Conditions: Asthma
Keywords: urban setting children and adolescents double-masked, placebo-controlled randomized trial asthma exacerbations (attacks) mepolizumab adjunctive therapy asthma exacerbations prevention difficult-to-control exacerbation-prone asthma
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 335
Healthy volunteers: no

Brief summary:
The purpose of this study is to see if treatment with a medication called Nucala® (mepolizumab), given along with standard asthma care, makes children less likely to have asthma attacks.

Detailed description:
Asthma is a growing problem, especially in children. It causes frequent wheezing, shortness of breath, chest tightness, and cough. Asthma attacks, or exacerbations, are problems for children with asthma.

The purpose of this study is to see if treatment with a medication called mepolizumab (Nucala®), given along with standard asthma care, makes children less likely to have asthma attacks. Mepolizumab is a new drug that is approved by the Food and Drug Administration (FDA) for use in children with asthma who are aged 12 years and older. Mepolizumab is given by injection. It is being studied by other researchers in children aged 6-11 years.

All participants will be prescribed standard asthma medications by a clinician who is trained in asthma care. Medications will include controller medications, a rescue medication, and a medication for severe asthma attacks (prednisone). The amount of medication that participants receive may be increased or decreased during the study based on their symptoms and breathing test results. Study clinicians will treat all participants according to the same guidelines. These treatment guidelines are based on recommendations from a group of national experts in asthma. This study has been designed this way so that all participants will have safe and effective standard asthma care.

In order to enroll in this study, participants must be willing to have their asthma managed by the study clinician during the entire study period. Participants must also be willing to bring study medications to all study visits.

This study will include up to 20 study visits. Participant involvement in the study will endure for approximately 1 year.

During the treatment period, participants will be placed in one of two treatment groups:

* Mepolizumab injection and guidelines-based asthma care or
* Placebo injection and guidelines-based asthma care.

Participants will not be able to choose which group they are assigned. This assignment is random and by chance, much like flipping a coin. Participants will not know if they are receiving mepolizumab or placebo. Investigators will compare the study results between the participants of each group.

Arms:
arm 1: Intervention: Mepolizumab plus guidelines-based standard of care asthma treatment. arm 2: Intervention: Placebo for mepolizumab plus guidelines-based standard of care asthma treatment.

Interventions: intervention 1: Mepolizumab intervention 2: Placebo
Intervention descriptions: intervention 1: Mepolizumab administered every 4 weeks by subcutaneous injection at a dose of:

* 100 mg for participants ≥12 years of age and
* 40 mg for participants ages 6 to 11 years and weighing ≥40 kg.

Note: Participants 6 to 11 years of age and weighing ≥40 kg who were enrolled in the study under previous versions of the protocol and were initially assigned a 100 mg dose will have their dose reduced to 40 mg.

Participants 11 years of age will increase to the 100 mg dose if they become age 12 years during the study. intervention 2: Placebo administered every 4 weeks by subcutaneous injection at a dose of:

* 100 mg for participants ≥12 years of age and
* 40 mg for participants ages 6 to 11 years and weighing ≥40 kg.

Note: Participants 6 to 11 years of age and weighing ≥40 kg who were enrolled in the study under previous versions of the protocol and were initially assigned a 100 mg dose will have their dose reduced to 40 mg.

Participants 11 years of age will increase to the 100 mg dose if they become age 12 years during the study.

Protocol document:
Prot_SAP_000.pdf: 
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Protocol ICAC-30 MUPPITS-2 
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INNER-CITY ASTHMA CONSORTIUM 
PROTOCOL ICAC-30 
Mechanisms Underlying Asthma Exacerbations Prevented and Persistent with Immune-Based 
Therapy: A Systems Approach Phase 2 
MUPPITS-2 
Version 9.0 / 11Jan2021 
 
Study Sponsor(s) 
The Division of Allergy, Immunology, and Transplantation 
(DAIT), The National Institute of Allergy and Infectious 
Diseases (NIAID) 
NIAID Funding Mechanism 
Grants 1 UM1 AI114271-01 and UM2AI117870 
IND Sponsor/Number 
IND sponsor: DAIT NIAID, IND# 136355 
Study Drug Manufacturer/Provider 
GlaxoSmithKline 
 
 
PROTOCOL CO-CHAIR –  
DANIEL J. JACKSON, MD 
Associate Professor of Pediatrics 
University of Wisconsin School of 
Medicine and Public Health 
600 Highland Avenue 
CSC K4/936 
Madison, WI 53792 
Phone: (608) 263-7686 
Fax: (608) 265-2207 
E-mail: djj@medicine.wisc.edu 
MEDICAL MONITOR –  
PETER J. GERGEN, MD, MPH 
Division of Allergy, Immunology, 
and Transplantation – NIAID/NIH 
5601 Fishers Lane, Room 6B58 
Rockville, MD 20892 MSC 9827 
Phone: (240) 627-3545   
Fax: (301) 480-4258 
E-mail: pgergen@niaid.nih.gov 
BIOSTATISTICIAN –  
CYNTHIA VISNESS, PHD 
Senior Research Scientist 
Rho, Inc. 
2635 E NC Hwy 54 
Durham, NC 27713 
Phone: (919) 408-8000 
Fax: (919) 408-0999 
E-mail: 
cindy_visness@rhoworld.com 
PROTOCOL CO-CHAIR –  
WILLIAM W. BUSSE, MD 
Professor of Medicine 
University of Wisconsin School of 
Medicine and Public Health 
Ultratec Building, Rm. 129 
5901 Research Park Blvd 
Madison, WI 53719 
Phone:  (608) 263-6183 
Fax:  (608) 261-1191 
Email:  wwb@medicine.wisc.edu 
PROJECT MANAGER –  
LISA GAGALIS, RN, BSN 
Division of Allergy, Immunology, 
and Transplantation 
National Institute of Allergy and 
Infectious Diseases 
5601 Fishers Lane, Room 6B53  
Rockville, MD 20852-9828, USA 
Phone:  (240) 472-1823 
Fax:  (301) 480-4258 
E-mail:  lisa.gagalis@nih.gov 
REGULATORY OFFICER –   
LYUDMILA LYAKH, MD, PHD 
Office of Regulatory Affairs 
Division of Allergy, Immunology, 
and Transplantation 
National Institute of Allergy and 
Infectious Diseases 
5601 Fishers Lane, Room 7B39 
Rockville, MD 20892-9828, USA 
Phone:  (240) 627-3530 
Fax:  (301) 480-1537 
E-mail:  lyudmill@niaid.nih.gov 
Confidentiality Statement 
The information contained within this document is not to be disclosed in any way without the prior permission of the 
Protocol Chair, 
or the Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases 
of the National Institutes of Health. 


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Protocol ICAC-30 MUPPITS-2 
Version 9.0 
 
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INVESTIGATOR SIGNATURE PAGE 
Protocol: ICAC-30 
Version/Date:  9.0 / 11Jan2021 
 
 
Title:  Mechanisms Underlying Asthma Exacerbations Prevented and Persistent with Immune-Based 
Therapy: A Systems Approach Phase 2 
Study Sponsor:   The Division of Allergy, Immunology, and Transplantation (DAIT),  The National 
Institute of Allergy and Infectious Diseases (NIAID) 
INSTRUCTIONS:   
The original signature page must be kept for your records. Return an electronic PDF copy of the signed 
signature page (*as described below) to the DAIT Regulatory Management Center via the applicable DAIT 
RMC email address for the protocol/network: 
DAITRegulatory_ICAC (SM) <DAITRegulatory_ICAC@ppdi.com> 
 
I confirm that I have read the above protocol in the latest version.  I understand it, and I will work 
according to the principles of Good Clinical Practice (GCP) as described in the United States Code of 
Federal Regulations (CFR) – 45 CFR part 46 and 21 CFR parts 50, 56, and 312, and in the International 
Conference on Harmonisation (ICH) document Integrated Addendum to ICH 
E6(R1): Guideline for Good Clinical Practice E6(R2).  Further, I will conduct the study in keeping with local 
legal and regulatory requirements. 
As the site Principal Investigator, I agree to carry out the study by the criteria written in the protocol 
and understand that no changes can be made to this protocol without the written permission of the 
IRB and NIAID. All personnel involved in the conduct of this study have completed Human Subjects 
Protection Training. 
I agree to ensure that all staff members involved in the conduct of this study are informed about their 
obligations in meeting the above commitments. 
[*The site Principal Investigator should sign and date at the indicated location below. A written 
signature/date is acceptable (e.g., scanned and sent via email as a PDF version). An electronic signature is 
also acceptable (e.g., sent via email as a PDF version).] 
____________________________________ 
Site Principal Investigator (Print) 
 
____________________________________ 
Site Principal Investigator (Signature) 
________________ 
Date 


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Protocol ICAC-30 MUPPITS-2 
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Protocol Synopsis 
Title 
Mechanisms Underlying Asthma Exacerbations Prevented and 
Persistent with Immune-Based Therapy: A Systems Approach Phase 2 
Short Title 
Protocol ICAC-30 MUPPITS-2 
Clinical Phase 
II 
Number of Sites 
Multiple 
IND Sponsor/Number 
IND sponsor: DAIT NIAD 
IND#: 136355 
Study Objectives 
The primary objective of the study is to determine if phenotype-directed 
use of mepolizumab reduces the rate of asthma exacerbations as 
defined by the need for systemic corticosteroid treatment in urban 
children and adolescents (ages 6-17) with difficult-to-control 
exacerbation-prone asthma and peripheral blood eosinophils ≥150 
cells/μl.  
Secondary objectives are:  
1. To determine whether mepolizumab will lead to an improved 
Composite Asthma Severity Index (CASI)1 
2. To determine whether mepolizumab will improve quality of life as 
assessed by the physician-patient global assessment2 
3. To determine whether mepolizumab improves lung function as 
assessed by spirometry and impulse oscillometry   
4. To determine whether mepolizumab increases the time to first 
asthma exacerbation 
5. To separately determine whether mepolizumab reduces the rate of 
asthma exacerbations in study participants who do not fit the FDA-
approved dosing table for omalizumab therapy and in study 
participants who fit the FDA-approved dosing table for omalizumab 
therapy  
6. To assess the safety of mepolizumab treatment 
Study Design 
Protocol ICAC-30 MUPPITS-2 is a multicenter, double-blind, placebo-
controlled, randomized trial of mepolizumab adjunctive therapy for the 
prevention of asthma exacerbations in urban children and adolescents 


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with difficult-to-control exacerbation-prone asthma and peripheral 
blood eosinophils ≥150 cells/μl. 
Primary Endpoint(s) 
The primary endpoint is the number of asthma exacerbations during the 
12-month treatment period.  
Secondary Endpoint(s)  
1. CASI during the treatment period 
2. Quality of life as measured by the physician-patient global 
assessment  
3. Lung function as assessed by spirometry and IOS during the 
treatment period 
4. Time to first asthma exacerbation during the treatment period 
5. Number of reported adverse events and serious adverse events, 
including their severity and treatment relatedness 
Accrual Objective 
290 
Study Duration 
15 months recruitment + 12 months treatment 
Agent/Treatment 
Description  
Mepolizumab (anti-IL-5 antagonist monoclonal antibody) by 
subcutaneous injection every 4 weeks at the following doses: 
• 
Age 12 years and above:  100 mg  
• 
Age 6-11 years:  40mg 
Participants 6 to 11 years of age and weighing ≥40 kg who were 
enrolled in Protocol ICAC-30 under the previous versions of the 
protocol and initially assigned a 100 mg dose will have their 
dose reduced to 40 mg. 
Participants age 11 years will increase to the 100 mg dose if they become 
age 12 years during the study. 
Inclusion Criteria 
1. Participant and/or parent guardian must be able to understand and 
provide informed consent and age-appropriate assent 
2. Are male and female aged 6-17 years, inclusive at randomization 
3. Have a primary place of residence in one of the pre-selected 
recruitment census tracts as outlined in the Protocol ICAC-30 
Recruitment Manual of Operations  
3a.  Participants who do not live in the pre-selected census tracts 
but live within the Office of Management and Budget (OMB) 
defined Metropolitan Statistical Area and have publicly-funded 
health insurance will qualify for inclusion. 


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4. Have had a diagnosis of asthma made > 1 year prior to recruitment; 
participants who received an asthma diagnosis by a clinician ≤ 1 
year prior to recruitment must report that their respiratory 
symptoms were present for more than 1 year prior to recruitment 
5. Have had at least two asthma exacerbations in the prior year 
(defined as a requirement for systemic corticosteroids and/or 
hospitalization) 
6. At Visit 0 (Screening), have the following requirement for asthma 
controller medication: for participants aged 6 to 11 years, 
treatments with at least fluticasone 250 mcg dry powder inhaler 
(DPI) one puff twice daily or its equivalent and for participants aged 
12 years and older, treatment with at least fluticasone 250 mcg plus 
LABA DPI one puff twice daily or its equivalent 
7. Have peripheral blood eosinophils ≥150 cells/μl obtained at Visit 0 
or via another ICAC protocol within 6 months 
8. Are able to perform spirometry at randomization  
9. Have documentation of current medical insurance with prescription 
coverage at randomization 
10. Have had varicella or the varicella vaccination 
Exclusion Criteria 
Individuals who meet any of the following criteria are not eligible for 
enrollment or randomization, if they: 
1. 
Are not able or willing to give written informed consent or comply 
with study protocol 
2. 
Have concurrent medical problems that would require systemic 
corticosteroids or other immunomodulators during the study 
3. 
Are currently receiving immunotherapy 
4. 
Are currently receiving treatment with omalizumab or have had 
omalizumab treatment within 6 months prior to randomization 
5. 
Are currently requiring greater than fluticasone 500 mcg bid plus 
LABA one puff twice daily or its equivalent and/or individuals using 
oral corticosteroids daily or every other day for more than 14 days 
at the time of Visit 0 (Screening) 
6. 
Are currently pregnant or lactating, or plan to become pregnant 
during the time of study participation. Females of child-bearing 
potential (post-menarche) must be abstinent or use a medically 
acceptable birth control method throughout the study (e.g. oral 
subcutaneous, mechanical, or surgical contraception) 
7. 
Have a known, pre-existing clinically important lung condition other 
than asthma 
8. 
Have a current malignancy or previous history of cancer in remission 
for less than 12 months prior to randomization 


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9. 
Have known, pre-existing, unstable liver disease 
10. Is a current smoker 
11. Have a known immunodeficiency disease 
12. Have other conditions that could lead to elevated eosinophils such 
as hypereosinophilic syndromes, including eosinophilic 
granulomatosis with polyangiitis 
13. Have a known, active pre-existing parasitic infestation or 
undergoing treatment for a parasitic infestation. Once the 
participant has been successfully treated, the participant may be 
reevaluated. 
14. Use of investigational drugs within 4 weeks of randomization 
15. Have past or current medical problems or findings from physical 
examination or laboratory testing that are not listed above, which, 
in the opinion of the investigator, may pose additional risks from 
participation in the study, may interfere with the participant’s 
ability to comply with study requirements or that may impact the 
quality or interpretation of the data obtained from the study 
16. Will not allow the study clinician, an asthma specialist, to manage 
their disease for the duration of the study or who are not willing to 
change their asthma medications to follow the protocol 
17. Have a known history of allergic reaction to previous biologic 
therapy for asthma 
18. Have had a life threatening asthma exacerbation in the last 2 years 
requiring intubation, mechanical ventilation or resulting in a hypoxic 
seizure 
Study Stopping Rules 
The occurrence of one death or an unexpected SAE related to the 
investigational agent. 
 
 


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Table of Contents 
1 
Background and Rationale .................................................................................................................. 15 
1.1 
Background and Scientific Rationale ........................................................................................... 15 
1.2 
Rationale for Selection of Investigational Product or Intervention ............................................ 16 
1.3 
Preclinical Experience ................................................................................................................. 17 
1.4 
Clinical Studies ............................................................................................................................ 17 
2 
Study Hypotheses/Objectives ............................................................................................................. 19 
2.1 
Hypotheses ................................................................................................................................. 19 
2.2 
Primary Objective(s) .................................................................................................................... 19 
2.3 
Secondary Objective(s) ............................................................................................................... 19 
2.4 
Exploratory Objective(s) ............................................................................................................. 19 
3 
Study Design ....................................................................................................................................... 20 
3.1 
Description of Study Design ........................................................................................................ 20 
3.2 
Primary Endpoint ........................................................................................................................ 21 
3.3 
Secondary Endpoint(s)/Outcome(s) ........................................................................................... 21 
3.4 
Exploratory Endpoint(s)/Outcome(s) .......................................................................................... 21 
3.5 
Stratification, Randomization, and Blinding/Masking ................................................................ 22 
3.5.1 
Procedure for Unblinding/Unmasking ................................................................................ 22 
4 
Selection of Participants and Clinical Sites/Laboratories ................................................................... 23 
4.1 
Rationale for Study Population ................................................................................................... 23 
4.2 
Inclusion Criteria ......................................................................................................................... 23 
4.3 
Exclusion Criteria ......................................................................................................................... 24 
5 
Known and Potential Risks and Benefits to Participants .................................................................... 26 
5.1 
Risks of Investigational Product or Intervention as Cited in GSK Investigator’s Brochure for 
mepolizumab .......................................................................................................................................... 26 
5.2 
Risks of Investigational Product or Intervention Cited in Medical Literature ............................ 26 
5.3 
Risks of Other Protocol Specified Medications ........................................................................... 27 
5.3.1 
Oral Corticosteroids ............................................................................................................ 27 
5.4 
Risks of Study Procedures ........................................................................................................... 27 
5.4.1 
Allergy Skin Testing ............................................................................................................. 27 
5.4.2 
Blood Collection .................................................................................................................. 27 
5.4.3 
Pulmonary Function Testing (Spirometry and Impulse Oscillometry) ................................ 27 
5.4.4 
Exhaled Nitric Oxide Measurement .................................................................................... 28 


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5.4.5 
Nasal Sample Collection ...................................................................................................... 28 
5.4.6 
Sputum Induction................................................................................................................ 29 
5.4.7 
Nasal Epithelial Cell Collection ............................................................................................ 29 
5.4.8 
Questionnaires .................................................................................................................... 29 
5.5 
Potential Benefits ........................................................................................................................ 29 
6 
Investigational Agent .......................................................................................................................... 29 
6.1 
Investigational Agent: Mepolizumab .......................................................................................... 29 
6.1.1 
Formulation, Packaging, and Labeling ................................................................................ 29 
6.1.2 
Dosage, Preparation, and Administration .......................................................................... 30 
6.2 
Placebo ........................................................................................................................................ 30 
6.3 
Drug Accountability ..................................................................................................................... 30 
6.4 
Assessment of Participant Compliance with Investigational Agent ........................................... 30 
6.5 
Toxicity Prevention and Management ........................................................................................ 31 
6.6 
Premature Discontinuation of Study Participation ..................................................................... 31 
6.7 
Premature Discontinuation of Investigational Product .............................................................. 31 
7 
Other Medications .............................................................................................................................. 31 
7.1 
Concomitant Medications ........................................................................................................... 31 
7.1.1 
Protocol-mandated ............................................................................................................. 31 
7.1.2 
Other permitted concomitant medications ........................................................................ 37 
7.2 
Prophylactic Medications ............................................................................................................ 37 
7.3 
Prohibited Medications ............................................................................................................... 37 
7.4 
Rescue Medications .................................................................................................................... 38 
7.4.1 
Definition and Management of Acute Exacerbations ......................................................... 38 
8 
Study Procedures ................................................................................................................................ 38 
8.1 
Study Procedures ........................................................................................................................ 38 
8.1.1 
Vital Signs and Growth Parameters .................................................................................... 39 
8.1.2 
Medical History and Physical Examination ......................................................................... 39 
8.1.3 
Aeroallergen Skin Testing ................................................................................................... 39 
8.1.4 
Measurement of Fractional Exhaled Nitric Oxide ............................................................... 40 
8.1.5 
Measurement of Pulmonary Function ................................................................................ 40 
8.1.6 
Questionnaire Assessments ................................................................................................ 41 
8.2 
Clinical and Research Laboratory Evaluations and Specimen Collection ................................... 41 
8.2.1 
Blood Sample Collection ..................................................................................................... 41 


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8.2.2 
Nasal Sample Collection ...................................................................................................... 41 
8.2.3 
Urine Pregnancy Testing ..................................................................................................... 42 
8.2.4 
Urine Cotinine ..................................................................................................................... 42 
8.2.5 
Induced Sputum .................................................................................................................. 42 
8.2.6 
Nasal Epithelial Cell Collection ............................................................................................ 42 
8.3 
Recruitment ................................................................................................................................ 42 
8.4 
Screening/Baseline Visit .............................................................................................................. 43 
8.5 
Randomization ............................................................................................................................ 44 
8.6 
Visit 2 (Week 8) ........................................................................................................................... 45 
8.7 
Visit 3 (Week 12) ......................................................................................................................... 45 
8.8 
Injection Only Visits (Visits 5, 6, 8, 9, 11, 12) .............................................................................. 46 
8.9 
Asthma Evaluation and Management Visits (Visits 4, 7, 10, 13) ................................................ 46 
8.10 
Final Visit (Visit 14) ...................................................................................................................... 46 
8.11 
Cold Visits .................................................................................................................................... 47 
8.12 
Exacerbation Follow-Up Visits .................................................................................................... 47 
8.13 
Unscheduled Visits and Telephone Follow-up ............................................................................ 48 
8.14 
Visit Windows ............................................................................................................................. 48 
9 
Mechanistic Assays ............................................................................................................................. 48 
10 
Biospecimen Storage ...................................................................................................................... 49 
11 
Criteria for Participant and Study Completion and Premature Study Termination ....................... 49 
11.1 
Participant Completion ............................................................................................................... 49 
11.2 
Participant Stopping Rules and Withdrawal Criteria .................................................................. 49 
11.3 
Participant Replacement ............................................................................................................. 50 
11.4 
Follow-up after Early Study Withdrawal ..................................................................................... 50 
11.5 
Study Stopping Rules .................................................................................................................. 50 
12 
Safety Monitoring and Reporting ................................................................................................... 51 
12.1 
Overview ..................................................................................................................................... 51 
12.2 
Definitions ................................................................................................................................... 51 
12.2.1 
Adverse Event (AE) .............................................................................................................. 51 
12.2.2 
Unexpected Adverse Event ................................................................................................. 53 
12.2.3 
Serious Adverse Event......................................................................................................... 53 
12.3 
Grading and Attribution of Adverse Events ................................................................................ 54 
12.3.1 
Grading Criteria ................................................................................................................... 54 


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12.3.2 
Attribution Definitions ........................................................................................................ 57 
12.4 
Collection and Recording of Adverse Events .............................................................................. 58 
12.4.1 
Collection Period ................................................................................................................. 58 
12.4.2 
Collecting Adverse Events ................................................................................................... 58 
12.4.3 
Recording Adverse Events ................................................................................................... 58 
12.5 
Reporting of Serious Adverse Events and Adverse Events ......................................................... 58 
12.5.1 
Reporting of Serious Adverse Events to the IND Sponsor (DAIT NIAID) ............................. 58 
12.5.2 
Reporting to FDA ................................................................................................................. 59 
12.5.3 
Reporting of Adverse Events to IRBs ................................................................................... 60 
12.6 
Pregnancy Reporting ................................................................................................................... 60 
12.7 
Reporting of Other Safety Information ....................................................................................... 61 
12.8 
Review of Safety Information ..................................................................................................... 61 
12.8.1 
Medical Monitor Review ..................................................................................................... 61 
12.8.2 
DSMB Review ...................................................................................................................... 61 
13 
Statistical Considerations and Analytical Plan ................................................................................ 61 
13.1 
Overview ..................................................................................................................................... 62 
13.2 
Endpoints/Outcomes .................................................................................................................. 62 
13.3 
Measures to Minimize Bias ......................................................................................................... 62 
13.4 
Analysis Plan................................................................................................................................ 63 
13.4.1 
Analysis Populations ........................................................................................................... 63 
13.4.2 
Primary Analysis of Primary Endpoint(s)/Outcome(s) ........................................................ 63 
13.4.3 
Supportive Analyses of the Primary Endpoint(s)/Outcome(s) ............................................ 63 
13.4.4 
Analyses of Secondary and Other Endpoint(s)/Outcome(s) ............................................... 64 
13.4.5 
Analyses of Exploratory Endpoint(s)/Outcome(s) .............................................................. 65 
13.4.6 
Descriptive Analyses ........................................................................................................... 65 
13.5 
Interim Analyses.......................................................................................................................... 65 
13.5.1 
Interim Analysis of Efficacy Data ......................................................................................... 66 
13.5.2 
Interim Analysis of Safety Data ........................................................................................... 66 
13.5.3 
Futility Analysis ................................................................................................................... 66 
13.6 
Statistical Hypotheses ................................................................................................................. 66 
13.7 
Sample Size Considerations ........................................................................................................ 66 
14 
Identification and Access to Source Data ....................................................................................... 67 
14.1 
Source Data ................................................................................................................................. 67 


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14.2 
Access to Source Data ................................................................................................................. 67 
15 
Protocol Deviations ......................................................................................................................... 67 
15.1 
Protocol Deviation Definitions .................................................................................................... 67 
15.1.1 
Protocol Deviation .............................................................................................................. 67 
15.1.2 
Major Protocol Deviation .................................................................................................... 68 
15.1.3 
Non-Major Protocol Deviation ............................................................................................ 68 
15.2 
Reporting and Managing Protocol Deviations ............................................................................ 68 
16 
Ethical Considerations and Compliance with Good Clinical Practice .............................................. 68 
16.1 
Quality Control and Quality Assurance ....................................................................................... 68 
16.2 
Statement of Compliance ........................................................................................................... 69 
16.3 
Informed Consent Process .......................................................................................................... 69 
16.4 
Privacy and Confidentiality ......................................................................................................... 69 
17 
Publication Policy ............................................................................................................................ 69 
18 
References ...................................................................................................................................... 70 
Appendix A:   Schedule of Procedures/Evaluations .................................................................................... 72 
Appendix B: Nasal Lavage Quality Control Methods .................................................................................. 74 
1 
Study Population ................................................................................................................................. 74 
 
Population Description ............................................................................................................... 74 
1.1.1 
Inclusion Criteria ................................................................................................................. 74 
 
Requirements .............................................................................................................................. 74 
 
Procedures .................................................................................................................................. 74 
Appendix C: Omalizumab Dosing Tables .................................................................................................... 75 
Appendix D:  Sputum Induction Quality Control Methods ......................................................................... 77 
1 
Study Population ................................................................................................................................. 77 
1.1 
Population Description ............................................................................................................... 77 
1.1.1 
Inclusion Criteria ................................................................................................................. 77 
1.2 
Requirements .............................................................................................................................. 77 
1.3 
Procedures .................................................................................................................................. 77 
Appendix E:  Study Restrictions Due to COVID-19 ...................................................................................... 78 
 
 
 


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Glossary of Abbreviations 
ACT 
Asthma Control Test 
AE 
Adverse Event 
APIC 
Asthma Phenotypes in the Inner City 
ATS 
American Thoracic Society 
BID 
Bis in die (twice a day) 
BP 
Blood pressure 
BMI 
Body Mass Index 
CASI 
Composite Asthma Severity Index 
CBC 
Complete blood count 
CFR 
Code of Federal Regulations 
CRF 
Case report form 
CTCAE 
Common Terminology Criteria for Adverse Events 
DAIT 
Division of Allergy, Immunology, and Transplantation 
DPI 
Dry powder inhaler 
DSMB 
Data Safety Monitoring Board 
ECP 
Eosinophil cationic protein 
eCRF 
Electronic case report form 
ED 
Emergency department 
E&M 
Evaluation and Management 
EPR-3 
Expert Panel Report 3 
FDA 
Food and Drug Administration 
FeNO 
Fractional exhaled nitric oxide 
FEV1 
Forced expiratory volume in 1 second 
GCP 
Good Clinical Practice 
GSK 
GlaxoSmithKline (GSK) Group Company 


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HIPAA 
Health Insurance Portability and Accountability Act 
ICAC 
Inner City Asthma Consortium 
ICATA 
Inner City Anti-IgE Therapy in Asthma 
ICH 
International Conference on Harmonisation 
ICS 
Inhaled corticosteroid 
IgE 
Immunoglobulin E 
IgG 
Immunoglobulin G 
IL 
Interleukin 
IND 
Investigational New Drug 
IOS 
Impulse oscillometry 
IRB 
Institutional Review Board 
ITT 
Intent-to-treat 
LABA 
Long-acting beta agonist 
MOP 
Manual of Procedures 
NAEPP 
National Asthma Education and Prevention Program 
NCI 
National Cancer Institute 
NIAID 
National Institute of Allergy and Infectious Diseases 
OHRP 
Office of Human Research Protections 
PCP 
Primary care provider 
PEF 
Peak expiratory flow 
PD 
Protocol deviation 
PP 
Per Protocol 
PFT 
Pulmonary function tests 
PHI 
Personal health identifiers 
PI 
Principal Investigator 
RV 
Rhinovirus 


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SACCC 
Statistical and Clinical Coordinating Center 
SAE 
Serious adverse event 
SAR 
Suspected adverse reaction 
SQ 
Subcutaneous 
SUSAR 
Serious unexpected suspected adverse reaction 
URECA 
The Urban Environment and Childhood Asthma 
 
 


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1 Background and Rationale  
1.1 Background and Scientific Rationale 
Asthma is the most common chronic disease of childhood, and is associated with $56 billion in health 
care costs in the United States annually. Episodic exacerbations are the major source of morbidity, 
mortality, and health care costs due to asthma. These events are particularly common in at risk urban 
children and adolescents with asthma.  Importantly, exacerbations lead to progressive loss of lung 
function 3,4 which contributes to increasing asthma severity over time. Moreover, it has recently been 
shown that a significant number of children with mild to moderate asthma at early school age progress 
to a pattern of fixed obstructive lung disease by early adulthood.5 Thus, it is a major unmet need to 
prevent asthma exacerbations, particularly in exacerbation-prone children. 
Protocol ICAC-30 MUPPITS-2 clinical trial is designed to determine whether an intervention that is 
directed towards a phenotype-defined population of urban children and adolescents with difficult-to-
control, exacerbation-prone asthma will improve disease management by preventing exacerbations. For 
a significant number of asthma patients, guidelines-directed treatment does not achieve disease control, 
suggesting the need, and potential benefit, for treatment(s) that are personalized to the phenotype of 
these patients. This trial is informed by the DAIT NIAID-sponsored Inner-City Asthma Consortium (ICAC) 
2 trial, Protocol ICAC-19, titled “Asthma Phenotypes in the Inner City”,6-8 and based on these 
observations and others in the literature9, the presence of peripheral blood eosinophils in patients with 
difficult-to-control asthma, despite appropriate guidelines-directed care, is a biomarker for asthma 
exacerbations and increased morbidity. Therefore, we hypothesize that targeting eosinophils with the 
addition of the anti-IL-5 monoclonal antibody, mepolizumab, will prevent exacerbations and, as a 
consequence, reduce overall morbidity, improve asthma control, and quality of life.  
To date, phenotype-directed trials using biologic agents have been performed primarily in adults. 
Protocol ICAC-30 MUPPITS-2 is designed to test whether this approach is effective in urban children and 
adolescents with difficult-to-control, exacerbation-prone asthma. From a public health perspective, the 
proposed trial will inform clinical guidelines for care of children at EPR3 Step 4 care and above, where 
there is currently a paucity of data to guide treatment decisions. The information will not only be useful 
in the inner-city population but also for the overall management of difficult-to-control, exacerbation-
prone asthma in the pediatric age group. This trial will serve as a model for future phenotype-directed 
protocols for difficult-to-control, exacerbation-prone asthma in at-risk urban youth. Finally, our focus on 
underlying mechanisms using whole genome transcriptomics of nasal airway and peripheral blood will 
provide insight to mechanisms by which eosinophils and IL-5 contribute to exacerbations. Furthermore, 
the transcriptomic characteristics of exacerbations that persist despite anti-IL5 therapy will provide 
potential new therapeutic targets for the treatment of this difficult-to-control, exacerbation-prone 
asthma phenotype. 
Protocol ICAC-30 MUPPITS-2 is a randomized, double-blind, placebo-controlled, parallel-group, multi-
center trial of the efficacy and safety of mepolizumab adjunctive therapy for 12 months in urban asthma 
patients aged 6-17 years with difficult-to-control, exacerbation-prone asthma with an eosinophilic 
phenotype (defined by a peripheral blood eosinophil count ≥150 cells/μl).  


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1.2 Rationale for Selection of Investigational Product or Intervention 
Nucala® 10 is an interleukin-5 antagonist monoclonal antibody (IgG1 kappa) indicated in the United 
States for add-on maintenance treatment of patients with severe asthma aged 12 years and older, with 
an eosinophilic phenotype.  
Asthma exacerbations are most commonly associated with viral respiratory infections, with human 
rhinoviruses (RV) the most frequent 11-13. A number of risk factors for exacerbations with respiratory 
infections have been identified including underlying allergic disease, allergic inflammation and a T2 
sputum cell profile11. The mechanisms underlying a reduction in asthma exacerbations associated with 
mepolizumab treatment 14 are unknown, and a greater understanding of mechanisms responsible for 
this effect will improve our understanding of the pathogenesis of asthma exacerbations15. Because IL-5 
is an important survival factor for eosinophils, the reduction in exacerbations is commonly thought to 
reflect the depletion in airway eosinophils, but this begs the question as to how airway eosinophils 
predispose to asthma exacerbations. We hypothesize that eosinophil products activate epithelial cell 
production of chemoattractants for other inflammatory cell types, such as mast cells and CD4+T 
lymphocytes. Based on this hypothesis, we expect that IL-5 inhibition will have broad effects on cellular 
inflammation in the airway. In particular, we anticipate that anti-IL-5 treatment will decrease airway 
mast cells and airway T2 inflammation16. 
A major unmet need in asthma care is to improve outcomes of disease control in patients with more 
severe disease that is not responsive to current therapy17. We have observed a pattern of treatment 
response in urban children where, despite intensive efforts to prevent asthma morbidity with asthma 
counseling18, cockroach allergen home mitigation19, and optimized guidelines-based asthma 
management including high-dose inhaled corticosteroids (ICS), long-acting beta-agonists (LABA), and 
omalizumab20,21, exacerbations still occurred frequently and disease control was not always achieved. 
48% of 400 ICAC participants who were managed for one year with guidelines-based care (i.e., the 
control participants in the ICAC Asthma Control Evaluation (ACE) 21 and DAIT NIAID-sponsored clinical 
trials (IND #100, 210) – Protocol ICAC-08/09, titled “Inner-City Anti-IgE Therapy in Asthma (ICATA)” 20) 
had at least one asthma exacerbation requiring a course of systemic corticosteroids, and 24% of the 
control treated patients in ICATA had at least two exacerbations. Importantly, exacerbations have been 
associated with progressive loss of lung function over time 3,22. Given the existing shortcomings in the 
effectiveness of current treatments for a significant proportion of children and adolescents with asthma, 
particularly those in urban environments, a new approach for their management is needed to improve 
disease control and reduce morbidity, focusing on exacerbations. 
One consideration in selecting a treatment in high-risk children and adolescents with difficult-to-control 
asthma is feasibility and a conveniently measurable marker to predict an effective response, i.e. high 
blood eosinophils. Mepolizumab meets these criteria and can be given monthly in a subcutaneous 
injection. Moreover, novel immune biologics are not necessarily good candidates for 
children/adolescents unless they have been well tested in older participants and their efficacy and 
safety demonstrated. Although a developing array of immune-based therapeutics may also be 
reasonable candidates for a phenotypic biomarker-directed approach to difficult asthma in at-risk urban 
youth, they are not sufficiently advanced at this time. 


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1.3 Preclinical Experience 
In mice, anti-IL-5 monoclonal antibodies removed 
eosinophils and virtually eliminated allergic inflammation 
and pulmonary dysfunction associated with antigen 
provocation 23. 
1.4 Clinical Studies 
The assessment of mepolizumab’s effectiveness in asthma in 
adults has been instructive for the need to identify 
appropriate patient populations to comprehensively 
evaluate new therapies, and is applicable to our proposed 
clinical trials in urban children and adolescents. In an initial 
clinical trial, Leckie et al 24,25 found mepolizumab significantly 
reduced peripheral blood and sputum eosinophils, but did not 
block either the late phase response to antigen or the post-challenge increase in airway hyper-
responsiveness. These results were a major surprise and raised the possibility that eosinophils, despite 
their much-recognized relationship to multiple features of asthma, may not have a major 
pathophysiological role in in this disease. When Flood-Page et al 10 tested mepolizumab in a large 
population of patients with moderate-to-severe asthma, lung function, symptoms and exacerbations did 
not improve. There was, however, a trend towards reduced exacerbations in a subpopulation of 
patients. 
At the same time, Green et al 26 compared treatment by British Thoracic Society guidelines to the 
addition of extra ICS aimed at the reduction of sputum eosinophils. The reduction in sputum eosinophils 
was associated with a decrease in the frequency of exacerbations. This relationship to the prevention of 
exacerbations was further confirmed by Haldar et al 25 and Nair et al 27 who evaluated mepolizumab in 
patients with severe asthma who required high doses of ICS and, in most cases, systemic prednisone, for 
disease control, but yet had frequent exacerbations and, importantly, persistent sputum and peripheral 
blood eosinophils. In a one-year treatment with mepolizumab, Haldar et al 25 found the frequency of 
exacerbations decreased by approximately 50% (Figure 4). Nair et al 27 found similar effects with 
mepolizumab. No changes in asthma symptoms, need for rescue treatment, or lung function measures 
were noted in either trial. Pavord et al 14 substantiated these findings with mepolizumab in a large trial. 
More recently, two additional trials demonstrated similar efficacy for exacerbation prevention using 
subcutaneous administration of mepolizumab, a more patient friendly route of administration than the 
intravenous administration in earlier trials 2,28,29. Therefore, the phenotype-profile in asthma where 
mepolizumab has been found to be effective is: difficult-to-control asthma with frequent exacerbations 
and the presence of eosinophils despite ongoing ICS treatment, with the primary outcome being 
prevention of exacerbations. Since mepolizumab effectively reduces exacerbations and also leads to a 
reduction in airway area as assessed by high-resolution computerized tomography scans after one year 
of treatment 26, it is intriguing to suggest that mepolizumab in school-age children and adolescents, who 
are exacerbation-prone, has the potential to prevent progressive loss of lung function and disease 
progression with time.  
1. What information can be used to select urban children and adolescents with difficult-to-control 
asthma for a trial with mepolizumab? A meta-analysis of mepolizumab in adult patients with severe 
Figure 4. Mepolizumab reduces asthma exacerbations 


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asthma and persistent eosinophilia revealed significant reductions in the risk for exacerbation across 
seven trials (OR 0.30 95% CI 0.13 to 0.67, p=0.004) 30. Studies of mepolizumab in adults have identified 
consistent benefit in exacerbation-prone participants whose peripheral blood eosinophil counts are 
≥150 cells/μl2,29. A post-hoc analysis of the relationship between blood eosinophilia and asthma 
exacerbations in 
the Protocols 
ICAC-08/09 
ICATA trials 
demonstrated 
that elevated 
peripheral 
blood 
eosinophils at 
randomization 
were 
significantly 
associated with 
an increased 
risk of 
exacerbations. 
In these analyses, the optimum cut-point for eosinophils was 340 cells/μl (52% vs. 33% over the 12 
month treatment period; p=0.0003: Table 1.4). Interestingly, and important in the selection of an 
intervention most likely to be effective in children with uncontrolled asthma, was the finding that 
exacerbation rates remained high (43%) even in children treated with omalizumab. Thus, even with 
conventional guidelines-based asthma management, including omalizumab, patients with peripheral 
blood eosinophilia continue to have frequent exacerbations. These findings suggest that an alternative 
therapeutic agent than omalizumab may be the best intervention. Given the effect of mepolizumab on 
exacerbations and its safety profile, mepolizumab is an ideal choice.  
Additional analyses of the Protocol ICAC-19 APIC study population characteristics at study screening 
demonstrate that the typical characteristics utilized in adult mepolizumab trials [eosinophils ≥150 
cells/μl, ≥2 exacerbations in the prior year, and requirement for high level controller therapy (6-11 
years: fluticasone DPI 250 mcg BID or equivalent, 12 and above: fluticasone/salmeterol DPI 250/50 mcg 
BID or equivalent)] identifies urban youth at high risk for exacerbation. Children meeting these 
characteristics had a 70% risk of exacerbation during the Protocol ICAC-19 APIC 12 month follow up 
despite guidelines-based care and good adherence with medications.  
2.  What are potential advantages of mepolizumab in this population? Mepolizumab is administered as a 
fixed subcutaneous dose of 100 mg every 4 weeks for patients aged 12 years and above; 40 mg every 4 
weeks for patients aged 6 to 11 years. These doses are consistent with the approved dosing per the 
Package Insert (September 2019). The use of mepolizumab will allow us to include children who were 
not eligible for our previous omalizumab studies (ICAC-08/09/20). For example, in DAIT-Sponsored 
Protocols ICAC-08/09 ICATA, 35% of children and adolescents identified with exacerbation-prone 
asthma were ineligible for enrollment due to their weight and/or total serum IgE level. In fact, more 
Table 1.4. Association between Blood Eosinophils at Randomization and Exacerbations during the Protocols 
ICAC-08/09 ICATA Double Blind Treatment Phase. 
Group 
Blood EOS at 
Randomization 
Size 
Exacerbation 
Difference 
OR 
(95% CI) 
p-value 
Both 
Placebo + 
Omalizumab 
< 340 
65% 
(243/373) 
33% 
19% 
2.23 
(1.44, 3.46) 
0.0003 
≥ 340 
35% 
(130/373) 
52% 
Placebo 
< 340 
64% 
(116/181) 
41% 
21% 
2.27 
(1.21, 4.23) 
0.0120 
≥ 340 
36% 
(65/181) 
62% 
Omalizumab 
< 340 
66% 
(127/192) 
25% 
18% 
2.25 
(1.19, 4.24) 
0.0127 
≥ 340 
34% 
(65/192) 
43% 
EOS=eosinophils; OR=odds ratio 


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than 50% of Protocol ICAC-19 APIC participants with difficult-to-control, exacerbation prone asthma 
would have been ineligible for omalizumab therapy based upon weight, total serum IgE level, or lack of 
aeroallergen sensitization. Of note, a post hoc analysis of the DREAM (Mepolizumab for Severe 
Eosinophilic Asthma) study suggests that this subgroup of patients with high body mass indices (BMIs) 
may be particularly responsive to mepolizumab29. Further, in the presence of elevated eosinophils, adult 
patients with and without aeroallergen sensitization responded similarly to mepolizumab31. In the same 
analysis, mepolizumab responses were similar across quartiles of total serum IgE31. Thus, it is possible 
that mepolizumab may be particularly effective in patients who do not fit the current omalizumab 
dosing paradigm, and have the potential to meet an important unmet need for this group of 
approximately 50% of urban youth with difficult to control, exacerbation prone asthma. 
2 Study Hypotheses/Objectives 
2.1 Hypotheses 
The primary research question of this study is whether mepolizumab will lead to a reduced rate of 
asthma exacerbations in urban children and adolescents (ages 6-17) with difficult-to-control, 
exacerbation-prone asthma and peripheral blood eosinophils ≥150 cells/μl. We hypothesize that 
targeting eosinophils with the addition of the anti-IL-5 monoclonal antibody, mepolizumab, will prevent 
exacerbations and, as a consequence, reduce overall morbidity and improve asthma control. We will 
also explore the mechanistic hypothesis that IL-5 inhibition will have broad effects on T2 inflammation in 
the airways. 
2.2 Primary Objective(s) 
The primary objective of this study is to determine whether mepolizumab, in addition to guidelines-
based care, will reduce the rate of asthma exacerbations compared to guidelines-based care alone.  
2.3 Secondary Objective(s) 
Secondary objectives are: 
1. To determine whether mepolizumab will lead to an improved Composite Asthma Severity Index 
(CASI)1 
2. To determine whether mepolizumab will improve quality of life as assessed by the physician-
patient global assessment2 
3. To determine whether mepolizumab improves lung function as assessed by spirometry and 
impulse oscillometry   
4. To determine whether mepolizumab increases the time to first asthma exacerbation 
5. To separately determine whether mepolizumab reduces the rate of exacerbations in study 
participants who do not fit the FDA-approved dosing table (see Appendix C) for omalizumab 
therapy and in study participants who fit the FDA-approved dosing table for omalizumab 
therapy  
6. To assess the safety of mepolizumab treatment 
2.4 Exploratory Objective(s) 
Exploratory objectives are: 


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1. To determine whether the following patient characteristics/biomarkers predict response to 
mepolizumab: 
• 
BMI percentile 
• 
Peripheral blood eosinophils 
• 
Bronchodilator responsiveness at baseline 
• 
Exacerbation history in year prior to study (2, 3 or 4+) 
• 
Total serum IgE 
• 
Fractional exhaled nitric oxide  
• 
Nasal mucus eosinophil cationic protein (ECP) 
2. To determine whether mepolizumab improves other important clinical outcomes, including rate 
of virus-induced asthma exacerbations, time to first virus-induced asthma exacerbation, Asthma 
Control Test (ACT) scores, maximum number of asthma symptom days, and bronchodilator 
response 
3. To use transcriptomics to identify immunologic pathways in the airways and peripheral blood 
that are characteristic of exacerbations prevented with and persistent despite anti-IL5 therapy. 
4. To measure levels of antibody to mepolizumab 
3 Study Design 
3.1 Description of Study Design  
Protocol ICAC-30 MUPPITS-2 is a multicenter, double-blind, placebo-controlled, randomized trial of 
mepolizumab adjunctive therapy for the prevention of asthma exacerbations in urban children and 
adolescents 6 to 17 years with exacerbation-prone asthma and peripheral blood eosinophilia. 
Approximately 290 participants will be randomized 1:1 to one of two study arms: 1) guidelines-based 
asthma treatment + placebo, or 2) guidelines-based asthma treatment + mepolizumab. All participants 
will be followed for one year.  
There will be a Screening Visit followed by a 4-week run-in period. After the run-in, children who 
continue to meet eligibility criteria will be randomized to one of the 2 treatment arms and receive their 
first injection.  Participants will receive monthly injections of either 40 mg or 100 mg of 
mepolizumab/placebo administered subcutaneously, according to their age. Participants 6 to 11 years of 
age and weighing ≥40 kg who were enrolled in Protocol ICAC-30 under the previous versions of the 
protocol and initially assigned a 100 mg dose will have their dose reduced to 40 mg.  Participants who 
receive the 40 mg dose at randomization will increase to the 100 mg dose if they become 12 years old 
during the study. All participants will have Evaluation and Management (E&M) visits every 3 months 
where their asthma will be assessed and adjustments made to their medications based on asthma 
guidelines.  
Participants will be asked to monitor and report cold symptoms. Participants will come to the clinic at 
the time of a cold, up to three times, for collection of blood and nasal secretions for associated 
mechanistic studies.  


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Participants will also be asked to come into the clinic following an asthma exacerbation for collection of 
blood and nasal secretions for associated mechanistic studies, assessments of airway physiology, and to 
collect information for ongoing asthma management. 
 
Figure 3.1. Protocol ICAC-30 MUPPITS-2 Study Design 
3.2 Primary Endpoint 
The primary endpoint is the number of asthma exacerbations during the 12-month treatment period. 
Exacerbations will be defined as a prescription of a course of systemic corticosteroids by a clinician, 
initiation of a course of systemic corticosteroids by a participant, or as a hospitalization for asthma. If a 
participant initiates and completes a course of systemic corticosteroids without clinician involvement, 
this course will be counted only if the study clinician agrees the treatment was warranted, and it meets 
the following dosage: the course for prednisone, prednisolone, or methylprednisolone will be at least 20 
mg daily dose for 3 of 5 consecutive days. The course for dexamethasone will be at least a 10 mg single 
daily dose. If a corticosteroid burst for the treatment of an asthma exacerbation is prescribed by a non-
ICAC clinician, it will be counted regardless of dose. 
3.3 Secondary Endpoint(s)/Outcome(s) 
1. CASI during the treatment period 
2. Quality of life, as measured by physician-patient global assessment  
3. Lung function as assessed by spirometry and IOS during the treatment period 
4. Time to first asthma exacerbation during the treatment period 
5. Number of reported adverse events and serious adverse events, including their severity and 
treatment relatedness 
3.4 Exploratory Endpoint(s)/Outcome(s) 
1. Time to first respiratory virus-induced exacerbation as measured by an exacerbation associated 
with a respiratory virus detected using nasal mucus samples obtained at the time of an 
exacerbation, during the treatment period 


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2. Number of respiratory virus-induced exacerbations as measured by an exacerbation associated 
with a respiratory virus detected using nasal mucus samples obtained at the time of an 
exacerbation, during the treatment period 
3. Childhood ACT/ACT during the treatment period 
4. Maximum number of asthma symptom days, defined as the highest value among the following 
three variables over a two-week period: number of days with wheezing, tightness in the chest, 
or cough; number of nights with disturbed sleep as a result of asthma; and number of days on 
which the participant had to slow down or discontinue play/physical activities 
5. Bronchodilator responsiveness at the end of the treatment period 
6. Gene expression using whole genome transcriptomics of nasal lavage samples during treatment 
period 
7. Gene expression using whole genome transcriptomics of whole blood RNA samples during 
treatment period 
8. Levels of antibody to mepolizumab during treatment period 
9. Other biomarkers (banking plasma, banking nasal sample, RNA, DNA) 
3.5 Stratification, Randomization, and Blinding/Masking 
Randomization will be performed using a validated system created by the DAIT Statistical and Clinical 
Coordinating Center (SACCC) called RhoRANDTM that automates the random assignment of treatment 
groups to study ID numbers. The randomization scheme will be reviewed and approved by a statistician 
at the DAIT SACCC. Participants will be randomized using a 1:1 ratio of active study drug and control 
(placebo) participants. A covariate adaptive randomization algorithm developed by Pocock and Simon 
(1975) 32 will be used to maintain a balance between treatment arms with respect to site, number of 
previous exacerbations (2 or 3+), peripheral blood eosinophils (< or ≥400 cells/μl), BMI (< or ≥95th 
percentile for age), total serum IgE (< or ≥540 kUA/L) and treatment dose (40 mg or 100 mg). This 
strategy was chosen to enhance our ability to balance the distribution of covariates that are known to 
be highly associated with our primary endpoint (e.g., number of previous exacerbations and peripheral 
blood eosinophils) as well as covariates that determine if a participant fits the FDA-approved dosing 
tables for omalizumab therapy (e.g., BMI and total serum IgE), which is related to Secondary Objective 5.  
Randomization data will be kept strictly confidential, accessible only to authorized persons, until the 
time of unblinding. When the study has been completed, the data files verified, and the protocol 
deviations determined, the investigational agent codes will be broken and made available for data 
analysis. 
The clinical site’s research pharmacy will dispense the study drug as per the randomization schedule 
provided by RhoRANDTM. The injections will be administered by trained clinical research staff. Prior to 
injection, an unblinded site pharmacist will confirm the expiration date, the dose, and randomization 
assignment. The product will remain blinded to blinded clinical research staff and the participant. 
3.5.1 
Procedure for Unblinding/Unmasking 
Unblinding must be approved by the DAIT NIAID Medical Monitor unless an immediate life threatening 
condition has developed and the Medical Monitor is not accessible. If unblinding is performed through 
RhoRANDTM, a notification will be sent to the protocol chair, the DAIT NIAID Medical Monitor, and the 
DAIT SACCC team of the unblinding event as soon as unblinding occurs. Otherwise, the site principal 


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investigator will notify the protocol chair and the DAIT SACCC team of the unblinding event on the next 
business day. The emergency unblinding will also be reported to the NIAID Allergy and Asthma Data and 
Safety Monitoring Board (DSMB). 
A full account of the event will be recorded, including the date and time of the unblinding, the reason 
for the decision to unblind, and the name of the individual who made the decision to unblind and the 
names of the DAIT NIAID Medical Monitor and others who were notified. The reasons for unblinding of a 
participant’s treatment will be included in the final clinical study report. 
Unblinding the study due to an approved interim analysis, final analysis, or study termination will 
require written approval from the DAIT NIAID Medical Monitor. 
4 Selection of Participants and Clinical Sites/Laboratories 
4.1 Rationale for Study Population 
The population selected for this trial is urban asthma patients aged 6-17 years with difficult-to-control, 
exacerbation-prone asthma and a peripheral blood eosinophil count ≥150 cells/μl. Previous DAIT NIAID-
sponsored inner-city asthma clinical trials have shown that high proportions of children who meet 
Protocol ICAC-30 MUPPITS-2 inclusion criteria continue to experience exacerbations despite receiving 
guidelines-based asthma management and maximum levels of treatment with inhaled steroids.7,8 
Omalizumab is an effective add-on treatment, but up to 50% of children and adolescents identified with 
difficult-to-control, exacerbation-prone asthma may be ineligible for omalizumab due to their high 
weight, high (or low) total serum IgE level, or lack of aeroallergen sensitization. Given the existing 
shortcomings in the effectiveness of current treatments for a significant proportion of children and 
adolescents with asthma, a new approach for their management is needed to improve disease control 
and reduce morbidity, focusing on exacerbations. 
4.2 Inclusion Criteria 
1. Participant and/or parent guardian must be able to understand and provide informed consent and 
age-appropriate assent 
2. Are male and female aged 6-17 years, inclusive at randomization  
3. Have a primary place of residence in one of the pre-selected recruitment census tracts as outlined 
in the Protocol ICAC-30 Recruitment MOP 
3a.  Participants who do not live in the pre-selected census tracts but live within the Office of 
Management and Budget (OMB) defined Metropolitan Statistical Area and have publicly-funded 
health insurance will qualify for inclusion. 
4. Have had a diagnosis of asthma made > 1 year prior to recruitment; participants who received an 
asthma diagnosis by a clinician ≤ 1 year prior to recruitment must report that their respiratory 
symptoms were present for more than 1 year prior to recruitment 
5. Have had at least two asthma exacerbations in the prior year (defined as a requirement for 
systemic corticosteroids and/or hospitalization) 
6. At Visit 0 (Screening), have the following requirement for asthma controller medication: for 
participants aged 6 to 11 years, treatments with at least fluticasone 250 mcg dry powder inhaler 


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(DPI) one puff twice daily or its equivalent and for participants aged 12 years and older, treatment 
with at least fluticasone 250 mcg plus LABA DPI one puff twice daily or its equivalent 
7. Have peripheral blood eosinophils ≥150 cells/μl obtained at Visit 0 or via another ICAC protocol 
within 6 months 
8. Are able to perform spirometry at randomization 
9. Have documentation of current medical insurance with prescription coverage at randomization 
10. Have had varicella or the varicella vaccination 
4.3 Exclusion Criteria 
Individuals who meet any of the following criteria are not eligible for enrollment or randomization, if 
they: 
1. 
Are not able or willing to give written informed consent or comply with study protocol 
2. 
Have concurrent medical problems that would require systemic corticosteroids or other 
immunomodulators during the study 
3. 
Are currently receiving immunotherapy 
4. 
Are currently receiving treatment with omalizumab or have had omalizumab treatment within 6 
months prior to randomization 
5. 
Are currently requiring greater than fluticasone 500 mcg bid plus LABA one puff twice daily or its 
equivalent and/or individuals using oral corticosteroids daily or every other day for more than 14 
days at the time of Visit 0 (Screening) 
6. 
Are currently pregnant or lactating, or plan to become pregnant during the time of study 
participation. Females of child-bearing potential (post-menarche) must be abstinent or use a 
medically acceptable birth control method throughout the study (e.g. oral subcutaneous, 
mechanical, or surgical contraception) 
7. 
Have a known, pre-existing clinically important lung condition other than asthma 
8. 
Have a current malignancy or previous history of cancer in remission for less than 12 months prior 
to randomization 
9. 
Have known, pre-existing, unstable liver disease 
10. Is a current smoker  
11. Have a known immunodeficiency disease 
12. Have other conditions that could lead to elevated eosinophils such as hypereosinophilic syndromes, 
including eosinophilic granulomatosis with polyangiitis 
13. Have a known, active parasitic infestation or undergoing treatment for a parasitic infestation. Once 
the participant has been successfully treated, the participant may be reevaluated.  
14. Use of investigational drugs within 4 weeks of randomization 
15. Have past or current medical problems or findings from physical examination or laboratory testing 
that are not listed above, which, in the opinion of the study clinician, may pose additional risks from 
participation in the study, may interfere with the participant’s ability to comply with study 
requirements or that may impact the quality or interpretation of the data obtained from the study 
16. Will not allow the study clinician, an asthma specialist, to manage their disease for the duration of 
the study or who are not willing to change their asthma medications to follow the protocol 
17. Have a known history of allergic reaction to previous biologic therapy for asthma 


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18. Have had a life threatening asthma exacerbation in the last 2 years requiring intubation, mechanical 
ventilation or resulting in a hypoxic seizure 
 
 


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5 Known and Potential Risks and Benefits to Participants 
5.1 Risks of Investigational Product or Intervention as Cited in GSK Investigator’s Brochure for 
mepolizumab 
Hypersensitivity reactions (e.g., anaphylaxis, angioedema, bronchospasm, hypotension, urticaria, rash) 
have occurred following administration of mepolizumab. These reactions generally occur within hours of 
administration, but in some instances can have a delayed onset (i.e., days).  
In controlled clinical trials, 2 serious adverse reactions of herpes zoster occurred in participants treated 
with mepolizumab compared with none in placebo. Varicella vaccination or history of varicella is 
required prior to randomization. 
Very common adverse reactions in subjects with severe eosinophilic asthma (incidence greater than or 
equal 10%) include headache and subcutaneous injection site reaction (such as pain, erythema, swelling, 
itching or burning sensation). Per the current IB for mepolizumab, the common adverse events are back 
pain, nasopharyngitis, urinary tract infection, nasal congestion, eczema, and abdominal pain upper. The 
incidence of AEs was similar for the placebo group as compared to the mepolizumab group regardless of 
the route of administration (SC or IV) with the exception of a higher rate of injection site reactions with 
SC administration of mepolizumab (8%) compared with placebo (3%) 33.   
5.2 Risks of Investigational Product or Intervention Cited in Medical Literature 
Other side effects from Nucala® 10 have been reported.  The MENSA trial2 was a randomized, double-
blind, double-dummy study of 576 patients aged 12-82 years old randomized to 75-mg mepolizumab 
administered intravenously, 100-mg mepolizumab administered subcutaneously, and placebo.  The 
overall frequency of adverse events was similar across the three treatment groups.  The most frequently 
reported adverse events were nasopharyngitis (24% given mepolizumab intravenously, 17% given 
mepolizumab subcutaneously, 24% given placebo) and headache (24%, 20%, and 17%).  The incidence of 
adverse events related to a study drug was 17%, 20% and 16%.  The incidence of injection-site reactions 
was more frequent in the subcutaneous-mepolizumab group (9%) than in the intravenous-mepolizumab 
and placebo groups (3% in both).  The incidence of serious adverse events (including asthma-related 
events) was 7%, 8%, and 14% 2.   
The DREAM study 14 was a multicenter, double-blind, placebo-controlled trial of 621 patients aged 12-74 
years old randomized to placebo, 75 mg mepolizumab, 250 mg mepolizumab and 750 mg mepolizumab 
administered intravenously. The overall frequency of serious adverse events was similar across 
treatment groups. The most frequently reported adverse events were headache (17% given placebo, 
21% given 75 mg mepolizumab, 21% given 250 mg mepolizumab, and 21% given 750 mg mepolizumab) 
and nasopharyngitis (15%, 22%, 22%, and 19%). The most frequently reported drug-related adverse 
event was infusion-related reaction (eg, non-allergic reactions), which was reported by 6% given 
placebo, 5% given 75 mg mepolizumab, 8% given 250 mg mepolizumab, and 12% given 750 mg 
mepolizumab. Hypersensitivity deemed to be possibly related to investigational product was reported 
by 2% given placebo, none given 75 mg mepolizumab, <1% given 250 mg mepolizumab, and 1% given 
750 mg mepolizumab 14.  


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5.3 Risks of Other Protocol Specified Medications 
5.3.1 
Oral Corticosteroids 
Oral prednisone will be dispensed to each participant at the beginning of the study for treatment of 
asthma exacerbations as per the participant’s Asthma Action Plan (see Section 7.1.1.4). Oral 
corticosteroids can cause hoarseness, sore throat, and yeast infection of the mouth or throat if taken in 
high doses for lengthy periods of time. In addition, they can cause weight gain, growth delay, bruising of 
the skin, cataracts, and glucose intolerance. These effects are more likely if the medicine is taken at very 
high doses for extended periods of time. These side effects are not anticipated in this study because of 
the length of time (4 days on any occasion) that oral corticosteroids will be taken. 
5.4 Risks of Study Procedures  
5.4.1 
Allergy Skin Testing 
Allergy skin testing is routinely performed in the management of asthma and allergic diseases. Skin 
testing will be completed by clinical research staff trained and certified to perform the procedure in 
accordance with the Protocol ICAC-30 MOP to maximize safety. If a participant is allergic to any of the 
allergens, redness, swelling, and itching of the skin may occur and last for 1 to 2 hours. These symptoms 
could occur up to 1 or 2 days after the skin test. A study clinician may provide a topical corticosteroid or 
oral antihistamine to treat these symptoms. There is also a very rare chance that the participant may 
have asthma symptoms or faint during the test. A medical provider trained in treating anaphylaxis will 
be available to provide immediate treatment in the event that a participant experiences a systemic 
allergic reaction. Stopping antihistamines before skin testing may make allergy (but not asthma) 
symptoms worse. Participants will be told they can take their medications if they need them, but the 
test will need to be rescheduled. 
To date, aeroallergen skin prick test procedures, conducted according to our MOP by trained and 
certified clinical research staff on thousands of children, have NEVER resulted in a systemic adverse 
reaction. Further, performance of such allergen evaluation is consistent with national asthma guidelines 
and provides direct benefits to both children and their families/caretakers. The results of the skin tests 
are provided to families, as well as relevant educational materials for environmental control. 
5.4.2 
Blood Collection 
The risks associated with a blood draw include possible pain from the stick, as well as bleeding, bruising, 
and infection of the skin. Lightheadedness and fainting rarely occur. To minimize these risks, a clinical 
staff member who is trained to draw blood from children will collect the samples. Additionally, clinical 
staff may apply a topical anesthetic to the skin before the blood draw to reduce the discomfort of the 
stick. Side effects from topical anesthetics include erythema, burning, paleness at the skin site, edema, 
and alterations in temperature. Reactions are mild and transient. There is a potential for cutaneous 
allergic reactions to topical anesthetics. Topical anesthetics are routinely used for usual care 
venipunctures to minimize discomfort. The amount of blood to be collected is within the NIH pediatric 
guidelines. 
5.4.3 
Pulmonary Function Testing (Spirometry and Impulse Oscillometry) 


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Pulmonary function measurements will be performed by trained and certified clinical research staff 
according to American Thoracic Society standards as performed routinely in usual care as part of 
subspecialist management of asthma. 
Pulmonary function tests can cause coughing or lightheadedness, which will go away shortly after the 
test is finished.  
Participants may be asked to withhold their asthma medications for 8-24 hours before the procedures 
depending on the medication. Withholding of asthma medications before testing may cause a 
worsening of asthma symptoms. These medications and withholding instructions are specified in the 
Protocol ICAC-30 MOP. Participants will be informed that they can take their asthma medications if 
needed. If participants do take their medications, the procedure will only be rescheduled as described in 
the Protocol ICAC-30 MOP. 
The albuterol that is given during reversibility testing can cause increased heart rate and blood pressure, 
nausea, headache, and a jittery or nervous feeling. These symptoms usually resolve in less than an hour. 
5.4.4 
Exhaled Nitric Oxide Measurement 
Trained and certified clinical research staff will measure exhaled nitric oxide. This test is minimal risk and 
well tolerated. Rarely, dizziness may occur, which goes away as soon as the test is finished. 
5.4.5 
Nasal Sample Collection 
Trained and certified clinical research staff will obtain nasal mucus and nasal lavage samples from 
participants according to the Protocol ICAC-30 MOP. There are no known risks to collecting a nasal 
mucus sample.   
If a participant is unable to come to a cold visit (Section 8.11) or an exacerbation visit (Section 8.12), 
he/she will be asked to collect a nasal swab sample at home.  The nasal swab collection may cause 
localized discomfort.  Rarely, mild epistaxis may occur.  There is a risk of irritation if the liquid reagent in 
the nasal swab collection tube comes in contact with the skin.  It is unknown whether the collection of 
the nasal swabs will increase the risk of infection to household members.  Because we do not know if 
there is an increased risk of infection transmission, the study will provide gloves and masks for each 
participant as a protection to those assisting with nasal swab collection at home. 
Nasal lavage may be associated with some transient discomfort due to the <10 second breath hold and 
the feeling of fluid in the nares. A very rare potential complication of nasal lavage is acute bacterial 
sinusitis (sinus infection). The nasal lavage procedure is considered minimal risk, and is often referred to 
as a nasal wash or nasal irrigation. A variety of over-the-counter products (such as the neti-pot filled 
with a saline solution) have been widely available for home use to safely flush out nasal passages and 
alleviate both nasal congestion and even sinusitis symptoms. In fact, the American Academy of 
Otolaryngology-Head and Neck Surgery Foundation has just issued new national guidelines 
recommending home irrigation of the nose with such saline solutions (as an alternative to antibiotic 
use), due to its ability to thin the mucus in the nose, promote drainage, and reduce inflammation as an 
effective intervention for both acute and chronic sinusitis. We are proposing to conduct this minimal risk 
procedure in the clinic, but to save and process this nasal drainage for analysis.  


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The study clinician may use their discretion as to whether to administer a nasal decongestant prior to 
the nasal collections. The nasal decongestant may be associated with temporary discomfort such as 
burning, stinging, sneezing, or an increase in nasal discharge. 
The nasosorption procedure may produce mild discomfort such as a tickle and/or tearing of the eyes. If 
a participant is unable to come to a cold visit (Section 8.11) or an exacerbation visit (Section 8.12), 
he/she will be asked to perform the nasosorption procedure at home.  It is unknown whether the 
nasosorption procedure will increase the risk of infection to household members.  Because we do not 
know if there is an increased risk of infection transmission, the study will provide gloves and masks for 
each participant as a protection to those assisting with the nasosorption procedure at home. 
5.4.6 
Sputum Induction 
Sputum induction may result in wheezing, coughing or chest tightness. Participants will be pre-
medicated with albuterol to minimize this risk.  
5.4.7 
Nasal Epithelial Cell Collection 
The risks associated with the nasal cell collection procedure include discomfort or pain, transient 
nosebleed, sneezing, tearing of the eyes, runny nose, and postnasal drip. 
5.4.8 
Questionnaires 
There is a possibility that participants and caretakers may find the questions too personal. Participants 
and caretakers may refuse to answer any questions that make them feel uncomfortable. 
5.5 Potential Benefits 
Whereas the participant’s asthma may or may not improve while in this study, participants may directly 
benefit from study participation by receiving study-based asthma assessments and care from an asthma 
specialist. Participants will receive information about their spirometry and allergy skin testing and 
relevant asthma education consistent with recommendations in the national asthma guidelines for 
patients with asthma. Furthermore, these participants will receive close monitoring and direct 
management of asthma exacerbations on a 24/7 basis throughout the study. Participant families will 
receive contact numbers for the study site and a tailored asthma action plan and education. A supply of 
prednisone will be provided in concert with this management. 
6 Investigational Agent  
6.1 Investigational Agent: Mepolizumab 
Mepolizumab (SB-240563) is the investigational agent and will be provided to the clinical research sites 
by the IND Sponsor (DAIT NIAID). Mepolizumab will be obtained by the IND Sponsor free of charge from 
the manufacturer (The Glaxo-Smith Kline Research and Development Ltd., Brentford, Middlesex, UK). 
6.1.1 
Formulation, Packaging, and Labeling 
Mepolizumab is a humanized monoclonal antibody (IgG1, kappa) that blocks interleukin-5 (IL-5) from 
binding to the IL-5 receptor complex expressed on the eosinophil cell surface and thus inhibits signaling, 
resulting in the reduction in production and survival of eosinophils. 


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Mepolizumab for injection (100 mg/vial) is supplied as a sterile, white to off-white, preservative-free, 
lyophilized powder. Mepolizumab is presented in a 10 mL Type I clear glass, stoppered, single-use vial. 
The drug product must be stored in a refrigerator at a temperature of 2°C to 8°C (36°F to 46°F), 
protected from light. 
6.1.2 
Dosage, Preparation, and Administration 
Mepolizumab is licensed for add-on maintenance treatment for severe eosinophilic asthma at a dose of 
100 mg every 4 weeks and is available as a powder for solution for subcutaneous (SC) injection. In the 
United States, the approved dose of Nucala® for children age 12 years and above is 100 mg 
administered once every 4 weeks by subcutaneous injection into the upper arm, thigh, or abdomen 34. 
For children between 6 and 11 years of age, the approved dose is 40 mg every 4 weeks. 
Mepolizumab for injection (100 mg/vial) is reconstituted in the vial with 1.2 mL Sterile Water for 
Injection, USP, preferably using a 2- or 3-mL syringe and a 21-G needle. The reconstituted solution will 
contain a concentration of approximately 100 mg/mL mepolizumab. Participants assigned to the 100 mg 
treatment group will receive 1.0 mL of reconstituted mepolizumab. Participants assigned to the 40 mg 
treatment group will receive 0.4 mL of reconstituted mepolizumab. 
The reconstituted solution should be kept at refrigerated or controlled room temperature (up to 25°C).  
It should be used as soon as possible and any unused solution remaining after 8 hours should be 
discarded. Complete reconstitution instructions are available in the GSK Investigator’s Brochure for 
mepolizumab. 
6.2 Placebo 
Placebo for mepolizumab will be 0.9% sodium chloride (normal saline) for injection.  Supplies of normal 
saline for injection will be obtained locally by the clinical site research pharmacists.   
6.3 Drug Accountability 
Under Title 21 of the Code of Federal Regulations (21CFR §312.62), the investigator will maintain 
adequate records of the disposition of the investigational agent, including the date and quantity of the 
drug received, to whom the drug was dispensed (participant-by-participant accounting), and a detailed 
accounting of any drug accidentally or deliberately destroyed. 
Records for receipt, storage, use, and disposition will be maintained by the study site.  A drug-dispensing 
log will be kept current for each participant.  This log will contain the identification of each participant 
and the date and quantity of drug dispensed. 
All remaining unused investigational product will be returned to the sponsor (DAIT, NIAID) or sponsor’s 
representative after study termination, or destroyed with the permission of the sponsor in accordance 
with applicable law and study site procedures.  If investigational product is to be destroyed locally, the 
investigator will provide documentation in accordance with sponsor’s specifications. 
All records regarding disposition of the investigational product will be available for inspection by the 
clinical trial monitor. 
6.4 Assessment of Participant Compliance with Investigational Agent 


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As participants will receive their mepolizumab/placebo injections in the clinic, compliance will be 
monitored by assessing the number of completed and missed clinic visits. 
6.5 Toxicity Prevention and Management 
Mepolizumab/placebo doses will not be modified.  Protocol Section 8.5 describes safety measures to 
monitor potential signs and symptoms post injection. 
6.6 Premature Discontinuation of Study Participation 
Study participation may be prematurely discontinued for any participant for any of the reasons 
identified in Section 11.2 Participant Stopping Rules and Withdrawal Criteria. Participants who are 
prematurely discontinued will follow end of study procedures as described in Section 11.4 Follow-up 
After Early Study Withdrawal. 
Study participation may also be prematurely discontinued for any participant if the study clinician 
believes that the study treatment is no longer in the best interest of the participant. 
6.7 Premature Discontinuation of Investigational Product 
Participants who are discontinued from investigational product for any reason after receiving at least 
one injection, and who agree to remain in the study, will have an altered visit schedule. These 
participants will be seen in clinic every 3 months for asthma management and evaluation of protocol 
defined outcomes and endpoints (i.e. Visits 3, 4, 7, 10, 13 and 14 and cold and exacerbation visits).  The 
participants will not attend the monthly protocol defined injection visits which do not involve outcome 
evaluation and asthma management. These participants will not receive any injections of the 
investigational product during the visits they do attend.  During the visits the participant attends, they 
will undergo all other scheduled procedures, evaluations, and blood draws. 
7 Other Medications 
7.1 Concomitant Medications 
7.1.1 
Protocol-mandated 
All participants will receive asthma step care according to the Guidelines for the Diagnosis and 
Management of Asthma (Expert Panel Report 3 [EPR-3], National Asthma Education and Prevention 
Program [NAEPP], 2007). Treatment will be supervised by a study clinician. The study clinician will 
prescribe initial appropriate concomitant asthma therapies (see Section 7.1.1.1) and will provide a 
written Asthma Action Plan for the participant at Visits 0, 1, 4, 7, 10 and 13 (see Section 7.1.1.4). The 
regimen will then be adjusted as necessary at those visits throughout the duration of the trial based on 
the principles of the EPR-3 guidelines (see Table 7.1.1.2a, below).  
The study clinician will prescribe the appropriate step controller therapy according to the participant’s 
insurance/health maintenance organization guidelines. The preferred controller steps and alternate 
equivalent medications may be modified or updated based on changes in standard clinical practice, 
discontinuation of current medications, or the introduction of new medications. For the standardized 
treatment of asthma exacerbations, the clinical research staff will provide oral prednisone and written 
instructions for use. Montelukast may be prescribed by study clinicians if the participant was already 


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taking the medication prior to study enrollment. Montelukast will not affect the algorithm for 
prescribing asthma treatment. 
All participants are required to have medical insurance at randomization that will cover, at least in part, 
the costs of their asthma medications. It is likely, however, that some participants may lose this 
coverage during the time that they are in the study. To maintain participant safety and avoid a loss of 
these participants to the study, Protocol ICAC-30 MUPPITS-2 will fund the cost of these participants’ 
asthma medications during the remainder of the study or until the participant regains insurance 
coverage during the study. Medications will be prescribed in the same manner using the same 
algorithms as all insured participants. Each research site will develop plans to use local pharmacies in a 
cost efficient and timely manner. This design is in place to mimic the support typical insured participants 
receive, i.e. they receive a prescription and have to fill it at a pharmacy. To limit the time that Protocol 
ICAC-30 MUPPITS-2 is required to fund the cost of asthma medications for a participant who has lost 
coverage, each research site will develop a plan for evaluation of insurance options and referral to 
appropriate support systems to obtain coverage for medication costs. In addition to addressing potential 
insurance from employers and governmental sources, this may include free clinics and support 
programs available through pharmaceutical firms. 
7.1.1.1 
Initial Regimen 
During Visit 0, the study clinician will determine the appropriate asthma control regimen that will be 
prescribed for the participant. Along with the participant’s medical history and physical examination 
results, the medication regimen is determined by the participant’s symptoms, number of systemic 
corticosteroid bursts in the past 6 months, percent-predicted forced expiratory volume in 1 second 
(FEV1), and current level of asthma controller therapy.  
First, the study clinician will determine the highest “control level” of the participant’s morbidity across 
the 4 categories in Table 7.1.1.1a. For example, if the participant has 8 days with symptoms (control 
level 2), 1 night with symptoms (control level 1), is at 75% predicted FEV1 (control level 3), and has 0 
systemic steroid bursts, (control level 1), then the participant is at control level 3 because that is the 
highest of these 4 categories. 
Table 7.1.1.1a Asthma Symptoms for Determining Run-in Asthma Medication Regimen 
Control Level 
Maximum of 1) # days 
with asthma 
symptoms/ two weeks 
and 2) # days with 
rescue albuterol or 
levalbuterol use/ two 
weeks* 
Maximum of 1) # 
nights of sleep 
disruption due to 
asthma/ 2 weeks and 
2) # nights use of 
albuterol or 
levalbuterol for 
awakening / 2 weeks* 
FEV1 
(% pred)** 
Courses of 
systemic steroids 
in the last 6 
months*** 
1 
0-3 days 
0-1 night 
≥ 85 
0 
2 
4-9 days 
2 nights 
80 - < 85 
1 
3  
10-13 days 
3-4 nights 
70 - < 80 
2 
4 
14 days 
5-14 nights 
< 70 
>2 


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FEV1 = forced expiratory volume in 1 second; pred = predicted 
* Determined from participant recall, based on the 2-week interval directly preceding the study visit. 
**Predicted references are provided in the Protocol ICAC-30 MOP. 
*** Defined as a prescription of a course of systemic steroids by a clinician or initiation of a course of systemic steroids by a 
participant to prevent a serious asthma outcome. If a participant initiates and completes a course of systemic steroids without 
clinician involvement, this course will be counted only if it meets the following dosage: the course for prednisone, prednisolone, or 
methylprednisolone will be at least 20 mg daily dose for 3 of 5 consecutive days. The course for dexamethasone will be at least a 10 
mg single daily dose. If a corticosteroid burst for the treatment of an asthma exacerbation is prescribed by a non-ICAC clinician, it 
will be counted regardless of dose. 
 
Next, the study clinician will determine the current level of controller therapy that the participant is 
using. Table 7.1.1.1b shows the asthma regimens that will be used during the treatment phase of 
Protocol ICAC-30 MUPPITS-2. If the participant is currently on one of the therapies below, then the step 
level of that therapy will be noted. Otherwise, the study clinician must refer to the Protocol ICAC-30 
MOP for equivalency tables for other asthma therapies. From the information in the Protocol ICAC-30 
MOP, the study clinician will determine the corresponding step level of therapy that the participant is 
currently using. For example, if the participant is currently taking Flovent® Diskus® 250 mcg twice per 
day (bid), then he/she is receiving Step 3 therapy. 
Table 7.1.1.1b Asthma Regimen by Step Level of Therapy 
Step 
Medication Equivalent* 
0 
No controller medication; albuterol or levalbuterol prn 
1 
fluticasone 50 mcg bid 
2 
fluticasone 100 mcg bid 
3 
fluticasone 250 mcg bid 
4 
fluticasone 250 mcg bid plus LABA 
5 
fluticasone 500 mcg bid plus LABA 
bid = twice per day; LABA = long-acting beta agonist 
*Equivalent medication covered by participant’s insurance formulary – see Protocol ICAC-30 MOP.   
 
Based on the participant’s current control level (from Table 7.1.1.1a) and the participant’s current step 
level of therapy (from Table 7.1.1.1b and the Protocol ICAC-30 MOP), the study clinician will find the 
corresponding row in Table 7.1.1.1c below that includes both the current regimen and the current 
control level. The last column of that row gives the corresponding regimen as a step level, which refers 
back to Table 7.1.1.1b. The study clinician will prescribe this regimen. Study eligibility in terms of 
treatment step level will be as follows: 
• 
For participants ages 6 to 11 years, who have a requirement for at least Step Level 3 (defined in 
Table 7.1.1.1b) at Visit 0 
• 
For participants ages 12 years and older, who have a requirement for at least Step Level 4 
(defined in Table 7.1.1.1b) at Visit 0 


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Continuing the example from above, since the participant is taking Step 3 therapy and is at control level 
3, the regimen assigned would be Step 4 (fluticasone 250 mcg bid with LABA from Table 5.2b). 
Table 7.1.1.1c Algorithm for Prescribing Treatment Regimen at Visit 0 
Current Regimen 
Current Control Level 
Regimen Assigned 
Regimen equivalent to Step 0 
(or 1-3 days/week of a regimen 
equivalent to Step 1) 
Control level 1 
Control level 2 
Control level 3 
Control level 4 
Step 2 
Step 2 
Step 2 
Step 2 (and may also need prednisone 
burst) 
Regimen equivalent to Step 1 
(or 1-3 days/week of a regimen 
equivalent to Step 2) 
Control level 1 
Control level 2 
Control level 3 
Control level 4 
Step 2 
Step 2 
Step 2 
Step 3 (and may also need prednisone 
burst) 
Regimen equivalent to Step 2 
(or 1-3 days/week of a regimen 
equivalent to Step 3) 
Control level 1 
Control level 2 
Control level 3 
Control level 4 
Step 2 
Step 3 
Step 3 
Step 4 (and may also need prednisone 
burst) 
Regimen equivalent to Step 3 
(or 1-3 days/week of a regimen 
equivalent to Step 4) 
Control level 1 
Control level 2 
Control level 3 
Control level 4 
Step 3 
Step 4 
Step 4 
Step 5 (and may also need prednisone 
burst) 
Regimen equivalent to Step 4 
(or 1-3 days/week of a regimen 
equivalent to Step 5) 
Control level 1 
Control level 2 
Control level 3 
Control level 4 
Step 4 
Step 5 
Step 5 
Step 5 (and may also need prednisone 
burst) 
Regimen equivalent to Step 5 
 
Control level 1 
Control level 2 
Control level 3 
Control level 4 
Step 5 
Step 5 
Step 5 (and may also need prednisone 
burst) 
Step 5 (and may also need prednisone 
burst) 
Note: Shading in the table corresponds to the example described in the text. 
In addition to the controller regimen assigned above, all participants will be prescribed albuterol by 
metered-dose inhaler beta-agonist or nebulizer (per clinician discretion) to be used as needed and will 
be provided oral prednisone to be used as per protocol – see Section 7.4 and the Protocol ICAC-30 MOP. 
The study clinician will prescribe enough medication to last until the next E&M visit. If a participant is 
not eligible to continue, the study clinician may prescribe an appropriate treatment regimen based on 
clinical judgment. 
7.1.1.2 
Study Period Treatment Regimen (Visits 1, 4, 7, 10 and 13) 
At Visits 1, 4, 7, 10 and 13 participants’ asthma medication regimen will be adjusted based on 
symptoms, albuterol/levalbuterol use, FEV1, recent exacerbations, and their current level of therapy.  
Except at Visit 1, participants will be stepped down from controller medications at each visit for which 
their control level is equal to 1. At Visit 1, it is not appropriate to step down a participant’s treatment 


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after 4 weeks of observation during the assumption care.  As such, participants will not be stepped 
down at Visit 1.  At Visit 1, a participant may be stepped up as per the protocol algorithm. 
Participants will undergo pre-bronchodilator spirometry and an assessment of symptoms, rescue 
bronchodilator usage, recent exacerbations and medication adherence. Bronchodilator use as a 
preventive measure prior to exercise will not count toward the assessment of rescue bronchodilator 
use. Based on these data, a study clinician will determine the participant’s current control level from 
Table 7.1.1.2a below. The control levels originated from the published national guidelines, Guidelines for 
the Diagnosis and Management of Asthma (EPR-3, NAEPP, 2007). 
For all participants, the highest control level for days with symptoms or albuterol/levalbuterol use, 
nights with symptoms or albuterol/levalbuterol use, percent personal best FEV1, and exacerbation 
history will be determined by the study clinician. The day and night symptoms, albuterol/levalbuterol 
use, adherence to prescribed asthma controller medications by self-report, and exacerbation history will 
be determined from questionnaires. The FEV1 personal best is defined in the Protocol ICAC-30 MOP. If 
the quality of the spirometry maneuver at the current visit is unacceptable according to the technician’s 
judgment, FEV1 in Table 7.1.1.2a will not be used, and the control level will be based on day and night 
symptoms, albuterol/levalbuterol use, and exacerbation history. For example, if a participant has 0 days 
with symptoms (control level 1), 4 nights with symptoms (control level 3), FEV1 at 85% of personal best 
(control level 1), and 1 exacerbation (control level 2), then the participant’s overall control level is 3 
because that is the maximum value of control levels 1, 3, 1, and 2.  
Table 7.1.1.2a Control Levels of Symptoms, Bronchodilator Usage, FEV1 (% personal best), and 
Exacerbations 
Control 
Level 
Maximum of 1) # days with asthma 
symptoms/ 2 weeks and 2) # days 
with rescue albuterol/levalbuterol 
use/ 2 weeks* 
Maximum of 1) # nights of sleep 
disruption due to asthma/ 2 
weeks and 2) # nights use of 
albuterol/levalbuterol for 
awakening/ 2 weeks* 
FEV1 
(% personal 
best) 
Courses of 
Systemic 
Steroids since 
the Last 
Medication 
Management 
Visit** 
1 
0-3 days 
0-1 night 
≥ 85 
0 
2 
4-9 days 
2 nights 
80-84 
1 
3 
10-13 days 
3-4 nights 
70-79 
- 
4 
14 days 
5-14 nights 
< 70 
- 
FEV1 = forced expiratory volume in 1 second 
* Determined from participant recall, based on the 2-week interval directly preceding the study visit. 
**Defined as a prescription of a course of systemic steroids by a clinician or initiation of a course of systemic steroids by a participant to prevent 
a serious asthma outcome. If a participant initiates and completes a course of systemic steroids without clinician involvement, this course will 
be counted only if it meets the following dosage: the course for prednisone, prednisolone, or methylprednisolone will be at least 20 mg daily 
dose for 3 of 5 consecutive days. The course for dexamethasone will be at least a 10 mg single daily dose. If a corticosteroid burst for the 
treatment of an asthma exacerbation is prescribed by a non-ICAC clinician, it will be counted regardless of dose. 
Note: Shading in the table corresponds to the example described in the text above. 
 


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Based on the overall control level and the participant’s estimated level of adherence, the study clinician 
will use Table 7.1.1.2bb below to determine how the participant’s current therapy should be modified. 
At E&M Visits, the participant will be considered to have acceptable adherence if he/she reports having 
taken 50% or more of the prescribed doses in the last 2 weeks. Participants with unacceptable 
adherence will not be stepped up in the same way as those with acceptable adherence. Continuing with 
the same example, since this participant is at control level 3 and assuming he/she has acceptable 
adherence, the study clinician would recommend a 2-step increase in therapy (or an increase to Step 5 if 
on Step 4 or maintenance on Step 5 if already on Step 5). In all cases, consideration will be given to a 
burst of prednisone according to the suggestions in the table. 
Table 7.1.1.2b Treatment Adjustment Based on Control Levels and Adherence 
Control 
Level 
Treatment Algorithm for Participants 
with Unacceptable Adherence 
Treatment Algorithm for Participants with Acceptable 
Adherence 
1 
Continue same controller regimen  
If on Step 0, maintain at Step 0  
If on Steps 1-5, decrease controller regimen by 1 step 
** Do not decrease controller regimen if at Visit 1  
2 
Continue same controller regimen or 
place on Step 2 therapy, whichever is 
higher 
Increase controller regimen by 1 step, or continue Step 
5 therapy if already on Step 5 
3 
Continue same controller regimen or 
place on Step 2 therapy, whichever is 
higher 
No systemic steroids since the Last Medication 
Management visit* 
If on Steps 0-4 increase controller regimen by 1 step 
If on Step 5 continue Step 5 or treat with Step 5 and a 4 
day burst of prednisone or equivalent; 
≥1 course(s) of systemic steroids since the last E&M 
visit*  
If on steps 0-3 increase controller regimen by 2 steps 
If on treatment Step 4 increase controller regimen to 
Step 5 or treat with Step 5 and a 4 day burst of 
prednisone or equivalent 
If on treatment Step 5 continue Step 5 or treat with 
Step 5 and a 4 day burst of prednisone or equivalent 
4 
Continue same controller regimen or 
place on Step 3 therapy, whichever is 
higher 
OR 
Treat with 4-day prednisone burst and 
continue same controller regimen or place 
on Step 3 therapy, whichever is higher  
If on Steps 0-3 increase controller regimen by 2 steps 
If on Step 4, increase to Step 5 or treat with Step 5 and 
a 4-day prednisone burst or equivalent 
If already on Step 5, continue on Step 5 or treat with 
Step 5 and a 4-day burst of prednisone or equivalent 
*Defined as a prescription of a course of systemic steroids by a clinician or initiation of a course of systemic steroids by a participant to 
prevent a serious asthma outcome. If a participant initiates and completes a course of systemic steroids without clinician involvement, this 
course will be counted only if it meets the following dosage: the course for prednisone, prednisolone, or methylprednisolone will be at 
least 20 mg daily dose for 3 of 5 consecutive days. The course for dexamethasone will be at least a 10 mg single daily dose. If a 
corticosteroid burst for the treatment of an asthma exacerbation is prescribed by a non-ICAC clinician, it will be counted regardless of dose. 
Note: Shading in the table corresponds to the example described in the text above. 
 
Based on the participant’s step level assigned at the last E&M visit and the change in steps determined 
above, the new regimen will be prescribed according to Table 7.1.1.2b above. In the example above, if 


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the participant were currently on Step 2 and having no problems with adherence, then the 
recommended new treatment step based on symptoms, albuterol/levalbuterol use, FEV1, and 
exacerbations is Step 4.  
7.1.1.3 
Final Study Visit 
At the final study visit (Visit 14), the final treatment regimen prescribed will be based on the protocol-
based medications management algorithm or the discretion of the study clinician who examines the 
participant. He/she will base the treatment on factors such as symptoms, albuterol use, spirometry, 
adherence, and the participant’s current level of therapy; however, the participant’s treatment will not 
be stepped down at Visit 14. The participant’s care will then be transferred back to their primary care 
provider (PCP) and/or asthma specialist. 
7.1.1.4 
Asthma Action Plan 
Clinical research staff will provide a written Asthma Action Plan consistent with NAEPP guidelines for the 
participant at Visits 0, 1, 4, 7, 10, 13, and 14. This plan describes a Green, Yellow, and Red Zone for the 
participant based on his/her symptoms. In the Green Zone, the participant has no symptoms of an 
asthma episode and is directed to use his/her usual asthma medications. In the Yellow Zone, the 
participant is experiencing asthma, allergy, or cold symptoms, and is directed to increase rescue 
medication use until the symptoms have been resolved. In the Red Zone, the participant is having 
persistent symptoms that cannot be controlled. The participant is instructed to contact a study clinician 
OR go to the emergency department (ED) if unable to contact a study clinician. 
7.1.1.5 
Asthma Education 
As part of the meeting at Visits 0, 1, 4, 7, 10, 13, and 14 with a clinical research staff member for asthma 
education, participants will be educated on topics related to asthma. These topics include background 
on asthma as a disease, use of the Asthma Action Plan (see Section 5.5), adherence to medications, 
using medications at school (when applicable), and allergen and irritant avoidance. Handouts will be 
provided and the education content will be tailored to each participant. For example, the allergen 
avoidance education will be based on the participant’s aeroallergen skin test/serum IgE results. The 
participant will receive education about the allergens to which he/she is sensitive. The information 
contained in the handouts will be based on the EPR-3: Guidelines for the Diagnosis and Management of 
Asthma and on experience from previous ICAC clinical trials. The involvement of the caretaker in these 
sessions depends on the age and maturity of the participant. 
7.1.2 
Other permitted concomitant medications 
During the study, maintenance medications, aside from those excluded in Section 4.3, Exclusion Criteria, 
will be permitted. 
7.2 Prophylactic Medications 
Not applicable. 
7.3 Prohibited Medications 
1. Allergen immunotherapy (sublingual or subcutaneous) 
2. Anti-IgE therapy  
3. Any investigational drug 
4. Additional medications listed in the Protocol ICAC-30 MUPPITS-2 MOP 


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7.4 Rescue Medications  
Use of albuterol by participants and study clinicians will be guided by each participant’s Asthma Action 
Plan (see Section 7.1.1.4), which will be updated and provided at Visits 0, 1, 4, 7, 10 and 13. To achieve 
as much uniformity in approach as possible across clinical sites, these plans will be pre-printed with 
specific albuterol dosing for the Yellow and Red zones. 
7.4.1 
Definition and Management of Acute Exacerbations 
Consistent with NAEPP 2007 guidelines, study clinicians caring for participants in the Protocol ICAC-30 
MUPPITS-2 study will start a course of corticosteroids for severe and/or unresponsive exacerbations of 
asthma. For the purposes of the proposed analyses, an asthma exacerbation is defined as a prescription 
of a course of systemic steroids by a clinician or initiation of a course of systemic steroids by a 
participant or a hospitalization to prevent a serious asthma outcome. If a participant initiates and 
completes a course of systemic steroids without clinician involvement, this course will be counted only if 
the study clinician agrees the treatment was warranted and it meets the following dosage: the course 
for prednisone, prednisolone, or methylprednisolone will be at least 20mg daily for 3 of 5 consecutive 
days. The course for dexamethasone will be at least a 10 mg single daily dose. Study clinicians will 
strongly consider initiation of corticosteroids if:  
• 
Albuterol is needed by inhaler (with or without a spacer) or by nebulization for more than 6 
individual treatments in 24 hours; or 
• 
Moderate-severe wheeze, cough, shortness of breath, and/or chest tightness or pain occurs for 
at least 5 of the preceding 7 days; or 
• 
Symptoms of wheeze, cough, shortness of breath, and/or chest tightness or pain severe enough 
to place a participant in his or her “Red Zone” on their Asthma Action Plan (see Section 7.1.1.4) 
do not significantly improve after 3 doses of albuterol. (In such situations, in addition to the 
initiation of oral corticosteroids, the study clinician should consider directing the participant to 
the nearest ED.); or  
• 
There is an unscheduled visit for acute asthma care requiring repeated doses of albuterol 
(clinician office, urgent care, ED); or 
• 
Hospitalization is needed for asthma. 
Permissible drugs for systemic corticosteroid treatment of asthma exacerbations include: prednisone, 
prednisolone, methylprednisolone, and dexamethasone. The course for prednisone, prednisolone, or 
methylprednisolone will be 2 mg/kg/day as a single daily dose for 4 days with a maximum dose of 60 mg 
per day. The course for dexamethasone will be 0.3 to 0.6 mg/kg/day as a single daily dose for 2 days 
with a maximum dose of 16 mg per day. Failure to respond to initial treatment will result in additional 
evaluation and possible hospitalization for further management. This management approach has been 
applied to previous ICAC clinical trials and is consistent with asthma specialist usual care practices. 
8 Study Procedures 
8.1 Study Procedures 


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8.1.1 
Vital Signs and Growth Parameters 
Height (using a calibrated stadiometer) will be measured at clinic visits as part of spirometry. Respiratory 
rate and temperature, along with a chest auscultation will be obtained at clinic visits as part of the 
targeted pulmonary exam. 
The following vital signs and growth parameters will be collected at asthma evaluation and management 
visits (Visits 0, 1, 4, 7, 10, 13 and 14) unless otherwise noted:  
• 
Weight in kilograms  
• 
Pulse rate 
• 
Blood pressure 
8.1.2 
Medical History and Physical Examination 
The participant’s medical history will be obtained, and a study clinician will perform a physical 
examination at Visit 0. The study clinician will perform a targeted pulmonary examination and current 
asthma symptom assessment at the other evaluation and management study visits. Additional 
examinations may be completed at the remainder of the visits at the study clinician’s discretion. 
Significant findings that are present prior to the start of the study must be included on the appropriate 
case report form (CRF). Significant findings that meet the definition of an adverse event (AE) must also 
be recorded on the AE form. 
If the participant is currently having an asthma exacerbation or other symptoms that the study nurse or 
study clinician feel may compromise the participant’s ability to complete the study procedures safely, a 
physical exam may be performed and the study visit may be rescheduled. If the study clinician observes 
any AEs during the study visit, a targeted physical exam may be performed. Additional details regarding 
AE assessment are outlined in Section 12, Safety Monitoring and Reporting. 
8.1.3 
Aeroallergen Skin Testing 
The participant’s atopic status will be assessed with skin prick tests to assess allergy to dust mites, 
cockroaches and various other aeroallergens. The allergens chosen include those that are likely to cause 
sensitization in people living in urban environments. Participants will be asked to stop taking 
antihistamines for 5 days prior to the visit at which the skin test is performed to limit interference with 
the results of the skin test. 
Skin testing will be done by the prick technique using the Greer Pick system (Greer; Lenoir, NC). Testing 
will be performed by certified clinical research staff according to the instructions in the Protocol ICAC-30 
MOP. Tests will be read after 15 minutes by measuring the wheal for each antigen and for the controls. 
Acceptable skin testing completed as part of a participant’s participation in other ICAC protocols within 
12 months will meet the requirement for this procedure. In this situation, the skin testing results 
documentation from the previous study will be added to the participant’s study file, and the skin testing 
procedure will not be repeated. 
The national asthma guidelines have emphasized that exposure of patients who have asthma to 
allergens to which they are sensitive has been shown to increase asthma symptoms and precipitate 
asthma exacerbations. They further state that the clinician should evaluate the potential role of 


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allergens, particularly indoor inhalant allergens via medical history and skin testing, and then assess the 
significance of positive tests in the context of the patient’s medical history. Patients who have asthma at 
any level of severity should:  reduce, if possible, exposure to allergens to which the patient is sensitized 
and exposed; know that effective allergen avoidance requires a comprehensive approach; and (3) be 
provided with relevant educational materials for control of environmental factors. For over 20 years, 
study clinicians with the DAIT NIAID-sponsored National Cooperative Inner-City Study (1991-1997), the 
DAIT NIAID-sponsored Inner-City Asthma Study (1994-2001), the DAIT NIAID-sponsored Inner-City 
Asthma Consoritium1 (ICAC1) (2002-2009), ICAC2 (2009-2014), and now ICAC3 as of 2015, have applied 
the recommendations from the asthma guidelines as best practices and “usual care” for children with 
asthma, especially as relevant to children residing in our inner-cities. These asthma specialists believe 
that participants and their families who enroll in our studies can receive direct benefit from the conduct 
of environmental histories, aeroallergen skin tests, and provision of education about personal allergen 
triggers and measures to avoid them. Seminal publications from the first study in 1997 reported that the 
enrolled study children who were both allergic to cockroach allergen and highly exposed had 
significantly higher rates of asthma hospitalization and asthma morbidity. Subsequent research has 
confirmed these observations and extended our knowledge on the extent of allergen sensitization in the 
inner-city environment, risks to these children, and successful interventions to mitigate these risks. For 
example, in the Protocol ICAC-07 Urban Environment and Childhood Asthma birth cohort study (URECA), 
children were aeroallergen skin prick tested as per the procedures we describe for Protocol ICAC-30 
MUPPITS-2. By age 3, 44% of the Protocol ICAC-07 URECA cohort (n=418) were sensitized, primarily to 
cockroach, mouse, dog, dust mite, and cat. There were statistically significant odds ratios of the 
relationship between allergic sensitization and recurrent wheeze. Each of the ICAC1, ICAC2, and now 
ICAC3 trials have incorporated aeroallergen skin prick testing procedures as an evaluation that provides 
direct value to both children and their families. Feedback from parents and caretakers consistently 
confirm this value. These standardized procedures, performed by trained and certified clinical research 
staff, have now been safely performed in thousands of participating children in all inner-city studies with 
no reports of systemic adverse events. 
8.1.4 
Measurement of Fractional Exhaled Nitric Oxide 
Measurement of FeNO will be obtained (if location of visit allows) prior to spirometry. Exhaled nitric 
oxide will be measured following American Thoracic Society  guidelines for FeNO assessment.27 This 
procedure is detailed in the Protocol ICAC-30 MOP. 
8.1.5 
Measurement of Pulmonary Function 
Spirometry and impulse oscillation spirometry will be conducted following the ATS and European 
Respiratory Society guidelines. For children under 8 years of age, ATS Preschool Guidelines will be used 
for spirometry acceptance evaluation. This procedure has been successfully implemented in previous 
DAIT NIAID-sponsored ICAC trials. Details regarding pulmonary function testing (PFT) are provided in the 
Protocol ICAC-30 MOP. All PFTs will be performed by certified clinical research staff. 
Participants may be asked to stop taking some asthma medications 8-24 hours before the visit 
(depending on the type of medication) to limit their interference with the results of the pulmonary 
function testing. These medications and withholding instructions are specified in the Protocol ICAC-30 
MOP.  


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8.1.6 
Questionnaire Assessments 
Questionnaires administered by site staff will collect inclusion/exclusion criteria information, participant 
contact information, demographic characteristics, asthma and allergy history and medication use, 
asthma exacerbation history, asthma symptoms and health care utilization, cold symptoms, concomitant 
medications, AE information, and primary care provider (PCP) contact information.  
8.2 Clinical and Research Laboratory Evaluations and Specimen Collection 
8.2.1 
Blood Sample Collection 
Blood will be collected by peripheral venipuncture for transcriptomics, to preserve DNA/RNA, to assess a 
complete blood count (CBC) and differential and blood chemistry, as well as total and allergen-specific 
serum IgE. With the participant’s consent, blood will be stored for use in the future for unplanned tests. 
Blood volume will be indicated in the informed consent document along with any possibility for a repeat 
blood draw, if needed. An eosinophil value obtained as part of a participant’s participation in another 
ICAC protocol within 6 months of the screening visit will determine the requirement for Protocol ICAC-
30 MUPPITS-2 eligibility.   
Table 8.2.1 CBC and Blood Chemistry Components 
CBC (and differential) 
Blood Chemistry 
Platelets 
BUN 
Hematocrit 
CO2 
Hemoglobin 
Creatinine 
Erythrocytes 
Glucose 
Leukocytes 
Serum chloride 
Monocytes 
Serum potassium 
Eosinophils 
Serum sodium 
Basophils 
Bilirubin 
Neutrophils 
Aspartate aminotransferase 
Lymphocytes 
Alanine aminotransferase 
 
8.2.2 
Nasal Sample Collection 
Nasal mucus samples will be collected as per the Protocol ICAC-30 MOP for respiratory virus/bacteria 
assessment. If a participant is unable to come to an exacerbation visit (Section 8.12), he/she will be 
asked to collect the nasal mucus sample at home.  Training and supplies will be provided to the 
participant by the site staff.   
If a participant is unable to come to a cold visit (Section 8.11) or exacerbation visit (Section 8.12), he/she 
will be asked to collect a nasal swab sample at home.  Training and supplies will be provided to the 
participant by the site staff as per the Protocol ICAC-30 MOP. 
As per the Protocol ICAC-30 MOP, nasal lavage samples will be collected by instilling preservative-free 
buffered saline into the nostrils and allowing fluid to return passively into collection specimens. If the 
nostrils are occluded, a nasal decongestant may be administered at the discretion of the study clinician. 
Samples will be split and processed for both cell differentials and RNA extraction. Site clinical research 
staff who are trained, study-authorized, and certified will perform the nasal lavage and processing 
procedure as specified in the Protocol ICAC-30 MOP. 


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Nasosorption is a non-invasive technique for sampling of undisturbed mucosal lining fluid from the 
upper airways through which quantification of in situ levels of immune mediators, such as cytokines and 
chemokines, will be performed. The sample will be obtained using the size-appropriate single use 
Nasosorption™ FX·i device (Hunt Developments, UK) consisting of a synthetic absorptive matrix strip 
(SAM) attached to an applicator handle.  Details of the nasosorption sample collection and processing 
procedures are described in the Protocol ICAC-30 MOP. If a participant is unable to come to a cold visit 
(Section 8.11) or an exacerbation visit (Section 8.12), he/she will be asked to perform the nasosorption 
procedure at home.  Training and supplies will be provided to the participant by the site staff. 
8.2.3 
Urine Pregnancy Testing 
All females who have reached menarche will be required to have a urine pregnancy test before 
completing study activities. If the result is positive, the participant will not undergo any procedures. 
Results of all pregnancy tests will be given to the participant or caretaker as per site-specific guidelines 
and relevant state laws.   
8.2.4 
Urine Cotinine 
Urinary cotinine (a metabolite of nicotine) will be measured to determine exposure to environmental 
tobacco smoke. A urine sample will be collected following procedures described in the Protocol ICAC-30 
MOP. The urine sample will be stored long-term for future research in the field of asthma. Participants 
will be asked to give permission for long-term storage and future use during the consent process. 
8.2.5 
Induced Sputum 
Sputum will be induced by inhalation of hypertonic saline solution using the method that was used in 
the Asthma Clinical Research Network (ACRN)35. Safety monitoring per spirometry and symptom report 
will be performed during and after sputum induction. Slides will be read at a central site for cellular 
determinations. Sputum cells will be processed for CyTOF analysis and RNA and DNA isolation for 
expression and epigenetic studies. Sputum supernatants will be collected, aliquoted, and stored pending 
further analysis.  This procedure will be performed in a subset of children ≥10 years of age. 
8.2.6 
Nasal Epithelial Cell Collection 
Nasal epithelial cell samples will be obtained by using a cytology brush. A trained study clinician will 
conduct the procedure. The inferior turbinate of one nasal passage will be sampled to obtain an 
adequate number of epithelial cells for mRNA and DNA isolation. The sampled area will be observed for 
hemostasis. Procedural details and instructions for processing the samples are included in the Protocol 
ICAC-30 MOP. This procedure will be performed in a subset of children ≥10 years of age. 
8.3 Recruitment 
The research site may use any Institutional Review Board (IRB)-approved means to identify potential 
participants. Examples include hospital, clinic, or emergency department admission records; study 
clinicians’ specialty clinic records; and advertising (in public locations and on the radio). Potential 
participants will be screened and recruited using a standardized questionnaire that collects contact 
information and inclusion/exclusion criteria information. Participants may be recruited by phone or in 
person. 
Retention methods involve a number of different approaches.  We will use an appointment reminder 
system that consists of phone calls several days and one day prior to scheduled appointments for 


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confirmation. To facilitate telephone contact with participants whose phone service may change during 
the study, up to three telephone contact numbers (relatives, neighbors, friends) will be collected for 
each participant.  This has proven to be an effective strategy in previous DAIT NIAID-sponsored ICAC 
trials. Those who have no obvious characteristics making them ineligible and who are interested will be 
invited to the clinic for a Screening Visit. 
8.4 Screening/Baseline Visit 
This research study will be explained in lay terms to the parent/legal guardian of each potential 
participant. Written informed consent and Health Insurance Portability and Accountability Act (HIPAA) 
authorization will be obtained from all parents/legal guardians at the beginning of this visit and before 
the child undergoes any screening study procedures. Children age 12 years and older will sign a written 
assent form. When the informed consent has been signed, the participant is considered enrolled in the 
study and will be assigned a unique participant number. Study procedures will be stopped, and the 
participant will be deemed ineligible for the study at any point during the Screening Visit if and when 
he/she fails to meet eligibility criteria.  
The purpose of the screening period is to confirm eligibility to continue in the study. After the consent 
(and assent, if applicable) is signed, participants will undergo screening study procedures as listed 
below: 
• 
Vital signs (see Section 8.1.1) 
• 
Urine collection for pregnancy test for female participants who have reached menarche (see 
Section 8.2.3)  
• 
Medical history and a physical examination by study clinician (see Section 8.1.2) 
• 
Concomitant medication assessment (see Sections 8.1.6 and 7.1) 
• 
Questionnaires (see Section 8.1.6) 
• 
Weight and height measurement, using a calibrated stadiometer (see Section 8.1.1)  
• 
Spirometry (see Section 8.1.5) 
• 
Assignment of asthma medication regimen by study clinician (see Section 7.1.1) 
• 
Blood sample collection (see Section 8.2.1.1) 
o CBC with differential 
o Blood chemistry 
o Total and allergen-specific IgE 
• 
Asthma counseling (see Section 7.1.1) (not completed if participant is a screen fail) 
• 
AE assessment (see Section 12) 
Participants will also undergo skin prick tests (see Section 8.1.3) to a panel of allergens detailed in the 
Protocol ICAC-30 MOP to characterize the study population. Participants who have valid skin test results 
within the previous year under another ICAC protocol will not need to be re-tested.  Clinical research 
staff may choose to perform the skin prick tests at Visits 2, 3, or 4 instead of Screening.  
Participants may be re-screened per study clinician discretion.  Participants who meet any of the 
following criteria are not eligible for re-screening: 
• 
Have a known, pre-existing clinically important lung condition other than asthma 
• 
Have known, pre-existing, unstable liver disease 


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• 
Have a known immunodeficiency disease 
• 
Have other conditions that could lead to elevated eosinophils such as hypereosinophilic 
syndromes, including eosinophilic granulomatosis with polyangiitis 
• 
Will not allow the study clinician, an asthma specialist, to manage their disease for the duration 
of the study or who are not willing to change their asthma medications to follow the protocol 
• 
Have a known history of allergic reaction to previous biologic therapy for asthma 
If total eosinophil counts were measured as a part of a CBC with differential in a previous ICAC protocol, 
total eosinophil results will be used to determine eligibility if drawn within 6 months of the Screening 
Visit. If values are not available from a previous ICAC protocol, total eosinophil counts obtained at Visit 0 
will be used to determine eligibility. If a participant fails eligibility due to total eosinophil count only, the 
study clinician may choose to redraw total eosinophil counts one additional time for re-screening.  
8.5 Randomization 
At this study visit, participants will be re-assessed to confirm they continue to meet study eligibility 
criteria.  
The study clinician will adjust the participant’s asthma medications as necessary according to the 
treatment algorithm (see Section 7.1.1.2), write an appropriate prescription, and provide a new asthma 
action plan (see Section 7.1.1.4). At Visit 1, it is not appropriate to step down a participant’s treatment 
after 4 weeks of observation during the assumption of care.  As such, participants will not be stepped 
down at Visit 1.  At Visit 1, a participant may be stepped up as per the protocol algorithm.  Participants 
will receive basic asthma education (see Section 7.1.1.5). 
Other assessments completed at this visit include: 
• 
Targeted pulmonary exam (see Section 8.1.2) 
• 
Spirometry and IOS with reversibility (see Section 8.1.4),  
• 
Exhaled nitric oxide (see Section 8.1.4) 
• 
Urine cotinine (see Section 8.2.4) 
• 
Urine pregnancy test, where indicated (see Section 8.2.3) 
• 
Nasal mucus sample collection (see Section 8.2.2) 
• 
Nasal lavage (see Section 8.2.2) 
• 
Blood sample collection (see Section 8.2.1) 
o CBC with differential 
o Blood markers (plasma/DNA/RNA) 
o Antibody to drug 
• 
Questionnaires (see Section 8.1.6) 
• 
Assignment of asthma medication regimen by study clinician (see Section 7.1.1) 
• 
Asthma education/counseling (see Section 7.1.1.5) 
 
After they have been found eligible for randomization, participants will be randomized (see Section 
13.3) and receive their first injection of mepolizumab/placebo.  


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Before each injection, participants will be screened for evidence of an ongoing allergic reaction or 
worsening of asthma. If a participant is unable to receive the study drug injection that day, the injection 
will be rescheduled.  Injections must be at least 14 days apart. 
The injection will be administered by trained clinical research staff. Clinical research staff may apply a 
topical anesthetic to the skin before the injection to reduce the discomfort of the stick. 
During all dosing visits, a medical provider trained in treating anaphylaxis will be available to provide 
immediate treatment in the event that a participant experiences an allergic reaction. Participants will 
remain at the clinic for observation for at least 60 minutes after the first 3 injections, after which a 30 
minute wait period will be required.  
8.6 Visit 2 (Week 8) 
At this visit, the following procedures and assessments will be performed: 
• 
Urine pregnancy test, where indicated (see Section 8.2.3) 
• 
Vital signs (see Section 8.1.1) 
• 
Lungs assessment 
• 
Study drug administration 
• 
AE assessment (see Section 12) 
• 
Concomitant medication assessment (see Sections 8.1.6 and 7.1.2) 
• 
Nasal mucus sample collection (see Section 8.2.2) 
• 
Allergen skin testing (see Section 8.1.3) if not performed at a previous study visit or in another 
ICAC protocol within 12 months 
8.7 Visit 3 (Week 12) 
At this visit, the following procedures and assessments will be performed: 
• 
Urine cotinine (see Section 8.2.4) 
• 
Urine pregnancy test, where indicated (see Section 8.2.3) 
• 
Vital signs (see Section 8.1.1) 
• 
Lungs assessment 
• 
Study drug administration 
• 
AE assessment (see Section 12) 
• 
Concomitant medication assessment (see Sections 8.1.6 and 7.1.2) 
• 
Nasal mucus sample collection (see Section 8.2.2) 
• 
Nasal lavage (see Section 8.2.2) 
• 
Blood sample collection (see Section 8.2.1) 
o CBC with differential 
o Blood chemistry 
o Blood markers (plasma/DNA/RNA) 
o Antibody to drug 
• 
Exhaled nitric oxide (see Section 8.1.4) 
• 
Allergen skin testing (see Section 8.1.3) if not performed at a previous study visit or in another 
ICAC protocol within 12 months 


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8.8 Injection Only Visits (Visits 5, 6, 8, 9, 11, 12) 
At these visits, the following procedures and assessments will be performed: 
• 
Urine pregnancy test, where indicated (see Section 8.2.3) 
• 
Vital signs (see Section 8.1.1) 
• 
Lungs assessment 
• 
Study drug administration 
• 
AE assessment (see Section 12) 
• 
Concomitant medication assessment (see Sections 8.1.6 and 7.1.2) 
• 
Nasal mucus sample collection (see Section 8.2.2) 
8.9 Asthma Evaluation and Management Visits (Visits 4, 7, 10, 13) 
At these visits, the following procedures and assessments will be performed: 
• 
Urine pregnancy test, where indicated (see Section 8.2.3) 
• 
Study drug administration 
• 
AE assessment (see Section 12) 
• 
Concomitant medication assessment (see Sections 8.1.6 and 7.1.2) 
• 
Questionnaires (see Section 8.1.6) 
• 
Vital signs (see Section 8.1.1) 
• 
Spirometry (see Section 8.1.5) 
• 
Nasal mucus sample collection (see Section 8.2.2) 
• 
Targeted pulmonary examination by study clinician (see Section 8.1.2) 
• 
Assignment of asthma medication regimen by study clinician (see Section 7.1.1) 
• 
Asthma education/counseling (see Section 7.1.1.5) 
At Visits 4 and 13 only, spirometry and IOS with reversibility will be performed. 
Visits 7 and 10 will include measurement of exhaled nitric oxide (see Section 8.1.4). 
Visit 10 will include blood collection for CBC and differential (total eosinophil count) (see Section 8.2.1). 
8.10 Final Visit (Visit 14) 
At the final visit, the following procedures and assessments will be performed: 
• 
Urine cotinine (see Section 8.2.4) 
• 
Urine pregnancy test, where indicated (see Section 8.2.3) 
• 
Questionnaires (see Section 8.1.6) 
• 
AE assessment (see Section 12) 
• 
Concomitant medication assessment (see Sections 8.1.6 and 7.1.2) 
• 
Vital signs (see Section 8.1.1) 
• 
Spirometry (see Section 8.1.5) 
• 
Targeted pulmonary examination by study clinician (see Section 8.1.2) 
• 
Assignment of asthma medication regimen by study clinician (see Section 7.1.1) 
• 
Asthma education/counseling (see Section 7.1.1.5) 


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• 
Exhaled nitric oxide (see Section 8.1.4) 
• 
Nasal mucus sample collection (see Section 8.2.2) 
• 
Nasal lavage (see Section 8.2.2) 
• 
Nasosorption (see Section 8.2.2) 
• 
Blood sample collection (see Section 8.2.1) 
o CBC with differential 
o Blood chemistry 
o Total and allergen-specific IgE 
o Blood markers (plasma/DNA/RNA) 
o Antibody to drug 
• 
Sputum induction for a subset of children ≥10 years of age 
• 
Nasal epithelial cell collection for a subset of children ≥10 years of age 
8.11 Cold Visits 
Participants will be asked to report cold symptoms and come to the clinic at the start of up to three 
colds over the course of the 12-month follow-up.  At this visit, the following activities will take place: 
• 
Urine cotinine (see Section 8.2.4) 
• 
Vital signs (see Section 8.1.1) 
• 
Questionnaires (see Section 8.1.6) 
• 
AE assessment (see Section 12) 
• 
Concomitant medication assessment (see Sections 8.1.6 and 7.1.2) 
• 
Spirometry and IOS (see Section 8.1.4) 
• 
Targeted pulmonary exam (see Section 8.1.2) 
• 
Exhaled nitric oxide (see Section 8.1.4) 
• 
Nasal swab sample collection (see Section 8.2.2) 
• 
Nasal lavage (see Section 8.2.2) 
• 
Nasosorption (see Section 8.2.2) 
• 
Blood sample collection (see Section 8.2.1) 
o CBC with differential 
o Blood markers (plasma/DNA/RNA) 
8.12 Exacerbation Follow-Up Visits 
Over the course of the 12-month follow-up, participants who exacerbate will be asked to come in for a 
follow-up visit approximately 7 days following the start of systemic corticosteroids. As described in 
Section 3.2, exacerbations will be defined as a prescription of a course of systemic corticosteroids by a 
clinician, initiation of a course of systemic corticosteroids by a participant, or as a hospitalization for 
asthma. This visit will include: 
• 
Urine cotinine (see Section 8.2.4) 
• 
Vital signs (see Section 8.1.1) 
• 
Questionnaires (see Section 8.1.6) 
• 
AE assessment (see Section 12) 
• 
Concomitant medication assessment (see Sections 8.1.6 and 7.1.2) 


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• 
Spirometry and IOS (see Section 8.1.4) 
• 
Targeted pulmonary exam (see Section 8.1.2) 
• 
Nasal swab sample collection (see Section 8.2.2) 
• 
Nasal lavage (see Section 8.2.2) 
• 
Nasosorption (see Section 8.2.2) 
• 
Blood sample collection (see Section 8.2.1) 
o CBC with differential 
o Blood markers (plasma/DNA/RNA) 
8.13 Unscheduled Visits and Telephone Follow-up 
Participants who experience asthma-related problems or concerns between scheduled study visits will 
be seen by a study clinician as warranted by the situation. If the site staff are notified by the participant, 
his/her family, an ED, a hospital, or clinic that the participant was seen for an unscheduled visit 
elsewhere, the site staff will contact the participant within 2 weeks of discharge to obtain an update on 
the participant’s clinical status.  A follow-up visit at the study center will be scheduled if needed. For 
details on the management plan, please refer to Section 7.1 and the Protocol ICAC-30 MOP. 
Participants who are at Control Level 4 at a study visit will either be seen in the clinic or will receive a 
follow-up phone call within 1-2 weeks of the visit to check the status of their symptoms. Participants 
prescribed systemic corticosteroids who do not have an exacerbation study visit will receive a follow-up 
phone call within 1-2 weeks of the visit to check the status of their symptoms.  If systemic 
corticosteroids were prescribed by a non-ICAC clinician and the participant does not come in for a study 
exacerbation visit, the participant will be seen in the clinic or will receive a follow-up phone call within 1-
2 weeks to check the status of their symptoms.  If this prescribing is uncovered more than two weeks 
after initiation of the corticosteroids, and the participant is doing well at the time of notification, then 
no follow up phone call is required. 
Participants who have 2 exacerbations within a 1-month period must be seen in a face-to-face visit to 
determine if continuation in the study is in the best interest of the participant. 
8.14 Visit Windows 
Mepolizumab/placebo injections should be scheduled as close as possible to the every 4 week target 
date. See the Protocol ICAC-30 MOP for details regarding visit scheduling.  
9 Mechanistic Assays 
To identify the inflammatory pathways affected by mepolizumab treatment, we will examine airway 
gene expression using whole genome transcriptomics of nasal lavage and peripheral blood. Blood and 
nasal lavage samples for these studies will be collected pre-treatment (V1), early in the treatment period 
(V3), at the end of the study (V14), as well as during cold visits as described in Section 8.11 and 
exacerbation visits as described in Section 8.12. The quality of nasal lavage samples will be monitored 
regularly throughout the course of the study. Specifically, RNA will be extracted from samples for 
assessment of RNA concentration as well as integrity. 


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10 Biospecimen Storage 
Unused samples of biological specimens collected during the course of the study will be stored 
(described in the Protocol ICAC-30 MOP) for future use for tests that may or may not be planned. These 
tests may or may not be related to the study of asthma and allergy. Participants will be asked to give 
permission for long-term storage and future use during the consent process.  With the participant’s 
approval and as approved by the Central IRB, de-identified biological samples will be stored indefinitely 
at the central repository. 
11 Criteria for Participant and Study Completion and Premature Study Termination 
11.1 Participant Completion 
Participants are considered to have completed the study once they have completed the Final Study Visit. 
11.2 Participant Stopping Rules and Withdrawal Criteria 
Participants may be prematurely terminated from the study for the following reasons: 
1. The participant elects to withdraw consent from all future study activities, including follow-
up. 
2. The participant is “lost to follow-up” as defined in the Protocol ICAC-30 MOP. 
3. The participant dies.  
4. Development of any serious medical illness whose natural history, sequela, or treatment 
would be worsened or impaired by continuation in the protocol. 
5. The study clinician no longer believes participation is in the best interest of the participant. 
6. The participant has an SAE related to investigational agent. 
7. The participant becomes pregnant. 
8. The participant has a need for > 3 bursts of systemic corticosteroids for asthma exacerbations 
during the treatment period OR has a need for > 2 bursts of systemic corticosteroids for 
asthma exacerbations within 6 months during the treatment period. If prescribed by an ICAC 
study clinician, a burst is defined as a course for prednisone, prednisolone, or 
methylprednisolone will be 2 mg/kg/day as a single daily dose for 4 days with a maximum 
dose of 60 mg per day. The course for dexamethasone will be 0.3 to 0.6 mg/kg/day as a 
single daily dose for 2 days with a maximum dose of 16 mg per day. If a corticosteroid burst 
for the treatment of an asthma exacerbation is prescribed by a non-ICAC clinician, it will be 
counted regardless of dose. If a participant initiates and completes a course of systemic 
corticosteroids without clinician involvement, this course will be counted only if the study 
clinician agrees the treatment was warranted, and it meets the following dosage: the course 
for prednisone, prednisolone, or methylprednisolone will be at least 20 mg daily dose for 3 of 
5 consecutive days. The course for dexamethasone will be at least a 10 mg single daily dose.   
9. The participant has a need for > 14 days of prednisone (or prednisolone or 
methylprednisolone; defined as a minimum of 5 mg/day) over a 21 day period from Visit 1 
through Visit 14. 
10. The participant has a hypoxic seizure due to asthma. 
11. The participant requires intubation due to asthma. 
12. The participant has intolerable adverse experiences. 


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13. There is a major violation of the clinical trial protocol (defined as any variation from the 
protocol-directed conduct of the study that affects the safety of a participant or the ability of 
the trial to evaluate efficacy of the study agent).  
14. The participant begins immunotherapy during the study period.  
15. The participant has a new diagnosis of malignancy.  
16. The participant has a new diagnosis requiring regular treatment with systemic 
corticosteroids, immunosuppressives, or any other drug that would interfere with 
participation in the study.  
17. The participant has a serious parasitic infection and does not respond to treatment. 
 
Note:  If investigational product is discontinued by a study clinician, participants may continue on-study 
if agreed upon by the participant and study clinician (see Section 8.13). 
11.3 Participant Replacement 
Participants who are discontinued prior to completing the 12-month follow up will not be replaced. All 
reasons for withdrawal will be captured on the appropriate electronic case report form (eCRF). 
11.4 Follow-up after Early Study Withdrawal 
Participants who withdraw or are dropped from the study between visits will be contacted by phone and 
will be invited to the study center for a final assessment. This assessment will include: 
• 
Urine pregnancy test, where indicated (see Section 8.2.3) 
• 
Questionnaires (see Section 8.1.6) 
• 
AE assessment (see Section 12) 
• 
Concomitant medication assessment (see Sections 8.1.6 and 7.1.2) 
• 
Vital signs (see Section 8.1.1) 
• 
Spirometry (see Section 8.1.5) 
• 
Targeted pulmonary exam (see Section 8.1.2) 
• 
Assignment of asthma medication regimen by study clinician (see Section 7.1.1) 
• 
Asthma education/counseling (see Section 7.1.1.5) 
• 
Blood sample collection (see Section 8.2.1) 
o CBC with differential 
o Blood chemistry 
 
Procedures contraindicated by the medical condition of the participant will not be conducted at the 
discretion of the study clinician. For participants who refuse to come to the clinic, the final clinical 
assessment as described above may be conducted over the phone. Besides this visit, no further follow-
up will be made, except for participants who are discontinued due to pregnancy or SAEs. These 
participants will be contacted to determine the outcome of the pregnancy or the SAE. Refer to Section 
12.6 for more information on AE reporting for pregnancy. 
11.5 Study Stopping Rules 
Study enrollment will be temporarily suspended pending expedited review of all pertinent data after the 
occurrence of one death or SAE which is unexpected and related to the investigational agent. 


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If the study enrollment is stopped due to meeting the above criteria, it may not be resumed until all 
pertinent information is discussed with the IND Sponsor (DAIT NIAID), NIAID Asthma and Allergy DSMB, 
and the Central IRB, and all parties concur with the resumption of the study. The FDA will be notified if 
stopping rules are met and also on resumption of the study. 
The study may be terminated by the IND sponsor (DAIT NIAID) or the NIAID Allergy and Asthma DSMB 
upon review of any observations, events, or new information that merits such action. 
12 Safety Monitoring and Reporting 
12.1 Overview 
This section defines the types of safety data that will be collected under this protocol and outlines the 
procedures for appropriately collecting, grading, recording, and reporting those data. Adverse events 
that are classified as serious according to the definition of Health Authorities must be reported promptly 
(per Section 12.5, Reporting of Serious Adverse Events and Adverse Events) to the IND sponsor (DAIT 
NIAID).  Appropriate notifications will also be made to site Principal Investigators, Institutional Review 
Boards (IRBs), and appropriate Health Authorities.  
Information in this section complies with ICH Guideline E2A: Clinical Safety Data Management: 
Definitions and Standards for Expedited Reporting, ICH Guideline E-6: Guideline for Good Clinical 
Practice, 21CFR Parts 312 and 320, and applies the standards set forth in the National Cancer Institute , 
Common Terminology Criteria for Adverse Events (CTCAE), Version [enter 4.0 or correct version 
applicable to trial] : http://ctep.cancer.gov/reporting/ctc.html. 
12.2 Definitions 
12.2.1 Adverse Event (AE) 
Any untoward or unfavorable medical occurrence, or worsening of an undesirable or unintended 
sign, symptom, laboratory finding or disease that occurs during participation in the trial, whether or 
not considered related to the participant’s participation in the research (modified from the definition 
of adverse events in the 1996 International Conference on Harmonisation E-6 Guidelines for Good 
Clinical Practice) (from OHRP "Guidance on Reviewing and Reporting Unanticipated Problems 
Involving Risks to Subjects or Others and Adverse Events (1/15/07)" 
http://www.hhs.gov/ohrp/policy/advevntguid.html#Q2)  
AEs that occur due to a study procedure will be collected and recorded.  The following clinical 
situations, when associated with study procedures, are defined as adverse events and will be 
recorded on the AE CRF.  These situations do not limit the Principal Investigator from reporting to the 
Study Sponsor (DAIT NIAID) any other events, associated or not with these procedures, as AEs.   
• 
Study therapy regimen: mepolizumab administered by the subcutaneous route 
• 
Study mandated procedures:  AEs that occur due to a study procedure will be collected and 
recorded. The following clinical situations, when associated with study procedures, are defined 
as adverse events and will be recorded on the AE eCRF.  These situations do not limit the 


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Principal Investigator from reporting to the Study Sponsor any other events, associated or not 
with these procedures, as AEs.    
Allergen Skin Testing 
• 
Prolonged (>24 hours) itching at test site 
• 
Swelling (> 10 cm) at site of test lasting more than 24 hours 
• 
Nasal allergic symptoms within 30 minutes of the procedure 
• 
Fainting/Vasovagal event within 30 minutes of the procedure 
• 
Anaphylaxis 
 
Blood Draws 
• 
Fainting/Vasovagal events 
• 
Bruising at puncture site larger than 2 cm diameter 
• 
Bleeding from puncture site lasting more than 30 minutes 
• 
Swelling at puncture site larger than 2 cm 
 
Pulmonary Function Testing  
• 
Wheezing or bronchoconstriction requiring treatment with bronchodilators within 30 
minutes from the procedure 
• 
Coughing requiring treatment with bronchodilators within 30 minutes from the 
procedure 
 
Sputum Induction  
• 
Wheezing or bronchoconstriction requiring treatment with bronchodilators within 30 
minutes from the procedure 
• 
Coughing requiring treatment with bronchodilators within 30 minutes from the 
procedure 
 
Nasal Lavage 
• 
Acute sinusitis diagnosed by study clinician or based upon assessment of outside health 
records within 72 hours after the procedure  
Nasal Blow / Nasal Mucus Sample Collection 
• 
Acute sinusitis diagnosed by study clinician or based upon assessment of outside health 
records within 72 hours after the procedure  
Nasal Epithelial Cell Collection 
• 
Epistaxis within 24 hours of the procedure 
 
Nasal Swab Sample Collection  


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• 
Epistaxis within 24 hours of the procedure 
• 
Headache, earache or rhinorrhea lasting longer than 24 hours  
 
12.2.1.1 Suspected Adverse Reaction   
Any adverse event for which there is a reasonable possibility that the investigational drug [or 
investigational study therapy regimen] caused the adverse event. For the purposes of safety reporting, 
‘reasonable possibility’ means there is evidence to suggest a causal relationship between the drug and 
the adverse event. A suspected adverse reaction implies a lesser degree of certainty about causality 
than adverse reaction, which means any adverse event caused by a drug (21 CFR 312.32(a)). 
12.2.2 Unexpected Adverse Event  
An adverse event or suspected adverse reaction is considered “unexpected” when its nature 
(specificity), or severity, or rate of occurrence is not consistent with applicable product information as 
described in the safety information provided in the current GSK Investigator’s Brochure for 
mepolizumab. 
“Unexpected” also refers to adverse events or suspected adverse reactions that are mentioned in the 
current GSK Investigator’s Brochure for mepolizumab as occurring with a class of drugs or as anticipated 
from the pharmacological properties of the drug, but are not specifically mentioned as occurring with 
the particular drug under investigation (21 CFR 312.32(a)). 
12.2.3 Serious Adverse Event  
An adverse event or suspected adverse reaction is considered “serious” if, in the view of either the 
investigator or the IND sponsor (DAIT NIAID), it results in any of the following outcomes (21 CFR 
312.32(a)): 
1. Death. 
2. A life-threatening event: An AE or SAR is considered “life-threatening” if, in the view of either the 
Principal Investigator or IND Sponsor, its occurrence places the participant at immediate risk of 
death. It does not include an AE or SAR that, had it occurred in a more severe form, might have 
caused death.  
3. Inpatient hospitalization or prolongation of existing hospitalization. 
4. Persistent or significant incapacity or substantial disruption of the ability to conduct normal life 
functions. 
5. Congenital anomaly or birth defect.  
6. Important medical events that may not result in death, be life threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical judgment, 
they may jeopardize the participant and may require medical or surgical intervention to prevent 
one of the outcomes listed above. 
Elective hospitalizations, hospitalizations for pre-existing conditions that do not worsen during the 
course of the trial, or hospital admissions for the purpose of conduct of protocol mandated procedures 
are not to be reported as an SAE unless hospitalization is prolonged due to complications. 


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Exacerbations of asthma are ordinary, anticipated complications of asthma observed in patients 
receiving standard of care. An asthma exacerbation that requires hospitalization and is determined to be 
a SAR (Section 12.2.1.1) will be considered a SAE. All other asthma hospitalizations will not be 
considered SAEs and will be entered only on the appropriate CRFs. The date of onset of the asthma 
exacerbation SAE will be the date of hospital admission and the date of resolution will be the discharge 
date. The underlying condition will be followed as per protocol. 
12.3 Grading and Attribution of Adverse Events 
Information in this section complies with ICH Guideline E-6: Guidelines for Good Clinical Practice and 
applies the following standards: 
• 
Guidance for Industry: Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled 
in Preventive Vaccine Clinical Trials (published September 2007) for local reactions to study 
procedures.  
• 
Grading System of Severity of Anaphylaxis adapted, from the grading scale of Brown et al. (36) for 
anaphylaxis and systemic reactions to study procedures. 
• 
National Cancer Institute Common Terminology Criteria for Adverse Events Version 4.03 (published 
June 14, 2010) for all other reactions. (This document is referred to herein as the “NCI-CTCAE 
manual.”) 
12.3.1 Grading Criteria 
12.3.1.1 Adverse Events Related to Skin Testing and Injection Site Reactions 
Skin Testing 
Excessive local reactions to skin testing not associated with systemic signs or symptoms will be graded 
according to Table 12.3.1.1a below. All AEs should be recorded on the eCRF. 
 
Table 12.3.1.1a Grading of Local Reactions to Study Procedures 
Grade 
1 (Mild) 
2 (Moderate) 
 (Severe) 
Skin testing 
 
 
Meets the 
minimum 
criteria listed in 
section 12.2.1, 
but requiring no 
medication 
other than 
topical 
corticosteroids 
or 
antihistamines. 
Interfering with 
usual daily 
activities or 
sleep and 
requiring oral 
steroids. 
Requiring a visit 
to a health care 
provider  for 
treatment 
Anaphylaxis 


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Criteria from 37Sampson, et al. will be used to determine whether systemic allergic reactions constitute 
anaphylaxis (see Table 12.3.1.1b Clinical Criteria for Diagnosing Anaphylaxis). To be considered 
anaphylaxis, the event must involve at least two organ systems (e.g. not be simply a skin reaction). All 
anaphylaxis events, regardless of severity grade, will be recorded as Adverse Events and will be graded 
according to Table 12.3.1c Grading System of Severity of Anaphylaxis, adapted from the grading scale of 
36Brown et al.  
Table 12.3.1.1b Clinical Criteria for Diagnosing Anaphylaxis 
  
 
 
 
 
 
 
 
 
Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled: 
1) Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal 
tissue, or both (e.g., generalized hives, pruritus or flushing, swollen lips-tongue-uvula) 
AND AT LEAST ONE OF THE FOLLOWING: 
a) Respiratory compromise (e.g., dyspnea, wheeze-bronchospasm, stridor, reducted PEF, 
hypoxemia 
b) Reduced BP or associated symptoms of end-organ dysfunction (e.g., hypotonia [collapse], 
syncope, incontinence) 
2) Two or more of the following that occur rapidly after exposure to a likely allergen for that 
patient (minutes to several hours): 
a) Involvement of the skin-mucosal tissue (e.g., generalized hives, itch-flush, swollen lips-
tongue-uvula) 
b) Respiratory compromise (e.g., dyspnea, wheeze-bronchospasm, stridor, reducted PEF, 
hypoxemia) 
c) Reduced BP or associated symptoms (e.g., hypotonia [collapse], syncope, incontinence) 
d) Persistent gastrointestinal symptoms (e.g., crampy abdominal pain, vomiting) 
3) Reduced BP after exposure to known allergen for that patient (minutes or several hours): 
a) Infants and children: low systolic BP (age specific) or greater than 30% decrease in systolic 
BP* 
b) Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease from that person’s 
baseline 
PEF, Peak expiratory flow; BP, blood pressure. 
*Low systolic blood pressure for children is defined as less than 70 mm Hg from 1 month to 1 year, less than (70 
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Table 12.3.1.1c Grading System of Severity of Anaphylaxis 
 
Grade 
Defined By 
1. Mild (skin & subcutaneous tissues, 
GI, &/or mild respiratory) 
Flushing, urticaria, periorbital or facial angioedema; 
mild dyspnea, wheeze or upper respiratory symptoms; 
mild abdominal pain and/or emesis 
2. Moderate (mild symptoms + features 
suggesting moderate respiratory, 
cardiovascular or GI symptoms) 
Marked dysphagia, hoarseness, and/or stridor; 
shortness of breath, wheezing & retractions; crampy 
abdominal pain, recurrent vomiting and/or diarrhea; 
and/or mild dizziness 
3. Severe (hypoxia, hypotension, or 
neurological compromise) 
Cyanosis or SpO2 < 92% at any stage, hypotension, 
confusion, collapse, loss of consciousness; or 
incontinence 
 
Injection Site Reactions (ISRs) 
This study will grade injection site reactions as defined by the following table, from the Guidance for 
Industry – Toxicity Grading Scale for healthy Adult and Adolescent Volunteers Enrolled in Preventative 
Vaccine Clinical Trials, Food and Drug Administration, September 200738. 
Table 12.3.1.1d Grading System of Severity of Injection Site Reactions 
Local Reaction to 
Injectable Product 
Mild  
(Grade 1) 
Moderate 
 (Grade 2) 
Severe 
 (Grade 3) 
Potentially 
Life 
Threatening  
(Grade 4) 
Pain 
Does not 
interfere with 
activity 
Repeated use of 
non-narcotic pain 
reliever >24 hours 
or interferes with 
activity 
Any use of 
narcotic pain 
reliever or 
prevents daily 
activity 
Emergency 
room (ER) visit 
or 
hospitalization 
Tenderness 
Mild discomfort 
to touch 
Discomfort with 
movement 
Significant 
discomfort at 
rest 
ER visit or 
hospitalization 
Erythema/Redness* 
2.5 – 5 cm 
5.1 – 10 cm 
>10 cm 
Necrosis or 
exfoliative 
dermatitis 
Induration/Swelling** 2.5 – 5 cm and 
does not 
interfere with 
activity 
5.1 – 10 cm or 
interferes with 
activity 
>10 cm or 
prevents daily 
activity 
Necrosis 
*In addition to grading the measured local reaction at the greatest single diameter, the 
measurement should be recorded as a continuous variable. 
**Induration/swelling should be evaluated and graded using the functional scale as well as the 
actual measurement. 


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12.3.1.2 Grading and Attribution of All Other Adverse Events 
The study site will grade the severity of adverse events experienced by the study participants according 
to the criteria set forth in the National Cancer Institute’s Common Terminology Criteria for Adverse 
Events (CTCAE) Version 4.0 with the exception of anaphylaxis and injection site reactions (Section 
12.3.1.1). This document (referred to herein as the NCI-CTCAE manual) provides a common language to 
describe levels of severity, to analyze and interpret data, and to articulate the clinical significance of all 
adverse events. The NCI-CTCAE has been reviewed by the Principal Investigators and has been deemed 
appropriate for the participant population to be studied in this protocol.  
Adverse events will be graded on a scale from 1 to 5 according to the following standards in the NCI-
CTCAE manual: 
Grade 1 = mild adverse event 
Grade 2 = moderate adverse event 
Grade 3 = severe and undesirable adverse event 
Grade 4 = life-threatening or disabling adverse event 
Grade 5 = death 
 
Events Grade 1 or higher will be recorded on the appropriate AE electronic case report form for this 
study. 
For grading an abnormal value or result of a clinical or laboratory evaluation (including, but not limited 
to, a radiograph, an ultrasound, an electrocardiogram etc.), a treatment-emergent adverse event will 
rely on clinical judgment of the study clinician to determine if the value is an adverse event.   
For additional information and a printable version of the NCI-CTCAE manual, consult the NCI-CTCAE web 
site: http://ctep.cancer.gov/reporting/ctc.html. 
12.3.2 Attribution Definitions 
The relationship, or attribution, of an adverse event to the study therapy regimen or study procedure(s) 
will initially be determined by the study clinician and recorded on the appropriate AE/SAE eCRF.  Final 
determination of attribution for safety reporting will be determined by DAIT NIAID.  The relationship of 
an adverse event to study therapy regimen or procedures will be determined using the descriptors and 
definitions provided in Table 12.3.2.  
For additional information and a printable version of the NCI-CTCAE manual, consult the NCI-CTCAE web 
site: http://ctep.cancer.gov/reporting/ctc.html. 
 
 


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Table 12.3.2 Attribution of Adverse Events 
Code 
Descriptor 
Relationship (to primary investigational product 
and/or other concurrent mandated study therapy or 
study procedure) 
UNRELATED CATEGORY 
1 
Unrelated 
The adverse event is clearly not related; there is 
insufficient evidence to suggest a causal relationship. 
RELATED CATEGORIES 
2 
Possible 
The adverse event has a reasonable possibility to be 
related; there is evidence to suggest a causal 
relationship. 
3 
Definite 
The adverse event is clearly related. 
12.4 Collection and Recording of Adverse Events 
12.4.1 Collection Period 
Adverse events will be collected from the time of consent until a participant completes study 
participation or until 30 days after he/she prematurely withdraws (without withdrawing consent) or is 
withdrawn from the study. 
12.4.2 Collecting Adverse Events 
Adverse events (including SAEs) may be discovered through any of these methods: 
• 
Observing the participant 
• 
Interviewing the participant  
• 
Receiving an unsolicited complaint from the participant 
• 
In addition, an abnormal value or result from a clinical or laboratory evaluation can also 
indicate an adverse event, as defined in Section 12.3, Grading and Attribution of Adverse 
Events 
12.4.3 Recording Adverse Events 
Throughout the study, the study clinician will record adverse events and serious adverse events as 
described previously (Section 12.2, Definitions) on the appropriate AE/SAE eCRF regardless of the 
relationship to study therapy regimen or study procedure. 
Once recorded, an AE/SAE will be followed until it resolves with or without sequelae, or until the end of 
study participation, or until 30 days after the participant prematurely withdraws (without withdrawing 
consent)/or is withdrawn from the study, whichever occurs first.  The DAIT NIAID Medical Officer may 
request continued follow-up of an adverse event beyond the stated timeframe if deemed clinically 
important. 
12.5 Reporting of Serious Adverse Events and Adverse Events 
12.5.1 Reporting of Serious Adverse Events to the IND Sponsor (DAIT NIAID) 
This section describes the responsibilities of the Principal Investigator to report serious adverse events 
to the IND sponsor via SAE eCRF. Timely reporting of adverse events is required by 21 CFR and ICH E6 
guidelines.  


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Principal Investigators will report all serious adverse events (see Section 12.2.3, Serious Adverse Event), 
regardless of relationship or expectedness within 24 hours of discovering the event. 
For serious adverse events, all requested information on the AE/SAE eCRF will be provided.  The 
following minimal criteria must be included in the initial SAE eCRF: 
• 
AE Term 
• 
Study Drug Treatment 
• 
Relationship to study drug 
• 
Reason why the event is serious 
However, unavailable details of the event will not delay submission of the known information.  As 
additional details become available, the AE/SAE eCRF will be updated and submitted. 
12.5.2 Reporting to FDA 
After an adverse event requiring 24 hour reporting (per Section 12.5.1, Reporting of Serious Adverse 
Events to Sponsor) is submitted by the Principal Investigator and assessed by the IND sponsor (DAIT 
NIAID), there are two options for DAIT NIAID to report the adverse event to the FDA: annual reporting 
and expedited safety reporting. 
12.5.2.1 IND Annual Reporting 
DAIT NIAID will include in the IND Annual Report to the FDA all adverse events classified as: 
• 
Serious, expected, suspected adverse reactions (see Section 12.2.1.1, Suspected Adverse 
Reaction, and Section 12.2.2, Unexpected Adverse Event). 
• 
Serious and not a suspected adverse reaction (see Section 12.2.1.1, Suspected Adverse 
Reaction). 
• 
Pregnancies. 
Note that all adverse events (not just those requiring 24-hour reporting) will be reported in the IND 
Annual Report. 
12.5.2.2 Expedited Safety Reporting  
This option, with 2 possible categories, applies if the adverse event is classified as one of the following: 
Category 1:  Serious and unexpected suspected adverse reaction [SUSAR] (see Section 
12.2.1.1, Suspected Adverse Reaction and Section 12.2.2, Unexpected Adverse Event and 21 
CFR 312.32(c)i).  
The sponsor shall report any suspected adverse reaction that is both serious and 
unexpected.  The sponsor shall report an adverse event as a suspected adverse 
reaction only if there is evidence to suggest a causal relationship between the study 
drug and the adverse event, such as: 
1. A single occurrence of an event that is uncommon and known to be 
strongly associated with drug exposure (e.g., angioedema, hepatic injury, 
or Stevens-Johnson Syndrome)  


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2. One or more occurrences of an event that is not commonly associated 
with drug exposure, but is otherwise uncommon in the population 
exposed to the drug (e.g., tendon rupture) 
3. An aggregate analysis of specific events observed in a clinical trial (such as 
known consequences of the underlying disease or condition under 
investigation or other events that commonly occur in the study population 
independent of drug therapy) that indicates those events occur more 
frequently in the drug treatment group than in a concurrent or historical 
control group 
 
Category 2: Any findings from studies that suggests a significant human risk  
The sponsor shall report any findings from other epidemiological studies, analyses of 
adverse events within the current study or pooled analysis across clinical studies or 
animal or in vitro testing (e.g. mutagenicity, teratogenicity, carcinogenicity) that 
suggest a significant risk in humans exposed to the drug that would result in a 
safety-related change in the protocol, informed consent, investigator brochure, or 
other aspects of the overall conduct of the study.   
 
DAIT NIAID must notify the FDA and all participating Principal Investigators of expedited Safety Reports 
within 15 calendar days; unexpected fatal or immediately life-threatening suspected adverse reaction(s) 
shall be reported as soon as possible or within 7 calendar days.  
12.5.3 Reporting of Adverse Events to IRBs 
All Principal Investigators must report adverse events, including expedited reports, in a timely fashion to 
the Central IRB in accordance with applicable regulations and guidelines. All IND Safety Reports to the 
FDA shall be distributed by the IND sponsor (DAIT NIAID) or designee to all participating institutions for 
Central IRB submission. 
12.6 Pregnancy Reporting 
The Principal Investigator shall be informed immediately of any pregnancy in a study participant 
occurring from time of consent through 30 days after the participant completes study participation. A 
pregnant participant shall be instructed to stop taking study medication. The investigator shall counsel 
the participant and discuss the risks of continuing with the pregnancy and the possible effects on the 
fetus. Monitoring of the pregnant participant shall continue until the conclusion of the pregnancy.   
The investigator shall report to the DAIT SACCC and the IND sponsor (DAIT NIAID) all pregnancies within 
1 business day of becoming aware of the event using the Pregnancy eCRF.  All pregnancies identified 
during the study shall be followed to conclusion and the outcome of each must be reported. The 
Pregnancy eCRF shall be updated and submitted to the DAIT SACCC when details about the outcome are 
available.   
Information requested about the delivery shall include: 
• 
Gestational age at delivery 
• 
Birth weight, length, and head circumference 
• 
Gender 


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• 
Appearance, pulse, grimace, activity, and respiration (APGAR) score at 1 minute, 5 minutes, and 
24 hours after birth, if available 
• 
Any abnormalities 
All pregnancy complications that result in a congenital abnormality, birth defect, miscarriage, and 
medically indicated abortion - an SAE shall be submitted to the DAIT SACCC and the IND sponsor (DAIT 
NIAID) using the SAE reporting procedures described above.  
12.7 Reporting of Other Safety Information 
A Principal Investigator shall promptly notify the Central IRB as well as the DAIT SACCC and the IND 
sponsor (DAIT NIAID) via email when an “unanticipated problem involving risks to subjects or others” is 
identified, which is not otherwise reportable as an adverse event. 
12.8 Review of Safety Information 
12.8.1 Medical Monitor Review 
The DAIT NIAID Medical Monitor shall receive monthly reports from the DAIT SACCC compiling new and 
accumulating information on AEs, SAEs, and pregnancies recorded by the study site(s) on appropriate 
eCRFs. 
In addition, the DAIT NIAID Medical Monitor shall review and make decisions on the disposition of the 
SAE and pregnancy reports received by the DAIT SACCC (See Sections 12.5 and 12.6).   
12.8.2 DSMB Review  
12.8.2.1 
Planned DSMB Reviews  
The NIAID Allergy and Asthma Data and Safety Monitoring Board (DSMB) shall review safety data at 
least yearly during planned DSMB Data Review Meetings. Data for the planned safety reviews will 
include, at a minimum, a listing of all reported AEs and SAEs.   
The DSMB will be informed of an Expedited Safety Report as determined by the DAIT NIAID Medical 
Monitor. An SAE which the DAIT NIAID Medical Monitor determines to be an unexpected safety risk will 
be sent to the DSMB immediately. 
12.8.2.2 
Ad hoc DSMB Reviews  
In addition to the pre-scheduled data reviews and planned safety monitoring, the DSMB may be called 
upon for ad hoc reviews. The DSMB will review any event that potentially impacts safety at the request 
of the protocol chair or the IND sponsor (DAIT NIAID). In addition, occurrences described in Section 11.5 
Study Stopping Rules will trigger an ad hoc comprehensive DSMB Safety Review. 
After review of the data, the DSMB will make recommendations regarding study conduct and/or 
continuation. 
A temporary halt in enrollment and study treatment will be implemented if an ad hoc DSMB safety 
review is required.   
13 Statistical Considerations and Analytical Plan 


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13.1 Overview  
The primary research question of this study is whether mepolizumab will lead to a reduced rate of 
asthma exacerbations in urban children and adolescents with difficult-to-control, exacerbation-prone 
asthma and peripheral blood eosinophils ≥150 cells/μl. This objective will be addressed using a 
multicenter, double-blind, placebo-controlled, randomized trial of mepolizumab adjunctive therapy for 
the prevention of asthma exacerbations in urban children and adolescents ages 6 to 17 years with 
difficult-to-control, exacerbation-prone asthma and peripheral blood eosinophilia. 
13.2 Endpoints/Outcomes 
The primary endpoint is the number of asthma exacerbations between randomization and the end of 
participant follow-up or 12 months since randomization, whichever comes first. Exacerbations will be 
defined as a prescription of a course of systemic corticosteroids by a clinician, initiation of a course of 
systemic corticosteroids by a participant, or as a hospitalization for asthma. If a participant initiates and 
completes a course of systemic corticosteroids without clinician involvement, this course will be 
counted only if the study clinician agrees the treatment was warranted, and it meets the following 
dosage: the course for prednisone, prednisolone, or methylprednisolone will be at least 20 mg daily 
dose for 3 of 5 consecutive days. The course for dexamethasone will be at least a 10 mg single daily 
dose.  If a corticosteroid burst for the treatment of an asthma exacerbation is prescribed by a non-ICAC 
clinician, it will be counted regardless of dose. 
Key secondary endpoints include: 
1. Asthma burden, as measured by a composite score (CASI) of asthma symptoms, medication 
usage, and exacerbation risk measured at Visits V1, V4, V7, V10, V13 and V14. 
2. Patient reported outcomes, as measured by physician-patient global assessment tool 
measured at Visit V14. 
3. Lung function, as assessed by spirometry measured at Visit V1, V4, V7, V10, V13, and V14 and 
IOS measured at Visit V1, V4, and V13. 
4. Time between randomization and first asthma exacerbation or the end of participant follow-
up, whichever comes first. Participants that do not have an asthma exacerbation will be right-
censored at the end of follow-up. 
13.3 Measures to Minimize Bias  
To minimize bias, randomization will be performed using a validated system created by the DAIT SACCC 
that automates the random assignment of treatment groups to study ID numbers. The randomization 
scheme will be reviewed by a statistician at the DAIT SACCC and locked after approval. Participants will 
be randomized using a 1:1 ratio of active and control (placebo) participants. A covariate adaptive 
randomization algorithm developed by Pocock and Simon (1975)32 will be used to maintain a balance 
between treatment arms with respect to study site, number of previous exacerbations (2 or 3+), 
peripheral blood eosinophils (< or ≥400 cells/μl), BMI (< or ≥95th percentile for age), total serum IgE (< or 
≥540 kUA/L) and treatment dose (40 mg or 100 mg). This strategy was chosen to enhance our ability to 
balance the distribution of covariates that are known to be highly associated with our primary endpoint 
(e.g., number of previous exacerbations and peripheral blood eosinophils) as well as covariates that 
determine if a participant fits the FDA-approved dosing tables for omalizumab therapy (e.g., BMI and 
total serum IgE), which is related to Secondary Objective 5. 


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13.4 Analysis Plan 
13.4.1 Analysis Populations 
The following groups of participants will define samples for endpoint analysis: 
• 
Modified Intent-to-treat (ITT) sample:  All participants who are randomized and receive at 
least one dose of study treatment. Participants will be analyzed according to the treatment 
arm to which they were randomized, regardless of the medication they actually received. 
• 
Safety sample: All participants who are randomized and receive at least one dose of study 
treatment. Participants will be analyzed according to the medication they actually received, 
regardless of the treatment arm to which they were randomized. Non-treatment emergent 
adverse events (e.g., any adverse event that occurs before the first injection) will be 
summarized in all participants who are enrolled, while treatment emergent adverse events 
(e.g., any adverse event that occurs on or after the first injection) will be summarized in the 
safety sample.  
• 
Per-protocol (PP) sample: All participants who are randomized, received the correct 
medication and dosage to which they were randomized, do not have a major protocol 
deviation and cannot have missed 3 or more consecutive injections or 4 or more scheduled 
injections. 
13.4.2 Primary Analysis of Primary Endpoint(s)/Outcome(s)   
The primary analysis will compare the rate of exacerbations during the treatment period using a 
negative binomial model applied to the modified intent-to-treat sample. The model will include an 
offset term to account for differential follow-up among participants. To account for adaptive 
randomization, the model will also be adjusted for study site, number of exacerbations in year prior to 
study (2 or 3+), peripheral blood eosinophils (< or ≥400 cells/μl), BMI (< or ≥95th percentile for age), 
total serum IgE (< or ≥540 kUA/L) and treatment dose (40 mg or 100 mg). Such a model will allow us to 
estimate the adjusted relative rate and corresponding 95% CI between the mepolizumab and placebo 
arms. A two-sided significance level of 0.05 will be used for this analysis.   The reduction of the dose of 
mepolizumab from 100 mg to 40 mg in children 6 to 11 years of age and >40 kg will not affect the 
primary outcome as data from the GSK-sponsored pediatric trial 200363, NCT02377427 is 
therapeutically equivalent. 
13.4.3 Supportive Analyses of the Primary Endpoint(s)/Outcome(s)  
Analyses for the primary endpoint may be supported by several analyses.  
One disadvantage of a covariate adaptive randomization strategy is that Type I error may be inflated in 
certain circumstances (e.g., time trends). Consequently, rather than adjusting the model for the 
variables used in the adaptive randomization as discussed in Section 13.4.2, a permutation test will be 
used for inference instead as it involves fewer assumptions. Under a permutation model, the observed 
relative rate between the mepolizumab and placebo arms will be assessed with reference to all possible 
permutations that the treatment arms could have been assigned to participants.  


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Rather than adjusting the model for the variables used in the adaptive randomization, the model will 
instead adjust for study site (as a random or fixed effect), number of exacerbations in year prior to study 
(2, 3 or 4+), BMI percentile (treated as a continuous variable), total serum IgE (treated as a continuous 
variable and log-transformed, if appropriate) peripheral blood eosinophils (treated as a continuous 
variable and log-transformed, if appropriate), and treatment dose (40 or 100 mg). 
To test if the effect of mepolizumab on the rate of asthma exacerbations during the treatment period is 
modified by particular sub-groups, separate negative binomial models of the rate of asthma 
exacerbations during the treatment period will be developed to test the two-way interaction between 
treatment arm and: 
• 
Indicator for whether or not a participant fits the FDA-approved dosing table for omalizumab 
therapy 
• 
BMI percentile at baseline (continuous or categorical) 
• 
Peripheral blood eosinophils at baseline (continuous or categorical and log-transformed, if 
appropriate)  
• 
Bronchodilator responsiveness at baseline (continuous or categorical) 
• 
Number of exacerbations in year prior to study (2, 3 or 4+) 
• 
Total serum IgE at baseline (continuous or categorical and log-transformed, if appropriate) 
• 
Dose at baseline (40 mg or 100 mg) 
• 
FeNO (continuous or categorical) at baseline 
• 
Nasal ECP at baseline  
To test if the effect of mepolizumab on the rate of asthma exacerbations during the treatment period is 
modified by both number of exacerbations in year prior to study as well as peripheral blood eosinophils, 
a separate negative binomial model of the rate of asthma exacerbations during the treatment period 
will be developed to test the three-way interaction between treatment arm, peripheral blood 
eosinophils (treated as either a piecewise linear spline or non-linear spline and log-transformed, if 
appropriate) and number of exacerbations in year prior to study (2, 3 or 4+). 
13.4.4 Analyses of Secondary and Other Endpoint(s)/Outcome(s) 
Generalized linear mixed models will be used to model CASI and lung function during the treatment 
period. A generalized logit model will be used to analyze the physician-patient global assessment at Visit 
14. Kaplan-Meier curves and a Cox PH model will also be used to model the time to first asthma 
exacerbation during the treatment period. 
As with the primary analyses, generalized linear mixed models, the generalized logit model, as well as 
the Cox PH model will include treatment arm as the primary exposure but will also adjust for study site, 
number of exacerbations in year prior to study (2 or 3+), peripheral blood eosinophils (above or below 
400 cells/μl), BMI (above or below 95th percentile for age) and total serum IgE (above or below 540 
kUA/L) to account for adaptive randomization. 
To determine if mepolizumab reduces the rate of asthma exacerbation in participants who do not fit the 
FDA-approved dosing table for omalizumab therapy or alternatively, if mepolizumab reduces the rate of 
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binomial model similar to that used for the primary analysis will be applied to all participants in the 
modified intent-to-treat sample in each of the 2 sub-groups. Because the goal of this objective is to 
estimate the effect of mepolizumab on the rate of asthma exacerbation in each sub-group, rather than 
compare these two effects using an interaction test, these effects will be reported regardless of the 
results obtained from the interaction test, which will be performed as part of the supportive analyses for 
the primary endpoint (see Section 13.4.3). 
Safety will be summarized by arm in the safety sample by the number and percentage of serious and 
non-serious adverse events stratified by grade and relationship to treatment as well as the number and 
percentage of participants who have a serious and non-serious adverse event stratified by grade and 
relationship to treatment. Levels of antibody to mepolizumab will be analyzed in the safety sample using 
generalized linear mixed models as stated above in the mepolizumab arm only. 
13.4.5 Analyses of Exploratory Endpoint(s)/Outcome(s) 
To determine whether mepolizumab improves other important clinical outcomes, including rate of virus-
induced asthma exacerbations, ACT/cACT scores, maximum number of asthma symptom days or 
bronchodilator response, negative binomial models, generalized linear mixed models, generalized logit 
models, Kaplan-Meier curves and Cox PH models will be applied as appropriate to each endpoint in a 
manner similar to that described in Sections 13.4.2 to 13.4.4.  
 
To identify immunologic pathways in the airways and peripheral blood that are characteristic of 
exacerbations prevented with and persistent despite anti-IL5 therapy, general linear models appropriate 
for RNA-sequencing count data will be used. Between group comparisons will be treated as a two 
independent group comparison and within group comparisons will use a mixed effect model with 
individual as a random effect. For comparisons where we are testing whether the two groups behave 
differently with a cold, an exacerbation, or over time, a general linear model will be created adding in 
these variables as main effects in the model and interaction terms between each effect. The general 
linear models will be expanded to include cell enumeration data as additional variables. Similarly, other 
salient variables (eg virus PCR data, collection site, collection time) that explain heterogeneity seen in 
the gene expression pattern, will be added to the model as appropriate. When relevant, predefined 
genes and gene sets of interest identified through Protocol ICAC-29 MUPPITS-1 results or previously 
published data will be tested separately without stringent multiple testing correction. Gene expression 
differences will be assigned to specific cell types using gene expression deconvolution algorithms 
appropriate for bulk cell population expression data. Predefined subgroups including PCR virus results, 
age, sex, race/ethnicity, obesity, timing of onset of asthma exacerbation relative to onset of cold 
symptoms, systemic corticosteroid use, season, nasal corticosteroid use, tobacco smoke exposure, and 
eNO will also be compared. 
13.4.6 Descriptive Analyses  
Descriptive analyses will be reported separately for mepolizumab and placebo arms. Continuous 
baseline measures will be reported 1) means (or geometric means) with 95% confidence intervals, or 2) 
median with first and third quartiles, as appropriate. Categorical baseline and demographic 
characteristics and study disposition will be reported as frequencies and proportions. 
13.5 Interim Analyses  


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13.5.1 Interim Analysis of Efficacy Data 
No formal interim analysis of efficacy data will be performed for this study.  
13.5.2 Interim Analysis of Safety Data 
The DSMB will receive periodic safety reports on enrolled participants. However, no formal interim 
analysis of safety data will be conducted. 
13.5.3 Futility Analysis 
No formal futility analysis will be performed for this study. 
13.6 Statistical Hypotheses  
All primary and secondary objectives will be based on two-sided superiority tests. For instance, the null 
and alternative hypotheses for the primary objective are: 
H0: The rate of asthma exacerbations during the treatment period in the mepolizumab arm is equal to 
the rate of asthma exacerbations during the treatment period in the placebo arm.  
Ha: The rate of asthma exacerbations during the treatment period in the mepolizumab arm is not equal 
to the rate of asthma exacerbations during the treatment period in the placebo arm.  
 Additionally, Secondary Objective 5 will separately determine whether mepolizumab reduces the rate 
of asthma exacerbations in the sub-group of study participants who do not fit the FDA-approved dosing 
table for omalizumab therapy and in study participants who fit the FDA-approved dosing table for 
omalizumab therapy. In this case, the null and alternative hypotheses for this objective are: 
H0: The rate of asthma exacerbations during the treatment period in the mepolizumab arm is equal to 
the rate of asthma exacerbations during the treatment period in the placebo arm in study participants 
who do not fit the FDA-approved dosing table for omalizumab therapy. 
Ha: The rate of asthma exacerbations during the treatment period in the mepolizumab arm is not equal 
to the rate of asthma exacerbations during the treatment period in the placebo arm in study 
participants who do not fit the FDA-approved dosing table for omalizumab therapy. 
H0: The rate of asthma exacerbations during the treatment period in the mepolizumab arm is equal to 
the rate of asthma exacerbations during the treatment period in the placebo arm in study participants 
who fit the FDA-approved dosing table for omalizumab therapy. 
Ha: The rate of asthma exacerbations during the treatment period in the mepolizumab arm is not equal 
to the rate of asthma exacerbations during the treatment period in the placebo arm in study 
participants who fit the FDA-approved dosing table for omalizumab therapy. 
13.7 Sample Size Considerations  
Based on Pavord et al,14 the estimated relative rate of clinically significant asthma exacerbations 
between 75 mg, 250 mg, and 750 mg Mepolizumab arms and the Placebo arm was 0.52, 0.61, and 0.48 
respectively. In Protocol ICAC-19 APIC, we found that among 94 enrolled participants that were difficult-
to-treat at screening, had at least 2 exacerbations in the previous year at screening and peripheral blood 
eosinophils ≥150 cells/μl, the rate of asthma exacerbations per patient –year was approximately 1.43 


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with an associated dispersion parameter of 0.47. Assuming that we will observe a relative rate similar to 
that seen in Pavord et al (2012) of 0.60 and that the event rate in the placebo arm is assumed to be 1.20 
asthma exacerbations per patient-year with corresponding dispersion parameter of 0.50 in both arms, a 
total sample size of 256 participants (128 participants per arm) is required to detect such a relative rate 
with 90% power, based on a two-sided significance level of 0.05 and the work outlined in Zhu & Lakkis,39 
using maximum likelihood (method 3) for estimating the variance under the null hypothesis. Assuming 
approximately 20% of randomized participants do not meet criteria for modified intent-to-treat and are 
not replaced, we originally proposed to enroll 320 participants (160 participants per arm). However, our 
observed post-randomization dropout rate has been lower than expected (11%), and therefore the 
sample size was revised to 290.  
Secondary Objective 5 will also determine if mepolizumab reduces the rate of asthma exacerbation in 
participants who do not fit the FDA-approved dosing table for omalizumab therapy and in participants 
who fit the FDA-approved dosing table for omalizumab therapy. In Protocol ICAC-19 APIC participants 
meeting Protocol ICAC-30 MUPPITS-2 eligible criteria, approximately 50% of participants did not fit the 
FDA-approved dosing table for omalizumab therapy and so we would expect approximately 128 
participants (64 participants per arm) in each of these sub-groups in Protocol ICAC-30 MUPPITS-2. 
Assuming an event rate in the placebo arm of 1.20 and dispersion parameter of 0.50 in both arms, such 
a sample size would allow us to detect a relative rate between arms of 0.53 with 80% power.   
14 Identification and Access to Source Data 
14.1 Source Data 
Source documents and source data are considered to be the original documentation where participant 
information, visits consultations, examinations and other information are recorded.  Documentation of 
source data is necessary for the reconstruction, evaluation and validation of clinical findings, 
observations and other activities during a clinical trial. All clinical site laboratory reports, spirometry 
reports, and any paper and electronic CRFs will be maintained as source data.  
14.2 Access to Source Data 
The Principal Investigators and site staff will make all source data available to the IND sponsor (DAIT 
NIAID), as well as to the FDA.  Authorized representatives as noted above are bound to maintain the 
strict confidentiality of medical and research information that may be linked to identified individuals. 
15 Protocol Deviations 
15.1 Protocol Deviation Definitions 
15.1.1 Protocol Deviation  
The Principal Investigators and site staff will conduct the study in accordance to the protocol; no 
deviations from the protocol are permitted.  Any change, divergence, or departure from the study 
design or procedures constitutes a protocol deviation.  As a result of any deviation, corrective actions 
will be developed by the site and implemented promptly. 


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15.1.2 Major Protocol Deviation 
A protocol violation is a deviation from the IRB-approved protocol that may affect the participant's 
rights, safety, or well-being and/or the completeness, accuracy and reliability of the study data.  In 
addition, protocol violations include willful or knowing breaches of human subject protection 
regulations, or policies, any action that is inconsistent with the NIH Human Research Protection 
Program’s research, medical, and ethical principles, and a serious or continuing noncompliance with 
federal, state, local or institutional human subject protection regulations, policies, or procedures.  
15.1.3 Non-Major Protocol Deviation 
A non-major protocol deviation is any change, divergence, or departure from the study design or 
procedures of a research protocol that does not have a major impact on the participant's rights, safety 
or well-being, or the completeness, accuracy and reliability of the study data. 
15.2 Reporting and Managing Protocol Deviations 
The Principal Investigator has the responsibility to identify, document and report major and non-major 
protocol deviations as directed by the study Sponsor. However, major and non-major protocol 
deviations may also be identified during site monitoring visits or during other forms of study conduct 
review.  
Upon determination that a protocol deviation (major or minor) has occurred, the study staff will a) 
notify the Principal Investigator (PI), b) notify the DAIT SACCC, and c) complete the Protocol Deviation 
form. The Protocol Deviation form will document at a minimum the date the protocol deviation (PD) 
occurred, the date PD identified, a description of event, whether the deviation resulted in SAE/AE, the 
signature of PI, report to Central IRB, and documentation of a corrective action plan. The DAIT SACCC 
and the IND sponsor (DAIT NIAID) may request discussion with the PI to determine the effect of the 
protocol deviation on the study participant and his/her further study participation, the effect of the 
protocol deviation on the overall study, and corrective actions. The PI will complete and sign the 
Protocol Deviation form and submit it to the DAIT SACCC and to the Central IRB, per IRB regulations.  
Major protocol deviations will be reported to the DSMB by the DAIT NIAID Medical Monitor at the 
Medical Monitor’s discretion.   
16 Ethical Considerations and Compliance with Good Clinical Practice 
16.1 Quality Control and Quality Assurance 
The Principal Investigator is required to keep accurate records to ensure that the conduct of the study is 
fully documented. The Principal Investigator is required to ensure that all CRFs are completed for every 
participant entered in the trial.  
The sponsor is responsible for regular inspection of the conduct of the trial, for verifying adherence to 
the protocol, and for confirming the completeness, consistency, and accuracy of all documented data.  
The CRFs will be completed online via a web-based electronic data capture (EDC) system that has been 
validated and is compliant with Part 11 Title 21 of the Code of Federal Regulations. Study staff at the site 
will enter information into the electronic CRFs, and the data will be stored remotely at a central 
database. Data quality will be ensured through the EDC system’s continuous monitoring of data and 
real-time detection and correction of errors. All elements of data entry (i.e., time, date, verbatim text, 


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and the name of the person performing the data entry) will be recorded in an electronic audit trail to 
allow all changes in the database to be monitored and maintained in accordance with federal 
regulations. 
16.2 Statement of Compliance 
This clinical study will be conducted using good clinical practice (GCP), as delineated in Guidance for 
Industry: E6 Good Clinical Practice Consolidated Guidance, and according to the criteria specified in this 
study protocol.  Before study initiation, the protocol and the informed consent documents will be 
reviewed and approved by the Central IRB.  Any amendments to the protocol or to the consent 
materials will also be approved by the Central IRB before they are implemented. 
The Principal Investigator will ensure that this study is conducted in full conformity with Regulations for 
the Protection of Human Subjects of Research codified in 45 CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 
and/or the ICH E6. 
16.3 Informed Consent Process 
The consent process will provide information about the study to a prospective participant and 
parent(s)/legal guardian(s) and will allow adequate time for review and discussion prior to his/her 
decision.  The Principal Investigator or designee listed on the FDA 1572 will review the consent and 
answer questions. The consent designee must be listed on the delegation log and have knowledge of the 
study. The prospective participant and parent(s)/legal guardian(s) will be told that being in the trial is 
voluntary and that he or she may withdraw from the study at any time, for any reason.  All participants 
(or their legally acceptable representative) and parent(s)/legal guardian(s) will read, sign, and date a 
consent form before undergoing any study procedures.  Assent will be obtained as per instruction by the 
Central IRB. Consent materials will be presented in participants’ primary language. A copy of the signed 
consent form will be given to the participant. 
The consent process will be ongoing.  The consent form will be revised when important new safety 
information is available, the protocol is amended, and/or new information becomes available that may 
affect participation in the study.  
16.4 Privacy and Confidentiality 
A participant’s privacy and confidentiality will be respected throughout the trial.  Each participant will be 
assigned a unique identification number and these numbers rather than names will be used to collect, 
store, and report participant information.  Site personnel will not transmit documents containing 
personal health identifiers (PHI) to the study sponsor or their representatives. 
17 Publication Policy 
Presentations and publication of the results of this trial will be governed by the ICAC Publication Policy. 
 
 


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18 References 
 
1. 
Wildfire JJ, Gergen PJ, Sorkness CA, et al. Development and validation of the Composite Asthma 
Severity Index--an outcome measure for use in children and adolescents. J Allergy Clin Immunol 
2012;129:694-701. 
2. 
Ortega HG, Liu MC, Pavord ID, et al. Mepolizumab Treatment in Patients with Severe 
Eosinophilic Asthma. The New England journal of medicine 2014. 
3. 
O'Byrne PM, Pedersen S, Lamm CJ, Tan WC, Busse WW, Group SI. Severe exacerbations and 
decline in lung function in asthma. American journal of respiratory and critical care medicine 
2009;179:19-24. 
4. 
O'Brian AL, Lemanske RF, Jr., Evans MD, Gangnon RE, Gern JE, Jackson DJ. Recurrent severe 
exacerbations in early life and reduced lung function at school age. J Allergy Clin Immunol 
2012;129:1162-4. 
5. 
McGeachie MJ, Yates KP, Zhou X, et al. Patterns of Growth and Decline in Lung Function in 
Persistent Childhood Asthma. The New England journal of medicine 2016;374:1842-52. 
6. 
Liu AH, Babineau DC, Krouse RZ, et al. Pathways through which asthma risk factors contribute to 
asthma severity in inner-city children. J Aller Clin Immunol 2016;138:1042-50. 
7. 
Pongracic JA, Krouse RZ, Babineau DC, et al. Distinguishing Characteristics of Difficult-to-Control 
Asthma in Inner-City Children and Adolescents. J Aller Clin Immunol 2016;138:1030-41. 
8. 
Zoratti EM, Krouse RZ, Babineau DC, et al. Asthma phenotypes in inner-city children. J Aller Clin 
Immunol 2016;138:1016-29. 
9. 
Price DB, Rigazio A, Campbell JD, et al. Blood eosinophil count and prospective annual asthma 
disease burden: a UK cohort study. The lancet Respiratory medicine 2015;3:849-58. 
10. 
Flood-Page P, Swenson C, Faiferman I, et al. A study to evaluate safety and efficacy of 
mepolizumab in patients with moderate persistent asthma. American journal of respiratory and critical 
care medicine 2007;176:1062-71. 
11. 
Busse WW, Lemanske RF, Jr., Gern JE. Role of viral respiratory infections in asthma and asthma 
exacerbations. Lancet 2010;376:826-34. 
12. 
Johnston SL, Pattemore PK, Sanderson G, et al. Community study of role of viral infections in 
exacerbations of asthma in 9-11 year old children. Bmj 1995;310:1225-9. 
13. 
Kloepfer KM, Gern JE. Virus/allergen interactions and exacerbations of asthma. Immunology and 
allergy clinics of North America 2010;30:553-63, vii. 
14. 
Pavord ID, Korn S, Howarth P, et al. Mepolizumab for severe eosinophilic asthma (DREAM): a 
multicentre, double-blind, placebo-controlled trial. Lancet 2012;380:651-9. 
15. 
Pavord ID, Bafadhel M. Exhaled nitric oxide and blood eosinophilia: independent markers of 
preventable risk. J Allergy Clin Immunol 2013;132:828-9. 
16. 
Robinson DS. The role of the mast cell in asthma: induction of airway hyperresponsiveness by 
interaction with smooth muscle? J Allergy Clin Immunol 2004;114:58-65. 
17. 
Busse WW. Asthma diagnosis and treatment: filling in the information gaps. J Allergy Clin 
Immunol 2011;128:740-50. 
18. 
Evans R, 3rd, Gergen PJ, Mitchell H, et al. A randomized clinical trial to reduce asthma morbidity 
among inner-city children: results of the National Cooperative Inner-City Asthma Study. The Journal of 
pediatrics 1999;135:332-8. 
19. 
Morgan WJ, Crain EF, Gruchalla RS, et al. Results of a home-based environmental intervention 
among urban children with asthma. The New England journal of medicine 2004;351:1068-80. 
20. 
Busse WW, Morgan WJ, Gergen PJ, et al. Randomized trial of omalizumab (anti-IgE) for asthma 
in inner-city children. The New England journal of medicine 2011;364:1005-15. 


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21. 
Szefler SJ, Mitchell H, Sorkness CA, et al. Management of asthma based on exhaled nitric oxide 
in addition to guideline-based treatment for inner-city adolescents and young adults: a randomised 
controlled trial. Lancet 2008;372:1065-72. 
22. 
Bai TR, Vonk JM, Postma DS, Boezen HM. Severe exacerbations predict excess lung function 
decline in asthma. Eur Respir J 2007;30:452-6. 
23. 
Bochner BS, Gleich GJ. What targeting eosinophils has taught us about their role in diseases. J 
Allergy Clin Immunol 2010;126:16-25; quiz 6-7. 
24. 
Leckie MJ, ten Brinke A, Khan J, et al. Effects of interleukin-5 blocking monoclonal antibody on 
eosinophils, airway hyperresponsiveness and the late asthmatic response. Lancet 2000;(in press). 
25. 
Haldar P, Brightling CE, Hargadon B, et al. Mepolizumab and exacerbations of refractory 
eosinophilic asthma. The New England journal of medicine 2009;360:973-84. 
26. 
Green RH, Brightling CE, McKenna S, et al. Asthma exacerbations and sputum eosinophil counts: 
a randomised controlled trial. Lancet 2002;360:1715-21. 
27. 
Nair P, Pizzichini MM, Kjarsgaard M, et al. Mepolizumab for prednisone-dependent asthma with 
sputum eosinophilia. The New England journal of medicine 2009;360:985-93. 
28. 
Bel EH, Wenzel SE, Thompson PJ, et al. Oral Glucocorticoid-Sparing Effect of Mepolizumab in 
Eosinophilic Asthma. The New England journal of medicine 2014. 
29. 
Ortega H, Li H, Suruki R, Albers F, Gordon D, Yancey S. Cluster analysis and characterization of 
response to mepolizumab: A step closer to personalized medicine for patients with severe asthma. 
Annals of the American Thoracic Society 2014. 
30. 
Liu Y, Zhang S, Li DW, Jiang SJ. Efficacy of anti-interleukin-5 therapy with mepolizumab in 
patients with asthma: a meta-analysis of randomized placebo-controlled trials. PloS one 2013;8:e59872. 
31. 
Ortega H, Chupp G, Bardin P, et al. The role of mepolizumab in atopic and nonatopic severe 
asthma with persistent eosinophilia. Eur Respir J 2014;44:239-41. 
32. 
Pocock SJ, Simon R. Sequential treatment assignment with balancing for prognostic factors in 
the controlled clinical trial. Biometrics 1975;31:103-15. 
33. 
Mepolizumab (SB-240563) Investigator's Brochure. 05Nov2016. 
34. 
NUCALA Prescribing Information. 2017. (Accessed 21 Apr, 2017, at 
https://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/N
ucala/pdf/NUCALA-PI-PIL.PDF.) 
35. 
Fahy JV, Boushey HA, Lazarus SC, et al. Safety and reproducibility of sputum induction in 
asthmatic subjects in a multicenter study. American journal of respiratory and critical care medicine 
2001;163:1470-5. 
36. 
Brown SG. Clinical features and severity grading of anaphylaxis. J Allergy Clin Immunol 
2004;114:371-6. 
37. 
Sampson HA M-FA, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, Brown SG, Camargo CA Jr, 
Cydulka R, Galli SJ, Gidudu J, Gruchalla RS, Harlor AD Jr, Hepner DL, Lewis LM, Lieberman PL, Metcalfe 
DD, O'Connor R, Muraro A, Rudman A, Schmitt C, Scherrer D, Simons FE, Thomas S, Wood JP, Decker 
WW. Second symposium on the definition and management of anaphylaxis: summary report--Second 
National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J 
Allergy Clin Immunol 2006;117:7. 
38. 
Guidance for Industry Toxixity Grading Scale for Healthy Adult and Adolescent Volunteers 
Enrolled in Preventive Vaccine Clinical Trials. 2007. (Accessed 21 Apr, 2017, at 
https://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/G
uidances/Vaccines/ucm091977.pdf.) 
39. 
Zhu H, Lakkis H. Sample size calculation for comparing two negative binomial rates. Statistics in 
medicine 2014;33:376-87. 
 


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Appendix A:   Schedule of Procedures/Evaluations 
 
 
Scree-
ning 
Rand
omiz
ation 
 
Treatment Phase (12 months) 
 
Asthma Management 
Week 
0 
4 
8 
12 
16 
20 
24 
28 
32 
36 
40 
44 
48 
52 
56 
PRN 
PRN 
Visit 
V0 
V1 
V2 
V3 
V4 
V5 
V6 
V7 
V8 
V9 
V10 
V11 
V12 
V13 
V14 
Cold+ 
EX# 
Consent/Assent 
+ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
+ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asthma Eval & Mgt 
+ 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
 
 
Asthma Counseling 
+ 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
 
 
Spirometry 
+ 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
+ 
+ 
IOS 
 
+ 
 
 
+ 
 
 
 
 
 
 
 
 
+ 
 
+ 
+ 
Bronchodilator 
reversibility (Spiro & 
IOS) 
 
+ 
 
 
+ 
 
 
 
 
 
 
 
 
+ 
 
 
 
CASI 
+ 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
 
 
ACT/c-ACT 
+ 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
 
 
Physician-patient 
global assessment tool 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+ 
 
 
Physical Exam 
+ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Targeted pulmonary 
exam 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
+ 
+ 
Lungs assessment 
 
 
+ 
+ 
 
+ 
+ 
 
+ 
+ 
 
+ 
+ 
 
 
 
 
FeNO 
 
+ 
 
+ 
 
 
 
+ 
 
 
+ 
 
 
 
+ 
+ 
 
SQ study drug/placebo 
 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
 
 
 
Pregnancy test 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
 
 
Urinary cotinine 
 
+ 
 
+ 
 
 
 
 
 
 
 
 
 
 
+ 
+ 
+ 
Blood collection 
+ 
+ 
 
+ 
 
 
 
 
 
 
+ 
 
 
 
+ 
+ 
+ 
CBC with differential 
+ * 
+ 
 
+ 
 
 
 
 
 
 
+ 
 
 
 
+ 
+ 
+ 
Blood chemistry 
+ 
 
 
+ 
 
 
 
 
 
 
 
 
 
 
+ 
 
 
Serum total IgE & 
specific IgE 
+ 
 
 
 
 
 
 
 
 
 
 
 
 
 
+ 
 
 
Blood markers 
(plasma/RNA/DNA) 
 
+ 
 
+ 
 
 
 
 
 
 
 
 
 
 
+ 
+ 
+ 
Antibodies to drug 
 
+ 
 
+ 
 
 
 
 
 
 
 
 
 
 
+ 
 
 
Skin Testing 
+* 
 
+* 
+* 
+* 
 
 
 
 
 
 
 
 
 
 
 
 
Nasal lavage 
 
+ 
 
+ 
 
 
 
 
 
 
 
 
 
 
+ 
+ 
+ 
Nasosorption 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+ 
+ 
+ 


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Nasal blow 
 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
 
 
Nasal resp virus 
 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
 
 
Nasal ECP 
 
+ 
+ 
+ 
+ 
 
 
+ 
 
 
 
 
 
 
+ 
 
 
Nasal swab collection^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+ 
+ 
Nasal epithelial cell 
collection 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+** 
 
 
Sputum Induction 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+** 
 
 
Vital signs and growth 
parameters 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
Adverse event 
assessment 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
Concomitant 
medication 
assessment 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
* may use CBC results collected in another ICAC protocol if within past 6 months and allergen skin tests performed in another ICAC protocol if within past 12 months – skin tests can 
be performed at V0, V2, V3 or V4 if not previously obtained in past 12 months 
+ up to two with an optional third cold visit will occur for each participant 
# as needed exacerbation visits to occur 7 days after start of systemic corticosteroids 
** to be performed in participants 10 years and older 
^Nasal swab collection replaced the nasal blow procedure at cold and exacerbation visits in Protocol Version 8.0 


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Appendix B: Nasal Lavage Quality Control Methods 
 
1 
Study Population 
 
Population Description 
Clinical research staff performing nasal lavage will be required to demonstrate proficiency in performing the procedure 
within Protocol ICAC-30 MUPPITS-2. The proficiency testing will be conducted by collecting and processing nasal lavage 
samples from individuals that have signed a consent specific to this procedure.  Up to 200 participants may be enrolled 
across the research sites to ensure all study staff members are trained.   
1.1.1 
Inclusion Criteria 
Participants to be included in this training are those: 
1. who are male or female age 6-17, inclusive 
2. have a history of asthma 
3. who are willing and able to provide informed consent 
4. who are willing and able to provide assent, if applicable 
 
Requirements 
All clinical research staff performing the nasal lavage collection and processing must perform at least two proficiency 
tests. After collection and processing, the site staff will send the samples to a central lab for review. The central lab will 
determine whether the samples are sufficient. If a sample is deemed not sufficient, then the staff member may be 
required to repeat the proficiency testing. 
 
Procedures 
The nasal lavage collection and processing procedures are detailed in the Protocol ICAC-30 MOP; however, the study 
clinician will not have the option to use a nasal decongestant prior to performing the nasal lavage for the quality control 
procedure (as described in Section 8.2.2). 
 
 


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Appendix C: Omalizumab Dosing Tables 
 
 
 
 
 


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Appendix D:  Sputum Induction Quality Control Methods 
 
1 Study Population 
1.1 Population Description 
Clinical research staff performing sputum induction will be required to demonstrate proficiency in performing the 
procedure within Protocol ICAC-30 MUPPITS-2.  The proficiency testing will be conducted by collecting and processing 
sputum samples from individuals who have signed a consent specific to this procedure.  Up to 100 participants may be 
enrolled across a subset of clinical research sites to ensure all study staff members are trained. 
1.1.1 
Inclusion Criteria 
Participants to be included in this procedure are those who: 
1. Are male and female age 10-17, inclusive 
2. Have a history of asthma 
3. Are willing and able to provide informed consent 
4. Are willing and able to provide assent 
1.2 Requirements 
All clinical research staff performing the sputum induction processing must perform at least two proficiency tests. After 
collection and processing, the site staff will send the samples to a central lab for review. The central lab will determine 
whether the samples are sufficient. If a sample is deemed not sufficient, then the staff member may be required to 
repeat the proficiency testing. 
1.3 Procedures 
The sputum induction collection and processing procedures are detailed in the Protocol ICAC-30 MUPPITS-2 MOP. 
 
 


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Appendix E:  Study Restrictions Due to COVID-19 
 
In the event of institutional or ICAC-wide restrictions on certain types of procedures or certain classes of research due to 
COVID-19, some study procedures may be suspended. This may include certain in-person study visits or specific 
inhalation or nasal procedures, such as: 
• 
Spirometry 
• 
Impulse Oscillometry 
• 
Exhaled nitric oxide 
• 
Sputum Induction 
• 
Nasal lavage sampling 
• 
Nasal blow sampling 
• 
Nasal epithelial cell collection 
If in-person visits are suspended, study staff will continue to make contact with study participants and will conduct visits 
over the phone. Prescriptions for asthma management medications can be sent to local pharmacies and additional 
prednisone, if needed, can be mailed to the participant.  
 


ICAC 
{Statistical Analysis Plan - Protocol #} 
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Version Date: 2021-04-01 
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PROPRIETARY — © 2019 Rho, Inc. 
 
STATISTICAL ANALYSIS PLAN 
 
MECHANISMS UNDERLYING ASTHMA EXACERBATIONS PREVENTED AND 
PERSISTENT WITH IMMUNE-BASED THERAPY:  
A SYSTEMS APPROACH PHASE 2 
 
PROTOCOL ICAC-30 
 
 
SHORT TITLE: 
MUPPITS-2 
NCT#: 
 
COMPOUND #: 
 
SPONSOR: 
The Division of Allergy, Immunology, and Transplantation (DAIT), The 
National Institute of Allergy and Infectious Diseases (NIAID) 
REGULATORY 
AGENCY 
IDENTIFIER 
NUMBER(S): 
 
IND #: 
136355 
PREPARED BY: 
Rho 
2635 E NC Hwy 54 
Durham, NC 27713 
Telephone: (919) 408-8000 
Fax: (919) 408-0999 
 
 
 
 
 
This document is confidential and proprietary to the National Institute of Allergy and Infectious Diseases. This 
study is being conducted in compliance with good clinical practice, including the archiving of essential 
documents. Acceptance of this document constitutes agreement by the recipient that no unpublished information 
contained herein will be reproduced, published, or otherwise disclosed without the prior written approval of 
National Institute of Allergy and Infectious Diseases, except that this document may be disclosed to appropriate 
Institutional Review Boards under the condition that they keep the information confidential. 
 
 
 
ACKNOWLEDGEMENT AND SIGNATURE SHEET 


ICAC 
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PROPRIETARY — © 2019 Rho, Inc. 
 
 
 
Approved: 
________________________________ 
Date: 
_______________ 
 
PROTOCOL CO-CHAIR -  
 
 
 
DANIEL J. JACKSON, MD 
 
 
 
Approved: 
________________________________ 
Date: 
_______________ 
 
PROTOCOL CO-CHAIR -  
 
 
 
WILLIAM W. BUSSE, MD 
 
 
 
Approved: 
________________________________ 
Date: 
_______________ 
 
MEDICAL MONITOR -  
 
 
 
PETER GERGEN, MD, MPH 
 
 
 
Approved: 
________________________________ 
Date: 
_______________ 
 
RESEARCH SCIENTIST – 
 
 
 
CYNTHIA VISNESS, PHD 
 
 
 
Approved: 
________________________________ 
Date: 
_______________ 
 
BIOSTATISTICIAN – 
 
 
 
MIGUEL VILLARREAL 
 
 
 
 
 
 
 


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PROPRIETARY — © 2019 Rho, Inc. 
 
VERSION HISTORY 
 
SAP Version 
Version Date 
Comments/Changes 
0.1 
16 DEC 2020 
Initial Version 
1.0 
01 APR 2021 
Version 1.0 
 
 


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PROPRIETARY — © 2019 Rho, Inc. 
 
TABLE OF CONTENTS 
1. 
LIST OF ABBREVIATIONS .................................................................................7 
2. 
PURPOSE OF THE ANALYSES ...........................................................................9 
3. 
PROTOCOL SUMMARY .................................................................................... 10 
4. 
GENERAL ANALYSIS AND REPORTING CONVENTIONS............................. 15 
5. 
ANALYSIS SAMPLES ........................................................................................ 16 
6. 
STUDY SUBJECTS ............................................................................................. 17 
6.1. 
Disposition of Subjects ......................................................................................... 17 
6.2. 
Demographic and Other Baseline Characteristics ................................................... 18 
6.3. 
Prior and Concomitant Medications ...................................................................... 18 
7. 
STUDY OPERATIONS ....................................................................................... 19 
7.1. 
Protocol Deviations .............................................................................................. 19 
7.2. 
Randomization ..................................................................................................... 19 
7.3. 
Measures of Treatment Adherence ........................................................................ 19 
8. 
ENDPOINT EVALUATION ................................................................................ 20 
8.1. 
Overview of Efficacy Analysis Methods................................................................ 20 
8.1.1. 
Multicenter Studies............................................................................................... 20 
8.1.2. 
Assessment Time Windows .................................................................................. 20 
8.1.3. 
Multiple Comparisons/Multiplicity........................................................................ 20 
8.2. 
Primary Endpoint ................................................................................................. 20 
8.2.1. 
Computation of the Primary Endpoint ................................................................... 20 
8.2.2. 
Primary Analysis of the Primary Endpoint............................................................. 21 
8.2.3. 
Sensitivity Analyses of the Primary Analysis......................................................... 21 
8.2.4. 
Secondary Analyses of the Primary Endpoint ........................................................ 21 
8.3. 
Secondary Endpoints ............................................................................................ 22 
8.3.1. 
Endpoint 1............................................................................................................ 22 
8.3.2. 
Endpoint 2............................................................................................................ 22 
8.3.3. 
Endpoint 3............................................................................................................ 23 
8.3.4. 
Endpoint 4............................................................................................................ 23 
8.3.5. 
Endpoint 5............................................................................................................ 23 
8.3.6. 
Endpoint 6............................................................................................................ 23 


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8.4. 
Other Endpoints ................................................................................................... 23 
8.4.1. 
Exploratory Analysis of the Primary Endpoint ....................................................... 23 
8.4.2. 
Exploratory Endpoints .......................................................................................... 24 
9. 
SAFETY EVALUATION..................................................................................... 25 
9.1. 
Overview of Safety Analysis Methods................................................................... 25 
9.2. 
Adverse Events .................................................................................................... 26 
9.3. 
Deaths, Serious Adverse Events ............................................................................ 27 
9.4. 
Clinical Laboratory Evaluation ............................................................................. 27 
9.5. 
Vital Signs and Growth Parameters, Physical Findings, and Targeted 
Pulmonary Exam Results ...................................................................................... 27 
9.5.1. 
Vital Signs and Growth Parameters ....................................................................... 27 
9.5.2. 
Physical Examinations .......................................................................................... 28 
9.5.3. 
Targeted Pulmonary Exam.................................................................................... 28 
10. 
OTHER ANALYSES ........................................................................................... 29 
11. 
INTERIM ANALYSES AND DATA MONITORING .......................................... 30 
12. 
CHANGES TO THE ANALYSES PLANNED IN THE PROTOCOL ................... 31 
13. 
REFERENCES..................................................................................................... 32 
14. 
APPENDIX.......................................................................................................... 33 
14.1. 
Study Flow Chart ................................................................................................. 33 
14.2. 
Schedule of Events ............................................................................................... 33 
 
 


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LIST OF TABLES 
Table 1: 
List of Abbreviations ..............................................................................................7 
 


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1. 
LIST OF ABBREVIATIONS 
Table 1: 
List of Abbreviations 
Abbreviation 
Term 
ACT 
Asthma Control Test 
AE  
Adverse Event 
BP 
Blood Pressure 
BMI 
Body Mass Index 
cACT 
Childhood Asthma Control Test 
CASI 
Composite Asthma Severity Index 
CI 
Confidence Interval 
COVID-19 
Coronavirus Disease 2019 
CSR 
Clinical Study Report 
CTCAE 
Common Terminology Criteria for Adverse Events 
DAIT 
Division of Allergy, Immunology, and Transplantation 
DSMB 
Data Safety Monitoring Board 
ECP 
Eosinophil Cationic Protein 
eCRF 
Electronic Case Report Form 
FeNO 
Fractional Exhaled Nitric Oxide 
FEV1 
Forced Expiratory Volume in 1 Second 
GCP 
Good Clinical Practice 
GSK 
GlaxoSmithKline (GSK) Group Company 
IB 
Investigator’s Brochure  
ICAC 
Inner City Asthma Consortium 
ICH 
International Conference on Harmonization 
ID 
Participant Study Identifier 
IgE 
Immunoglobulin E 
IgG 
Immunoglobulin G 
IL 
Interleukin 
IND 
Investigational New Drug 
IOS 
Impulse Oscillometry 
IRB 
Institutional review Board 


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NIAID 
National Institute of Allergy and Infectious Diseases 
MedDRA 
Medical Dictionary for Regulatory Activities  
mITT 
Modified Intent-to-Treat 
PD 
Protocol Deviation 
PT 
Preferred Term 
SACCC 
Statistical and Clinical Coordinating Center 
SD 
Standard Deviation 
SAE 
Serious Adverse Event 
SAP  
Statistical Analysis Plan 
SAR 
Suspected Adverse Reaction 
SOC 
System Organ Class 
TEAE 
Treatment-Emergent Adverse Event 
 


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2. 
PURPOSE OF THE ANALYSES 
 
The purpose of this statistical analysis plan (SAP) is to describe the planned analyses and data 
displays to be included in the Clinical Study Report (CSR) for Protocol ICAC-30 MUPPITS-2. 
This document provides details on study populations, how the variables will be derived, how 
missing data will be handled and details on statistical methods to be used to analyze the safety 
and efficacy data. 
The statistical analysis plan (SAP) is based on ICH guidelines E3 and E9 (Statistical Principles 
for Clinical Trials). 
The document may evolve over time, for example, to reflect the requirements of protocol 
amendments or regulatory requests. However, the final SAP must be finalized, approved by the 
Sponsor, and placed on file before database is locked. Deviations from the final approved plan 
will be noted in the clinical study report. 
 


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3. 
PROTOCOL SUMMARY 
 
Title 
Mechanisms Underlying Asthma Exacerbations Prevented and 
Persistent with Immune-Based Therapy: A Systems Approach 
Phase 2 
Short Title 
Protocol ICAC-30 MUPPITS-2 
Clinical Phase 
II 
Number of Sites 
Multiple 
IND Sponsor/Number 
IND sponsor: DAIT NIAD 
IND#: 136355 
Primary Hypothesis 
The primary research question of this study is whether 
mepolizumab will lead to a reduced rate of asthma exacerbations in 
urban children and adolescents (ages 6-17) with difficult-to-control, 
exacerbation-prone asthma and peripheral blood eosinophils ≥150 
cells/μl. We hypothesize that targeting eosinophils with the addition 
of the anti-IL-5 monoclonal antibody, mepolizumab, will prevent 
exacerbations and, as a consequence, reduce overall morbidity and 
improve asthma control. 
Study Objectives 
The primary objective of the study is to determine if phenotype-
directed use of mepolizumab reduces the rate of asthma 
exacerbations as defined by the need for systemic corticosteroid 
treatment in urban children and adolescents (ages 6-17) with 
difficult-to-control exacerbation-prone asthma and peripheral blood 
eosinophils ≥150 cells/μl.  
 
Secondary objectives are:  
1. To determine whether mepolizumab will lead to an improved 
Composite Asthma Severity Index (CASI)1 
2. To determine whether mepolizumab will improve quality of 
life as assessed by the physician-patient global assessment2 
3. To determine whether mepolizumab improves lung function as 
assessed by spirometry and impulse oscillometry   
4. To determine whether mepolizumab increases the time to first 
asthma exacerbation 
5. To separately determine whether mepolizumab reduces the rate 
of asthma exacerbations in study participants who do not fit the 


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FDA-approved dosing table for omalizumab therapy and in 
study participants who fit the FDA-approved dosing table for 
omalizumab therapy  
6. To assess the safety of mepolizumab treatment 
Study Design 
Protocol ICAC-30 MUPPITS-2 is a multicenter, double-blind, 
placebo-controlled, randomized trial of mepolizumab adjunctive 
therapy for the prevention of asthma exacerbations in urban 
children and adolescents with difficult-to-control exacerbation-
prone asthma and peripheral blood eosinophils ≥150 cells/μl. 
Primary Endpoint(s) 
The primary endpoint is the number of asthma exacerbations during 
the treatment period.  
Secondary Endpoint(s)  
1. CASI during the treatment period 
2. Quality of life as measured by the physician-patient global 
assessment  
3. Lung function as assessed by spirometry and IOS during the 
treatment period 
4. Time to first asthma exacerbation during the treatment period 
5. Number of reported adverse events and serious adverse events, 
including their severity and treatment relatedness 
Accrual Objective 
290 
Study Duration 
27 months recruitment + 12 months treatment 
Agent/Treatment 
Description  
Mepolizumab (anti-IL-5 antagonist monoclonal antibody) by 
subcutaneous injection every 4 weeks at the following doses: 
• Age 12 years and above:  100 mg  
• Age 6-11 years:  40 mg 
Participants 6 to 11 years of age and weighing ≥40 kg who 
were enrolled in Protocol ICAC-30 MUPPITS-2 under the 
previous versions of the protocol and initially assigned a 
100 mg dose will have their dose reduced to 40 mg. 
Participants age 11 years will increase to the 100 mg dose if they 
become age 12 years during the study. 
Inclusion Criteria 
1. Participant and/or parent guardian must be able to understand 
and provide informed consent and age-appropriate assent 
2. Are male and female aged 6-17 years, inclusive at 
randomization 


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3. Have a primary place of residence in one of the pre-selected 
recruitment census tracts as outlined in the Protocol ICAC-30 
Recruitment Manual of Operations  
3a.  Participants who do not live in the pre-selected census 
tracts but live within the Office of Management and Budget 
(OMB) defined Metropolitan Statistical Area and have 
publicly-funded health insurance will qualify for inclusion. 
4. Have had a diagnosis of asthma made > 1 year prior to 
recruitment; participants who received an asthma diagnosis by 
a clinician ≤ 1 year prior to recruitment must report that their 
respiratory symptoms were present for more than 1 year prior 
to recruitment 
5. Have had at least two asthma exacerbations in the prior year 
(defined as a requirement for systemic corticosteroids and/or 
hospitalization) 
6. At Visit 0 (Screening), have the following requirement for 
asthma controller medication: for participants aged 6 to 11 
years, treatments with at least fluticasone 250 mcg dry powder 
inhaler (DPI) one puff twice daily or its equivalent and for 
participants aged 12 years and older, treatment with at least 
fluticasone 250 mcg plus LABA DPI one puff twice daily or its 
equivalent 
7. Have peripheral blood eosinophils ≥150 cells/μl obtained at 
Visit 0 or via another ICAC protocol within 6 months 
8. Are able to perform spirometry at randomization  
9. Have documentation of current medical insurance with 
prescription coverage at randomization 
10. Have had varicella or the varicella vaccination 
Exclusion Criteria 
Individuals who meet any of the following criteria are not eligible 
for enrollment or randomization, if they: 
1. 
Are not able or willing to give written informed consent or 
comply with study protocol 
2. 
Have concurrent medical problems that would require systemic 
corticosteroids or other immunomodulators during the study 
3. 
Are currently receiving immunotherapy 
4. 
Are currently receiving treatment with omalizumab or have had 
omalizumab treatment within 6 months prior to randomization 


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5. 
Are currently requiring greater than fluticasone 500 mcg bid 
plus LABA one puff twice daily or its equivalent and/or 
individuals using oral corticosteroids daily or every other day 
for more than 14 days at the time of Visit 0 (Screening) 
6. 
Are currently pregnant or lactating, or plan to become pregnant 
during the time of study participation. Females of child-bearing 
potential (post-menarche) must be abstinent or use a medically 
acceptable birth control method throughout the study (e.g. oral 
subcutaneous, mechanical, or surgical contraception) 
7. 
Have a known, pre-existing clinically important lung condition 
other than asthma 
8. 
Have a current malignancy or previous history of cancer in 
remission for less than 12 months prior to randomization 
9. 
Have known, pre-existing, unstable liver disease 
10. Is a current smoker 
11. Have a known immunodeficiency disease 
12. Have other conditions that could lead to elevated eosinophils 
such as hypereosinophilic syndromes, including eosinophilic 
granulomatosis with polyangiitis 
13. Have a known, active pre-existing parasitic infestation or 
undergoing treatment for a parasitic infestation. Once the 
participant has been successfully treated, the participant may 
be reevaluated. 
14. Use of investigational drugs within 4 weeks of randomization 
15. Have past or current medical problems or findings from 
physical examination or laboratory testing that are not listed 
above, which, in the opinion of the investigator, may pose 
additional risks from participation in the study, may interfere 
with the participant’s ability to comply with study requirements 
or that may impact the quality or interpretation of the data 
obtained from the study 
16. Will not allow the study clinician, an asthma specialist, to 
manage their disease for the duration of the study or who are 
not willing to change their asthma medications to follow the 
protocol 
17. Have a known history of allergic reaction to previous biologic 
therapy for asthma 


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18. Have had a life threatening asthma exacerbation in the last 2 
years requiring intubation, mechanical ventilation or resulting 
in a hypoxic seizure 
Study Stopping Rules 
The occurrence of one death or an unexpected SAE related to the 
investigational agent. 
 


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4. 
GENERAL ANALYSIS AND REPORTING CONVENTIONS 
 
The following analyses and reporting conventions will be used: 
Categorical variables will be summarized using counts (n) and percentages (%) and will be 
presented in the form “n (%).”  Percentages will be rounded to one decimal place. If a 
count is 0, 0% will be shown for the percentage. 
Continuous variables will be summarized using sample size (n), mean, standard deviation 
(SD), median, first and third quartiles, minimum (min), and maximum (max), as 
appropriate.  The mean will be reported at one more significant digit than the precision of 
the data, the standard deviation will be reported at two more significant digits than the 
precision of the data, and first and third quartiles, minimum, maximum, and median will 
be reported at the same precision as the data. The median will be reported as the average 
of the two middle numbers if the dataset contains an even number of observations. 
Test statistics including t, z, and χ2 test statistics will be reported to two decimal places.  
P-values will be reported to three decimal places if greater than or equal to 0.001.  If less than 
0.001, the value will be reported as “<0.001.”  A p-value can be reported as “1.000” only 
if it is exactly 1.000 without rounding.  A p-value can be reported as “0.000” only if it is 
exactly 0.000 without rounding. 
Each data listing will be sorted by treatment arm and subject identifier (ID) unless otherwise 
noted. 
If departures from these general conventions are present in the specific evaluations section of this 
SAP, then those conventions will take precedence over these general conventions. 


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5. 
ANALYSIS SAMPLES 
 
The following groups of participants will define samples for endpoint analysis: 
• Modified Intent-to-treat (ITT) sample:  All participants who are randomized and 
receive at least one dose of study treatment. Participants will be analyzed according to 
the treatment arm to which they were randomized, regardless of the medication they 
actually received. 
• Safety sample: All participants who are randomized and receive at least one dose of 
study treatment. Participants will be analyzed according to the medication they 
actually received, regardless of the treatment arm to which they were randomized. 
Non-treatment emergent adverse events (e.g., any adverse event that occurs before the 
first injection) will be summarized in all participants who are enrolled, while treatment 
emergent adverse events (e.g., any adverse event that occurs on or after the first 
injection) will be summarized in the safety sample.  
• Per-protocol (PP) sample: All participants who are randomized, received the correct 
medication and dosage to which they were randomized, do not have a major protocol 
deviation and cannot have missed 3 or more consecutive injections or 4 or more 
scheduled injections. 
 


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6. 
STUDY SUBJECTS 
6.1. 
Disposition of Subjects 
The disposition of all enrolled participants, defined as those who consented/assented, will be 
summarized in a table and listed. The following disposition information will be included in the 
table: 
• The number of participants who had a screening visit (Visit 0) 
• Among screened participants: 
o The number and percentage of participants who were deemed ineligible 
• Among randomized participants: 
o The number and percentage of participants in the mITT population.  
o The number and percentage of participants in the safety population.  
o The number and percentage of participants in the PP population. 
• Among participants in the mITT population and grouped by treatment arm: 
o The number and percentage of participants in the safety population.  
o The number and percentage of participants in the PP population. 
o The number and percentage of participants who withdrew during the study due to: 
 Withdrawal of consent/assent 
 Major protocol violation 
 Pregnancy 
 Investigator decision 
 Started exclusionary medication 
 Started immunotherapy 
 Intubation due to asthma 
 Hypoxic seizure due to asthma 
 Developed exclusionary condition 
 Development of serious medical illness 
 >14 days of prednisone over a 21-day period 
 Exacerbation stopping rules 
 Death 
 SAE related to injection  
 Intolerable adverse event 
 Lost to follow-up 
 Did not meet randomization criteria 
 Withdrawal of consent/assent due to positive diagnosis of Coronavirus 
Disease 2019 (COVID-19) 
 
 Coronavirus Disease restrictions 


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 Other 
o The number and percentage of participants who discontinued study treatment and 
primary reason for discontinuation. 
 
A data listing of participant disposition will be provided for the mITT population, sorted by 
treatment arm and ID. 
6.2. 
Demographic and Other Baseline Characteristics 
Descriptive statistics for demographic and baseline characteristics will be summarized for the 
mITT population grouped by randomized treatment arm and overall. 
 
Demographic data will include age at randomization, sex, race, ethnicity, and clinical study site. 
 
Baseline will be defined as the last measurement prior to or on the day of randomization. 
Baseline characteristics will include: 
• Weight 
• Height 
• Body Mass Index (BMI) percentile, BMI categorical variable (< or ≥95% for age) 
• Number of previous exacerbations (2 or 3+) 
• Peripheral blood eosinophils (< or >=400 cells/ul) 
• Total serum IgE (< or >=540 kUA/L) 
• Treatment dose (40 mg or 100 mg) 
 
A data listing of demographics, baseline characteristics, and medical history will be provided for 
the mITT population. A data listing of all participants who had visits that were remote or missed 
due to COVID-19 will be provided for the mITT population and will include the number of visits 
that were remote or missed due to COVID-19 for each participant 
6.3. 
Prior and Concomitant Medications 
Prior and concomitant medications will be listed for the mITT population by treatment arm and 
ID. 


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7. 
STUDY OPERATIONS 
7.1. 
Protocol Deviations 
Protocol deviations will be recorded on the protocol deviation electronic case report form 
(eCRF) page. Major protocol deviations will be identified by the DAIT Medical Monitor and 
study team prior to unblinding of treatment assignment and database lock. 
 
Protocol deviations will be summarized in tabular format by treatment arm and by type of 
deviation (including major deviations). A data listing of all protocol deviations sorted by 
treatment arm and participant ID.  
7.2. 
Randomization 
Randomization was performed using a validated system created by the DAIT SACCC that 
automated the random assignment of treatment groups to study ID numbers. Participants were 
randomized using a 1:1 ratio of active and control (placebo) participants. A covariate adaptive 
randomization algorithm developed by Pocock and Simon (1975)4 was used to maintain a 
balance between treatment arms with respect to study site, number of previous exacerbations (2 
or 3+), peripheral blood eosinophils (< or ≥400 cells/μl), BMI (< or ≥95th percentile for age), 
total serum IgE (< or ≥540 kUA/L) and treatment dose (40 mg or 100 mg). This strategy was 
chosen to enhance the ability to balance the distribution of covariates that are known to be highly 
associated with our primary endpoint (e.g., number of previous exacerbations and peripheral 
blood eosinophils) as well as covariates that determine if a participant fits the FDA-approved 
dosing tables for omalizumab therapy (e.g., BMI and total serum IgE). 
7.3. 
Measures of Treatment Adherence 
The number of completed injections will be determined for each participant, and divided by the 
total number of expected injections (up to 13) given the amount of time in the study. The 
proportion of completed injections will be summarized by treatment arm and overall. Each 
injection, injection dose, baseline age, age at clinical visit, and weight will be listed by 
participant ID, visit, and by treatment arm.  


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8. 
ENDPOINT EVALUATION 
 
8.1. 
Overview of Efficacy Analysis Methods 
8.1.1. 
Multicenter Studies 
Although this is a multicenter study, the data is intended to be collected and analyzed as a whole. 
There are too few participants enrolled in the study relative to the number of sites to perform 
formal analyses stratified by site.  
8.1.2. 
Assessment Time Windows 
Mepolizumab/placebo injections were scheduled as close as possible to the every 4-week target 
date as outlined in the Schedule of Events (Section 15.1). Any data collected outside of a visit 
window will still be included in any analyses of the scheduled visit. 
At the onset of the COVID-19 pandemic, the following procedures were restricted, and were 
site-specific: Impulse oscillometry, spirometry, FeNO, nasal lavage samples, nasal blow 
samples, nasal epithelial cell collection, and sputum samples. Exacerbation visits were conducted 
only via telephone and cold visits were suspended. If participants were unable to come into the 
study center for visits, the visits were conducted via telephone. 
8.1.3. 
Multiple Comparisons/Multiplicity 
Adjustment for multiplicity will not be performed for the primary or secondary endpoints. 
8.2. 
Primary Endpoint 
8.2.1. 
Computation of the Primary Endpoint 
For participants who completed the study, the primary endpoint is the number of asthma 
exacerbations between randomization and the end of participant follow-up (Visit 14), or four 
weeks from the final injection--whichever comes first. For participants who terminated from the 
study early, the primary endpoint is number of exacerbations between randomization and their 
last known completed visit.  
Exacerbations are defined as a prescription of a course of systemic corticosteroids by a clinician, 
initiation of a course of systemic corticosteroids by a participant, or as a hospitalization for 
asthma. If a participant initiated and completed a course of systemic corticosteroids without 
clinician involvement, this course will be counted only if the study clinician agrees the treatment 
was warranted, and it meets the following dosage: the course for prednisone, prednisolone, or 
methylprednisolone will be at least 20 mg daily dose for 3 of 5 consecutive days. The course for 
dexamethasone will be at least a 10 mg single daily dose. If a corticosteroid burst for the 
treatment of an asthma exacerbation was prescribed by a non-ICAC clinician, it was counted 
regardless of dose. 


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8.2.2. 
Primary Analysis of the Primary Endpoint 
 
The primary analysis will compare the rate of exacerbations during the treatment period using a 
negative binomial model applied to the mITT sample. The model will include an offset term to 
account for differential follow-up among participants. To account for adaptive randomization, 
the model will also be adjusted for study site, number of exacerbations in year prior to study (2 
or 3+), peripheral blood eosinophils (< or ≥400 cells/μl), BMI (< or ≥95th percentile for age), 
total serum IgE (< or ≥540 kUA/L) and treatment dose (40 mg or 100 mg). Such a model will 
allow us to estimate the adjusted relative rate and corresponding 95% CI between the 
mepolizumab and placebo arms. A two-sided significance level of 0.05 will be used for this 
analysis.    
 
Although the primary version of the primary analysis will be conducted on the mITT sample, the 
same analysis of the primary endpoint will be performed for the PP population.  
8.2.3. 
Sensitivity Analyses of the Primary Analysis 
At the time of the COVID-19 pandemic and subsequent quarantine period, observable 
exacerbation rates decreased relative to observed rates in the prior years of the study. In order to 
account for the unknown effects of the pandemic on the primary endpoint, the exacerbation rate 
will be analyzed using the same model as specified in section 8.2.2, but only including 
participants who were randomized, received at least one injection, and who had at least one 
follow-up visit prior to March 16, 2020. For participants who met this definition, only 
exacerbations that occurred between randomization and March 16, 2020 will be analyzed in the 
model. All subsequent exacerbations and follow-up time will be censored after March 16, 2020. 
The offset variable used in the model will be defined as the length of time, in years, from 
randomization to the end of a participant’s follow-up, or March 16, 2020, whichever occurs first. 
The same analysis will be applied to the PP population.  
8.2.4. 
Secondary Analyses of the Primary Endpoint 
 
Analyses for the primary endpoint may be supported by several analyses.  
 
One disadvantage of a covariate adaptive randomization strategy is that Type I error may be 
inflated in certain circumstances (e.g., time trends). Consequently, rather than adjusting the 
model for the variables used in the adaptive randomization as discussed in Section 8.2.2, a 
permutation test will be used for inference instead as it involves fewer assumptions. Under a 
permutation model, the observed relative rate between the mepolizumab and placebo arms will 
be assessed with reference to all possible permutations that the treatment arms could have been 
assigned to participants, or up to 5000 iterations.  
 
Rather than adjusting the model for the variables used in the adaptive randomization, the model 
will instead adjust for study site (as a random or fixed effect), number of exacerbations in year 
prior to study (2, 3 or 4+), BMI percentile (treated as a continuous variable), total serum IgE 
(treated as a continuous variable and log-transformed, if appropriate) peripheral blood 


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eosinophils (treated as a continuous variable and log-transformed, if appropriate), and treatment 
dose (40 or 100 mg). 
8.3. 
Secondary Endpoints 
8.3.1. 
Endpoint 1 
Variable: Composite Asthma Severity Index (CASI) at Visits 4, 7, 10, 13, and 14.  
Analysis: A generalized linear mixed model will be used to model CASI during the treatment 
period. The model will include a fixed effect for treatment arm as the primary exposure but will 
also adjust for baseline CASI, study site, number of exacerbations in year prior to study (2 or 
3+), peripheral blood eosinophils (above or below 400 cells/μl), BMI (above or below 95th 
percentile for age) and total serum IgE (above or below 540 kUA/L) to account for adaptive 
randomization. Visit will be treated as a categorical variable in the model, and an interaction 
term between treatment arm and visit will be used to estimate the least square mean CASI for 
each treatment arm for each timepoint of measurement. The difference in least square mean, the 
corresponding 95% CI and the p-values will be provided for the comparison of mepolizumab vs 
placebo. The model will be fit using restricted maximum likelihood, and each fixed effect will be 
tested using an F-test statistic, the Kenward-Roger approximation for the degrees of freedom, an 
unstructured covariance matrix, and a two-sided significance level of 0.05. If the model 
assuming an unstructured covariance matrix does not converge, other covariance structures, such 
as a spatial power covariance structure, will be considered. Descriptive statistics including the 
number of participants, mean, and standard deviation will also be presented. This analysis will be 
conducted on the mITT population.  
As sites were restricted to limited visit assessments due to COVID-19, lung function assessments 
were not performed and FEV1 (% predicted), a domain of the CASI score, was not collected. In 
these cases, the last known FEV1 (% predicted) value, from Visit 4 or onward, will be used to 
calculate a participant’s CASI at subsequent visits.  Additionally, sites were discouraged from 
stepping down participants’ asthma controller therapy during the pandemic, another domain of 
the CASI score, which could bias the results towards the null.    
8.3.2. 
Endpoint 2 
Variable: Quality of life, as measured by physician-patient global assessment, at Visit 14 
Analysis: A generalized logit model will be used to analyze the physician-patient global 
assessment at Visit 14 for the mITT population. The model will include treatment arm as a fixed 
effect as the primary exposure but will also adjust for study site, number of exacerbations in year 
prior to study (2 or 3+), peripheral blood eosinophils (above or below 400 cells/μl), BMI (above 
or below 95th percentile for age) and total serum IgE (above or below 540 kUA/L). A table will 
summarize the observed quality of life measurements, as recorded in the CRF at Visit 14, by 
treatment arm. No imputation of missing data will be used for participants who were not assessed 
for quality of life measurements at Visit 14.   


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8.3.3. 
Endpoint 3 
Variable: Lung function as assessed by spirometry and impulse oscillometry  
Analysis: A generalized mixed model as described in section 8.3.1 will be used to analyze each 
spirometry and impulse oscillometry parameter, separately, at each visit where the lung function 
was collected for the mITT population. It is noted that lung function data was not collected 
during the limited assessment visits during the COVID-19 pandemic and is considered missing 
completely at random. No imputation of missing data will be used in the analysis of lung 
function data.  
 
8.3.4. 
Endpoint 4 
Variable: Time to first asthma exacerbation  
Analysis: Kaplan-Meier curves and a Cox PH model will also be used to model the time to first 
asthma exacerbation during the treatment period. The Cox PH model will include treatment arm 
as the primary exposure but will also adjust for study site, number of exacerbations in year prior 
to study (2 or 3+), peripheral blood eosinophils (above or below 400 cells/μl), BMI (above or 
below 95th percentile for age) and total serum IgE (above or below 540 kUA/L). The analysis 
will be conducted for the mITT population ignoring the COVID-19 intercurrent event  
8.3.5. 
Endpoint 5 
Variable: Rate of exacerbations (mepolizumab vs. placebo) during the treatment period for 
participants in the mITT sample who do not fit the FDA-approved dosing table for omalizumab 
therapy and for participants who do fit the FDA-approved dosing table.   
Analysis: A negative binomial model, as specified in section 8.2.2, will be used to estimate the 
effect of mepolizumab on the rate of exacerbation, as compared to the placebo group, in the 
omalizumab-eligible and omalizumab-ineligible sub-groups. A treatment and a treatment by 
omalizumab-eligibility interaction term will be used to estimate the exacerbation rates.     
8.3.6. 
Endpoint 6 
Variable: Adverse Events 
Analysis: Safety will be summarized treatment arm in the safety sample by the number and 
percentage of serious and non-serious adverse events stratified by grade and relationship to 
treatment as well as the number and percentage of participants who have a serious and non-
serious adverse event stratified by grade and relationship to treatment. See Section 9 for further 
details and definitions. 
8.4. 
Other Endpoints 
8.4.1. 
Exploratory Analysis of the Primary Endpoint 
 


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To test if the effect of mepolizumab on the rate of asthma exacerbations during the treatment 
period is modified by particular sub-groups, separate negative binomial models of the rate of 
asthma exacerbations during the treatment period will be developed to test the two-way 
interaction between treatment arm and: 
• BMI percentile at baseline (continuous or categorical) 
• Peripheral blood eosinophils at baseline (continuous or categorical and log-
transformed, if appropriate)  
• Bronchodilator responsiveness at baseline (continuous or categorical) 
• Number of exacerbations in year prior to study (2, 3 or 4+) 
• Total serum IgE at baseline (continuous or categorical and log-transformed, if 
appropriate) 
• Dose at baseline (40 mg or 100 mg) 
• FeNO (continuous or categorical) at baseline 
 
To test if the effect of mepolizumab on the rate of asthma exacerbations during the treatment 
period is modified by both number of exacerbations in year prior to study as well as peripheral 
blood eosinophils, a separate negative binomial model of the rate of asthma exacerbations during 
the treatment period will be developed to test the three-way interaction between treatment arm, 
peripheral blood eosinophils (treated as either a piecewise linear spline or non-linear spline and 
log-transformed, if appropriate) and number of exacerbations in year prior to study (2, 3 or 4+). 
8.4.2. 
Exploratory Endpoints 
 
Analyses of exploratory endpoints and outcomes will be conducted as described in section 13.4.5 
of the protocol. 
 


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9. 
SAFETY EVALUATION 
 
9.1. 
Overview of Safety Analysis Methods 
The safety analyses will be performed in the safety population defined in Section 5. Safety 
assessment summaries will include: 
• AEs, defined in Protocol Section 12.2.1. 
• Suspected Adverse Reactions (SARs), defined in Protocol Section 12.2.1.1. 
• Unexpected Adverse Event, defined in Protocol Section 12.2.2 
• AEs leading to discontinuation of study drug 
• AEs leading to discontinuation from study 
• Serious adverse events (SAEs), defined in Protocol Section 12.2.3. 
• Deaths 
• Clinical laboratory results 
• Vital signs 
 
Adverse events were collected from the time of consent until a participant completes study 
participation or until 30 days after he/she prematurely withdraws (without withdrawing consent) 
or is withdrawn from the study.  
For this analysis, a treatment-emergent adverse event (TEAE) will be defined as any AE not 
present prior to the initiation of study drug or any AE already present that worsens in either 
intensity or frequency following exposure to study drug. TEAEs will be summarized in the 
safety population. 
 Partial dates will be imputed for the purposes of defining TEAEs as follows: 
• For a missing start day where the month and year are present, the start day will be set to 
the first day of the month, unless: 1) the first day of the month is before the date of 
administration of study drug and the month and year are the same as the month and year 
of the date of administration of study drug; and 2) the end date is on or after the date of 
administration of study drug or the end date is completely missing, in which case the start 
day will be set to the day of administration of study drug.  
• For a missing start day and month where the year is present, the start day and month will 
be set to January 1st, unless: 1) January 1st is before the date of administration of study 
drug and the year is the same as the year of the date of administration of study drug; and 
2) the end date is on or after the date of administration of study drug or the end date is 
completely missing, in which case the start day and month will be set to that of the date 
of administration of study drug.  


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• For a missing end day where the month and year are present, the end day will be set to 
the last day of the month, unless the month and year are the same as the month and year 
of the last contact date for the participant, in which case the end day will be set to that of 
the participant’s last contact date.  
• For a missing end day and month where the year is present, the end day and month will 
be set to the participant’s last contact date, unless the year of the participant’s last contact 
date is greater than the end year, in which case the end day and month will be set to 
December 31st.  
Unless otherwise specified, a data listing for all measurements in Section 9 will be provided for 
the safety population and sorted in order of treatment arm, participant ID, and time of assessment 
(e.g., visit, time, and/or event). 
9.2. 
Adverse Events 
All AEs will be classified by system organ class (SOC) and preferred term, according to a 
standardized thesaurus (Medical Dictionary for Regulatory Activities [MedDRA]). MedDRA 
V20.0 or later will be used to classify all AEs.  
The severity of AEs will be classified, as applicable, using the following criteria and complies 
with ICH Guideline E-6: Guidelines for Good Clinical Practice:  
• Guidance for Industry: Toxicity Grading Scale for Healthy Adult and Adolescent 
Volunteers Enrolled in Preventive Vaccine Clinical Trials (published September 2007) 
for local reactions to study procedures.  
• Grading System of Severity of Anaphylaxis adapted, from the grading scale of Brown et 
al. (3) for anaphylaxis and systemic reactions to study procedures.  
• National Cancer Institute Common Terminology Criteria for Adverse Events Version 4.03 
(published June 14, 2010) for all other reactions. (This document is referred to herein as 
the “NCI-CTCAE manual.”)  
The relationship, or attribution, of an adverse event to the study therapy regimen or study 
procedure(s) will initially be determined by the study clinician and recorded on the appropriate 
AE/SAE eCRF. Final determination of attribution for safety reporting will be determined by 
DAIT NIAID. The relationship of an adverse event to study therapy regimen or procedures will 
be determined using the descriptors and definitions provided in Table 12.3.2 of the protocol. 
Overall summary tables will be developed using the safety population to report the number of 
events and the number and percentage of participants having at least one treatment-emergent 
event in the following categories:  
• AEs  
• AEs by maximum grade for each of the following: 
• Skin Testing 
• Anaphylaxis 


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• Injection Site Reactions 
• CTCAE 
TEAEs classified by treatment arm, MedDRA SOC, and preferred term will be summarized in 
the Safety Population for each of the following categories: 
• AEs 
• AEs by relationship to study drug 
Summary tables will present the total number of events as well as the number and percentage of 
participants experiencing the events. If a participant experiences the same AE on multiple 
occasions, the event will be counted once for each occurrence when reporting the number of 
AEs. When reporting the number of participants experiencing the events, a participant will only 
be counted once if they experience an event within the particular SOC or preferred term. 
Percentages will be based on the number of participants in the safety population. 
Similar summaries will be generated for SARs (defined in Protocol Section 12.2.3), AEs leading 
to discontinuation of study drug, and AEs leading to study withdrawal separately.  
Data listings will be provided separately for AEs, SARs, AEs leading to discontinuation of study 
drug, and cases of COVID-19. 
9.3. 
Deaths, Serious Adverse Events 
SAEs will be listed and summarized in the same manner described in Section 9.2. Separate 
displays listing death, including time to death and primary cause of death, will also be created. 
9.4. 
Clinical Laboratory Evaluation 
Clinical laboratory measurements will be performed at Screening and at various visits throughout 
the study and include a complete blood count with differential (CBC). Results will be converted 
to standardized units where possible. For numeric laboratory results, descriptive statistics of 
laboratory values will be presented for each treatment arm and overall. For categorical laboratory 
results, the number and percentage of participants reporting each result will be presented for each 
treatment arm and overall. A data listing of all laboratory measurements including an indication 
of any abnormal values and clinical significance will be provided. 
9.5. 
Vital Signs and Growth Parameters, Physical Findings, and Targeted 
Pulmonary Exam Results 
9.5.1. 
Vital Signs and Growth Parameters 
Vital sign measurements (including temperature, heart rate, respiratory rate, systolic blood 
pressure, and diastolic blood pressure) and growth parameters will be collected at each clinic 
visit.  
A data listing of all vital sign and growth parameter measurements will be provided. 


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9.5.2. 
Physical Examinations 
A study clinician performed a physical examination at Visit 0. Additional examinations may 
have been completed at the remainder of the visits, but at the study clinician’s discretion. 
Significant findings that met the definition of an adverse event (AE) were recorded on the AE 
form. 
9.5.3. 
Targeted Pulmonary Exam 
Targeted pulmonary exams were conducted at randomization; Asthma Evaluation and 
Management Visits 4, 7, 10, 13; Cold Visits; Exacerbation Follow-up Visits; and at the Final 
Visit. Chest auscultation results, including inspiratory wheeze, retractions, rhonchi, and crackles, 
will be listed by ID and study visit. Evidence of oral candidiasis, any significant findings, and 
participant’s discontinuation from the study will also be reported in the listing.   
 


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10. 
OTHER ANALYSES 
No formal interim analyses of efficacy data were performed for this study. 


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11. 
INTERIM ANALYSES AND DATA MONITORING 
The DSMB received annual periodic safety reports on enrolled and randomized participants. 
However, no formal interim analysis of safety data was conducted. 


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12. 
CHANGES TO THE ANALYSES PLANNED IN THE PROTOCOL 
 


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13. 
REFERENCES 
1. 
Wildfire JJ, Gergen PJ, Sorkness CA, et al. Development and validation of the Composite 
Asthma Severity Index--an outcome measure for use in children and adolescents. J Allergy 
Clin Immunol 2012;129:694-701. 
2. 
Ortega HG, Liu MC, Pavord ID, et al. Mepolizumab Treatment in Patients with Severe 
Eosinophilic Asthma. The New England journal of medicine 2014. 
3. 
Brown SG. Clinical features and severity grading of anaphylaxis. J Allergy Clin Immunol 
2004;114:371-6. 
4. 
Pocock SJ, Simon R. Sequential treatment assignment with balancing for prognostic factors in 
the controlled clinical trial. Biometrics 1975;31:103-15. 


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14. 
APPENDIX 
14.1. 
Study Flow Chart 
14.2. 
Schedule of Events 
 


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Scree-
ning 
Rand
omiz
ation 
 
Treatment Phase (12 months) 
 
Asthma Management 
Week 
0 
4 
8 
12 
16 
20 
24 
28 
32 
36 
40 
44 
48 
52 
56 
PRN 
PRN 
Visit 
V0 
V1 
V2 
V3 
V4 
V5 
V6 
V7 
V8 
V9 
V10 
V11 
V12 
V13 
V14 
Cold+ 
EX# 
Consent/Assent 
+ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
+ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asthma Eval & Mgt 
+ 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
 
 
Asthma Counseling 
+ 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
 
 
Spirometry 
+ 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
+ 
+ 
IOS 
 
+ 
 
 
+ 
 
 
 
 
 
 
 
 
+ 
 
+ 
+ 
Bronchodilator 
reversibility (Spiro & 
IOS) 
 
+ 
 
 
+ 
 
 
 
 
 
 
 
 
+ 
 
 
 
CASI 
+ 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
 
 
ACT/c-ACT 
+ 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
 
 
Physician-patient 
global assessment tool 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+ 
 
 
Physical Exam 
+ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Targeted pulmonary 
exam 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
 
 
+ 
+ 
+ 
+ 
Lungs assessment 
 
 
+ 
+ 
 
+ 
+ 
 
+ 
+ 
 
+ 
+ 
 
 
 
 
FeNO 
 
+ 
 
+ 
 
 
 
+ 
 
 
+ 
 
 
 
+ 
+ 
 
SQ study drug/placebo 
 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
 
 
 
Pregnancy test 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
 
 
Urinary cotinine 
 
+ 
 
+ 
 
 
 
 
 
 
 
 
 
 
+ 
+ 
+ 
Blood collection 
+ 
+ 
 
+ 
 
 
 
 
 
 
+ 
 
 
 
+ 
+ 
+ 
CBC with differential 
+ * 
+ 
 
+ 
 
 
 
 
 
 
+ 
 
 
 
+ 
+ 
+ 
Blood chemistry 
+ 
 
 
+ 
 
 
 
 
 
 
 
 
 
 
+ 
 
 
Serum total IgE & 
specific IgE 
+ 
 
 
 
 
 
 
 
 
 
 
 
 
 
+ 
 
 
Blood markers 
(plasma/RNA/DNA) 
 
+ 
 
+ 
 
 
 
 
 
 
 
 
 
 
+ 
+ 
+ 
Antibodies to drug 
 
+ 
 
+ 
 
 
 
 
 
 
 
 
 
 
+ 
 
 
Skin Testing 
+* 
 
+* 
+* 
+* 
 
 
 
 
 
 
 
 
 
 
 
 


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Nasal lavage 
 
+ 
 
+ 
 
 
 
 
 
 
 
 
 
 
+ 
+ 
+ 
Nasosorption 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+ 
+ 
+ 
Nasal blow 
 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
 
 
Nasal resp virus 
 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
 
 
Nasal ECP 
 
+ 
+ 
+ 
+ 
 
 
+ 
 
 
 
 
 
 
+ 
 
 
Nasal swab collection^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+ 
+ 
Nasal epithelial cell 
collection 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+** 
 
 
Sputum Induction 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
+** 
 
 
Vital signs and growth 
parameters 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
Adverse event 
assessment 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
Concomitant 
medication 
assessment 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+