bmj...2017/05/18 · confidential: for review only effect of high dose folic acid supplementation...

Confidential: For Review Only

Effect of high dose folic acid supplementation in pregnancy on preeclampsia (FACT): a double-bind, phase III,

randomised controlled, international, multicentre trial

Journal: BMJ

Manuscript ID BMJ.2018.044406.R1

Article Type: Research

BMJ Journal: BMJ

Date Submitted by the Author: 17-May-2018

Complete List of Authors: Wen, Shi; Ottawa Hospital Research Institute, OMNI Research Group, Clinical Epidemiology Program ; University of Ottawa, School of Epidemiology, Public Health and Preventive Medicine & Department of Obstetrics, Gynecology and Newborn Care Rennicks White, Ruth; Ottawa Hospital Research Institute, OMNI Research Group, Clinical Epidemiology Program

Rybak, Natalie; Ottawa Hospital Research Institute, OMNI Research Group, Clinical Epidemiology Program Gaudet, Laura; Ottawa Hospital Research Institute, OMNI Research Group, Clinical Epidemiology Group; University of Ottawa, School of Epidemiology, Public Health and Preventive Medicine & Department of Obstetrics, Gynecology and Newborn Care Robson, Stephen; Newcastle Medical School, Institute of Cellular Medicine, Newcastle University Hague, William; University of Adelaide Robinson Institute, Obstetric Medicine; Women's and Children's Hospital Adelaide Simms-Stewart, Donnette; University of the West Indies, Department of Obstetrics and Gynecology, Faculty of Medical Sciences

Carroli, G; Centro Rosarino de Estudios Perinatales (CREP) Smith, Graeme; Kingston General Hospital, Queens Perinatal Research Unit; Queens University, Department of Obstetrics and Gynecology Fraser, William; Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Mother & Child Axis; Universite de Sherbrooke, Centre de recherche Wells, George; University of Ottawa Heart Institute, Cardiovascular Research Methods Centre; University of Ottawa, Department of Medicine, School of Epidemiology, Public Health and Preventive Medicine Davidge, Sandra; Women and Children's Health Research Institute; University of Alberta, Department of Obstetrics and Gynecology & Department of Physiology

Kingdom, John ; Mount Sinai Hospital , Maternal-Fetal Medicine division, Department of Obstetrics and Gynecology Coyle, Douglas; University of Ottawa, School of Epidemiology, Public

https://mc.manuscriptcentral.com/bmj

BMJ

Confidential: For Review OnlyHealth and Preventive Medicine Fergusson, Dean; Ottawa Hospital Research Institute, Clinical Epidemiology Program ; University of Ottawa, Department of Medicine, School of Epidemiology, Public Health and Preventive Medicine Corsi, Daniel; Ottawa Hospital Research Institute, OMNI Research Group, Clinical Epidemiology Program Champagne, Josee; Ottawa Hospital Research Institute, Clinical Epidemiology Program Sabri , Elham; Ottawa Hospital Research Institute, Clinical Epidemiology

Program Ramsay, Timothy; Ottawa Hospital Research Institute, Clinical Epidemiology Program ; University of Ottawa, Department of Medicine, School of Epidemiology, Public Health and Preventive Medicine Mol, Ben ; Monash University , Department Of Obstetrics and Gynecology; University of Adelaide Robinson Institute, Obstetric Medicine Oudijk, Martijn; Universitair Medisch Centrum Utrecht, Obstetrics & Gynaecology; AMC, Department of Obstetrics Walker, Mark; Ottawa Hospital Research Institute, OMNI Research Group, Clinical Epidemiology Program; University of Ottawa, School of Epidemiology, Public Health and Preventive Medicine & Department of Obstetrics, Gynecology and Newborn Care

Keywords: preeclampsia, folic acid, RCT

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Folic Acid Clinical Trial-OHRI

Version 5.1, 31 January_ 2014 - Confidential - Page 2 of 32

TABLE OF CONTENTS Abbreviations ____________________________________________________________________________ 5 Synopsis _________________________________________________________________________________ 6 1. Introduction_________________________________________________________________________ 8

1.1. Prevalence of PE and Implication of PE on maternal health _____________________________ 8

1.2. Implications of PE on infant health __________________________________________________ 8

1.3. Evidence from Clinical Trials and Epidemiologic Studies _______________________________ 8

1.4. Folic Acid _______________________________________________________________________ 9

2. Summary of Safety __________________________________________________________________ 10 2.1. Existing policies: ________________________________________________________________ 10

2.2. Short term effects: _______________________________________________________________ 10

2.3. Long term effects: _______________________________________________________________ 10

3. Study Rationale _____________________________________________________________________ 11 3.1. Biological rationale why folic acid can reduce the risk of PE ____________________________ 11

3.2. Folic acid may improve early placentation (Stage I) ___________________________________ 11

3.3. Folic acid may improve systemic endothelial function _________________________________ 12

3.4. Folic acid reduces plasma homocysteine _____________________________________________ 12

3.5. Why a high dose of folic acid is needed for women with high risk of developing PE. ________ 12

4. Study Objectives ____________________________________________________________________ 13 4.1. Primary Objective _______________________________________________________________ 13

4.2. Secondary Objectives ____________________________________________________________ 13

5. Trial Design ________________________________________________________________________ 13 5.1. Study Timeline __________________________________________________________________ 13

5.2. Study duration for each subject ____________________________________________________ 13

5.3. Sample Size Determination _______________________________________________________ 13

5.4. Subject Population ______________________________________________________________ 13

5.5. Inclusion Criteria _______________________________________________________________ 14

5.6. Exclusion Criteria _______________________________________________________________ 14

5.7. Randomization _________________________________________________________________ 15

5.8. Blinding Procedures/ Breaking the Blind ____________________________________________ 15

6. Study Intervention __________________________________________________________________ 15 6.1. Administration of Study Treatment ________________________________________________ 15

6.2. Possible Side Effects and/or Risks __________________________________________________ 15

7. Study Treatment Supplies ____________________________________________________________ 16 7.1. Formulation and Packaging _______________________________________________________ 16

7.2. Study Treatment Dispensing ______________________________________________________ 16

7.3. Study Treatment Storage and Study Treatment Accountability _________________________ 16

8. Study Procedures ___________________________________________________________________ 17 8.1. Physical and Medical History _____________________________________________________ 17

8.2. Concomitant Medication _________________________________________________________ 18

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8.3. Compliance ____________________________________________________________________ 18

8.4. Study Visits ____________________________________________________________________ 18

8.5. Screening and Eligibility Assessment _______________________________________________ 18

8.6. Baseline Visit (Visit 1 - Randomization Day) _________________________________________ 19

8.7. Visit 2 (Week 240/7 - 266/7) _________________________________________________________ 19

8.8. Visit 3 (Week 340/7 -366/7) __________________________________________________________ 19

8.9. Visit 4 (After Delivery Visit) _______________________________________________________ 20

8.10. Visit 5 (42±3 days Post Partum telephone interview and chart review) _______________ 20

8.11. Additional Chart Review _____________________________________________________ 20

9. Premature Withdrawal/ Discontinuation Criteria ________________________________________ 20 9.1. Subject’s withdrawal ____________________________________________________________ 20

9.2. Sponsor Discontinuation Criteria __________________________________________________ 20

10. Study Outcomes ____________________________________________________________________ 21 10.1. Primary Outcomes __________________________________________________________ 21

10.2. Secondary outcome measures _________________________________________________ 21

11. Adverse Events _____________________________________________________________________ 22 11.1. Definitions _________________________________________________________________ 22

11.2. Reporting __________________________________________________________________ 22

12. Serious Adverse Events (SAEs) ________________________________________________________ 22 12.1. Definition __________________________________________________________________ 23

12.2. Serious Adverse Event Reporting ______________________________________________ 23

12.3. Notification of SAEs to Health Canada _________________________________________ 24

12.4. Notification of SAEs to IRB/EC _______________________________________________ 24

13. Subject reporting AEs and SAEs ______________________________________________________ 24 14. Severity Assessment _________________________________________________________________ 24 15. Expected/anticipated, Unexpected/Unanticipated _________________________________________ 25 16. Causality Assessment ________________________________________________________________ 25 17. .Data Analysis/Statistical Methods _____________________________________________________ 25

17.1. Populations to be analyzed ___________________________________________________ 25

17.2. Analysis of Primary Outcomes ________________________________________________ 25

17.3. Analysis of Secondary outcomes _______________________________________________ 25

17.4. Safety Analysis _____________________________________________________________ 26

17.5. Interim Analysis ____________________________________________________________ 26

18. Data Monitoring ____________________________________________________________________ 26 18.1. Independent Data Safety Monitoring Board (DSMB) _____________________________ 26

18.2. Quality Control and Quality Assurance _________________________________________ 26

19. Data Handling and Record Keeping ____________________________________________________ 27 19.1. Case Report Forms/electronic Data Record _____________________________________ 27

19.2. Data Management __________________________________________________________ 27

19.3. Record Retention ___________________________________________________________ 27

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20. Ethics _____________________________________________________________________________ 27 20.1. Institutional Review Board (IRB)/Independent Ethics Committee (IEC) _____________ 27

20.2. Revision and/or Amendments to the Protocol ____________________________________ 28

20.3. Ethical Conduct of the Study__________________________________________________ 28

20.4. Reporting of Safety Issues and Serious Breaches of the Protocol or ICH/GCP _________ 28

20.5. Communication of Results by the Sponsor ______________________________________ 28

20.6. Privacy in Research _________________________________________________________ 28

References ______________________________________________________________________________ 29

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Abbreviations

AE Adverse event AR Adverse reaction AST Aspartate Aminotransferase BMI Body Mass Index CI Confidence Interval CRA Clinical Research Associate (Monitor) CRF Case Report Form CT Clinical Trials DM Diabetes Mellitus DNA Deoxyribonucleic acid DSMB Data Safety Monitoring Board EC Ethics Committee (see REC) eNOS Endothelial Nitric Oxide Synthase FACT Folic Acid Clinical Trial FHR Fetal Heart Rate GCP Good Clinical Practice GP General Practitioner HC Health Canada HELLP Hemolysis, Elevated Liver enzyme levels and a Low Platelet count ICF Informed Consent Form ICH International Conference on Harmonisation IEC Independent Ethics Committee IRB Independent Review Board ITT Intent-to-treat Kg/m2 Kilogram Per Meter Squared LDH Lactate Dehydrogenase LMP Last Menstrual Period mg milligram mmHg millimeter of mercury mmol millimole NICU Neonatal Intensive Care Unit NO Nitric oxide O2 Oxygen OHREB Ottawa Hospital Research Ethics Board OHRI Ottawa Hospital Research Institute OR Odds Ratio PE Preeclampsia PO Per os/Per Orem (by mouth) REC Research Ethics Committee RR Relative Risk SAE Serious Adverse Event SAR Serious Adverse Reaction SOGC Society of Obstetricians and Gynaecologists of Canada SOP Standard Operating Procedure TPD Therapeutic Product Directorate TSC Trial Steering Committee

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Synopsis

Study Title Effect of folic acid supplementation in pregnancy on preeclampsia Folic Acid

Clinical Trial (FACT) Internal ref. no. 2009-107 Clinical Phase Phase III Primary Objective The overall aim of this randomized controlled trial is to evaluate a new

preeclampsia (PE) prevention strategy of high dose folic acid supplementation from early (80/7 to 166/7

Secondary Objectives weeks of gestation) pregnancy until delivery.

To evaluate whether or not the effect of folic acid on PE risk differs according to: a) gestational age at intervention (8-13 and 14-16 weeks of gestation), b) smoking, c) age, d) dietary and commercial folic acid consumption at the time of randomization, e) subject compliance (percent of tablets used), and f) Canadian and international centres.

Trial Design This study is a multi-centre, randomized, double-blind, placebo-controlled clinical trial

Settings Subjects will be recruited in Canada and internationally. Trial Subjects Pregnant females (80/7 and 166/7 weeks of gestation) > 18 years of age.

Subjects must fulfill at least one of the following identified risk factors for pre-eclampsia (PE)

x Pre-existing hypertension (documented evidence of diastolic blood pressure ��PP+J��RQ�WZR�VHSDUDWH�RFFDVLRQV�RU�DW�OHDVW��KRXUV�DSDUW�prior to randomization, or use of antihypertensive medication during this pregnancy specifically for the treatment of hypertension prior to randomization,

x Pre-pregnancy diabetes (documented evidence of Type I or Type II DM),

x Twin pregnancy, x History of PE in a previous pregnancy (documented evidence), x BMI > 35 kg/m2 within 3 months prior to this pregnancy and up to

Randomization of this pregnancy (documented evidence of height and weight to calculate BMI is required).

Planned Sample Size With an alpha error of 5%, and a power of 90%, 3,064 women (1,532 in each group) are required to demonstrate a decrease of 30% in the incidence of PE (from 12.0% to 8.4%) in the trial group (4.0 mg of folic acid) as compared with the placebo group. 3,656 high risk pregnant women will be recruited to adjust for non-compliance, withdrawals, loss to follow up, and other unanticipated events.

Intervention Subjects will be randomized to receive folic acid 4.0 mg (1.0mg x 4 tablets) or placebo (4 tablets) administered daily per os.

Planned Treatment Period

From Randomization Day at (80/7 - 166/7weeks of gestation) until delivery.

Primary Outcomes Preeclampsia (PE)

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Secondary Outcomes Secondary outcomes include: x Maternal death, x Severe PE, x Placenta Abruptio x Preterm delivery, x Premature rupture of membranes, x Antenatal inpatient length of stay, x Intrauterine growth restriction, x Spontaneous abortion, x Perinatal mortality: � Stillbirth, � Neonatal death,

x Neonatal morbidity such as: � Retinopathy of prematurity, � Periventricular leukomalacia, � Early onset sepsis, � Necrotising enterocolitis, � Intraventricular haemorrhage, � Ventilation, � Need for O2 at 28 days, � Length of stay in neonatal Intensive Care Unit (NICU).

Investigational Medicinal Products

Folic Acid

Form Tablet

Dose 4.0 mg (1.0mg x 4 tablets) daily

Route Oral

Trial duration Planned 4 year recruitment period

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1. Introduction 1.1. Prevalence of PE and Implication of PE on maternal health PE is hypertension that develops in pregnancy with proteinuria, affecting at least 5% of all pregnancies worldwide (ACOG Practice Bulletin, 2002). Different from non-proteinuric hypertension in pregnancy that is mild with uncertain impact on the health of the affected women and their offspring, PE is a leading cause of maternal and neonatal morbidity and mortality (ACOG Practice Bulletin, 2002, Roberts & Lain, 2002). It accounts for about one-third of maternal deaths, ranking second amongst causes of pregnancy associated deaths in Canada and other industrialized countries (Duley, 1992, Sibai, 1992), with a 3- to 25-fold increased risk of abruptio placentae, thrombocytopenia, disseminated intravascular coagulation, pulmonary edema and aspiration pneumonia (Zhang et al, 2003). Furthermore, women with a history of PE continue to be at risk for future cardiovascular events later in life (Irgens et al, 2001).

1.2. Implications of PE on infant health Since delivery is the only known cure, PE is a leading cause of indicated preterm delivery (Meis et al, 1998). The mean gestation age at delivery varies from 38.3 weeks to 35.3 weeks depending on severity of PE but is earlier than in general population. Perinatal mortality rate is higher than in general population ranging from 2% to 4% respectively in the mild and severe PE groups as compared with 5-6 per 1,000 in the general population (Peek et al, 1995). PE accounts for 25% of very low birth weight infants (Ales et al, 1988) and as many as 60% of these infants suffer from learning disabilities and low IQ (Whitfield et al, 1997). According to our analysis of the provincial perinatal database, the cost to care for extremely low birth weight infants in the first two years of life attributable to PE in Ontario in 2005 alone was estimated to be as high as 19 million dollars Canadian (Liu et al, 2008). PE may also increase the risk of cardiovascular diseases in offspring through ‘fetal origins of adult diseases’ (Barker, 1999, Dekker & Sibai, 1998). PE is the leading medical complication of pregnancy; it has profound health implications to women and infants in both the short and long term and has a significant economical impact on the society. A successful preventative therapy, such as folic acid, would have a significant impact on the disease burden in this population. There is strong evidence based on studies from both animal and human beings, including our own large cohort (Wen et al, 2008) to support the hypothesized protective effect of folic acid on PE.

1.3. Evidence from Clinical Trials and Epidemiologic Studies Merchant et al conducted a randomized trial to evaluate the effect of multivitamin (20 mg thiamine, 20 mg riboflavin, 25 mg B-6, 50 ȝg B-12, 500 mg C, 30 mg E, and 0.8 mg folic acid) and vitamin A supplements (30 mg beta-carotene plus 5000 IU preformed vitamin A) in relation to hypertension in pregnancy (systolic blood pressure � 140 mm Hg or diastolic blood pressure � 90 mm Hg at any time during pregnancy) in 955 HIV-positive pregnant Tanzanian women (Merchant et al, 2005). They found that women who received multivitamins were 38% less likely to develop hypertension during pregnancy than those who received placebo (RR = 0.62, 95% CI 0.40-0.94) while no such effect was found in women who received vitamin A (RR = 1.00, 95% CI 0.66-1.51). The outcome measure in this RCT was very heterogeneous and included all forms of hypertension in pregnancy instead of PE. Because the disease severity, pathophysiology, and pathogenesis of non-proteinuric hypertension in pregnancy are quite different from PE, a mixing of the two may weaken the study findings. The trial intervention included other vitamins not just folic acid, and there was a baseline supplementation of 5 mg folic acid in both trial and placebo arms

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which may have diluted the effect. Despite these limitations, the results of this RCT in HIV-positive patients with folic acid as a co-intervention for gestational hypertension (including PE) were consistent with findings from observational studies, which add to the weight of evidence. Epidemiologic studies found that supplementation with multivitamins containing folic acid was associated with reduced risk of PE. Bodnar et al examined the association between regular use of multivitamins containing folic acid at <16 weeks' gestation and the risk of PE in 1,835 women in Pittsburgh, Pennsylvania between 1997-2001, and found that regular use of multivitamins containing folic acid was associated with a 45% reduction in PE risk compared with nonusers (OR= 0.55, 95% CI 0.32, 0.95) (Bodnar et al, 2006). Using data collected from 2,100 women with nonmalformed infants in a case-control study conducted in the United States and Canada who participated in the Sloan Epidemiology Center Birth Defects Study between 1993 and 2000, Hernandez-Diaz et al observed that the multivariate-adjusted relative risk of developing gestational hypertension during the month after supplementation of multivitamins containing folic acid, compared with not using folic acid during that same month, was 0.55 (95% CI 0.39, 0.79) (Hernandez-Diaz et al, 2002). In our Ottawa and Kingston (OaK) Birth Cohort data, we found that supplementation with �1.0 mg folic acid or multivitamins containing �1.0 mg folic acid in early second trimester was associated with increased serum folate, lowered plasma homocysteine, and reduced the risk of PE by 63% (Wen et al, 2008). Most women in these studies had supplementation of multivitamins containing folic acid. There are three reasons for us to believe that folic acid may have played more important role on PE than other vitamins. First, recent randomized controlled trials found that supplementation with vitamin C and E during pregnancy at doses many times higher than the ones in our study had no protective effect on PE (Poston et al, 2006, Rumbold et al, 2006). Second, in a clinical trial of supplementation of multivitamin containing 0.8 mg folic acid and hypertension in pregnancy in HIV-positive women, a 38% reduction in the rate of gestational hypertension (including PE) in the intervention group as compared to placebo group was observed (Merchant et al, 2005). Third, in sub-group of women who had supplementation of folic acid alone (n=421), we did observe a statistically non-significant trend towards similar protective effect on PE (Wen et al, 2008). In another study, we compared the occurrences of PE between pregnant women exposed to folic acid antagonists and non-exposed women (matched by year of childbirth, type of institute at birth, and mother’s residence (postal code), using the 1980 to 2000 Canadian province of Saskatchewan databases. The risks of PE (adjusted odds ratio (OR) 1.52, 95% confidence interval (95% CI): 1.39, 1.66) and severe PE (OR: 1.77, 95% CI: 1.38, 2.28) were increased in mothers with folic acid antagonists exposure (Wen et al, 2008). Supplementary analyses by tight matching with propensity scores, restricting study subjects to first and second trimester exposure and to specific categories of folic acid antagonists yielded similar results. Folic acid antagonists include a broad spectrum of drugs with a common mechanism of depleting maternal folate. Findings from the effect of maternal exposure to folic acid antagonists on the increased risk of PE add to the weight of evidence that folic acid supplementation may decrease the risk of PE.

1.4. Folic Acid Folic acid (also known as vitamin B9 or folacin) and folate (the naturally occurring form), as well as pteroyl-L-glutamic acid and pteroyl-L-glutamate, are forms of the water-soluble vitamin B9. Folic acid is itself not biologically active with its biological importance being due to tetrahydrofolate and other derivatives after its conversion to dihydrofolic acid in the liver.

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http://en.wikipedia.org/wiki/Tetrahydrofolate




Vitamin B9 (folic acid and folate inclusive) is essential to numerous bodily functions ranging from nucleotide biosynthesis to the remethylation of homocysteine. The human body needs folate to synthesize DNA, repair DNA, and methylate DNA as well as to act as a cofactor in biological reactions involving folate. It is especially important during periods of rapid cell division and growth. Both children and adults require folic acid to produce healthy red blood cells and prevent anemia. Folate and folic acid derive their names from the Latin word folium (which means "leaf"). Leafy vegetables are a principal source, although in Western diets fortified cereals and bread may be a larger dietary source. Vitamin B9 (folic acid) helps prevent birth defects. A lack of dietary folic acid leads to folate deficiency which can result in many health problems, most notably neutral tube defects in embryos. Low folate can also lead to homocysteine accumulation which is a known risk factor of adult vascular disease.

2. Summary of Safety

2.1. Existing policies: It is recommended by the federal government of Canada (Health Canada, 1999) that women with a previous pregnancy complicated by neural tube defects should take a folic acid supplementation of 4.0 mg daily during their first trimester of any subsequent pregnancy. The Society of Obstetricians and Gynaecologists of Canada’s (SOGC) recent recommendation (Wilson et al, 2007) is even more liberal in terms of dosage of 5.0 mg instead of 4.0 mg of folic acid supplementation daily, and their target population includes women with other risk profiles such as: epilepsy, family history, high-risk ethnic group or women without obviously increased risk but with poor compliance to life-style changes for healthy pregnancy for high dose supplementation. The SOGC also suggests the federal agency change policies on food fortification to increase fortification of folic acid from 140 mg/100 g to 300 mg/100g in flour.

2.2. Short term effects: No adverse outcomes were observed in women who took very high doses of folic acid in suicide attempts (Czeizel & Tomcsik, 1999). No short term adverse outcome associated with folic acid supplementation in pregnancy at the recommended dosage has been reported.

2.3. Long term effects: The literature has been controversial on the potential benefits/risks of the effect of folic acid supplementation on cancers, with some studies showing a protective effect while other studies showing a potential causative effect. An interpretation for the inconsistent findings of previous studies of the effects of folic acid supplementation on cancer (both animal experiments and human studies) is that as an essential coenzyme in purine and thymine nucleotide biosynthesis and hence DNA and RNA metabolism, folic acid may promote the growth of precarcinomatous cells but inhibiting cancer cells by promoting the growth of normal cells in subjects with no precursor of cancer (Bonaa et al, 2006, Charles et al, 2004, Cole et al, 2007, Lonn et al, 2006, Larsson et al, 2007, Oakley & Mandel, 2004). Most of these studies examined the long term effects of folic acid. The effect of long term folic acid supplementation for cancer prevention (usually multi-years) may be quite different from the effect of short term folic acid supplementation for PE prevention (usually a few months). Charles et al followed up subjects from a clinical trial of folic acid supplementation in pregnancy and found a non-significant increase in the risk of breast cancer deaths in the two supplementation groups (0.2 and 5.0 mg folic acid/d) as compared with placebo group (Charles et al, 2004). This is a short report with little description of the study population and

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http://en.wikipedia.org/wiki/Children




research methodology. The number of deaths was small, the confidence intervals were wide, and the authors had no pre-specified hypothesis that taking folic acid supplementation in pregnancy would increase the risk of cancer (Charles et al, 2004). In the accompanying commentary, Oakley & Mandel suggested that the most likely explanation for the reported association is chance (Oakley & Mandel, 2004). Contrarily, a number of other studies found that folic acid supplementation was associated with lower risk of breast cancer (Larsson et al, 2007, Oakley & Mandel, 2004). In conclusion to ascertain the feasibility and safety of high dose supplementation of folic acid throughout pregnancy, we conducted an informal survey of 16 high risk obstetricians in Canada. The majority of obstetricians expressed no concern of safety issues related to the trial dosage of folic acid supplementation suggested for this trial and agreed that the study would provide valuable information in the management of PE.

3. Study Rationale

Given the disease burden of PE, novel therapies such as folic acid supplementation need to undergo proper scientific investigation to make a recommendation for the use of folic acid for PE prevention in women with high risk of developing PE. If high dose folic acid is truly beneficial and more conclusive evidence of the benefit is not forthcoming, this treatment may not be offered to women at increased risk of PE, thus denying future generations of women and their offspring this potentially beneficial therapy. On the other hand, if high dose folic acid supplementation is not truly beneficial and more evidence concerning lack of benefit is not forthcoming, practice may gradually change to increase the dose of folic acid supplementation, particularly because there are no other effective therapies to offer.

3.1. Biological rationale why folic acid can reduce the risk of PE One important criterion of judging causation is whether there is a strong biological rationale behind the observed association. There are several biological mechanisms that may explain the effect of folic acid on PE. The current paradigm of the pathophysiology of PE is that it likely is a two-stage disorder: at stage I (most likely at late first trimester or early second trimester), there is a decrease in placental perfusion, which is secondary to abnormal migration of trophoblasts into maternal spiral arteries; and, at stage II (most likely at early third trimester) the maternal syndrome of PE, which is secondary to systemic endothelial dysfunction (e.g., impairments in the nitric oxide system, over-activity of the autonomic nervous and/or renin-angiotensin systems, activation of a systemic inflammatory response, and activation of circulating proteins that interfere with angiogenesis) (Podjarny et al, 2004, Roberts & Sheer, 2004). Supplementation of large doses of folic acid in early gestation may work at both stages of PE development (Figure 1).

3.2. Folic acid may improve early placentation (Stage I) Folic acid or folate is one of the B vitamins. It is a co-enzyme in the production of nucleic acids, and therefore is required by all cells for growth. The placenta develops from a single cell to a complex organ with a weight of about 500 grams during pregnancy. Adequate cellular folate supply, which is essential for DNA and protein synthesis, may play an important role in the implantation and development of the placenta. Folic acid from food intake and routine supplementation may be sufficient during periconception period. A larger dose of folic acid may be needed in early gestation (late first trimester or early second trimester) when the growth and development of the placenta are at their peaks, especially for women with higher risk of developing PE.

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3.3. Folic acid may improve systemic endothelial function Folate may reduce the risk of developing PE by improving systemic endothelial function. Nitric oxide (NO) is an important protective molecule in the vasculature, and endothelial NO synthase (eNOS) is responsible for most of the vascular NO produced. Laboratory investigations found that folic acid can improve eNOS coupling and decrease superoxide and peroxynitrite production (Antoniades et al, 2006). Folic acid deficiency, even just mild deficiency, is proatherosclerotic (Brown et al, 2006). Diabetes is associated with endothelial dysfunction, which in part may be related to uncoupling of the endothelial NO synthase enzyme, thus reducing the availability of NO, and folic acid supplementation normalizes endothelial dysfunction in patients with diabetes (MacKenzie et al, 2006, Title et al, 2006).

Figure 1: Schematic of different proposed mechanisms of action by which folic acid decreases the risk of developing preeclampsia

3.4. Folic acid reduces plasma homocysteine Another possible mechanism of folic acid reducing the risk of developing PE is through its effect of lowering blood homocysteine. Hyperhomocysteinemia is a known risk factor of adult vascular disease (Graham et al, 1997), and there are similarities between systemic vascular dysfunction and placental vascular dysfunction (Ray & Laskin, 1999). Endothelial dysfunction is demonstrable within the myometrial arteries of women with PE, and the incubation of healthy vessels within plasma obtained from women with PE induces similar endothelial changes (Ashworth et al, 1998). Young women with hyperhomocysteinemia may be prone to not only systemic endothelial dysfunction but also placental endovasculature dysfunction (Roberts et al, 1991). Folic acid supplementation can substantially lower blood homocysteine levels in healthy subjects and patients with kidney disease (Bernasconi et al, 2006, Chuang et al, 2006, Olthof et al, 2006).

3.5. Why a high dose of folic acid is needed for women with high risk of developing PE. The preliminary analysis of our OaK Birth Cohort data demonstrated a clear dose-response relationship between folic acid supplementation and PE risk in women with additional identified risk factors. A high dose may be needed for these women because they may have placental, endothelial, and metabolic defects (including those of folate metabolism) leading to increased risk of developing PE.

Folic acid

Endothelial function Homocysteine

Maternal endothelial injury

Preeclampsia

Placental implantation

and development

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4. Study Objectives

4.1. Primary Objective The overall aim is to evaluate a new preeclampsia (PE) prevention strategy: 4.0mg (1.0mg x 4) of folic acid supplementation vs. placebo from early (80/7 to 166/7 weeks of gestation) pregnancy until delivery.

4.2. Secondary Objectives To evaluate whether or not the effect of folic acid on PE risk differs according to: a) gestational age at intervention (8-13 and 14-16 weeks of gestation), b) smoking, c) age, d) dietary and commercial folic acid consumption at the time of randomization, e) subject compliance (percent of tablets used), and f) Canadian and international centers.

5. Trial Design

This study is a randomized, double-blind, placebo-controlled, Phase III, international multi-centre study of 4.0 mg of folic acid supplementation in pregnancy for prevention of preeclampsia in women who are at high risk of developing preeclampsia.

5.1. Study Timeline To complete this trial from start to study close-out of the last participating site will require approximately five (5) years.

5.2. Study duration for each subject From Randomization day at (80/7 to 166/7 weeks of gestation) until the completed postpartum visit (42 ±3 days postpartum).

5.3. Sample Size Determination Two-sided test is assumed in the sample size calculation. Based on literature (Duckitt & Harrington, 2008) and our own cohort study, the best estimation of incidence of PE in the high risk population is 12%. With an alpha error of 5%, and a power of 90%, 3,064 women (1,532 in each group) are required to demonstrate a decrease of 30% in the incidence of PE (from 12.0% to 8.4%) in the trial group (4.0 mg of folic acid) as compared with the placebo group (Lemeshow et al 1990). We will be able to recruit 3,656 high risk women. This will leave sufficient room for non-compliance, withdrawn, loss to follow up, and other unanticipated events. Therefore, the power in our study to detect 30% reduction of PE is 90%. The choice of 30% decrease in PE was based on findings from observational studies; all showed unanimously a 30% or more reduction in PE in the supplementation group, suggesting that a 30% reduction in the trial arm as compared with placebo arm is achievable. Moreover, a 30% reduction would be considered clinically important.

5.4. Subject Population This study can fulfill its objectives only if appropriate subjects are enrolled. The following eligibility criteria are designed to select subjects at high-risk of developing PE. All relevant medical and non-medical conditions should be taken into consideration when deciding whether this protocol is suitable for a particular subject.

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5.5. Inclusion Criteria Subjects must meet all of the following inclusion criteria to be eligible for enrollment into the study: 1. Capability of subject to comprehend and comply with study requirements 2. ��\HDUV�RI�DJH at time of consent 3. Subject is taking ��PJ�RI�IROLF�DFLG�GDLO\�DW�WKH�WLPH�RI�UDQGRPL]DWLRQ 4. Live fetus (documented positive fetal heart prior to randomization) 5. Gestational age between 80/7 and 166/7 weeks of pregnancy (Gestational age of subjects will be calculated based on the first day of the last menstrual period or ultrasound performed before 126/7. If early ultrasound and LMP dates differ by ��GD\V��EDVH�GA estimate on LMP date; if > 7 days, use early <126/7 ultrasound) 6. Subject plans to give birth in a participating hospital site 7. Pregnant subjects must fulfill at least one of the following identified risk factors for

pre-eclampsia (PE): a) Pre-existing hypertension (documented evidence of diastolic blood pressure ��mmHg on two separate occasions or at least 4 hours apart prior to randomization, or use of antihypertensive medication during this pregnancy specifically for the treatment of hypertension prior to randomization) b) Pre-pregnancy diabetes (documented evidence of Type I or Type II DM) c) Twin pregnancy d) Documented evidence of history of PE in a previous pregnancy e) BMI > 35 kg/m2 within 3 months prior to this pregnancy and up to Randomization of this pregnancy (documented evidence of height and weight to calculate BMI is required).

5.6. Exclusion Criteria Any individual meeting any of the following criteria is not eligible for participation in this study. 1. Known history or presence of any clinically significant disease or condition which

would be a contraindication to folic acid supplementation of up to 5.1 mg daily for the duration of pregnancy

2. Known major fetal anomaly or fetal demise 3. History of medical complications, including: a) renal disease with altered renal function, b) epilepsy, c) cancer, or d) use of folic acid antagonists such as valproic acid 4. Individual who is currently enrolled or has participated in another clinical trial or who

received an investigational drug within 3 months of the date of randomization (unless approved by the Trial Coordinating Centre)

5. Known presence of: a) Alcohol abuse (��GULQNV�SHU�GD\��RU�DOFRKRO�GHSHQGHQFH� b) Illicit drug/substance use and/or dependence

6. Known hypersensitivity to folic acid 7. Multiple Pregnancy (triplets or more) 8. Participation in this study in a previous pregnancy

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5.7. Randomization Subjects will be randomized in a 1:1 ratio to folic acid or placebo. A permuted blocked randomization method, stratified by centre, will be used to allocate eligible subjects. The Methods Centre (The Data Coordinating Centre) statistician at the OHRI will generate randomization lists for each centre. The randomization process will consist of computer-generated random lists of treatment allocations in variable permuted blocks of 4 and 6, with a separate list for each centre. A web-based randomization system will be developed to allow participating sites to login in to obtain allocated treatment after confirming eligibility through inclusion and exclusion criteria. Treatment will be blinded and the site’s pharmacy will receive only a number indicating which bottle of pills to dispense.

5.8. Blinding Procedures/ Breaking the Blind This study is a double-blinded study and as such, the subject, clinical site staff including the Site Investigator/Delegate, the Coordinating Investigator and the Trial Coordinating Centre will not be aware of the treatment assignment of each subject. The Data Coordinating Centre will manage the treatment allocation of subjects for the trial. The DSMB will review summary safety data and may request unblinded review of the data. The DSMB Terms of Reference will provide the option for the DSMB to request unblinded review of the data. In the event of an emergency, when knowledge of the study drug is essential for the immediate clinical management or well-being of a specific subject, the Site Investigator may decide to unblind a subject’s treatment assignment. If unblinding occurs, the Site Investigator must record the reason for unblinding, as well as the date and time of the event. Corresponding information will be recorded on the CRF by the Site Investigator and reported to the Coordinating Investigator/Trial Coordinating Centre at the time of unblinding.

6. Study Intervention

Folic Acid 1.0 mg or placebo x 4 tablets will be taken daily by oral administration. The dosage of folic acid is based on the maximum acceptable dose regimens in Canadian centers and data from randomized controlled trials. The majority of women in our study will routinely take 1.0 mg folic acid in a prenatal vitamin supplement as recommended by their primary obstetrical provider, and the study requirements do not require that subjects change their practice. The actual total daily dose may be up to 5.1 mg of folic acid in the trial arm (4.0 mg from Study Treatment and 1.1 mg from routine supplementation), and up to 1.1 mg of folic acid daily in the placebo arm (from routine supplementation).

6.1. Administration of Study Treatment Study Treatment will be self-administered by the subject as specified in study procedures. Four tablets will be taken daily, all at once or can be taken one at a time within a span of no more than 30 minutes. Study Treatment may be taken with or without food.

6.2. Possible Side Effects and/or Risks Folic Acid is relatively nontoxic in humans (Gilman AG, Goodman LS et al. 1990), However, in rare instances it can cause allergic reactions or hypersensitivity including (2008 CPS (Compendium of Pharmaceuticals and Specialties. The Canadian Drug Reference for Health Professionals): x redness of the skin,

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x skin rash, x itching.

7. Study Treatment Supplies

7.1. Formulation and Packaging Treatment arm: each tablet contains the active ingredient 1.0 mg of Folic Acid, and inactive ingredients of Dicalcium phosphate dehydrate, Microcrystalline cellulose, Croscarmellose sodium and Vegetable magnesium stearate. Placebo arm: each tablet contains the inactive ingredients of Dicalcium phosphate dehydrate, Microcrystalline cellulose, Croscarmellose sodium and Vegetable magnesium stearate, Purified Water and FD&C Yellow #5.

7.2. Study Treatment Dispensing Each bottle of Study Treatment will contain 175 demarcated tablets. At each study visit the subject will receive amount of Study Treatment (2-3 bottles) sufficient to take the required daily dose until the next study visit with a window of +7 days. The Study Treatment bottles will be dispensed to the subject with intact seal and lid. The Study Treatment will be labeled with the subject study name, protocol number and ID, drug name (Folic Acid or Placebo), the recommended drug storage conditions dosage, expiry date, lot number, number of tablets, sponsor name and address. There will also be a statement on the label to indicate that the drug is an investigational drug to be used only by a qualified investigator. The subject and study staff will be unable to determine from the dispensed bottle packaging as to which arm of the treatment the subject is assigned. The subject will be provided with written instructions on how to take the Study Treatment.

7.3. Study Treatment Storage and Study Treatment Accountability All Study Treatment supplies for the study must be stored as per manufacturer’s instructions in a cool dry place. The Site Investigator will ensure that all Study Treatment is stored in accordance with all applicable regulatory requirements and Site institutional requirements but no less than as per manufacturer’s instructions and in a secured (locked) area with access restricted only to Site Investigator/Delegate. To ensure adequate records, all Study Treatment supplies will be accounted for in the Study Treatment accountability inventory forms as instructed by the Coordinating Investigator and will be monitored by the accounting of unused Study Treatment returned by the subjects. At the end of the clinical trial, all Study Treatment supplies unallocated or unused by the subjects must be destroyed by the participating site in an approved manner authorized by the Coordinating Investigator and in compliance with all applicable regulatory requirements.

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8. Study Procedures Table 1: The schedule of events for the study

* Screening and Randomization visits can be combined ** Refer to Sections 8.6, 8.7 and 8.8 for specific Physical examination requirements *** Refer to Section 8.2 **** Done only if additional information is needed to complete data collection

8.1. Physical and Medical History x Medical history and physical examination conducted by the primary care provider as

part of standard of care will be obtained from the subject’s medical chart by the Site Investigator/Delegate. The information is transcribed to the appropriate study documents and a photocopy of the document is made and filed in subject’s study binder.

x Site Investigator/Delegate shall perform a physical examination (includes but not limited to fetal wellbeing, blood pressure measurement, urine dipstick test and weight). The collected data is then entered on the appropriate study documents.

Procedures Screening* Randomization* Treatment Period Post partum

42 days post partum phone interview and chart review

Additional Chart Review****

Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Informed consent X X Eligibility Confirmation X X Randomization X Height X Physical examination** X X X Medical history X Demographic information/social history

X

Concomitant*** medications X X X X

Dietary Folate Equivalents Screener X X

Collection of Study Treatment diary and unused Study Treatment

X X X

Study Treatment diary review X X X

Adverse events recording X X X X

Study Treatment dispensing and instructions for use

X X X

Study Treatment diary distribution and instructions for use

X X X

Maternal and Infant(s) information collection

X X X

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8.2. Concomitant Medication All over-the-counter or prescription medication, vitamins, and/or herbal supplements will be recorded on appropriate study documents. For the purposes of this study, the following concomitant medications should not be recorded at delivery:

x Medication for the management of pain during labour and delivery (including epidural and/or spinal and/or general anesthesia)

x Medication for the management of induction and/or augmentation of labour x Medication for postpartum pain management

This exception does not apply in the event of an SAE where documentation of relevant concomitant medication is required. In the event of an SAE, all relevant concomitant medications must be documented on the SAE form.

8.3. Compliance Compliance of the Study Treatment will be monitored by review of the subject Study Treatment diary and by the accounting of unused Study Treatment returned by the subject at Visit 2 (week 240/7 - 266/7), Visit 3 (week 340/7 - 366/7), and Visit 4 (after delivery). Compliance will be documented on the appropriate source documents and CRF. The Site Investigator/Delegate is to counsel the non-compliant subject and ensure steps are taken to improve compliance.

8.4. Study Visits

8.5. Screening and Eligibility Assessment The following procedures will be performed at Screening: x Subject’s eligibility confirmation x Informed consent review and signing Subjects will be screened for eligibility (inclusion and exclusion criteria) between 80/7 and 166/7 weeks of gestation. The Site Investigator/Delegate will discuss with each subject the nature of the study and the study requirements and restrictions. Written informed consent must be obtained from the subject prior to performance of any protocol-specific procedures. The informed consent procedure will consist of an overview of the exact nature of the study, the implications and constraints of the protocol, the known side effects and any risks involved in the subject taking part in the study. It will be clearly stated that the subject is free to withdraw from the study at any time for any reason without prejudice to future care, and with no obligation to give the reason for withdrawal. The subject will be allowed as much time as required to consider the information, and the opportunity to question the Site Investigator/Delegate, their primary care provider or other independent parties (including their spouse, partner or significant other) to decide whether they will participate in the study. Written Informed Consent will be signed and dated by the subject and the Site Investigator/Delegate. A copy of the signed Informed Consent will be given to the subject. The original signed Informed Consent form will be retained at the study site. Subject may be randomized on screening day provided all screening requirements are met.

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8.6. Baseline Visit (Visit 1 - Randomization Day) Procedures that will be performed at (randomization day) Baseline/Day 1, prior to the first study dose include: Physical Examination:

� Confirmation of fetal/embryonic viability* � Blood Pressure Measurement � Height and Weight Measurement � Urine dipstick test

x Demographic information and Social history x Medical and Obstetrical history collection x Recording of Concomitant Medications x Administration of Dietary Folate Equivalents Screener x Randomization and Study Treatment assignment x Study Treatment dispensing x Instruction on Study Treatment regimen x Subject Study Treatment diary dispensing and instructions

*Fetal/embryonic viability must be confirmed by one of the following:

a) Trans-abdominal Ultrasound (TA-US) or trans-vaginal Ultrasound (TV-US) with documentation of cardiac activity, and subject has had no significant vaginal bleeding since the confirmatory TA-US or TV-US.

b) Confirmation of FHR (by Doppler or fetoscope) if the subject is greater than 120/7 weeks of gestation, and subject has had no significant vaginal bleeding since the confirmation of FHR.

8.7. Visit 2 (Week 240/7 - 266/7) Procedures that will be performed include: x Adverse Event monitoring x Physical Examination:

� Confirmation of fetal wellbeing (fetal heart rate or fetal movements) � Blood Pressure Measurement � Weight Measurement � Urine dipstick test

x Recording of Concomitant Medications x Administration of Dietary Folate Equivalents Screener x Review Study Treatment diary x Study Treatment dispensing x Instruction on Study Treatment regimen x Subject Study Treatment diary dispensing and instructions x Collection of Study Treatment bottles and all unused Study Treatment x Study Treatment accountability

8.8. Visit 3 (Week 340/7 -366/7) Procedures that will be performed include: x Adverse Event monitoring x Physical Examination:

� Confirmation of fetal wellbeing (fetal heart rate or fetal movements) � Blood Pressure Measurement

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� Weight Measurement � Urine dipstick test

x Recording of Concomitant Medications x Review Study Treatment diary x Study Treatment dispensing x Instruction on Study Treatment regimen x Subject Study Treatment diary dispensing and instructions x Collection of Study Treatment bottles and all unused Study Treatment x Study Treatment accountability

8.9. Visit 4 (After Delivery Visit) Procedures that will be performed include: x Collection of delivery information, baseline neonatal information from the hospital

records x Adverse Event monitoring x Recording of Concomitant Medications x Review Study Treatment diary x Collection of Study Treatment bottles and all unused Study Treatment x Study Treatment accountability

8.10. Visit 5 (42±3 days Post Partum telephone interview and chart review) x Collection of maternal and perinatal information on study outcomes x Adverse Event monitoring

8.11. Additional Chart Review A final chart review will be conducted if additional information is required to complete the maternal and infant(s) data collection, and/or new information is revealed during the postpartum telephone interview.

9. Premature Withdrawal/ Discontinuation Criteria

9.1. Subject’s withdrawal Reasons for subject withdrawal from study drug are recorded in the source documents and may include, but are not limited to: x Withdrawal of consent, x At request of the Site Investigator/Delegate due to the occurrence of an AE that, in the

opinion of the Site Investigator warrants the subject’s permanent discontinuation from Study Treatment. In the event of discontinuation from Study Treatment due to the occurrence of an AE, the study site should notify the Coordinating Investigator. The site staff should make every attempt to obtain end-of-study information from the subject and/or the subject’s medical records.

9.2. Sponsor Discontinuation Criteria The study maybe terminated prematurely if the DSMB has determined that the incidence or severity of AEs in the study indicates a potential health hazard to subjects or because of a regulatory authority decision. If the study is prematurely terminated or discontinued for safety reasons, the Sponsor/Coordinating Investigator will promptly notify the Site Investigator(s). After

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notification, the Site Investigator must contact all participating subjects and the Site pharmacy (if applicable) within one week from notification. As directed by the Coordinating Investigator, all study materials must be collected and all CRFs completed to the greatest extent possible.

10. Study Outcomes

10.1. Primary Outcomes PE is the primary outcome measure. PE is defined as blood pressure �G�� PP+J� RQ� WZR� RFFDVLRQV� �� KRXUV� DSDUW� DQG�proteinuria developed in women greater than 20 weeks of gestation.

Or HELLP (Haemolysis, Elevated, Liver Enzymes, Low Platelets) syndrome

o Haemolysis (characteristic peripheral blood smear) o Serum LDH ��8�/ o Serum AST ��8�/ o Platelet count <100 x109/L (Audibert A, et al 1996, Saphier C et al. 1998)

Or

Superimposed pre-eclampsia, defined as history of pre-existing hypertension (diagnosed pre-pregnancy or before 20 weeks’ gestation) with new proteinuria.

Proteinuria is defined as:

o urinary protein ��PJ�LQ��KRXU�XULQH�FROOHFWLRQ��25 o in the absence of 24 hour collection, ��GLSVWLFN�SURWHLQXULD��25� o random protein-creatinine ratio ��PJ�SURWHLQ�PPRO��'LDJQRVLV��(YDOXDWLRQ ,

and Management of the Hypertensive Disorders of Pregnancy, JOGC 2008). In order to minimize ascertainment bias in the primary outcome of preeclampsia, an adjudication process will be conducted by an Adjudication Committee of experts who will be masked to study group allocation and will review the recorded maternal complications to confirm inclusion in the primary outcome. Those subjects with insufficient or discordant data that may limit a definitive diagnosis of preeclampsia will require additional data collection at the site to ensure a final diagnosis can be achieved by the committee members.

10.2. Secondary outcome measures Secondary outcomes will include: x Maternal death, x Severe PE (PE with convulsion or HELLP or delivery <34 weeks), x Placenta Abruptio x Preterm delivery, x Premature rupture of membranes, x Antenatal inpatient length of stay, x Intrauterine growth restriction, x Spontaneous abortion, x Perinatal mortality, x Stillbirth

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x Neonatal death Neonatal morbidity such as: x Retinopathy of prematurity, x Periventricular leukomalacia, x Early onset sepsis, x Necrotising enterocolitis, x Intraventricular haemorrhage, x Ventilation, x Need for O2 at 28 days, x Length of stay in Neonatal Intensive Care Unit.

11. Adverse Events

11.1. Definitions Adverse event (AE) An adverse event is any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have to have a causal relationship with this treatment. An adverse event can therefore be any unfavourable and unintended sign (for example, an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal product, whether or not considered related to this medicinal product.

Adverse reaction (AR) In the pre-approval clinical experience with a new medicinal product or its new usages, particularly as the therapeutic dose(s) may not be established: All noxious and unintended responses to a medicinal product related to any dose should be considered adverse drug reactions. The phrase "responses to a medicinal products" means that a causal relationship between a medicinal product and an adverse event is at least a reasonable possibility, i.e., the relationship cannot be ruled out.

11.2. Reporting

The Site Investigator/Delegate is responsible for reporting all AEs that are observed or reported during the study, regardless of their relationship to Study Treatment or their clinical significance. Any AE whose onset occurred between the first administration of Study Treatment and the last completed study visit will be collected. All observed or volunteered AEs will be reported by completing an Adverse Event Form as described in the Procedure Manual. Description, date of onset, end date, severity, Study Treatment causality assessment, and action taken will be recorded in appropriate forms. Follow-up information should be provided as necessary. For the purposes of this study, preeclampsia/HELLP and the associated maternal morbidities, as well as, preterm birth (<370/7 weeks of gestation) and the associated neonatal morbidities, will not be reported as AEs or SAEs. Preeclampsia/HELLP, and preterm birth and the associated morbidities are anticipated in this population and will be captured in the subjects CRF.

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12. Serious Adverse Events (SAEs)

12.1. Definition A serious adverse event or serious adverse drug reaction is any untoward medical occurrence that: x Results in maternal, fetal, or neonatal death*, x Is life-threatening (immediate risk of death), x Requires inpatient hospitalization or prolongation of existing hospitalization,** x Results in persistent or significant disability/incapacity, x Results in congenital anomaly/birth defect***, x Is an important medical event****

NOTE: The term "life-threatening" in the definition of "serious" refers to an event in which the subject was at risk of death at the time of the event; it does not refer to an event which hypothetically might have caused death if it were more severe. * Maternal death defined as death of the mother occurred before 42 days postpartum Miscarriage defined as death of a fetus <500g or <20 weeks of gestation Stillbirth defined as death of a fetus ��J�RU��ZHHNV�RI�JHVWDWLRQ Neonatal death defined as death of the infant occurred before 28 days of life

** For the purposes of this study, “hospitalization” is defined as a hospitalization lasting for a period of 24 hours or more. The following anticipated “hospitalizations” should not be reported as SAEs:

1. Hospitalization for labour that results in birth; 2. Hospitalization and/or prolonged stay in hospital for preeclampsia/HELLP and the

associated maternal morbidities; 3. Preterm birth (<370/7 weeks of gestation) and the associated neonatal morbidities that results in admission to hospital and/or NICU and/or prolonged stay in the hospital and/or NICU

***For the purposes of this study, all congenital anomalies detected at the time of birth will be recorded in the CRF and should not be reported as an SAE. **** Medical and scientific judgment should be exercised in determining whether an

event is an important medical event. An important medical event may not be immediately life threatening and/or result in death or hospitalization. However, if it is determined that the event may jeopardize the subject and/or may require intervention, to prevent one of the other serious adverse event outcomes listed above, the important medical event should be reported as serious.

12.2. Serious Adverse Event Reporting Serious Adverse Events will be reported to the appropriate regulatory authorities in accordance with applicable regulations and requirements.

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If a SAE occurs, the Coordinating Investigator is to be notified by the Site Investigator/Delegate within 24 hours from the time the Site Investigator/Delegate becomes aware of the event by completing a Serious Adverse Event Form as described in the Procedure Manual. This information may be more detailed than that captured on the Adverse Event Form. In general, this will include a description of the SAE in sufficient detail to allow for a complete medical assessment of the case and independent determination of possible causality. Information on other possible causes of the event, such as concomitant medications and illnesses must be provided. For all SAEs, the Site Investigator/Delegate is obligated to pursue and provide information to the Coordinating Investigator in accordance with the timeframes for reporting specified above. In addition, a Site Investigator/Delegate may be requested by the Coordinating Investigator to obtain specific additional follow-up information in an expedited fashion. In the case of a subject death, a summary of available autopsy findings must be submitted as soon as possible to the Coordinating Investigator. If during the follow-up period for a SAE, a subject dies due to another event unrelated to the SAE being followed, the event causing the death will be reported as a separate SAE.

12.3. Notification of SAEs to Health Canada The Coordinating Investigator will be responsible for reporting any serious, unexpected and related adverse events to Health Canada. In the case where the SAE is neither fatal nor life-threatening, it should be reported within 15 days after becoming aware of the information. In the case where the SAE is fatal or life-threatening, it should be reported immediately where possible and, in any event, within 7 days after becoming aware of the information Within 8 days after having informed Health Canada of the SAEs, a complete report which includes an assessment of the importance and implication of any findings should be submitted to Health Canada.

12.4. Notification of SAEs to IRB/EC The Site Investigator/Delegate is responsible for promptly notifying their IRB/EC of SAEs, as per local requirements about any follow-up information, occurring at the Site and any SAE regulatory reports received from the Coordinating Investigator.

13. Subject reporting AEs and SAEs Subjects are to be encouraged to call the site to report any unexpected symptoms or problems they encounter between hospital visits. These events should be considered in the same fashion as if they had been reported at a scheduled hospital visit. At each scheduled hospital visit, after the subject has had an opportunity to spontaneously mention any problems, the Site Investigator/Delegate should inquire about adverse events by asking standard questions such as:

x Have you taken any new prescribed or over the counter medicines or herbal/vitamin preparations, other than those given to you in this study, since your last visit?

x Have you had (other) medical problems since your last visit?

14. Severity Assessment

To assess the severity of an adverse event the Site Investigator will use the following: Mild events require minimal or no treatment and do not interfere with the subject’s daily activities.

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Moderate events result in a low level of inconvenience or concern with the therapeutic measures. Moderate events may cause some interference with functioning. Severe events interrupt a subject’s usual daily activity and may require systemic drug therapy or other treatment. Severe events are usually incapacitating.

15. Expected/anticipated, Unexpected/Unanticipated

For purposes of consistency, these intensity grades are defined as follows: Expected/anticipated: An adverse reaction, the nature or severity of which is consistent with the applicable product information such as the product monograph (summary of product characteristics for an approved product). Unexpected/Unanticipated: An adverse reaction, the nature or severity of which is not consistent with the applicable product information such as the product monograph (summary of product characteristics for an approved product). More Prevalent: Occurs more frequently than anticipated or at a higher prevalence than expected.

16. Causality Assessment The Site Investigator’s assessment of causality must be provided for all adverse events (serious and non-serious) and the Site Investigator must record the causal relationship in the CRF, as appropriate, and report such an assessment in accordance with the serious adverse reporting requirements if applicable. A Site Investigator’s causality assessment is the determination of whether there exists a reasonable possibility that the Study Treatment caused or contributed to an adverse event. If the Site Investigator does not know whether or not the Study Treatment caused the event, then the event will be handled as “related to the Study Treatment” for reporting purposes (see section 13-17 Reporting Requirements). If the causality assessment is "unknown but not related to Study Treatment", this should be clearly documented on study records. In addition, if the Site Investigator/Delegate determines a serious adverse event is associated with study procedures, the Site Investigator/Delegate must record this causal relationship in the source documents and CRF, as appropriate, and report such an assessment in accordance with the serious adverse event reporting requirements, if applicable.

17. .Data Analysis/Statistical Methods

17.1. Populations to be analyzed Intent-to-treat (ITT) Population: ITT Population will consist of all randomized subjects. All subjects will be analyzed in the group to which they were randomized regardless of whether the subject received study drug.

17.2. Analysis of Primary Outcomes Chi-square test will be used in the comparison of incidence of PE between the intervention and placebo groups. Multiple logistic regression analysis will be used (Kleinbaum et al, 1982, Rothman & Greenland, 1998) to adjust for potential confounding by parity (0, ��as the reference), age (<20, 20-34, ��-34 as the reference), cigarette smoking (yes, no, no as the reference), and other important prognostic factors identified at the description stage. Relative risks with 95% confidence intervals will be used.

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17.3. Analysis of Secondary outcomes Chi-square test will be used in the comparison of the occurrences of secondary outcome measures, and t-test will be used in the comparison of means of birth weight and gestational age, between the intervention and placebo groups. Multiple logistic regressions will be used for binary outcomes and multiple linear regression analysis will be used for continuously distributed outcomes to adjust for confounding by parity, age, cigarette smoking, and other important prognostic factors. Again, relative risks with 95% confidence intervals will be used.

17.4. Safety Analysis All the safety data will be summarized descriptively by system-organ class, relationship to the study treatment, severity and seriousness. Adverse events data will be reviewed on an ongoing basis during the study to evaluate the safety of subjects.

17.5. Interim Analysis An interim analysis will be performed when approximately 50% or 1828 subjects have been enrolled and the post partum telephone interview at 42±3 days has been completed, in order to verify the study trial assumptions. Interim stopping level (P-value) is set at 0.001 according to Haybittle-3HWR� UXOH� IRU� RQH� LQWHULP� DQDO\VLV� ZLWK� RYHUDOO� Į �� Peter C O’Brien, Marc A. Shampo 1988).

18. Data Monitoring

18.1. Independent Data Safety Monitoring Board (DSMB) A DSMB will be established with the responsibility of safeguarding the interest of study subjects. The DSMB will review interim safety and efficacy data during the conduct of the study. The interim review is not designed to stop the study early for outstanding efficacy, although efficacy data will be reviewed by the DSMB to evaluate the risk/benefit profile of each treatment arm. The DSMB will review study data for interim analysis after the first 1828 subjects’ data has been received at the Data Coordinating Centre after the completion of the post partum telephone interview. The DSMB shall convene for meetings to evaluate safety based on DSMB Terms of Reference developed and adopted by the TSC. The following data will be reviewed by the DSMB:

1. Subject demographics 2. Adverse events 3. Primary and Secondary Outcomes

Based on the risk/benefit profile of each treatment arm, the DSMB will recommend continuing the study, amending the protocol, or stopping the study due to safety concerns. Further details of DSMB responsibilities, membership, organization, and recommendations by the Sponsor/TSC will be outlined in a DSMB Terms of Reference.

18.2. Quality Control and Quality Assurance During study treatment phase, monitoring visits will be conducted to ensure that the protocol, GCP and applicable regulatory requirements are being followed. The monitors may review source documents to confirm that the data recorded on CRFs is accurate. The Site

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Investigator/Delegate will allow study monitors and appropriate regulatory authorities direct access to source documents to perform this verification. The study Site may also be subject to audit or inspection by appropriate regulatory authorities. It is important that the Site Investigator(s) and their relevant personnel are available during the monitoring visits and possible audits or inspections and that sufficient time is devoted to the process.

19. Data Handling and Record Keeping

19.1. Case Report Forms/electronic Data Record A CRF is required and must be completed for each included subject. An electronic CRF (eCRF) format developed by the Methods Centre (Data Coordinating Centre) at OHRI will be made available to the Site Investigator/Delegates at each Site. A unique account and password will be set up to access the on-line system. Subject data will be entered through a web interface into eCRFs. The data will be entered as per the study protocol and procedural manual. Data validation (range and logic checks for all variables) will be embedded into the eCRF. Data queries will be generated if required. An audit trail will be maintained for all data entry and modification. The on-line system will allow viewing the audit trail for all of the eCRFs for subjects. The Site Investigator has the ultimate responsibility for the accuracy, authenticity, and timely collection and reporting of all clinical, safety, laboratory data entered on the eCRFs and any source documents. Source documentation serves to substantiate the integrity of trial data, confirm observations that are recorded, and confirm the existence of subjects. The source documents includes but is not limited to the hospital’s or the physician's subject chart. Data collected on the eCRFs must match the data in the source documents. In some cases a printed version of the eCRF, or part of the eCRF, may also serve as a source document. The eCRFs must be signed by the Site Investigator to attest that the data contained on the eCRFs is true. Any corrections to entries made in the source documents must be dated, signed and explained (if necessary) and will not obscure the original entry.

19.2. Data Management Data management will be coordinated by the Data Coordinating Centre at the OHRI in close collaboration with the Coordinating Investigator and the Trial Coordinating Centre.

19.3. Record Retention All records and documents pertaining to the study will be retained by the study sites and by the Sponsor according to applicable regulatory agencies/authorities, and will be available for inspection by all applicable regulatory agencies/authorities. The records should be retained by the Site Investigator according to ICH/GCP, local regulations, or as specified in the Clinical Study Agreement, whichever is longer.

20. Ethics

20.1. Institutional Review Board (IRB)/Independent Ethics Committee (IEC) The study will be initiated by the Coordinating Investigator upon the written approval of the OHREB. The OHREB is constituted and operates in accordance with Division 5 of the Food and Drug Regulations, ICH Harmonized Tripartite Guidelines (GCP Consolidated Guideline), and Therapeutic Product Directorate (TPD) Information Sheets: Guidance for IRBs and Clinical Investigators.

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It is the responsibility of the Site Investigator to obtain ethics approval and if applicable, ongoing renewals of the study protocol, protocol amendments, informed consent forms, and all other relevant documents, e.g., recruitment advertisements, if applicable, from their local IRB/IEC. Copies of IRB/IEC approvals must be forwarded to the Coordinating Investigator prior to the study initiation or continuation at the site. The only circumstance in which an amendment may be initiated prior to IRB/IEC approval is where the change is necessary to eliminate apparent immediate hazards to the subjects. In that event, the Site Investigator must notify the local IRB/IEC and the Coordinating Investigator in writing immediately after the implementation.

20.2. Revision and/or Amendments to the Protocol Revisions and/or amendments to the protocol must be documented and approved by the OHREB. If the revision/amendment will affect subject safety and/or study design, then the amendment will be re-submitted to applicable regulatory agencies/authorities for approval. Administrative changes (i.e. change analytical facility) will not be reviewed by the OHREB. A copy of the OHREB’s approval documents will be included in the final report.

20.3. Ethical Conduct of the Study The study will be conducted in accordance with the Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, adopted by the General Assembly of the World Medical Association (2008). In addition, the study will be conducted in accordance with the protocol, the International Conference on Harmonisation guideline on Good Clinical Practice, and applicable local regulatory requirements and laws.

20.4. Reporting of Safety Issues and Serious Breaches of the Protocol or

ICH/GCP If the Site Investigator/Delegate is aware of any new information which might influence the evaluation of the benefits and risks of the Study Treatment, the Coordinating Investigator should be informed immediately. In addition, the Site Investigator/Delegate will inform the Coordinating Investigator immediately of any urgent safety measures taken by the Site Investigator/Delegate to protect the study subjects against any immediate hazard, and of any serious breaches of this protocol or of ICH GCP of which the Site Investigator/Delegate becomes aware of.

20.5. Communication of Results by the Sponsor The Sponsor fulfils its commitment to publicly disclose the results of studies through posting the results of this study on http://www.controlled-trials.com and http://clinicaltrials.gov. The study results synopsis posted on http://www.controlled-trials.com using the format established by the ICH-E3 Clinical Study Report (CSR) Synopsis.

20.6. Privacy in Research Privacy is a fundamental value, perceived by many as essential for the protection and promotion of human dignity (TCPS). Every effort should be made to protect the right of the subject for privacy according to jurisdictional regulations. All personal health information will be treated in a confidential manner and will be subject to all legal and regulatory legislation within the jurisdiction of the research subject regarding the collection, use and disclosure.

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http://www.controlled-trials.com/

http://www.controlled-trials.com/




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1

Effect of high dose folic acid supplementation in pregnancy on preeclampsia (FACT): a

double-bind, phase III, randomised controlled, international, multicentre trial

Authors and Affiliation

Shi Wu Wen1,2,3

,PhD, Ruth Rennicks White1,RN, Natalie Rybak

1, BSc, Laura M Gaudet

1,2,3,

MD, Stephen Robson4, MD, William Hague

5,6,MD, Donnette Simms-Stewart

7, MD, Guillermo

Carroli8, MD, Graeme Smith

9, MD, William D. Fraser

10,11,12, MD, George Wells

2,13,14,19, PhD,

Sandra T. Davidge15,16,17

, MD, John Kingdom18

, MD, Doug Coyle2, PhD, Dean Fergusson

19,20,

PhD, Daniel J Corsi1, PhD, Josee Champagne

19, HBSc, Elham Sabri

19, MSc, Tim Ramsay

19,20,

PhD, Ben Willem J. Mol5,23

, MD, Martijn A Oudijk21,22

, MD, Mark C Walker1,2,3*

, MD, on

behalf of the FACT Collaborating Group and all Participants**

1OMNI Research Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario,

Canada; 2School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario,

Canada; 3Department of Obstetrics, Gynecology & Newborn Care, University of Ottawa, Ottawa, Ontario, Canada; 4Institute of Cellular Medicine, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom;

5Obstetric Medicine, Robinson Research Institute, University of Adelaide, South Australia, Australia; 6Women's and

Children's Hospital, Adelaide, South Australia, Australia; 7Department of Obstetrics and Gynaecology, Faculty of

Medical Sciences, The University of the West Indies, Mona, Kingston, Jamaica; 8Centro Rosarino de Estudios

Perinatales (CREP), Rosario, Santa Fé, Argentina; 9Queen's Perinatal Research Unit, Kingston General Hospital,

Department of Obstetrics and Gynecology, Queens University, Kingston, Ontario, Canada; 10Mother & Child Axis,

Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada; 11Centre de

Recherche, Universite de Sherbrooke, Sherbrooke, Quebec, Canada; 12Department of Obstetrics and Gynecology,

Faculty of Medicine and Health Sciences, Centre de recherche du CHUS, University of Sherbrooke, Sherbrooke,

Quebec, Canada;13Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario,

Canada; 14Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; 15Women and Children's Health

Research Institute, University of Alberta , Edmonton, Alberta, Canada; 16Department of Obstetrics and Gynecology,

University of Alberta, Edmonton, Alberta, Canada; 17Department of Physiology, University of Alberta, Edmonton,

Alberta, Canada; 18Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mount Sinai

Hospital, University of Toronto, Toronto, Ontario, Canada; 19Clinical Epidemiology Program, Ottawa Hospital

Research Institute, Ottawa, Ontario, Canada; 20Departments of Medicine, School of Epidemiology, Public Health

and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada 21Department of Obstetrics, University

Medical Center, Utrecht, Utrecht, the Netherlands; 22Department of Obstetrics, Academic Medical Center,

Amsterdam, the Netherlands, 23Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria,

Australia.

*Correspondence to Dr. Mark Walker, Ottawa Hospital Research Institute, 501 Smyth Rd, Box 241, Ottawa, ON,

K1H 8L6, Tel – 613-737-8899 ext 73232, email: [email protected] (please CC [email protected]) **See Acknowledgements

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ABSTRACT

Objective To determine the efficacy of high dose folic acid supplementation for prevention of

preeclampsia in women with at least one of these risk factors: pre-existing hypertension, pre-

pregnancy diabetes (type I or II), twin pregnancy, preeclampsia in a previous pregnancy, or body

mass index (BMI) > 35 (kg/m2).

Design Randomised, phase III, double-blinded international, multicentre clinical trial.

Setting 70 obstetrical centres in five countries (Argentina, Australia, Canada, Jamaica, UK)

Participants 2464 pregnant women with at least one high risk factor for preeclampsia were

randomised between 2011 and 2015; 2301 were included in the intention to treat analyses, with

1144 assigned to the folic acid group.

Intervention Eligible women were randomised to receive either daily high dose folic acid (four

1.0 mg oral tablets) or placebo from 80/7

- 166/7

weeks’ gestation until delivery. Clinicians,

participants, adjudicators, and all study staff were masked to study treatment allocation.

Main outcome measures The primary outcome was preeclampsia defined as hypertension

presenting after 20 weeks’ gestation with significant proteinuria or HELLP.

Results Preeclampsia occurred in 169 (14.8%) women in the folic acid group and 156 (13.5%) in

the placebo group (relative risk 1.10, 95% confidence interval 0.90 to1.34; P=0.37). No evidence

of differences was found between the groups for any other adverse maternal or neonatal

outcomes.

Conclusion Folic acid supplementation with 4.0 mg/day beyond the first trimester does not

prevent preeclampsia in women at high risk for preeclampsia.

Trial Registration FACT is registered with ISRCTN Registry (#ISRCTN23781770) and

clinicaltrials.gov (#NCT01355159).

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PRINT ABSTRACT

Study question Can high dose folic acid supplementation (4.0mg daily) from early (80/7

to 166/7

weeks of gestation) pregnancy until delivery be used as a prevention strategy for preeclampsia?

Methods A randomised, phase III, double-blinded international, multicentre clinical trial in 70

obstetrical centres in five countries (Argentina, Australia, Canada, Jamaica, UK). A total of 2464

pregnant women with at least one high risk factor for preeclampsia were randomised to either

daily high dose folic acid or placebo from 80/7

- 166/7

weeks’ gestation until delivery. The primary

outcome was preeclampsia defined as hypertension presenting after 20 weeks’ gestation with

significant proteinuria or HELLP.

Study answer and limitations Preeclampsia occurred in 169 (14.8%) women in the folic acid

group and 156 (13.5%) in the placebo group (relative risk 1.10, 95% confidence interval 0.90

to1.34; P=0.37). No evidence of differences was found between the groups for any other adverse

maternal or neonatal outcomes. Some international clinical practice guidelines changed the

definition of preeclampsia during the trial.

What this study adds This trial is the largest international randomized controlled trial

comparing high dose folic acid supplementation to placebo and demonstrates no benefit for

preventing preeclampsia. However, folic acid supplementation remains indicated in

preconception and early pregnancy but there was a need to define when to discontinue

supplementation as current clinical practice guidelines do not provide clear guidance beyond the

first trimester. International guidelines may be adapted because of this trial to further clarify

dosing of folic acid.

Funding, competing interests, data sharing Supported by grants (198801 and 98030) from the

Canadian Institutes of Health Research. All authors have completed the ICMJE disclosure form

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and have no competing interests to declare. The authors of this trial commit to making data

available upon reasonable request.

Study Registration ISRCTN Registry (#ISRCTN23781770) and clinicaltrials.gov

(#NCT01355159).

Summary Boxes

What is already known on this topic:

Evidence from epidemiological and biological studies have demonstrated a clear dose-response

relationship between increasing folic acid supplementation and decreasing PE risk in women

with additional identified risk factors. Until now, a lack of randomised evidence has limited the

development of a comprehensive recommendation for the use of high dose folic acid for

preeclampsia prevention in women with high risk of developing preeclampsia.

What this study adds: This report is based on the largest international randomized controlled

trial comparing high dose folic acid supplementation to placebo. Our study suggests that high

dose folic acid supplementation in later pregnancy has no benefit for preventing preeclampsia.

However, folic acid supplementation remains indicated in preconception and early pregnancy but

there is a need to define when to discontinue supplementation as current clinical practice

guidelines do not provide clear guidance beyond the first trimester. International guidelines may

be adapted because of this trial to further clarify dosing of folic acid.

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INTRODUCTION

Preeclampsia is a serious medical condition, affecting about 3-5% of pregnancies,[1,2]

accounting for more than 35,000 maternal deaths annually worldwide and a significant factor in

maternal morbidity.[1,3,4] A disease impacting multiple organ systems, preeclampsia leads to an

increased risk of severe complications in pregnancy.[5] Since delivery of the placenta is the only

known cure, preeclampsia is a leading cause of indicated preterm delivery,[1,2] perinatal

morbidity, mortality, and long-term disability.[6,7] Epidemiologic studies of the association

between folic acid supplementation and the incidence of preeclampsia have shown a potential

protective effect [cite wen AJOG 2008], though findings have been inconsistent.[8–14] In a

randomised trial of supplementation with a multivitamin containing 0.8 mg folic acid and

hypertension in pregnancy in high risk population of HIV-positive women, a 38% reduction was

observed in the primary composite outcome of gestational hypertension (including

preeclampsia/eclampsia) in the intervention group compared to placebo. [15] Other forms of

folate including 5-methyltetrahydrofolate (5-MTHF) have been investigated with similar results

[16] while folic acid antagonists have shown the opposite effect, increasing the risk of

preeclampsia.[17]

Based on large randomised trials,[18,19] supplementation of folic acid to prevent neural

tube defects has been recommended worldwide during the preconception period and the first

trimester of pregnancy. Doses of 4.0-5.0mg/daily up to 12 weeks’ gestation for women at high

risk of having an affected fetus, and 0.4-1.0mg for women at low risk are recommended. [20–

22] While the neural tube closes in the first trimester, preeclampsia is a two-stage disorder with

the first stage occurring in the late first trimester (after 8 weeks) and second stage occurring in

the third trimester. Supplementation of high doses of folic acid in early gestation may work at

both stages of PE development and a larger dose at in late first trimester/early second trimester

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(between 8-16 week’s gestation) during the peak period of placental growth and development

may be most effective in preventing preeclampsia. Findings from the OaK birth cohort suggested

a 60% reduction in risk of PE and a dose-response association between folic acid and PE risk in

women with identified risk factors.[9,23] A high dose of 4.0 mg folic acid may be needed for

these women because they may have placental, endothelial, and metabolic defects (including

those of folate metabolism) leading to an increased risk of developing PE. Previous studies have

been observational in nature and thus warranted a large randomised controlled trial. The Folic

Acid Clinical Trial (FACT) was designed and conducted to evaluate the effect of 4.0 mg folic

acid daily supplementation beyond the first trimester for the risk of developing preeclampsia

among pregnant women at high risk for this disease.

METHODS

Trial design and study population

FACT was a randomised, double-blinded, placebo-controlled, Phase III, international multi-

centre trial at 70 high risk obstetric referral centers covering diverse populations in Canada,

Argentina, Australia, Jamaica, and United Kingdom (Table S1). Study sponsor was the Ottawa

Hospital Research Institute (OHRI).

Pregnant women between 80/7

and 166/7

weeks gestation with confirmed fetal viability who had at

least one of the following risk factors for preeclampsia: pre-existing hypertension, pre-pregnancy

diabetes (type I or II), twin pregnancy, preeclampsia in a previous pregnancy, or body mass

index (BMI) > 35(kg/m2) were considered for participation in the trial. Documentation of BMI

measured (height and weight) between 3 months prior to pregnancy and up to the time of

randomization was required as part of study eligibility. Women were excluded if they had a

known fetal anomaly or fetal demise, a history of maternal medical complications (including

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renal disease with altered renal function), epilepsy, cancer, or current use of folic acid

antagonists, illicit drug or alcohol abuse (≥ 2 drinks per day) during current pregnancy, known

hypersensitivity to folic acid, higher order multiples, previous participation in this trial, or a

history or presence of any significant disease or condition that would preclude the use of high

dose (up to 5.1mg/daily) folic acid.

Participant recruitment and randomization

The purpose and requirements of the trial were explained to eligible women, and after written

informed consent, participants were randomised to either folic acid or placebo.

Randomization was implemented by the Methods Centre at the OHRI, using a web-based

randomization platform that generated a unique randomization ID. Randomization used variable

permuted blocks of four and six with stratification by center. Study data was entered into the

web-based platform at each site. Study treatment was centrally prepared, pre-labeled with unique

study IDs and provided to each site.

The trial intervention consisted of 4.0 mg of folic acid or placebo, taken as four 1.0mg tablets

once per day, from randomization (80/7

-166/7

weeks) until delivery. Participants could continue

taking prenatal vitamins or low-dose folic acid supplements containing up to 1.1mg of folic acid.

The folic acid and placebo tablets had no taste and identical external appearance, thereby

masking the participants to their treatment group. The Data Coordinating Centre managed

treatment allocation and all participants, site investigators, coordinators and other research staff,

and the Trial Coordinating Centre (TCC) members were blinded to treatment allocation after

randomization. No unmasking occurred during the trial.

Frequency and duration of follow-up

A total of four follow-up visits occurred at 240/7

-266/7

weeks of gestation, 340/7

-366/7

weeks of

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gestation, after delivery, and 42 days postpartum. At the initial study visit information was

collected on demographics and maternal medical history. A physical examination (blood

pressure, weight, urine dipstick, and fetal well-being) and concomitant medications were

documented at study visits. Laboratory values were obtained at delivery, and maternal and

neonatal information was collected from hospital records. Adverse events were assessed and

documented at each visit. Adherence to the study treatment was assessed with the aid of a

medication diary and pill counts. At each visit, participants were asked to return their study

treatment bottles. Compliance was measured as the percentage of pills remaining in the returned

bottles, and the Dietary Folate Equivalent Screener (Block Food Frequency Questionnaire:

http://www.nutritionquest.com) was completed at randomization and at 240/7

-266/7

weeks of

gestation.

Patient Involvement

While patient engagement was not actively sought in the development of this protocol, physician

input was provided via a survey, suggesting that their patient population would be interested in

the trial and sought their advice on best practices to roll out the trial. A Steering Committee of

international content experts with varied expertise provided input in the development of the

protocol, study outcomes and trial procedures. The Committee also examined how to minimize

impact on trial participants, as such trial follow up visits were coordinated with routine antenatal

care visits. Patients were not involved in setting the research question or the outcome measures,

nor were they involved in developing plans for recruitment or implementation of the study.

Patients were not asked to advise on interpretation or writing up of the results. Participants are

acknowledged and thanked for their contribution and participation in this important trial. A

dissemination strategy has been developed to work closely with stakeholders and knowledge

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users to facilitate transfer of the findings to relevant users including patients and clinicians.

Primary outcome

The primary outcome was preeclampsia, defined using the accepted definition at the time the

trial commenced: diastolic blood pressure >90 mmHg on two occasions > 4 hours apart and

proteinuria (> 2+ on dipstick, or urinary protein > 300 mg in 24-hour urine collection, or random

protein-creatinine ratio > 30mg protein/mmol) in women 20 weeks of gestation or greater, or

diagnosis of HELLP syndrome (Haemolysis, Elevated Liver Enzymes, Low Platelets) or

superimposed preeclampsia (history of pre-existing hypertension diagnosed pre-pregnancy or

before 20 weeks gestation with new proteinuria).[2] The primary outcome (the trial protocol

definition of preeclampsia), was adjudicated based on the consensus opinion of three

investigators (MW, LG, SWW). Adjudication was conducted prior to any statistical data

analysis, masked with respect to treatment group, country, and site. Women who experienced a

miscarriage, early intrauterine fetal death (20-24 weeks of gestation) or who withdrew consent

were excluded from the primary outcome analysis.

Secondary outcomes

Prespecified secondary outcomes included maternal death, severe preeclampsia (preeclampsia

with convulsion or HELLP or delivery < 34 completed weeks of gestation), placental abruption,

preterm delivery (< 37 completed weeks of gestation), premature rupture of membranes,

antenatal inpatient length of stay, intrauterine growth restriction (< 3rd centile), perinatal

mortality, spontaneous abortion (miscarriage), stillbirth, neonatal mortality, and neonatal

morbidity: retinopathy of prematurity, periventricular leukomalacia, early onset sepsis,

necrotizing enterocolitis, intraventricular hemorrhage, ventilation, need for O2 at 28 days, length

of stay in Neonatal Intensive Care Unit (NICU).

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Adverse events reporting and safety monitoring

Safety of the trial was monitored by an independent Data Safety and Monitoring Board (DSMB).

All adverse events from randomization through 42 days postpartum were collected and reviewed.

An adverse event was defined as an untoward medical occurrence in a participant that may or

may not have a causal relationship to the study treatment. A serious adverse event was defined as

any untoward medical occurrence that resulted in maternal/fetal/neonatal death, was life

threatening, required or prolonged hospitalization, caused persistent or significant

disability/incapacity/congenital anomaly, or was deemed an important medical event. No safety

issues were detected by DSMB reviews.

Statistical analysis

Based on data from high risk pregnant women,[24] it was originally estimated that a sample of

3656 pregnant women was needed to detect a 30% reduction of preeclampsia from 12.0% to

8.4% (90% power, two-sided type I error 0.05) and to allow for up to 30% non-adherence,

withdrawal, loss to follow-up, or other unanticipated events. However, due to budget limitations,

and because our follow-up rate was better than expected, the sample size was re-calculated to

2464 women which retained study power >80% and still allowed for up to 10% loss to follow-up

and withdrawal rate. In September 2015, the sample size adjustment was approved by the Trial

Steering Committee and the DSMB was notified of the adjustment. . Based on the recruitment

rate at the time of these meetings, total new anticipated recruitment target of 2464 participants

would be achieved by November and as a result no interim analysis of outcomes would be

conducted.

The analysis was carried out on an ‘intention to treat’ basis. Baseline characteristics, compliance,

folic acid intake from other sources, and supplementation of aspirin and/or calcium, between

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intervention and placebo groups were first compared. The outcomes between the intervention

and placebo groups were then compared, using Chi-squared tests for the comparison of incidence

of preeclampsia and categorical secondary outcomes and t-tests for the comparison of means of

continuously distributed secondary outcomes. Multiple log binomial regression was conducted

on the primary outcome to adjust for potential confounding by parity, age, cigarette smoking,

and other important prognostic factors identified a priori. A generalized estimating equation

model was used to account for the correlation between two fetuses or infants from the same

pregnancy in analyses of neonatal outcomes. Treatment effects are expressed as relative risk

(RR) with 95% confidence intervals (CI). No allowance for multiplicity was made for secondary

outcomes. All statistical analyses were performed using Statistical Analysis System, Version 9.1

(SAS Institute Inc., Cary, North Carolina, USA).

RESULTS

Characteristics of the trial participants

Between April 2011 and November 2015, 6499 pregnant women were screened and 2464 of

these women were enrolled into the trial, 1228 of whom were randomised to folic acid and 1236

to placebo. After excluding women who experienced miscarriage (37), early intrauterine fetal

death (20-24 weeks of gestation, n=12), those with no primary outcome data available (28) or

withdrawal of consent prior to outcome ascertainment (85), primary outcome data were available

for 2301 women (93.4%) (1144 in the folic acid group; 1157 in the placebo group) (Figure 1),

representing a follow-up rate of 96.5%. A total of 485 women across both groups discontinued

study treatment but remained in the trial and provided data for primary and secondary outcomes.

The distribution of baseline and pregnancy characteristics was similar between the two groups.

Over 80% of pregnant women in both study groups reported taking supplemental folic acid or

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folic acid containing vitamins. Among the 1941 (78.8%) women who returned study treatment

bottles, 1465 (75.5%) took at least 75% of their pills, confirming a high compliance rate (Table

1). Analyses of blood samples from 50 participants (19 in folic acid group and 31 in placebo) in

Canadian centres indicated that serum folate was substantially higher in the folic acid group

(mean 260.1 Nmol/L vs 77.8, p=0.008) and RBC folate levels were similar (2700 Nmol/L vs

2680, p=0.88).

Among participants who had primary outcome data available (n=2301); 169 (14.8%) were

diagnosed with preeclampsia in the folic acid group versus 156 (13.5%) in the placebo group

(relative risk [RR] 1.10, 95% confidence interval [95%CI]: 0.90 to1.34, P=0.37) (Table 2).

Differences in the rates of HELLP (RR 1.21, 95% CI: 0.37 to 3.96, P=0.75), severe preeclampsia

(RR 1.52, 95% CI: 0.81 to 2.84, P=0.19) (Table 3), and all other maternal outcomes were not

statistically significant (Table 3).

A total of 2738 i3nfants were born to participants recruited into the trial (1364 in the folic acid

group and 1374 in the placebo group). The rate of stillbirth was 1.1% in the folic acid group and

1.9% in the placebo group (RR 0.60, 95% CI: 0.30 to1.19), (Table 4). No statistically significant

differences in the occurrence of adverse neonatal outcomes between the two groups were

observed.

No statistically significant differences were observed in the reported adverse events or severe

adverse events between the two groups (Table S2). There was no effect difference by country

(Table S4).

DISCUSSION

Principal findings

The results of our international randomised controlled multicentre trial did not find evidence that

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supplementation with high dose folic acid (4.0-5.1 mg) initiated between 80/7

and 166/7

weeks of

gestation and continued until delivery prevents preeclampsia in at-risk women. Our randomised

controlled trial is the largest of its kind conducted for high dose folic acid as a prevention

mechanism for the outcome of preeclampsia. Analyses were adjusted for potential confounders

by parity, maternal age, and cigarette smoking and confirmed there was no effect of folic acid for

the prevention of preeclampsia. When the effect of high dose folic acid on risk of preeclampsia

was explored by country, no difference in effect was observed.

Comparison with other studies

Supplementation with folic acid during pregnancy is now exceedingly common in many

areas of the world. In our previous cohort study, of 2951 pregnant women recruited between

2002 and 2005 in Ottawa and Kingston, 2713 (92%) took folic acid supplements during

pregnancy,[9] and of women who supplemented with folic acid, only 544 (20%) discontinued in

third trimester, while 447 (16%) supplemented >2.0 mg/day.[9] Similar patterns were observed

in our trial population with more than 80% of women taking supplemental folic acid.

Supplementation with high dose folic acid (usually 4.0 to5.0 mg) in pregnant women has already

become widespread beyond the first trimester.[9,13,14,25–29] Anecdotal evidence suggests that

high dose folic acid supplementation is occurring outside the recommendations for use only in

early pregnancy for prevention of neural tube defects, even though the most recent Cochrane

review of folic acid in pregnancy for maternal health outcomes was not able to report on

preeclampsia due to lack of data from clinical trials. [30] Caution should always be exercised in

recommending treatments before thorough evaluation has been completed, including follow-up

of the offspring when possible.

Strengths and limitations of study

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FACT has several notable strengths. First, it was designed to be as conclusive as possible

in a rigorous, large, randomised, double-blinded, placebo-controlled, Phase III, international, and

multi-center trial. The conduct adhered to strong research and ethical principles, high data

completeness, and compliance by participants. The follow up rate was greater than 95% and

compliance to the study treatment was greater than 75% in the large majority of the study

population. All steps were taken to ensure the lowest possible risk of bias, although baseline FA

values, compliance and levels during pregnancy in subgroups of high risk factors for PE were not

investigated.

The robust randomised design is a clear advantage of our trial although some limitations

are present. Preeclampsia has a complex heterogenous etiology despite characteristic phenotypic

outcomes.[31] The criteria for the definition of preeclampsia were clearly laid out in the original

trial protocol and used for case adjudication. These criteria have remained consistent with NICE

guidelines for diagnosis of PE, although there have been revisions to the definition of

preeclampsia in other settings including Canada.[32] As a result, using the revised guidelines,

there may be additional women in the study population who would be diagnosed with

preeclampsia, however, due to the randomised design this would be balanced across the

treatment groups and not anticipated to impact the folic acid-PE association regardless of

definition. Finally, power was reduced from 90% to 80%, but because evidence in favor of the

study intervention was not found, even an increase of power would have been unlikely to find a

treatment effect.

Conclusion and policy Implications

Future directions for this research include exploration of the increased risk of

preeclampsia in mothers carrying twins supplementing with high dose folic acid, and the

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potential protective effect of folic acid on perinatal death warrants ongoing study. Perhaps most

importantly, FACT provides a unique opportunity to follow the participants and their offspring to

study the effects of high dose folic acid exposure during prenatal development on long-term

maternal and child health, given the potential epigenetic effects of folic acid. Funding has been

obtained to follow these FACT offspring for mortality and neurocognitive development through

to six years of age.

In summary, our well powered trial did not find benefit for high dose folic acid

supplementation beyond the first trimester for the prevention of preeclampsia or related maternal

and neonatal adverse outcomes. The trial addresses an important public health issue: the lack of

demonstrated benefit of high dose folic acid supplementation beyond the first trimester for

women at high risk of developing preeclampsia indicates that high dose recommendation should

now cease, and the search for an effective and acceptable strategy to prevent preeclampsia must

continue.

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Contributors MCW and SWW designed the trial, planned the analyses, and wrote the

manuscript with assistance from RRW, NR, LMG, SR, WH, DSS, GC, GS, WDF, GW, STD,

JK, DC, DF, DJC, JC, TR, BJM, and MAO. ES with assistance from DJC carried out the

statistical analyses. All authors participated in the review, and critical revisions of the final

manuscript. The corresponding author attests that all listed authors meet authorship criteria and

that no others meeting the criteria have been omitted.

No potential conflict of interest relevant to this article was reported.

Funding: Supported by grants (198801 and 98030) from the Canadian Institutes of Health

Research. FACT was conceived, designed, and coordinated independently of the funding source

(Canadian Institutes of Health Research). The funder did not act as sponsor for the trial and had

no role in analysis, interpretation of the data, writing of the report, or decision to submit for

publication.

Competing interests: All authors have completed the ICMJE uniform disclosure form at

www.icmje.org/coi_disclosure.pdf and declare: no support from any organisations for the

submitted work; no financial relationships with any organisations that might have an interest in

the submitted work in the previous three years; no other relationships or activities that could

appear to have influenced the submitted work.

Data sharing: The authors of this trial commit to making data available upon reasonable

request. Requests for access to data from FACT should be addressed to the corresponding author.

Transparency declaration: The lead author (MW) affirms that this manuscript is an honest,

accurate, and transparent account of the study being reported; that no important aspects of the

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study have been omitted; and that any discrepancies from the study as planned (and, if relevant,

registered) have been explained.

Ethics Approval: FACT was approved by the Ottawa Health Sciences Research Ethics Board

(2009107), and at all participating sites. All applicable regulatory agency approvals were also

obtained.

Acknowledgements

We thank all participants in FACT, the site investigators, research staff at all participating sites

and the Ottawa Hospital Research Institute for their support and hard work. A full list of the

FACT Collaborating Group is available as a Supplemental Appendix.

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29 Hashemi M, Heshmat-Ghahdarijani K, Zarean E, et al. Evaluation of the effect of high-

dose folic acid on endothelial dysfunction in pre-eclamptic patients: A randomized clinical

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30 Lassi ZSZ, Salam RR a, Haider B a, et al. Folic acid supplementation during pregnancy

for maternal health and pregnancy outcomes. Cochrane database Syst Rev

2013;3:CD006896. doi:10.1002/14651858.CD006896.pub2.www.cochranelibrary.com

31 Uzan J, Carbonnel M, Piconne O, et al. Pre-eclampsia: pathophysiology, diagnosis, and

management. Vasc Health Risk Manag 2011;7:467–74. doi:10.2147/VHRM.S20181

32 Tranquilli A, Dekker G, Magee L, et al. The classification, diagnosis and management of

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Figure and Tables

Figure 1 – Trial Flow Diagram

Participants who completed the study and

were analyzed for the primary outcome

N= 1144

Excluded from primary

analysis n=28

• 22 spontaneous abortion

(<20 weeks) (miscarriage)

• 6 Early intrauterine fetal

death (20-24 weeks)

Total screened N= 6499

Not eligible n=1221

• 613 Taking more than 1·1mg of folic

acid

• 146 Delivery elsewhere

• 124 Fetal demise

• 338 Other

Randomised N = 2464

Intervention

Folic Acid 4mg

Placebo

Allocated to receive folic acid 4mg

N = 1228

Study treatment withdrawal

only n= 249

Allocated to receive placebo

N=1236

Study treatment withdrawal

only n= 236

Analyzed for baseline characteristic N=1227

Excluded n=55

• 38 withdrew consent

• 17 no primary outcome data

Excluded n=1


Analyzed for baseline characteristic N=1236

Excluded n=58


• 11 no primary outcome data

Excluded from primary

analysis n=21

• 15 spontaneous abortion

(<20 weeks) (miscarriage)

• 6 Early intrauterine fetal

death (20-24 weeks)

Participants who completed the study and

were analyzed for the primary outcome

N= 1157

Declined to participate n=2598

Loss to follow-up n=216

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Table 1. Comparison of maternal baseline and pregnancy characteristics between the two

arms

Characteristics Folic Acid N = 1227 Placebo N = 1236

Country n n

Canada 600 607

Australia 157 153

Argentina 61 61

Jamaica 29 32

UK 380 383

Inclusion Criteria n n

History of Preeclampsia 308 303

Chronic Hypertension 203 241

Type I diabetes 84 72

Type II diabetes 98 84

Twin Pregnancy 233 229

BMI >35 (kg/m2) 606 656

Parity n n

0 413 420

1 498 499

>=2 316 317

Maternal age (years) n n

<20 10 10

20-29 439 447

30-34 411 441

>= 35 367 338

Mean (SD) 31 (5.4) 31 (5.4)

Maternal Background n n

Native/Aboriginal 35 24

Caucasian 970 987

Black 93 107

Asian 45 50

Latino/Hispanic 31 22

Indian/South Asian 45 36

Declined to answer 8 10

Pre-pregnancy BMI(kg/m2) n n

<18.5 15 11

18.5-<25 230 225

25-<30 210 199

30-<35 164 146

>= 35 607 655

Mean (SD) 34 (8.6) 34 (13)

Education Level n n

High school and below 353 348

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Compliance* n n

<= 50% 108 106

50-<75% 140 122

>= 75% 716 749

*Compliance calculated on returned study treatment (n=1941), remaining participants did not return any study

treatment and compliance could not be calculated (n=523)

*GA=gestational age; FA=folic acid

College/university not complete 198 197

College/university completed 675 689

GA (weeks) at recruitment n n

8-12 386 433

13-16 841 803

Mean (SD) 14 (1.9) 14 (1.9)

Smoking during pregnancy n n

Yes 98 95

No 1046 1035

Quit During Pregnancy 83 106

Alcohol during pregnancy n n

Yes 23 27

No 977 955

Quit During Pregnancy 227 254

Supplementation of FA or multi-

vitamin containing FA at

randomisation

n

n

Yes 989 1016

Supplementation of high dose (>4.0

g/day FA at randomisation (n, %) n n

Yes 346 335

Aspirin supplementation at

randomisation (n, %) n n

Yes 358 340

Calcium supplement at

randomisation (n, %) n n

Yes 97 109

Dietary Folate in ug (Mean, SD)

Visit 1 (80/7

- 166/7)

n=1215 n=1225

494 (209) 504 (222)

Visit 2 (240/7

- 266/7)

n=1008 n=1023

494 (209) 500 (213)

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Table 2. Comparison of primary outcome between the two arms

Folic Acid, N = 1144 Placebo, N = 1157

Dichotomized outcomes

n % n % RR (95% CI) P value

Preeclampsia 169 15 156 13 1.10 (0.90 to 1.34) 0.37

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Table 3. Comparison of maternal outcomes between the two arms

Folic Acid Placebo

Outcomes n % n % RR (95% CI) P value

Maternal Death 0 0 0 0 N/A N/A

Spontaneous abortion

(miscarriage)

n = 1172 n = 1180 1.29 (0.74 to 2.28) 0.37

27 2.3 21 1.8

Placental abruption n = 1169 n = 1179

0.64 (0.31 to 1.31) 0.21 12 1.0 19 1.6

Premature rupture of

membranes

n=1169 n=1180 0.97 (0.82 to 1.15) 0.71

215 18 224 19

n=1150 n=1164

Gestational Age < 37

weeks 297 26 304 26 0.99 (0.86 to 1.13) 0.87

HELLP n=1144 n=1156

1.21 (0.37 to 3.96) 0.75 6 0.52 5 0.43

Severe preeclampsia n=1144 n=1156

1.52 (0.81 to 2.84) 0.19 24 2.10 16 1.4

Folic Acid Placebo

n=221 n=232

Antenatal inpatient

length of stay (days)

Mean SD Mean SD Mean (SD)

difference 95% CI

P

value

5.6 7.7 5.2 6.2 0.34(7.0) (-0.96 to 1.63) 0.61

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Table 4. Comparison of fetal/infant outcomes between the two arms

Folic Acid Placebo

Outcomes n % n % RR (95% CI)* P value*

Dichotomized outcomes

Stillbirth

n=1364 n=1374

15 1.1 26 1.9 0.60 (0.30 to 1.19) 0.14

Intrauterine growth

restriction<3rd percentile

n=1347 n=1348

20 1.4 25 1.9 0.76 (0.41 to 1.39) 0.37

Intrauterine growth restriction

<10th percentile

n=1347 n=1348

151 11.2 144 11 1.03 (0.81 to 1.30) 0.82

Neonatal death n=1343 n=1347

8 0.60 11 0.82 0.87 (0.31 to 2.44) 0.79

Perinatal Mortality n=1364 n=1374

23 1.7 37 2.7 0.63 (0.37 to 1.05) 0.07

Retinopathy of prematurity n=1342 n=1347

21 1.6 13 0.97 1.20 (0.54 to 2.66) 0.65

Periventricular leukomalacia n=1343 n=1347

4 0.30 2 0.15 2.00 (0.37 to 10.92) 0.42

Early onset sepsis n=1342 n=1347

3 0.22 9 0.67 0.34 (0.09 to 1.23) 0.10

Necrotizing enterocolitis n=1343 n=1347

8 0.60 3 0.22 2.04 (0.49 to 8.57) 0.33

Intraventricular hemorrhage n=1343 n=1347

18 1.3 19 1.4 0.97 (0.47 to 2.00) 0.94

Ventilation n=1346 n=1348

49 3.6 30 2.2 1.61 (0.97 to 2.66) 0.06

Need for O2 at 28 days n=1220 n=1227

9 0.74 3 0.2 2.37 (0.61 to 9.14) 0.21

NICU admission n=1346 n=1348

299 22 267 20 1.08 (0.91 to 1.28) 0.37

Composite severe adverse fetal/

neonatal outcome*

n=1349 n=1348

63 4.7 51 3.8 1.20 (0.80 to 1.80) 0.38

Continuously distributed outcomes

Outcomes Mean SD Mean SD Mean difference

(95% CI) * P value*

NICU length of stay n=299 n=263

16 27 17 23 -1.60 (-5.84 to 2.64) 0.46

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* The generalized estimating equations was used to account for the correlation between the two fetuses or infants from the same pregnancy.

Composite outcome included any of retinopathy of prematurity, periventricular leukomacia, early onset sepsis, necrotizing enterocolitis,

intraventricular haemorrhage, ventilation. Need for O2at 28 days, NICU admission

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FACT Collaborating Group - Acknowledgements

In addition to the authors, the following people participated in and contributed to the FACT study: The

Trial Coordinating Centre (TCC): Patti Waddell, Romina Fakhraei, Elisabet White, Adriana Francis,

Melin Peng, Meghan Perkins, Alexandre Simon, Dana Burke, Leslie Webb, Allycia Gagnon, Francois

Tshibemba, Svetlana Shachkina, Students and Trainees; FACT Collaborators: Shoo K. Lee, Mathew

Sermer, Sherry Perkins; DSMB: Dr. Douglas A. Woelkers, Dr. Robin Walker, Dr. Kevin E. Thorpe;

TCC Pharmacy: Anne-Marie Dugal, Susan Fetzer, Wendy Aikens; The Ottawa Hospital—General

Campus and Civic Campus: Dr. George Tawagi, Maureen Rybak, Jenna Rainey, Dr. Jessica Dy,

Dynika St. Omer, Kristina Sabou, Dr. Amanda Black; London Health Sciences Centre – Victoria

Hospital: Robert J. Gratton, Laura McMurphy, Jennifer Ryder; Kingston General Hospital &Queen’s

University at Kingston: M. Roddy; The Moncton Hospital: Lynn Murphy-Kaulbeck, Claire Williams,

Stephanie Gillespie, Ruth Macdonald; The University of Manitoba: Shayne P. Taback, S. Menticoglou,

Carol Schneider, Jennifer C. Hunt, Gregory Reid, Lucy Chura, Laura Soice, Jennifer Swan, Daniel Catte,

Krista Rossum, Jaymie Walker, Raj Maharaj, Silvana Fux, Erika Bloomfield; St. Boniface General

Hospital: Michael E. Helewa, Jennifer C. Hunt, Craig Burym, Janis Harms, Jamie Greco; Children’s &

Women’s Health Centre of British Columbia: Julie E. Robertson, Anna Hutfield, Laura A. Magee,

Chantal Mayer, Ariadna Fernandez, Judy Needham; Foothills Medical Centre: Stephan Wood, Leslie

Miller, Greta Ellsworth, Jennifer Mercer; Hôpital Saint-Luc, CHUM : Marie-Josee Bedard, Bilan Wo,

Andre Masse, Marie-Danielle Dionne, Sylvie Daigle; Health Sciences Centre – General Hospital,

Newfoundland: Joan M.G. Crane, Donna Hutchens; Regina General Hospital: George Carson, Suzanne

Williams, Sheila Kelly; Lois Hole Hospital: Sue Chandra, Cheryl Lux, Venu Jain, Radha Chari, Nestor

Demianczuk; Centre Hospitalier Universitaire Sainte-Justine: Francois Audibert, Hasna Medour;

Royal Victoria Hospital: Robert Gagnon, Jennifer Snyder, Monique Guigère, Kathleen Raiche, Ourida

Anki; Centre Hospitalier Universitaire de Québec: Emmanuel Bujold, Valerie Morin, Katy Gouin,

Francois Rousseau, Sylvie Tapp, Amélie Tétu, Josee Mailhot, Francine Dufour, Elisabeth Clouet, Mario

Girard, Lucie Dallaire, Eric Proulx, Lorraine Beliveau, Karine Desharmais, Michele Dubeau, Denise St-

Pierre; Sunnybrook Research Institute—Sunnybrook Health Sciences Centre: Howard Cohen, Jon

Barrett, Julie Lowe, Anna Rogowsky, Afsheen Ayaz; McMaster University Medical Centre: Bryon F.

De France, Suzanne Hamilton, Barbara Brennan; The Dr. Everett Chalmers Regional Hospital: Dr.

Kimberly Butt, Dr. Erin Holloway, Lynda Nicoll BNRN; St-Mary's Hospital: Dr. Isabelle Girard, Siham

Aboulfadl, Alexandra Dumont, Julia Rodrigues, Dr. Sonia Macfarlane MDCM, FRCSC; Saint John

Regional Hospital: James Andrews, Patricia Shea, Mary C. Fraser; Sault Area Hospital: Maxine

Lingurar, Natalie Kovacevich, Carrie Seguin; St-Paul's Hospital: Valerie Rychel, Nicole A. Koenig;

Fairfield General Hospital, North Manchester General Hospital, The Royal Oldham Hospital &

Rochdale Infirmary: Mr Sachchidananda Maiti, Rachel Newport, Zainab Sarwar Yasin, Grainne

O'Connor, Mfon Sam, Uchenna Elenwa; Newcastle Upon Tyne Hospital: Nicola Goudie, Alison

Kimber, Jill Riches, Carly Allan; Sunderland Royal Hospital: Aarti Ullal, Kim Hinshaw, Hm Cameron,

A.O Ahmed, CM Emmerson, Eileen Walton, Lesley Hewitt, Gilli Campbell, Deb Bonney, Kath Hubbard,

Kathryn Wittee; Wansbeck General Hospital & North Tyneside General Hospital: Vinita Raheja, Joy

Strachtan, Sarah Cass, Helen Howlett, Siobhan Limerick; South Tyneside District Hospital: Umo Esen,

Judith Ormonde; Gateshead Queen Elizabeth Hospital: Dr. Helene Brandon FRCOG, Christine Moller-

Christensen, Barbara Lynam; James Cook University Hospital: Dr. Deepika Meneni, Hazel Alexander;

Guy’s & St Thomas’ Hospital: Andrew Shennan, Annette Briley, Jo Birtwhistle, Jenie Fetherston,

Eleanor Hendy, Natasha Hezelgrave, Ruth Leary, Catherine Nelson-Piercy, Hayley Traft, Louise

Webster, Hannah Wilson; West Middlesex University Hospital: Joanna Girling, Marie O'Connell,

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FACT Collaborating Group - Acknowledgements

Christine Adamson, Abdul Sattar Abbasi; St George's Hospital: Asma Khalil, Sarah Davies; University

Hospital of North Tees: Iona Macleod, Sharon Gowans, Anne-Marie Jones; 49 Marine Avenue

Surgery: Justine Norman, Siobhan Limerick; University Hospital of North Durham & Darlington

Memorial Hospital: Dr. Seema Sen, Eileen Walton, Jean Dent, Vicki Atkinson, Jacqui Jennings; North

Cumbria University Hospital: Dr. Andrene Hamilton, Mr Ajith Wijesiriwardana, Dr. Leon Jonker,

Rachel McCarthy, Toni Wilson, Bev McGuirk, Chris Brewer; The Hillingdon Hospital: Shruti Mohan,

Laura Pearse; Nottingham City Hospital: Nia Jones, Catriona Hussain, Carys Smith, Gill Kirkwood,

Yvette Davis, Yvette Gunn; Hinchingbrooke Hospital: Dr. Sangeeta Pathak MRCOG MD, Mrs. Tara

Pauley BSc(Hons) BA (Hons), Pamela Oracki Research Nurse; New Cross Hospital: David Churchill,

Kate Cheshire, Julia Icke, Laura Gardiner; Warrington Hospital: Dr. Rita Arya, Lindsay Roughley,

Rachel Crone; Leighton Hospital: Karen McIntyre, Caroline Dixon, Janet Brown; Burnley General

Hospital: Justine Nugent, Bev Hammond; Lincoln County Hospital: Sunday Ikhena, Sally-Ann

Molshter; Norfolk & Norwich: Martin Cameron, Rachel Appleton, Elizabeth Turner; The Royal

Women's Hospital: Andrea Khaw, Dianna Maxwell, Megan Poth; The Townsville Hospital: Dr. David

Watson, Annemarie Lawrence, Cherie Boniface, Audra Davis; Ipswich Hospital: Kassam Mahomed,

Jane Hoare, Ann Green, Alison Drew; The Women’s and Children’s Hospital: S Coat, BW Mol, EA

Clark, MR Morton, H Grigg, KL Miller; Nepean Hospital: Sue Downward, Peta Armstrong, Tracey

Codner, Sarah Johnson-Clark, Diane Hansen, Emily Masson, Michael John Peek; Sunshine Hospital:

Joanne M Said, Lee-Anne Lynch, Jennifer Edwards, Glyn R Teale; Spanish Town Hospital, The

University of West Indies—Mona Campus & Victoria Jubilee Hospital: Carol Jones Cooper, Orville

P. Morgan, Alexander Onyonyor, Sharon White, Faithlee Welsh, Olubunmi Asunmo, Delmore Tyrell,

Robert Marston, Jeunette Small, Paul A. Mitchell, Natassia Tate; Hospital Escuela Eva Perón: Miguel

Angel Paciocco, Sandra Formula, Julia Pasquale, Schwank Sofia, Soso, German A.; CEMIC: Gustavo

Leguizamón, Veronica Ramill, Denise Trigubo; Maternidad Martin: Daniel Natalio Crosta, Maria

Fernanda Troiano, María Belen Bosch, Diana Sacarano, Anibal Hernan Pidone, Ricardo Spataro;

Hospital Provincial: Ricardo Velasco, Celina Gialdini, Martina Salvai, Laura Truzzi, Hermán Garnica;

Sanatorio de la Mujer: Haroldo Capurro, José Ignacio Emidi, Mauricio Fernando Belizán; Hospital

Roque Saenz Pena: Gustavo Baccifava, Estefanía Solis, Marcelo Quacesi; Hosptial Iturraspe:

Guillermo Koch, Lucas Lavoy, M. Alida Tulián, Florencia Pieroni; CREP: Guillermo Carroli, Ranata

Zanello, Berenise Carroli, Fernando Burgueño, Daniel Giodano, Hugo Gamerro, Liana Campodónico,

Ivana Lopez, Fernanda Candio.

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Supplemental Appendix

Effect of folic acid supplementation in pregnancy on preeclampsia - FACT

Shi Wu Wen, Ruth Rennicks White, Natalie Rybak, Laura Gaudet, Stephen Robson, William Hague, Donnette

Simms-Stewart, Guillermo Carroli, Graeme Smith, William D. Fraser, George Wells, Sandra T. Davidge, John

Kingdom, Doug Coyle, Dean Fergusson, Daniel J Corsi, Josee Champagne, Elham Sabri, Tim Ramsay, Ben Willem

J. Mol, Martijn A Oudijk, Mark C Walker, on behalf of the FACT Collaborating Group

Table of Contents

1. Table S1: List of Participating Countries and Sites (Total Recruited)

2. Table S2: Reported adverse events between the two arms

3. Table S3: Comparison of maternal inclusion criteria between the two arms

4. Table S4: Comparison of primary outcome by country

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Table S1 – List of Participating Countries and Sites (Total Recruited) CANADA (1207)

Centre Hospitalier Universitaire de Québec (225)

Centre Hospitalier Universitaire Sainte-Justine (31) Children’s & Women’s Health Centre of British Columbia (16)

Foothills Medical Centre (35)

Health Sciences Centre – General Hospital, Newfoundland (29)

Hôpital Saint-Luc, CHUM (133)

Kingston General Hospital &Queen’s University at Kingston (71)

Lois Hole Hospital (31) London Health Sciences Centre – Victoria Hospital (23)

McMaster University Medical Centre (161)

Regina General Hospital (8) Royal Victoria Hospital (1)

Saint John Regional Hospital (2)

Sault Area Hospital (2) St. Boniface General Hospital (16)

St-Mary's Hospital (34)

St-Paul's Hospital (6) Sunnybrook Research Institute—Sunnybrook Health Sciences Centre (21)

The Dr. Everett Chalmers Regional Hospital (52)

The Moncton Hospital (102) The Ottawa Hospital—Civic Campus (33)

The Ottawa Hospital—General Campus (96)

The University of Manitoba (79)

UNITED KINGDOM (764)

49 Marine Avenue Surgery (6)

Burnley General Hospital (18) Darlington Memorial Hospital (7)

Fairfield General Hospital (3) Gateshead Queen Elizabeth Hospital (28)

Guy’s & St Thomas’ Hospital (66)

Hinchingbrooke Hospital (8) James Cook University Hospital (54)

Leighton Hospital (20)

Lincoln County Hospital (9) Newcastle Upon Tyne Hospital (76)

New Cross Hospital (5)

Norfolk & Norwich (18) North Cumbria University Hospital (5)

North Manchester General Hospital (4)

North Tyneside General Hospital (21) Nottingham City Hospital (2)

Queen’s Medical Centre (13)

Rochdale Infirmary (1) Royal Blackburn Hospital (16)

South Tyneside District Hospital (43)

St George's Hospital (50) Sunderland Royal Hospital (122)

The Hillingdon Hospital (7) The Royal Oldham Hospital (2)

University Hospital of North Durham (28)

University Hospital of North Tees (33) Wansbeck General Hospital (31)

Warrington Hospital (11)

West Cumberland Hospital (21) West Middlesex University Hospital (36)

AUSTRALIA (310)

Ipswich Hospital (92) Nepean Hospital (7)

Sunshine Hospital (35)

The Royal Women's Hospital (105) The Townsville Hospital (5)

The Women’s and Children’s Hospital (66)

ARGENTINA (122)

CEMIC (12)

Hospital Escuela Eva Perón (12)

Hospital Provincial (17)

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Table S2 - Reported adverse events between the two arms

Adverse Events

n % n % RR (95% CI) p value

Infants

Any Event 289 20.73 318 22.75 0.89 (0.76 to 1.03) 0.12

0 1105 79.27 1080 77.25

1-2 268 19.23 279 19.96

3 and more 21 1.51 39 2.79

Mothers

Experiment n=1227 Placebo n=1236

Any Event 961 78.32 968 78.32 1.00 (0.96 to 1.04) 1.00

0 266 21.68 268 21.68

1-2 368 29.99 355 28.72

3 and more 593 48.33 613 49.6

Severe Adverse Event

n % n % RR (95% CI) p value

Infants

Any Event 116 8.33 109 7.8 1.00 (0.75 to 1.32) 0.97

0 1277 91.67 1289 92.2

1 111 7.97 108 7.73

2 5 0.36 1 0.07

Mothers

Experiment n=1227 Placebo n=1236

Any Event 227 18.5 195 15.78 1.17 (0.99 to 1.40) 0.07

0 1000 81.5 1041 84.22

1 186 15.16 156 12.62

2 and more 41 3.34 39 3.16

Hospital Roque Saenz Pena (24)

Hosptial Iturraspe (8) Maternidad Martin (47)

Sanatorio de la Mujer (2)

JAMAICA (61)

Spanish Town Hospital (20)

The University of West Indies—Mona Campus (40)

Victoria Jubilee Hospital (1)

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Table S3. Comparison of maternal inclusion criteria between the two arms

Folic Acid n=1144 Placebo n=1157

Criteria n % n % RR (95% CI) P value

Pre-existing hypertension 43 22.63 53 22.75 0.99 (0.70 to 1.42) 0.98

Diabetes 30 18.18 22 15.07 1.21 (0.73 to 2.00) 0.46

Twin pregnancy 37 17.21 21 9.86 1.75 (1.06 to 2.88) 0.03

PE in previous pregnancy 63 21.21 66 23.24 0.91 (0.67 to 1.24) 0.56

BMI ≥ 35 kg/m2 65 11.61 77 12.54 0.93 (0.68 to 1.26) 0.62

Table S4. Comparison of primary outcome by country

Folic Acid n=1144 Placebo n=1157

Country n % n % RR (95% CI) P value

Canada 83 14.69 75 12.89 1.14 (0.85 to 1.52) 0.3755

Australia 27 18.12 29 20.86 0.87 (0.54 to 1.39) 0.5568

Argentina 11 19.64 10 17.54 1.12 (0.52 to 2.43) 0.7743

West India 5 20.83 4 13.33 1.56 (0.47 to 5.19) 0.4624

UK 43 12.29 38 10.89 1.13 (0.75 to 1.70) 0.5638

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bmj...2017/05/18 · confidential: for review only effect of high dose folic acid supplementation...

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