters obtained in this study will be presented in a future large-scale RCT 
protocol.   
  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
Page 13 of 18  
Early Stopping Rules:  
1. Participants who experience hypercalcemia as defined by a serum calcium greater than 
13.5 mg/dL or with a spot urine calcium to creatinine ratio >2 times ULN will be allowed 
to stop the study and resume standard of care of treatment of their vitamin D 
insufficiency and will be required to receive  treatment for their severe hypercalcemia 
(defined below in section 10 under “steps taken to minimize the risks”).  
2. Participants who experience a 25OHD level as defined by a level of >100 ng/mL will 
continue to be followed in the study and be monitored for hypercalcemia or 
hypercalciuria with the study protocol.    
  
 
10.  
Risks:  
Risks of the trial include:  
a. Venipuncture risks at baseline, 1 week, 3 mo, 6 mo, & 12 mo;   
b. Swallowing risks at baseline;  
c. risk of hypervitaminosis D at 3 mo, 6 mo, & 12 mo;   
d. risk of hypercalcemia at 1 week, 3 mo, 6 mo, & 12 mo;  
e. risk of renal stones at 1 week, 3 mo, 6 mo, & 12 mo;  
f. risk of continued vitamin D deficiency/insufficiency regardless of treatment throughout 
the study duration;  
g. Other minor risks associated with the trial include upset stomach (nausea) and taking a 
vitamin supplement by mouth.  
  
Steps taken to minimize the risks:  
a. Standard precautions will be used with other venipuncture occurrences;  
b. Patients will be monitored as they are administered their one-time, oral, high dose 
vitamin D in CF Clinic. They will be provided with water to take it with by mouth;  
c. To minimize the risk of hypervitaminosis D and hypercalcemia, the participants are 
having their serum levels of 25OHD, calcium and phosphorus monitored in the study. 
Participants with an elevated serum calcium will be called and queried about symptoms 
of hypercalcemia as well as instructed to stop any calcium containing supplements, any 
vitamin D containing supplements, and to limit foods containing calcium from their diet.  
d. In the event of hypervitaminosis D, hypercalcemia, and/or hyperphosphatemia, Dr. 
Green, study Principal Investigator, will be notified as soon as possible. She will evaluate 
the event and decide on the appropriate action for further testing and/ or referral. Subjects 
with calcium levels >ULN for age will require a spot urine calcium to creatinine ratio.  
Those with Grade 4 severity will require further intervention.   
1. Grade 1 severity:  corrected serum calcium of >ULN – 11.5 mg/dL   
2. Grade 2 severity:  corrected serum calcium of > 11.5 -12.5 mg/dL   
3. Grade 3 severity: corrected serum calcium >12.5- 13.5 mg/dL   
4. Grade 4 severity or severe hypercalcemia corrected serum calcium of >13.5 
mg/dL. If subjects are found to have grade 4 severity or severe hypercalcemia, 
they will be treated as follows (16, 17):  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
Page 14 of 18  
a. Volume expansion with isotonic saline at an initial rate of 200 to 300 
mL/hour that is then adjusted to maintain the urine output at 100 to 150 
mL/hour   
b. Administration of calcitonin (4 IU/kg) and repeat measurement of serum 
calcium in several hours.   
If a hypocalcemic response is noted, then the patient is 
calcitoninsensitive and the calcitonin can be repeated every 6 to 12 
hours (4 to 8 IU/kg). We typically administer calcitonin (along with a 
bisphosphonate) in patients with calcium >14 mg/dL who are also 
symptomatic.   
c. The concurrent administration of a bisphosphonate, such as zoledronic 
acid or pamidronate, per institutional guidelines.  
  
Significant reduction in serum calcium levels should be seen within 12-48 hours of 
administration of saline plus calcitonin  
  
During the study, we may obtain research data about the participant’s health. If there are 
unexpected findings from our research that are important to their health and should be discussed 
with them and or their family, we will notify them.  
  
Patient data will be stored for research purposes as a HIPAA defined limited data set in a secure, 
password protected web-based electronic data capture (EDC) system. Each patient will be 
assigned a unique Participant ID number in the EDC system. Access to the EDC system will be 
restricted to those users identified as part of the research study team and permission will be 
granted based on levels of access deemed necessary for their role. Data extractions as well as 
modifications or edits to data will be logged appropriately to adhere to audit trail requirements. 
No financial risks to participants have been identified.  
  
 
11.  
Benefits  
Previous studies of a high dose of vitamin D3, in adults with CF, have shown that they have a 
decrease in markers of inflammation, specifically interleukin and TNF. Studies have also shown 
that adequate vitamin D may help to maintain or improve lung function although this has not 
been proven. Adequate vitamin D is widely known to improve bone mineral density in children 
and adults, with and without CF. It is hoped that this study might provide additional information 
regarding the role of a high dose of vitamin D in relation to sustaining an appropriate serum 
25OHD level for up to 12 months, safely and feasibly.  
  
 
12.  
Costs  
Labs:   
Serum calcium levels measured at 1 week post administration of the high dose vitamin D3 and at 
the 3 month visit post administration of vitamin D3 will be covered by a grant. The cost of each 
serum calcium measurement will be billed as “research” and will cost approximately $62.64 for 
each draw.   
  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
Page 15 of 18  
Serum phosphorus will be measured at baseline, 1 week post administration of the high dose 
vitamin D3 and again at the 3 month visit along with serum calcium and 25OHD. The cost of 
serum phosphorus will be billed as “research” and is $31.42 per draw and will be covered by a 
grant provided by the ACH foundation.  
  
Spot urine calcium to creatinine ratio levels will be done as a part of the screening process for 
this study as well as if a participant has a serum calcium level >ULN. The cost of one spot urine 
calcium to creatinine ratio is $73.52. This will cost approximately $2205.60 for the screening 
purpose of this test for 30 participants.   
  
We will additionally budget the cost of three participants requiring this test as a measure of 
safety, as this will be 10% of our overall goal number of study participants. Once we have 10% 
of our study participants with hypercalcemia and requiring additional safety testing, the study 
will be held until the DSMB can review.. The cost of three participants requiring this test at week 
1 and at month 3, will cost $441.12 ($73.52 per test).   
  
The cost for the urine pregnancy tests will be about $1.98 per test or $49.63 per box of 25 tests. 
We do not expect to need more than 25 pregnancy tests since these will only be used for female 
participants greater than 8 years old.   
  
25OHD level is a part of the standard of care for pediatric patients with Cystic Fibrosis and will 
be measured for “baseline” measures prior to enrollment in the study and upon annual exam. 
Therefore, the cost fits within the usual cost to the participant even if they weren’t participating 
in the study. In addition, each time they are required to have it re-measured at 3 mo, 6 mo & 12 
mo it will continue to be a part of the standard of care for assessing their vitamin D. There will 
be standard costs associated with it that the participant would be paying even if they weren’t 
participating in this study.  
  
Vitamins/Supplements:  
Vitamin D3 water miscible form will be purchased via grant funds from BioTechPharmacal.com 
for $18.00 per 100 capsules of a water soluble and vegetarian vitamin D3 – 50,000 IU per 
capsule (18 cents per capsule or maximum cost per STOSS dosage of 250,000 IU is $0.90).  
  
CF specific vitamins are currently prescribed to all patients upon diagnosis. Therefore, 
participants will already be prescribed these as a part of the standard of care for the nutritional 
management of pediatric patients with CF and pancreatic insufficiency. Patients who are 
pancreatic sufficient will be on a standard regular multivitamin with minerals as a part of the 
standard of care. Neither of these will accrue additional cost to our center or to the patient.  
  
Other: Support Personnel  
A research coordinator will act as a part of the research time. He/she will assist in approaching 
eligible patients to obtain consent for participation in this study, scheduling necessary lab work, 
conducting the 10-item questionnaire and inputting the necessary data into the Red Cap database 

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
Page 16 of 18  
over the course of 12 months from the start of the study. This person’s salary will be covered by 
a grant previously awarded to our CF Center and through CTRO funds.   
  
Diana Hodge will  work as the regulatory affairs and quality measures manager for this study.   
  
Other: Data Safety Monitoring Board – DSMB  
We will require 3 members for our DSMB, one of which will be the chair person. The first 
DSMB meeting will occur at 50% of participant enrollment, the second meeting when 50% of 
participants have had their 3-month evaluation (after the  safety endpoints have been evaluated), 
the third meeting when 50% of participants have completed the study and the fourth meeting 
when all have completed study.    
  
References:   
1. Green D, Carson K, Leonard A, Davis J, Rosenstein B, Zeitlin P, Mogayzel P. Current 
treatment recommendations for correcting vitamin D deficiency in pediatric patients with 
Cystic Fibrosis are inadequate. J of Ped 2008; 153:4.  
2. Grey V, Atkinson S, Drury D, Casey L, Ferland G, Gundberg C, Lands L. Prevalence of 
low bone mass and deficiencies of vitamins D and K in pediatric patients with Cystic 
Fibrosis from 3 Canadian centers. Pediatrics 2008; 122:1014-1020.  
3. Grossman RE, Zughaier SM, Lui S, Lyles RH, Tangpricha V. Impact of vitamin D 
supplementation on markers of inflammation in adults with cystic fibrosis hospitalized 
for a pulmonary exacerbation. European Journal of Clinical Nutrition 2012;66: 
10721074.   
4. Tangpricha V, Kelly A, Stephenson A, Maguiness K, Enders J, Robinson A, Marshall B, 
Borowitz D. An update on the screening, diagnosis, management, and treatment of 
vitamin D deficiency in individuals with Cystic Fibrosis: evidenced-based 
recommendations from the Cystic Fibrosis Foundation. J Clin Endocrinol Metab 2012; 
97:1082-1093.   
5. Ferguson JH, Chang AB. Vitamin D supplementation for Cystic Fibrosis (review). The 
Cochrane Library2014; 5.  
6. Tolppanen A, Fraser A, Fraser W, Lawlor D. Risk factors for variation in 
25hydroxyvitamin D3 and D2 concentrations and vitamin D deficiency in children. J Clin 
Endocrinol Metab 2012; 97:1202-1210.  
7. Shepard D, Belessis Y, Katz T, Morton J, Field P, Jaffe A. Single high-dose oral vitamin 
D3 (stoss) therapy – a solution to vitamin D deficiency in children with cystic fibrosis? J 
of Cystic Fibrosis 2013; 12:177-182.  
8. Hackman K, Gagon C, Briscoe R, Lam S, Anpalahan M, Ebeling P. Efficacy and safety 
of oral continuous low-dose versus short-term high-dose vitamin D: a prospective 
randomized trial conducted in a clinical setting. MJA 2010; 192:686-689.  
9. Cipriani C, Romagnoli E, Scillitani A, Chiodini I, Clerico R, Carnevale V, Lucia Mascia  
M, Battista C, Viti R, Pileri M, Eller-Vainicher C, Minisola S. Effect of a single dose of 
600,000 IU of cholecalciferol on serum calciotropic hormones in young subjects with 
vitamin D deficiency: A prospective intervention study. J Clin Endocrinol Metab 2010; 
95:4771-4777.  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
Page 17 of 18  
10. Heaney RP.  Vitamin D and bone health: discussion points, following the recent Institute 
of Medicine recommendations. US Endocrinol 2011; 7:137–140.  
11. Wagner C, Frank R, Greer R. Prevention of Rickets and Vitamin D Deficiency in Infants, 
Children, and Adolescents. Pediatrics 2008; 122:1142 -1152.   
12. IOM (Institute of Medicine) 2011 Dietary reference intakes for calcium and vitamin D. 
Committee to Review Dietary Reference Intakes for Calcium and Vitamin D.  
13. Ross, A. C., Manson, J. E., Abrams, S. A., Aloia, J. F., Brannon, P. M., Clinton, S. K., 
Shapses, S. A. (2011). The 2011 report on dietary reference intakes for calcium and 
vitamin D from the Institute of Medicine: what clinicians need to know. J Clin 
Endocrinol Metab,   
14. Vogiatzi M, Jacobson-Dickman E, DeBoer M. Vitamin D supplementation and risk of 
toxicity in pediatrics: a review of current literature. J Clin Endocrinol Metab 2014; 
99:1132-1141.   
15. Bilezikian JP. Clinical review 51: Management of hypercalcemia. J Clin Endocrinol 
Metab 1993; 77:1445.  
16. Bilezikian JP. Management of acute hypercalcemia. N Engl J Med 1992; 326:1196.  
17. Fatemi S, Singer FR, Rude RK. Effect of salmon calcitonin and etidronate on 
hypercalcemia of malignancy. Calcif Tissue Int 1992; 50:107.   
  
Appendix A – Phone Survey 1 – week following dosage  
NOTE: the following questions will be based on the previous week only and will be about how you 
usually feel or symptoms you otherwise usually have.  
1) Over the last week, since you have taken the vitamin D3 of 250,000 IU have you:  
i) Experienced feeling an increased amount of nausea?  
(1) 
NO  
(2) 
YES ii) Experienced an increased frequency of emesis (vomiting)?  
(1) 
NO  
(2) 
YES iii) Experienced an increased amount of diarrhea?  
(1) 
NO  
(2) 
YES iv) Experienced any constipation?  
(1) NO  
(2) YES  
v) Experienced increased gas production, such as burping or passing gas?  
(1) 
NO  
(2) 
YES vi) Experienced an increased amount of abdominal pain/stomach 
aches?  
(1) NO  
(2) YES  
  
2) Since taking the vitamin D3 last week, have you experienced an increase in heart burn or reflux? i) NO  
ii) YES  
  
3) Did you find the one-time dose of vitamin D3 to be easy to take?  
i) NO  
ii) YES  

Date: December 20, 2016  
Principal Investigator: Deanna Green, MD  
Application Number: IRB00081746 (IND # 128487 – IND Sponsor: Deanna Green, MD)  
JHMIRB eFormA 01  
 
Protocol Template Version 3 Dated: 06/2007  
  
Page 18 of 18  
  
4) Would this type of medication be something you would do next year if you had another low vitamin D 
level?  
i) NO  
ii) YES  
  
5) Would you prefer taking a one-time dose of vitamin D to treat a low vitamin D level instead of taking a 
daily vitamin D supplement?  
i) NO  
ii) YES     
  
Appendix B Normal Calcium Values for age (JHACH Laboratory reference values)  
  
 
  
  
Normal  
0 Year 00M 00D F   
7.5-11.3  
0 Year 00M 00D M   
7.5-11.4  
0 Year 00M 08D F   
8.4-11.9  
0 Year 00M 08D M   
8.6-11.7  
0 Year 01M 00D F   
8.0-11.1  
0 Year 01M 00D M   
8.5-11.3  
0 Year 03M 00D F   
7.7-11.5  
0 Year 03M 00D M   
8.3-11.4  
0 Year 06M 00D F   
7.8-11.1  
0 Year 06M 00D M   
7.7-11.0  
1 Year 00M  F or M  
8.7-9.8  
4 Year 00M  F or M  
8.8-10.1  
10 Year 00M  F or M  8.9-10.1  
12 Year 00M  F or M  8.8-10.6  
14 Year 00M  F or M  9.2-10.7  
16 Year 00M  F or M  8.9-10.7  
20 Year 00M  F or M  8.4-10.2  
  
Appendix C Normal Urine Calcium:Creatinine Ratios for age (Harriet Lane Handbook Table 19-3)  
  
 
  
  
Normal 
< 07 M F or M    
0.86  
7-18 M F or M    
0.60  
19 M -6 Y F or M  
0.42  
>6 Y  F or M    
0.22