Vitamin D analogs decrease in vitro secretion of RANTES and enhance the effect of budesonide

International consensus statement on allergy and rhinology: rhinosinusitis 2021

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EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Effects of vitamin D on drugs: Response and disposal

Vitamin D supplementation and vitamin D deficiency are common in clinical experience and in daily life. Vitamin D not only promotes calcium absorption and immune regulation, but also changes drug effects (pharmacodynamics and adverse reactions) and drug disposal in vivo when combined with various commonly used clinical drugs. The extensive physiological effects of vitamin D may cause synergism effects or alleviation of adverse reactions, and vitamin D's affect on drugs in vivo disposal through drug transporters or metabolic enzymes may also lead to changes in drug effects. Herein, the effects of vitamin D combined with commonly used drugs were reviewed from the perspective of drug efficacy and adverse reactions. The effects of vitamin D on drug transport and metabolism were summarized and analyzed. Hopefully, more attention will be paid to vitamin D supplementation and deficiency in clinical treatment and drug research and development.

The Immunomodulatory Role of Vitamin D in Respiratory Diseases

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The growing interest in the new role of vitamin D, particularly as an immunomodulatory factor, has spurred basic research and the development of clinical trials to better understand the influence of supplementation on various diseases. Vitamin D is an important nutrient factor in human health due to its role in calcium metabolism regulation, cellular growth, differentiation and its fundamental discovered activity in immune functions. It has influenced different diseases, particularly inflammatory and autoimmune diseases, through immune response regulation, modulating innate and adaptive immunity.

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The aim of this review was to explore the role of vitamin D in the main respiratory diseases in children such as asthma, chronic rhinosinusitis, cystic fibrosis and recurrent respiratory infections.

Vitamin D3 Deficiency and its Association with Nasal Polyposis in Patients with Cystic Fibrosis and Patients with Chronic Rhinosinusitis

Background

Currently vitamin D3 (VD3) or cholecalciferol is considered an immunomodulator that may be implicated in nasal polyposis (NP) pathophysiology.

Objectives

This study aimed to investigate if deficiency of VD3 is associated with the presence of NP in patients with cystic fibrosis (CT) and patients with chronic rhinosinusitis (CRS).

Methods

In total, 152 adult participants were included in five phenotypic groups: CT with NP (CTwNP) (n = 27), CT without NP (CTsNP) (n = 31), CRS with NP (CRSwNP) (n = 32), CRS without NP (CRSsNP) (n = 30), and controls (n = 32). The serum levels of 25(OH)-VD3 <20 ng/mL are considered as a deficiency, 21–29 ng/mL as insufficiency, and >30 ng/mL as sufficiency. Endoscopic and imaging staging of the mucosal disease performed with the Lund-Kennedy (LK) and Lund-Mackay (LM) scoring systems, respectively. The genotype of the patients with CT and the nasal microbial colonization of the patients with CT and patients with CRS were also recorded.

Results

The patients with CTwNP had the lowest percentage of sufficiency in VD3 and the highest percentage in insufficiency among all the groups. The LM imaging scores were inversely correlated with the VD3 levels in both arms of the study (CT and CRS). Moreover, the LK endoscopic scores had a similar correlation in the CT groups; however, this was not the case with the CRS groups. The genotype of the patients with CT was not correlated with the VD3 serum levels. The patients with positive microbial colonization (mainly Pseudomonas and Staphylococcus aureus) had significantly lower VD3 serum levels in both the CT and CRS process.

Conclusion

VD3 deficiency seemed to be associated with the presence of nasal polyps in the patients with CRS and in the patients with CT in a similar manner. The lower the level of serum VD3, the more severe the mucosal disease was found in the imaging studies and the more frequent microbial colonization of the patients with CT and the patients with CRS.

Vit D deficiency is a possible risk factor in ARS

Vitamin D deficiency is effective in the development of acute rhinosinusitis and prolongation of inflammation by increasing inflammation in the sinonasal epithelium. Vitamin D deficiency is important in the development of bone barriers that prevent the complication of acute rhinosinusitis. Although Vitamin D levels may be a variable risk factor for various respiratory tract disorders, there are limited data on the role in sinonasal infections. Our aim was to investigate the association of 25-hydroxy-vitamin D (25OHD) levels with acute rhinosinusitis (ARS) and preseptal cellulitis complications. The type of the study is prospective case-control study. Fifteen patients in the pediatric age group with ARS-induced preseptal cellulitis complication were identified as Group 1, fifteen patients with ARS and without complication were identified as Group 2, and fifteen healthy volunteers were identified as Group 3. Serum 25OHD levels (nmol/l) were measured in addition to routine blood tests at the first admission of patients participating in the study. Statistical analysis was performed between groups. The ages of the cases ranged from 1 to 14 years with a mean of 5.62 ± 3.42 years. 55.6% of the cases (n = 25) were male; 44.4% (n = 20) were female children. As a result of classification in which vitamin D levels were compared with normal values, there was a statistically significant difference according to the presence of ARS (Group-1 and Group 2) and absence of ARS (Group-3) (p < 0.05). A statistically significant difference was also found between Group 1 and Group-3 (p < 0.05). Statistically significant difference between Group 1 and Group 3 suggests that lack of vitamin D predisposes to the complication of preseptal cellulitis. Comparison of Group 1 and 2 with Group 3 (normal subjects) suggests that Vit D has a protective effect against developing sinusitis.

The relationship between serum vitamin D and chronic rhinosinusitis: A systematic review

BACKGROUND

An exciting development in upper respiratory tract disease is the pathophysiology of vitamin D (VD3). There now is substantial literature to indicate that VD3 acts as an immunomodulator of adaptive and innate immunity locally within the respiratory epithelium. Chronic rhinosinusitis (CRS) places a relatively large socioeconomic burden on developed nations, yet remains a difficult disease to treat. VD3, therefore, has become an area of clinical interest because it may provide an adjunctive drug therapy option in CRS, thereby potentially improving the quality of life of these patients.

OBJECTIVE

A systematic review of the relationship among serum VD3 levels, CRS phenotype, and disease severity by using outcome assessments.

METHODS

A systematic search was performed by using the PubMed, MEDLINE, and EMBASE databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Studies that measured serum VD3 levels and correlated the measurements to any subtype of CRS (with or without nasal polyps) were included for qualitative analysis.

RESULTS

Seven articles were included (four prospective and three retrospective studies), with a total of 539 patients. There were significantly lower VD3 levels in the polypoid phenotypes of CRS compared with controls. Low VD3 levels were often associated with an increased degree of inflammation.

CONCLUSION

The available evidence indicated that there is a significant relationship between low VD3 levels and polypoid CRS phenotypes. The association between VD3 levels and disease severity and VD3 potential for drug therapy remains unclear, which warrants further research in the area.

Vitamin D deficiency is associated with increased human sinonasal fibroblast proliferation in chronic rhinosinusitis with nasal polyps

BACKGROUND

Vitamin D3 (VD3) is a steroid hormone with known antiproliferative properties. Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have been shown to be VD3-deficient. Moreover, VD3 deficiency is associated with worse disease in patients with CRSwNP. One cell type thought to play a role in chronic rhinosinusitis (CRS) is the human sinonasal fibroblast (HSNF). The aim of this study was to investigate VD3 deficiency and HSNF proliferation in CRSwNP.

METHODS

Blood and sinus tissue explants were collected at the time of surgery from patients with CRSwNP (n = 15). Control subjects (n = 12) were undergoing surgery for cerebrospinal fluid leak repair or to remove non-hormone-secreting pituitary tumors. Ex vivo HSNF proliferation was analyzed with flow cytometry using expression of fibroblast-specific protein (FSP) and the proliferation marker Ki67. Plasma levels of 25-hydroxyvitamin D3 (25VD3) were measured by enzyme-linked immunosorbent assay. In vitro analysis of HSNF proliferation after treatment with calcitriol (1,25VD3) was performed using carboxyfluorescein succinimidyl ester (CFSE) and analyzed with flow cytometry.

RESULTS

In CRSwNP patients there was an inverse correlation between 25VD3 and proliferating HSNFs (p = 0.0135). This correlation was not seen for control patients (p = 0.3869). In vitro analysis showed that HSNFs from patients with CRSwNP had a higher proliferation index at baseline than HSNFs from control patients (p < 0.01). When treated with 1,25VD3, there was a significant decrease in HSNF proliferation index in patients with CRSwNP (p < 0.01), but not control patients.

CONCLUSION

VD3 deficiency is associated with increased HSNF proliferation in CRSwNP. Further investigation into how HSNFs and VD3 impact CRSwNP pathophysiology is warranted.

The Role of the Fibroblast in Inflammatory Upper Airway Conditions

Upper airway inflammation is one of the most frequent health care presentations. This is perhaps not surprising with our exposure to a myriad of environmental microbes, pollutants, and allergens. The precise pathophysiological mechanisms that cause persistent, exaggerated, upper airway inflammation rather than acute resolving illness remain unclear. Analysis of upper airway specimens identifies specific inflammatory cells, cytokine signatures, and fibrotic airway remodeling. Recent research has highlighted the role of stromal cells in the generation and persistence of chronic inflammation. Rather than simply being scaffolding or extracellular matrix-secreting cells on which organ systems are built, stromal cells including fibroblasts and osteocytes have their own independent immunologic functions. Here, we review the emerging inflammatory roles of upper airway fibroblasts, the majority of which appear to influence immune cell chemotaxis and amplify the inflammatory response.

Association of Vitamin D Status and Acute Rhinosinusitis: Results From the United States National Health and Nutrition Examination Survey 2001-2006

Although vitamin D status may be a modifiable risk factor for various respiratory ailments, limited data exists regarding its role in sinonasal infections. Our goal was to investigate the association of 25-hydroxyvitamin D (25OHD) levels with acute rhinosinusitis (ARS) in a large, nationally representative sample of non-institutionalized individuals from the United States. In this cross-sectional study of individuals ≥ 17 years from the National Health and Nutrition Examination Survey 2001-2006, we used multivariable regression analysis to investigate the association of 25OHD levels with ARS, while adjusting for season, demographics (age, sex, race, and poverty-to-income ratio), and clinical data (smoking, asthma, chronic obstructive pulmonary disease, diabetes mellitus, and neutropenia). A total of 3921 individuals were included in our analyses. Median 25OHD level was 22 (interquartile range 16-28) ng/mL. Overall, 15.8% (95% confidence interval [CI] 14.4-17.7) of participants reported ARS within the 24 hours leading up to their survey participation. After adjusting for season, demographics, and clinical data, 25OHD levels were associated with ARS (odds ratio 0.88, 95% CI 0.78-0.99 per 10 ng/mL). When vitamin D status was dichotomized, 25OHD levels < 20 ng/mL were associated with 33% higher odds of ARS (odds ratio 1.33, 95% CI 1.03-1.72) compared with levels ≥ 20 ng/mL. Our analyses suggest that 25OHD levels are inversely associated with ARS. Randomized, controlled trials are warranted to determine the effect of optimizing vitamin D status on the risk of sinonasal infections.

Vitamin D for the treatment of respiratory diseases: is it the end or just the beginning?

A large number of human, animal and in vitro studies have suggested that vitamin D3 (VD3) plays a critical role in inflammatory airway diseases such as asthma, chronic rhinosinusitis, and allergic rhinitis. VD3 acts upon a broad range of immune cells involved in the pathogenesis of these diseases including T-cells, dendritic cells (DCs), macrophages, and B-cells. In addition, VD3 can also regulate the functions of a number of non-immune cells including epithelial cells, fibroblasts, and smooth muscle cells. Given that VD3 has known effects on the immune system, it seems logical that supplementation with VD3 would prove efficacious in the treatment of these three diseases. While many studies, most of which are observational, have suggested that VD3 deficiency is associated with more severe disease, VD3 supplementation trials in humans have resulted in varied outcomes in terms of efficacy. In this review article we will discuss the role of VD3 in these three commonly associated respiratory diseases. We will explore the literature describing associations of VD3 deficiency with patient outcomes, cells in the respiratory microenvironment susceptible to VD3 regulation, conflicting results of VD3 supplementation trials, and potential gaps in our knowledge that may be limiting the widespread use of VD3 for the treatment of respiratory diseases such asthma, chronic rhinosinusitis and allergic rhinitis. This article is part of a Special Issue entitled '17th Vitamin D Workshop'.

Vitamin D3 as a novel regulator of basic fibroblast growth factor in chronic rhinosinusitis with nasal polyposis

BACKGROUND

The immunopathogenesis of chronic rhinosinusitis (CRS) is largely unknown, but it is thought that different inflammatory profiles are responsible for the different CRS subtypes. 25-Hydroxyvitamin-D (25-VD3) has been shown to alter inflammatory mediators in other disease processes and 25-VD3 deficiency is associated with CRS with nasal polyps (CRSwNP), but it is unknown if 25-VD3 levels impact local inflammation in CRS. This study investigated the correlation between plasma 25-VD3 and sinonasal mucus monocyte chemoattractant protein-1 (MCP-1), regulated upon activation normal T cell expressed and secreted (RANTES), and basic fibroblast growth factor (bFGF) levels in patients with CRS.

METHODS

Study subjects undergoing endoscopic sinus surgery (ESS) for CRS were prospectively enrolled from January 2012 to August 2014. Control subjects included patients undergoing ESS for noninflammatory pathology. Blood and sinonasal mucus were collected at the time of ESS. Plasma 25-VD3 was measured by enzyme-linked immunosorbent assay (ELISA) and mucus levels of MCP-1, RANTES, and bFGF by cytometric bead array (CBA).

RESULTS

A total of 57 patients were enrolled and categorized as CRS without nasal polyps (CRSsNP) (n = 31), CRSwNP (n = 14), and controls (n = 12). No significant correlation was found between MCP-1 and 25-VD3. There was a significant negative correlation between 25-VD3 and RANTES (r = -0.612; p = 0.026) and bFGF (r = -0.578; p = 0.039) in CRSwNP patients; however, there was no significant correlation in CRSsNP patients.

CONCLUSION

This data suggests that 25-VD3 may play a role in regulation of RANTES and bFGF expression in CRSwNP. This may occur through regulation of NP fibroblasts or other immune cells. Further investigation is warranted to better elucidate the role of RANTES, bFGF, and 25-VD3 in CRSwNP.

Vitamin D decreases the secretion of eotaxin and RANTES in nasal polyp fibroblasts derived from Taiwanese patients with chronic rhinosinusitis with nasal polyps

Eosinophils are important inflammatory cells involved in the pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP). Vitamin D and its derivatives, in addition to their classic role as regulators of electrolytes homeostasis, have modulatory effects in immunological and inflammatory responses. Such properties suggest that vitamin D might also play a role in inflammatory airway diseases such as CRSwNP. In this study, we investigated the effect of vitamin D derivatives (calcitriol and tacalcitol) on the secretion of eotaxin and Regulated on Activation, Normal T Cell Expressed and Secreted (RANTES), the two major eosinophil chemoattractants, in fibroblasts derived from the polyps of Taiwanese CRSwNP patients. Patients diagnosed with eosinophilic CRSwNP but without malignancies or asthma and undergoing elective endoscopic sinus surgery were recruited. Three primary fibroblast cultures were established using the polyp specimens obtained from these patients. The third to eighth passages of the fibroblasts were used for in vitro studies. Nasal polyp-derived fibroblasts were stimulated with IL-1β (10 ng/mL) for 24 hours, followed by replacement with media alone or with calcitriol or tacalcitol (10 μM) and incubation for another 24 hours. After the treatments, the levels of secreted eotaxin and RANTES were evaluated by ELISA assays. The results showed that IL-1β could substantially stimulate the secretion of eotaxin (p < 0.01) and RANTES (p < 0.01) in nasal polyp-derived fibroblasts. More importantly, this stimulatory effect was significantly suppressed by adding calcitriol (p ≤ 0.002 for eotaxin and p ≤ 0.008 for RANTES) or tacalcitol (p ≤ 0.009 for eotaxin and p ≤ 0.02 for RANTES). Therefore, the inhibitory effect of vitamin D derivatives on eotaxin and RANTES secretion might shed light not only on the disease mechanism, but also on the potential use of vitamin D in pharmacotherapy of Taiwanese patients with CRSwNP.