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3 more rheumatic studies found vitamin D deficiencies – June 2010

Vitamin D deficiency confirmed as common across a range of rheumatic conditions

Rome, Italy, Friday 18 June 2010: Two separate studies have shown that vitamin D deficiency is common in patients with a range of rheumatic diseases, with over half of all patients having below the 'normal' healthy levels of vitamin D (48-145 nmol/L) in their bodies. A further study assessing response to vitamin D supplementation found that taking the recommended daily dose did not normalise vitamin D levels in rheumatic disease patients. The results of these three studies were presented today at EULAR 2010, the Annual Congress of the European League Against Rheumatism in Rome, Italy.

A UK study1 of 180 patients aimed to assess mean levels of vitamin D in patients with inflammatory joint diseases, osteoarthritis and myalgia (muscle pain that, when experienced long term may be associated with nutritional deficiency). Data on vitamin D levels were gathered and results showed that 58% of individuals with a rheumatic condition had levels below that clinically considered to be 'sufficient' in healthy subjects (48-145 nmol/L).

An Italian study2 of 1,191 RA patients aimed to determine a correlation between vitamin D deficiency and several different clinical measures of disease activity. Researchers found that, regardless of supplementation, levels of 25-hydroxyvitamin D (25(OH)D), (a standard clinical measure of vitamin D in the blood), were lower than healthy levels (<50 nmol/L) in 85% of the patients not taking a vitamin D supplement and in 60% of those taking 800 IU or more vitamin D daily as a supplement. In non-supplemented patients levels of 25(OH)D significantly correlated with three measures of disease activity - the Health Assessment Questionnaire Disability Index, (p=0.000) the Mobility Activities of Daily Living Score (p=0.000) and the Number of Swollen Joints count (p=0.000).

"We have seen in studies that vitamin D deficiency is common in patients with a range of rheumatic diseases, and our results have confirmed this using several clinically accepted measures of disease activity," said Dr. L. Idolazzi, of the Rheumatology Unit, University of Verona, Italy. "What we need to see now is a range of long term studies, which examine the clinical response of patients to vitamin D supplementation."

Furthermore, a third study undertaken in Italy3 aimed to evaluate the affect of vitamin D supplementation in patients with inflammatory autoimmune disease (IAD) and non-inflammatory autoimmune disease (NIAD). Following supplementation, only 29% patients reached vitamin D levels greater than the level clinically considered to be 'sufficient' in healthy subjects, with no significant differences in vitamin D levels observed between the IAD and NIAD groups.

"Whilst it is well known that hypovitaminosis D is often seen in patients with inflammatory autoimmune diseases, the effects of supplementation have not been fully investigated in this setting," said Dr. Pier Paolo Sainaghi of the Immuno-Rheumatology Clinic, A. Avogadro University of Eastern Piedmont, Novara, Italy and author of the third study. "The results of our study show that daily 800-1,000 IU supplementation is not sufficient to normalise vitamin D levels in patients with rheumatologic or bone conditions. What is unclear is whether a higher dose would be more effective."

Study designs and key statistics

The UK study1 involved patients with a diagnosis of rheumatoid arthritis (RA), osteoporosis, or unexplained muscle pain, (total n=90, 30 from each group). These patients were matched with a control group of patients presenting with chronic back pain for a minimum of 6 months (n=90). The RA patient group registered median levels of vitamin D of 36 nmol/L (range 16-85 nmol/L, p=0.045) and in osteoporosis patients, these levels were slightly lower with a median value of 31 nmol/L (range 7-82 nmol/L, p=0.005). Patients with unexplained muscle pain had equally low median levels of vitamin D at 31 nmol/l (range 11-79 nmol/L, p= 0.008).

In the first Italian study2 of 1,191 patients (85% women) from 22 rheumatology centres, researchers measured levels of 25(OH)D, alongside paramaters of disease activity, calcium intake, sun exposure and bone mineral density. The association found by researchers between disease activity scores and vitamin D levels remained statistically significant when adjusted for both sun exposure and body mass index (BMI), both known risk factors for vitamin D deficiency. Significantly lower 25(OH)D levels were found in patients with active disease compared with those in disease remission (mean level 21.8 nmol/L 25(OH)D vs. 23.6 nmol/L respectively, p=0.057), and in those who were not responding to treatment compared to patients with a good response to treatment (20.5 nmol/L vs. 23.4 nmol/L p=0.020).

In the third Italian study3, 100 patients (43 with IAD and 57 with NIAD) received daily supplementation of 800-1000 IU of cholecalciferol (a form of vitamin D often used to fortify foods) over the course of six months. Abstract Numbers: FRI0509, SAT0093, SAT0506

For further information on this study, or to request an interview with the study lead, please do not hesitate to contact the EULAR congress Press Office on the 1st floor of Hall 5 of the Congress Centre during EULAR 2010 or on: Email: eularpressoffice at uk.cohnwolfe.com

from https://b-com.mci-group.com/AbstractList/EULAR10.aspx Abstracts


C. Kelly 1,*, K. Scott 1, G. Bell 1, E. Pellas 1, C. Tully 1, J. Dyson 1

1Rheumatology, Queen Elizabeth Hospital, Gateshead, United Kingdom

Background: Interest in the role of vitamin D in rheumatic disease has developed apace with reports that low levels of vitamin D may be associated with inflammatory joint disease and other auto immune disorders. Indeed, low levels of vitamin D have been reported in a wide variety of different rheumatic disease processes. The relevance of these findings in some categories of musculoskeletal disease remains unclear.

Objectives: We performed a comparative study of vitamin D levels in outpatients with a wide range of rheumatic disease to assess mean levels of vitamin D in inflammatory joint disease, osteoporosis and myalgia.

Methods: We measured 25-hydroxy D levels in four groups of outpatients recruited from clinic. The groups comprised 30 patients with each of: Rheumatoid arthritis (RA), osteoporosis, unexplained muscle pain, and a control group with chronic low back pain of over 6 months duration (n= 90). Patients already on supplements with vitamin D and calcium were excluded from this study. Our normal range for vitamin D is 48-145 nmol/l. and we calculated median levels (range) in each group. We compared values within the three groups with values of those control patients with chronic pain using Students unpaired t test.

Results: Groups were matched for age and gender mix with a female: male ratio of 2:1 and a mean age of 58 years. Within all patients combined (n=180), the overall median level of vitamin D was 38 nmol/l and 58% of individuals had values below the normal range. Median values in the control group were 51 nmol/l (range 11 - 105 nmol/l). All three comparator patient groups had significantly reduced levels. RA patients had median levels of vitamin D of 36 nmol/l (range 16-85 nmol/l) p=0.045. Levels in osteoporosis patients were even lower with a median value of 31 nmol/l (range 7-82 nmol/l) p=0.005. Intriguingly, patients with unexplained muscle pain had equally low median levels of vitamin D at 31 nmol/l (range 11-79 nmol/l) p= 0.008.

Conclusion: Our data confirms that vitamin D deficiency is common in patients with a range of rheumatic diseases. It supports published evidence showing that vitamin D levels are low in RA and supports the need to consider supplementation in such patients. The relevance of vitamin D deficiency in osteoporosis is well recognised and our data supports the need for routine supplementation in such patients. Less anticipated was our finding of low levels of vitamin D among patients with diffuse muscle pain. This may represent a symptomatic manifestation of vitamin D deficiency in a significant proportion of such patients and highlights the need to consider this within the differential diagnosis of muscle pain


L. Idolazzi 1,*, G. Bagnato 2, G. Bianchi 3, M. Caminiti 4, F. P. Cantatore 5, A. Del Puente 6, B. Frediani 7, A. Iagnocco 8, M. Muratore 9, M. L. Sorgi 8, S. Adami 1, M. Rossini 1 and Vitamin D in Rheumatoid Arthritis (VITAR) Study Group

1University, Verona, 2University, Messina, 3Ospedale La Colletta, Arenzano, 4Az. Ospedaliera "Bianchi-Melacrino-Morelli", Reggio Calabria, 5University, Foggia, 6University Federico II, Napoli, 7University, Siena, 8University La Sapienza, Roma, 9Ospedale, Lecce, Italy

Background: Vitamin D deficiency is quite common among elderly individuals and it is associated with musculoskeletal symptoms. In rheumatoid arthritis (RA), its deficiency may be associated with increased disease activity and disability.

Objectives: To estimate the prevalence and determinants of vitamin D deficiency and secondary hyperparathyroidism and to study the association of vitamin D deficiency with disease activity and disability in RA.

Methods: We studied 1191 consecutive RA patients (85% women) from 22 Italian rheumatology centres. Together with parameters of disease activity, calcium intake, mean summer sun exposure time (sun exposure) and bone mineral density, in all patients the serum levels 25-hydroxyvitamin D 25(OH)D and serum parathyroid hormone were measured in a centralized laboratory.

Results: Fifty five% of the patients were not taking vitamin D supplements. The proportion of patients with 25(OH)D level <20 ng/ml was 52% in the subjects not on vitamin D supplements and in one third of those supplemented.

In non-supplemented patients 25(OH)D levels were significantly correlated with Health Assessment Questionnaire Disability Index, Mobility Activities of daily living score, and number of swollen joints. Significantly lower 25(OH)D values were found in patients not on disease remission or poorly responding to treatment, with the highest Steinbrocker functional state, and on treatment with disease-modifying antirheumatic drug or anti-TNF? agents. Good predictors of 25(OH)D values (p>0.000) were body mass index (BMI, kg/m2) and sun exposure.

The patients with the worse indices of disease activity were spending significantly less time at sunshine. The association between disease activity scores and 25(OH)D levels remained statistically significant also for 25(OH)D levels adjusted for both sun exposure and BMI.

Conclusion: In RA patients, disease activity scores are inversely related with 25(OH)D levels, and these relationships remained statistically significant even when the 25(OH)D values are adjusted for the known risk factors for vitamin D deficiency. The causality (low 25(OH)D levels being responsible of worse disease activity) of these associations must be confirmed by longitudinal studies by examining the clinical response to large vitamin D supplements.
Disclosure of Interest: None declared


P. P. Sainaghi 1, 2,*, M. Bellan 1, S. Carda 3, C. Cerutti 1, D. Sola 1, C. Cisari 3, G. C. Avanzi 1, 2

1Clinical Immunology, DMCS Università del Piemonte Orientale "A. Avogadro" and AOU "Maggiore della Carità", 2IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), 3Physical & Rehabilitative Medicine, DMCS Università del Piemonte Orientale "A. Avogadro" and AOU "Maggiore della Carità", Novara, Italy

Background: It is well known that hypovitaminosis D is frequent in patients with inflammatory autoimmune diseases (IAD) but response to vitamin D supplementation has not been fully investigated in this setting.

Objectives: To evaluate 25-OHvitamin D plasma level variations after supplementation in patients with IAD and in controls.

Methods: We reviewed the clinical records of 572 consecutive adult patients admitted to the rheumatology and bone metabolic disease outpatient clinics of our institution from January 2006 to October 2009. We included any patient with a diagnosis of IAD (rheumatoid arthritis, spondyloarthritis, connective tissue diseases) or non-inflammatory autoimmune disease (osteoarthritis, osteoporosis) who started a daily supplementation of 800 to 1000 IU of cholecalciferol (also an equivalent once-weekly dose was accepted) and continued the treatment for at least 6 months. We excluded patients with renal failure, primary hyperparathyroidism, liver failure or already receiving vitamin D supplementation. 25-OHvitaminD plasma concentration together to other clinical data were recorded at the beginning and after 6 months of treatment. Appropriate statistical analysis was performed with a statistical software.

Results: 100 (43 IAD and 57 NIAD) patients were included. The mean 25-OHvitaminD concentration before treatment was not significantly different between the IAD (12.6±7.5 ng/ml) and the NIAD patients (13.1±8.8, p=n.s.) so was for the mean concentration reached after 6-months supplementation (24.0±11.0 vs 24.3±11.0 respectively, p=n.s.). Only 29% patients reached 25-OHvitaminD plasma level ?30 ng/ml without differences between IAD and NIAD (?2=n.s.). In stepwise logistic regression analysis, sex, age, season, presence of IAD or CRP value at diagnosis did not influence the increase of 25-OHvitaminD plasma levels (? 20 ng/ml with respect to basal levels).

Conclusion: Daily 800 to 1000 IU supplementation is not sufficient to normalize the 25-OHvitaminD plasma levels of patients in rheumatological and bone disease settings but the response to treatment is not influenced by the presence of an inflammatory autoimmune disease.

Disclosure of Interest: None declared

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