Long-term bioavailability after a single oral or intramuscular administration of 600,000 IU of ergocalciferol or cholecalciferol: implications for treatment and prophylaxis

Effects of High Dose Bolus Cholecalciferol on Free Vitamin D Metabolites, Bone Turnover Markers and Physical Function

High dose bolus cholecalciferol supplementation has been associated with falls and fracture, and this does not appear to be due to hypercalcaemia. The primary aim of this study was to determine the change in free vitamin D and metabolites after high dose bolus supplementation. This was a single centre, double-blinded, randomised, controlled trial of three different oral bolus doses of vitamin D3 (50,000 IU, 150,000 IU, and 500,000 IU) in otherwise healthy, vitamin D deficient (total 25-hydroxylated vitamin 25(OH)D < 30 nmol/L) postmenopausal women. Thirty-three women were randomized to one of the three treatment groups. Twenty-seven vitamin D sufficient (25(OH)D > 50 nmol/L) postmenopausal women were recruited as a concurrent control group. Participants attended five study visits over three months. We measured total 25(OH)D3 and free 25(OH)D, total and free 1,25(OH)2D, parathyroid hormone, fibroblast-growth factor-23, serum calcium, ionised calcium, urinary calcium excretion, and bone turnover markers (procollagen I N-propeptide (PINP), serum C-telopeptides of type I collagen (CTX-I) and Osteocalcin (OC)). We assessed muscle strength and function with grip strength and a short physical performance battery. Postural blood pressure and aldosterone:renin ratio (ARR) was also measured. Total 25(OH)D3 and free 25(OH)D increased in response to dose, and there were proportionate increases in total and free metabolites. Treatment did not affect serum calcium, postural blood pressure, ARR, or physical function. Bone turnover markers increased transiently one week after administration of 500,000 IU. High dose bolus cholecalciferol supplementation does not cause disproportionate increases in free vitamin D or metabolites. We did not identify any effect on blood pressure regulation or physical function that would explain increased falls after high dose treatment. A transient increase in bone turnover markers one week after a 500,000 IU bolus suggests that very high doses can have acute effects on bone metabolism, but the clinical significance of this transient increase is uncertain.

The effect of vitamin D2 supplementation on vitamin D levels in humans: A time and dose-response meta-analysis of randomized controlled trials

BACKGROUND

Inconsistencies exist regarding the influence of vitamin D2 (ergocalciferol) supplementation on serum vitamin D levels. These inconsistencies could be attributed to numerous factors, such as dosage, baseline vitamin D levels, and duration of intervention. Hence, this dose-response meta-analysis of randomized controlled trials was conducted to assess the efficacy of vitamin D2 supplementation on vitamin D levels.

METHODS

Relevant studies were searched in PubMed/Medline, Web of Science, Embase, and Scopus, from their inception to 3 January 2023. Variable alterations were considered to calculate the pooled weighted mean difference (WMD) with 95% confidence interval (CI) using the random effects model.

RESULTS

Pooled results from 33 study arms demonstrated that Vitamin D2 treatment significantly increases total vitamin D concentrations (WMD: 11.47 ng/mL, 95 %CI: 9.29 to 13.64, p < 0.001), 25(OH)D2 concentrations (WMD: 11.40 ng/mL, 95 %CI: 4.72 to 18.09, p = 0.001), and 1,25(OH)D concentrations (WMD: 5.61 ng/mL, 95 %CI: 0.74 to 10.48, p = 0.024), but decreases 25(OH)D3 concentrations (WMD: -4.63 ng/mL, 95 %CI: -6.46 to -2.81, p < 0.001). In subgroup analyses, increase in total vitamin D concentrations was more significant in vitamin D2 doses >2000 IU/day (WMD: 13.82 ng/mL), studies with duration ≤12 weeks (WMD: 12.53 ng/mL), participants aged ≥60 years (WMD: 14.40 ng/mL), and trials with basal 25(OH)D concentrations <20 ng/mL (WMD: 11.47 ng/mL).

CONCLUSIONS

This meta-analysis indicates that the supplementation of vitamin D2 significantly increases the serum concentrations of total vitamin D, 25(OH)D2, and 1,25(OH)D, but decreases 25(OH)D3 concentrations. Careful consideration of patient characteristics, dosage, and treatment duration is recommended for vitamin D2 supplementation.

The Association between Serum Level of Vitamin D and Inflammatory Biomarkers in Hospitalized Adult Patients: A Cross-Sectional Study Based on Real-World Data

Objective

The association between vitamin D status and inflammation remains unclear in hospitalized patients.

Materials and Methods

We performed the current study based on real-world data from two teaching hospitals. Serum level of vitamin D (assessed by 25-hydroxyvitamin D) was evaluated within 2 days after admission. All the patients were further classified into three groups: deficiency (<12 ng/mL), insufficiency (12-20 ng/mL), and adequate (≥20 ng/mL). White blood cell (WBC) count, serum level of C-reactive protein (CRP), and procalcitonin were also measured and used to evaluate inflammation. Other potential covariates were abstracted from medical records. Charlson comorbidity index (CCI) was calculated to assess the severity of disease.

Results

A total number of 35,528 hospitalized adult patients (21,171 men and 14,357 women) were included. The average age and BMI were 57.5 ± 16.2 years and 23.4 ± 3.7 kg/m2, respectively, while medium vitamin D level was 16.1 ng/mL (interquartile range: 11.4 ng/mL, 21.6 ng/mL) and median CCI was one point (interquartile range: 0 point, two points). The prevalence of deficiency and insufficiency was 28.0% and 40.5%. Multivariate linear regression model showed that serum level of vitamin D was significantly associated with WBC and CRP but not associated with procalcitonin. Each standard deviation (≈7.4 ng/mL) increase in vitamin D was associated with a decrease in WBC by 0.13 × 109/mL (95% CI: 0.2 × 109/mL, 0.06 × 109/mL) and 0.62 mg/L (95% CI: 0.88 mg/L, 0.37 mg/L) for CRP. Subgroup analysis and sensitivity analysis (excluding those whose eGFR <60 ml/min/1.73 m2, those whose daily calorie intake <1,000 kcal, and those who were recruited from Xin Hua hospital) generated similar results.

Conclusions

The deficiency and insufficiency of vitamin D in the hospitalized adult patients was very common. However, the results should be interpreted with caution for limited representation of the whole inpatients. Low level of vitamin D was associated with inflammatory biomarkers, which provide the evidences to early intervention for lower the risk of infection.

Vitamin D Supplementation: Effect on Cytokine Profile in Multiple Sclerosis

Vitamin D is known for its role in modulating calcium and phosphate homeostasis and is implicated both in bone mineralization and immune system regulation. The immune-modulatory role of vitamin D and its impact on multiple sclerosis (MS) courses are still debated. The aim of this review was to check the effect of vitamin D supplementation on cytokine profile regulation in people with MS. A significant increase in serum concentrations of interleukin (IL)-10 and Transforming growth factor (TGF)-β1 after vitamin D supplementation was demonstrated in most studies, with some of them reporting a reduction in disability scores after vitamin D supplementation and an inverse correlation between IL-10 levels and disability. The effect of vitamin D on the serum levels of IL-17 and IL-6 was controversial; different results across studies could be explained by a variability in the treatment duration, route, and frequency of administration, as well as the dosage of vitamin D supplementation, responses to vitamin D treatment and the serum levels reached with supplementation, including the methods used for cytokine analysis and the different cell types investigated, the MS phenotype, the disease phase (active vs. non-active) and duration, and concomitant treatment with disease-modifying therapies. Nevertheless, the significant increase in the serum concentrations of IL-10 and TGF-β1, demonstrated in most studies, suggests an anti-inflammatory effect of vitamin D supplementation.

Intervention Approaches in Studying the Response to Vitamin D3 Supplementation

Vitamin D intervention studies are designed to evaluate the impact of the micronutrient vitamin D3 on health and disease. The appropriate design of studies is essential for their quality, successful execution, and interpretation. Randomized controlled trials (RCTs) are considered the "gold standard" for intervention studies. However, the most recent large-scale (up to 25,000 participants), long-term RCTs involving vitamin D3 did not provide any statistically significant primary results. This may be because they are designed similarly to RCTs of a therapeutic drug but not of a nutritional compound and that only a limited set of parameters per individual were determined. We propose an alternative concept using the segregation of study participants into different groups of responsiveness to vitamin D3 supplementation and in parallel measuring a larger set of genome-wide parameters over multiple time points. This is in accordance with recently developed mechanistic modeling approaches that do not require a large number of study participants, as in the case of statistical modeling of the results of a RCT. Our experience is based on the vitamin D intervention trials VitDmet, VitDbol, and VitDHiD, which allowed us to distinguish the study participants into high, mid, and low vitamin D responders. In particular, investigating the vulnerable group of low vitamin D responders will provide future studies with more conclusive results both on the clinical and molecular benefits of vitamin D3 supplementation. In conclusion, our approach suggests a paradigm shift towards detailed investigations of transcriptome and epigenome-wide parameters of a limited set of individuals, who, due to a longitudinal design, can act as their own controls.

Efficacy and safety of high-dose intramuscular vitamin D2 injection in type 2 diabetes mellitus with distal symmetric polyneuropathy combined with vitamin D insufficiency: study protocol for a multicenter, randomized, double-blinded, and placebo-controlled trial

Background

Distal symmetric polyneuropathy (DSPN) is the most common chronic complication of type 2 diabetes mellitus (T2DM). DSPN may lead to more serious complications, such as diabetic foot ulcer, amputation, and reduced life expectancy. Observational studies have suggested that vitamin D deficiency may be associated with the development of DSPN in T2DM. However, interventional studies have found that low-dose vitamin D supplementation does not significantly improve neuropathy in DSPN. This study aims to evaluate the efficacy and safety of intramuscular injection of high-dose vitamin D (HDVD) in T2DM with DSPN combined with vitamin D insufficiency.

Methods and analysis

We will conduct a multicenter, randomized, double-blinded, and placebo-controlled trial in four large hospitals. All eligible participants will be randomly assigned to either the vitamin D₂ supplement or placebo control group and injected intramuscularly monthly for 3 months. Additionally, anthropometric measurements and clinical data will be collected at baseline and 3 months. Adverse events will be collected at 1, 2, and 3 months. The primary outcome measure is the change in the mean Michigan Neuropathy Screening Instrument (MNSI) score at baseline and 3 months post-intervention. We will use the gold-standard liquid chromatography-tandem mass spectrometry method to distinguish between 25(OH)D₂ and 25(OH)D₃ levels. The MNSN score before the intervention will be used as a covariate to compare the changes between both groups before and after the intervention, and the analysis of covariance will be used to analyze the change in the MNSI score after HDVD supplementation.

Discussion

Glycemic control alone does not prevent the progression of DSPN in T2DM. Some studies have suggested that vitamin D may improve DSPN; however, the exact dose, method, and duration of vitamin D supplementation are unknown. Additionally, neuropathy repair requires HDVD supplementation to sustain adequate vitamin D levels. This once-a-month intramuscular method avoids daily medication; therefore, compliance is high. This study will be the first randomized controlled trial in China to analyze the efficacy and safety of HDVD supplementation for patients with T2DM and DSPN and will provide new ideas for pharmacological research and clinical treatment of diabetic neuropathy.

Clinical trial registration

https://www.chictr.org.cn/, identifier ChiCTR2200062266.

Approach to nutritional rickets

Rickets is the disease of a growing skeleton and results from impaired apoptosis of hypertrophic chondrocytes and mineralization of the growth plate. Nutritionally induced rickets, secondary to vitamin D and/or calcium deficiency, remains a major global problem. In this review, we discuss pathogenesis, clinical signs, investigation and management of nutritional rickets.

Vitamin D-A prominent immunomodulator to prevent COVID-19 infection

COVID-19 remains a life-threatening infectious disease worldwide. Several bio-active agents have been tested and evaluated in an effort to contain this disease. Unfortunately, none of the therapies have been successful, owing to their safety concerns and the presence of various adverse effects. Various countries have developed vaccines as a preventive measure; however, they have not been widely accepted as effective strategies. The virus has proven to be exceedingly contagious and lethal, so finding an effective treatment strategy has been a top priority in medical research. The significance of vitamin D in influencing many components of the innate and adaptive immune systems is examined in this study. This review aims to summarize the research on the use of vitamin D for COVID-19 treatment and prevention. Vitamin D supplementation has now become an efficient option to boost the immune response for all ages in preventing the spread of infection. Vitamin D is an immunomodulator that treats infected lung tissue by improving innate and adaptive immune responses and downregulating the inflammatory cascades. The preventive action exerted by vitamin D supplementation (at a specific dose) has been accepted by several observational research investigations and clinical trials on the avoidance of viral and acute respiratory dysfunctions. To assess the existing consensus about vitamin D supplementation as a strategy to treat and prevent the development and progression of COVID-19 disease, this review intends to synthesize the evidence around vitamin D in relation to COVID-19 infection.

Effect of PM2.5 exposure on Vitamin D status among pregnant women: A distributed lag analysis

BACKGROUND

Serum vitamin D levels are associated with exposure to air pollution, however, the lagged effect of exposure to air pollution remains unknown in pregnant women.

METHODS

Pregnant women who delivered at a maternity center in Shanghai, China, from 2015 to 2019 were included in the present study. The concentration of particulate matter 2.5 (PM_2.5) before 25-Hydroxyvitamin D [25(OH)D] detection was estimated using the satellite-based grid models. The distributed lag non-linear models were performed to examine the lagged association between weekly-specific PM_2.5 exposure and vitamin D deficiency (VDD) or serum 25(OH)D levels.

RESULTS

Among the 58,025 pregnant women included in the study (mean age at conception, 30.77 ± 3.75 years; mean prepregnancy BMI, 21.09 ± 2.55 kg/m²), 61.32% were diagnosed with VDD. Weekly-specific PM_2.5 exposure at weeks 1-10 before the detection of 25(OH)D was significantly associated with an increased incidence of VDD (p < 0.05). For every 10 μg/m³ increase in PM_2.5 exposure, the serum 25(OH)D level decreased by 1.346 nmol/L (95%CI: 1.183-1.508 nmol/L). The association between average PM_2.5 exposure and VDD at 1-10 weeks was more significant in weather conditions with low mean sunshine hours (OR: 1.246, 95%CI: 1.221-1.271).

CONCLUSION

Our study provided suggestive evidence that PM_2.5 exposure at 1-10 weeks before the 25(OH)D detection may decrease the circulating 25(OH)D levels in pregnant women and increase VDD risk in pregnant women. More attention should be paid to the long-term impact of PM_2.5, in particular, during weather conditions with a relatively short duration of sunshine.

Effect of Calcifediol on Physical Performance and Muscle Strength Parameters: A Systematic Review and Meta-Analysis

There is general agreement that optimal vitamin D status is necessary for bones, muscles, and general health, particularly in older adults, who are at higher risk of negative consequences of vitamin D deficiency, including sarcopenia; vitamin D supplementation is proposed as a potential intervention to mitigate sarcopenia. Several RCTs have reported that calcifediol (25(OH)D) was more potent than cholecalciferol in increasing plasma 25(OH)D. The present systematic review and meta-analysis aimed to summarize the effects of calcifediol on physical performance and muscle strength. We searched databases from inception to 1 January 2022 for studies investigating calcifediol on physical performance or muscle strength parameters. We calculated the difference between the means of follow-up vs. baseline data using standardized mean differences (SMD) and their 95% confidence intervals (CIs); a random-effect model was considered for all of the analyses. Seven RCTs were included in the meta-analysis. Calcifediol significantly improved gait speed (SMD = 2.500; 95%CI = 1.768−3.223; p < 0.0001); handgrip strength (n = 5446 participants, SMD = 0.532; 95%CI: 0.305−0.758; p < 0.0001; I2 = 20.2%); and leg extension (n = 4318 participants, SMD = 0.641; 95%CI: 0.346 to 0.935; p < 0.0001; I2 = 18.8%;) vs. baseline values. In conclusion, in this systematic review and meta-analysis, we observed that calcifediol may have a positive effect on muscle strength parameters, with less evidence on physical performance. These data further indicate the importance of vitamin D and, in particular, of calcifediol, not only on bone metabolism but also on muscle parameters and sarcopenia.

Relative Efficacy of Vitamin D2 and Vitamin D3 in Improving Vitamin D Status: Systematic Review and Meta-Analysis

BACKGROUND

Widespread prevalence of vitamin D deficiency has been documented globally. Commonly used interventions to address this deficiency include supplementation and/or fortification with either ergocalciferol (vitamin D₂) or cholecalciferol (vitamin D₃), but the relative efficacy of these two vitamers is unclear. The current study aimed to evaluate the relative efficacy of ergocalciferol (vitamin D₂) and cholecalciferol (vitamin D₃) for raising the serum levels of vitamin D metabolites and functional indicators including serum parathyroid (PTH) levels, isometric muscle strength, hand grip strength and bone mineral density.

METHODS

Randomized and non-randomized controlled studies evaluating relative efficacy of ergocalciferol and cholecalciferol were systematically reviewed to synthesize quantitative and qualitative evidence as per the recommendations of according to "Preferred Reporting Items for Systematic reviews and Meta-analysis" guidelines. Search terms were constructed on the basis of the "participants", "intervention", "control", "outcome" and "study type" (PICOS) strategy to systematically search the popular electronic databases. Relevant data from studies meeting inclusion and exclusion criteria were extracted and analyzed. Meta-regression, subgroup and sensitivity analyses were performed to investigate the influence of study-level characteristics including intervention dosage, frequency of dosing, interval between the last dose and test for outcome assessment, participant characteristics and analytical methods.

RESULTS

Apparently healthy human participants (n = 1277) from 24 studies were included for meta-analysis. The quantitative analysis suggested higher efficacy of cholecalciferol than ergocalciferol in improving total 25(OH)D (mean difference: 15.69, 95%CI: 9.46 to 21.93 nmol/L) and reducing PTH levels, consistently across variable participant demographics, dosage and vehicle of supplementation. Meta-regression suggested smaller differences in the efficacy of cholecalciferol and ergocalciferol at lower doses. Average daily dose was the single significant predictor of effect size, as revealed by multivariate meta-regression analysis.

CONCLUSIONS

Compared to ergocalciferol, cholecalciferol intervention was more efficacious in improving vitamin D status (serum levels of total 25(OH)D and 25(OH)D₃) and regulating PTH levels, irrespective of the participant demographics, dosage and vehicle of supplementation.

Conundrum of vitamin D on glucose and fuel homeostasis

As an endocrine hormone, vitamin D plays an important role in bone health and calcium homeostasis. Over the past two decades, the non-calcemic effects of vitamin D were extensively examined. Although the effect of vitamin D on beta cell function were known for some time, the effect of vitamin D on glucose and fuel homeostasis has attracted new interest among researchers. Yet, to date, studies remain inconclusive and controversial, in part, due to a lack of understanding of the threshold effects of vitamin D. In this review, a critical examination of interventional trials of vitamin D in prevention of diabetes is provided. Like use of vitamin D for bone loss, the benefits of vitamin D supplementation in diabetes prevention were observed in vitamin D-deficient subjects with serum 25-hydroxyvitamin D < 50 nmol/L (20 ng/mL). The beneficial effect from vitamin D supplementation was not apparent in subjects with serum 25-hydroxyvitamin D > 75 nmol/L (30 ng/mL). Furthermore, no benefit was noted in subjects that achieved serum 25-hydroxyvitamin D > 100 nmol/L (40 ng/mL). Further studies are required to confirm these observations.

Reasons to avoid vitamin D deficiency during COVID-19 pandemic

The effects of vitamin D on the musculoskeletal system are well established. Its deficiency causes osteomalacia, secondary hyperparathyroidism, and an increased risk for fractures and falls. However, clinical and experimental evidence points to extra-skeletal actions of vitamin D, including on immune and respiratory systems. Thus, during this COVID-19 pandemic, a possible deleterious role of vitamin D deficiency has been questioned. This paper aims to present a brief review of the literature and discuss, based on evidence, the role of vitamin D in the lung function and in the prevention of respiratory infections. Relevant articles were searched in the databases MEDLINE/PubMed and SciELO/LILACS. The mechanisms of vitamin D action in the immune system response will be discussed. Clinical data from systematic reviews and meta-analyses show benefits in the prevention of respiratory infections and improvement of pulmonary function when vitamin D-deficient patients are supplemented. At the time of writing this paper, no published data on vitamin D supplementation for patients with COVID-19 have been found. Vitamin D supplementation is recommended during this period of social isolation to avoid any deficiency, especially in the context of bone outcomes, aiming to achieve normal values of 25(OH)D. The prevention of respiratory infections and improvement of pulmonary function are additional benefits observed when vitamin D deficiency is treated. Thus far, any protective effect of vitamin D specifically against severe COVID-19 remains unclear. We also emphasize avoiding bolus or extremely high doses of vitamin D, which can increase the risk of intoxication without evidence of benefits.

Vitamin D Sources, Metabolism, and Deficiency: Available Compounds and Guidelines for Its Treatment

Studies on vitamin/hormone D deficiency have received a vast amount of attention in recent years, particularly concerning recommendations, guidelines, and treatments. Moreover, vitamin D’s role as a hormone has been confirmed in various enzymatic, metabolic, physiological, and pathophysiological processes related to many organs and systems in the human body. This growing interest is mostly due to the evidence that modest-to-severe vitamin D deficiency is widely prevalent around the world. There is broad agreement that optimal vitamin D status is necessary for bones, muscles, and one’s general health, as well as for the efficacy of antiresorptive and anabolic bone-forming treatments. Food supplementation with vitamin D, or the use of vitamin D supplements, are current strategies to improve vitamin D levels and treat deficiency. This article reviews consolidated and emerging concepts about vitamin D/hormone D metabolism, food sources, deficiency, as well as the different vitamin D supplements available, and current recommendations on the proper use of these compounds.

Long-Term Bioavailability of Single Doses of Intramuscular Vitamin D2

OBJECTIVE

We sought to determine the long-term bioavailability of single doses of intramuscular (IM) vita-min D₂ (D₂) in healthy adults.

METHODS

Forty healthy volunteers with hypovitaminosis D received a single dose of 200,000, 400,000, or 600,000 IU intramuscular D₂ or no treatment. Levels of 25-hydroxyvitamin D₂ (25&lsqb;OH]D₂) and 25-hydroxyvitamin D₃ (25&lsqb;OH]D₃) in serum were measured by liquid chromatography-tandem mass spectrometry. Vitamin D binding protein (DBP) and intact parathyroid hormone (iPTH), bone turnover markers (BTMs), and serum and urinary calcium were also measured.

RESULTS

After a single dose of D₂ injection, the level of 25(OH)D₂ increased slowly and reached a plateau at 8 weeks. The plateau remained stable for 12 weeks. The mean increase in 25(OH)D₂ was 6.8, 9.6, or 15.6 ng/mL after injection of 200,000 IU, 400,000 IU, or 600,000 IU D₂. Although endogenous 25(OH)D₃ levels were reduced by IM D₂, the total 25(OH)D levels increased by 5.0, 7.0, or 10.3 ng/mL in average after injection of 200,000 IU, 400,000 IU, or 600,000 IU D₂. The iPTH levels were also decreased by IM D₂. However, levels of serum calcium, BTMs, and DBP and urinary calcium were not altered by IM D₂.

CONCLUSION

A single dose of 200,000 IU, 400,000 IU, or 600,000 IU IM D₂ raises total 25-hydroxyvitamin D levels by 5.0, 7.0, or 10.3 ng/mL on average for at least 12 weeks and reduces iPTH and endogenous 25(OH)D₃ levels without affecting levels of serum calcium, BTMs, DBP, and urinary calcium.

Effects of Monthly Intramuscular High-Dose Vitamin D2 on Serum 25-Hydroxyvitamin D and Immune Parameters in Very Elderly Chinese Patients with Vitamin D Deficiency

PURPOSE

Vitamin D deficiency is highly prevalent among the very elderly and is associated with a wide variety of clinical conditions other than musculoskeletal diseases. This study aims to ascertain the efficacy and safety of high-dose intramuscular vitamin D2 in very elderly Chinese patients with vitamin D deficiency.

METHODS

Very elderly (aged 80 years or over) Chinese patients with vitamin D deficiency were recruited to receive monthly intramuscular injections of 600,000 IU vitamin D2 until their serum 25-hydroxyvitamin D (25(OH)D) reached ≥30 ng/mL. The serum levels of 25(OH)D2, 25(OH)D3, iPTH, BTMs, immune parameters, and other biochemical parameters were measured at baseline and one month after each dose.

RESULTS

Of the 30 very elderly Chinese patients who had been recruited into the study, 27 (90.0%) had their vitamin D deficiency corrected, and 26 (86.7%) reached vitamin D sufficiency. The mean time (±SD) was 3.1 (±1.3) months for vitamin D deficiency to be corrected, and 6.1 (±0.8) months for vitamin D sufficiency to be reached. The mean (±SD) serum level of 25(OH)D2 increased from 0.69 (±1.51) ng/mL to 29.07 (±5.68) ng/mL, while the mean (±SD) serum level of 25(OH)D3 decreased from 9.82 (±2.75) ng/mL to 5.30 (±3.09) ng/mL (both P < 0.001). The total T cells in serum remained unchanged (P > 0.05), and the CD4 and B cells (CD19+) were increased significantly (both P < 0.05). In addition, no significant change was observed in the serum levels of iPTH and BTMs.

CONCLUSION

Monthly intramuscular injection of 600,000 IU vitamin D2 is an effective and safe dosing regimen to reach vitamin D sufficiency and enhances immune function in the very elderly Chinese patients with vitamin D deficiency.

Hypervitaminosis D and acute interstitial nephritis: Tale of injections

A 33-year-old man came with nausea, vomiting and abdominal pain due to hypercalcaemia and renal dysfunction following two doses of intramuscular vitamin D injections. Levels of vitamin D were repeatedly above 300 ng/ml over a period of 10 months. Whole-body PET CT scan revealed a thin-walled collection in the right gluteal region. The patient refused a surgical intervention for the same. After 7 months of follow-up, the abscess ruptured spontaneously and was then surgically debrided. At this point, a history of pentazocine addiction was uncovered. One month later, vitamin D levels began to fall along with improvement in serum calcium and creatinine. This case unravels a diagnostic odyssey which ended with a simple surgical debridement. We aim to highlight that vitamin D supplementation in ‘megadoses’ in the presence of active infection can have an exaggerated response and may take months to resolve.

Osteomalacia and Vitamin D Status: A Clinical Update 2020

Historically, rickets and osteomalacia have been synonymous with vitamin D deficiency dating back to the 17th century. The term osteomalacia, which literally means soft bone, was traditionally applied to characteristic radiologically or histologically documented skeletal disease and not just to clinical or biochemical abnormalities. Osteomalacia results from impaired mineralization of bone that can manifest in several types, which differ from one another by the relationships of osteoid (ie, unmineralized bone matrix) thickness both with osteoid surface and mineral apposition rate. Osteomalacia related to vitamin D deficiency evolves in three stages. The initial stage is characterized by normal serum levels of calcium and phosphate and elevated alkaline phosphatase, PTH, and 1,25‐dihydroxyvitamin D [1,25(OH)₂D]—the latter a consequence of increased PTH. In the second stage, serum calcium and often phosphate levels usually decline, and both serum PTH and alkaline phosphatase values increase further. However, serum 1,25(OH)₂D returns to normal or low values depending on the concentration of its substrate, 25‐hydroxyvitamin D (25OHD; the best available index of vitamin D nutrition) and the degree of PTH elevation. In the final stage, hypocalcemia and hypophosphatemia are invariably low with further exacerbation of secondary hyperparathyroidism. The exact,or even an approximate, prevalence of osteomalacia caused by vitamin D deficiency is difficult to estimate, most likely it is underrecognized or misdiagnosed as osteoporosis. Signs and symptoms include diffuse bone, muscle weakness, and characteristic fracture pattern, often referred to as pseudofractures, involving ribs, scapulae, pubic rami, proximal femurs, and codfish‐type vertebrae. The goal of therapy of vitamin D‐deficiency osteomalacia is to alleviate symptoms, promote fracture healing, restore bone strength, and improve quality of life while correcting biochemical abnormalities. There is a need for better understanding of the epidemiology of osteomalacia. Simplified tools validated by concurrent bone histology should be developed to help clinicians promptly diagnose osteomalacia. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

LC-MS/MS quantification of fat soluble vitamers - A systematic review

Fat soluble vitamers (FSV) are several biochemically diverse micronutrients essential for healthy development, growth, metabolism, and cell regulation. We cannot synthesize FSV completely or at the required concentrations. Deficiency or excess of FSV can result in many health problems. Plasma is the most accessible sample matrix for the quantification of FSV. However, due to its complexity and other analytical challenges (e.g., FSV sensitivity to light, oxygen, heat, pH, chemical heterogeneity, standard availability), developing a method for the simultaneous quantification of multiple FSV at physiological concentrations has been challenging. In this systematic review, we examine the parameters and criteria used in existing Liquid Chromatography with tandem Mass Spectrometry (LC-MS/MS) methods for FSV quantification to the extraction method, chromatographic resolution, matrix effects, and method validation as critical to a sensitive and robust method. We conclude that the final FSV method sensitivity is predominantly based on aforementioned criteria and future method development using LC-MS/MS will benefit from the application of this systematic review.

Vitamin D screening

At present, there is no need and no sufficient evidence to support universal screening for vitamin D status. There are four categories of subjects in whom there is no requirement for screening, since a number of studies indicate beneficial effects of vitamin D supplementation; these are represented by children and adolescents, pregnant women, patients taking bone active drugs and subjects with documented hypovitaminosis D. In the remaining subjects, the utilization of adequate questionnaires will target with sufficient sensitivity and specificity those with hypovitaminosis D. These must be first supplemented and, at a later time, serum 25(OH)D assay should be requested to confirm attainment of sufficiency, independently of the threshold chosen. This strategy will cut costs deriving from both widespread use of vitamin D assays and vitamin D supplementation.

Impact of vitamin D supplementation on falls and fractures-A critical appraisal of the quality of the evidence and an overview of the available guidelines

INTRODUCTION

The beneficial effect of vitamin D supplementation on musculo-skeletal outcomes have been recently questioned and recommendations regarding supplementation vary widely. The aim of this paper is to systematically assess the quality of the evidence evaluating the effect of vitamin D supplementation on falls and fractures.

METHODS

We conducted a systematic search in Medline, PubMed, and Embase and selected systematic reviews (SRs) / meta-analyses (MAs) of randomized controlled trials (RCTs) on vitamin D supplementation and falls or fracture, published between 2012 - 2018. We identified 5 MAs of RCTs on falls, 4 on fractures and 4 on both outcomes. We applied the critical appraisal tool "A MeaSurement Tool to Assess systematic Reviews 2" - AMSTAR 2 - to assess the quality of the identified MAs.

RESULTS

Vitamin D and calcium supplementation (CaD), compared to calcium only or placebo, may reduce the risk of falls, in institutionalized individuals and/or those from the community, but the data is inconsistent. The largest and most consistent evidence for a protective effect of CaD, compared to placebo or control, is in reducing the risk of hip fracture, by 16-33%, and any fracture, by 5-19%. This effect was demonstrated when combining trials in community-dwelling and institutionalized individuals, potentially driven by data from institutionalized individuals as shown in 3 SRs/MAs. Major limitations to the quality of the evidence include variability in the methodology of MAs, but more importantly, differences between trials in terms of subjects' characteristics, vitamin D regimens, outcome definition and ascertainment, risk of bias, trial duration and/or low power. The quality of the included MAs was moderate to critically low.

CONCLUSIONS

While the effect on falls is inconsistent, CaD reduces the risk of fracture (hip and any fracture), as shown in meta-analyses pooling data of studies combining institutionalized and community individuals. The evidence is however limited by major shortcomings and heterogeneity.

Long-term vitamin D treatment decreases human uterine leiomyoma size in a xenograft animal model

OBJECTIVE

To study the effects of short- and long-term vitamin D treatment on uterine leiomyomas in vivo through cell proliferation, extracellular matrix (ECM) degradation, and apoptosis.

DESIGN

Preclinical study of human leiomyoma treatment with vitamin D in an nonhuman animal model.

SETTING

Hospital and university laboratories.

PATIENT(S)/ANIMAL(S)

Human leiomyomas were collected from patients and implanted in ovariectomized NOD-SCID mice.

INTERVENTION(S)

Mice were treated with vitamin D (0.5 μg/kg/d or 1 μg/kg/d) or vehicle for 21 or 60 days.

MAIN OUTCOME MEASURE(S)

Vitamin D effect in xenograft tissue was assessed by monitoring tumor size (¹⁸F-FDG positron-emission tomography/computerized tomography and macroscopic examination), cell proliferation (immunohistochemistry and quantitative real-time polymerase chain reaction [qRT-PCR]), ECM (Western blot), transforming growth factor (TGF) β3 (qRT-PCR), and apoptosis (Westrn blot and TUNEL).

RESULT(S)

Short-term treatment with vitamin D did not appear to alter leiomyoma size, based on in vivo monitoring and macroscopic examination. However, long-term high-dose treatment induced a significant reduction in leiomyoma size. Cell proliferation was not decreased in the short term, whereas 1 μg/kg/d vitamin D in the long term significantly reduced proliferation compared with control. Although collagen-I and plasminogen activator inhibitor 1 were not modified by short-term treatment, they were both significantly reduced by long-term high-dose vitamin D. Similarly, long-term high-dose vitamin D significantly reduced TGF-β3 expression. Finally, apoptosis significantly increased with both short- and long-term high-dose vitamin D treatment.

CONCLUSION(S)

Long-term vitamin D acts as an antiproliferative, antifibrotic, and proapoptotic therapy that provides a safe, nonsurgical therapeutic option for reducing uterine leiomyoma size without side-effects.

Observational Study of Third-Trimester Vitamin D3 Supplementation and Implications for Mothers and Neonates at Term

Objective

To determine 25-hydroxyvitamin D (25OHD) levels in pregnant women at 28 weeks and supplement based on these levels and check maternal and neonatal levels after delivery at term.

Design

This is a prospective observational study wherein pregnant women aged 18-35 years received cholecalciferol from 28 weeks till delivery at term. Women with 25OHD levels ≥ 75 nmol/L received 12.5 μg/day, those with levels 50-74.9 nmol/L received 100 μg/day and those with  levels ≤ 49.9 nmol/L received 1500 μg/week.

Results

Of 555, 532 women (95.8%) completed the study. Of 532, 77 (14.5%) women had 25OHD ≥ 75 nmol/L at 28 weeks; 34/77 (44.15%) became deficient at term, and the mean 25OHD reduced from 99 ± 29.9 to 77 ± 30.4 nmol/L (p < 0.0001). One hundred and seventy-one women had 25OHD 50-74.9 nmol/L at 28 weeks; in 99 (57.89%), levels normalised at term, and mean 25OHD increased from 60.5 ± 7.5 to 78.2 ± 21.9 nmol/L (p < 0.0001). Two hundred and nineteen women had 25OHD 25-49.9 nmol/L at 28 weeks; in 135 (61.64%), levels normalised at term, and mean 25OHD increased from 36.6 ± 7.5 to 83.3 ± 32.7 nmol/L (p < 0.0001). Sixty-five women had 25OHD < 25 nmol/L at 28 weeks; In 39 (60.94%), levels normalised at term, and the mean 25OHD increased from 17.9 ± 5 to 80.6 ± 34.1 nmol/L (p < 0.0001). Seven neonates (1.3%) had cord blood ionised calcium values < 1 mmol/L, and all these had 25OHD < 50 nmol/L (mean 22.2 ± 2.5 nmol/L).

Conclusions

Standard 12.5 μg/day supplementation in women with normal 25OHD levels at 28 weeks leads to deficiency in 44% women by term. Cholecalciferol in doses of 100 μg/day and 1500 μg/week leads to a significant increase in 25OHD levels in vitamin D-deficient pregnant women though nearly 40% may still have deficient levels at term along with their newborns. Only 1.3% of newborns had hypocalcaemia.

Investigating subtle kidney injury in primary hyperparathyroidism by means of sensitive and specific biomarkers

OBJECTIVE

Kidney involvement is a common complication in primary hyperparathyroidism (PHPT). No study so far has assessed the prevalence of kidney injury developing before the reduction in glomerular filtration rate (GFR) in PHPT. The study was aimed at establishing the potential role of biomarkers of kidney injury in detecting subtle renal damage in patients with PHPT.

DESIGN

Cross-sectional study.

PATIENTS

A total of 69 postmenopausal patients with PHPT and 41 healthy age- and sex-matched subjects were studied. Exclusion criteria were as follows: GFR < 30 mL/min, chronic inflammatory disease, nephrotic syndrome, infection, malignancy, heart failure, recent exposure to iodinated contrast media or nonsteroidal anti-inflammatory drugs.

MEASUREMENTS

We measured a panel of sensitive biomarkers of kidney injury in PHPT vs controls.

RESULTS

Mean FGF23 and Klotho were higher in PHPT (72 ± 48 and 811 ± 366 pg/mL, respectively) than controls (53 ± 23.5 and 668.6 ± 17; P < .02 and P < .05). Urine KIM-1/uCr was significantly higher in PHPT (1.4^-6  ± 1.3^-6 ) than controls (9.2^-7  ± 7^-7 ; P < .05); this was particularly evident in the CrCl 60-89 mL/min category (1.3⁶  ± 9⁷ vs 8.2^-7  ± 3.6^-7 ; P < .02). Mean values of urine NGAL/uCr were higher in PHPT with (n = 28) compared to those without kidney stones (n = 35; 1.8^-5  ± 1.4^-5 and 1^-5  ± 8^-6 ; P < .0001). We found significant positive associations between urine NGAL/uCr and Ca (R = .292, P < .02) and urine KIM1/uCr and PTH (R = .329, P < .01).

CONCLUSIONS

We propose the utilization of these molecules, particularly urine KIM-1/uCr and urine NGAL/uCr ratios for the assessment of subtle kidney injury in patients with PHPT. These molecules are elevated in tubular necrosis and have potential role in the development of kidney damage in PHPT, according to the severity of the disease.

Efficiency of vitamin D supplementation in patients with mechanical low back ache

BACKGROUND

Preliminary evidence suggests an association of hypovitaminosis D (hypo.D) with mechanical Low back ache (mLBA).

AIM

This study was designed to 1. Explore the relationship of hypovitaminosis D with mLBA in the absence of other confounding factors 2. Formulate and validate an appropriate treatment protocol and 3. Explore the differences in outcomes with various oral formulations of vitamin D available in Indian market.

MATERIALS & METHODS

Three randomised groups of patients with mLBA and hypo.D between 18 and 45 years of age without any co morbid conditions were studied for the effectiveness of adjunctive vit.D supplementation of 6,00,000 IUs (60,000 IUs/day for ten consecutive days) in the form of granule or nano syrup or soft gel capsule for the treatment of mLBA. Review evaluation of pain, functional disability and vit.D was done at three weeks and an additional evaluation of vit.D was done at nine months. Evaluation with 3,00,000 IUs of vit.D (60,000 IUs/day for five consecutive days) was done with nano syrup in a different cohort.

RESULTS

High prevalence of hypo.D (96%) was noted in patients with mLBA. Significant improvement was noted after supplementation of vit.D. The subjects of nano syrup group have shown significantly better improvement compared to others (P < 0.000). Non obese and chronic patients have shown significantly better results than their peers. Though there was significant difference in vit.D before treatment, the difference of improvement between the genders, deficiency and insufficiency, in-door and out-door, smokers and non smoker subgroups was not significant. Seasonal variation in vit.D before and after the treatment was significant.

CONCLUSION

Hypovitaminosis D can be a potential causative factor for mLBA in addition to the other known causes. Proper evaluation and adjunctive vit.D supplementation can effectively break the vicious cycle of low back ache with significant improvement in serum vit.D level, effective relief of pain and significant functional improvement without any adverse effects. Improvement in vit.D was not significantly related to its initial status and obese individuals have shown significantly lesser improvement. The results with nano syrup formulation were significantly better compared to others. Formulation based dosage adjustments assume significance in view of these results.

Single high-dose oral vitamin D3 treatment in New Zealand children with inflammatory bowel disease

BACKGROUND

High-dose oral vitamin D (stoss) is a novel treatment in children with inflammatory bowel disease (IBD). Vitamin D supplementation may have benefits in IBD beyond bone health including reduced disease activity and improvements in inflammatory markers. The aim of this study was to retrospectively assess the efficacy, safety and impact on disease activity of single oral high-dose vitamin D3 therapy in New Zealand (NZ) children with IBD and vitamin D deficiency.

METHODS

In this retrospective chart review, children with IBD and vitamin D deficiency [serum 25-OH vitamin D level (25-OHD) <50 nmol/L] in Christchurch, NZ, who were managed with single high-dose vitamin D3 therapy were identified. Measurements of serum 25-OHD, calcium and standard serum inflammatory markers prior to and up to 6 months following stoss therapy were extracted from patient records. Disease activity was also defined using the Pediatric Crohn's Disease (CD) Activity Index (PCDAI) at time points before and 3 months following stoss.

RESULTS

Twenty-eight doses of stoss were given to 23 children, aged 3-16 years. Mean 25-OHD levels increased after stoss therapy from 39 nmol/L (95% CI: 37-42 nmol/L) at baseline to 189 nmol/L (148-231 nmol/L) at 1-2 months (P<0.001). All children with 1 month levels measured achieved 25-OHD >75 nmol/L. One child had a serum calcium of 2.7 (normal range, 2.2 to 2.6 mmol/L) 2 weeks after treatment, which normalized on repeat testing 10 days later. PCDAI scores, mean platelet count, erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) all reduced significantly from baseline to 3 months following stoss therapy.

CONCLUSIONS

Single high-dose oral vitamin D therapy was used successfully and safely to manage vitamin D deficiency in these children with IBD. An improvement in inflammatory markers and disease activity scores also occurred following stoss therapy.

MANAGEMENT OF ENDOCRINE DISEASE: Therapeutics of Vitamin D

OBJECTIVE

The central role of vitamin D in bone health is well recognized. However, controversies regarding its clinical application remain. We therefore aimed to review the definition of hypovitaminosis D, the skeletal and extra-skeletal effects of vitamin D and the available therapeutic modalities.

DESIGN

Narrative and systematic literature review.

METHODS

An international working group that reviewed the current evidence linking bone and extra-skeletal health and vitamin D therapy to identify knowledge gaps for future research.

RESULTS

Findings from observational studies and randomized controlled trials (RCTs) in vitamin D deficiency are discordant, with findings of RCTs being largely negative. This may be due to reverse causality with the illness itself contributing to low vitamin D levels. The results of many RCTs have also been inconsistent. However, overall evidence from RCTs shows vitamin D reduces fractures (when administered with calcium) in the institutionalized elderly. Although controversial, vitamin D reduces acute respiratory tract infections (if not given as bolus monthly or annual doses) and may reduce falls in those with the lowest serum 25-hydroxyvitamin D (25OHD) levels. However, despite large ongoing RCTs with 21 000–26 000 participants not recruiting based on baseline 25OHD levels, they will contain a large subset of participants with vitamin D deficiency and are adequately powered to meet their primary end-points.

CONCLUSIONS

The effects of long-term vitamin D supplementation on non-skeletal outcomes, such as type 2 diabetes mellitus (T2DM), cancer and cardiovascular disease (CVD) and the optimal dose and serum 25OHD level that balances extra-skeletal benefits (T2DM) vs risks (e.g. CVD), may soon be determined by data from large RCTs.

Vitamin D and critical illness outcomes

PURPOSE OF REVIEW

Although low vitamin D levels have been shown to be a risk factor for adverse outcomes in critical care, it is not clear to date if supplementation can alter such outcomes in all ICU patients. The focus of vitamin D research now is on interventional trials to identify a critically ill patient subset who may benefit from high-dose vitamin D supplementation.

RECENT FINDINGS

The VITdAL-ICU trial, a randomized, double-blind, placebo-controlled, single center trial of 475 heterogeneous critically ill patients, did not show improvement in hospital length of stay or overall mortality but did demonstrate in a secondary outcome that high-dose oral vitamin D3 improved mortality in patients with severe vitamin D deficiency.

SUMMARY

Vitamin D supplementation may represent a personalized and targeted therapy for critical illness. Vitamin D regulates over 1000 genes in the human genome, and the mechanism of action is influenced by gene polymorphisms and epigenetics. The study of the metabolomics, transcriptomics and epigenetics of vitamin D status and supplementation holds promise generating insights into critical illness outcomes.

Italian Association of Clinical Endocrinologists (AME) and Italian Chapter of the American Association of Clinical Endocrinologists (AACE) Position Statement: Clinical Management of Vitamin D Deficiency in Adults

Vitamin D deficiency is very common and prescriptions of both assay and supplementation are increasing more and more. Health expenditure is exponentially increasing, thus it is timely and appropriate to establish rules. The Italian Association of Clinical Endocrinologists appointed a task force to review literature about vitamin D deficiency in adults. Four topics were identified as worthy for the practicing clinicians. For each topic recommendations based on scientific evidence and clinical practice were issued according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) System. (1) What cut-off defines vitamin D deficiency: even though 20 ng/mL (50 nmol/L) can be considered appropriate in the general population, we recommend to maintain levels above 30 ng/mL (75 nmol/L) in categories at risk. (2) Whom, when, and how to perform screening for vitamin D deficiency: categories at risk (patients with bone, liver, kidney diseases, obesity, malabsorption, during pregnancy and lactation, some elderly) but not healthy people should be screened by the 25-hydroxy-vitamin D assay. (3) Whom and how to treat vitamin D deficiency: beyond healthy lifestyle (mostly sun exposure), we recommend oral vitamin D (vitamin D2 or vitamin D3) supplementation in patients treated with bone active drugs and in those with demonstrated deficiency. Dosages, molecules and modalities of administration can be profitably individually tailored. (4) How to monitor the efficacy of treatment with vitamin D: no routine monitoring is suggested during vitamin D treatment due to its large therapeutic index. In particular conditions, 25-hydroxy-vitamin D can be assayed after at least a 6-month treatment. We are confident that this document will help practicing clinicians in their daily clinical practice.

The Impact of Vitamin D in the Treatment of Essential Hypertension

The aim of this review is to investigate, whether there is a possible link between vitamin D supplementation and the reduction of blood pressure in hypertensive patients. The renin-angiotensin-aldosterone system is known for being deeply involved in cardiovascular tonus and blood pressure regulation. Hence, many of the pharmaceutical antihypertensive drugs inhibit this system. Interestingly, experimental studies in mice have indicated that vitamin D supplementation significantly lowers renin synthesis and blood pressure. It is conceivable that similar mechanisms may be found in the human organism. Regarding this, large-scale cross-sectional studies suggest the serum 25(OH)D-level to be inversely correlated to the prevalence of hypertension. However, randomized controlled trials (RCTs) have not found a clear association between vitamin D supplementation and improvements in hypertension. Nevertheless, the missing association of vitamin D and hypertension in clinical trials can be due to suboptimal study designs. There are hints that restoration of serum 25(OH)D levels during vitamin D therapy is essential to achieve possible beneficial cardiovascular effects. It is important to perform long-term trials with a short dose interval and a high bioavailability of supplementation. Taken together, more RCTs are required to further investigate if vitamin D can be beneficial for the reduction of blood pressure.

Raising awareness on the therapeutic role of cholecalciferol in CKD: a multidisciplinary-based opinion

Vitamin D is recognized to play an essential role in health and disease. In kidney disease, vitamin D analogs have gained recognition for their involvement and potential therapeutic importance. Nephrologists are aware of the use of oral native vitamin D supplementation, however, uncertainty still exists with regard to the use of this treatment option in chronic kidney disease as well as clinical settings related to chronic kidney disease, where vitamin D supplementation may be an appropriate therapeutic choice. Two consecutive meetings were held in Florence in July and November 2016 comprising six experts in kidney disease (N = 3) and bone mineral metabolism (N = 3) to discuss a range of unresolved issues related to the use of cholecalciferol in chronic kidney disease. The panel focused on the following six key areas where issues relating to the use of oral vitamin D remain controversial: (1) vitamin D and parathyroid hormone levels in the general population, (2) cholecalciferol in chronic kidney disease, (3) vitamin D in cardiovascular disease, (4) vitamin D and renal bone disease, (5) vitamin D in rheumatological diseases affecting the kidney, (6) vitamin D and kidney transplantation.

Correction of vitamin D status by calcidiol: pharmacokinetic profile, safety, and biochemical effects on bone and mineral metabolism of daily and weekly dosage regimens

RATIONALE

Calcidiol can be employed to correct vitamin D deficiency.

MAIN RESULTS

Calcidiol administered at daily and weekly regimens over a period of 3 months was able to successfully raise 25-hydroxyvitamin D levels without altering other markers related to bone and mineral metabolism.

SIGNIFICANCE

Calcidiol supplementation is effective and safe.

INTRODUCTION

The correction of vitamin D status is necessary to maintain an optimal mineral and skeletal homeostasis. Despite cholecalciferol (vitamin D₃) is the most commonly used drug for vitamin D supplementation, the more hydrophilic compound calcidiol (25-hydroxyvitamin D₃) can be employed at daily, weekly, and monthly regimens to reach in the short term the target levels of serum 25-hydroxyvitamin D [25(OH)D]. In the administration of different doses of calcidiol pharmacokinetic study (ADDI-D study), the efficacy and safety of daily and weekly dosages of calcidiol were tested.

METHODS

A total of 87 Caucasian, community-dwelling, postmenopausal women, aged 55 years or older, with vitamin D inadequacy (serum 25(OH)D levels <30 ng/ml, with mean 25(OH)D below 20 ng/ml, namely 16.5 ± 7.5 ng/ml) were randomized to receive three different dosages of calcidiol: 20 μg/day, 40 μg/day, and 125 μg/week for 3 months. The attained level of serum 25(OH)D was selected as primary endpoint to assess efficacy, while other parameters of mineral metabolism, (serum calcium, parathyroid hormone, phosphate, FGF23, urinary calcium, and markers of bone turnover) were assessed as secondary endpoints to establish safety.

RESULTS

In all the three groups, serum 25(OH)D values significantly and promptly rose and plateaued above the 30 ng/ml threshold remaining within safety interval after 14 days of treatment, with similar efficacy for the similar daily and weekly dose regimens. The different dosages were also equally effective in controlling secondary hyperparathyroidism. No significant changes in calcium and phosphate metabolism and in bone turnover markers were observed for any of the treatments, confirming the safety of this compound.

CONCLUSIONS

The results of this study demonstrate the short- and mid-term efficacy and safety on core parameters of mineral metabolism of different daily or weekly dosages of calcidiol when used to treat vitamin D inadequacy or deficiency in postmenopausal women. Further studies are needed to assess falls as primary outcome of calcidiol supplementation.

Parenteral vitamin D supplementation is superior to oral in vitamin D insufficient patients with type 2 diabetes mellitus

BACKGROUND/OBJECTIVES

Oral vitamin D supplementation is better than parenteral in improving vitamin D deficiency in individuals with no systemic illness. Our aim was to compare the efficacy of oral and parenteral routes of vitamin D supplementation on circulating serum 25(OH) vitamin D level in patients with type 2 diabetes mellitus.

METHODS

Total 85 cases of with type 2 diabetes mellitus were screened for vitamin D status of which 71 patients were vitamin D insufficient/deficient. They were randomized into two intent to treat groups with different vitamin D supplementation protocols (a) Oral-60000 IU per day for 5days (group I; n=40) and (b) injectable-300000 IU intramuscularly once (group II; n=31). Baseline and one month post supplementation 25(OH) vitamin D levels were measured in both the groups.

RESULTS

Baseline clinical characteristics and 25(OH) vitamin D levels were comparable in both the groups. Post treatment 25(OH) vitamin D level in group I was 26.06±9.06ng/ml and in group II was 49.69±18.92ng/ml. After one month of vitamin D supplementation, increment in 25(OH) vitamin D level from baseline was significantly higher in group II than group I (p<0.001).

INTERPRETATION & CONCLUSIONS

Injectable method of supplementation was better than oral route in improving serum 25 (OH) vitamin D status in patients with type 2 diabetes. The study suggested impaired absorption of vitamin D from the gastrointestinal tract in patients with type 2 diabetes mellitus and a need for parenteral route of vitamin D supplementation in deficient patients with type 2 diabetes mellitus.

Oral calcidiol is a good form of vitamin D supplementation

Vitamin D supplementation represents an important topic in the field of metabolic bone disease. Calcidiol, the 25-hydroxy-vitamin D [25(OH)D], is the form of vitamin D most recently introduced in clinical practice. Advantages of the use of calcidiol derive from the pharmacokinetic properties and are related to the possibility of use in patients with liver disease, obese patients, patients with intestinal malabsorption, secondary hyperparathyroidism associated with chronic kidney disease as well as to avoid any possible toxic effect when high doses are used. The ADDI-D study demonstrated the efficacy and safety of calcidiol at the daily dose of 20 or 40 μg and 125 μg/week. In particular, the daily dose of 40 μg can be suggested as an alternative in severely deficient patients, as it has demonstrated to ensure higher vitamin D levels, compared to the 20 μg/day and the weekly 125 μg dose. The last can be an option when issues with compliance to the supplementation are present.

Vitamin D Stored in Fat Tissue During a 5-Year Intervention Affects Serum 25-Hydroxyvitamin D Levels the Following Year

CONTEXT

Vitamin D and 25-hydroxyvitamin D [25(OH)D] are stored in adipose tissue, but the clinical relevance is uncertain.

OBJECTIVE

To evaluate changes in serum 25(OH)D and adipose tissue vitamin D levels after stopping vitamin D supplementation.

DESIGN

A prospective, double-blind cohort follow-up study.

SETTING

Clinical Research Unit at University Hospital of North Norway.

PATIENTS

Seventy-six subjects were included after participation in a 3- to 5-year prevention of type 2 diabetes study and were administered 20,000 IU of vitamin D or placebo per week.

INTERVENTION

During the 12-month follow-up period, blood samples were drawn at the beginning and after 1, 3, 6, 9, and 12 months. Fat biopsies were taken at the start and end.

MAIN OUTCOME MEASURES

Changes in 25(OH)D level in serum and 25(OH)D and vitamin D levels in adipose tissue.

RESULTS

Forty-one of 42 subjects who were given vitamin D and 33 of 34 subjects who were given placebo completed the study. At the inclusion, mean serum 25(OH)D levels were 122 and 71 nmol/L in the vitamin D and placebo groups, respectively. Serum 25(OH)D levels were significantly higher in the vitamin D group than in the placebo group throughout and were 84.5 and 73.1 nmol/L, respectively, after 12 months. In the vitamin D group, adipose tissue vitamin D levels decreased by 52% over 12 months.

CONCLUSION

Vitamin D and 25(OH)D stored in adipose tissue after 3 to 5 years of vitamin D supplementation may have a clinically relevant effect on serum 25(OH)D level the following year.

Effect of a single intravenous zoledronic acid administration on biomarkers of acute kidney injury (AKI) in patients with osteoporosis: a pilot study

AIMS

The pilot study was designed to evaluate the early effect of intravenous (i.v.) zoledronic acid (ZA) on renal function.

METHODS

Five mg i.v. ZA was administered to 23 patients with osteoporosis (17 women and 6 men, mean age 73 ± 7 SD years). Urinary NGAL, KIM-1, and MCP-1, plasma (p) MCP-1 and serum (s) IL-18, serum calcium (sCa), Creatinine clearance (CrCl), parathyroid hormone (PTH), plasma C-terminal FGF23 (pFGF23), serum (s) Klotho, calcium excretion (CaEx) and renal threshold phosphate concentration/GFR (TmPO₄ /GFR) were assessed at baseline, 24 h and Day 30 after administration.

RESULTS

There was a significant decrease in sCa and CaEx at 24 h (-4.1 ± 2.8%, P < 0.01 and -28 ± 59%, P < 0.05, respectively) and Day 30 (-3.9 ± 4%, P < 0.001 and -26 ± 43%, P < 0.01) and a significant increase in PTH (79.8 ± 95.8%) at Day 30 (P < 0.001) compared to baseline. TmPO₄ /GFR decreased significantly at 24 h and Day 30 (-8.6 ± 15.9%, P < 0.05 and -11.3 ± 13.5%, P < 0.001) compared to baseline. We observed no difference in the concentration of pFGF23, sKlotho and urinary AKI biomarkers at any time points. Mean levels of sIL-18 and pMCP-1 increased significantly at 24 h (44 ± 88%; P < 0.01 and 198 ± 237%; P < 0.001) and returned to baseline at Day 30.

CONCLUSIONS

Our pilot study suggests that there is no direct acute effect of ZA on kidney function. The increase in plasma MCP-1 and serum IL-18 concentration could be associated with the stimulation of immunity mechanisms occurring soon after the administration of the drug. Secondary hyperparathyroidism develops shortly after the infusion of ZA and is maintained even after 1 month.

Rapid vs Maintenance Vitamin D Supplementation in Deficient Children With Asthma to Prevent Exacerbations

BACKGROUND

Whether vitamin D reduces clinically important exacerbations of childhood asthma remains uncertain. We compared rapid to maintenance vitamin D repletion analyzed by baseline vitamin D level.

METHODS

Children presenting to the ED with moderate-to-severe asthma exacerbations and vitamin D levels ≤ 25 ng/mL underwent masked randomization, and then open dosing to either IM+oral (the latter daily) therapy or daily oral-only therapy, and were followed for 12 months. The primary outcome was patient-initiated unplanned visits for asthma exacerbations, examined two ways: cumulative proportions with an exacerbation, and average exacerbation frequency. As this was a nutrient study, we analyzed treatment groups by quartile of baseline vitamin D level, collecting repeat levels and clinical observations at 3, 6, 9, and 12 months after enrollment.

RESULTS

One hundred and sixteen patients in the IM+oral cohort vs 115 in the oral-only cohort had similar mean (SD) baseline levels: 15.1 (5.4) vs 15.8 (5.2) ng/mL (range, 3-25 ng/mL). There was no difference in the primary outcome over the entire 12-month observation period. However, rapid IM+oral supplementation significantly reduced unplanned visits for asthma exacerbations for children with baseline levels of 3 to 11 ng/mL during the initial 3 months: the relative exacerbation rate for the IM+oral cohort compared with the oral-only cohort at 3 months was 0.48 (95% CI, 0.28-0.89; P = .008); average exacerbation frequency per child analysis, relative rate 0.36 (95% CI, 0.13-0.87; P = .017). Otherwise, there were no significant differences between groups.

CONCLUSIONS

Rapid compared to maintenance vitamin D supplementation for children with the lowest levels resulted in short- but not long-term reduction in asthma exacerbations.

Nutritional rickets around the world: an update

Worldwide, nutritional rickets continues to be an evolving problem with several causes. This paper provides an updated literature review characterising the prevalence, aetiology, pathophysiology and treatment of nutritional rickets worldwide. A systematic review of articles on nutritional rickets from various geographical regions was undertaken. For each region, key information was extracted, including prevalence, cause of rickets specific to the region, methods of confirming the diagnosis and current treatment and preventive measures. Calcium deficiency continues to be a major cause of rickets in Africa and Asia. Vitamin D deficiency rickets is perhaps increasing in the Americas, Europe and parts of the Middle East. There continues to be a distinct presentation of calcium-predominant versus vitamin D predominant rickets, although there are overlapping features. More careful diagnosis of rickets and reporting of 25-OHD concentrations has improved accurate knowledge of rickets prevalence and better delineated the cause. Nutritional rickets continues to be an evolving and multi-factorial problem worldwide. It is on a spectrum, ranging from isolated vitamin D deficiency to isolated calcium deficiency. Specific areas which require emphasis include a consistent community approach to screening and diagnosis, vitamin D supplementation of infants and at-risk children, prevention of maternal vitamin D deficiency and the provision of calcium in areas with low calcium diets.

Vitamin D deficiency as a public health issue: using vitamin D2 or vitamin D3 in future fortification strategies

The role of vitamin D in supporting the growth and maintenance of the skeleton is robust; with recent research also suggesting a beneficial link between vitamin D and other non-skeletal health outcomes, including immune function, cardiovascular health and cancer. Despite this, vitamin D deficiency remains a global public health issue, with a renewed focus in the UK following the publication of Public Health England's new Dietary Vitamin D Requirements. Natural sources of vitamin D (dietary and UVB exposure) are limited, and thus mechanisms are needed to allow individuals to achieve the new dietary recommendations. Mandatory or voluntary vitamin D food fortification may be one of the mechanisms to increase dietary vitamin D intakes and subsequently improve vitamin D status. However, for the food industry and public to make informed decisions, clarity is needed as to whether vitamins D2 and D3 are equally effective at raising total 25-hydroxyvitamin D (25(OH)D) concentrations as the evidence thus far is inconsistent. This review summarises the evidence to date behind the comparative efficacy of vitamins D2 and D3 at raising 25(OH)D concentrations, and the potential role of vitamin D food fortification as a public health policy to support attainment of dietary recommendations in the UK. The comparative efficacy of vitamins D2 and D3 has been investigated in several intervention trials, with most indicating that vitamin D3 is more effective at raising 25(OH)D concentrations. However, flaws in study designs (predominantly under powering) mean there remains a need for a large, robust randomised-controlled trial to provide conclusive evidence, which the future publication of the D2-D3 Study should provide (BBSRC DRINC funded: BB/I006192/1). This review also highlights outstanding questions and gaps in the research that need to be addressed to ensure the most efficacious and safe vitamin D food fortification practices are put in place. This further research, alongside cost, availability and ethical considerations (vitamin D3 is not suitable for vegans), will be instrumental in supporting government, decision-makers, industry and consumers in making informed choices about potential future vitamin D policy and practice.

Vitamin D Status and Its Association with Parathyroid Hormone Concentration in Brazilians

Vitamins are organic compounds that play a vital role in the control of metabolic processes. The D complex is considered a nutrient with a hormonal action and has an important participation in the constant maintenance of serum and extracellular calcium levels. The present study aims to analyze the results of 105.588 vitamin D (25(OH)D) measurements obtained from a database from a clinical analysis laboratory in Brazil, between the years of 2011 and 2013. The values of 25(OH)D were correlated with age, gender, and values of PTH. The results show a high prevalence of values of 25(OH)D considered inadequate, characterizing 76% of the studied population. It was observed that 26,5% of the individuals had deficiency and 49,5% had insufficiency of vitamin D. It was also shown that there was a negative correlation between 25(OH)D and PTH levels. In conclusion, this study is in accordance with others that show a high prevalence of vitamin D deficiency in different populations and alerts us for the importance of these measurements and analysis in clinical practice and as a base for diagnosis and treatment of hypovitaminosis.

Effect of oral versus intramuscular Vitamin D replacement in apparently healthy adults with Vitamin D deficiency

CONTEXT

A number of controversies exist regarding appropriate treatment strategy for Vitamin D deficiency.

AIMS

The aim of this study was to investigate the efficacy of equivalent doses of oral cholecalciferol (60,000 IU weekly for 5 weeks) versus intramuscular (IM) cholecalciferol (300,000 IU) in correcting Vitamin D deficiency in apparently healthy volunteers working in a hospital.

SETTINGS AND DESIGN

Prospective randomized open-label single institution study.

SUBJECTS AND METHODS

This study enrolled 40 apparently healthy adults with Vitamin D deficiency into 2 arms. The oral cholecalciferol group (n = 20) received oral cholecalciferol 60,000 IU weekly for 5 weeks while the IM cholecalciferol group (n = 20) received a single injection of cholecalciferol 300,000 IU. The main outcome measure was serum 25-hydroxyvitamin D (25OHD) levels at baseline, 6 and 12 weeks after the intervention.

STATISTICAL ANALYSIS USED

Differences in serum 25OHD and other biochemical parameters at baseline and follow-up were analyzed using general linear model.

RESULTS

Mean 25OHD level at baseline was 5.99 ± 1.07 ng/mL and 7.40 ± 1.13 ng/mL (P = 0.332) in the oral cholecalciferol and IM cholecalciferol group, respectively. In the oral cholecalciferol group, serum 25OHD level was 20.20 ± 1.65 ng/mL at 6 weeks and 16.66 ± 1.36 ng/mL at 12 weeks. The corresponding serum 25OHD levels in the IM cholecalciferol group were 20.74 ± 1.81 ng/mL and 25.46 ± 1.37 ng/mL at 6 and 12 weeks, respectively. At 12 weeks, the mean 25OHD levels in IM cholecalciferol group was higher as compared to the oral cholecalciferol group (25.46 ± 1.37 vs. 16.66 ± 1.36 ng/mL; P < 0.001).

CONCLUSIONS

Both oral and IM routes are effective for the treatment of Vitamin D deficiency. 25-hydroxyvitamin D levels in the IM cholecalciferol group showed a sustained increase from baseline.

Global Consensus Recommendations on Prevention and Management of Nutritional Rickets

BACKGROUND

Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication.

EVIDENCE

A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describes the strength of the recommendation and the quality of supporting evidence.

PROCESS

Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus.

RESULTS

This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts.

CONCLUSION

Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.

An oral high dose of cholecalciferol restores vitamin D status in deficient postmenopausal HIV-1-infected women independently of protease inhibitors therapy: a pilot study

The best repletion and maintenance dosing regimens with cholecalciferol in vitamin D-deficient HIV-1 patients remain unknown. Protease inhibitors (PIs) have been shown to inhibit vitamin D 1α- and 25α-hydroxylation in hepatocyte and monocyte cultures. We therefore evaluated the effect of a single high dose of cholecalciferol in vitamin D-deficient HIV-1 postmenopausal women undergoing treatment with highly active anti-retroviral therapy (cART), with and without PIs. Forty HIV-1 postmenopausal women treated with cART, with hypovitaminosis D (<20 ng/ml), were enrolled. We measured serum changes of 25-hydroxyvitamin D [25(OH)D]; 1,25-dihydroxyvitamin D [1,25(OH)2D], parathyroid hormone (PTH), serum calcium, and urinary calcium excretion following a loading dose of 600,000 IU of cholecalciferol after 3, 30, 60, 90, and 120 days. Patients were divided into two groups, whether or not they were taking PI. A significant increase in mean 25(OH)D and 1,25(OH)2D levels at day 3 and throughout the entire observation period was found in both groups (p < 0.001). PTH levels concomitantly decreased in both groups (p < 0.001). Mean albumin-adjusted serum calcium increases with respect to baseline were significant only at day 3 and day 30 for both groups (p < 0.01). Considering remaining parameters, there were no significant differences between the groups at any time, by two-way RM ANOVA. An oral dose of 600,000 IU of cholecalciferol in HIV-1 postmenopausal women rapidly increases 25(OH)D and 1,25(OH)2D levels reducing PTH levels, regardless of the presence of PIs in the cART scheme.

Low-dose oral cholecalciferol is associated with higher numbers of Helios(+) and total Tregs than oral calcitriol in renal allograft recipients: an observational study

Background

Regulatory T cells (Tregs) are a cornerstone of graft acceptance. High numbers of Tregs are associated with better long-term graft survival. Recently, Vitamin D was suggested as an immunomodulator, in addition to its classical role in calcium metabolism. Vitamin D modulates Tregs and might, thereby, promote graft acceptance and long-term graft survival.

Methods

One hundred twenty-three renal allograft recipients attending either Heidelberg nephrology or Giessen internal medicine clinic were enrolled in this cross- sectional study. Sixteen healthy controls were studied in addition. Sixty-nine patients were receiving no vitamin D, 38 calcitriol, and 16 cholecalciferol supplementations. We evaluated whether there was a difference in the absolute numbers of Helios⁺, Helios⁻, CTLA-4⁺, IFNg⁺, and total Tregs among the patient groups.

Results

Cholecalciferol supplementation was associated with higher absolute numbers of Helios⁺, CTLA-4⁺, and total Tregs than calcitriol (p < 0.001, p = 0.004, p = 0.001 respectively). Helios⁺ Tregs were also higher in cholecalciferol than no vitamin D supplementation patients (p = 0.001), whereas CTLA-4⁺ and total Tregs were similar in both groups (p = NS). Helios⁺, Helios⁻, CTLA-4⁺, IFNg⁺, and total Tregs were similar in the cholecalciferol and healthy control groups (p = NS).

Conclusion

Our findings indicate that cholecalciferol, even when administered at low dosages, has a stabilizing effect on Tregs (particularly the Helios + subset), in contrast to calcitriol which showed neither a stabilizing nor a proliferation-inducing effect on the same cell population.