Study Protocol Outline (Vitamin D and Autism Pilot Study)

Transcription

1 Page 1 of 9 Study Protocol Outline (Vitamin D and Autism Pilot Study) Visit 1 Screening Visit/Pre-Baseline: Informed Consent The PI will perform a brief physical evaluation o Blood pressure, pulse, temperature, height and weight will be measured Clinical interview to establish DSM-IV diagnosis, including the DSM IV Symptom Checklist The following assessments will be administered: IQ Test: The study design includes inclusion criteria requiring subjects to have an overall IQ score above 40. Which IQ test used will depend on the age of the child, as these IQ test are intended for different age ranges, and apparent verbal ability. The following standard measures may be used: o The Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III), or the Wechsler Abbreviated Scale of Intelligence (WASI) may be administered to confirm mental age if not performed within 1 year before study start. - OR - o The Stanford Binet Fifth Edition (SB:V): The SB-V is a standardized measure comprised of ten subtests which provide a full scale IQ score, nonverbal and verbal IQ scores, and five composite scores. Autism Diagnostic Observation Schedule (ADOS-G): Administered to obtain a diagnosis of autism. This assessment may not be administered if already performed within 1 year before study start and PI feels results to be reliable Clinical Global Impression-Severity (CGI-S): Administered to screen out subjects that are not at least moderately affected (below CGI score of 4) and subjects that are categorized as severely affected (CGI score of 7) ZRT (2011 ZRT Laboratory, LLC) Vitamin D Blood Spot Test: Lab analysis of vitamin D: 25-OH Vitamin D 2, 25-OH Vitamin D 3, and Total D, using spot test methods, without blood draw, in order to screen potential subjects to enroll only those with a 25(OH)D serum level below 30 ng/ml. Visit 2 Baseline (Week 1): Blood pressure, pulse, and weight will be measured ZRT Vitamin D Blood Spot Test: o Baseline administration of the ZRT blood spot test for vitamin D will be taken at the time of visit, and caregivers will be instructed on how to conduct the test at home (for before visit 3) and given pre-paid envelopes to mail the kit to ZRT for analysis. Loading dose of 6,000 IU vitamin D 3 will be administered o For ten days, including the initial dose, subjects will be prescribed 6,000 IU a day (3 drops). The following questionnaires will be mailed to the parent prior to the appointment and the parent will be asked to complete them within the 24 hours before the visit: Aberrant Behavior Checklist (ABC): This will be rated by the parent or primary caregiver under guidance of the investigator. Social Responsiveness Scale (SRS): parent rating form to rate the severity of autism spectrum symptoms as they occur in natural social settings. Pervasive Developmental Disorders Behavior Inventory (PDD-BI): a parent rated form consisting of 188 items evaluating the severity of symptoms in the domains of approach/withdraw problems and receptive/expressive social communication abilities in children 1.5 years and older.

2 Page 2 of 9 Children s Communication Checklist (CCC-2): rates various aspects of communication in children who speak in sentences. Sensory Profile: evaluates sensory-related difficulties in children. Social Communication Questionnaire (SCQ): a simple to complete (40 yes-or-no items), commonly used measure to evaluate social and communication functioning in children who may have an ASD. The following assessments will be administered during the office visit: Peabody Picture Vocabulary Test (PPVT): a standardized measure of receptive language for children 2.5 years and older. Expressive Vocabulary Test (EVT): a standardized measure of expressive language for children 2.5 years and older. Clinical Global Impression-Severity (CGI-S): Administered to gain a baseline score. Urine Test: An increase in serum calcium is a late manifestation of vitamin D intoxication. Therefore, as an added safety measure, subject will be asked to provide urine sample to measure for urine calcium to creatinine ratio in spot urine specimens as a better indicator of early Vitamin D excess. Blood Draw: A blood draw will be performed at UCSF facilities and approximately 4 ml of blood plasma will be collected. Laboratory evaluations (at base and final visits) will include a Red Blood Cell Count (RBC), serum 25(OH)D, C Reactive Protein, glutathione, homocysteine, cytokines and total serum calcium levels corrected for serum albumin. There will also be an option for donating an additional blood sample (one tablespoon) for future research. If the parents agree, this blood will be kept at UCSF and may be used in research to learn more about autism (possibly including genomic microarrays and/or genetic testing specific to Vitamin D). 0.5 ml of the blood will be collected for iaa and LC/MS work, and will be frozen and stored at Celsius. Using LC/MS/MS following a Diels Alder derivation to increase sensitivity to determine: 25(OH)D3 its biologically active 1,25(OH)2D3 metabolite other key vitamin D 2 and D 3 metabolites Same sample will be used to determine: key metabolites by immunoassay (to compare to the data from LC/MS analysis) Week 2: On the 11 th day (day 4 of week 2), the subject s dosage will be changed to 300 IU/Kg of vitamin D3 per day, rounded up to the nearest factor of 2,000 IU dosage, but not to exceed 10,000 IU per day. o When ZRT serum 25(OH)D blood spot results are available on-line (approx. 7 business days from lab s receipt of sample), the dose will be changed by phone as follows: 25(OH)D results are > 35 and <90: no change, stay at 300 IU/Kg/day, not to exceed 10,000 IU per day 25(OH)D >90 and <100 ng/ml: reduce dose by 50% rounded down to nearest factor of 2,000 IU 25(OH)D > 100 ng/ml: discontinue vitamin D, administer vitamin D spot test, and when results are available follow the above protocol. If results are still above 100 ng/ml discontinue vitamin D 3 until spot results are available for week 4 visit (caregivers will be provided with additional spot test).

3 Page 3 of 9 o As a safety measure, the caregiver will be interviewed over the phone regarding symptoms of vitamin D toxicity appearing in the pediatric subject 13 days prior to week 4 visit: Research staff member will phone the caregiver of subject to remind them of the date (11 days prior to week 4 visit) to administer the spot test and answer any questions they may have about the procedure o As a safety measure, the caregiver will be interviewed over the phone regarding symptoms of vitamin D toxicity appearing in the pediatric subject Caregivers will administer the blood spot test and mail the results to the ZRT company Week 4 Visit: Blood pressure, pulse, and weight will be measured Subject will be evaluated for symptoms of vitamin D toxicity Urine Test: An increase in serum calcium is a late manifestation of vitamin D intoxication. Therefore, as an added safety measure, subject will be asked to provide urine sample to measure for urine calcium to creatinine ratio in spot urine specimens as a better indicator of early Vitamin D excess. ZRT serum 25(OH)D blood spot results will be available Vitamin D 3 Dose can be titrated during the scheduled visit to UCSF in order to keep the vitamin D level inside the high end of the reference range ( ng/ml). o Dosage change protocol: (No dose to exceed 12,000 IU per day) 25(OH)D <50 ng/ml: increase dose by 50%, rounded up to nearest factor of 2,000 IU 25(OH)D <50 and <90: no change in dose 25(OH)D >90 and <100 ng/ml: reduce dose by 50% rounded down to nearest factor of 2,000 IU 25(OH)D > 100 ng/ml: discontinue vitamin D 3, administer vitamin D spot test, and when results are available follow the above protocol. If results still above 100 ng/ml discontinue vitamin D 3 until spot results available for week 8 visit 13 days prior to week 8 visit: Research staff member will phone the caregiver of subject to remind them of the date (11 days prior to week 8 visit) to administer the spot test and answer any questions they may have about the procedure o As a safety measure, the caregiver will be interviewed over the phone regarding symptoms of vitamin D toxicity appearing in the pediatric subject Caregivers will administer the blood spot test and mail the results to the ZRT company Week 8: Blood pressure, pulse, and weight will be measured Clinical Global Impression-Improvement (CGI-I) will be administered: Completed by the PI. The CGI-I provides an impression of the overall improvement of child s autism symptoms compared with screening visit. Subject will be evaluated for symptoms of vitamin D toxicity Urine Test: An increase in serum calcium is a late manifestation of vitamin D intoxication. Therefore, as an added safety measure, subject will be asked to provide urine sample to measure for urine calcium to creatinine ratio in spot urine specimens as a better indicator of early Vitamin D excess.

4 Page 4 of 9 ZRT serum 25(OH)D blood spot results will be available Vitamin D 3 Dose can be titrated during the scheduled visit to UCSF in order to keep the vitamin D level inside the high end of the reference range ( ng/ml). o Dosage change protocol: (No dose to exceed 14,000 IU per day) 25(OH)D <50 ng/ml: increase dose by 50%, rounded up to nearest factor of 2,000 IU 25(OH)D <50 and <90: no change in dose 25(OH)D >90 and <100 ng/ml: reduce dose by 50% rounded down to nearest factor of 2,000 IU 25(OH)D > 100 ng/ml: discontinue vitamin D 3, administer vitamin D spot test, and when results are available follow the above protocol. If results still above 100 ng/ml discontinue vitamin D 3 supplementation. 10 days prior to week 12 visit: Research staff member will phone the caregiver of subject to remind them of the appointment date of their final visit, week 12. o Caregivers will also be asked to watch for the questionnaires in the mail so they can fill them out within 24 hours of their final appointment. As a safety measure, the caregiver will be interviewed over the phone regarding symptoms of vitamin D toxicity appearing in the pediatric subject Final Visit, Week 12: The following questionnaires will be mailed to the parent and the parent will be asked to complete them within the 24 hours before the visit: o Aberrant Behavior Checklist (ABC) o Social Responsiveness Scale (SRS) o Pervasive Developmental Disorders Behavior Inventory (PDD-BI) Parent form only o Peabody Picture Vocabulary Test (PPVT) o Expressive Vocabulary Test (EVT) o Children s Communication Checklist (CCC-2) o Sensory Profile o Social Communication Questionnaire (SCQ) The following assessments will be administered during the visit: o Peabody Picture Vocabulary Test (PPVT) o Expressive Vocabulary Test (EVT) o Clinical Global Impression-Improvement (CGI-I) o IQ Test: The study design includes inclusion criteria requiring subjects to have an overall IQ score above 40. Which IQ test used will depend on the age of the child, as these IQ test are intended for different age ranges, and apparent verbal ability. The following standard measures may be used: o The Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III), or the Wechsler Abbreviated Scale of Intelligence (WASI) may be administered to confirm mental age if not performed within 1 year before study start. - OR - o The Stanford Binet Fifth Edition (SB:V): The SB-V is a standardized measure comprised of ten subtests which provide a full scale IQ score, nonverbal and verbal IQ scores, and five composite scores.

5 Page 5 of 9 ZRT serum 25(OH)D blood spot will be administered at the UCSF location The PI will perform a physical evaluation o Blood pressure, pulse, height and weight will be measured Urine Test: An increase in serum calcium is a late manifestation of vitamin D intoxication. Therefore, as an added safety measure, subject will be asked to provide urine sample to measure for urine calcium to creatinine ratio in spot urine specimens as a better indicator of early Vitamin D excess. Blood Draw: A blood draw will be performed at UCSF facilities and approximately 4 ml of blood plasma will be collected. Laboratory evaluations (at base and final visits) will include a Red Blood Cell Count (RBC), serum 25(OH)D, C Reactive Protein, glutathione, homocysteine, cytokines and total serum calcium levels corrected for serum albumin. There will also be an option for donating an additional blood sample (one tablespoon) for future research. 0.5 ml of the blood will be collected for iaa and LC/MS work, and will be frozen and stored at Celsius. Using LC/MS/MS following a Diels Alder derivation to increase sensitivity to determine: 25(OH)D3 its biologically active 1,25(OH)2D3 metabolite other key vitamin D 2 and D 3 metabolites Same sample will be used to determine: key metabolites by immunoassay (to compare to the data from LC/MS analysis) Follow-up, (1 Week After Final Visit): The results of the final ZRT blood spot test will be available on-line The caregiver will receive a follow up phone call to discuss the results of the spot test and discuss any concerns or questions regarding the continuation of vitamin D 3 with a practitioner of their choice. The caregiver will be given information on how to obtain vitamin D 3 if they wish to continue supplementation. Caregivers will be instructed on the necessity of regular lab work-ups by a qualified professional to ensure safe blood levels of vitamin D are maintained. If referrals to a physician are needed they will be provided. Parents will be asked whether or not they plan to continue giving the supplement to their child and why or why not.

6 Page 6 of 9 Simplified Vitamin D 3 Dosage Schedule If at anytime 25(OH)D > 100 ng/ml: D 3 will be discontinued and spot test administered, when results are available the protocol outlined for that week will be followed. If results still above 100 ng/ml D 3 will be discontinued until the next scheduled titration. If any subject s 25(OH)D spot test is 150 ng/ml, serum blood analysis will be ordered, including a basic metabolic panel with calcium levels. It is not anticipated that any subject will have levels reaching this concentration. Day ,000 IU per day Day 11 to Week 4 Visit 300 IU/Kg/day, rounded up to the nearest factor of 2,000 IU, not to exceed 10,000 IU per day When baseline serum 25(OH)D spot results are available approx day 10-14: If 25(OH)D > 35 and <90: no change, 300 IU/Kg/day, not to exceed 10,000 IU If 25(OH)D >90 and <100 ng/ml: reduce dose by 50% round down to nearest factor of 2,000 IU Week 4 Visit to Week 8 Visit No dose to exceed 12,000 IU per day: 25(OH)D <50 ng/ml: increase dose by 50%, rounded up to nearest factor of 2,000 IU 25(OH)D <50 and <90: no change in dose 25(OH)D >90 and <100 ng/ml: reduce dose by 50% rounded down to nearest factor of 2,000 IU Week 8 Visit to Week 12 Visit No dose to exceed 14,000 IU per day: 25(OH)D <50 ng/ml: increase dose by 50%, rounded up to nearest factor of 2,000 IU 25(OH)D <50 and <90: no change in dose 25(OH)D >90 and <100 ng/ml: reduce dose by 50% rounded down to nearest factor of 2,000 IU

7 Page 7 of 9 Measures/Questionnaires ALL MEASURES ARE STANDARD o Clinical Global Impression-Severity (CGI-S) o CGI improvement (CGI-I) o IQ Testing, One or More of the Following Measures: o Stanford Binet Fifth Edition (SB:V) o Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III) o Wechsler Abbreviated Scale of Intelligence (WASI) o Autism Diagnostic Observation Schedule (ADOS-G) o DSM-IV symptom checklist o Aberrant Behavior Checklist (ABC) o Social Responsiveness Scale (SRS) o Pervasive Developmental Disorders Behavior Inventory (PDD-BI) Parent form only o Peabody Picture Vocabulary Test (PPVT) o Expressive Vocabulary Test (EVT) o Children s Communication Checklist (CCC-2) o Sensory Profile o Social Communication Questionnaire (SCQ) Urine Test: An increase in serum calcium is a late manifestation of vitamin D intoxication. Therefore, as an added safety measure, subject will be asked to provide urine sample to measure for urine calcium to creatinine ratio in spot urine specimens as a better indicator of early Vitamin D excess. This urine test will be done at baseline, week 4, week 8 and week 12 (final) visit. The subject will be given a urine cup during the visit to UCSF. Blood Work: Blood Draw: A blood draw will be performed at UCSF facilities and approximately 4 ml of blood plasma will be collected. Laboratory evaluations (at base and final visits) will include a Red Blood Cell Count (RBC), serum 25(OH)D, C Reactive Protein, glutathione, homocysteine, cytokines and total serum calcium levels corrected for serum albumin. There will also be an option for donating an additional blood sample (one tablespoon) for future research. 0.5 ml of the blood will be collected for iaa and LC/MS work, and will be frozen and stored at Celsius. Using LC/MS/MS following a Diels Alder derivation to increase sensitivity to determine: 25(OH)D3 its biologically active 1,25(OH)2D3 metabolite other key vitamin D 2 and D 3 metabolites Same sample will be used to determine: key metabolites by immunoassay (to compare to the data from LC/MS analysis) If at any time a subject has a blood spot test 25(OH)D test of 150 ng/ml or above they will be asked to come to UCSF for immediate blood work. The blood work will include a basic metabolic panel, including calcium levels. It is not anticipated that any subject will have blood levels reaching this concentration. We will use UCSF Clinical Laboratory for the calcium reference range defined according to age. The results will be available usually in 1-2 days. The normal range adopted from Beckman Coulter s Pediatric Reference Range Guidelines for Synchron Systems Bulletin 9345 for 1-3 year olds and Tietz Fundamentals of Clinical Chemistry 5 th ed, 2001 for 2-12 year olds showed reference intervals of mg/dl. In the unlikely event that values exceed the upper reference range, we will repeat

8 Page 8 of 9 the serum calcium and if the repeated result is normal, subject will continue in the study. If the repeated result is abnormal, subject will stop the study and receive work up for hypercalcemia. ZRT serum 25(OH)D blood spot: 2011 ZRT Laboratory, LLC liquid chromatography and mass spectrometry (LC, MS and MS), filter paper serum 25(OH)D spot testing Screening visit, baseline visit, and week 12 spot test done at UCSF 2 spot tests done at home, 11 days before week 4 and week 8 visits At baseline appointment caregivers will be instructed on how to conduct the simple, practically painless test. The kit comes with easy step-by-step instruction, skin cleansing wipes, two lancets, band-aid, and filter paper to collect the blood spot Blood spot samples are collected in the morning before eating or drinking Lab analysis of vitamin D: 25-OH Vitamin D 2, 25-OH Vitamin D 3, and Total D, using spot test methods, without blood draw The dry blood sample does not require special handling and can be returned in the prepaid return package Ddrops Product Information: Vitamin D 3 in thin vegetable oil (purified from coconut and palm kernel oil) Wheat-free, gluten-free, soya-free, sugar-free and peanut-free, no harm to animals in production Tasteless, odorless, and without artificial coloring Vitamin D 3 source is lanolin that has been exposed to UV light to activate the vitamin D 3, which is then purified out. Drops dispensed directly from the bottle (by turning the bottle up-side-down) on to a spoon, flat surface, or food, the dropper system provides 2,000 IU per drop of liquid Pre-screening Everyday Study Schedule For Caregivers Day What Happens? Time Estimate Screening Visit Day before starting study treatment Recruitment phone call Your child s eligibility to participate is preliminarily determined Fill out daily sun chart Give your child the vitamin D 3 at the dosage determined by the doctor UCSF appointment to determine your child s eligibility for participation in this study (includes blood draw, interviews, & brief physical exam) Fill out the seven questionnaires that were mailed to you after the screening visit 2 10 min 2 min per day 1 min per day Total: 4.2 hrs hrs 1 2 hrs

9 Page 9 of 9 Week 1 Visit (Baseline) UCSF appointment Your child will begin taking vitamin D 3 once a day [The doctor will tell you how many drops to give your child] Your child will stay at this dosage for days: hrs Week 2 Study staff member will call to adjust the number of vitamin D 3 drops your child will be taking starting day 11 When spot test results come back (around day: 10 to 14) your child s dose may again be changed by phone 11 days prior to week 4 visit: Staff member will call prior to this date to schedule next appointment date and remind you of spot test Give your child the ZRT spot test 10 min Week 4 Visit to UCSF: The doctor will adjust the vitamin D3 dosage based on results of spot test Brief physical exam and clinical interview 1 hr 11 days prior to week 8 visit: Staff member will call prior to this date to schedule next appointment date and remind you of spot test Give your child the ZRT spot test 10 min Week 8 Visit to UCSF: The doctor will adjust the vitamin D3 dosage based on results of spot test Brief physical exam and clinical interview (1 hour) 1 hr 1 day prior to week 12 visit: You will have received reminder call with week 12 visit time, and asked to watch mail for questionnaires Fill out the seven questionnaires that were mailed to you within 1 day of week 12 appointment Final Visit, Week Final UCSF appointment includes blood draw, interviews, and brief physical exam 1 2 hrs 2 3 hrs Follow-Up: 1 week after final visit Receive phone call to discuss final lab results and discuss whether or not you plan to continue supplementation of vitamin D with your child 10 min