Asthma in the elderly: a study of the role of vitamin D

Gender Differences in the Interplay between Vitamin D and Microbiota in Allergic and Autoimmune Diseases

The synergic role of vitamin D and the intestinal microbiota in the regulation of the immune system has been thoroughly described in the literature. Vitamin D deficiency and intestinal dysbiosis have shown a pathogenetic role in the development of numerous immune-mediated and allergic diseases. The physiological processes underlying aging and sex have proven to be capable of having a negative influence both on vitamin D values and the biodiversity of the microbiome. This leads to a global increase in levels of systemic inflammatory markers, with potential implications for all immune-mediated diseases and allergic conditions. Our review aims to collect and analyze the relationship between vitamin D and the intestinal microbiome with the immune system and the diseases associated with it, emphasizing the effect mediated by sexual hormones and aging.

Does Vitamin D Work Synergistically with Anti-Asthmatic Drugs in Airway Remodeling?

Vitamin D is commonly known for its properties of airway remodeling inhibition. Due to this, we decided to analyze the action of calcitriol with anti-asthmatic drugs in airway remodeling. The HFL1 cell line was treated with calcitriol, beclomethasone 17-propionate, montelukast sodium, LTD4 and TGF-β in different combinations. Real-time PCR was used to analyzed the expression of ACTA2, CDH-1, Vimentin, ADAM33, MMP-9 and CysLTR1 on the mRNA level, whereas Western blot was used to analyze gene expression on the protein level. One-way analysis variants, the Kruskal-Wallis test, Student's t-test or Welch's t-test were used for statistical analysis. Concerning the results, pre-treatment with calcitriol increased the inhibitory effect of beclomethasone 17-propionate and montelukast sodium on the expression of ACTA2 (p = 0.0072), Vimentin (p = 0.0002) and CysLTR1 (p = 0.0204), and 1,25(OH)2D3 had an influence on the effects of beclomethasone 17-propionate and montelukast sodium and of CDH1 expression (p = 0.0076). On the protein level, pre-treatment with calcitriol with beclomethasone 17-propionate and montelukast sodium treatment decreased ACTA2 expression in comparison to the LT (LTD4 and TGF-β) control group (p = 0.0191). Hence, our study not only confirms that vitamin D may inhibit airway remodeling, but also shows that vitamin D has a synergistic effect with anti-asthmatic drugs.

Impact of rapid correction of vitamin D deficiency in asthmatic patients

BACKGROUND

Asthma is one of the most common chronic diseases, which is a growing public health concern worldwide. In recent years, there has been an increasing number of interests in the relationship between vitamin D level and asthma control. Hence, the objective of this study was to assess the effect of high doses of vitamin D₃ injection on asthmatic patient's respiratory condition and quality of life.

METHODS

This was a single arm, before and after interventional study involving 18 patients with moderate to severe asthma. Spirometry test, St George's respiratory questionnaire (SGRQ) and serum vitamin D assay were performed. Subjects with 25-hydroxyvitamin D₃ (25-(OH) D₃) < 20 ng/ml were deemed deficient (n = 18) and received 2 intramuscular injections of vitamin D₃ 300,000 IU at monthly intervals consecutively.

RESULTS

The mean changes of forced expiratory volume in the first second (FEV1) were significantly different in subjects who received vitamin D₃ injections (p = 0.008). Also, the mean changes in FEV1/forced vital capacity ratio (FEV1/FVC) were significant (p < 0.001) as well as maximum expiratory flow between 25% and 75% of FVC (MEF25-75) (p = 0.001). Interestingly, improvement in clinical parameters of SGRQ was also observed with significant differences in total score (p = 0.001). Naturally, serum vitamin D levels were increased in our patients following the injections (p < 0.001).

CONCLUSIONS

Our findings suggest that screening for serum 25-(OH) D₃ deficiency is important in asthmatic patients and correction of this deficiency with high doses of vitamin D₃ injection may lead to improvement in pulmonary function, symptoms and quality of life (QOL).

Meta-analysis of vitamin D and lung function in patients with asthma

Background

There is growing literature suggesting a link between vitamin D and asthma lung function, but the results from systematic reviews are conflicting. We conducted this meta-analysis to investigate the relation between serum vitamin D and lung function in asthma patients.

Methods

Major databases, including OVID, MEDLINE, Web of Science and PUBMED, were searched until 10th October 2018. All published observational studies related to vitamin D and asthma were extracted. All meta-analyses were performed using Review Manager 5.3.5.

Results

This quantitative synthesis found that asthma patients with low vitamin D levels had lower forced expiratory volume In 1 s (FEV1) (mean difference (MD) = − 0.1, 95% CI = − 0.11 to − 0.08,p < 0.01;I2 = 49%, p = 0.12) and FEV1% (MD = − 10.02, 95% CI = − 11 to − 9.04, p < 0.01; I2 = 0%, p = 0.82) than those with sufficient vitamin D levels. A positive relation was found between vitamin D and FEV1 (r = 0.12, 95% CI = 0.04 to 0.2, p = 0.003; I2 = 59%,p = 0.01), FEV1% (r = 0.19, 95% CI = 0.13 to 0.26, p < 0.001; I2 = 42%, p = 0.11), forced vital capacity (FVC) (r = 0.17, 95% CI = 0.00 to 0.34, p = 0.05; I2 = 60%, p = 0.04), FEV1/FVC (r = 0.4, 95% CI = 0.3 to 0.51, p < 0.001; I2 = 48%, p = 0.07), and the asthma control test (ACT) (r = 0.33, 95% CI = 0.2 to 0.47, p < 0.001; I2 = 0%, p = 0.7). Subgroup analysis indicated that the positive correlation between vitamin D and lung function remained significant in both children and adults.

Conclusions

Our meta-analysis suggested that serum vitamin D levels may be positively correlated with lung function in asthma patients. Future comprehensive studies are required to confirm these relations and to elucidate potential mechanisms.

Factors associated with uncontrolled asthma in adult asthmatics in Kinshasa, Democratic Republic of Congo

Background

The ultimate goal of asthma treatment is long-term control. Uncontrolled asthma is a major public health problem worldwide, but there is a lack of data on asthma control and its causes in the Democratic Republic of Congo (DRC).

Objective

To determine the socio-demographic, environmental, clinical, and biological factors and comorbidities associated with uncontrolled adult asthma in Kinshasa, DRC.

Methods

We performed a cross-sectional study of 216 male and female asthmatics aged 18 and over consecutively recruited from tertiary clinics and the community in Kinshasa between June 2017 and February 2018. For each subject, socio-demographic, clinical, para clinical and environmental data were recorded. Forced Expiratory Volume in one second (FEV₁) values were obtained by Spirometry, allergen testing performed using the skin prick test, serum vitamin D levels measured by radioimmunoassay, and asthma control assessed using the asthma control test (ACT) score. Multiple logistic regression identified factors associated with uncontrolled asthma.

Results

The average age of participants was 45.2 (SD 17.6) years, 74% were female, and 42% had a low educational level. Among all asthmatics, the prevalence of uncontrolled asthma was 56%, abnormal serum vitamin D level 95%, abnormal FEV₁ 65%, sensitization to two allergens (cat dander and dust mites) 18%, sleep disorders 37%, and heartburn 60%. Male (aOR 2.24; 95% CIs 1.04–4.79), low educational level (aOR 3.26; 95% CIs 1.54–6.67), sensitization to both cat dander and dust mites (aOR 2.67; 95% CIs 1.16–6.14), FEV₁ ≤80% (aOR 2.07; 95% CIs 1.08–3.96), abnormal serum vitamin D level (aOR 5.11; 95% CIs 1.17–22.33), sleep disorders (aOR 1.96; 95% CIs 1.04–3.71), and heartburn (aOR 2.02; 95% CIs 1.04–3.92) were significantly associated with uncontrolled asthma.

Conclusion

Uncontrolled asthma is common in Kinshasa, and these factors associated with uncontrolled asthma may be considered as targets for future intervention strategies.

Cross-sectional associations of vitamin D status with asthma prevalence, exacerbations, and control in New Zealand adults

BACKGROUND

Previous studies, mostly with children, have reported inconsistent findings on the associations of vitamin D status with asthma prevalence, exacerbations, and control. Because of limited research with adults, we examined these associations in a large community-based sample of New Zealand adults.

METHODS

5110 participants, aged 50-84 years, were recruited from the community into a clinical trial of vitamin D supplementation. The current analysis is based on baseline blood sample collection to measure serum 25-hydroxyvitamin D (25(OH)D), which was deseasonalized for data analyses; and baseline asthma assessment, which included questions on asthma prevalence, urgent medical care for asthma in the previous 12 months, and control of asthma symptoms in the previous 4 weeks.

RESULTS

702 (13.2%) of 5088 participants reported having doctor-diagnosed asthma. There was no difference in mean (SE) 25(OH)D concentration between participants with and without asthma: 66 (0.9) and 66 (0.4) nmol/L, respectively, adjusting for sex (p = 0.71). However, in multivariable analyses restricted to participants who reported having asthma, mean (SE) 25(OH)D concentration was 6.3 (2.6) nmol/L lower in those who reported having urgent medical care for asthma in the previous 12 months compared to others (p = 0.02), and 10.4 (3.9) nmol/L lower in those with very poor asthma control compared to those who were well-controlled (p = 0.03).

CONCLUSION

These cross-sectional results suggest that asthmatic adults with lower vitamin D status are more likely to receive urgent asthma medical care and to experience poor asthma control. Clinical trials are needed to determine the role of vitamin D supplementation in asthma management.

The potential of anti-infectives and immunomodulators as therapies for asthma and asthma exacerbations

Asthma is responsible for approximately 25,000 deaths annually in Europe despite available medicines that maintain asthma control and reduce asthma exacerbations. Better treatments are urgently needed for the control of chronic asthma and reduction in asthma exacerbations, the major cause of asthma mortality. Much research spanning >20 years shows a strong association between microorganisms including pathogens in asthma onset, severity and exacerbation, yet with the exception of antibiotics, few treatments are available that specifically target the offending pathogens. Recent insights into the microbiome suggest that modulating commensal organisms within the gut or lung may also be a possible way to treat/prevent asthma. The European Academy of Allergy & Clinical Immunology Task Force on Anti-infectives in Asthma was initiated to investigate the potential of anti-infectives and immunomodulators in asthma. This review provides a concise summary of the current literature and aimed to identify and address key questions that concern the use of anti-infectives and both microbe- and host-based immunomodulators and their feasibility for use in asthma.

Modulation of inflammatory and immune responses by vitamin D

Vitamin D (VitD) is a prohormone most noted for the regulation of calcium and phosphate levels in circulation, and thus of bone metabolism. Inflammatory and immune cells not only convert inactive VitD metabolites into calcitriol, the active form of VitD, but also express the nuclear receptor of VitD that modulates differentiation, activation and proliferation of these cells. In vitro, calcitriol upregulates different anti-inflammatory pathways and downregulates molecules that activate immune and inflammatory cells. Administration of VitD has beneficial effects in a number of experimental models of autoimmune disease. Epidemiologic studies have indicated that VitD insufficiency is frequently associated with immune disorders and infectious diseases, exacerbated by increasing evidence of suboptimal VitD status in populations worldwide. To date, however, most interventional studies in human inflammatory and immune diseases with VitD supplementation have proven to be inconclusive. One of the reasons could be that the main VitD metabolite measured in these studies was the 25-hydroxyVitD (25OHD) rather than its active form calcitriol. Although our knowledge of calcitriol as modulator of immune and inflammatory reactions has dramatically increased in the past decades, further in vivo and clinical studies are needed to confirm the potential benefits of VitD in the control of immune and inflammatory conditions.

Serum Magnesium and Vitamin D Levels as Indicators of Asthma Severity

Background. Serum magnesium levels affect the concentration of circulating vitamin D in blood and subsequently it affects the immunity; thus it plays significant role in the pathogenesis of asthma. Asthma, in adults, is less studied and hypomagnesemia along with vitamin D deficiency and insufficiency is common in asthmatic individuals, which causes frequent asthma attacks, respiratory infections, severe exacerbations, and poor response to bronchodilators. Objective. To detect the magnitude of vitamin D insufficiency and deficiency and serum magnesium levels among asthmatic patients and to correlate them with the severity of asthma. Materials and Methods. This is a cross-sectional case-control study which includes 60 patients of chronic stable asthma and 60 healthy controls. After taking clinical history and systemic examination, pulmonary function test was done. Serum levels of magnesium, 25-hydroxycholecalciferol [25(OH)D], and calcium were measured in all the subjects. Results. Significant correlation was found between vitamin D deficiency, hypomagnesemia, and asthma severity. Serum calcium levels were unaffected by that. Conclusion. Vitamin D and serum magnesium deficiency are highly prevalent in patients with asthma. Increased asthma severity, frequency of attacks, and exacerbation are associated with lower levels of one or both. Serum 25(OH)D and magnesium levels may serve as important markers of asthma severity.

Vitamin D modulation of innate immune responses to respiratory viral infections

Vitamin D, in addition to its classical functions in bone homeostasis, has a modulatory and regulatory role in multiple processes, including host defense, inflammation, immunity, and epithelial repair. Patients with respiratory disease are frequently deficient in vitamin D, implying that supplementation might provide significant benefit to these patients. Respiratory viral infections are common and are the main trigger of acute exacerbations and hospitalization in children and adults with asthma and other airways diseases. Respiratory monocytes/macrophages and epithelial cells constitutively express the vitamin D receptor. Vitamin D, acting through this receptor, may be important in protection against respiratory infections. Whether the in vitro findings can be translated into a substantial in vivo benefit still remains uncertain. Here we review the in vitro data on the role of vitamin D in antiviral innate immunity, the data concerning the deficient levels of vitamin D in lung diseases, and the in vivo role of supplementation as protection against respiratory viral infections in healthy individuals and in patients with chronic respiratory diseases. Finally, we suggest ways of improving the effectiveness of vitamin D as an adjuvant in the prevention and treatment of acute respiratory infections.

Asthma in the elderly: the effect of choline supplementation

Background

Asthma in the elderly is poorly understood as very few studies have included these patients. DNA methylation can affect the expression of asthma susceptibility genes. Methyl groups can be produced through a choline dependent pathway. Asthmatics have decreased serum choline. We studied the effect of choline supplementation in elderly asthmatics and associations between different parameters at baseline.

Methods

This is a double-blind, placebo-controlled, cross-over study. Thirty asthmatics 65 years old and older were evaluated at baseline and 3, 6, 9, and 12 weeks later. They randomly received choline bitartrate 310 mg and placebo capsules twice daily for 6 weeks.

Results

Ninety percent of the study subjects were atopic and 97 % of them were using inhaled corticosteroids. Choline supplementation did not affect ACT (asthma control test), spirometric values, eosinophil counts or total serum IgE vs. placebo (p > 0.86 for all comparisons). In subjects with lower ACT (≤20), lower FEV1 % (<60 %), or higher eosinophil counts (≥0.6), there was similarly no difference between choline and placebo (p > 0.63). We found no significant association between eosinophil counts and IgE and the other parameters at baseline including in subjects with lower ACT or on higher inhaled steroid doses (p > 0.09). Asthmatic women had lower baseline ACT scores compared to men (p = 0.02).

Conclusions

In this study of elderly asthmatics, choline supplementation for 6 weeks did not affect ACT scores, spirometric values, peripheral blood eosinophils, or total serum IgE. These results will require confirmation in larger and longer studies.

Trial registration ClinicalTrials.gov NCT02371993

Vitamin D deficiency is associated with impaired disease control in asthma-COPD overlap syndrome patients

Introduction

The association between vitamin D and clinical parameters in obstructive lung diseases (OLDs), including COPD and bronchial asthma, was previously investigated. As asthma–COPD overlap syndrome (ACOS) is a new clinical entity, the prevalence of vitamin D levels in ACOS is unknown.

Aim

Our aim was to assess the levels of circulating vitamin D (25-hydroxyvitamin D [25(OH)D]) in different OLDs, including ACOS patients, and its correlation with clinical parameters.

Methods

A total of 106 men and women (control, n=21; asthma, n=44; COPD, n=21; and ACOS, n=20) were involved in the study. All patients underwent detailed clinical examinations; disease control and severity was assessed by disease-specific questionnaires (COPD assessment test, asthma control test, and modified Medical Research Council); furthermore, 25(OH)D levels were measured in all patients.

Results

The 25(OH)D level was significantly lower in ACOS and COPD groups compared to asthma group (16.86±1.79 ng/mL and 14.27±1.88 ng/mL vs 25.66±1.91 ng/mL). A positive correlation was found between 25(OH)D level and forced expiratory volume in 1 second (r=0.4433; P<0.0001), forced vital capacity (FVC) (r=0.3741; P=0.0004), forced expiratory flow between 25% and 75% of FVC (r=0.4179; P<0.0001), and peak expiratory flow (r=0.4846; P<0.0001) in OLD patient groups. Asthma control test total scores and the 25(OH)D level showed a positive correlation in the ACOS (r=0.4761; P=0.0339) but not in the asthma group. Higher COPD assessment test total scores correlated with decreased 25(OH)D in ACOS (r=−0.4446; P=0.0495); however, this was not observed in the COPD group.

Conclusion

Vitamin D deficiency is present in ACOS patients and circulating 25(OH)D level may affect disease control and severity.

Vitamin D as an adjunctive therapy in asthma. Part 2: A review of human studies

Vitamin D deficiency (VDD) is highly prevalent worldwide, with adverse effects on bone health but also potentially other unfavorable consequences. VDD and asthma-incidence/severity share many common risk factors, including winter season, industrialization, poor diet, obesity, dark skin pigmentation, and high latitude. Multiple anatomical areas relevant to asthma contain both the enzyme responsible for producing activated vitamin D and the vitamin D receptor suggesting that activated vitamin D (1,25-dihydroxyvitamin D) may have important local effects at these sites. Emerging evidence suggests that VDD is associated with increased airway hyperresponsiveness, decreased pulmonary function, worse asthma control, and possibly decreased response to standard anti-asthma therapy. However the effect is inconsistent with preliminary evidence from different studies suggesting vitamin D is both beneficial and detrimental to asthma genesis and severity. Current evidence suggests that supplementation with moderate doses of vitamin D may be appropriate for maintenance of bone health in asthmatics, particularly steroid users. However emerging data from an increasing number of randomized, controlled, intervention studies of vitamin D supplementation in pediatric and adult asthma are becoming available and should help determine the importance, if any of vitamin D for asthma pathogenesis. The purpose of this second of a two-part review is to review the current human literature on vitamin D and asthma, discussing the possible consequences of VDD for asthma and the potential for vitamin D repletion as adjunct therapy.

The Role of Vitamin D in Pediatric Asthma

The detrimental effects of vitamin D deficiency in pediatrics have become increasingly apparent and extend beyond skeletal health. Unfortunately, vitamin D deficiency is highly prevalent in atopic pediatric patients, in whom it may disrupt the immune system and induce significant worsening of reactive airways. This review presents evidence that lung development and immune regulatory functions are vitamin D-dependent. We also review clinical studies that explore how vitamin D supplementation may prevent respiratory infections and help improve asthma control, and we elaborate how these effects may vary among populations. We reveal the strong need of screening measures for vitamin D deficiency in high risk pediatric populations, particularly African-Americans, Hispanic-Americans, and children with obesity. Finally, we emphasize that all children, especially those who are asthmatic, should be assessed to ensure adequate intake or supplementation with at least the minimum recommended doses of vitamin D. The simple intervention of vitamin D supplementation may provide significant clinical improvement in atopic disease, especially asthma.