Vitamin D3 Treatment in Pediatric Systemic Lupus Erythematosus

Vitamin D3 Effects on Immune Function in Pediatric Systemic Lupus Erythematosus (SLE)

The primary objective of this study is to evaluate the effects of 18 weeks of high-dose vitamin D3 supplementation compared with standard-dose vitamin D3 supplementation on immune function, glucose homeostasis, and bone metabolism in children with systemic lupus erythematosus (SLE) and serum 25-hydroxyvitamin D [25(OH)D] levels ≤20 ng/mL.

Study Overview

• Status: Terminated
• Conditions: Systemic Lupus Erythematosus
• Intervention / Treatment: Drug: Vitamin D3 6000 IU; Drug: Vitamin D3 400 IU

Detailed Description

This is a multi-center, phase II, 18-week, two arm, unblinded randomized clinical trial.

Seventy-eight pediatric subjects with SLE and 25(OH)D levels ≤ 20 ng/mL will be randomized in a 1:1 ratio to receive either standard-dose (400 IU/day) or high-dose (6,000 IU/day) vitamin D3 for 18 weeks based upon weight at baseline. Subjects randomized to the high-dose vitamin D3 treatment arm will receive 6,000 IU per day from baseline until the subject's vitamin D levels reach ≥ 40 ng/mL at which point the vitamin D3 dose will be reduced to 4,000 IU per day. Subjects randomized to the high-dose treatment arm weighing < 40 kg will receive supplementation five days per week and all other subjects will receive supplementation seven days a week.

In addition to the baseline, and weeks 6, 12, and 18 visits, subjects randomized to the high-dose treatment arm will return at Weeks 3 and 9 to assess for symptoms of vitamin D toxicity. If a subject in the high-dose arm is found to exhibit evidence of vitamin D toxicity at the week 12 visit, he/she will be asked to return to their clinical research site for an additional vitamin D toxicity assessment at week 15. Study personnel will record each subject's interval history, assess adverse events, disease activity, and collect samples for safety and mechanistic assessments.

• Study Type: Interventional
• Enrollment (Actual): 7
• Phase: Phase 2

Contacts and Locations

Study Locations

• United States
  • California
    • Los Angeles, California, United States, 90027
      • Children's Hospital Los Angeles
    • Palo Alto, California, United States, 94304
      • Lucile Packard Children's Hospital, Stanford University
    • San Francisco, California, United States, 94143
      • UCSF School of Medicine
  • Illinois
    • Chicago, Illinois, United States, 60611
      • Ann & Robert H. Lurie Children's Hospital of Chicago
    • Chicago, Illinois, United States, 60637
      • University of Chicago
  • Indiana
    • Indianapolis, Indiana, United States, 46202
      • Riley Hospital for Children
  • New York
    • Bronx, New York, United States, 10467
      • Montefiore Medical Center
    • New York, New York, United States, 10032
      • Columbia University
    • Rochester, New York, United States, 14642
      • University of Rochester
  • North Carolina
    • Durham, North Carolina, United States, 27710
      • Duke University Medical Center
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19104
      • The Children's Hospital of Philadelphia
  • Texas
    • Dallas, Texas, United States, 75235
      • Children's Medical Center of Dallas
  • Washington
    • Seattle, Washington, United States, 98101
      • Seattle Children's Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 3 years to 18 years (Child, Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Written informed consent signed by the subject or parent/guardian as appropriate; child assent as appropriate;
• Before the age of 19, met at least 4 of the 11 modified American College of Rheumatology (ACR) 1982 Revised Criteria for the Classification of Systemic Lupus Erythematosus as updated in 1997;
• Date of SLE diagnosis (as described in Inclusion Criterion 2) at least 24 weeks prior to randomization;
• Serum 25-hydroxyvitamin D [25(OH)D] < 20 ng/mL at Screening;
• SELENA SLEDAI score > 0 and < 8 at Screening and at Baseline;
• If taking prednisone (or equivalent corticosteroid), the dose must be ≤ 15 mg/day or ≤0.5 mg/kg/day, whichever is lower, and stable for at least four weeks prior to randomization. Note, if subjects are taking steroids every other day, divide their dose by 2 to evaluate eligibility;

• Stable immunosuppressive dose for at least 12 weeks prior to randomization;

  --Immunosuppressive medications allowed include mycophenolate (MMF), azathioprine, methotrexate, antimalarial medications (e.g., hydroxychloroquine), cyclosporine A (CsA), tacrolimus, intravenous immune globulin (IVIG), and abatacept.

• Body weight > 25 kg;
• Able to swallow pills;
• Males and females with reproductive potential must agree to practice effective measures of birth control.

Exclusion Criteria:

• Any condition or treatment that, in the opinion of the investigator, places the subject at an unacceptable risk as a participant in the trial;
• Current pharmacologic vitamin D2 or D3 intake > 800 IU daily or use of calcitriol at any dose over the past four weeks prior to randomization;
• Cyclophosphamide or IV glucocorticoid exposure within 12 weeks prior to randomization;
• Any BILAG A or B manifestation with the exception of a BILAG B mucocutaneous manifestation at screening, and excluding the renal BILAG criteria (see rituximab or belimumab criterion, below);

• Significant renal insufficiency defined as:

  • Estimated GFR < 60 mL/min/1.73m^2 or estimated GFR < 90 mL/min/1.73m^2 with a reduction of the GFR by > 15% from the last measurement;
  • Urine dipstick value of 2+ or higher for protein, unless this is a stable value from the last measurement or, urine protein-creatinine ratio ≥ 50 mg/mmol unless the value represents an improvement of ≥ 25% from the last measurement.
• Rituximab or belimumab exposure use within 24 weeks prior to randomization;

• The following laboratory parameters at the Screening visit:

  • Platelets < 50,000; WBC < 2,500; ANC < 1,000;
  • Hemoglobin < 9 mg/dL;
  • ALT, AST, bilirubin > 2x upper limit of normal (ULN);
  • Hypercalcemia (calcium > ULN);
  • Hypercalciuria (urinary calcium/creatinine ratio > 0.2).
• Primary hyperparathyroidism (known);
• History of nephrolithiasis (known);
• Diabetes mellitus requiring insulin therapy;
• Medications that interfere with vitamin D absorption;
• History of vertebral compression fractures (known);
• Pregnancy (girls ≥ 11 years of age must have a negative urine/serum pregnancy test);
• A history of non-adherence/non-compliance;
• Other investigational drug and/or treatment during the four weeks or seven half-lives of the other investigational drug prior to the start of study product dosing (Day 0), whichever is the greater length of time to enrollment;
• Current diagnosis of cancer or chronic infection such as Hepatitis B, Hepatitis C, or tuberculosis;
• Treatment with digoxin;
• Flu (influenza) vaccination within one week prior to randomization.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Vitamin D3 6000 IU; 6000 IU of vitamin D3 by mouth daily until the subject's serum 25(OH) level is ≥ 40ng/mL at which point the supplementation dose is reduced to 4,000 IU/day. Note: Subjects weighing <40 kilograms (kg) at study entry will receive their dose five days a week and all other subjects seven days a week.	Drug: Vitamin D3 6000 IU; Subjects will receive 6,000 IU of vitamin D3 by mouth daily until the subject's serum 25(OH) level is ≥ 40ng/mL at which point the supplementation dose will be reduced to 4,000 IU/day. Note: Subjects weighing <40 kilograms (kg) at study entry will receive their dose five days a week and all other subjects seven days a week.; Other Names: high-dose vitamin D; high-dose cholecalciferol (D3); high-dose 25(OH)D
Active Comparator: Vitamin D3 400 IU; 400 IU/day of vitamin D3 by mouth daily.	Drug: Vitamin D3 400 IU; Subjects will receive 400 IU/day of vitamin D3 daily by mouth.; Other Names: standard-dose vitamin D; standard-dose cholecalciferol (D3); standard-dose 25(OH)D

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Average IFN Module Expression Level	No mechanistic analyses were performed due to recruitment feasibility issues.	Baseline to Week 18
Percentage of Subjects by Treatment Arm Experiencing Any Adverse Event (AE) ≥ Grade 3	Adverse event grading based on National Cancer Institute- Common Terminology Criteria for Adverse Events (NCI-CTCAE), Version 4.0	Baseline to 18 Weeks

Collaborators and Investigators

• Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)
• Collaborators: Autoimmunity Centers of Excellence
• Investigators: Study Chair: Jon M Burnham, MD, MSCE, University of Pennsylvania; Study Chair: Emily Von Scheven, MD, MAS, University of California, San Francisco

Publications and helpful links

Helpful Links

• National Institute of Allergy and Infectious Diseases (NIAID)
• Autoimmunity Centers of Excellence (ACE)

Study record dates

Study Major Dates

• Study Start: June 1, 2013
• Primary Completion (Actual): July 1, 2014
• Study Completion (Actual): July 1, 2014

Study Registration Dates

• First Submitted: October 16, 2012
• First Submitted That Met QC Criteria: October 16, 2012
• First Posted (Estimate): October 18, 2012

Study Record Updates

• Last Update Posted (Estimate): December 17, 2015
• Last Update Submitted That Met QC Criteria: December 15, 2015
• Last Verified: December 1, 2015

More Information

Terms related to this study

• Keywords: SLE; Vitamin D3; Vitamin D deficiency; IFN alpha expression
• Additional Relevant MeSH Terms: Immune System Diseases; Autoimmune Diseases; Connective Tissue Diseases; Lupus Erythematosus, Systemic; Physiological Effects of Drugs; Micronutrients; Bone Density Conservation Agents; Calcium-Regulating Hormones and Agents; Vitamin D; Cholecalciferol; Vitamins; Ergocalciferols
• Other Study ID Numbers: DAIT ALE05