Vitamin D is described a fat-soluble vitamin, but it actually functions as a hormone in the body. It is produced in the skin and released into the blood to affect the bones. Its main function is to maintain levels of calcium in the blood. There is a feedback system with the parathyroid gland to produce active vitamin D3 when the body needs it, and this "vitamin" is closely related structurally to the body hormones, estrogen and cortisone. Because it can be manufactured by the body through skin exposure to the sun, it is not classed as an essential nutrient. Vitamin D, also called calciferol, has several vitamin variants, all of which are sterol (cholesterol-like) substances. Vitamin D2, or activated ergo-calciferol, is the major synthetic form of provitamin D. Vitamin D3, or cholecalciferol, is found in animals, mainly in fish liver oils. These are converted in the liver and kidneys to 25-hydroxycholecalciferol and 1, 25-dihydroxylcholecalciferol, the major circulating active forms of vitamin D.

Vitamin D is manufactured in the human skin when in contact with the ultraviolet light in the sun’s rays. The sunlight interacts with 7-dehydrocholesterol to form cholecalciferol, which is then transferred to the liver or kidneys and converted to active vitamin D. Wintertime, clouds, smog, and darkly pigmented skin reduce the body’s production of vitamin D. Vitamin D is stored in the skin, brain, spleen, and bones and prevents osteoporosis; increases bone strength; increases calcium absorption/ and is used to treat psoriasis.

Beyond calcium metabolism, vitamin D aids normal calcification of the bones in the body and influences utilization of the minerals phosphorus and magnesium. Calcium, phosphorus, and magnesium, together with other minerals make up our bones. Vitamin D3 helps increase the absorption of calcium from the gut, decreases excretion from the kidneys, stimulates reabsorption of calcium and phosphorus from bone, helps put them into teeth, and helps to maintain normal blood levels of calcium and phosphorus. Vitamin D deficiency results in rickets (in children) and osteomalacia (in adults) – both of which are characterized by a reduced level of calcium being deposited in bones and a weakening of bone strength. It also helps prevent osteoporosis.

Dietary Sources: Provitamin D is found mainly in animal foods. D3, or "natural" vitamin D, is found in fish liver oil, which is the traditional source of both A and D. Egg yolks, butter, and liver have some D, as do the oily fish, such as mackerel, salmon, sardines, and herring. Plant foods are fairly low in D, which means that strict vegetarians who do not get adequate exposure to sunlight do not get adequate amounts of vitamin D.

Dosage: The RDA for vitamin D is 400 IU per day.

Side Effects: Because vitamin D is a fat-soluble vitamin, it is stored in the body and has the potential to reach toxic levels if taken in high doses for prolonged periods of time. Intakes over 1000IU (nearly 3 times the daily value) can cause nausea, diarrhea, skin rash, headaches, muscle weakness, calcium deposits and kidney stones. It is considered by many authorities to be the most potentially toxic vitamin.

(Source: www.supplementwatch.com)

Research Overview

Vitamin D research shows the following:
1. Maintains calcium levels in the body
2. Reduces cancer risk
3. Controls prostate cancer
4. Reduces prostate cancer mortality
5. Reduces blood pressure
6. Improves blood glucose levels in diabetics
7. Improves glucose intolerance
8. Improves rheumatoid arthritis
9. Can improve symptoms of multiple sclerosis
10. Vitamin D deficiency affects insulin secretion and action
11. May prevent fractures in general population
12. Prevents fractures in postmenopausal women
13. Prevents hip fractures
14. Reduces risk of colorectal cancer
15. Is necessary for normal fetal growth and development
16. Increases bone density
17. Reduces risk of type I diabetes
18. Prevents ischemia-induced brain damage
19. May help prevent inflammatory bowel disease
20. May help prevent cardiovascular disease
21. Is a treatment for hyperparathyroidism
22. Contributes to death of breast cancer cells
23. Prevents rickets
24. Is treatment for psoriasis
25. Promotes tooth retention
26. Increases immune function
27. Treats seasonal affective disorder
28. Treats acne
29. Treats ichythyoses
30. Treats skin cancer

Vitamin D Abstracts (266)

Vitamin D Citations (414)

Cancer

1. Nutr Rev. 2003 Jul;61(7):227-38. Vitamin D and vitamin D analogs as cancer chemopreventive agents. Guyton KZ, Kensler TW, Posner GH. CCS Associates, 2005 Landings Drive, Mountain View, CA 94043, USA.

Epidemiologic studies have associated vitamin D, attained through nutrition and sun exposure, with reduced cancer risk. Although dose-limiting hypercalcemia has limited the use of natural vitamin D in cancer prevention, several promising new synthetic vitamin D analogs (deltanoids) are under development. Examples are KH-1060, EB-1089, 1alpha-hydroxyvitamin D5, vitamin D2, and QW-1624F2-2. Clinical targets for deltanoids include colon, prostate, and breast. Studies to elucidate the molecular mechanisms underlying the observed efficacy of deltanoids are ongoing. The vitamin D receptor, a steroid/thyroid receptor superfamily member, appears to control most deltanoid effects on proliferation, apoptosis, differentiation, and angiogenesis.

2. Circ Res. 2000 Aug 4;87(3):214-20. 1 alpha,25-dihydroxyvitamin D(3) inhibits angiogenesis in vitro and in vivo. Mantell DJ, Owens PE, Bundred NJ, Mawer EB, Canfield AE. Wellcome Trust Centre for Cell Matrix Research, Department of Medicine University of Manchester, Manchester, UK.

Modulation of angiogenesis is now a recognized strategy for the prevention and treatment of pathologies categorized by their reliance on a vascular supply. The purpose of this study was to evaluate the effect of 1 alpha,25-dihydroxyvitamin D(3) [1, 25(OH)(2)D(3)], the active metabolite of vitamin D(3), on angiogenesis by using well-characterized in vitro and in vivo model systems. 1,25(OH)(2)D(3) (1 x 10(-9) to 1 x 10(-7) mol/L) significantly inhibited vascular endothelial growth factor (VEGF)-induced endothelial cell sprouting and elongation in vitro in a dose-dependent manner and had a small, but significant, inhibitory effect on VEGF-induced endothelial cell proliferation. 1, 25(OH)(2)D(3) also inhibited the formation of networks of elongated endothelial cells within 3D collagen gels. The addition of 1, 25(OH)(2)D(3) to endothelial cell cultures containing sprouting elongated cells induced the regression of these cells, in the absence of any effect on cells present in the cobblestone monolayer. Analysis of nuclear morphology, DNA integrity, and enzymatic in situ labeling of apoptosis-induced strand breaks demonstrated that this regression was due to the induction of apoptosis specifically within the sprouting cell population. The effect of 1,25(OH)(2)D(3) on angiogenesis in vivo was investigated by using a model in which MCF-7 breast carcinoma cells, which had been induced to overexpress VEGF, were xenografted subcutaneously together with MDA-435S breast carcinoma cells into nude mice. Treatment with 1,25(OH)(2)D(3) (12.5 pmol/d for 8 weeks) produced tumors that were less well vascularized than tumors formed in mice treated with vehicle alone. These results highlight the potential use of 1,25(OH)(2)D(3) in both the prevention and regression of conditions characterized by pathological angiogenesis.

3. Carcinogenesis. 2000 Jul;21(7):1341-5.

Conceptually new deltanoids (vitamin D analogs) inhibit multistage skin tumorigenesis.

Kensler TW, Dolan PM, Gange SJ, Lee JK, Wang Q, Posner GH.

Department of Environmental Health Sciences and Department of Epidemiology, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, MD 21205, USA. tkensler@jhsph.edu

Development of vitamin D analogs (deltanoids) as chemopreventive agents requires separation of desirable antiproliferative and pro-differentiating activities from the undesirable calcemic activity also found in the hormone calcitriol (1 alpha, 25-dihydroxyvitamin D(3)). Therefore, several conceptually new deltanoids were synthesized with modifications to the 1alpha- and/or 25-hydroxyl groups, positions traditionally considered essential for stimulating biological responses. In this study, 1 beta-hydroxymethyl-3-epi-25-hydroxyvitamin D(3), a non-calcemic CH(2) homolog of the natural hormone with antiproliferative activity in vitro, was ineffective as an inhibitor of 12-O-tetradecanoylphorbol-13-acetate (TPA)-induced induction of ornithine decarboxylase activity in mouse epidermis. However, a hybrid analog incorporating not only the calcemia-ablating 1 beta-hydroxymethyl alteration, but potentiating C,D ring 16-unsaturation and side chain 24,24-fluorination and 26, 27-homologation was found to be as effective as calcitriol. Several non-calcemic 24- or 25-t-butyl sulfones, some containing side chain fluorination but all lacking the 25-hydroxyl group, were also shown to be active in this assay. Three sulfones and the 1 beta-hydroxymethyl hybrid were evaluated as inhibitors of multistage carcinogenesis in mouse skin. Female CD-1 mice were initiated with a single dose of 7,12-dimethylbenz[a]anthracene and then promoted twice weekly for 20 weeks with TPA. Deltanoids were applied topically 30 min before TPA. Unlike calcitriol, none of the atypical deltanoids affected body weight gain in these animals. Minimal effects on urinary calcium excretion were observed following chronic treatment with these analogs. All deltanoids inhibited the incidence and multiplicity of papilloma formation, with the hybrid analog showing the greatest efficacy. With this deltanoid, tumor incidence was significantly reduced by 28% and tumor multiplicity by 63%. These results, coupled with the rich chemical diversity available in side chain sulfur-containing deltanoids, particularly when combined with A ring modifications such as 1 beta-hydroxylalkyl groups, provide important new advances in the fundamental understanding of chemical structure-biological activity relationships as well as more potent and safe vitamin D analogs for cancer chemoprevention and other medicinal uses.

Colon Cancer

4. Nat Rev Cancer. 2003 Aug;3(8):601-14.

Chemoprevention of colon cancer by calcium, vitamin D and folate: molecular mechanisms.

Lamprecht SA, Lipkin M.

Strang Cancer Prevention Center and Strang Cancer Research Laboratory at The Rockefeller University, 1230 York Avenue, New York, New York 10021, USA. lampres@mail.rockefeller.edu

Recent findings have indicated that dietary calcium, vitamin D and folate can modulate and inhibit colon carcinogenesis. Supporting evidence has been obtained from a wide variety of preclinical experimental studies, epidemiological findings and a few human clinical trials. Important molecular events and cellular actions of these micronutrients that contribute to their tumour-modulating effects are discussed. They include a complex series of signalling events that affect the structural and functional organization of colon cells. Biochem Biophys Res Commun. 2002 Dec 20;299(5):730-8.

5. Liganded VDR induces CYP3A4 in small intestinal and colon cancer cells via DR3 and ER6 vitamin D responsive elements.

Thompson PD, Jurutka PW, Whitfield GK, Myskowski SM, Eichhorst KR, Dominguez CE, Haussler CA, Haussler MR.

Department of Biochemistry and Molecular Biophysics, College of Medicine, University of Arizona, Tucson, AZ 85724, USA.

The nuclear vitamin D receptor (VDR) mediates the effects of 1,25-dihydroxyvitamin D(3) (1,25D(3)) to alter intestinal gene transcription and promote calcium absorption. Because 1,25D(3) also exerts anti-cancer effects, we examined the efficacy of 1,25D(3) to induce cytochrome P450 (CYP) enzymes. Exposure of human colorectal adenocarcinoma cells (HT-29) to 10(-8)M 1,25D(3) resulted in >/=3-fold induction of CYP3A4 mRNA and protein as assessed by RT-PCR and Western blotting, respectively. Six vitamin D responsive element (VDRE)-like sequences in the promoter region of the CYP3A4 gene were then individually tested for their ability to enhance transcription. A canonical DR3-type element in the distal region of the promoter (-7719-GGGTCAgcaAGTTCA-7733), and a proximal, non-classical everted repeat with a spacer of 6 bp (ER6; -169-TGAACTcaaaggAGGTCA-152) were identified as functional VDREs in this CYP gene. These data suggest that 1,25D(3)-dependent, VDR-mediated induction of CYP3A4 may constitute a chemoprotective mechanism for detoxification of enteric xenobiotics and carcinogens.

6. Mol Cell Endocrinol. 2001 Oct 25;183(1-2):141-9.

Synthetic low-calcaemic vitamin D(3) analogues inhibit secretion of insulin-like growth factor II and stimulate production of insulin-like growth factor-binding protein-6 in conjunction with growth suppression of HT-29 colon cancer cells.

Oh YS, Kim EJ, Schaffer BS, Kang YH, Binderup L, MacDonald RG, Park JH.

Division of Life Sciences and Institute of Environment and Life Science, Hallym University, 1 Okchon Dong, Chunchon, 200-702, South Korea.

The aims of the present study were to compare the ability of various synthetic analogues of 1 alpha,25-dihydroxyvitamin D(3) [1 alpha,25-(OH)(2)D(3)] to inhibit proliferation of HT-29 cells, a human colon adenocarcinoma cell line. HT-29 cells were incubated for 144 h with various concentrations (0-100 nM) of 1 alpha,25-(OH)(2)D(3), or the analogues EB1089, CB1093 or 1 beta,25-(OH)(2)D(3). All these analogues except 1 beta,25-(OH)(2)D(3) inhibited cell proliferation, but relative potencies and efficacies of EB1089 and CB1093 were much greater than that of the native vitamin. Cells grew in serum-free medium, reaching a plateau density at day 10 of culture, and addition of 10 nM 1 alpha,25-(OH)(2)D(3) or 1 beta,25-(OH)(2)D(3) did not alter the long-term growth characteristics of HT-29 cells. However, cells treated with 10 nM EB1089 or CB1093 grew at a rate slower than control and reached final densities that were 53+/-1 and 36+/-2% lower than control, respectively. Immunoblot analysis of serum-free conditioned medium using a monoclonal anti-insulin-like growth factor-(IGF)-II antibody showed that both 10 nM EB1089 and CB1093 markedly inhibited secretion of both mature 7500 M(r) and higher M(r) forms of IGF-II. Ligand blot and immunoblot analyses of conditioned media revealed the presence of IGFBPs of M(r) 24,000 (IGFBP-4), 30,000 (glycosylated IGFBP-4), 35,000 (IGFBP-2) and 32,000-34,000 (IGFBP-6). The level of IGFBP-2 was decreased by 42+/-8 and 49+/-7% by 10 nM EB 1089 and CB1093, respectively, compared to controls. IGFBP-6 was increased approximately twofold by EB1089 and CB1093, and exogenously added IGFBP-6 inhibited HT-29 cell proliferation. These results suggest that inhibition of HT-29 cell proliferation by EB1089 and CB1093 may be attributed, at least in part, to the decreased secretion of IGF-II. The increase in IGFBP-6 concentration coupled with its high affinity for IGF-II may also contribute to decreased cellular proliferation by an indirect mechanism involving sequestration of endogenously produced IGF-II.

7. Cancer Causes Control. 2000 May;11(5):459-66.

Calcium, vitamin D, sunshine exposure, dairy products and colon cancer risk (United States).

Kampman E, Slattery ML, Caan B, Potter JD.

Fred Hutchinson Cancer Research Center, Cancer Prevention Research Program, Seattle, WA 98109-1024, USA.

OBJECTIVE: Epidemiologic studies on calcium, vitamin D and colon cancer are inconsistent, whereas experimental studies more regularly show a protective effect. To evaluate potential sources of inconsistencies, data from a large case-control study were analyzed, stratifying on potential effect modifiers. METHODS: Data were collected by certified interviewers in Northern California, Utah and Minnesota. Analyses included 1993 incident colon cancer cases and 2410 population-based controls. Multivariate logistic regression models included age, sex, BMI, family history, physical activity, intake of energy, dietary fiber, aspirin and NSAIDs. RESULTS: Dietary calcium was inversely associated with colon cancer risk in men (OR highest vs lowest quintile = 0.6, 95% CI = 0.5-0.9) and women (OR = 0.6, 95% CI = 0.4-0.9). No statistically significant associations were observed for dietary vitamin D or sunshine exposure. Consumption of total low-fat dairy products was associated with a statistically significantly decreased risk in men and women (ORs highest vs lowest category of intake = 0.8 and 0.7 respectively). Calcium supplement use was inversely associated with risk in both sexes (ORs use vs non-use = 0.8). Vitamin D supplements were inversely associated with risk in men (OR = 0.5) and women (OR = 0.6) but confidence limits included 1.0. CONCLUSIONS: These data provide additional support of an inverse association between high levels of calcium intake and colon cancer risk.

8. Int J Oncol. 1999 May;14(5):979-85.

Novel 19-nor-hexafluoride vitamin D3 analog (Ro 25-6760) inhibits human colon cancer in vitro via apoptosis.

Evans SR, Soldatenkov V, Shchepotin EB, Bogrash E, Shchepotin IB.

Department of Surgery, George Washington University, Washington, DC 20037, USA.

Our previously performed experiments clearly showed a significant VDR-mediated growth inhibitory effect of 1,25-dihydroxyvitamin D3 and its synthetic analogs in a variety of human cancer cells including human colon and breast cancer, soft tissue sarcoma, and malignant melanoma cell lines. The mechanisms by which 1, 25-dihydroxyvitamin D3 and its synthetic analogs growth inhibit human cancer cells is poorly elucidated. The exposure of human colon cancer cells HT-29 to 1,25-dihydroxyvitamin D3 or its analog, 1alpha, 25-dihydroxy-16-ene-23yne-26,27-hexafluoro-19-nor-choleca lci ferol (Ro 25-6760), at the 10(-6) M concentration resulted in significant growth inhibition with induction of the apoptotic process after three days of treatment detected by TUNEL assay and agarose gel electrophoresis of DNA. As a logical link with DNA fragmentation analyses and TUNEL assay, cleavage of the 116 kDa PARP protein was accompanied by the appearance of a characteristic 85 kDa fragment of PARP in a population of floating cells after both treatments. The results of cell cycle analysis showed a G0/G1 phase block after three days of administration of either compound when compared with untreated cells. On day 4, G0/G1 cell cycle arrest remained on the same level in comparison with control. Paralleling the G0/G1 phase block, was a notable decrease in the number of cells in the S phase which also became significant after three days of treatment. The results of these experiments show that the newly developed 19-nor synthetic vitamin D3 analog, Ro 25-6760, as well as 1, 25-dihydroxyvitamin D3, induced the expression of p21waf1, resulted in a significant G1/G0 cell cycle arrest leading to impressive growth inhibition and induction of apoptosis associated with proteolytic cleavage of poly(ADP-ribose) polymerase (PARP) showing a possible involvement of apoptosis-specific activation of the ICE/CED-3 proteolitic pathway.

9. Dis Colon Rectum. 1997 Mar;40(3):317-21. (Animal Study) Vitamin D3 analog, EB1089, inhibits growth of subcutaneous xenografts of the human colon cancer cell line, LoVo, in a nude mouse model.

Akhter J, Chen X, Bowrey P, Bolton EJ, Morris DL.

University of New South Wales, Department of Surgery, Sydney, Australia.

PURPOSE: In this study, we investigated the effect of the vitamin D3 analog, EB1089, on the growth of subcutaneous xenografts of the human colon cancer cell line, LoVo, in a nude mouse model. METHODS: BALB/c Nu/Nu nude mice were inoculated subcutaneously with 10(6) LoVo cells. EB1089 dissolved in isopropanol was administered intraperitoneally and orally on alternate days at doses of 0.1, 0.5, and 2.5 microg/kg/day. Control animals received isopropanol alone. Tumor volumes estimated using the formula 0.5 X length X (width)2. The tumor kinetic index was determined by immunohistochemical detection of proliferating cell nuclear antigen. RESULTS: Significant dose-dependent inhibition of tumor growth was seen. After 20 days of treatment with 0.1 microg/kg/day EB1089, mean tumor volume in treated mice was 41 to 49 percent less than that in control animals (P < 0.01). Significant inhibition of tumor growth was also seen with 0.5 microg/kg/day EB1089 after 22 days of treatment (51 percent of control P < 0.01). Treatment with 2.5 microg/kg/day resulted in weight loss that required termination of this group; these mice were subsequently found to be hypercalcemic. The tumor kinetic index was significantly lower in tumors treated with 0.1 microg/kg/day EB1089 compared with that for control tumors (8 vs. 30 percent in controls). CONCLUSION: These findings suggest that the vitamin D3 analog, EB1089, is a potent antiproliferative agent for some human colon cancers.

10. Anticancer Res. 1996 Jul-Aug;16(4B):2333-7.

Vitamin D receptor and cytokeratin expression may be progression indicators in human colon cancer.

Cross HS, Bajna E, Bises G, Genser D, Kallay E, Potzi R, Wenzl E, Wrba F, Roka R, Peterlik M.

Department of General and Experimental Pathology, University Hospital (AKH), Vienna, Austria.

Epidemiological data suggest the protective role of vitamin D against the development of colorectal carcinoma in man. This could be due to the anti-mitogenic effect of the steroid hormone on human colon carcinoma cells which is mediated by a specific nuclear vitamin D receptor (VDR). Western blot analysis showed that VDR expression increases during the transition from normal mucosa to polyps and later to pT3 tumors. In later stages, however, VDR is dramatically reduced. Cytokeratin 20, which was monitored as a differentiation marker, decreases in parallel with advancing proliferation and disappears from "normal" mucosa adjacent to later stage carcinoma. Interestingly, VDR density was conspicuously higher in all tumors tested when compared to adjacent "normal" tissue. This suggest that, up to a certain degree of dedifferentiation, malignant colonocytes can upregulate the VDR, probably as a counteractive measure in response to tumor cell growth, but that this ability is finally lost in highly undifferentiated carcinoma cells.

11. Am J Epidemiol. 1996 May 1;143(9):907-17.

Calcium, vitamin D, and dairy foods and the occurrence of colon cancer in men.

Kearney J, Giovannucci E, Rimm EB, Ascherio A, Stampfer MJ, Colditz GA, Wing A, Kampman E, Willett WC.

Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA.

To examine the associations between intakes of calcium, Vitamin D, and dairy foods and the risk of colon cancer, the authors analyzed data from a prospective study of 47,935 US male professionals, 40-75 years of age and free of cancer in 1986. Within this cohort, 203 new cases of colon cancer were documented between 1986 and 1992. After adjusting for age and total energy intake, the authors found that the intake of calcium from foods and supplements was inversely associated with colon cancer risk (relative risk (RR) = 0.58, 95% confidence interval (CI) 0.39-087 between high and low intakes of calcium). However, after adjusting for confounding variables, they found that the trend was no longer statistically significant (p = 0.22), and the relative risk for the highest quintile group of intake was attenuated: 0.75 (95% CI 0.48-1.15). Similar results were observed for total vitamin D intake; the age- and energy-adjusted relative risk was 0.54% (95% CI 0/34-0/85) for the highest versus lowest quintile group, and this was attenuated in the multivariate model (RR = 0.66, 95% CI 0.42-1.05). The inverse association was weaker for dietary vitamin D (RR highest vs. lowest quintile = 0.88. 95% CI 0.54-1.42) and strongest for vitamin D arising from vitamin supplements (RR = 0.48, 95% CI 0.22-1.02). Thus, it is possible that other components of multivitamin use rather than vitamin D accounted for the reduction in risk. Consumption of milk and fermented dairy products was not significantly associated with the risk of colon cancer; individuals consuming two or more glasses of "whole" or skim milk per day had a relative risk of 1.09 (95% CI 0.69-1.72), compared with those who consumed "whole or skim milk less than once a month. These prospective data do not support the hypothesis that calcium intake is strongly protective against colon cancer risk, although a modest association cannot be excluded.

12. Cancer Res. 1996 Feb 1;56(3):623-32.

Antiproliferative responses to two human colon cancer cell lines to vitamin D3 are differently modified by 9-cis-retinoic acid.

Kane KF, Langman MJ, Williams GR.

Department of Medicine, Queen Elizabeth Hospital, University of Birmingham, Edgbaston, United Kingdom.

1 alpha,25-Dihydroxyvitamin D3 [1,25(OH)2D3] exerts antiproliferative actions in colorectal cancer, but their underlying molecular mechanisms have not been determined. 1,25(OH)2D3 regulates target gene transcription via a specific nuclear vitamin D receptor (VDR), which mediates hormone action preferentially as a heterodimer with 9-cis-retinoic acid receptors (RXRs). We investigated the actions of 1,25(OH)2D3 and 9-cis-retinoic acid (RA) in two human colon cancer cell lines, HT-29 and Caco-2. Both expressed mRNAs encoding VDR, RXR alpha, and RXR gamma, and VDR was regulated posttranscriptionally in Caco-2 cells. There was an antiproliferative response of both cell lines to 1,25(OH)2D3. 9-cis-RA exerted antiproliferative effects on Caco-2 cells but blocked 1,25(OH)2D3 actions in HT-29 cells. The 1,25(OH)2D3-responsive gene 25-hydroxyvitamin D3 24-hydroxylase was induced in both cell lines b 1,25(OH)2D3 but in only HT-29 cells by 9-cis-RA. 1,25(OH)2D3 and 9-cis-RA cotreatment enhanced 24-hydroxylase expression in HT-29 cells only. The 24-hydroxylase enzyme is known to result in catabolism of 1,25(OH)2D3 and attenuation of its actions. Increased 24-hydroxylase activity in HT-29 cells, but not in Caco-2 cells, in response to 9-cis-RA may account for some of the complex cell-specific responses demonstrated in these studies.

13. Am J Epidemiol. 1993 Jun 15;137(12):1302-17.

Relation of calcium, vitamin D, and dairy food intake to incidence of colon cancer among older women. The Iowa Women's Health Study.

Bostick RM, Potter JD, Sellers TA, McKenzie DR, Kushi LH, Folsom AR.

Department of Family Practice and Community Health, Medical School, University of Minnesota, Minneapolis 55454.

To investigate whether a high intake of calcium, vitamin D, or dairy products may protect against colon cancer, the authors analyzed data from a prospective cohort study of 35,216 Iowa women aged 55-69 years without a history of cancer who completed a dietary questionnaire in 1986. Through 1990, 212 incident cases of colon cancer were documented. Adjusted for age, intakes of calcium and vitamin D were significantly inversely associated with the risk of colon cancer. The relative risks for the highest quintile of intake as compared with the lowest were 0.52 (95% confidence interval (CI) 0.33-0.82) for calcium and 0.54 (95% CI 0.35-0.84) for vitamin D. After multivariate adjustment, the trends were no longer statistically significant and the relative risks for the highest versus the lowest quintiles of calcium and vitamin D intakes were attenuated: 0.68 (95% CI 0.41-1.11) for calcium and 0.73 (95% CI 0.45-1.18) for vitamin D. Although the multivariate-adjusted findings did not reach statistical significance at p < or = 0.05, when considered in the context of the whole body of literature on this subject, they are consistent with a possible role for calcium or vitamin D in modestly reducing colon cancer risk.

14. Endocrinology. 1993 Apr;132(4):1808-14.

Regulation of vitamin D receptor abundance and responsiveness during differentiation of HT-29 human colon cancer cells.

Zhao X, Feldman D.

Division of Endocrinology, Stanford University School of Medicine, California 94305.

We have studied the effects of 1,25-dihydroxyvitamin D [1,25-(OH)2D3] on cellular differentiation in the HT-29 human colon cancer cell line. Our aim was to evaluate the regulation of 1,25-dihydroxyvitamin D receptor (VDR) abundance and hormone responsiveness during the transition of rapidly proliferating to differentiated cells. Differentiation was induced by three means: cells were cultured in galactose-supplemented medium without glucose (GAL), grown on Matrigel-coated surfaces (MTG), or treated with 1,25(OH)2D3. Cell proliferation, assessed by [3H]thymidine incorporation, was equivalently inhibited by treatment with 1,25(OH)2D3, GAL or MTG. Differentiation was assessed by the induction of amino-oligo peptidase activity which was low in the proliferating cells. Following treatment with 1,25(OH)2D3, or growth in GAL or on MTG, amino-oligo peptidase activity increased 8- to 9-fold. The abundance of VDR measured by [3H]1,25(OH)2D3 binding, decreased to half without significant change in affinity, in cells differentiated by all three means compared to proliferating cells. Northern blot analyses of differentiated cells showed decreased steady-state levels of VDR messenger RNA (mRNA), indicating that all three treatments similarly decreased the abundance of VDR, at least in part, at the mRNA level. When exposed to 1,25(OH)2D3, the proliferating cells exhibited homologous up-regulation of VDR as well as the induction of 24-hydroxylase mRNA; the differentiated cells failed to exhibit both of these biological responses. Our findings demonstrate that 1,25(OH)2D3, GAL and MTG treatment all inhibit HT-29 cell proliferation and stimulate differentiation. Postproliferative differentiation achieved by the three approaches was associated with decreased VDR abundance, loss of VDR homologous up-regulation, and development of hormone unresponsiveness to 1,25(OH)2D3.

15. Gut. 1992 Dec;33(12):1660-3.

Vitamin D and its metabolites inhibit cell proliferation in human rectal mucosa and a colon cancer cell line.

Thomas MG, Tebbutt S, Williamson RC.

Department of Surgery, Royal Postgraduate Medical School, Hammersmith Hospital, London.

Like calcium, vitamin D may protect against colorectal neoplasia as it reduces epithelial cell proliferation and induces differentiation. Although its therapeutic use is limited by its effects on calcium metabolism, analogues such as calcipotriol produce little hypercalcaemia. Stathmokinetic and immunohistochemical techniques were used to study the effect of 1,25 (OH)2 D3 and its analogues on cell proliferation in human rectal mucosa and a colon cancer cell line. Paired sigmoidoscopic biopsy specimens were obtained from 17 control patients and five patients with familial adenomatous polyposis. Explants were established in organ culture, with or without the addition of vitamin D. Proliferation was assessed using (1) metaphase arrest to determine the crypt cell production rate (CCPR) and (2) Ki-67 monoclonal antibody directed against an antigen present in proliferating cells. 1,25 (OH)2 D3 in concentrations of 1 microM-100 pM (10(-6)-10(-10) M) reduced the CCPR (cells/crypt/hour) from 4.74 to 2.15-2.67 (p < 0.001), and the Ki-67 labelling index from 7.28-3.74 (p < 0.01). Likewise, vitamin D2, 10 nM (10(-8) M) reduced the CCPR from 4.74-2.74 (p < 0.05) and calcipotriol from 4.86-2.38 (p < 0.05). In familial adenomatous polyposis patients 1,25 (OH)2 D3 100 pM (10(-10) M) halved the CCPR from 8.75-4.22. Calcipotriol (10(-5) M to 10(-9) M) produced a clearcut dose response inhibition of HT-29 cell growth. Thus, vitamin D and its metabolites inhibit proliferation in normal and premalignant rectal epithelium and suppress growth in a colorectal cancer cell line.

16. Am J Clin Nutr. 1991 Jul;54(1 Suppl):193S-201S.

Can colon cancer incidence and death rates be reduced with calcium and vitamin D?

Garland CF, Garland FC, Gorham ED.

Department of Community and Family Medicine, University of California, San Diego, La Jolla 92093-0607.

It was proposed in 1980 that vitamin D and calcium could reduce the risk of colon cancer. This assertion was based on the decreasing gradient of mortality rates from north to south, suggesting a mechanism related to a favorable influence of ultraviolet-induced vitamin D metabolites on metabolism of calcium. A 19-y prospective study of 1954 Chicago men found that a dietary intake of greater than 3.75 micrograms vitamin D/d was associated with a 50% reduction in the incidence of colorectal cancer, whereas an intake of greater than or equal to 1200 mg Ca/d was associated with a 75% reduction. Clinical and laboratory studies further support these findings. A nested case-control study based on serum drawn from a cohort of 25,620 individuals reported that moderately elevated concentrations of 25-hydroxyvitamin D, in the range 65-100 nmol/L, were associated with large reductions (P less than 0.05) in the incidence of colorectal cancer.

17. Anticancer Res. 1987 Jul-Aug;7(4B):817-21.

The role of vitamin D3 in the proliferation of a human colon cancer cell line in vitro.

Lointier P, Wargovich MJ, Saez S, Levin B, Wildrick DM, Boman BM.

M. D. Anderson Hospital and Tumor Institute, Section of Gastrointestinal Oncology and Digestive Diseases, Houston, Texas 77030.

LoVo, a cultured colon cancer cell line, is shown to possess a receptor for 1,25-dihydroxy vitamin D3 (1 alpha,25(OH)2D3) with a low capacity (28 fmol/mg protein) and high affinity (Kd: 1.9 x 10(-21)0M). When these cells were grown in monolayer culture in a chemically defined serum-free medium, a significant inhibition of proliferation was seen in the presence of 10 nM to 1 microM of 1 alpha,25(OH)2D3 (p less than 0.005. Furthermore, 1 alpha,25(OH)2D3 delayed early attachment of cells. After 8 days of treatment, aggregated cuboidal cells showed a marked change to an apparently spindle like morphology. The 1 alpha,25(OH)2D3 growth-inhibitory effect was modulated by verapamil (1 microM), a calcium channel blocker, hydrocortisone (1 microM), and moxestrol (1 mM), an estrogen analogue, and 2% charcoal-treated fetal bovine serum. This study represents the first demonstration of 1 alpha,25(OH)2D3 modulation of growth of human colon cells.

18. Int J Epidemiol. 1980 Sep;9(3):227-31.

Do sunlight and vitamin D reduce the likelihood of colon cancer?

Garland CF, Garland FC.

It is proposed that vitamin D is a protective factor against colon cancer. This hypothesis arose from inspection of the geographic distribution of colon cancer deaths in the U.S., which revealed that colon cancer mortality rates were highest in places where populations were exposed to the least amounts of natural light--major cities, and rural areas in high latitudes. The hypothesis is supported by a comparison of colon cancer mortality rates in areas that vary in mean daily solar radiation penetrating the atmosphere. A mechanism involving cholecalciferol (vitamin D3) is suggested. The possibility that an ecological fallacy or other indirect association explains the findings is explored.

Melanoma

19. Br J Dermatol. 2002 Aug;147(2):197-213.

Vitamin D and systemic cancer: is this relevant to malignant melanoma?

Osborne JE, Hutchinson PE.

Department of Dermatology, Leicester Royal Infirmary, Leicester LE1 5WW, UK. joyos@doctors.org.uk

1,25-dihydroxyvitamin D3[1,25(OH)2D3] is a well-known potent regulator of cell growth and differentiation and there is recent evidence of an effect on cell death, tumour invasion and angiogenesis, which makes it a candidate agent for cancer regulation. The classical synthetic pathway of 1,25(OH)2D3 involves 25- and 1 alpha-hydroxylation of vitamin D3, in the liver and kidney, respectively, of absorbed or skin-synthesized vitamin D3. There is recent focus on the importance in growth control of local metabolism of 1,25(OH)2D3, which is a function of local tissue synthetic hydroxylases and particularly the principal catabolizing enzyme, 24-hydroxylase. The classical signalling pathway of 1,25(OH)2D3 employs the vitamin D nuclear receptor (VDR), which is a transcription factor for 1,25(OH)2D3 target genes. Effects of this pathway include inhibition of cellular growth and invasion. Cytoplasmic signalling pathways are increasingly being recognized, which similarly may regulate growth and differentiation but also apoptosis. 1,25(OH)2D3 has a major inhibitory effect on the G1/S checkpoint of the cell cycle by upregulating the cyclin dependent kinase inhibitors p27 and p21, and by inhibiting cyclin D1. Indirect mechanisms include upregulation of transforming growth factor-beta and downregulation of the epidermal growth factor receptor. 1,25(OH)2D3 may induce apoptosis either indirectly through effects on the insulin-like growth receptor and tumour necrosis factor-alpha or more directly via the Bcl-2 family system, the ceramide pathway, the death receptors (e.g. Fas) and the stress-activated protein kinase pathways (Jun N terminal kinase and p38). Inhibition of tumour invasion and metastasis potential has been demonstrated and mechanisms include inhibition of serine proteinases, metalloproteinases and angiogenesis. The lines of evidence for an effect of vitamin D3 in systemic cancer are the laboratory demonstration of relevant effects on cellular growth, differentiation, apoptosis, malignant cell invasion and metastasis; epidemiological findings of an association of the occurrence and outcome of cancers with derangements of vitamin D3/1,25(OH)2D3 and the association of functional polymorphisms of the VDR with the occurrence of certain cancers. In addition, vitamin D3 analogues are being developed as cancer chemotherapy agents. There is accumulating evidence that the vitamin D3/1,25(OH)2D3/VDR axis is similarly important in malignant melanoma (MM). MM cells express the VDR, and the antiproliferative and prodifferentiation effects of 1,25(OH)2D3 have been shown in cultured melanocytes, MM cells and MM xenografts. Recently, an inhibitory effect on the spread of MM cells has been demonstrated, low serum levels of 1,25(OH)2D3 have been reported in MM patients and the VDR polymorphisms have been shown to be associated with both the occurrence and outcome of MM. The relationship between solar irradiation and MM is more complex than for the systemic cancers. As in other cancers, there is evidence of a protective effect of vitamin D3 in MM, but ultraviolet radiation, which is a principal source of vitamin D3, is mutagenic. Further work is necessary on the influence of serum vitamin D3 levels on the occurrence and prognosis of MM, the effects of sun protection measures on serum vitamin D3 levels in temperate climates and epidemiological studies on geographical factors and skin type on the prognosis of MM. Meanwhile, it would seem mandatory to ensure an adequate vitamin D3 status if sun exposure were seriously curtailed, certainly in relation to carcinoma of breast, prostate and colon and probably also MM.

20. Clin Cancer Res. 2000 Feb;6(2):498-504.

Vitamin D receptor polymorphisms are associated with altered prognosis in patients with malignant melanoma.

Hutchinson PE, Osborne JE, Lear JT, Smith AG, Bowers PW, Morris PN, Jones PW, York C, Strange RC, Fryer AA.

Department of Dermatology, Leicester Royal Infirmary, United Kingdom.

Calcitriol [1,25(OH)2D3], the hormonal derivative of vitamin D3, is an antiproliferative and prodifferentiation factor for several cell types, including cultured melanocytes and malignant melanoma (MM) cells. Several polymorphisms of the vitamin D receptor (VDR) gene have been described including a FokI RFLP in exon 2, BsmI, and ApaI polymorphisms in intron 8 and an adjacent TaqI RFLP in exon 9. Alterations in vitamin D/1,25(OH)2D3 levels and polymorphisms of the VDR have been shown to be associated with several systemic malignancies. We hypothesize that polymorphism in this gene may be associated with altered susceptibility and outcome in patients with MM. A hospital-based case-control study, using 316 MM cases and 108 controls, was used to assess associations with MM susceptibility. Breslow thickness, the most important single prognostic factor in MM, was used as the outcome measure. Polymorphisms at the FokI and TaqI restriction sites were determined using PCR-based methods. Polymorphism at the FokI, but not TaqI, RFLP was associated with an altered risk of MM (P = 0.014). More importantly, variant alleles were associated with increased Breslow thickness. Thus, homozygosity for variant alleles at both RFLP (ttff genotype combination) was significantly associated with thicker tumors. (> or = 3.5 mm; P = 0.001; odds ratio = 31.5). Thus, polymorphisms of the VDR gene, which would be expected to result in impaired function, are associated with susceptibility and prognosis in MM. These data suggest that 1,25(OH)2D3, the ligand of the VDR, may have a protective influence in MM, as has been proposed for other malignancies.

21. Med Hypotheses. 1997 Apr;48(4):351-4.

A role for photoproducts of vitamin D in the etiology of cutaneous melanoma?

Braun MM, Tucker MA.

Epidemiology and Biostatistics Program, National Cancer Institute, National Institutes of Health, Rockville, MD 20852, USA.

Several clinical and epidemiological aspects of cutaneous melanoma seem anomalous because they contrast with other sunlight-associated skin cancers. For example, persons with the greatest risk of melanoma are not those with the greatest cumulative solar exposure, the anatomic areas that receive the most solar exposure are not preferentially affected, and the incidence of the disease is seasonal, with more cases reported in summer than winter. This article discusses the synthesis and biologic effects of vitamin D photoproducts and suggests that sun-related local skin effects, mediated by vitamin D photoproducts, on melanocytes previously damaged by excessive solar exposure may help explain the seemingly anomalous aspects of melanoma.

22. J Surg Res. 1996 Feb 15;61(1):127-33.

Vitamin D receptor and growth inhibition by 1,25-dihydroxyvitamin D3 in human malignant melanoma cell lines.

Evans SR, Houghton AM, Schumaker L, Brenner RV, Buras RR, Davoodi F, Nauta RJ, Shabahang M.

Department of Surgery, Lombardi Cancer Center, Georgetown University Hospital, Washington, DC 20007, USA.

The expression of vitamin D receptors (VDR) and growth inhibition induced by 1,25-dihydroxyvitamin D3 have been noted in certain human malignant melanoma cell lines. In this study, widely disparate levels of VDR mRNA expression were demonstrated in a panel of eight human malignant melanoma cell lines. Quantitation of receptor level by ligand binding assay showed a similar pattern. Proliferation and growth curve analysis was performed in two cell lines: RPMI 7951 (high VDR) and SK-MEL-28 (low VDR). Significant growth inhibition was noted in RPMI 7951 cells at 10(-9) M 1,25-dihydroxyvitamin D3. SK-MEL-28 cells, which express much lower levels of VDR, did not show any growth inhibition except at extremely high concentrations of 1,25-dihydroxyvitamin D3, namely 10(-5) M. These findings suggest a receptor-mediated mechanism of growth inhibition for 1,25-dihydroxyvitamin D3 and a role for this hormone in the growth of malignant melanoma cells.

23. J Clin Endocrinol Metab. 1983 Sep;57(3):627-31.

The synthesis of vitamin D metabolites by human melanoma cells.

Frankel TL, Mason RS, Hersey P, Murray E, Posen S.

Two melanin-producing human melanoma cell lines originally established from fresh surgical specimens were incubated with 25 hydroxyvitamin D3 (25 OHD3). Both cell lines produced material comigrating with 1,25 dihydroxy-vitamin D3 (1,25(OH)2D3) and 24,25 dihydroxyvitamin D3 (24,25(OH)2D3) in straight and reverse phase high performance liquid chromatography systems and displacing the relevant labeled ligands in competitive binding assays. The material designated 1,25(OH)2D3 was found almost entirely within the cells, whereas 24,25(OH)2D3 was evenly distributed between cells and medium. The synthesis of dihydroxylated materials was time dependent and was not observed if the cells were boiled before incubation with 25 OHD3. Preincubation with 1,25(OH)2D3 caused an increase in the synthesis of 24,25(OH)2D3 and a decrease in the synthesis of 1,25(OH)2D3. Michaelis-Menten constant (Km) values were 1.4 X 10(-9) mol/liter 25 OHD3 for the 1-alpha-hydroxylase enzyme and 72 X 10(-9) mol/liter for 24-hydroxylase. These studies constitute further evidence for the extrarenal synthesis of 1,25(OH)2D3. The suppressibility of 1 alpha-hydroxylase by preincubation with 1,25(OH)2D3 suggests a regulatory function for this system in the skin.

Breast Cancer

24. Int J Cancer. 2003 Aug 20;106(2):178-86.

Vitamin D enhances caspase-dependent and -independent TNFalpha-induced breast cancer cell death: The role of reactive oxygen species and mitochondria.

Weitsman GE, Ravid A, Liberman UA, Koren R.

Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Calcitriol, the hormonal form of vitamin D, potentiates the activity of some common anticancer drugs and agents of the anticancer immune system, including tumor necrosis factor alpha (TNFalpha). TNFalpha-induced cytotoxicity is due to both caspase-dependent and -independent pathways. Cotreatment with calcitriol enhanced both modes of TNFalpha-induced death in MCF-7 breast cancer cells. It increased caspase-3-like activity as assayed by the cleavage of poly-(ADP-ribose)polymerase and of the fluorogenic substrate ac-DEVD-AMC. It also enhanced TNFalpha-induced caspase-independent cytotoxicity in the presence of the pan-caspase inhibitor zD-2,6-dichlorobenzoyloxymethylketone. The antioxidants N-acetylcysteine, reduced glutathione, lipoic acid and ascorbic acid markedly reduced the enhancing effect of the hormone on TNFalpha-induced caspase activation. N-acetylcysteine and reduced glutathione also decreased caspase-independent cytotoxicity in the presence or absence of calcitriol, indicating that reactive oxygen species (ROS) have a key role in the cross talk between TNFalpha and calcitriol. Mitochondrial damage is common to both TNFalpha-induced caspase-dependent and -independent pathways and may underlie excessive production of ROS. Mitochondrial membrane potential (DeltaPsi) was assessed by the specific potential-sensitive fluorescent probe JC-1. The hormone augmented the drop in DeltaPsi and release of cytochrome c from mitochondria, induced by TNFalpha. The effect of calcitriol on DeltaPsi was mimicked by rotenone, which increased both the drop in DeltaPsi and caspase activation induced by TNFalpha. It is possible that the interaction of TNFalpha and calcitriol on the level of the mitochondria is the underlying mechanism responsible for the enhancement of TNFalpha-induced, ROS-mediated caspase-dependent and -independent cell death. Copyright 2003 Wiley-Liss, Inc.

25. J Steroid Biochem Mol Biol. 2003 Feb;84(2-3):181-92.

Efficacy of Vitamin D compounds to modulate estrogen receptor negative breast cancer growth and invasion.

Flanagan L, Packman K, Juba B, O'Neill S, Tenniswood M, Welsh J.

Department of Biological Sciences, University of Notre Dame, 126 Galvin Life Sciences Building, IN 46556, USA.

In estrogen receptor (ER) positive breast cancer cells such as MCF-7 cells, the anti-tumor effects of 1,25(OH)(2)D(3) (1,25D(3)) may be secondary to disruption of estrogen mediated survival signals. If so, then sensitivity to 1,25D(3) mediated growth arrest could be reduced in estrogen independent breast cancer cells. The aim of these studies was to determine the effects of 1,25D(3) and EB1089 on the ER negative, invasive human breast cancer cell line SUM-159PT. 1,25D(3) and EB1089 reduced SUM-159PT cell growth subsequent to elevation of p27 and p21 levels. 1,25D(3) mediated apoptosis of SUM-159PT cells was associated with an enrichment of membrane bound bax, a redistribution of cytochome c from the mitochondria to the cytosol and PARP cleavage. 1,25D(3) and EB1089 also inhibited SUM-159PT cell invasion through an 8 microM Matrigel membrane. In pre-clinical studies, EB1089 dramatically reduced the growth of SUM-159PT xenografts in nude mice. The decreased size of tumors from EB1089 treated mice was associated with decreased proliferation and increased DNA fragmentation. Our data support the concept that Vitamin D(3) compounds trigger apoptosis by mechanisms independent of estrogen signaling. These studies indicate that Vitamin D(3) based therapeutics may be beneficial, alone or in conjunction with other agents, for the treatment of estrogen independent breast cancer.

26. Histochem J. 2002 Jan-Feb;34(1-2):35-40.

Analysis of vitamin D-receptor (VDR) and retinoid X-receptor alpha in breast cancer.

Friedrich M, Axt-Fliedner R, Villena-Heinsen C, Tilgen W, Schmidt W, Reichrath J.

Department of Gynecology and Obstetrics, University Hospital of Saarland, Homburg/Saar, Germany.

The expression of vitamin D-receptor (VDR) and retinoid X-receptor alpha (RXR-alpha) has been analysed immunohistochemically in benign (n = 62 and n = 5 respectively) and malignant (n = 228 and n = 15 respectively) breast tissue samples using a monoclonal antibody 9A7gamma against VDR and a polyclonal antibody against RXR-alpha. A recently developed immunoreactive scoring method (IRS) was employed. The expression of VDR was detected at the RNA-level using the reverse transcriptase-polymerase chain reaction. A statistically significant higher expression of VDR at the protein level was seen in breast cancer compared with benign breast tissue, whereas at the mRNA level no visible differences in the expression of VDR were found. A higher expression of RXR-alpha was seen in breast cancer compared with benign breast tissue. Our findings indicate that breast tissue may be a new target organ for therapeutically applied vitamin D and retinoid analogues. VDR and RXR-alpha are upregulated at the protein level in breast carcinomas as compared to normal breast tissue, indicating a possibly increased sensitivity to therapeutically applied vitamin D analogues. New vitamin D analogues exerting less calcemic side effects may be promising new drugs for the treatment or chemoprevention of breast carcinomas as well as of precancerous breast lesions. Combination therapies of vitamin D and retinoid analogues with fewer side effects seen promising for the treatment of breast cancer.

27. J Natl Cancer Inst. 2002 Sep 4;94(17):1301-11.

Intake of dairy products, calcium, and vitamin d and risk of breast cancer.

Shin MH, Holmes MD, Hankinson SE, Wu K, Colditz GA, Willett WC.

Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA.

BACKGROUND: Laboratory data suggest that calcium and vitamin D, found at high levels in dairy products, might reduce breast carcinogenesis. However, epidemiologic studies regarding dairy products and breast cancer have yielded inconsistent results. We examined data from a large, long-term cohort study to evaluate whether high intake of dairy products, calcium, or vitamin D is associated with reduced risk of breast cancer. METHODS: We followed 88 691 women in the Nurses' Health Study cohort from the date of return of their food-frequency questionnaire in 1980 until May 31, 1996. Dietary information was collected in 1980 and updated in 1984, 1986, 1990, and 1994. We identified 3482 women (premenopausal = 827, postmenopausal = 2345, and uncertain menopausal status = 310) with incident invasive breast cancer. We used pooled logistic regression to estimate multivariable relative risks (RRs) using 2-year time increments. The RRs and 95% confidence intervals (CIs) were calculated for each category of intake compared with the lowest intake group. All statistical tests were two-sided. RESULTS: Intakes of dairy products, calcium, or vitamin D were not statistically significantly associated with breast cancer risk in postmenopausal women. In premenopausal women, however, consumption of dairy products, especially of low-fat dairy foods and skim/low-fat milk, was inversely associated with risk of breast cancer. The multivariable RRs comparing highest (>1 serving/day) and lowest (<or=3 servings/month) intake categories were 0.68 (95% CI = 0.55 to 0.86) for low-fat dairy foods and 0.72 (95% CI = 0.56 to 0.91) for skim/low-fat milk. Dairy calcium (>800 mg/day versus <or=200 mg/day; RR = 0.69, 95% CI = 0.48 to 0.98), total vitamin D (>500 IU/day versus <or=150 IU/day; RR = 0.72, 95% CI = 0.55 to 0.94), and lactose (quintile 5 versus quintile 1; RR = 0.68, 95% CI = 0.54 to 0.86] also had inverse associations with premenopausal breast cancer risk. By taking into account supplemental calcium and vitamin D intake, we found that association with calcium was due mainly to dairy sources whereas the association with vitamin D may be independent of dairy intake. CONCLUSIONS: We found no association between intake of dairy products and breast cancer in postmenopausal women. Among premenopausal women, high intake of low-fat dairy foods, especially skim/low-fat milk, was associated with reduced risk of breast cancer. Similar inverse associations were seen with components (calcium and vitamin D) of dairy foods, but their independent associations with breast cancer are difficult to distinguish.

28. J Biol Chem. 2002 Aug 23;277(34):30738-45. Epub 2002 Jun 18.

Calcium and calpain as key mediators of apoptosis-like death induced by vitamin D compounds in breast cancer cells.

Mathiasen IS, Sergeev IN, Bastholm L, Elling F, Norman AW, Jaattela M.

Apoptosis Laboratory, Danish Cancer Society, Strandboulevarden 49, DK 2100 Copenhagen O, Denmark.

The active form of vitamin D(3) (1,25(OH)(2)D(3)) induces an increase in the intracellular free calcium ([Ca(2+)](i)) and caspase-independent cell death in human breast cancer cells. Here we show that the treatment of MCF-7 breast cancer cells with 1,25(OH)(2)D(3) or its chemotherapeutic analog, EB 1089, releases Ca(2+) from the endoplasmic reticulum. The increase in [Ca(2+)](i) was associated with the activation of a calcium-dependent cysteine protease, mu-calpain. Interestingly, ectopic expression of a calcium-binding protein, calbindin-D(28k), in MCF-7 cells not only attenuated the elevation in [Ca(2+)](i) and calpain activation, but also reduced death triggered by vitamin D compounds. Similarly, the inhibition of calpain activity by structurally unrelated chemical inhibitors increased the survival of the cells and reduces the amount of annexin V-positive cells. Despite the complete absence of effector caspase activation, transmission electron microscopy of MCF-7 cells treated with 1,25(OH)(2)D(3) or EB 1089 revealed apoptosis-like morphology characterized by the condensed cytoplasm, nuclei, and chromatin. Overall, these results suggest that calpain may take over the role of the major execution protease in apoptosis-like death induced by vitamin D compounds. Thus, these compounds may prove useful in the treatment of tumors resistant to therapeutic agents dependent on the classical caspase cascade.

29. J Biol Chem. 2002 Jul 19;277(29):25884-92. Epub 2002 Apr 30.

The p38 and JNK pathways cooperate to trans-activate vitamin D receptor via c-Jun/AP-1 and sensitize human breast cancer cells to vitamin D(3)-induced growth inhibition.

Qi X, Pramanik R, Wang J, Schultz RM, Maitra RK, Han J, DeLuca HF, Chen G.

Department of Radiation Oncology, Loyola University of Chicago, Maywood, Illinois 60153, USA.

The signaling connection between mitogen-activated protein kinases(MAPKs) and nuclear steroid receptors is complex and remains mostly unexplored. Here we report that stress-activated protein kinases p38 and JNK trans-activate nuclear steroid vitamin D receptor (VDR) gene and increase vitamin D(3)-dependent growth inhibition in human breast cancer cells. Activation of p38 and JNK by an active MAPK kinase 6 stimulates VDR promoter activity independently of the ligand vitamin D(3) and estrogen receptor expression. Moreover, stimulation of the endogenous stress pathways by adenovirus-mediated delivery of recombinant MAPK kinase 6 also activates VDR and sensitizes MCF-7 cells to vitamin D(3)-dependent growth inhibition. Both the p38 and JNK MAPK pathways and the downstream transcription factor c-Jun/AP-1 are required for the VDR stimulation, as revealed by application of their dominant negatives, the specific p38 inhibitor SB203580, and site-directed mutagenesis of the AP-1 element in the VDR promoter. The essential role of the p38 and JNK stress pathways in up-regulation of VDR expression is further confirmed by using the chemical stimulator arsenite. These results establish a signaling connection between the stress MAPK pathways and steroid hormone receptor VDR expression and thereby offer new insights into regulation of cell growth by the MAPK pathways through regulation of vitamin D(3)/VDR activity.

30. Endocr Relat Cancer. 2002 Mar;9(1):45-59.

Mechanisms implicated in the growth regulatory effects of vitamin D in breast cancer.

Colston KW, Hansen CM.

Department of Oncology, Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School, London SW17 0RE, UK. k.colston@sghms.ac.uk

It is now well established that, in addition to its central role in the maintenance of extracellular calcium levels and bone mineralization, 1,25-dihydroxyvitamin D(3) (1,25(OH)(2)D(3)), the active form of vitamin D, also acts as a modulator of cell growth and differentiation in a number of cell types, including breast cancer cells. The anti-proliferative effects of 1,25(OH)(2)D(3) have been linked to suppression of growth stimulatory signals and potentiation of growth inhibitory signals, which lead to changes in cell cycle regulators such as p21(WAF-1/CIP1) and p27(kip1), cyclins and retinoblastoma protein as well as induction of apoptosis. Such studies have led to interest in the potential use of 1,25(OH)(2)D(3) in the treatment or prevention of certain cancers. Since this approach is limited by the tendency of 1,25(OH)(2)D(3) to cause hypercalcaemia, synthetic vitamin D analogues have been developed which display separation of the growth regulating effects from calcium mobilizing actions. This review examines mechanisms by which 1,25(OH)(2)D(3) and its active analogues exert both anti-proliferative and pro-apoptotic effects and describes some of the synthetic analogues that have been shown to be of particular interest in relation to breast cancer.

31. Cancer Res. 2001 Feb 15;61(4):1439-44.

Vitamin D is a prooxidant in breast cancer cells.

Koren R, Hadari-Naor I, Zuck E, Rotem C, Liberman UA, Ravid A.

Basil and Gerald Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel. rkoren@post.tau.ac.il

The anticancer activity of the hormonal form of vitamin D, 1,25-dihydroxyvitamin D [1,25(OH)2D], is associated with inhibition of cell cycle progression, induction of differentiation, and apoptosis. In addition, 1,25(OH)2D3 augments the activity of anticancer agents that induce excessive reactive oxygen species generation in their target cells. This study aimed to find out whether 1,25(OH)2D3, acting as a single agent, is a prooxidant in cancer cells. The ratio between oxidized and reduced glulathione and the oxidation-dependent inactivation of glyceraldehyde-3phosphate dehydrogenase (GAPDH) are considered independent markers of cellular reactive oxygen species homeostasis and redox state. Treatment of MCF-7 breast cancer cells with 1,25(OH)2D3 (10-100 nM for 24-48 h) brought about a maximal increase of 41+/-13% (mean +/- SE) in the oxidized/reduced glutathione ratio without affecting total glutathione levels. The in situ activity of glutathione peroxidase and catalase were not affected by 1,25(OH)2D3, as assessed by the rate of H2O2 degradation by MCF-7 cell cultures. Neither did treatment with 1,25(OH)2D3 affect the levels of glutathione reductase or glutathione S-transferase as assayed in cell extracts. The hormone did not affect overall glutathione consumption and efflux as reflected in the rate of decline of total cellular glutathione after inhibition of its synthesis by buthionine sulfoximine. The extent of reversible oxidation-dependent inactivation of GAPDH in situ was determined by comparing the enzyme activity before and after reduction of cell extracts with DTT. The oxidized fraction was 0.13+/-0.02 of total GAPDH in control cultures and increased by 56+/-5.3% after treatment with 1,25(OH)2D3, which did not affect the total reduced enzyme activity. Treatment with 1,25(OH)2D3 resulted in a approximately 40% increase in glucose-6-phosphate dehydrogenase, the rate-limiting enzyme in the generation of NADPH. This enzyme is induced in response to various modes of oxidative challenge in mammalian cells. Taken together, these findings indicate that 1,25(OH)2D3 causes an increase in the overall cellular redox potential that could translate into modulation of redox-sensitive enzymes and transcription factors that regulate cell cycle progression, differentiation, and apoptosis.

32. Br J Cancer. 2001 Mar 2;84(5):686-90.

Anti-oestrogen resistant human breast cancer cell lines are more sensitive towards treatment with the vitamin D analogue EB1089 than parent MCF-7 cells.

Larsen SS, Heiberg I, Lykkesfeldt AE.

Department of Tumor Endocrinology, Institute of Cancer Biology, Danish Cancer Society, Strandboulevarden 49, Copenhagen, DK-2100 O, Denmark.

Most breast cancer patients treated with anti-oestrogens will eventually develop resistance towards treatment. Therefore it is important to find new therapeutic agents effective for treatment of patients relapsing on anti-oestrogen. The vitamin D analogue EB1089 (Seocalcitol(TM)) is a promising new agent for treatment of breast cancer patients with advanced disease, and in this study we show that two different anti-oestrogen-resistant human breast cancer cell lines are more sensitive towards treatment with EB1089, than the parent MCF-7 cell line. The two resistant cell lines both express a lower content of the anti-apoptotic protein Bcl-2, and we suggest that this may explain the higher sensitivity towards EB1089. The importance of Bcl-2 for response to EB1089 is supported by our observation that oestradiol abrogates the effect of EB1089 in cell lines which increase Bcl-2 in response to oestradiol treatment. Overall these results indicate that treatment with Seocalcitol(TM)may prove effective when patients become refractory to anti-oestrogen therapy, and that Bcl-2 may be used as a predictive marker. Copyright 2001 Cancer Research Campaign.

33. Steroids. 2001 Mar-May;66(3-5):309-18.

Interaction of vitamin D analogs with signaling pathways leading to active cell death in breast cancer cells.

Pirianov G, Colston KW.

Department of Oncology, Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School, Cranmer Terrace, SW17 0RE, London, UK.

Induction of apoptosis is a feature of the anti-tumor effects of certain vitamin D analogs. The aim of this study was to identify if common effectors are involved in cell death mediated by serum starvation, vitamin D analogs and tumor necrosis factor (TNF) alpha in 3 human breast cancer cell lines: MCF-7, T47-D and Hs578T. Incubation of cells in serum-free medium induced apoptosis as assessed by loss of cell viability and increased DNA fragmentation. Addition of IGF-I (30 ng/ml) protected against loss of cell viability in MCF-7 cells and co-treatment with two synthetic analogs (CB1093 and EB1089, 50 nM for 4 days) prevented these anti-apoptotic effects of IGF-I. Pretreatment of MCF-7 and Hs578T cells with the vitamin D analogs substantially potentiated the cytotoxic effects of TNFalpha. This cytokine was not cytotoxic for T47-D cells but co-incubation with CB1093 led to loss of cell viability. Potentiation by CB1093 of TNFalpha-induced apoptosis in MCF-7 cells was accompanied by increased activation of cytosolic phospholipase A2 and arachidonic acid release, which was partially inhibited by AACOCF3, a specific cPLA2 inhibitor. The broad-spectrum caspase inhibitor z-VAD-fmk prevented TNFalpha but not CB1093 mediated cell death and activation of cPLA2. Serum starvation induced apoptosis was accompanied by cPLA2 activation, which was inhibited by IGF-I and by z-VAD-fmk. However, the ability of these agents to suppress cPLA2 activation was abrogated by co-treatment with CB1093, suggesting a role for arachidonic acid release in the caspase-independent mechanism by which vitamin D analogs prevent the protective effects of IGF-I on breast cancer cell survival.

34. Mol Cell Endocrinol. 2001 Feb 14;172(1-2):69-78.

Interactions of vitamin D analogue CB1093, TNFalpha and ceramide on breast cancer cell apoptosis.

Pirianov G, Colston KW.

Department of Oncology, Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School, Cranmer Terrace, Tooting, SW17 ORE, London, UK.

Mechanisms by which vitamin D analogues promote apoptosis in tumour cells are unclear. In this study we have examined possible interactions between the synthetic vitamin D analogue CB1093 and two other known mediators of apoptosis, TNFalpha and ceramide, in MCF-7, T47D and Hs578T breast cancer cells. These studies indicated that cytosolic phospholipase A(2) (cPLA(2)) is involved in CB1093 as well as TNFalpha-mediated cell death. CB1093 promoted both TNFalpha and ceramide-induced c-PLA(2) activation, which was inversely related to loss of cell viability in MCF-7 and Hs578T cells. TNFalpha alone (5-20 ng/ml) failed to induce cytotoxicity and activation of cPLA(2) in T47D cells. However, pretreatment of these cells with CB1093 potentiated C(2)-ceramide-induced cPLA(2) activation and cell death. Treatment with CB1093 alone induced loss of cell viability and DNA fragmentation in all three cell lines by 5 days and these effects were accompanied by activation of cPLA(2). Furthermore, co-treatment with the cPLA(2) inhibitor AACOCF(3) led to partial protection against loss of cell viability induced by CB1093 in Hs578T and T47D cells as well as MCF-7 cells. The broad-spectrum caspase inhibitor z-VAD-fmk prevented TNFalpha but not C(2)-ceramide and CB1093-mediated release of arachidonic acid and cell death in MCF-7 cells. These results indicate that CB1093 potentiates responsiveness of breast cancer cells to TNFalpha and suggest that ceramide and/or cPLA(2) might be involved as downstream effectors in vitamin D-mediated caspase-independent cell death.

35. J Biol Chem. 2001 Mar 23;276(12):9101-7. Epub 2000 Oct 26.

Role of mitochondria and caspases in vitamin D-mediated apoptosis of MCF-7 breast cancer cells.

Narvaez CJ, Welsh J.

Department of Biological Sciences, University of Notre Dame, Notre Dame, Indiana 46556, USA.

Vitamin D(3) compounds are currently in clinical trials for human breast cancer and offer an alternative approach to anti-hormonal therapies for this disease. 1alpha,25-Dihydroxyvitamin D(3) (1alpha,25(OH)(2)D(3)), the active form of vitamin D(3), induces apoptosis in breast cancer cells and tumors, but the underlying mechanisms are poorly characterized. In these studies, we focused on the role of caspase activation and mitochondrial disruption in 1alpha,25(OH)(2)D(3)-mediated apoptosis in breast cancer cells (MCF-7) in vitro. The effect of 1alpha,25(OH)(2)D(3) on MCF-7 cells was compared with that of tumor necrosis factor alpha, which induces apoptosis via a caspase-dependent pathway. Our major findings are that 1alpha,25(OH)(2)D(3) induces apoptosis in MCF-7 cells by disruption of mitochondrial function, which is associated with Bax translocation to mitochondria, cytochrome c release, and production of reactive oxygen species. Moreover, we show that Bax translocation and mitochondrial disruption do not occur after 1alpha,25(OH)(2)D(3) treatment of a MCF-7 cell clone selected for resistance to 1alpha,25(OH)(2)D(3)-mediated apoptosis. These mitochondrial effects of 1alpha,25(OH)(2)D(3) do not require caspase activation, since they are not blocked by the cell-permeable caspase inhibitor z-Val-Ala-Asp-fluoromethylketone. Although caspase inhibition blocks 1alpha,25(OH)(2)D(3)-mediated events downstream of mitochondria such as poly(ADP-ribose) polymerase cleavage, external display of phosphatidylserine, and DNA fragmentation, MCF-7 cells still execute apoptosis in the presence of z-Val-Ala-Asp-fluoromethylketone, indicating that the commitment to 1alpha,25(OH)(2)D(3)-mediated cell death is caspase-independent.

36. Cancer Res. 2000 Aug 15;60(16):4412-8. (Animal Study)

The vitamin D analogue EB 1089 prevents skeletal metastasis and prolongs survival time in nude mice transplanted with human breast cancer cells.

El Abdaimi K, Dion N, Papavasiliou V, Cardinal PE, Binderup L, Goltzman D, Ste-Marie LG, Kremer R.

Department of Medicine, McGill University and Royal Victoria Hospital, Montreal, Quebec, Canada.

1,25-Dihydroxyvitamin D has potent antiproliferative and anti-invasive properties in vitro in cancer cells. However, its calcemic effect in vivo limits its therapeutic applications. Here, we report the efficacy of EB 1089, a low calcemic analogue of vitamin D, on the development of osteolytic bone metastases after intracardiac injection of the human breast cancer cell line MDA-MB-231 in nude mice. Animals injected with tumor cells were implanted simultaneously with osmotic minipumps containing either EB 1089 or vehicle. Both groups remained normocalcemic for the duration of the experiment. The total number of bone metastases, the mean surface area of osteolytic lesions, and tumor burden within bone per animal were markedly decreased in EB1089-treated mice. Furthermore, longitudinal analysis revealed that mice treated with EB1089 displayed a marked increase in survival and developed fewer bone lesions and less hind limb paralysis over time as compared with untreated animals. These results suggest that EB1089 may be beneficial in the prevention of metastatic bone lesions associated with human breast cancer.

Biochem Biophys Res Commun. 2000 Jul 5;273(2):675-80.

37. Vitamin D induced up-regulation of keratinocyte growth factor (FGF-7/KGF) in MCF-7 human breast cancer cells.

Lyakhovich A, Aksenov N, Pennanen P, Miettinen S, Ahonen MH, Syvala H, Ylikomi T, Tuohimaa P.

Tampere University Medical School, Tampere, 33101, Finland. alex.lyakhovich@uta.fi

Keratinocyte growth factor (FGF-7/KGF) is a secreted member of the fibroblast growth factor family, which functions primarily as an important paracrine mediator of cell growth and differentiation. Inhibitory pathways of vitamin D may also involve participation of some growth factors. To determine whether vitamin D may play a role in the expression of FGF-7, we investigated FGF-7 expression in human breast cancer cells treated with 1,25-dihydroxyvitamin D3, which inhibited the growth of the cells. By means of cDNA microarray, RT-PCR, and Western blot analysis, we have shown an increase in expression of FGF-7 on both mRNA and protein levels after vitamin D exposure. This is the first demonstration of vitamin D regulation of FGF-7 expression and its possible involvement in mediating growth and differentiation by vitamin D. Copyright 2000 Academic Press.

38. Eur J Cancer. 2000 Apr;36(6):780-6.

Induction of differentiation by 1alpha-hydroxyvitamin D(5) in T47D human breast cancer cells and its interaction with vitamin D receptors.

Lazzaro G, Agadir A, Qing W, Poria M, Mehta RR, Moriarty RM, Das Gupta TK, Zhang XK, Mehta RG.

Department of Surgical Oncology, University of Illinois College of Medicine, 840 S. Wood St (M/C 820), Chicago 60612, USA.

The role of the active metabolite of vitamin D, 1,25 dihydroxyvitamin D(3) (1,25(OH)(2)D(3)), in cell differentiation is well established. However, its use as a differentiating agent in a clinical setting is precluded due to its hypercalcaemic activity. Recently, we synthesised a relatively non-calcaemic analogue of vitamin D(5), 1alpha-hydroxyvitamin D(5) (1alpha(OH)D(5)), which inhibited the development of carcinogen-induced mammary lesions in culture and suppressed the incidence of chemically induced mammary carcinogmas in rats. In the present study, we determined the differentiating effects of 1alpha-(OH)D(5) in T47D human breast cancer cells and compared its effects with 1,25(OH)(2)D(3). Cells incubated with either 10 or 100 nM of the analogues inhibited cell proliferation in a dose-dependent manner, as measured by the dimethylthiazolyl-2,5-diphenyltetrazolium bromide (MTT) assay. Similar growth-inhibitory effects were also observed for MCF10(neo) cells. Both vitamin D analogues induced cell differentiation, as determined by induction of casein expression and lipid production. However, MCF10(neo) cells failed to respond to either vitamin D analogue and did not undergo cell differentiation. Since the cell differentiating effect of vitamin D is considered to be mediated via the vitamin D receptor (VDR), we examined the induction of VDR using reverse transcriptase-polymerase chain reaction (RT-PCR) in both cells. The results showed that, in T47D cells, both 1,25(OH)(2)D(3) and 1alpha(OH)D(5) induced VDR in a dose-dependent manner. Moreover, both analogues of vitamin D upregulated the expression of vitamin D response element-chloramphenicol acetyl transferase (VDRE-CAT). These results collectively indicate that 1alpha-(OH)D(5) may mediate its cell-differentiating action via VDR in a manner similar to that of 1,25(OH)(2)D(3).

39. Oncol Res. 1999;11(6):265-71.

Influence of static magnetic field on the antiproliferative effects of vitamin D on human breast cancer cells.

Pacini S, Aterini S, Pacini P, Ruggiero C, Gulisano M, Ruggiero M.

Department of Anatomy, Histology and Forensic Medicine, University of Firenze at the Careggi General Hospital, Italy.

We describe the effect of a 0.2 tesla (T) static magnetic field generated by a magnetic resonance tomograph and of vitamin D treatment on a human breast cancer cell line (MCF-7). Cell damage and proliferation were monitored by measuring the incorporation of [3H]thymidine in duplicating DNA and by the clonogenic assay. [3H]Thymidine incorporation in MCF-7 was stimulated by vitamin D at low doses (10(-12)-10(-10) M), whereas it was inhibited at higher concentrations (10(-9)-10(-6) M). Magnetic field treatment (0.2 T) decreased [3H]thymidine incorporation in human breast cancer cells, eliminating the proproliferative effect of low doses of vitamin D, and enhanced the vitamin D antiproliferative effect, further reducing [3H]thymidine incorporation, from -12.5% (P < 0.05) to -66.7% (P < 0.001), over the range of 10(-9) to 10(-6) M. In the clonogenic assay, ability of MCF-7 to form colonies was inhibited by vitamin D 10(-9) M and above, whereas 3-h exposure to 0.2 T magnetic field had no effect on the number of cell colonies formed. In conclusion, vitamin D treatment yields a permanent antiproliferative effect, while magnetic field exposure only temporarily slows down cellular growth. These findings suggest that therapy with vitamin D may prove beneficial for chemoprevention or treatment of breast cancer. Static magnetic field, alone or in combination, does not appear to represent an effective candidate for breast cancer therapy, at least at the intensity used in the present study.

40. Eur J Cancer. 1999 Nov;35(12):1717-23.

Vitamin D analogues suppress IGF-I signalling and promote apoptosis in breast cancer cells.

Xie SP, Pirianov G, Colston KW.

Department of Oncology, Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School, London, U.K.

Survival factors are known to promote cell viability, and factor deprivation can be a potent apoptotic signal. Insulin-like growth factors are potent mitogens and inhibitors of apoptosis for many normal and neoplastic cells with insulin-like growth factor-I (IGF-I) being the most effective in many breast cancer cell lines. 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) and its analogues inhibit IGF-I-stimulated growth of MCF-7 human breast cancer cells. The aim of this study was to determine the relationship between inhibition of IGF-I responsiveness and induction of apoptosis by vitamin D analogues in breast cancer cells. Vitamin D analogues EB1089 and CB1093 inhibited autonomous and IGF-I-stimulated growth of MCF-7 and T47D cells and autonomous growth of IGF-I-insensitive Hs578T cells. In MCF-7 cells, IGF-I alone (4 nM) protected against apoptosis mediated by serum deprivation. Co-treatment with vitamin D analogues prevented the anti-apoptotic effects of IGF-I. In T47D cells, IGF-I treatment provided only partial protection against apoptosis induced by serum deprivation and co-incubation of serum-deprived cells with 100 nM CB1093 and IGF-I abrogated this partial protection. In Hs578T cells, addition of IGF-I did not prevent apoptosis induced by serum deprivation. However, treatment with CB1093 attenuated the protective effect of the serum in these cells. Our findings suggest that vitamin D analogues inhibit IGF-I signalling pathways to promote apoptosis in breast cancer cells.

41. Ann N Y Acad Sci. 1999;889:107-19.

Calcium and vitamin D. Their potential roles in colon and breast cancer prevention.

Garland CF, Garland FC, Gorham ED.

Department of Family and Preventive Medicine, University of California, San Diego 92093, USA. cgarland@ucsd.edu

The geographic distribution of colon cancer is similar to the historical geographic distribution of rickets. The highest death rates from colon cancer occur in areas that had high prevalence rates of rickets--regions with winter ultraviolet radiation deficiency, generally due to a combination of high or moderately high latitude, high-sulfur content air pollution (acid haze), higher than average stratospheric ozone thickness, and persistently thick winter cloud cover. The geographic distribution of colon cancer mortality rates reveals significantly low death rates at low latitudes in the United States and significantly high rates in the industrialized Northeast. The Northeast has a combination of latitude, climate, and air pollution that prevents any synthesis of vitamin D during a five-month vitamin D winter. Breast cancer death rates in white women also rise with distance from the equator and are highest in areas with long vitamin D winters. Colon cancer incidence rates also have been shown to be inversely proportional to intake of calcium. These findings, which are consistent with laboratory results, indicate that most cases of colon cancer may be prevented with regular intake of calcium in the range of 1,800 mg per day, in a dietary context that includes 800 IU per day (20 micrograms) of vitamin D3. (In women, an intake of approximately 1,000 mg of calcium per 1,000 kcal of energy with 800 IU of vitamin D would be sufficient.) In observational studies, the source of approximately 90% of the calcium intake was vitamin D-fortified milk. Vitamin D may also be obtained from fatty fish. In addition to reduction of incidence and mortality rates from colon cancer, epidemiological data suggest that intake of 800 IU/day of vitamin D may be associated with enhanced survival rates among breast cancer cases.

42. Int J Cancer. 1999 Dec 10;83(6):723-6.

Association of A vitamin D receptor polymorphism with sporadic breast cancer development.

Curran JE, Vaughan T, Lea RA, Weinstein SR, Morrison NA, Griffiths LR.

Genomics Research Centre, Griffith University Gold Coast, Southport, Queensland, Australia.

Breast cancer is the leading cause of cancer death among Australian women and its incidence is annually increasing. Genetic factors are involved in the complex etiology of breast cancer. The seco-steroid hormone, 1.25 dihydroxy vitamin D3 can influence breast cancer cell growth in vitro. A number of studies have reported correlations between vitamin D receptor (VDR) gene polymorphisms and several diseases including prostate cancer and osteoporosis. In breast cancer, low vitamin D levels in serum are correlated with disease progression and bone metastases, a situation also noted in prostate cancer and suggesting the involvement of the VDR. In our study, 2 restriction fragment length polymorphisms (RFLP) in the 3' region (detected by Apa1 and Taq1) and an initiation codon variant in the 5' end of the VDR gene (detected by Fok1) were tested for association with breast cancer risk in 135 females with sporadic breast cancer and 110 cancer-free female controls. Allele frequencies of the 3' Apa1 polymorphism showed a significant association (p = 0.016; OR = 1.56, 95% CI = 1.09-2.24) while the Taq1 RFLP showed a similar trend (p = 0.053; OR = 1.45, 95% CI = 1.00-2.00). Allele frequencies of the Fok1 polymorphism were not significantly different (p = 0.97; OR = 0.99, 95% CI = 0.69-1.43) in the study population. Our results suggest that specific alleles of the VDR gene located near the 3' region may identify an increased risk for breast cancer and justify further investigation of the role of VDR in breast cancer.

43. Cancer Res. 1999 Oct 1;59(19):4848-56.

Apoptosis induced by vitamin D compounds in breast cancer cells is inhibited by Bcl-2 but does not involve known caspases or p53.

Mathiasen IS, Lademann U, Jaattela M.

Apoptosis Laboratory, Institute of Cancer Biology, Danish Cancer Society, Copenhagen.

The hormonally active form of vitamin D3, 1,25-dihydroxyvitamin D3, and its two analogues, EB 1089 and CB 1093, are novel putative anticancer agents with an interesting profile of induction of growth inhibition, differentiation, and apoptosis in tumor cells. To study the signaling pathways mediating these events, we used two human breast cancer cell lines: MCF-7 cells, expressing a wild-type p53 tumor suppressor protein, and T47D cells, lacking a functional p53. Vitamin D compounds induced a growth arrest followed by apoptosis in both cell lines at concentrations ranging from 1 to 100 nM, indicating that p53 is not necessary for growth-inhibitory effects induced by vitamin D compounds. Surprisingly, apoptosis induced by these compounds occurred also independently of known caspases. Inhibition of caspase activation by overexpression of a cowpox-derived caspase inhibitor CrmA or by addition of inhibitory peptides acetyl-Asp-Glu-Val-Asp-aldehyde (200 microM), acetyl-Ile-Glu-Thr-Asp-aldehyde (50 microM), and Z-Val-Ala-D,L-Asp-fluoromethylketone (1 microM) showed no effect on the induction of growth arrest or apoptosis by vitamin D compounds under assay conditions in which apoptosis induced by TNF or staurosporine was effectively inhibited. Moreover, overexpression of caspase-3 in MCF-7 cells had no sensitizing effect to vitamin D compounds, and neither caspase-3-like protease activity nor cleavage of a caspase substrate poly(ADP)ribose polymerase was detected in lysates from apoptotic cells following the treatment with these compounds. Contrary to CrmA, overexpression of an antiapoptotic protein Bcl-2 in MCF-7 cells conferred a nearly complete protection from apoptosis induced by vitamin D compounds. Taken together, these data indicate that vitamin D compounds induce apoptosis via a novel caspase- and p53-independent pathway that can be inhibited by Bcl-2. This may prove useful in the treatment of tumors that are resistant to therapeutic agents that are dependent on the activation of p53 and/or caspases.

44. Int J Oncol. 1999 Sep;15(3):589-94.

Inhibition of insulin-like growth factor I receptor signaling by the vitamin D analogue EB1089 in MCF-7 breast cancer cells: A role for insulin-like growth factor binding proteins.

Rozen F, Pollak M.

Lady Davis Institute for Medical Research of the Jewish General Hospital and Departments of Medicine and Oncology, McGill University, Montreal, Quebec H3T 1E2, Canada.

Insulin-like growth factors I and II (IGF-I and IGF-II) are potent mitogens involved in growth regulation of breast epithelial cells and are implicated in the pathophysiology of breast cancer. Their bioactivity is enhanced or inhibited by specific IGF-binding proteins (IGFBPs). Vitamin D-related compounds (VDRCs) have been shown to inhibit proliferation and induce apoptosis of MCF-7 breast carcinoma cells. We have previously demonstrated that VDRCs antagonize the growth-promoting activity of IGF-I by stimulating autocrine production of IGFBP-5 in MCF-7 cells, but the effect of VDRCs on IGF-I receptor (IGF-IR) intracellular signaling has not been elucidated. We report here that the vitamin D analogue EB1089 interferes with the IGF-IR signaling pathway by attenuating IGF-I-induced tyrosine phosphorylation of IRS-1, and to a lesser extent, IRS-2. It does not affect protein levels of IRS-1, IRS-2 or IGF-IR. However, EB1089 does not inhibit tyrosine phosphorylation of IRS-1 induced by des(1-3) IGF-I, an IGF-I analogue with greatly reduced affinity for IGFBPs. Furthermore, we demonstrate that an antisense IGFBP-5 oligodeoxynucleotide attenuates EB1089-induced inhibition of IGF-I-stimulated tyrosine phosphorylation of IRS-1 and EB1089-induced IGFBP-5 accumulation. These data strongly suggest that IGFBP-5 plays a functional role in the interfering action of EB1089 with the IGF-IR signal transduction pathway.

45. Cancer Epidemiol Biomarkers Prev. 1999 May;8(5):399-406.

Vitamin D and breast cancer risk: the NHANES I Epidemiologic follow-up study, 1971-1975 to 1992. National Health and Nutrition Examination Survey.

John EM, Schwartz GG, Dreon DM, Koo J.

Northern California Cancer Center, Union City 94587, USA. ejohn@nccc.org

We analyzed data from the first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study to test the hypothesis that vitamin D from sunlight exposure, diet, and supplements reduces the risk of breast cancer. We identified 190 women with incident breast cancer from a cohort of 5009 white women who completed the dermatological examination and 24-h dietary recall conducted from 1971-1974 and who were followed up to 1992. Using Cox proportional hazards regression, we estimated relative risks (RRs) for breast cancer and 95% confidence intervals, adjusting for age, education, age at menarche, age at menopause, body mass index, alcohol consumption, and physical activity. Several measures of sunlight exposure and dietary vitamin D intake were associated with reduced risk of breast cancer, with RRs ranging from 0.67-0.85. The associations with vitamin D exposures, however, varied by region of residence. The risk reductions were highest for women who lived in United States regions of high solar radiation, with RRs ranging from 0.35-0.75. No reductions in risk were found for women who lived in regions of low solar radiation. Although limited by the relatively small size of the case population, the protective effects of vitamin D observed in this prospective study are consistent for several independent measures of vitamin D. These data support the hypothesis that sunlight and dietary vitamin D reduce the risk of breast cancer.

46. Br J Pharmacol. 1998 Nov;125(5):953-62.

EB1089, a synthetic analogue of vitamin D, induces apoptosis in breast cancer cells in vivo and in vitro.

James SY, Mercer E, Brady M, Binderup L, Colston KW.

Division of Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School London.

1. Effects of the synthetic vitamin D analogue EB1089 on indices of apoptosis in cultured human breast cancer cells and in nitrosomethylurea-induced rat mammary tumours in vivo were investigated. 2. At a dose of 0.5 microg kg(-1) body weight, EB1089 caused significant inhibition of tumour progression over the 28 day treatment period in the absence of a significant increase in serum calcium concentration. Higher doses of EB1089 (1 and 2.5 microg kg(-1)) produced substantial regression of the experimental tumours which was accompanied by a striking change in the histological appearance of tumours consistent with induction of tumour cell death. 3. Fragmentation of genomic DNA is a characteristic feature of apoptosis. With the terminal transferase (TdT) assay, 3' DNA breaks indicative of DNA fragmentation were detected histochemically in mammary tumour cells from animals treated with EB1089 (2.5 microg kg(-1)) for 14 days. 4. Effects of the vitamin D analogue on induction of apoptosis were examined in vitro using the MCF-7 human breast cancer cell line. Using the TUNEL method, positive nuclear staining indicative of DNA fragmentation was detected in cells treated for 4 days with 10 nM EB1089. Apoptosis was also quantitated using a cell death ELISA which revealed a time and dose dependent induction of apoptosis by EB1089. 5. The effects of EB1089 on the expression of two oncoproteins which may regulate apoptosis, bcl-2 and bax were examined by Western analysis. In MCF-7 cell cultures treated with 1,25(OH)2D3 or EB1089 (1 x 10(-8) M), bcl-2 protein levels were decreased in a time-dependent manner relative to control levels. In contrast bax protein was not markedly regulated by these compounds. Densitometric analyses indicate that the vitamin D compounds lower the bcl-2/bax ratio favouring increased susceptibility of MCF-7 cells to undergo apoptosis. 6. These results suggest that the synthetic vitamin D analogue EB1089 may promote tumour regression by inducing active cell death.

47. J Mol Endocrinol. 1998 Feb;20(1):157-62.

Growth inhibition of both MCF-7 and Hs578T human breast cancer cell lines by vitamin D analogues is associated with increased expression of insulin-like growth factor binding protein-3.

Colston KW, Perks CM, Xie SP, Holly JM.

Division of Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School, London, UK.

The effects of two vitamin D analogues, EB1089 and CB1093, on insulin-like growth factor binding protein (IGFBP) expression have been examined in MCF-7 and Hs578T human breast cancer cell lines. Both vitamin D analogues inhibited IGF-1 stimulated growth of MCF-7 cells and enhanced the production of IGFBP-3 as determined by Western-ligand blotting. Recombinant human IGFBP-3 inhibited the growth of MCF-7 cells over the concentration range 1-235 ng/ml. Hs578T cells were unresponsive to the mitogenic effects of IGF-1 but growth was inhibited by the two vitamin D analogues. Treatment of Hs578T cells with EB1089 and CB1093 (10 nM) as well as 100 nM 9-cis retinoic acid (9-cis RA) or all-trans retinoic acid (ATRA) was associated with increased accumulation of IGFBP-3 in conditioned medium. Furthermore, cotreatment of Hs578T cells with EB1089 and 9-cis RA led to augmented effects on both inhibition of cell growth and IGFBP-3 accumulation in conditioned medium as assessed by Western ligand blotting and radioimmunoassay. These findings suggest a role for IGFBP-3 in the growth inhibitory effects of vitamin D analogues.

48. J Endocrinol. 1997 Sep;154(3):495-504.

Vitamin D derivatives inhibit the mitogenic effects of IGF-I on MCF-7 human breast cancer cells.

Xie SP, James SY, Colston KW.

Division of Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School, London, UK.

The effects of 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) and four novel synthetic analogues (EB1089, KH1060, KH1230 and CB1093) on IGF-I-stimulated growth of MCF-7 human breast cancer cells have been determined. A significant time- and dose-dependent inhibition of IGF-I-stimulated cell growth was seen with EB1089, such that after 7 days of treatment with 10(-8) M EB1089, the mitogenic effect of IGF-I (30 ng/ml) was negated. Comparison with 1,25(OH)2D3 showed the synthetic analogues to be more potent. The anti-oestrogen ICI 182,780 similarly inhibited IGF-I-stimulated growth of these cells and in combination with EB1089 exerted additional inhibitory effects. Retinoids (all-trans-retinoic acid or the isomer 9-cis-retinoic acid) were less effective in limiting MCF-7 cell responsiveness to IGF-I but, in combination with EB1089, a co-operative effect was achieved. Using radioligand-binding techniques, we observed that 1,25(OH)2D3 and EB1089 down-regulated the levels of 125I-IGF-I binding to MCF-7 cell membranes. Scatchard analysis showed that EB1089 decreased maximal binding approximately 2-fold. Vitamin D derivatives were also demonstrated to reduce IGF-I receptor expression in MCF-7 cells by Western analysis. Our findings demonstrate that vitamin D derivatives limit responsiveness of MCF-7 cells to the mitogenic effects of IGF-I, which may be mediated by reduction of IGF-I receptor expression.

49. J Steroid Biochem Mol Biol. 1995 Aug;54(3-4):147-53.

Modulation of vitamin D receptor and estrogen receptor by 1,25(OH)2-vitamin D3 in T-47D human breast cancer cells.

Davoodi F, Brenner RV, Evans SR, Schumaker LM, Shabahang M, Nauta RJ, Buras RR.

Department of Surgery, Lombardi Cancer Research Center, Georgetown University Medical Center, Washington, DC, USA.

1,25(OH)2-Vitamin D3 inhibits breast cancer cell proliferation through interaction with the vitamin D receptor (VDR). Regulation of VDR is under the influence of several factors which include the functional ligand for this receptor (1,25(OH)2-vitamin D3) as well as heterologous steroid hormones. We evaluated the nature of homologous regulation in T-47D human breast cancer cells with a radiolabelled ligand binding assay and a ribonuclease protection assay for VDR. Significant VDR up-regulation, as measured by hormone binding assays, occurred with pre-incubations with 10(-9)M through 10(-6)M 1,25(OH)2-vitamin D3 (P < 0.05). A 7-fold VDR up-regulation with 10(-8)M 1,25(OH)2-vitamin D3 occurred at 4 h treatment and was not associated with an increase in VDR mRNA expression on ribonuclease protection assay. This supports the hypothesis that up-regulation of VDR is probably the result of ligand-induced stabilization of pre-existing receptor. All-trans-retinoic acid, the progesterone analog R-5020, and prednisone were found to induce heterologous up-regulation of the VDR. We then determined with ligand binding assays whether 1,25(OH)2-vitamin D3 could influence receptor levels for another hormone in a manner analogous to the heterologous regulation of VDR. Regulation of estrogen receptor (ER) by 1,25(OH)2-vitamin D3 was studied in T-47D and MDA-MB-231 breast cancer cells. Incubation of T-47D cells, which are ER (+), with 10(-8)M 1,25(OH)2-vitamin D3 did not result in up-regulation of ER. Yet estrogen binding was significantly up-regulated in a cell line that is ER(-), MDA-MB-231. The increased estrogen binding was associated with a shift in binding affinity and ribonuclease protection assay showed absence of ER mRNA in these cells, suggesting an up-regulation of estrogen binding proteins and not of the ER itself.

50. J Mol Endocrinol. 1995 Jun;14(3):391-4.

Vitamin D derivatives in combination with 9-cis retinoic acid promote active cell death in breast cancer cells.

James SY, Mackay AG, Colston KW.

Department of Clinical Biochemistry, St George's Hospital Medical School, London.

The effects of the novel vitamin D analogue, EB1089 alone, or in combination with the retinoid, 9-cis retinoic acid (9-cis RA) on indices of apoptosis in MCF-7 breast cancer cells have been examined. EB1089 was capable of reducing bcl-2 protein, a suppressor of apoptosis, and increasing p53 protein levels in MCF-7 cell cultures following 96h treatment. In the presence of 9-cis RA, EB1089 acted to further enhance the down-regulation and up-regulation of bcl-2 and p53 respectively. Furthermore, EB1089 induces DNA fragmentation in MCF-7 cells, a key feature of apoptosis, alone and in combination with 9-cis RA in situ. The observation that EB1089 and 9-cis RA act in a cooperative manner to enhance induction of apoptosis in these cells may have therapeutic implications.

51. Cancer Lett. 1995 May 25;92(1):77-82.

The antiproliferative effect of vitamin D analogs on MCF-7 human breast cancer cells.

Brenner RV, Shabahang M, Schumaker LM, Nauta RJ, Uskokovic MR, Evans SR, Buras RR.

Department of Surgery, Lombardi Cancer Research Center, Georgetown University Medical Center, Washington, DC 20007-2197, USA.

We analyzed the antiproliferative effect of 1,25-dihydroxyvitamin D3 and four vitamin D analogs on MCF-7, a human breast cancer cell line known to express the vitamin D receptor. Growth curve studies and [3H]thymidine incorporation assays were used to assess the antiproliferative effect of 1,25-dihydroxyvitamin D3 (vitamin D), Ro 23-7553, Ro 24-5531, Ro 25-5317, and Ro 24-5583. Growth of MCF-7 cells was significantly inhibited by 1,25-dihydroxyvitamin D3 and all four analogs at 10(-8) M (P < 0.05). MCF-7 cells treated with analog had significantly less [3H]thymidine incorporation than cells treated with 1,25-dihydroxyvitamin D3 (P < 0.05). The affinity of the analogs for the vitamin D receptor was similar to that of 1,25-dihydroxyvitamin D3. These results demonstrate that analogs of 1,25-dihydroxyvitamin D3 are potent antiproliferative agents on human breast cancer cells and that this activity is likely mediated through the vitamin D receptor.

52. J Endocrinol. 1994 Jun;141(3):555-63.

Effects of a new synthetic vitamin D analogue, EB1089, on the oestrogen-responsive growth of human breast cancer cells.

James SY, Mackay AG, Binderup L, Colston KW.

Department of Clinical Biochemistry, St George's Hospital Medical School, London, UK.

The anti-proliferative effects of the novel vitamin D analogue, EB1089, were assessed in the hormone-dependent breast cancer cell line, MCF-7, in vitro. In the present study, EB1089 was shown to be at least an order of magnitude more potent at inhibiting MCF-7 cell proliferation than the native hormone, 1 alpha,25-dihydroxyvitamin D3 (1,25(OH)2D3). Treatment of MCF-7 cell cultures with combinations of oestradiol and EB1089 ranging from 5 x 10(-11) M to 5 x 10(-9) M revealed the ability of EB1089 to suppress the mitogenic effects of oestradiol in these cells dose-dependently, as determined by [3H]thymidine incorporation and cell counts. EB1089 also exhibited a significant time- and dose-dependent decrease in MCF-7 oestrogen receptor (ER) concentration, as assessed by ligand binding assay. A fourfold reduction of ER levels by 5 x 10(-9) M EB1089 relative to control ER levels was observed, whilst 5 x 10(-9) M 1,25(OH)2D3 produced a significant but less dramatic decrease in ER levels. In addition, reduction of ER protein in EB1089-treated cell cultures was also demonstrated using an oestrogen receptor enzyme immunoassay. The interaction of EB1089 and anti-oestrogens on the oestradiol-stimulated growth of MCF-7 cells was investigated. The treatment of cell cultures with 5 x 10(-10) M EB1089 in combination with the pure anti-oestrogen, ICI 182,780 (5 x 10(-8) M), and in the presence of between 5 x 10(-10) M and 5 x 10(-9) M oestradiol, produced an augmented inhibition of MCF-7 cell proliferation compared with the actions of either compound alone.(ABSTRACT TRUNCATED AT 250 WORDS)

53. Cancer Res. 1994 Apr 1;54(7):1653-6. (Animal Study)

1 alpha,25-Dihydroxy-16-ene-23-yne-26,27-hexafluorocholecalciferol (Ro24-5531), a new deltanoid (vitamin D analogue) for prevention of breast cancer in the rat.

Anzano MA, Smith JM, Uskokovic MR, Peer CW, Mullen LT, Letterio JJ, Welsh MC, Shrader MW, Logsdon DL, Driver CL, et al.

Laboratory of Chemoprevention, National Cancer Institute, Bethesda, Maryland 20892.

We have used the vitamin D analogue, 1 alpha,25-dihydroxy-16-ene-23-yne-26,27-hexafluorocholecalcifero l (Ro24-5531), for inhibition of mammary carcinogenesis induced by N-nitroso-N-methylurea (NMU) in Sprague-Dawley rats. Rats were first treated with a single dose of either 15 or 50 mg/kg body weight NMU and then fed Ro24-5531 (2.5 or 1.25 nmol/kg of diet) for 5-7 months. Ro24-5531 significantly extended tumor latency and lessened tumor incidence as well as tumor number in rats treated with the lower dose of NMU. In rats treated with the higher dose of NMU, Ro24-5531 was fed in combination with tamoxifen; in these experiments, Ro24-5531 significantly enhanced the ability of tamoxifen to reduce total tumor burden, as well as to increase the probability that an animal would be tumor free at the end of the experiment. In vitro, Ro24-5531 was 10-100 times more potent than 1,25-dihydroxyvitamin D3 for inhibition of proliferation of human breast cancer cell lines as well as primary cultures of cells from 2 patients with acute myelogenous leukemia. When fed chronically, Ro24-5531 did not elevate serum calcium in the present studies. We propose the new term, "deltanoids," for the set of molecules composed of vitamin D and its synthetic analogues, in a manner similar to the naming of "retinoids" for the corresponding set of molecules related to vitamin A.

54. Breast Cancer Res Treat. 1994;31(2-3):191-202.

Vitamin D receptors in breast cancer cells.

Buras RR, Schumaker LM, Davoodi F, Brenner RV, Shabahang M, Nauta RJ, Evans SR.

Department of Surgery, Georgetown University, Washington DC.

1,25-(OH)2-Vitamin D3, the active metabolite of vitamin D, is a secosteroid hormone with known differentiating activity in leukemic cells. Studies have demonstrated the presence of vitamin D receptors (VDR) in a wide range of tissues and cell types. Antiproliferative activity of 1,25-(OH)2-vitamin D3 has been documented in osteosarcoma, melanoma, colon carcinoma, and breast carcinoma cells. This study was designed to analyze vitamin D receptor level in breast cancer cells as a marker of differentiation and as a predictor of growth inhibition by 1,25-(OH)2-vitamin D3. VDR messenger RNA was found to be present in relatively high levels in well-differentiated cells and in low levels in poorly differentiated cells. All cell lines had detectable VDR mRNA. Radiolabeled ligand binding assay showed a similar pattern. MCF-7 and T47D cells, which express VDR at moderate levels, showed significant growth inhibition by 10(-9) M1,25-(OH)2-vitamin D3 (p < 0.05). MDA-MB-231 cells, which have very low levels of VDR, demonstrated no growth inhibition by 1,25-(OH)2-vitamin D3 at concentrations up to 10(-6) M. Based on these results it can be stated that VDR expression is lost with de-differentiation and that receptor is essential for the antiproliferative response to 1,25-(OH)2-vitamin D3.

55. Adv Exp Med Biol. 1994;364:109-14.

Vitamin D adequacy: a possible relationship to breast cancer.

Newmark HL.

Memorial Sloan-Kettering Cancer Center, New York, New York, USA.

(1) Low levels of dietary calcium and vitamin D, biochemically interrelated, increase the promoting action of high dietary fat on chemically induced mammary carcinogenesis in animal studies. (2) High dietary fat increases mammary epithelial cell proliferation, particularly the "hormonally driven" hyperproliferation during breast growth and development in young animals. Increased dietary calcium (and probably vitamin D) lessens the increase of proliferation induced by high fat. These data, although limited, suggest that the maximum effect of diet (high fat increase, as well as calcium and vitamin D modulation) on eventual breast cancer may be during puberty, and adolescence, when the mammary gland is actively growing and developing. (3) An inverse epidemiological correlation has been developed between sunlight availability as a source of vitamin D and the risk of breast cancer in the U.S. and Canada. (4) Current vitamin D and calcium dietary intake in the U.S. is far below the RDA in all female age groups, particularly for the elderly. (5) Reduction of breast cancer risk, and simultaneously osteoporosis, might be achieved by increasing dietary intake of calcium and vitamin D to RDA levels. This may be particularly applicable to females during puberty and adolescence.

56. Biochem Pharmacol. 1992 Dec 15;44(12):2273-80. (Animal Study)

EB1089: a new vitamin D analogue that inhibits the growth of breast cancer cells in vivo and in vitro.

Colston KW, Mackay AG, James SY, Binderup L, Chander S, Coombes RC.

Department of Clinical Biochemistry, St Georges Hospital Medical School, Tooting, London, U.K.

EB1089 is a novel vitamin D analogue which has been tested for its effects on breast cancer cell growth in vitro, using the established human breast cancer cell line MCF-7, and in vivo on the growth of established rat mammary tumours. Both EB1089 and 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) inhibited MCF-7 cell proliferation with the synthetic analogue being at least an order of magnitude more potent than the native hormone. In vivo anti-tumour effects were investigated using the N-methyl-nitrosourea-induced rat mammary tumour model. Oral treatment with EB1089 was tested at three doses. With the lower dose, significant inhibition of tumour growth was seen in the absence of a rise in serum calcium. The same dose of 1,25-(OH)2D3 had no effect on tumour growth but caused hypercalcaemia. With the higher dose of EB1089, striking tumour regression was seen although serum calcium rose. This report demonstrates that EB1089 possess enhanced anti-tumour activity coupled with reduced calcaemic effects relative to 1,25-(OH)2D3 and thus may have therapeutic potential as an anti-tumour agent.

57. Biochem Pharmacol. 1992 Aug 18;44(4):693-702.

Effects of synthetic vitamin D analogues on breast cancer cell proliferation in vivo and in vitro.

Colston KW, Chander SK, Mackay AG, Coombes RC.

Department of Clinical Biochemistry, St George's Hospital Medical School, London, U.K.

Calcipotriol (MC903) is a novel vitamin D analogue which effects cellular differentiation and proliferation in vitro and has reduced effects on calcium metabolism in vivo. In the present study its in vitro activity was evaluated using the MCF-7 breast cancer cell line, and its effects on calcium metabolism and mammary tumour growth were measured in vivo in adult female rats. Calcipotriol was compared to the natural metabolite of vitamin D3, 1 alpha,25-dihydroxycholecalciferol [1,25(OH)2D3] and its synthetic analogue 1 alpha hydroxycholecalciferol [1 alpha(OH)D3]. Both calcipotriol and 1,25(OH)2D3 produced significant inhibition of MCF-7 cell proliferation at a concentration of 5 x 10(-11) M. Intraperitoneal administration of calcipotriol to normal female rats showed that the analogue was 100-200 times less active than 1,25(OH)2D3 in raising serum calcium concentration and urinary calcium excretion. Anti-tumour activity of the vitamin D analogues was investigated in vivo using the nitrosomethylurea-induced rat mammary tumor model. Rats, maintained on a low calcium diet, were treated with 1 alpha(OH)D3 (0.25 and 1.25 micrograms/kg). Both doses produced a response rate of 25% but hypercalcaemia developed. Treatment with calcipotriol (50 micrograms/kg) of rats maintained on a normal laboratory diet caused inhibition of tumour progression (response rate 17%) without the development of severe hypercalcaemia. This study supports the concept that vitamin D derivatives may inhibit breast cancer cell proliferation in vivo.

58. Lancet. 1989 Jan 28;1(8631):188-91.

Possible role for vitamin D in controlling breast cancer cell proliferation.

Colston KW, Berger U, Coombes RC.

Department of Chemical Pathology, St George's Hospital Medical School, London.

By means of an immunocytochemical method the 1.25-dihydroxyvitamin D [1.25(OH)2D] receptor status of tumours from 136 patients with primary carcinoma of the breast was determined. Patients with receptor-positive tumours had significantly longer disease-free survival than those with receptor-negative tumours (Chi2 = 4.01, p less than 0.05). 1.25(OH)2D3 inhibits the proliferation of several established human breast cancer cell lines in vitro. Effects of 1.25(OH)2D3 on breast tumour growth in vitro were assessed by means of the nitrosomethylurea-induced rat mammary tumour model of hormone-responsive breast cancer. Treatment of tumour-bearing animals with 0.1 microgram of the synthetic analogue, 1 alpha-hydroxyvitamin D3, three times weekly produced significant inhibition of tumour progression. Taken together, these studies suggest that the levels of 1.25(OH)2D occurring in vivo may exert an inhibitory effect on receptor-positive tumours. Further studies are required to evaluate the role of vitamin D metabolites in the treatment of human malignant disease.

Prostate Cancer

59. Endocr Relat Cancer. 2003 Jun;10(2):131-40.

The role of vitamin D and retinoids in controlling prostate cancer progression.

Peehl DM, Feldman D.

Department of Urology, Stanford University School of Medicine, Stanford, California, USA. dpeehl@stanford.edu

Prostate cancer is a leading cause of cancer-related deaths in many countries. Premalignant lesions and invasive cancer occur more frequently in the prostate than in any organ other than the skin. Yet, the incidence of clinically detected prostate cancer is much lower than the histopathological incidence. The slow growth of prostate cancer and the low incidence of clinically manifest disease in some geographical locations or racial/ethnic groups suggest that prostate cancer can be controlled, perhaps by dietary factors. Vitamin D and retinoids have emerged as leading candidates both to prevent and to treat prostate cancer. Many of the activities of these compounds, established from epidemiological studies, research with cell culture and animal models, and clinical trials, are consistent with tumor suppressor effects. However, retinoids may have additional tumor enhancer properties that balance or negate anti-cancer activity. This perhaps explains the overall lack of protective effects of vitamin A compounds against prostate cancer found in epidemiological studies, and the minimal efficacy of retinoids in clinical trials to treat prostate cancer. While current efforts focus on developing strategies to use vitamin D compounds to control prostate cancer, the possibility exists that prostate cancer cells may become resistant to tumor suppressor effects of vitamin D. Analyses of experimental model systems show that prostate cancer cells become less sensitive to vitamin D through loss of receptors or signaling molecules that mediate vitamin D's actions, or through changes in metabolic enzymes that synthesize or degrade vitamin D compounds. The potential promise of exploiting vitamin D to control prostate cancer is tempered by the possibility that prostate cancer, perhaps even at early stages, may develop mechanisms to escape tumor suppressor activities of vitamin D and/or retinoids.

60. Int J Urol. 2003 May;10(5):261-6.

Vitamin D receptor gene polymorphism in familial prostate cancer in a Japanese population.

Suzuki K, Matsui H, Ohtake N, Nakata S, Takei T, Koike H, Nakazato H, Okugi H, Hasumi M, Fukabori Y, Kurokawa K, Yamanaka H.

Department of Urology, Gunma University School of Medicine, Gunma, Japan. kazu@showa.gunma-u.ac.jp

AIM: Vitamin D acts as an antiproliferative agent against prostate cells. Epidemiological study has shown that a low level of serum vitamin D concentration is a risk factor for prostate cancer. Vitamin D acts via vitamin D receptor (VDR), and an association of genetic polymorphisms of the VDR gene has been reported. In the current study, we examined the association of VDR gene polymorphisms with familial prostate cancer in a Japanese population. METHODS: We performed a case-control study consisting of 81 familial prostate cancer cases and 105 normal control subjects. Three genetic polymorphisms (BsmI, ApaI and TaqI) in the VDR gene were examined by the restriction fragment restriction length polymorphism method. RESULTS: Overall, there was no significant association of the VDR gene polymorphisms with familial prostate cancer risk in the cases and control subjects. However, a weak association between BsmI or TaqI genotypes and cancer risk was observed in subjects under 70 years of age. Stratification of cases by clinical stage or pathological grade did not show significant association between the VDR gene polymorphisms and prostate cancer risk. CONCLUSION: In the present study, we could not confirm any significant association between VDR gene polymorphisms with familial prostate cancer risk in a Japanese population. Further large-scale case-control studies are warranted to confirm the importance of VDR gene polymorphisms in familial prostate cancer.

61. J Cell Biochem. 2003 Feb 1;88(2):363-71.

Inhibition of prostate cancer growth by vitamin D: Regulation of target gene expression.

Krishnan AV, Peehl DM, Feldman D.

Department of Medicine, Stanford University School of Medicine, Stanford, California 94305, USA.

Prostate cancer (PCa) cells express vitamin D receptors (VDR) and 1,25-dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) inhibits the growth of epithelial cells derived from normal, benign prostate hyperplasia, and PCa as well as established PCa cell lines. The growth inhibitory effects of 1,25(OH)(2)D(3) in cell cultures are modulated tissue by the presence and activities of the enzymes 25-hydroxyvitamin D(3) 24-hydroxylase which initiates the inactivation of 1,25(OH)(2)D(3) and 25-hydroxyvitamin D(3) 1alpha-hydroxylase which catalyses its synthesis. In LNCaP human PCa cells 1,25(OH)(2)D(3) exerts antiproliferative activity predominantly by cell cycle arrest through the induction of IGF binding protein-3 (IGFBP-3) expression which in turn increases the levels of the cell cycle inhibitor p21 leading to growth arrest. cDNA microarray analyses of primary prostatic epithelial and PCa cells reveal that 1,25(OH)(2)D(3) regulates many target genes expanding the possible mechanisms of its anticancer activity and raising new potential therapeutic targets. Some of these target genes are involved in growth regulation, protection from oxidative stress, and cell-cell and cell-matrix interactions. A small clinical trial has shown that 1,25(OH)(2)D(3) can slow the rate of prostate specific antigen (PSA) rise in PCa patients demonstrating proof of concept that 1,25(OH)(2)D(3) exhibits therapeutic activity in men with PCa. Further investigation of the role of calcitriol and its analogs for the therapy or chemoprevention of PCa is currently being pursued. Copyright 2002 Wiley-Liss, Inc.

62. Cancer Metastasis Rev. 2002;21(2):147-58.

Vitamin D-related therapies in prostate cancer.

Johnson CS, Hershberger PA, Trump DL.

candace.johnson@roswellpark.org

Calcitriol or 1,25-dihydroxycholecalciferol (vitamin D) is classically known for its effects on bone and mineral metabolism. Epidemiological data suggest that low vitamin D levels increase the risk and mortality from prostate cancer. Calcitriol is also a potent anti-proliferative agent in a wide variety of malignant cell types including prostate cancer cells. In prostate model systems (PC-3, LNCaP, DU145, MLL) calcitriol has significant anti-tumor activity in vitro and in vivo. Calcitriol's effects are associated with an increase in cell cycle arrest, apoptosis, differentiation and in the modulation of growth factor receptors. Calcitriol induces a significant G0/G1 arrest and modulates p21(Waf/Cip1) and p27(Kip1), the cyclin dependent kinase inhibitors. Calcitriol induces PARP cleavage, increases the bax/bcl-2 ratio, reduces levels of phosphorylated mitogen-activated protein kinases (P-MAPKs, P-Erk-1/2) and phosphorylated Akt (P-Akt), induces caspase-dependent MEK cleavage and up-regulation of MEKK-1, all potential markers of the apoptotic pathway. Glucocorticoids potentiate the anti-tumor effect of calcitriol and decrease calcitriol-induced hypercalcemia. In combination with calcitriol, dexamethasone results in a significant time- and dose-dependent increase in VDR protein and an enhanced apoptotic response as compared to calcitriol alone. Calcitriol can also significantly increase cytotoxic drug-mediated anti-tumor efficacy. As a result, phase I and II trials of calcitriol either alone or in combination with the carboplatin, paclitaxel, or dexamethasone have been initiated in patients with androgen-dependent and -independent prostate cancer and advanced cancer. Patients were evaluated for toxicity, maximum tolerated dose (MTD), schedule effects, and PSA response. Data from these studies indicate that high-dose calcitriol is feasible on an intermittent schedule, the MTD is still being delineated and dexamethasone or paclitaxel appear to ameliorate toxicity. Studies continue to define the MTD of calcitriol whichcan be safely administered on this intermittent schedule either alone or with other agents and to evaluate the mechanisms of calcitriol effects in prostate cancer.

63. BJU Int. 2002 Oct;90(6):607-16. (Animal Study)

Vitamin D receptor-dependent antitumour effects of 1,25-dihydroxyvitamin D3 and two synthetic analogues in three in vivo models of prostate cancer.

Oades GM, Dredge K, Kirby RS, Colston KW.

Department of Urology, St. George's Hospital and Medical School, London, UK. gmoades@baus.org.uk

OBJECTIVE: To determine the in vitro and in vivo effects of 1,25-dihydroxyvitamin D3 (calcitriol) and two newer less hypercalcaemic analogues, EB1089 and CB1093 (as the use of calcitriol as a therapeutic agent in humans has been limited by hypercalcaemia) in three rodent models of prostate cancer. MATERIALS AND METHODS: The highly metastatic MAT LyLu Dunning prostate model, PAIII tumours in Lobund-Wistar rats and LNCaP xenografts in nude mice were used. Vitamin D receptor (VDR) expression and binding were assessed in all cell lines. The effects of calcitriol, EB1089 and CB1093 on tumour growth, cell cycle and angiogenesis in vitro, and growth and serum calcium levels in vivo, were assessed. RESULTS: The growth of prostate adenocarcinoma was inhibited by calcitriol, EB1089 and CB1093 in the Dunning prostate model. Although both analogues increased serum calcium levels, the levels were significantly less than in rats treated with calcitriol. Tumour growth was also inhibited in male athymic nu/nu mice with LNCaP tumour xenografts. PAIII cells failed to express functional VDR and were insensitive to calcitriol and its analogues, either in vitro or in vivo. The analogues of calcitriol did not inhibit angiogenesis in a rat aorta assay. CONCLUSION: This is the first report comparing the actions of calcitriol and its analogues in different in vivo models. The results suggest that the newer less hypercalcaemic analogues of calcitriol may offer a novel therapeutic option for treating prostate cancer. VDR-dependent growth inhibition and not the inhibition of angiogenesis is the main mechanism of action of these compounds in vivo. J Urol. 2002 Oct;168(4 Pt 1):1583-8.

64. Preclinical activity of ketoconazole in combination with calcitriol or the vitamin D analogue EB 1089 in prostate cancer cells.

Peehl DM, Seto E, Hsu JY, Feldman D.

Department of Urology, Stanford University School of Medicine, California 94305-5118, USA.

PURPOSE: Ketoconazole is a general inhibitor of P450 enzymes, of which some are necessary for androgen biosynthesis and the metabolism of vitamin D compounds. We tested the growth inhibitory activity of ketoconazole combined with 1,25-dihydroxyvitamin D3 (calcitriol) and with the vitamin D analogue EB 1089 in a preclinical model of prostate cancer. MATERIALS AND METHODS: Clonal assays with primary cultures of human prostatic cancer cells were performed to test anti-proliferative effects of ketoconazole alone or in combination with calcitriol or EB 1089. Enzyme substrate reactions were done to determine whether the ability of ketoconazole to potentiate the activity of calcitriol or EB 1089 was due to the inhibition of 25-hydroxyvitamin D3-24-hydroxylase (24-hydroxylase), the enzyme that initiates conversion of active vitamin D compounds to inactive products. RESULTS: Ketoconazole, calcitriol and EB 1089 each inhibited the growth of prostatic cancer cells. In combination 0.1 microg./ml. ketoconazole potentiated growth inhibitory activity of calcitriol 50-fold and EB 1089 10-fold. Induction of 24-hydroxylase by calcitriol or EB 1089 was partially blocked by this level of ketoconazole. CONCLUSIONS: Combination therapy with ketoconazole and calcitriol or EB 1089 may enhance antitumor activities of vitamin D compounds for prostate cancer and alleviate side effects of vitamin D deficiency that are likely associated with ketoconazole therapy.

65. J Chromatogr B Analyt Technol Biomed Life Sci. 2002 Sep 25;777(1-2):261-8.

Isoflavonoids inhibit catabolism of vitamin D in prostate cancer cells.

Farhan H, Wahala K, Adlercreutz H, Cross HS.

Institute of Pathophysiology, University of Vienna Medical School, AKH, Wahringergurtel 18-20 A-1090, Vienna, Austria.

The high ingestion of soybean products in Asian countries has been suggested to be responsible for a reduced incidence of prostate cancer. The mechanism of action, however, is unknown. Our data demonstrate that genistein and some isoflavone metabolites reduce the activity of 25-D3-24-hydroxylase (CYP24) in the human prostate cancer-derived cell line DU-145. CYP24 is also responsible for degradation of the active vitamin D metabolite 1,25-dihydroxyvitamin D3 which is known to be antimitotic and prodifferentiating in prostate cancer cells. High levels of CYP24 frequently found in prostate cancer cells may thus degrade the active metabolite. This could be prevented by ingestion of genistein-containing food such as soybeans.

66. Urol Clin North Am. 2002 Feb;29(1):95-106, ix.

Vitamin D and prostate cancer.

Konety BR, Getzenberg RH.

Departments of Urology, Pathology, and Pharmacology, University of Pittsburgh, 5200 Centre Avenue, G-40, Pittsburgh, PA 15232, USA.

Current approaches to the management of prostate cancer include surgery, radiation therapy or hormonal manipulation either individually or in combination. Diet is increasingly being recognized as playing a role in many cancers including that of the prostate. There is now considerable evidence suggesting a role for vitamin D in prostate cancer. In this article, we have reviewed the current evidence supporting the use of vitamin D in the prevention and treatment of prostate cancer.

67. Cancer Epidemiol Biomarkers Prev. 2002 Jun;11(6):555-63. (Animal Study)

The G gamma / T-15 transgenic mouse model of androgen-independent prostate cancer: target cells of carcinogenesis and the effect of the vitamin D analogue EB 1089.

Perez-Stable CM, Schwartz GG, Farinas A, Finegold M, Binderup L, Howard GA, Roos BA.

Geriatric Research, Education, and Clinical Center and Research Service, Veterans Affairs Medical Center, Miami, Florida 33125, USA. cperez@med.miami.edu

Transgenic mouse models of prostate cancer provide unique opportunities to understand the molecular events in prostate carcinogenesis and for the preclinical testing of new therapies. We studied the G gamma T-15 transgenic mouse line, which contains the human fetal globin promoter linked to SV40 T antigen (Tag) and which develops androgen-independent prostate cancer. Using the immunohistochemistry of normal mouse prostates before tumor formation, we showed that the target cells of carcinogenesis in G gamma T-15 mice are located in the basal epithelial layer. We tested the efficacy of the 1,25(OH)(2)D(3) analogue, EB 1089, to chemoprevent prostate cancer in these transgenic mice. Compared with treatment with placebo, treatment with EB 1089 at three different time points before the onset of prostate tumors in mice did not prevent or delay tumor onset. However, EB 1089 significantly inhibited prostate tumor growth. At the highest dose, EB 1089 inhibited prostate tumor growth by 60% (P = 0.0003) and the growth in the number of metastases, although this dose also caused significant hypercalcemia and weight loss. We conducted several in vitro experiments to explore why EB 1089 did not prevent the occurrence of the primary tumors. EB 1089 significantly inhibited the growth of a Tag-expressing human prostate epithelial cell line, BPH-1, and an androgen-insensitive subline of LNCaP cells [which was not inhibited by 1,25(OH)(2)D(3)]. Thus, neither Tag expression nor androgen insensitivity explain the absence of chemopreventive effect. Conversely, neither 1,25(OH)(2)D(3) nor EB 1089 inhibited the growth of the normal rat prostate basal epithelial cell line NRP-152. It is likely that EB 1089 was not effective in delaying the growth of the primary tumor in G gamma T-15 transgenic mice because the target cells of carcinogenesis in these mice are located in the basal epithelial layer. We conclude that G gamma T-15 transgenic mice are a useful model for testing vitamin D-based therapies in androgen-insensitive prostate cancer but are not suitable for studies of vitamin D-based chemoprevention. The superiority of EB 1089 over 1,25(OH)(2)D(3) in the growth suppression of androgen-insensitive prostate cancer cells supports the use of EB 1089 in androgen-insensitive prostate cancer.

68. Cancer Res. 2002 Jun 1;62(11):3084-92.

A novel targeting modality to enhance adenoviral replication by vitamin D(3) in androgen-independent human prostate cancer cells and tumors.

Hsieh CL, Yang L, Miao L, Yeung F, Kao C, Yang H, Zhau HE, Chung LW.

Department of Urology, Molecular Urology and Therapeutics Program, Emory University School of Medicine, Atlanta, GA 30322, USA. chsieh2@emory.edu

We report the development of a novel replication-competent adenoviral vector, Ad-hOC-E1, containing a single bidirectional human osteocalcin (hOC) promoter to drive both the early viral E1A and E1B gene. This vector selectively replicated in OC-expressing but not non-OC-expressing cells, with viral replication enhanced at least 10-fold on vitamin D(3) exposure. Both the artificial TATA-box and hOC promoter element in this bidirectional promoter construct were controlled by a common OC regulatory element which selectively activated OC expression in cells. The expression ofE1A and E1B gene by Ad-hOC-E1 can be markedly induced by vitamin D(3). Unlike Ad-sPSA-E1, an adenoviral vector with viral replication controlled by a strong super prostate-specific antigen (sPSA) promoter which only replicates in PSA-expressing cells with androgen receptor (AR), Ad-hOC-E1 retarded the growth of both androgen-dependent and androgen-independent prostate cancer cells irrespective of their basal level of AR and PSA expression. A single i.v. administration of 2 x 10(9) plaque-forming units of Ad-hOC-E1 inhibited the growth of previously established s.c. DU145 tumors (an AR- and PSA-negative cell line). Viral replication is highly enhanced by i.p. administration of vitamin D(3). Ultimately, enhancing Ad-hOC-E1 viral replication by vitamin D(3) may be used clinically to treat localized and osseous metastatic prostate cancer in men.

69. Mol Cell Endocrinol. 2002 Apr 25;190(1-2):115-24.

Regulation of PTH-related protein gene expression by vitamin D in PC-3 prostate cancer cells.

Tovar Sepulveda VA, Falzon M.

Department of Pharmacology and Toxicology and Sealy Center for Molecular Science, University of Texas Medical Branch, 10th and Market Streets, , Galveston 775550 1031, USA.

Parathyroid hormone-related protein (PTHrP) is expressed by prostate cancer cells. Since PTHrP increases prostate cancer cell growth and enhances the osteolytic effects of prostate cancer cells, it is important to control PTHrP expression in prostate cancer. Vitamin D exerts a protective effect against prostate cancer through its antiproliferative actions. We investigated whether this steroid also downregulates PTHrP gene transcription, using the human prostate cancer cell line PC-3 as a model system. We report that PTHrP mRNA and secreted protein levels are downregulated by 1,25-dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) via a transcriptional mechanism. We also show that PTHrP gene expression is upregulated, also via a transcriptional mechanism, by epidermal growth factor (EGF), which is normally secreted by prostate cancer cells. 1,25(OH)(2)D(3) reversed the EGF-induced PTHrP upregulation at both the mRNA and protein levels. Since PTHrP enhances prostate cancer cell growth, this study demonstrates the importance of maintaining adequate levels of 1,25(OH)(2)D(3).

70. Mol Cell Endocrinol. 2002 Jan 15;186(1):69-79.

Vitamin D-mediated growth inhibition of an androgen-ablated LNCaP cell line model of human prostate cancer.

Yang ES, Maiorino CA, Roos BA, Knight SR, Burnstein KL.

Department of Molecular and Cellular Pharmacology (R-189), University of Miami School of Medicine, PO Box 016189 (R-189), Miami, FL 33136, USA.

1,25-(OH)(2) vitamin D(3) (1,25-(OH)(2) D), the active metabolite of vitamin D, exerts antiproliferative effects on a variety of tumor cells including prostate. This inhibition requires vitamin D receptors (VDRs) as well as downstream effects on the G1 to S phase checkpoint of the cell cycle. Recent data raise the possibility that androgen plays a role in the antiproliferative effects of 1,25-(OH)(2) D in prostate cancer cells; however, this hypothesis has been difficult to test rigorously as the majority of prostate cancer cell lines (unlike human prostate tumors) lack androgen receptors (ARs). We utilized two different models of androgen-independent prostate cancer that express functional ARs and VDRs to evaluate a possible role of androgen in 1,25-(OH)(2) D mediated growth inhibition. We stably introduced the AR cDNA into the human prostate cancer cell line ALVA 31, which expresses functional VDR but is relatively resistant to growth inhibition by 1,25-(OH)(2) D. Neither ALVA-AR nor the control cells, ALVA-NEO, exhibited substantial growth inhibition by 1,25-(OH)(2) D in the presence or absence of androgen. This observation suggests that the basis for the resistance of ALVA 31 to 1,25-(OH)(2) D-mediated growth inhibition is not the lack of AR. The second model was LNCaP-104R1, an AR-expressing androgen independent prostate cancer cell line derived from androgen dependent LNCaP. 1,25-(OH)(2) D inhibited the growth of LNCaP-104R1 cells in the absence of androgen and this effect was not blocked by the antiandrogen Casodex. As was observed in the parental LNCaP cells, this effect was correlated with G1 phase cell cycle accumulation and upregulation of the cyclin dependent kinase inhibitor (CKI) p27, as well as increased association of p27 with cyclin dependent kinase 2. These findings suggest that the antiproliferative effects of 1,25-(OH)(2) D do not require androgen-activated AR but do involve 1,25-(OH)(2) D induction of CKIs required for G1 cell cycle checkpoint control.

71. J Steroid Biochem Mol Biol. 2001 Jan-Mar;76(1-5):125-34.

Vitamin D and prostate cancer.

Tuohimaa P, Lyakhovich A, Aksenov N, Pennanen P, Syvala H, Lou YR, Ahonen M, Hasan T, Pasanen P, Blauer M, Manninen T, Miettinen S, Vilja P, Ylikomi T.

Medical School, University of Tampere, 33014, Tampere, Finland. pentti.tuohimaa@uta.fi

Our recent epidemiological study (Ahonen et al., Cancer Causes Control 11(2000) (847-852)) suggests that vitamin D deficiency may increase the risk of initiation and progression of prostate cancer. The nested case-control study was based on a 13-year follow-up of about 19000 middle-aged men free of clinically verified prostate cancer. More than one-half of the serum samples had 25OH-vitamin D (25-VD) levels below 50 nmol/l, suggesting VD deficiency. Prostate cancer risk was highest among the group of younger men (40-51 years) with low serum 25-VD, whereas low serum 25-VD appeared not to increase the risk of prostate cancer in older men (>51 years). This suggests that VD has a protective role against prostate cancer only before the andropause, when serum androgen concentrations are higher. The lowest 25-VD concentrations in the younger men were associated with more aggressive prostate cancer. Furthermore, the high 25-VD levels delayed the appearance of clinically verified prostate cancer by 1.8 years. Since these results suggest that vitamin D has a protective role against prostate cancer, we tried to determine whether full spectrum lighting (FSL) during working hours could increase serum 25-VD concentrations. After 1-month exposure, there was no significant increase in the serum 25-VD level, although there was a bias towards slightly increasing values in the test group as opposed to decreasing values in controls. There was no significant change in the skin urocanic acid production. The possibility to use FSL in cancer prevention is discussed. In order to clarify the mechanism of VD action on cell proliferation and differentiation, we performed studies with the rat and human prostates as well prostate cancer cell lines. It is possible that 25-VD may have a direct role in the host anticancer defence activity, but the metabolism of vitamin D in the prostate may also play an important role in its action. We raised antibodies against human 1alpha-hydroxylase and 24-hydroxylase. Our preliminary results suggest that vitamin D is actively metabolised in the prostate. Vitamin D appears to upregulate androgen receptor expression, whereas androgens seem to upregulate vitamin D receptor (VDR). This may at least partially explain the androgen dependence of VD action. VD alone or administered with androgen causes a suppression of epithelial cell proliferation. VD can activate mitogen-activated kinases, erk-1 and erk-2, within minutes and p38 within hours. Also, auto/paracrine regulation might be involved, since keratinocyte growth factor (mRNA and protein) was clearly induced by VD. Based on these studies, a putative model for VD action on cell proliferation and differentiation is presented.

72. Endocrinology. 2000 Jul;141(7):2567-73.

Hepatocyte growth factor and vitamin D cooperatively inhibit androgen-unresponsive prostate cancer cell lines.

Qadan LR, Perez-Stable CM, Schwall RH, Burnstein KL, Ostenson RC, Howard GA, Roos BA.

Geriatric Research, Education, and Clinical Center and Research Service, Veterans Affairs Medical Center, Department of Medicine, University of Miami School of Medicine, Florida 33101, USA.

Expression of MET, the receptor for hepatocyte growth factor (HGF), has been associated with androgen-insensitive prostate cancer. In this study we evaluated MET activation by HGF and HGF action in prostate cancer cell lines. HGF causes phosphorylation (activation) of the MET receptor in three androgen-unresponsive cell lines (DU 145, PC-3, and ALVA-31) together with morphological change. Although HGF is known to stimulate the growth of normal epithelial cells, including those from prostate, we found that HGF inhibited ALVA-31 and DU 145 (hormone-refractory) cell lines. Moreover, HGF and vitamin D additively inhibited growth in each androgen-unresponsive cell line, with the greatest growth inhibition in ALVA-31 cells. Further studies in ALVA-31 cells revealed distinct cooperative actions of HGF and vitamin D. In contrast to the accumulation of cells in G1 seen during vitamin D inhibition of androgen-responsive cells (LNCaP), growth inhibition of the androgen-unresponsive ALVA-31 cell line with the HGF and vitamin D combination decreased, rather than increased, the fraction of cells in G1, with a corresponding increase in the later cell cycle phases. This cell cycle redistribution suggests that in androgen-unresponsive prostate cancer cells, HGF and vitamin D act together to slow cell cycle progression via control at sites beyond the G1/S checkpoint, the major regulatory locus of growth control in androgen-sensitive prostate cells.

73. Cancer Res. 2000 Feb 15;60(4):779-82. (Animal Study)

Comment in: Cancer Res. 2001 May 15;61(10):4294.

A calcitriol analogue, EB1089, inhibits the growth of LNCaP tumors in nude mice.

Blutt SE, Polek TC, Stewart LV, Kattan MW, Weigel NL.

Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas 77030, USA.

Limited options for the treatment of prostate cancer have spurred the search for new therapies. One innovative approach is the use of 1alpha,25-dihydroxyvitamin D3 (calcitriol) analogues to inhibit cancer growth. We demonstrate here that the calcitriol analogue, EB1089, extensively inhibits the growth of LNCaP prostate cancer cells in culture and causes the cells to both accumulate in G0-G1 and undergo apoptosis. Importantly, we found that EB1089 inhibits the growth of LNCaP tumor xenografts in nude mice. Because of these antiproliferative properties in vivo, EB1089 is a potential new therapeutic agent for the treatment of prostate cancer.

74. J Urol. 2000 Jan;163(1):187-90.

Treatment of vitamin D deficiency in patients with metastatic prostate cancer may improve bone pain and muscle strength.

Van Veldhuizen PJ, Taylor SA, Williamson S, Drees BM.

Department of Internal Medicine, Veterans Affairs Medical Center, Kansas City, Missouri 64128, USA.

PURPOSE: We performed a phase II study to determine whether pain associated with prostate cancer bone metastasis would respond to vitamin D replacement and parameters of muscle strength would be improved by vitamin D replacement therapy. MATERIALS AND METHODS: After a 4-week placebo period, eligible patients received orally 2,000 units vitamin D daily for 12 weeks. Pain questionnaires and measurements of muscle strength were competed at study enrollment and every 4 weeks thereafter. Serum calcium and vitamin D were measured at each clinic visit. RESULTS: A total of 16 patients with advanced hormone refractory prostate cancer were enrolled in this phase II study, of whom 7 (44%) had decreased baseline vitamin D. With vitamin D treatment, 4 patients (25%) had improvement in pain scores and 6 (37%) had improvement in muscle strength measurements. Improvement in pain scores correlated with improvement in subjective symptoms but did not result in a significant decrease in regular scheduled analgesic requirements. CONCLUSIONS: Vitamin D deficiency develops in a significant percent of patients with advanced hormone refractory prostate cancer. Supplementation with vitamin D may be a useful adjunct for improving pain, muscle strength and quality of life in this patient population.

75. Eur Urol. 1999;35(5-6):392-4.

Vitamin D and prostate cancer risk.

Peehl DM.

Department of Urology, Stanford University School of Medicine, Stanford, Calif. 94305, USA. dpeehl@leland.stanford.edu

Prostate cancer is a progressive, multistep disease which presents many stages for intervention. Microscopic cancer is found in the prostate beginning by age 30 in about 20% of men, and the incidence increases steadily so that by the time a man is 90 years old, he has almost a 100% chance of having cancer in his prostate. Independent, multiple foci of cancer are present in the majority of prostate specimens, and the incidence of premalignant lesions is even higher than that of cancer. Yet, despite the high incidence of microscopic cancer, only 8% of men in the US present with clinically significant disease during their lifetime. Furthermore, only 3% of men in the US die of prostate cancer. In no other human cancer is there such disparity between the high incidence of microscopic malignancy and the relatively low death rate. Thus, there are many windows of opportunity for control of prostate cancer. Evidence from diverse areas of study - epidemiologic, molecular, genetic, cellular, animal models, and clinical trials - suggests that vitamin D may be an effective preventive agent against prostate cancer.

76. Proc Soc Exp Biol Med. 1999 Jun;221(2):89-98.

Vitamin D and prostate cancer.

Blutt SE, Weigel NL.

Department of Cell Biology, Baylor College of Medicine, Houston, Texas 77030, USA.

Classically, the actions of vitamin D have been associated with bone and mineral metabolism. More recent studies have shown that vitamin D metabolites induce differentiation and/or inhibit cell proliferation of a number of malignant and nonmalignant cell types including prostate cancer cells. Epidemiological studies show correlations between the risk factors for prostate cancer and conditions that can result in decreased vitamin D levels. The active metabolite of vitamin D, 1,25-dihydroxyvitamin D3 (calcitriol), inhibits growth of both primary cultures of human prostate cancer cells and cancer cell lines, but the mechanism by which the cells are growth-inhibited has not been clearly defined. Initial studies suggest that calcitriol alters cell cycle progression and may also initiate apoptosis. One of the disadvantages of using vitamin D in vivo is side-effects such as hypercalcemia at doses above physiological levels. Analogs of calcitriol have been developed that have comparable or more potent antiproliferative effects but are less calcemic. Further research into the mechanisms of vitamin D action in prostate and identification of suitable analogs for use in vivo may lead to its use in the treatment or prevention of prostate cancer.

77. Cancer Causes Control. 1998 Dec;9(6):559-66.

Comment in: Cancer Causes Control. 1998 Dec;9(6):541-3.

Dairy products, calcium, phosphorous, vitamin D, and risk of prostate cancer (Sweden)

Chan JM, Giovannucci E, Andersson SO, Yuen J, Adami HO, Wolk A.

Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA.

OBJECTIVES: Dairy products consistently have been associated with an increased risk of prostate cancer, yet the mechanism of this relationship remains unknown. Recent hypotheses propose that 1,25 dihydroxyvitamin D (1,25 D) is protective for prostate cancer. One study in the United States found that calcium consumption, which can lower circulating 1,25 D, was associated with higher risk of advanced prostate cancer, and we sought to address this hypothesis in a distinct population. METHODS: We analyzed data from a population-based case-control study of prostate cancer conducted in Orebro, Sweden, with 526 cases and 536 controls. Using unconditional logistic regression models, we examined the relationship of dairy products, dietary calcium, phosphorous, and vitamin D with risk of total, extraprostatic, and metastatic prostate cancer. RESULTS: Calcium intake was an independent predictor of prostate cancer (relative risk (RR) = 1.91, 95 percent confidence interval (CI) 1.23-2.97 for intake > or = 1183 vs. < 825 mg/day), especially for metastatic tumors (RR = 2.64, 95 percent CI 1.24-5.61), controlling for age, family history of prostate cancer, smoking, and total energy and phosphorous intakes. High consumption of dairy products was associated with a 50 percent increased risk of prostate cancer. CONCLUSIONS: Our results support the hypothesis that high calcium intake may increase risk of prostate cancer, and this relation may underlie previously observed associations between dairy products and prostate cancer.

78. Clin Cancer Res. 1997 Aug;3(8):1331-8.

Three synthetic vitamin D analogues induce prostate-specific acid phosphatase and prostate-specific antigen while inhibiting the growth of human prostate cancer cells in a vitamin D receptor-dependent fashion.

Hedlund TE, Moffatt KA, Uskokovic MR, Miller GJ.

Department of Pathology, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA.

Numerous studies have indicated that the secosteroid hormone 1alpha, 25-dihydroxyvitamin D3 protects against the development of clinical prostate cancer (PC). Whether this hormone also has therapeutic potential for patients with advanced PC has not yet been evaluated. Several synthetic vitamin D analogues are now available that have reduced hypercalcemic effects and yet effectively induce differentiation in some cell types. For these reasons, these analogues may be safer and more effective for cancer therapy than the natural hormone. In the current study, 13 such analogues were screened for their abilities to inhibit the growth of PC cell lines. Three of the most consistently effective analogues (Ro 23-7553, Ro 24-5531, and Ro 25-6760) were then chosen for further analysis. Growth studies using clones of the JCA-1 cell line that were transfected with the vitamin D receptor cDNA indicate that the antiproliferative effects of these analogues require vitamin D receptor expression. Furthermore, these three analogues induce the secretion of prostate-specific acid phosphatase and prostate-specific antigen (two markers of the differentiated prostatic phenotype) in the cell line LNCaP. These in vitro studies suggest that Ro 23-7553, Ro 24-5531, and Ro 25-6760 should be further evaluated as therapeutic agents for the treatment of PC.

79. Int J Oncol. 1998 Jul;13(1):137-43.

Regulation of insulin-like growth factor (IGF) II and IGF binding protein 3 autocrine loop in human PC-3 prostate cancer cells by vitamin D metabolite 1,25(OH)2D3 and its analog EB1089.

Huynh H, Pollak M, Zhang JC.

Lady Davis Research Institute of the Jewish General Hospital and Departments of Medicine, McGill University, Montreal, Quebec H3T 1E2, Canada.

Prostate cancer and benign prostate hyperplasia (BPH) are major public health problems. Prostate epithelial cell proliferation is regulated by insulin-like growth factor I (IGF-I) which is mitogenic and anti-apoptotic, and IGF binding protein 3 (IGFBP-3) which is an apoptotic agent in these cells. We demonstrate that the 1,25(OH)2D3 and its analog EB1089-induced growth inhibition was associated with increased IGFBP-3 mRNA abundance, IGFBP-3 mRNA stability, IGFBP-3 protein accumulation, and decreased IGF-II gene expression. Anti-IGF-II antibody and exogenous recombinant human IGFBP-3 inhibit PC-3 cell proliferation. The results document the inhibitory effects of 1,25(OH)2D3 and EB1089 on the IGF system of mitogens in prostate cancer cells, and suggest a potential therapeutic use of EB1089 in treatment of BPH and prostate cancer.

80. Cancer Epidemiol Biomarkers Prev. 1996 Feb;5(2):121-6.

Circulating vitamin D metabolites in relation to subsequent development of prostate cancer.

Gann PH, Ma J, Hennekens CH, Hollis BW, Haddad JG, Stampfer MJ.

Division of Preventive Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.

An emerging hypothesis suggests that vitamin D metabolites suppress the development of prostate cancer. In a recent epidemiological study, elevated levels of 1,25-dihydroxyvitamin D (1,25-D) in blood were associated with a greatly reduced risk, particularly in older men. We conducted a nested case-control study to evaluate the relationship between plasma levels of the two major vitamin D metabolites, 1,25-D and 25-hydroxyvitamin D (25-D), and subsequent diagnosis of prostate cancer. We also measured vitamin D-binding protein to investigate the influence of free metabolite levels on risk. Plasma samples from 14,916 participants in the Physicians' Health Study were collected and frozen in 1982-1983. This analysis included 232 cases diagnosed up to 1992 and 414 age-matched control participants. Vitamin D metabolite and vitamin D-binding protein assays were conducted without knowledge of case-control status. Median levels of 25-D, 1,25-D, and vitamin D-binding protein were indistinguishable between cases and controls. Analysis of risk for increasing quartiles of total or free metabolites did not reveal a pattern of decreasing risk. For 1,25-D, men in the highest quartile had an odds ratio of 0.88 (95% confidence interval = 0.53-1.45) compared to those in the lowest quartile. Significant reductions in risk were not seen in analyses restricted to older men, to cases occurring > 3 years from blood collection, or to cases presenting as aggressive prostate cancer. Nonsignificant inverse associations for 1,25-D appeared for some groups according to 25-D level, particularly when the cutoff for defining low 25-D was reduced. These results do not support the hypothesis that high circulating levels of vitamin D metabolites reduce prostate cancer risk, although small to moderate effects cannot be excluded.

81. Cancer Epidemiol Biomarkers Prev. 1995 Sep;4(6):655-9.

Seasonal variation in vitamin D, vitamin D-binding protein, and dehydroepiandrosterone: risk of prostate cancer in black and white men.

Corder EH, Friedman GD, Vogelman JH, Orentreich N.

Center for Demographic Studies, Duke University, Durham, North Carolina 27708, USA.

Our previous study provided evidence that higher serum levels of the active form of vitamin D, 1,25-dihydroxyvitamin D (1, 25-D), might possibly slow the progression of subclinical to clinically significant prostate cancer in both black and white men, especially after age 57. This paper extends the prior study by contrasting seasonal variation in 1,25-D and its precursor, 25-hydroxyvitamin D (25-D), in case and control subjects. In addition, the risk of prostate cancer is related to serum levels of vitamin D-binding protein (VDBP) and total dehydroepiandrosterone and to polymorphic variation in VDBP. The expected elevated summer levels of 25-D were seen in case and control subjects and, as expected, 1,25-D did not vary throughout the year in the control subjects. Unexpectedly, lower case levels of 1,25-D were limited largely to the summer months (P = 0.01) in both black and white cases and to cases greater than or equal to the median age of 57 years. Levels of VDBP and dehydroepiandrosterone and the frequencies of VDBP polymorphisms were similar in case and control subjects, although striking differences were seen in allelic frequencies in black and white men. These observations provide additional evidence that vitamin D metabolism may impact the risk of prostate cancer.

82. Anticancer Res. 1994 May-Jun;14(3A):1077-81.

Human prostate cancer cells: inhibition of proliferation by vitamin D analogs.

Schwartz GG, Oeler TA, Uskokovic MR, Bahnson RR.

Department of Clinical Epidemiology and Family Medicine, University of Pittsburgh Medical Center, PA.

1,25-Dihydroxyvitamin D [1,25(OH)2D3, calcitriol] can inhibit the proliferation of some human prostate cancer cells but its clinical use is limited by hypercalcemia. We therefore explored the bioactivity of less calcemic vitamin D analogs. We studied the effects of calcitriol and 3 synthetic analogs at concentrations of 10(-6) to 10(-12) M on the in vitro proliferation of 3 human prostate carcinoma cell lines: DU 145, PC-3, and LNCaP. Calcitriol and analogs showed significant antiproliferative activity on PC-3 and LNCaP cells. DU 145 cells were inhibited by the analogs only. We conclude that vitamin D analogs warrant further investigation as therapeutic agents in prostate cancer.

83. Endocrinology. 1993 May;132(5):1952-60.

Vitamin D and prostate cancer: 1,25 dihydroxyvitamin D3 receptors and actions in human prostate cancer cell lines.

Skowronski RJ, Peehl DM, Feldman D.

Department of Medicine, Stanford University School of Medicine, California 94305.

It has been suggested that vitamin D deficiency may promote prostate cancer, although the mechanism is not understood. In this study three human prostate carcinoma cell lines, LNCaP, DU-145, and PC-3, were examined both for the presence of specific 1,25 dihydroxyvitamin D3 [1,25(OH)2D3] receptors (VDRs) and also employed to study the effects of hormone on cell proliferation and differentiation. Ligand binding experiments demonstrated classical VDR in all three cell lines examined with an apparent dissociation constant of 7.5, 5.4, and 6.3 x 10(-11) M for LNCaP, DU-145, and PC-3 cells, respectively. Corresponding binding capacity for the three prostate carcinoma cell lines were 27, 31, and 78 fmol/mg protein, respectively. The presence of VDR in the three cell lines was also confirmed by immunocytochemistry. In addition, one major 4.6-kilobase messenger RNA transcript hybridizing with a specific human VDR complementary DNA probe was identified in all three cell lines. Interestingly, both DU-145 and PC-3 but not LNCaP cell lines exhibited 1,25(OH)2D3-stimulated induction of 24-hydroxylase messenger RNA employed as a marker of 1,25(OH)2D3 action. Physiological levels of 1,25(OH)2D3 dramatically inhibited proliferation of the LNCaP and PC-3 cell lines. However, in spite of the presence of high affinity VDR, proliferation of DU-145 cells was not inhibited by 1,25(OH)2D3 at the doses tested. Treatment with 1,25(OH)2D3 caused a dose-dependent stimulation of prostate-specific antigen secretion by LNCaP cells. In conclusion, these results demonstrate that these three human prostate carcinoma cell lines all possess specific VDR and that 1,25(OH)2D3 treatment can elicit both an antiproliferative and a differentiating action on these cancer cells. The findings lend support to the hypothesis that vitamin D might exert beneficial actions on prostate cancer risk.

84. Anticancer Res. 1990 Sep-Oct;10(5A):1307-11.

Is vitamin D deficiency a risk factor for prostate cancer? (Hypothesis).

Schwartz GG, Hulka BS.

Department of Epidemiology, University of North Carolina, School of Public Health, Chapel Hill 27599.

Prostate cancer is a major cause of cancer death among males, yet little is known about its etiology. We hypothesize that Vitamin (Hormone) D deficiency may underlie the major risks for prostate cancer, including age, Black race, and northern latitudes. These factors all are associated with decreased synthesis of Vitamin D. Mortality rates from prostate cancer in the U.S. are inversely correlated with ultraviolet radiation, the principal source of Vitamin D. This hypothesis is consistent with known antitumor properties of Vitamin D, and may suggest new avenues for research in prostate cancer.

Ovarian Cancer

85. Int J Cancer. 2000 Apr 1;86(1):40-6.

Androgen receptor and vitamin D receptor in human ovarian cancer: growth stimulation and inhibition by ligands.

Ahonen MH, Zhuang YH, Aine R, Ylikomi T, Tuohimaa P.

Department of Anatomy, Medical School, University of Tampere, Finland.

The data suggest that 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] and androgens are essential for regulation of growth and differentiation in, e.g., human reproductive tissues. We investigated the possible cross-talk between 1,25(OH)2D3 and androgens in the human ovarian cancer cell line OVCAR-3. Our data demonstrate that 1,25(OH)2D3 and androgen (dihydrotestosterone, DHT) regulate the growth of OVCAR-3 cells. Nine days' treatment of OVCAR-3 cells with 100 nM DHT resulted in 48% stimulation of growth, whereas growth inhibition (73%) was observed after treatment with 100 nM 1,25(OH)2D3. The combination of 1,25(OH)2D3 and DHT showed that 1,25(OH)2D3 clearly reduces the growth-stimulatory effect of DHT on OVCAR-3 cells. Moreover, Western blot analysis revealed that these cells contain receptors for 1,25(OH)2D3 (VDR) and androgen (AR). Expression of VDR and AR was up-regulated by their cognate ligands. Up-regulation of AR by 1,25(OH)2D3 and of VDR by DHT provides evidence of cross-talk between 2 signaling pathways in OVCAR-3 cells. We also studied the immuno-histochemical distribution of VDRs and ARs in rat ovaries and human ovarian cancer cases. In rat ovaries, VDRs were observed mainly in granulosa and theca cells and ARs in granulosa cells and surface epithelium. In the human ovarian cancer cases studied, 43% were VDR-positive and 64% AR-positive. Combining the results suggests that the growth of ovarian tissue might be regulated by 1,25(OH)2D3 and androgen.

86. Int J Epidemiol. 1994 Dec;23(6):1133-6.

Sunlight, vitamin D, and ovarian cancer mortality rates in US women.

Lefkowitz ES, Garland CF.

Department of Family and Preventive Medicine, University of California, San Diego, La Jolla 92093-0620, USA.

BACKGROUND. In general, ovarian cancer incidence and mortality is higher in northern than southern latitudes. This ecologic study tests the hypothesis that vitamin D produced in the skin from sunlight exposure may be associated with a protective action in ovarian cancer mortality. METHODS. The association between average annual sunlight energy and age-specific ovarian cancer mortality rates in counties containing the 100 largest US cities was evaluated for 1979-1988. Simple linear regression was performed by decade using sunlight and ozone as independent variables and ovarian cancer rates as the dependent variable. Multiple regression was used to adjust for ozone and sulphur dioxide, since these atmospheric components may absorb ultraviolet light. RESULTS. Fatal ovarian cancer in these areas was inversely proportional to mean annual intensity of local sunlight in a univariate analysis (P = 0.0001), and in a regression adjusted for air pollution (P = 0.04). The association was also seen when restricted to 27 major urban areas of the US; however, probably due to a small sample size, this statistic did not reach significance. CONCLUSIONS. This ecologic study supports the hypothesis that sunlight may be a protective factor for ovarian cancer mortality.

Psoriasis

87. Cutis. 2002 Nov;70(5 Suppl):21-4.

Vitamin D and scalp psoriasis.

Koo J.

Department of Dermatology, University of California, San Francisco, USA.

Calcipotriene has been shown to be safe and effective for the treatment of psoriasis. For scalp psoriasis, the safety advantage of this nonsteroid agent is as important as its efficacy. Even though monotherapy with calcipotriene solution may not always be efficacious for severe scalp psoriasis, many patients are managed effectively with a sequential therapy regimen consisting of 3 phases. In phase 1 (clearing), patients apply clobetasol solution or gel in the morning and calcipotriene solution in the evening daily for 2 weeks. After the scalp psoriasis improves, clobetasol is reduced to weekends and calcipotriene solution is applied on weekdays (phase 2, transitional). Phase 3 is maintenance on calcipotriene solution alone to prevent recurrence. For patients with recalcitrant scalp psoriasis-where only a clobetasol-strength, superpotent topical corticosteroid is effective-a flip-flop therapy regimen has been proposed that allows for the safe, prolonged use of clobetasol solution by limiting its treatment to twice a day for 2-week periods with the use of calcipotriene solution twice a day for a minimum of 2 weeks during the corticosteroid-free in-between periods.

88. BMJ. 2000 Apr 8;320(7240):963-7.

Comment in: BMJ. 2000 Aug 12;321(7258):452.

Systematic review of comparative efficacy and tolerability of calcipotriol in treating chronic plaque psoriasis.

Ashcroft DM, Po AL, Williams HC, Griffiths CE.

Centre for Evidence-Based Pharmacotherapy, School of Life and Health Sciences, Aston University, Birmingham B4 7ET.

OBJECTIVES: To evaluate the comparative efficacy and tolerability of topical calcipotriol in the treatment of mild to moderate chronic plaque psoriasis. DESIGN: Quantitative systematic review of randomised controlled trials. SUBJECTS: 6038 patients with plaque psoriasis reported in 37 trials. MAIN OUTCOME MEASURES: Mean difference in percentage change in scores on psoriasis area and severity index, and response rate ratios for both patients' and investigators' overall assessments of marked improvement or better. Adverse effects were estimated with the rate ratio, rate difference, and number needed to treat. RESULTS: Calcipotriol was at least as effective as potent topical corticosteroids, calcitriol, short contact dithranol, tacalcitol, coal tar, and combined coal tar 5%, allantoin 2%, and hydrocortisone 0.5%. Calcipotriol caused significantly more skin irritation than potent topical corticosteroids (number needed to treat to harm for irritation 10, 95% confidence interval 6 to 34). Calcipotriol monotherapy also caused more irritation than calcipotriol combined with a potent topical corticosteroid (6, 4 to 8). However, the number needed to treat for dithranol to produce lesional or perilesional irritation was 4 (3 to 5). On average, treating 23 patients with short contact dithranol led to one more patient dropping out of treatment owing to adverse effects than if they were treated with calcipotriol. CONCLUSIONS: Calcipotriol is an effective treatment for mild to moderate chronic plaque psoriasis, more so than calcitriol, tacalcitol, coal tar, and short contact dithranol. Only potent topical corticosteroids seem to have comparable efficacy at eight weeks. Although calcipotriol caused more skin irritation than topical corticosteroids this has to be balanced against the potential long term effects of corticosteroids. Skin irritation rarely led to withdrawal of calcipotriol treatment. Longer term comparative trials of calcipotriol versus dithranol and topical corticosteroids are needed to see whether these short term benefits are mirrored by long term outcomes such as duration of remission and improvement in quality of life.

89. J Med Assoc Thai. 1999 Oct;82(10):974-7.

Treatment of psoriasis vulgaris with topical vitamin D analogue (calcipotriol): open multicenter study.

Kullavanijaya P, Gritiyarangsan P, Huiprasert P, Leenutaphong V.

Department of Medical Services, Ministry of Public Health, Bangkok, Thailand.

Sixty-one psoriasis patients, 46 males and 15 females (mean age: 40 years, range: 20-70 years) with baseline PASI score of 7.16 (+/- 3.66 SD) were enrolled in the study. All subjects were advised to apply calcipotriol ointment twice daily for 6 weeks. Six patients dropped out, five after 2 weeks and one after 4 weeks of treatment. PASI scores of fifty five patients were reduced to 2.16 per cent, 46.78 per cent and 55.55 per cent by 2 weeks, 4 weeks and 6 weeks respectively versus the baseline. Overall clinical assessment showed remission in 7.27 per cent marked improvement 74.54 per cent and slight improvement 18.18 per cent. Mild erythema were observed in fourteen patients (22.95%) that were mostly transient except for one patient. Serum creatinine, calcium and phosphate were normal throughout the study.

90. J Am Acad Dermatol. 1996 Nov;35(5 Pt 1):690-5.

Effect of UVB phototherapy and oral calcitriol (1,25-dihydroxyvitamin D3) on vitamin D photosynthesis in patients with psoriasis.

Prystowsky JH, Muzio PJ, Sevran S, Clemens TL.

Irving Center for Clinical Research, New York, USA.

BACKGROUND: Phototherapy and activated froms of vitamin D help clear psoriasis. OBJECTIVE: The influence of UVB phototherapy and oral calcitriol (1,25-dihydroxyvitamin D3) on vitamin D photosynthesis was assessed in 16 patients. METHODS: Patients were randomly selected to receive orally either placebo or calcitriol (0.5 to 2 micrograms daily) for the duration of the 8-week study; all patients received approximately 21 UVB treatments. Before and after treatment, serum levels of 25-hydroxyvitamin D and calcitriol were measured by high-pressure liquid chromatography. RESULTS: Although calcitriol had no additive effect on phototherapy as a treatment modality, a significant increase in serum 25-hydroxyvitamin D levels occurred in both groups; in three patients extraordinarily high levels developed (> 120 ng/ml). Oral calcitriol significantly increased calcitriol serum levels. Increased serum calcitriol did not inhibit cutaneous synthesis of vitamin D or its hepatic conversion to serum 25-hydroxyvitamin D. CONCLUSION: UVB induces high levels of vitamin D photosynthesis. Because oral or topical calcitriol alone helps clear psoriasis, studies to explore the possible influence of UVB phototherapy on its production should be considered. If UVB phototherapy induces cutaneous calcitriol synthesis this could explain the lack of added benefit to treatment when oral calcitriol is administered with phototherapy.

91. Br J Dermatol. 1996 Sep;135(3):347-54.

Vitamin D analogues in psoriasis: effects on systemic calcium homeostasis.

Bourke JF, Iqbal SJ, Hutchinson PE.

Department of Dermatology, Leicester Royal Infirmary, UK.

Vitamin D and its analogues are effective in the treatment of psoriasis. The principal concern about the use of these agents is the possibility of adverse effects on systemic calcium homeostasis. We review the effects of vitamin D and its analogues on systemic calcium homeostasis and discuss the implications for patients with psoriasis.

92. Clin Sci (Lond). 1994 May;86(5):627-32.

Cyclosporin A and vitamin D metabolism: studies in patients with psoriasis and in rats.

Shaw AJ, Hayes ME, Davies M, Edwards BD, Ballardie FW, Chalmers RJ, Mawer EB.

University of Manchester Bone Disease Research Centre, Department of Medicine, U.K.

1. Cyclosporin A, an immunosuppressive drug used to treat psoriasis, stimulates renal synthesis of 1,25-dihydroxyvitamin D in rats. 1,25-Dihydroxyvitamin D can also reduce the activity of psoriasis, and in the present study we have examined the possibility that cyclosporin A mediates some of its actions in psoriasis by renal or extra-renal production of 1,25-dihydroxyvitamin D. 2. Treatment of 12 psoriatic patients with cyclosporin A (5 mg day-1 kg-1) for 3 months significantly improved the psoriasis activity and severity index and reduced glomerular filtration rate, but serum 1,25-dihydroxyvitamin D levels were not changed. However, 1-3 months after stopping cyclosporin A treatment, an increase in the psoriasis activity and severity index score was accompanied by a small, but significant, increase in serum 1,25-dihydroxyvitamin D concentration. Plasma 1,25-dihydroxyvitamin D levels in rats gavaged with cyclosporin A (15 mg day-1 kg-1 for 2 weeks) were significantly increased compared with controls, but a lower dose of cyclosporin A (2.4 mg day-1 kg-1) had no effect. Renal 25-hydroxyvitamin D-24-hydroxylase activity in rat kidney homogenates was not different between control and cyclosporin A-treated rats. Renal 25-hydroxyvitamin D-1 alpha-hydroxylase activity was not detectable in these homogenates. Extra-renal production of 1,25-dihydroxyvitamin D by activated macrophages isolated from the synovial fluid of patients with inflammatory arthritis was reduced after incubation with cyclosporin A (0.1-10 mumol/l) for 30 h or 5 days.(ABSTRACT TRUNCATED AT 250 WORDS)

93. Tidsskr Nor Laegeforen. 1993 Nov 30;113(29):3580-1.

[New treatment of psoriasis with the vitamin D analogue calcipotriol]

[Article in Norwegian]

Austad J.

Rikshospitalet, Oslo.

A new topical treatment for psoriasis was introduced in 1992 when the vitamin D analogue calcipotriol was registered in Norway. This is a new therapeutic principle for psoriasis. Calcipotriol induces differentiation and inhibits proliferation of the keratinocytes. Application twice daily for 6-8 weeks gives a 60-70% improvement in plaque type psoriasis. No serious side effects have been reported when using up to 100 grams of the ointment weekly.

94. J Am Acad Dermatol. 1992 Dec;27(6 Pt 1):1001-8.

Treatment of psoriasis with calcipotriol and other vitamin D analogues.

Kragballe K.

Department of Dermatology, Marselisborg Hospital, University of Aarhus, Denmark.

The discovery of a high-affinity receptor for the bioactive form of vitamin D3, 1,25-dihydroxyvitamin D3 (1,25[OH]D3), in most skin cells has led to the finding of previously unknown effects of vitamin D on epidermal growth and on the skin immune system. 1,25(OH)2D3 inhibits epidermal proliferation and promotes epidermal differentiation. These properties provided the rationale for introducing 1,25(OH)2D3 in the treatment of psoriasis vulgaris. In addition to 1,25(OH)2D3, the synthetic vitamin D3 analogues 1 alpha(OH)D3, 1,24(OH)2D3, and calcipotriol have undergone clinical evaluation. Calcipotriol has been studied most extensively. Compared with 1,25(OH)2D3, calcipotriol is about 200 times less potent in its effects on calcium metabolism, although similar in receptor affinity. In double-blind, placebo-controlled, randomized studies, topical calcipotriol (50 micrograms/gm, up to 100 gm weekly) has been shown to be efficacious and safe for the treatment of psoriasis. A similar therapeutic profile has been seen in long-term studies. In comparative studies topical calcipotriol is slightly more efficacious than betamethasone 17-valerate and dithranol. The mode of action of calcipotriol and other vitamin D3 analogues in psoriasis is not known. Although vitamin D3 analogues affect epidermal growth, their immunosuppressive properties may be equally important for their antipsoriatic effect.

95. Br J Dermatol. 1992 Aug;127(2):71-8.

Vitamin D analogues and psoriasis.

Berth-Jones J, Hutchinson PE.

Department of Dermatology, Leicester Royal Infirmary, U.K.

Topical vitamin D analogues offer a new, effective, more convenient and generally well-tolerated option for the treatment of psoriasis. Only psoriasis vulgaris has been intensively studied, but other forms of the disease may also respond. Both calcitriol and calcipotriol have been shown to be effective in numerous clinical trials, and the latter has compared well with betamethasone valerate and short-contact dithranol in controlled studies. Their mechanism of action is not yet fully understood and may prove complex. The most important effect may be a direct regulation of keratinocyte proliferation and differentiation. However, these compounds also have potent immunological properties, and may act by inhibition of cytokine production by keratinocytes or lymphocytes. Topical application of vitamin D analogues appears generally to be remarkably safe, but hypercalcaemia and hypercalciuria may develop if large quantities are used.

96. Nutr Rev. 1992 May;50(5):138-42.

Vitamin D and psoriasis.

Lowe KE, Norman AW.

Department of Biochemistry, University of California, Riverside 92521.

Skin can serve as the source of vitamin D when exposed to sunlight so that cutaneous 7-dehydrocholesterol can be converted to the vitamin. Skin is also a target organ for the hormone form of vitamin D: 1,25-(OH)2D3. Both skin keratinocytes grown in tissue culture and samples of human skin have the nuclear receptor for 1,25(OH)2D3. New results suggest that this hormone or its analogs may be effective in treating some forms of psoriasis.

97. DICP. 1991 Jul-Aug;25(7-8):835-9.

Vitamin D therapy in psoriasis.

Araugo OE, Flowers FP, Brown K.

Department of Pharmacy Practice, College of Pharmacy, University of Florida, Gainesville.

The use of vitamin D3 in the treatment of psoriasis is discussed with emphasis on positive and negative results of many clinical trials. Investigations indicate the treatment with topical vitamin D3 provides consistently more rapid clinical improvement than its oral counterpart, with no reported adverse effects. Studies have shown that 68 of 83 patients exhibited significant improvement of their psoriatic lesions with the topical application of vitamin D3 analogs, including 1,24-dihydroxycholecalciferol, calcitriol, and MC 903. Clinical trials involving 35 patients treated with oral vitamin D3 analogs resulted in moderate improvement in 24 of the patients. Adverse effects can be minimized by bedtime dosing and possibly the use of new noncalciotropic analogs. Vitamin D3 analogs appear to provide one more promising treatment option for psoriasis.

98. Acta Derm Venereol. 1990;70(4):351-4.

Vitamin D metabolism in psoriasis before and after phototherapy.

Guilhou JJ, Colette C, Monpoint S, Lancrenon E, Guillot B, Monnier L.

Department of Dermatology and Phlebology, Hopital Saint Charles, Montpellier, France.

Epidermis plays a major role in vitamin D synthesis and is a target tissue for 1,25 (OH)2 vitamin D, which could be involved in abnormal proliferation and differentiation of psoriatic keratinocytes. We investigated plasma calcium, phosphorus, alkaline phosphatases, parathyroid hormone, 25 (OH) D, 24,25 (OH)2 D and 1,25 (OH)2 D in 15 control subjects and 20 psoriatic patients before and after 3 weeks of phototherapy (UVB or PUVA). Before irradiation, all parameters were similar in psoriatics and controls, except for serum phosphorus (lower in psoriasis p less than 0.01). After phototherapy, P rose to normal values in psoriatic patients; 25 (OH) D and 24,25 (OH)2 D were dramatically increased by UVB (but not by PUVA) in psoriatic patients as well as in controls; 1,25 (OH)2 D was unmodified in controls but was significantly increased in psoriasis. Since 1,25 (OH)2 D has been reported to be an effective treatment for psoriasis, the UV-induced increase in 1,25 (OH)2 D could account for the beneficial effect of phototherapy in psoriasis.

99. Acta Derm Venereol. 1989;69(2):147-50.

Efficacy of topical treatment in psoriasis with MC903, a new vitamin D analogue.

Staberg B, Roed-Petersen J, Menne T.

Department of Dermatology, Gentofte Hospital, Copenhagen, Denmark.

In 10 in-patients with chronic plaque psoriasis, the antipsoriatic effect of MC903, a new synthetic analogue of vitamin D was evaluated. In each patient two symmetrical located psoriatic plaques were selected for the study. Topical treatment with MC903 cream (containing 1.2 mg MC903 per g cream) was compared with placebo cream in a double-blind, controlled, left-right, randomized way during 6 weeks of therapy. Compared with baseline, the clinical (erythema, scaling and infiltration) improvement was significant after 1 week of therapy with MC903 cream, while lateral comparison showed MC903 cream significantly better than cream base after 4 weeks of therapy (p less than 0.05). Measurements of skin blood flow by the laser Doppler technique in evaluating the disease activity was not superior to the clinical assessments. In 3 patients the psoriatic lesions treated with MC903 cream cleared completely during 6 weeks of therapy. No essential adverse reactions were observed. MC903 has a potent effect on cell proliferation and cell differentiation, but has minimal effect on calcium metabolism. It is concluded that this synthetic vitamin D analogue is potentially useful in the treatment of psoriasis.

100. Acta Derm Venereol. 1988;68(5):436-9.

Is the effect of phototherapy in psoriasis partly due to an impact on vitamin D metabolism?

Staberg B, Oxholm A, Klemp P, Hartwell D.

Department of Dermatology, Gentofte Hospital, Copenhagen, Denmark.

To elucidate the effect of phototherapy on vitamin D metabolism in psoriatics, the serum concentrations of the major vitamin D metabolites (25-hydroxy-vitamin D (25(OH)D), 1,25-dihydroxy-vitamin D (1,25(OH)2D), and 24,25-dihydroxy-vitamin D (24,25(OH)2D)) were studied in 10 patients with disseminated psoriasis, both before and after phototherapy. Some 3-4 weeks of Goeckerman therapy induced significantly increased serum levels of 25(OH)D (mean: 24.6 ng/ml versus 54.4 ng/ml; (p less than 0.001] and 24,25(OH)2D (mean: 2.01 ng/ml versus 3.49 ng/ml; (p less than 0.001)). After phototherapy the mean serum level of 1,25(OH)2D increased nearly to the level found in healthy controls (mean: 23.8 vs. 32.2 pg/ml). However, this increase was not significant. It is shown that conventional phototherapy does have an impact on vitamin D metabolism in psoriatics. Since previous investigations have indicated an abnormal vitamin D metabolism in patients with psoriasis, it is possible that the beneficial effect of phototherapy in this disease might be due partly to an impact on vitamin D metabolism.

101. Arch Dermatol. 1987 Dec;123(12):1677-1683a.

Skin as the site of vitamin D synthesis and target tissue for 1,25-dihydroxyvitamin D3. Use of calcitriol (1,25-dihydroxyvitamin D3) for treatment of psoriasis.

Holick MF, Smith E, Pincus S.

US Department of Agriculture/Human Nutrition Research Center, Tufts University, Boston, MA.

Vitamin D is a hormone, not a vitamin. The skin is responsible for producing vitamin D. During exposure to sunlight, ultraviolet radiation penetrates into the epidermis and photolyzes provitamin D3 to previtamin D3. Previtamin D3 can either isomerize to vitamin D3 or be photolyzed to lymisterol and tachysterol. Vitamin D is also sensitive to sunlight and is photolyzed to 5,6-transvitamin D3, suprasterol I, and suprasterol II. In Boston, solar irradiation only produces previtamin D3 in the skin between the months of March and October. Aging, sunscreens, and melanin all diminish the capacity of the skin to produce previtamin D3. Once formed, vitamin D3 enters the circulation and is sequentially metabolized to 25-hydroxyvitamin D3 and 1,25-dihydroxyvitamin D3 (1,25-[OH]2-D3). The epidermis possesses receptors for 1,25-(OH)2-D3. 1,25-(OH)2-D3 inhibits the proliferation of cultured keratinocytes and induces them to terminally differentiate. The topical or oral administration of 1,25-(OH)2-D3 has proved to be effective for the treatment of psoriasis. Therefore, the skin is the site for the synthesis of vitamin D and a target tissue for its active metabolite. The successful use of 1,25-(OH)2-D3 for the treatment of psoriasis heralds a new approach for the treatment of this enigmatic disorder.

102. Acta Derm Venereol. 1987;67(1):65-8.

Abnormal vitamin D metabolism in patients with psoriasis.

Staberg B, Oxholm A, Klemp P, Christiansen C.

To elucidate if psoriatic skin involvement induces changes in vitamin D metabolism, the serum concentrations of the major vitamin D metabolites (25-hydroxy-vitamin D(2+3) (25OHD), 1,25-dihydroxyvitamin D(2+3) (1,25(OH)2D), and 24,25-dihydroxyvitamin D(2+3) (24,25(OH)2D)) were studied in a group of patients with psoriasis, who had not been exposed to ultraviolet radiation at least three months before the investigation. Serum concentrations of 1,25(OH)2D were significantly reduced in 17 patients with disseminated psoriasis compared to healthy age and sex matched controls (22.3 pg/ml versus 35.0 pg/ml (p less than 0.001)) and compared to 15 patients with moderate extended psoriasis (22.3 pg/ml versus 38.3 pg/ml (p less than 0.005)). Serum concentrations of the two other metabolites were not significantly decreased. In patients with moderate psoriatic skin manifestations, the values of the three vitamin D metabolites were normal. It is concluded that patients with disseminated psoriasis demonstrate decreased serum concentrations of the vitamin D metabolite 1,25(OH)2D. Since 1,25(OH)2D plays a role in differentiation and proliferation of epidermal cells, the abnormal low serum level of 1,25(OH)2D might be of importance for the abnormalities in cell maturation and proliferation found in psoriatic skin.

Diabetes

103. J Clin Endocrinol Metab. 2003 Jul;88(7):3137-40.

Vitamin D receptor gene polymorphism affects onset pattern of type 1 diabetes.

Motohashi Y, Yamada S, Yanagawa T, Maruyama T, Suzuki R, Niino M, Fukazawa T, Kasuga A, Hirose H, Matsubara K, Shimada A, Saruta T.

Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan. asmd@sc.itc.keio.ac.jp

Type 1 diabetes mellitus is recognized as a T-cell-mediated autoimmune disease. Vitamin D compounds are known to suppress T-cell activation by binding to the vitamin D receptor (VDR); and thus, VDR gene polymorphisms may be related to T-cell-mediated autoimmune diseases. We, therefore, investigated a VDR gene polymorphism in type 1 diabetes. We examined the VDR gene Bsm I polymorphism in 203 type 1 diabetic patients and 222 controls, and the association between the VDR gene polymorphism and type 1 diabetes and their onset pattern. We found a significantly higher frequency of B allele in type 1 diabetics overall, compared with controls (P = 0.0010). Moreover, there was a significant difference in B-allele frequency between acute-onset type 1 diabetics and controls (P = 0.0002), whereas this difference was not observed between slow-onset type 1 diabetics and controls. Regardless of the existence of islet-associated autoantibody, we found a significant difference in B-allele frequency between acute-onset type 1 diabetics and controls. In conclusion, we found an association between a VDR gene polymorphism and acute-onset type 1 diabetes. Assessment of this VDR gene polymorphism may contribute to prediction of the onset pattern in individuals with a high risk of type 1 diabetes.

104. Lancet. 2001 Nov 3;358(9292):1500-3.

Comment in: Lancet. 2001 Nov 3;358(9292):1476-8. Lancet. 2002 Apr 6;359(9313):1246-7; discussion 1247-8. Lancet. 2002 Apr 6;359(9313):1246; discussion 1247-8. Lancet. 2002 Apr 6;359(9313):1247; discussion 1247-8. Lancet. 2002 Apr 6;359(9313):1248.

Intake of vitamin D and risk of type 1 diabetes: a birth-cohort study.

Hypponen E, Laara E, Reunanen A, Jarvelin MR, Virtanen SM.

Department of Paediatric Epidemiology and Biostatistics, Institute of Child Health, WC1N 1EH, London, UK. e.hypponen@ich.ucl.ac.uk

BACKGROUND: Dietary vitamin D supplementation is associated with reduced risk of type 1 diabetes in animals. Our aim was to ascertain whether or not vitamin D supplementation or deficiency in infancy could affect development of type 1 diabetes. METHODS: A birth-cohort study was done, in which all pregnant women (n=12055) in Oulu and Lapland, northern Finland, who were due to give birth in 1966 were enrolled. Data was collected in the first year of life about frequency and dose of vitamin D supplementation and presence of suspected rickets. Our primary outcome measure was diagnosis of type 1 diabetes by end of December, 1997. FINDINGS: 12058 of 12231 represented live births, and 10821 (91% of those alive) children were followed-up at age 1 year. Of the 10366 children included in analyses, 81 were diagnosed with diabetes during the study. Vitamin D supplementation was associated with a decreased frequency of type 1 diabetes when adjusted for neonatal, anthropometric, and social characteristics (rate ratio [RR] for regular vs no supplementation 0.12, 95% CI 0.03-0.51, and irregular vs no supplementation 0.16, 0.04-0.74. Children who regularly took the recommended dose of vitamin D (2000 IU daily) had a RR of 0.22 (0.05-0.89) compared with those who regularly received less than the recommended amount. Children suspected of having rickets during the first year of life had a RR of 3.0 (1.0-9.0) compared with those without such a suspicion. INTERPRETATION: Dietary vitamin D supplementation is associated with reduced risk of type 1 diabetes. Ensuring adequate vitamin D supplementation for infants could help to reverse the increasing trend in the incidence of type 1 diabetes.

105. Diabetologia. 1999 Jan;42(1):51-4.

Vitamin D supplement in early childhood and risk for Type I (insulin-dependent) diabetes mellitus. The EURODIAB Substudy 2 Study Group.

[No authors listed]

The initiation of the immunopathogenetic process that can lead to Type I (insulin-dependent) diabetes mellitus in childhood probably occurs early in life. Studies in vitro have shown that vitamin D3 is immunosuppressive or immunomodulating and studies in experimental models of autoimmunity, including one for autoimmune diabetes, have shown vitamin D to be protective. Seven centres in Europe with access to population-based and validated case registers of insulin-dependent diabetes patients participated in a case-control study focusing on early exposures and risk of Type I diabetes. Altogether data from 820 patients and 2335 control subjects corresponding to 85% of eligible patients and 76% of eligible control subjects were analysed. Questions focused on perinatal events and early eating habits including vitamin D supplementation. The frequency of vitamin D supplementation in different countries varied from 47 to 97% among control subjects. Vitamin D supplementation was associated with a decreased risk of Type I diabetes without indication of heterogeneity. The Mantel-Haenszel combined odds ratio was 0.67 (95% confidence limits: 0.53, 0.86). Adjustment for the possible confounders: a low birth weight, a short duration of breast feeding, old maternal age and study centre in logistic regression analysis did not affect the significant protective effect of vitamin D. In conclusion, this large multicentre trial covering many different European settings consistently showed a protective effect of vitamin D supplementation in infancy. The findings indicate that activated vitamin D might contribute to immune modulation and thereby protect or arrest an ongoing immune process initiated in susceptible people by early environmental exposures.

106. J Nutr Sci Vitaminol (Tokyo). 1985 Dec;31 Suppl:S27-32.

Osteopenia and circulating levels of vitamin D metabolites in diabetes mellitus.

Imura H, Seino Y, Ishida H.

The degree of diabetic osteopenia and serum vitamin D metabolite levels were measured in 14 type 1 (insulin-dependent) and 168 type 2 (non-insulin-dependent) diabetic patients. Based on six indices obtained by microdensitometry, we found the bone mass in 28.6% of type 1 and 26.2% of type 2 diabetic patients to be decreased and in 14.3% and 11.9%, respectively, the decrease was severe. Our method of analysis of bone mass has shown that diabetic osteopenia differs from typical osteoporosis in character. In addition, serum 24,25-dihydroxyvitamin D was significantly decreased both in type 1 and in type 2 diabetes (p less than 0.01), but 1,25-dihydroxyvitamin D was significantly decreased only in type 1 diabetes (p less than 0.01) compared to the controls, being lower than that in type 2 diabetes (p less than 0.05). On the other hand, 25-hydroxyvitamin D was similar to that of the controls, in both types of diabetes.

Pregnancy

107. J Pediatr. 2003 Feb;142(2):169-73.

Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer: a justification for vitamin D supplementation of breast-feeding infants.

Dawodu A, Agarwal M, Hossain M, Kochiyil J, Zayed R.

Department of Paediatrics, Faculty of Medicine and Health Sciences, UAE University, United Arab Emirates.

OBJECTIVE: To determine the prevalence of hypovitaminosis D in exclusively breast-feeding infants and their mothers in a community where maternal sunshine exposure is low. STUDY DESIGN: Serum levels of calcium, phosphate, alkaline phosphatase, 25-hydroxy vitamin D (25-OHD), and intact parathyroid hormone were measured in 90 unsupplemented healthy term breast-feeding Arab/South Asian infants and their mothers in summer. Maternal dietary vitamin D intake was also estimated. RESULTS: The median age of infants was 6 weeks. The median serum 25-OHD concentrations in mothers (8.6 ng/mL) and infants (4.6 ng/mL) were low, and 61% of the mothers and 82% of the 78 infants tested had hypovitaminosis D (serum 25-OHD <10 ng/mL). The infants with hypovitaminosis D had elevated serum alkaline phosphatase and a tendency to higher serum intact parathyroid hormone levels. The average daily maternal vitamin D intake from commercial milk was 88 IU. CONCLUSIONS: Hypovitaminosis D is common in summer in exclusively breast-feeding infants and their mothers. The results provide justification for vitamin D supplementation of breast-feeding infants and mothers in the United Arab Emirates. Low vitamin D intake probably contributed to low maternal vitamin D status.

108. Calcif Tissue Int. 2002 Oct;71(4):364-75. Epub 2002 Aug 29. (Animal Study)

Vitamin D deficiency in guinea pigs: exacerbation of bone phenotype during pregnancy and disturbed fetal mineralization, with recovery by 1,25(OH)2D3 infusion or dietary calcium-phosphate supplementation.

Rummens K, van Bree R, Van Herck E, Zaman Z, Bouillon R, Van Assche FA, Verhaeghe J.

Department of Obstetrics and Gynecology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium. katrien.rummens@uz.kuleuven.ac.be

Vitamin D (D) deficiency during human pregnancy appears to disturb fetal growth and mineralization, but fetal development is normal in D-deficient rats and vitamin D receptor gene-ablated mice. We used the guinea pig model to investigate maternal and fetal effects of D deficiency. Pregnant (Pr) and nonpregnant (NPr) animals were fed a D-replete (+D) or D-deficient diet (-D) for 8 weeks. We further studied whether the effects of a -D diet are reversed by continuous 1,25(OH)2D3 infusion (-D+1,25) and/or by a lactose-, Ca- and P-enriched D-deficient diet (-D+Ca/P). Bone analyses included histomorphometry of the proximal tibiae, dual-energy X-ray absorptiometry (DXA), and quantitative computed tomography (QCT) of the femora. Depletion of 25(OH)D3 and 1,25(OH)2D3 levels and the D-deficiency syndrome were more severe in pregnant animals. Indeed, Pr/-D but not NPr/-D guinea pigs were hypophosphatemic, and showed robust increases in growth plate width and osteoid surface and thickness; in addition, bone mineral density on DXA was lower in Pr/-D animals only, which was exclusively in cortical bone on QCT. Bone phenotype was partly normalized in Pr/-D+1,25 and Pr/-D+Ca/P animals. Compared with +D fetuses, -D fetuses had very low or undetectable 25(OH)D3 and 1,25(OH)2D3, were hypercalcemic and hypophosphatemic, and had lower osteocalcin levels. In addition, body weight and total body bone mineral content were 10-15% lower; histomorphometry showed hypertrophic chondrocyte zone expansion and hyperosteoidosis. 1,25(OH)2D3 levels were restored in -D+1,25 fetuses, and the phenotype was partially corrected. Similarly, the fetal +D phenotype was rescued in large part in -D+Ca/P fetuses, despite undetectable circulating 25(OH)D3 and 1,25(OH)2D3. We conclude that pregnancy markedly exacerbates D deficiency, and that augmenting Ca and P intake overrides the deleterious effects of D deficiency on fetal development.

109. J Gynecol Obstet Biol Reprod (Paris). 2001 Dec;30(8):761-7.

[Winter supplementation in the 3rd trimester of pregnancy by a dose of 80,000 IU of vitamin D]

[Article in French]

Madelenat P, Bastian H, Menn S.

Hopital Bichat Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris.

A non-comparative study was conducted to examine the effects of 80,000 IU vitamin D given in a single dose to 59 pregnant women from northern or southern France between their 27th and 32nd week of gestation during the winter season. Serum levels of 25 hydroxy-vitamin D (25 OH D), intact Parathyroid Hormone (iPTH), calcium, phosphates, proteins were measured at the inclusion, at delivery (mother and arterial cord) and in the newborn between the 3rd and the 5th day of life. The mothers' sun exposure and their vitamin D dietary intakes were evaluated with scores at the inclusion and at delivery. Before vitamin D supplementation, 34% of the women had a 25 OH D concentration below 10 ng/ml and 32% had hypocalcemia. At delivery, only one woman had a low 25 OH D concentration, whereas 15% of the women showed hypocalcemia. No neonatal hypocalcemia was observed and no vitamin D overdose was recorded in this study. The mothers' vitamin D dietary intakes were quite high; the lack of sun exposure during last summer appeared as a major vitamin D deficiency risk. A single dose of 80,000 IU vitamin D, taken between the 27th and the 32nd amenorrhoea weeks in winter, seems to be a good compromise between efficacy and tolerance.

110. Cochrane Database Syst Rev. 2000;(2):CD000228.

Vitamin D supplementation in pregnancy.

Mahomed K, Gulmezoglu AM.

Department of Obstetrics and Gynaecology, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe. kmahomed@healthnet.zw

BACKGROUND: Vitamin D deficiency can occur in people whose diet is relatively low in the vitamin and those who are not exposed to much sunlight. OBJECTIVES: The objective of this review was to assess the effects of vitamin D supplementation on pregnancy outcome. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (October 1998). SELECTION CRITERIA: Acceptably controlled trials of vitamin D supplementation during pregnancy. DATA COLLECTION AND ANALYSIS: One reviewer assessed trial quality and extracted data. MAIN RESULTS: Two trials involving 232 women were included. In one trial the mothers had higher mean daily weight gain and lower number of low birthweight infants. In the other trial the supplemented group had lower birthweights. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the effects of vitamin D supplementation during pregnancy.

111. J Clin Endocrinol Metab. 1999 Dec;84(12):4541-4.

Vitamin D supplementation during infancy is associated with higher bone mineral mass in prepubertal girls.

Zamora SA, Rizzoli R, Belli DC, Slosman DO, Bonjour JP.

Department of Pediatrics, University Hospital, Geneva, Switzerland. samuel.zamora@hcuge.ch

The objective of this study was to determine whether vitamin D supplementation of breast-fed infants during the first year of life is associated with greater bone mineral content and/or areal bone mineral density (aBMD) in later childhood. The design was a retrospective cohort study. One hundred and six healthy prepubertal Caucasian girls (median age, 8 yr; range, 7-9 yr) were classified as vitamin D supplemented or unsupplemented during the first year of life on the basis of a questionnaire sent to participating families and their pediatricians. Bone area (square centimeters) and bone mineral content (grams) were determined by dual energy x-ray absorptiometry at six skeletal sites. Vitamin D receptor (VDR) 3'-gene polymorphisms (BsmI) were also determined. The supplemented (n = 91) and unsupplemented (n = 15) groups were similar in terms of season of birth, growth in the first year of life, age, anthropometric parameters, and calcium intake at time of dual energy x-ray absorptiometry. The supplemented group had higher aBMD at the level of radial metaphysis (mean +/- SEM, 0.301+/-0.003 vs. 0.283+/-0.008; P = 0.03), femoral neck (0.638+/-0.007 vs. 0.584+/-0.021; P = 0.01), and femoral trochanter (0.508+/-0.006 vs. 0.474+/-0.016; P = 0.04). At the lumbar spine level aBMD values were similar (0.626+/-0.006 vs. 0.598+/-0.019; P = 0.1). In a multiple regression model taking into account the effects of vitamin D supplementation, height, and VDR genotype on aBMD (dependent variable), femoral neck aBMD remained higher by 0.045 g/cm2 in the supplemented group (P = 0.02). Vitamin D supplementation in infancy was found to be associated with increased aBMD at specific skeletal sites later in childhood in prepubertal Caucasian girls.

112. Calcif Tissue Int. 1999 Jul;65(1):23-8.

Bone mineral density of the spine and femur in healthy Saudi females: relation to vitamin D status, pregnancy, and lactation.

Ghannam NN, Hammami MM, Bakheet SM, Khan BA.

Department of Medicine (MBC-46), King Faisal Specialist Hospital and Research Centre, PO Box 3354, Riyadh 11211, Saudi Arabia.

Bone mineral density (BMD) measurements of the anterio-posterior lumbar spine and the proximal femur using dual-energy x-ray absorptiometry, as well as relevant clinical and biochemical parameters, were determined in 321 healthy Saudi females in order to establish reference values and to study the effects of physical and lifestyle factors on BMD. Mean +/- SD of age, body mass index (BMI), number of pregnancies, and total duration of lactation were 35.4 +/- 11.3 years, 26.5 +/- 5.2 kg/m2, 3.1 +/- 3.1, and 23.7 +/- 42.4 months, respectively. Mean +/- SD of serum calcium, 25-hydroxyvitamin D (25OHD), and PTH levels were 2.37 +/- 0.09 mmol/liter, 24.5 +/- 17.2 nmol/liter, and 52.0 +/- 30.8 pg/ml, respectively. Peak BMD values were observed around age 35 years at the spine and earlier at the femur. Compared with USA females, Saudi females had lower weight-matched Z scores at the spine (-0.126 +/- 1. 078, P = 0.04), femoral neck (-0.234 +/- 0.846, P < 0.0001), and Ward's triangle (-0.269 +/- 1.015, P < 0.0001). Further, the prevalence of osteopenia and osteoporosis in subjects >/=31 years old were 18-41% and 0-7%, respectively, depending on the site examined. Severe hypovitaminosis D (25OHD level </=20 nmol/liter) was present in 52% of the subjects. However, there was no correlation between 25OHD level and BMD at any site. Parathyroid hormone (PTH) levels correlated significantly with 25OHD levels (r = -0.28, P < 0.0001) and with weight-matched BMD Z scores at the spine (r = -0.17, P = 0.005), femoral neck (r = -0.16, P = 0.007), and Ward's triangle (r = -0.2, P = 0.0008), suggesting that the distribution of 25OHD levels in the cohort is below the threshold needed for maintaining normal BMD. On the other hand, number of pregnancies and total duration of lactation correlated with weight-matched BMD Z scores at the spine (r = -0.17, P = 0.003; r = -0.1, P = 0.08, respectively). We conclude that BMD in healthy Saudi females is significantly lower than in their USA counterparts. This may be due in part to increased number of pregnancies and longer duration of lactation together with prevalent vitamin D deficiency. http://link.springer-ny.com/link/service/journals/00223/bibs /65n1p23. html

PIP: This paper examines the relationship between bone mineral density (BMD) of the spine and femur and vitamin D status, pregnancy, and lactation among women in Saudi Arabia. The aims of the study are the following: 1) establish normative data for BMD at the anterio-posterior lumbar spine and femur using dual x-ray absorptiometry; 2) compare the BMD of Saudi females and their US counterparts; and 3) examine the relation of BMD to vitamin D status, pregnancy, and lactation. Samples included 321 healthy Saudi females recruited from the city of Riyadh, Saudi Arabia. Results suggest that the mean standard deviation (SD) of age, body mass index, number of pregnancies, and total duration of lactation were, respectively, 35.4 +or- 11.3 years, 26.5 +or- 5.2 kg/sq. m, 3.1 +or- 3.1, and 23.7 +or- 42.4 months. Mean +or- SD of serum calcium, 25-hydroxyvitamin D (25OHD), and PTH levels were 2.37 +or- 0.09 mmol/liter, 24.5 +or- 17.2 nmol/liter, and 52.0 +or- 30.8 pg/ml, respectively. Peak BMD values were observed around age 35 years at the spine and earlier at the femur. Compared with US females, Saudi females had lower weight-matched Z scores at the spine, femoral neck, and Ward's triangle. On the other hand, the number of pregnancies and total duration of lactation correlated with weight-matched BMD Z scores at the spine. This made the BMD in healthy Saudi females significantly lower than their US counterparts. This may due to the increase number of pregnancies and longer duration of lactation together with prevalent vitamin D deficiency.

113. Arch Pediatr. 1995 Apr;2(4):373-6.

[Vitamin D supplementation in pregnancy: a necessity. Committee for Nutrition]

[Article in French]

[No authors listed]

In septentrional countries without vitamin D supplementation of milk and dairy products, many pregnant women are vitamin D deficient. Consequently vitamin D deficiency is present in many newborn infants, which may lead to neonatal hypocalcemia and vitamin D deficient rickets. A prevention of vitamin D deficiency is therefore a necessity in pregnant women through a vitamin D supplementation. This can be done either by a daily supplementation of 400 IU during all pregnancy, or a daily supplementation of 1,000 IU during the third trimester, or by giving a unique dose of 100,000 to 200,000 IU during the seventh month of pregnancy.

114. Am J Clin Nutr. 1994 Feb;59(2 Suppl):484S-490S; discussion 490S-491S.

Do North American women need supplemental vitamin D during pregnancy or lactation?

Specker BL.

Department of Pediatrics, University of Cincinnati Medical Center, OH 45267-0541.

Studies in European and other countries have shown that vitamin D deficiency during pregnancy may adversely affect fetal growth, bone ossification, tooth enamel formation, and neonatal calcium homeostasis. Whether effects of vitamin D deficiency on pregnant or lactating mothers differ from effects observed in nonpregnant or nonlactating women is not clear. Poor maternal vitamin D status during lactation results in low breast-milk vitamin D. However, human milk usually contains small vitamin D amounts and, under normal circumstances, the sunshine exposure of human-milk--fed infants is the major factor affecting their vitamin D status. Mothers at risk of vitamin D deficiency are those who avoid dairy products, which are routinely vitamin D fortified, and live in more northern latitudes. Dark-skinned women also are theoretically at risk of vitamin D deficiency. Sunshine exposure is a major vitamin D source, and given adequate exposure, supplemental vitamin D is not necessary. However, defining adequate sunshine exposure is difficult.

115. Ann Nutr Metab. 1991;35(4):208-12. (Animal Study)

Effect of vitamin D supplementation during pregnancy on the neonatal skeletal growth in the rat.

Marya RK, Saini AS, Jaswal TS.

Department of Physiology, Medical College, Rohtak, India.

In rats on normal intakes of calcium, phosphorus and vitamin D3, 3,000 and 7,500 IU of vitamin D3 were injected on the 10th day of pregnancy and the pups were investigated for the skeletal growth on 28th day of age. Compared to controls, the pups in the supplemented groups showed significantly greater dry weight and ash weight of the tibiae. However, the ash weight/dry bone weight ratios in the supplemented groups were not different from controls. Histological examination of the upper ends of decalcified tibiae and plasma calcium estimations revealed no abnormality in any group. The results suggest that vitamin D3 supplementation in pregnancy enhances the skeletal growth of the pups which involves both the organic and inorganic components.

116. Gynecol Obstet Invest. 1988;25(2):99-105.

Alterations in vitamin D metabolites and minerals in diabetic pregnancy.

Kuoppala T.

Department of Obstetrics and Gynecology, University Central Hospital of Tampere, Finland.

Vitamin D metabolites and minerals involved in bone metabolism were studied in 68 control mothers, 14 gestational diabetics and 68 insulin-dependent diabetics during pregnancy and at delivery. 25(OH)D and 1,25(OH)2D concentrations were significantly (p less than 0.001) lower in insulin-dependent diabetics than in the control or gestational diabetic groups. A similar difference was also observed between infants. 24,25(OH)2D, phosphorus and magnesium values were similar in all groups. Corrected calcium values were significantly lower in both mothers (p less than 0.001) and infants (p less than 0.05) in the insulin-dependent group than in the other two groups. Postpartum, 10% of infants of diabetic mothers received calcium therapy. Our results show alterations in vitamin D and mineral metabolism in pregnant insulin-dependent diabetics and their newborn infants and indicate observation during pregnancy and after delivery.

117. Obstet Gynecol. 1986 Sep;68(3):300-4.

Vitamin D supplementation in pregnancy: a controlled trial of two methods.

Mallet E, Gugi B, Brunelle P, Henocq A, Basuyau JP, Lemeur H.

A randomized study was conducted to evaluate the effects of single-dose and daily vitamin D supplementation in pregnant women during the last trimester of a winter pregnancy in the Northwest of France. The women were divided into three randomized groups: one (N = 21) was given a vitamin D2 supplement of 1000 IU/day during the last three months of pregnancy, one (N = 27) was given a single oral dose of 5 mg at the seventh month of pregnancy, and one (N = 29) acted as a control. Venous plasma samples were obtained at delivery from the women and from cord blood, and levels of calcium, 25-OHD, and 1,25(OH)2D were determined. No significant difference in plasma calcium concentration was found among the three groups, but within each group plasma calcium concentrations were higher in the cord samples than in the respective maternal samples. The levels of the two metabolites measured were consistently lower in the cord samples than in the respective maternal samples. Cord 25-OHD concentrations correlated with those of maternal plasma. No significant modification of maternal calciuria or of the birth weight of term infants was observed. 25-OHD concentrations were greater in maternal and cord plasma from treated mothers, but only a slight difference was observed between the supplemented groups. 1,25(OH)2D concentrations were not significantly different in the three groups. A single 5-mg dose of vitamin D given orally at the seventh month of pregnancy provides effective prophylaxis in the authors' region.

118. J Pediatr. 1986 Aug;109(2):328-34.

Vitamin D supplementation during pregnancy: effect on neonatal calcium homeostasis.

Delvin EE, Salle BL, Glorieux FH, Adeleine P, David LS.

We assessed whether modification of vitamin D nutritional status during the last trimester of pregnancy affects maternal and neonatal calcium homeostasis. At the end of the first trimester, 40 pregnant women were randomly assigned to either of two groups, and blood taken to assess the basal values of Ca, Pi, Mg, iPTH, 25-OHD, and 1,25(OH)2D. From the sixth month on, group 1 (+D) received 1000 IU vitamin D3 daily; group 2 (-D) served as control. At the time of delivery, maternal serum 25-OHD was higher in the +D group (P less than 0.0005). Ca, Pi, iPTH, and 1,25(OH)2D were not affected. At term, venous cord 25-OHD levels were also higher in the +D group (P less than 0.0005), and 1,25(OH)2D levels slightly lower (P less than 0.05), but neither Ca, Pi, nor iPTH differed between the two groups. Serum CaT dropped significantly (P less than 0.002) at 4 days of age in the infants from both groups, although to a lesser extent in these from the +D group (P less than 0.05). Circulating iPTH increased in both groups. Serum 25-OHD remained low in the -D group, and dropped slightly in the +D group; 1,25(OH)2D remained stable during the first 4 days of life in the -D group, and increased in the +D group (P less than 0.001). Our data demonstrate the importance of providing adequate maternal vitamin D stores to ensure better perinatal handling of calcium. This is of particular importance for populations at risk for hypovitaminosis D.

119. Hum Nutr Clin Nutr. 1986 Jul;40(4):287-93.

Serum levels of vitamin D metabolites, calcium, phosphorus, magnesium and alkaline phosphatase in Finnish women throughout pregnancy and in cord serum at delivery.

Kuoppala T, Tuimala R, Parviainen M, Koskinen T, Ala-Houhala M.

Serum concentrations of 25(OH)D, 24,25(OH)2D, 1,25(OH)2D, total calcium, protein, phosphorus, magnesium and alkaline phosphatase were measured in two groups of Finnish women throughout pregnancy and in cord serum at delivery. The autumn group delivered in August-September and the spring group in February-March. There was strong seasonal variation in the 25(OH)D concentrations in both groups. Maternal values (mean +/- s.d.) at delivery were 44.3 +/- 20.8 nmol/l in autumn and 26.0 +/- 13.0 nmol/l in spring. Fetal concentrations were 28.8 +/- 14.3 and 18.3 +/- 11.3 nmol/l, respectively. In both mothers and infants low 25(OH)D values were measured in winter. In the autumn group 7 out of 21 mothers (33 per cent) and in the spring group 17 out of 36 mothers (47 per cent) had values below 17 nmol/l, which is the lowest winter reference value recorded in our laboratory. No significant seasonal variation was observed in dihydroxylated vitamin D metabolites, although 24,25(OH)2D values were a little higher in summer than in winter. Concentrations of 1,25(OH)2D tended to rise towards delivery. Corrected calcium, magnesium and phosphorus concentrations did not change during pregnancy. Fetal calcium and phosphorus concentrations were significantly (P less than 0.001) higher than maternal ones. The data indicate that many mothers and infants have poor vitamin D status in the latitude of Finland. Our results support the concept that vitamin D supplementation should be considered in Finland for pregnant women at least in winter.

120. Rev Fr Gynecol Obstet. 1986 Jun-Jul;81(6-7):365-7.

[Vitamin D and pregnancy: value of a single dose in the third trimester. Comparative study of 100 cases]

[Article in French]

Rideau F, Allisy C, Girard O, Michel F, Sommier M, Wipff J.

A comparative study (100 treated subjects, 100 controls) was carried out at the Centre Hospitalier at Meaux during the winter of 1984-85 in which pregnant women were given single doses of vitamin D to be taken at the seventh month of pregnancy. The results obtained for neonatal blood calcium levels clearly demonstrated the value of vitamin D supplements in pregnant women. This study was original in that a single dose of vitamin D was provided; this led to almost perfect therapeutic observance (99%).

121. Acta Paediatr Scand. 1983 Nov;72(6):817-21.

Effect of season and vitamin D supplementation on plasma concentrations of 25-hydroxyvitamin D in Norwegian infants.

Markestad T.

Plasma concentrations of 25-hydroxyvitamin D (25OHD) were determined in 81 vitamin D supplemented or unsupplemented infants at the end of winter. The values were compared with maternal levels and with concentrations found in 22 unsupplemented infants at the end of summer. The 25OHD levels of the neonates were lower, but closely related to maternal values (r = 0.95, p less than 0.0005). Unsupplemented breast-fed infants had lower 25OHD levels at 6 weeks than at 4 days (16 +/- 7 vs. 32 +/- 15 nmol/l, mean +/- 1 SD, p less than 0.0005). The mean 25OHD level of vitamin D supplemented 6-12 months old infants was intermediate between those of the unsupplemented nursed groups and the unsupplemented children studied during summer (53 +/- 28 vs. 85 +/- 28 nmol/l, p less than 0.0005). Six weeks old infants who had received a milk formula containing 400 IU vitamin D3 per liter had levels similar to the latter group (92 +/- 21 nmol/l). The data suggest that the vitamin D stores acquired during fetal life, or from ultraviolet light exposure during the summer, may be inadequate to maintain safe levels of 25OHD throughout the winter, but that a daily supplement of 400 IU is adequate to establish concentrations in the summer range.

122. Br J Obstet Gynaecol. 1983 Oct;90(10):971-6.

Vitamin D metabolism in normal and hypoparathyroid pregnancy and lactation. Case report.

Markestad T, Ulstein M, Bassoe HH, Aksnes L, Aarskog D.

Plasma concentrations of vitamin D metabolites in 17 non-pregnant women, 22 pregnant women at delivery, and in eight lactating women 3 and 16 days after delivery, were compared with those in a postpartum hypoparathyroid patient treated with 1 alpha-hydroxyvitamin D (1 alpha-OHD). The mean concentration of 1,25-dihydroxyvitamin D [1,25-(OH)2 D] was 203 (SD 61) pmol/l in the pregnant, and 86 (SD 27) pmol/l in the non-pregnant women (P less than 0.0005). The levels 3 and 16 days after delivery were similar [57 (11) compared with 62 (19) pmol/l], and lower than the non-pregnant value (P less than 0.01). The 25-hydroxyvitamin D (25-OHD) concentration remained unchanged between the 3rd and 16th days after delivery, whereas the 24,25-dihydroxyvitamin D [24,25-(OH)2D] level increased from 2.7 (SD 1.8) to 3.7 (SD 2.3) nmol/l (P less than 0.025). The patient temporarily required an increased supplement of l alpha-OHD during pregnancy, but a dose which was appropriate before pregnancy resulted in marked hypercalcaemia and a rise of 1,25-(OH)2D concentration within 16 days of delivery despite lactation. The results suggest that the metabolic need for the active vitamin D metabolite 1,25-(OH)2D is increased during pregnancy and rapidly reduced during early lactation in healthy and hypoparathyroid women.

123. Gynecol Obstet Invest. 1981;12(3):155-61.

Effects of vitamin D supplementation in pregnancy.

Marya RK, Rathee S, Lata V, Mudgil S.

Serum calcium, inorganic phosphate and heat-labile alkaline phosphatase (HLAP) have been estimated in maternal and cord sera of 120 pregnant women at labour. 75 women who did not take any vitamin D supplements during pregnancy showed statistically significant hypocalcaemia, hypophosphataemia and elevation of HLAP. Hypocalcaemia and hypophosphataemia were present in cord blood, too. 25 women who had received 1,200 U vitamin D/day throughout the 3rd trimester, showed significantly lower HLAP levels and increased fetal birth weight but there was no other improvement in maternal or cord blood chemistry. Administration of vitamin D in two large doses of 600,000 U each in the 7th and 8th months of pregnancy in 20 women proved more efficacious. Statistically significant improvement was observed in all the three biochemical parameters in maternal as well as cord sera. Fetal birth weight was also significantly greater with this mode of therapy.

124. Lancet. 1977 Jan 29;1(8005):222-5.

Altered vitamin-D metabolism in pregnancy.

Turton CW, Stanley P, Stamp TC, Maxwell JD.

Low levels of plasma-25-hydroxy-vitamin-D (25-OHD) (less than 16 nmol/1) were found in 33% of a group of pregnant women studied in South London. Non-White women in the last 10 weeks of pregnancy had significantly reduced levels compared with non-pregnant controls (P less than 0.02). Plasma-25-OHD was unrelated to dietary vitamin-D intake, age, parity, social class, plasma-calcium, and plasma-albumin. Reduction of plasma-25-OHD could contribute to the fall in plasma-calcium during pregnancy, and may result from enhanced maternal metabolism or increased utilisation of vitamin D by the fetus.

Tuberculosis

125. J Assoc Physicians India. 2002 Apr;50:554-8.

Comment in: J Assoc Physicians India. 2003 Mar;51:325-6; author reply 327.

Tuberculosis and vitamin D deficiency.

Sasidharan PK, Rajeev E, Vijayakumari V.

Department of Medicine, Calicut Medical College, Kerala.

OBJECTIVES: a) To find out the normal level of 25 hydroxy vitamin D in healthy individuals b) To look for evidence of vitamin D deficiency in patients with active tuberculosis. METHODS: There were 35 cases of pulmonary and extra-pulmonary tuberculosis and 16 controls, whose clinical characteristics, dietary intake of vitamin D and biochemical characteristics including serum vitamin D levels were compared. Exclusion criteria: malabsorption, liver or renal disorders, intake of drugs, which can reduce vitamin D levels, HIV infection, diabetes, immunosuppressive treatment, and severe protein energy malnutrition. RESULTS: There was a statistically significant difference (p < 0.005) in mean vitamin D levels between controls (19.5 ng/ml) and study subjects (10.7 ng/ml). Sixteen patients out of 35 had values well below the lower limit of normal (9 ng/ml). No one in the control group had vitamin D level less than 9 ng/ml. However the mean vitamin D level in the control group was less than the mean value quoted in the literature from the West. Sunlight exposure was adequate in those with deficiency but there was reduced dietary intake of vitamin D. CONCLUSIONS: Serum 25 hydroxy vitamin D levels less than 9 ng/ml indicates deficiency. Vitamin D deficiency exists in patients with tuberculosis and it is possibly a cause rather than effect of the disease; deficiency is due to decreased dietary intake. Vitamin D deficiency can occur without any symptoms. If symptoms are present, it indicates severe deficiency. Serum calcium and phosphorus values do not often predict the existence of deficiency.

126. Calcif Tissue Int. 2000 Jun;66(6):476-8.

Comment on: Calcif Tissue Int. 1997 Jan;60(1):91-3.

Vitamin D deficiency and susceptibility to tuberculosis.

Chan TY.

Division of Clinical Pharmacology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.

Vitamin D, a modulator of macrophage function, can activate human anti-mycobacterial activity. Vitamin D deficiency is therefore associated with a higher risk of tuberculosis (TB) infection, as indicated by several observations. First, TB tends to occur during the colder seasons when cutaneous synthesis of vitamin D from sun exposure is reduced and serum vitamin D levels are lower. Second, patients with untreated TB, particularly those from a temperate climate, have lower serum vitamin D levels than healthy subjects. Third, the incidence of TB is higher among subjects with relatively low serum vitamin D levels, such as the elderly, uremic patients, and Asian immigrants in the U.K.

127. Lancet. 2000 Feb 19;355(9204):618-21.

Comment in: Lancet. 2000 Feb 19;355(9204):588-9. Lancet. 2000 Jul 1;356(9223):73-4; discussion 74-5. Lancet. 2000 Jul 1;356(9223):74; discussion 74-5. Lancet. 2000 Jul 1;356(9223):74; discussion 74-5. Lancet. 2001 Mar 24;357(9260):961.

Influence of vitamin D deficiency and vitamin D receptor polymorphisms on tuberculosis among Gujarati Asians in west London: a case-control study.

Wilkinson RJ, Llewelyn M, Toossi Z, Patel P, Pasvol G, Lalvani A, Wright D, Latif M, Davidson RN.

Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH, USA.

BACKGROUND: Susceptibility to disease after infection by Mycobacterium tuberculosis is influenced by environmental and host genetic factors. Vitamin D metabolism leads to activation of macrophages and restricts the intracellular growth of M. tuberculosis. This effect may be influenced by polymorphisms at three sites in the vitamin D receptor (VDR) gene. We investigated the interaction between serum vitamin D (25-hydroxycholecalciferol) concentrations and VDR genotype on susceptibility to tuberculosis. METHODS: This study was a hospital-based case-control analysis of Asians of Gujarati origin, a mainly vegetarian immigrant population with a high rate of tuberculosis. We typed three VDR polymorphisms (defined by the presence of restriction endonuclease sites for Taq1, Bsm1, and Fok1) in 91 of 126 untreated patients with tuberculosis and 116 healthy contacts who had been sensitised to tuberculosis. Serum 25-hydroxycholecalciferol was recorded in 42 contacts and 103 patients. FINDINGS: 25-hydroxycholecalciferol deficiency was associated with active tuberculosis (odds ratio 2.9 [95% CI 1.3-6.5], p=0.008), and undetectable serum 25-hydroxycholecalciferol (<7 nmol/L) carried a higher risk of tuberculosis (9.9 [1.3-76.2], p=0.009). Although there was no significant independent association between VDR genotype and tuberculosis, the combination of genotype TT/Tt and 25-hydroxycholecalciferol deficiency was associated with disease (2.8 [1.2-6.5]) and the presence of genotype ff or undetectable serum 25-hydroxycholecalciferol was strongly associated with disease (5.1 [1.4-18.4]). INTERPRETATION: 25-hydroxycholecalciferol deficiency may contribute to the high occurrence of tuberculosis in this population. Polymorphisms in the VDR gene also contribute to susceptibility when considered in combination with 25-hydroxycholecalciferol deficiency.

128. Ethn Health. 1998 Nov;3(4):247-53.

Does vitamin D deficiency account for ethnic differences in tuberculosis seasonality in the UK?

Douglas AS, Ali S, Bakhshi SS.

Birmingham Communicable Disease Unit, UK.

OBJECTIVES: Notifications of tuberculosis in England and Wales are reported to peak in the summer season. The purpose of this study was to confirm that finding and to determine to what extent patients of Indian Subcontinent (ISC) ethnic origin contributed to the seasonality. The clinical presentation of the disease is presumed to occur some months following reactivation of the endogenous latent focus of tuberculosis infection. There arises the possibility of vitamin D deficiency producing immunological inadequacy at the end of winter and beginning of spring. PATIENTS AND METHODS: Monthly (or 4-weekly) aggregated data over 7 years were collected from the three countries of mainland Britain, England, Wales, Scotland and from the city of Birmingham in England. The notifications from Birmingham were divided into those of ISC ethnic origin and 'whites'. The presence or absence of seasonality was determined by fitting a sinusoidal curve by the technique called 'cosinor analysis'. In this method amplitude gives a measure of the extent of the seasonal variation. RESULTS: The summer peak of clinical diagnosis was confirmed in the UK series from England, Wales and Scotland. In England and Wales without Scotland a larger seasonal variation was present. Scotland, with a lower proportion of population of ISC ethnic origin, was examined separately and the results in Scotland alone failed to confirm seasonality. In the data from Birmingham, seasonality was confirmed with a greater amplitude, particularly in those over 60 years of age. The finding was influenced by those of ISC ethnic origin, seasonality not being present in the 'white' population. CONCLUSION: The results from Birmingham are very striking, but there were almost three times as many patients in the ISC ethnic group as in indigenous 'white' patients. A series with larger numbers of 'white' patients would be necessary to confirm the absence of seasonality in the 'white' population. The discussion reviews the evidence that vitamin D may have an important hormonal role in immunological defence in the prevention of tuberculosis.

129. Calcif Tissue Int. 1997 Jan;60(1):91-3.

Comment in: Calcif Tissue Int. 2000 Jun;66(6):476-8.

Differences in vitamin D status and calcium intake: possible explanations for the regional variations in the prevalence of hypercalcemia in tuberculosis.

Chan TY.

Department of Clinical Pharmacology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.

The prevalence of hypercalcemia in patients with untreated tuberculosis (TB) varies widely between countries. Since the vitamin D status and calcium intake are important determinants of hypercalcemia in TB, these two factors were compared among four populations (U.K., Hong Kong, Malaysia, Thailand) with a low prevalence (<3%) and two populations (Sweden, Australia) with a high prevalence (>25%). In the three Asian countries, the circulating vitamin D levels are abundant, but the calcium intakes are low. Subjects from the U.K. have the lowest circulating vitamin D level of all, although their calcium intake is high. In Sweden and Australia, both the circulating vitamin D levels and calcium intakes are high. Since serum 1,25(OH)2D concentration will only be raised if its substance for extrarenal conversion, 25(OH)D, is plentiful and the effect of a given serum 1,25 (OH)2D concentration on serum calcium is determined by the calcium intake, it is postulated that the regional variation in the prevalence of hypercalcemia in TB may be due to differences in the circulating vitamin D levels and calcium intakes in these populations.

130. Eur Respir J. 1994 Jun;7(6):1103-10.

Vitamin D metabolism by alveolar immune cells in tuberculosis: correlation with calcium metabolism and clinical manifestations.

Cadranel JL, Garabedian M, Milleron B, Guillozzo H, Valeyre D, Paillard F, Akoun G, Hance AJ.

INSERM U.82, Faculte de Medecine Xavier Bichat, Paris, France.

The aim of this study was to investigate the relationship between the pulmonary vitamin D metabolism in tuberculosis and the calcium metabolism abnormalities and other clinical characteristics of the disease. The metabolism of 25-hydroxyvitamin D3 (25(OH)D3) by alveolar immune cells recovered by bronchoalveolar lavage (BAL) was evaluated in parallel to the results of calcium metabolism, 25(OH) D and 1,25 dihydroxyvitamin D (1,25(OH)2D) plasma levels and other clinical parameters obtained in 14 tuberculosis patients. Whilst predominant metabolites produced by lavage cells in patients and controls were 5(E)--and 5(Z) -19-nor-10-oxo-25(OH)D3, 1,25(OH)2D3 was produced by cells from all tuberculosis patients but not by cells from controls. Calcium metabolism abnormalities were observed in only some patients, but the production of 1,25 (OH)2D3 by lavage cells was found to correlate both with 1,25(OH)2D levels (r = 0.67) and post-load urinary calcium excretion (r = 0.59). 1,25(OH)2D3 production by lavage cells was increased in patients of black origin, and those presenting with hilar adenopathy without pulmonary infiltrates, and was correlated with the number of lymphocytes recovered by lavage (r = 0.87). We conclude that 1,25(OH)2D3 production by alveolar immune cells makes a major contribution to the abnormalities in calcium metabolism seen in tuberculosis patients, and may be partly dependent on the clinical characteristics evaluated here.

131. Tubercle. 1985 Sep;66(3):187-91.

A study of vitamin D levels in Indonesian patients with untreated pulmonary tuberculosis.

Grange JM, Davies PD, Brown RC, Woodhead JS, Kardjito T.

The levels of serum vitamin D, measured as 25-hydroxycholecalciferol (25-OHD3), among 40 Indonesian patients with pulmonary tuberculosis and 38 healthy controls were very similar. In both groups the distribution of the serum 25-OHD3 levels were bimodal with about a quarter of the individuals belonging to the group with higher levels. There was a tendency for controls in this group to be tuberculin negative and for patients in this group to have less extensive active pulmonary disease. Although it is uncertain whether such associations result from a direct effect of vitamin D on protective immune reactions, the use of this vitamin as an adjunct to antituberculosis therapy merits consideration.

Leukemia

132. Blood. 2001 Dec 1;98(12):3290-300.

The acute promyelocytic leukemia-associated protein, promyelocytic leukemia zinc finger, regulates 1,25-dihydroxyvitamin D(3)-induced monocytic differentiation of U937 cells through a physical interaction with vitamin D(3) receptor.

Ward JO, McConnell MJ, Carlile GW, Pandolfi PP, Licht JD, Freedman LP.

Programs of Cell Biology and Human Genetics, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.

Monocyte differentiation induced by 1,25-dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) is interrupted during the course of acute promyelocytic leukemia (APL). One form of APL is associated with the translocation t(11;17), which joins the promyelocytic leukemia zinc finger (PLZF) and retinoic acid receptor alpha (RARalpha) genes. Because PLZF is coexpressed in the myeloid lineage with the vitamin D(3) receptor (VDR), the interplay between PLZF and VDR was examined. It was found that PLZF interacts directly with VDR. This occurred at least partly through contacts in the DNA-binding domain of VDR and the broad complex, tram-trak, bric-a-brac/pox virus zinc finger (BTB/POZ) domain of PLZF. Moreover, PLZF altered the mobility of VDR derived from nuclear extracts when bound to its cognate binding site, forming a slowly migrating DNA-protein complex. Overexpression of PLZF in a monocytic cell line abrogated 1,25(OH)(2)D(3) activation from both a minimal VDR responsive reporter and the promoter of p21(WAF1/CIP1), a target gene of VDR. Deletion of the BTB/POZ domain significantly relieved PLZF-mediated repression of 1,25(OH)(2)D(3)-dependent activation. In addition, stable, inducible expression of PLZF in U937 cells inhibited the ability of 1,25(OH)(2)D(3) to induce surface expression of the monocytic marker CD14 and morphologic changes associated with differentiation. These results suggest that PLZF may play an important role in regulating the process by which 1,25(OH)(2)D(3) induces monocytic differentiation in hematopoietic cells.

133. Cancer Lett. 2000 Mar 13;150(1):1-13.

Anticlastogenic potential of 1alpha,25-dihydroxyvitamin D3 in murine lymphoma.

Sarkar A, Saha BK, Basak R, Mukhopadhyay I, Karmakar R, Chatterjee M.

Department of Pharmaceutical Technology, Jadavpur University, Calcutta, India.

Vitamin D3, having gained scientific interest for so long because of its role in mineral homeostasis, has now received great importance as a possible antitumor agent. This study was undertaken in an attempt to visualize the possible anticlastogenic potential of the vitamin in an ascitic mouse lymphoma model namely, Dalton's lymphoma. Frequencies of structural type chromosomal aberrations, sister chromatid exchanges and micronucleus assays have been chosen as the genotoxic endpoints in the proposed investigation. All these cytogenetic markers have been found to be markedly elevated during the progression of lymphoma in bone marrow cells. Vitamin D3 effectively suppressed the frequencies of chromosomal aberrations and sister chromatid exchanges in the lymphoma-bearing mice during the entire phase of tumor growth that significantly coupled with almost two-fold increase in survival time (37 +/- 2 and 68 +/- 2 days in lymphoma controls and vitamin D3-treated lymphoma-bearing mice, respectively), thus substantiating the antineoplastic efficacy of this secosteroid. The outcome of this study also is clearly reflected in the depletion of circulating (serum) vitamin D3 levels in the lymphoma control mice compared with normal (vehicle) controls while a still higher level was maintained in the VD3-treated lymphoma mice. This anticlastogenic property of the vitamin has so far been neglected and this is the first attempt to unravel the vitamin D3's effect in combating tumor development in vivo by limiting the frequencies of chromosomal aberrations, sister chromatid exchanges and micronuclei at least in transplantable murine model studied herein.

134. Endocrinology. 1999 Oct;140(10):4779-88.

Vitamin D analogs, 20-Epi-22-oxa-24a,26a,27a,-trihomo-1alpha,25(OH)2-vitamin D3, 1,24(OH)2-22-ene-24-cyclopropyl-vitamin D3 and 1alpha,25(OH)2-lumisterol3 prime NB4 leukemia cells for monocytic differentiation via nongenomic signaling pathways, involving calcium and calpain.

Berry DM, Meckling-Gill KA.

Department of Human Biology and Nutritional Sciences, University of Guelph, Ontario, Canada.

Side-chain modified vitamin D analogs including 20-Epi-22-oxa-24a,26a,27a-trihomo-1alpha,2 5-dihydroxyvitamin D3 (KH1060), and 1,24-dihydroxy-22-ene-24-cyclopropyl-vitamin D3 (MC903) were originally designed to aid in the treatment of hyperproliferative disorders including psoriasis and cancer. Here we demonstrate that these analogs, as well as the 6-cis-locked conformer, 1alpha,25-dihydroxy-lumisterol3 (JN) prime NB4 cells for monocytic differentiation. Previously, the action of MC903 and KH1060 was presumed to be mediated by the nuclear vitamin D receptor (VDRnuc). Differentiation in response to all analogs was shown to be inhibited by 1beta,25-dihydroxyvitamin D3 (HL), the antagonist to the nongenomic activities of 1,25D3. These data suggest that although MC903 and KH1060 may bind the VDRnuc, that the differentiative activities of these agents requires nongenomic signaling pathways. Here we show that 1alpha,25(OH)2-d5-previtamin D3 (HF), JN, KH1060, and MC903 induce expression of PKC alpha and PKC delta and translocation of both isoforms to the particulate fraction, and PKC alpha to the nuclear fraction. The full differentiation response with combinations of analogs and TPA was inhibited 50% by the membrane permeable Ca2+ chelator, 1,2-bis(o-aminophenoxy)-ethane-N,N,N',N'-tetraacetic acid (BAPTA-AM) or calpain inhibitor I. These data demonstrate that intracellular free calcium and the calcium-dependent protease, calpain play critical roles in monocytic differentiation. Intracellular calcium appears to be most critical in the 1,25D3-priming stage of differentiation, while calpain is essential in the TPA maturation response.

135. Gen Pharmacol. 1999 Jan;32(1):143-54.

Leukemia cell differentiation: cellular and molecular interactions of retinoids and vitamin D.

James SY, Williams MA, Newland AC, Colston KW.

Division of Gastroenterology, Endocrinology, and Metabolism, St. George's Hospital Medical School, London.

1. The conventional approach to treatment of acute myeloid leukemia has been the use of chemotherapy, which although being cytotoxic to malignant clones, is also cytodestructive to normal cells. In addition, some leukemia cells develop resistance to chemotherapy and are therefore difficult to eradicate. 2. Differentiation therapy, whereby immature cells are induced to attain a mature phenotype by differentiation agents, has provided an alternative strategy in the treatment of hyperproliferative disorders. This has been highlighted by the use of all-trans retinoic acid (ATRA) in the treatment of acute promyelocytic leukemia (APL). 3. Another differentiation agent, 1,25-dihydroxyvitamin D3 (1,25(OH)2D3), directs monocytic maturation of normal and leukemic cells. Cellular studies have revealed that combinations of vitamin D derivatives and retinoids such as ATRA and 9-cis retinoic acid (9-cis RA) exhibit cooperative effects on differentiation in established leukemia cell lines such as HL-60, U937, and NB4. Furthermore, vitamin D compounds, although not able to induce apoptosis when used alone, potentiate apoptosis induced by 9-cis RA in HL-60 cells and differentially regulate the expression of the apoptosis-related gene products bcl-2 and bax. The molecular mechanisms involved in regulating differentiation and apoptosis by these agents are mediated through the interactions of the nuclear receptors for vitamin D (VDR), ATRA (RAR), and 9-cis RA (RXR), which are able to form homo- or heterodimeric complexes and transcriptionally activate or repress target gene expression. 4. There is evidence to suggest that nitric oxide may also play a role in leukemic cell differentiation and that 1,25(OH)2D3 may influence endogenous nitric oxide production either by directly increasing tumor necrosis factor-alpha (TNF-alpha) or through a secondary mediator such as the C-type lectin CD23.

136. Leuk Lymphoma. 1998 Oct;31(3-4):279-84.

Vitamin D analogs, leukemia and WAF1.

Munker R, Zhang W, Elstner E, Koeffler HP.

Medizinische Klinik III der LMU (Klinikum Grosshadern) Munich, Germany. munker@gsf.de

Vitamin D compounds induce differentiation of human leukemic cells and have potential for the treatment of leukemia. In this review we summarize some of the basic mechanisms underlying the action of vitamin D compounds. A variety of vitamin D analogues were synthesized until now, some of which have enhanced antileukemic activity and a decreased propensity to cause hypercalcemia. Most actions of vitamin D compounds are mediated by nuclear receptors. In vivo, vitamin D binding protein interacts with free vitamin D compounds. Both in normal and leukemic cells, vitamin D compounds cause a differentiation to monocytes and macrophages. A variety of genes are regulated by vitamin D compounds. Recently, the cell cycle inhibitory gene p21/WAF-1/CIP-1 was characterized. The expression de novo of WAF-1 in blasts of acute myelogenous leukemia is an independent factor of unfavorable prognosis. In HL-60 leukemic cells treated with vitamin D analogs, WAF-1 can be induced by nano- or picomolar concentrations of vitamin D analogs and correlates with the induction of a differentiated phenotype. When vitamin D analogs are combined in-vitro with retinoids, an irreversible differentiation is observed. Clinical trials of vitamin D analogs are indicated in the situation of minimal residual disease and in combination with standard chemotherapy.

137. Blood. 1998 Oct 1;92(7):2441-9.

19-nor vitamin-D analogs: a new class of potent inhibitors of proliferation and inducers of differentiation of human myeloid leukemia cell lines.

Asou H, Koike M, Elstner E, Cambell M, Le J, Uskokovic MR, Kamada N, Koeffler HP.

Division of Hematology/Oncology, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles, CA 90048, USA.

We have studied the in vitro biological activities and mechanisms of action of 1,25-dihydroxyvitamin D3 (1,25D3) and nine potent 1,25D3 analogs on proliferation and differentiation of myeloid leukemia cell lines (HL-60, retinoic acid-resistant HL-60 [RA-res HL-60], NB4 and Kasumi-1). The common novel structural motiff for almost all the analogs included removal of C-19 (19-nor); each also had unsaturation of the side chain. All the compounds were potent; for example, the concentration of analogs producing a 50% clonal inhibition (ED50) ranged between 1 x 10(-9) to 4 x 10(-11) mol/L when using the HL-60 cell line. The most active compound [1, 25(OH)2-16,23E-diene-26-trifluoro-19-nor-cholecalciferol (Ro 25-9716)] had an ED50 of 4 x 10(-11) mol/L; in contrast, the 1,25D3 produced an ED50 of 10(-9) mol/L with the HL-60 target cells. Ro 25-9716 (10(-9) mol/L, 3 days) was a strong inducer of myeloid differentiation because it caused 92% of the HL-60 cells to express CD11b and 75% of these cells to reduce nitroblue tetrazolium (NBT). This compound (10(-8) mol/L, 4 days) also caused HL-60 cells to arrest in the G1 phase of the cell cycle (88% cells in G1 v 48% of the untreated control cells). The p27(kip-1), a cyclin-dependent kinase inhibitor which is important in blocking the cell cycle, was induced more quickly and potently by Ro 25-9716 (10(-7) mol/L, 0 to 5 days) than by 1,25D3, suggesting a possible mechanism by which these analogs inhibit proliferation of leukemic growth. The NB4 promyelocytic leukemia cells cultured with the Ro 25-9716 were also inhibited in their clonal proliferation (ED50, 5 x 10(-11) mol/L) and their expression of CD11b was enhanced (80% positive [10(-9) mol/L, 4 days] v 27% untreated NB4 cells). Moreover, the combination of Ro 25-9716 (10(-9) mol/L) and all-trans retinoic acid (ATRA, 10(-7) mol/L) induced 92% of the NB4 cells to reduce NBT, whereas only 26% of the cells became NBT positive after a similar exposure to the combination of 1,25D3 and ATRA. Surprisingly, Ro 25-9716 also inhibited the clonal growth of poorly differentiated leukemia cell lines (RA-res HL-60 [ED50, 4 x 10(-9) mol/L] and Kasumi-1 [ED50, 5 x 10(-10) mol/L]). For HL-60 cells, Ro 25-9716 markedly decreased the percent of the cells in S phase of the cell cycle and increased the expression of the cyclin-dependent kinase inhibitor, p27(kip-1). In summary, 19-nor vitamin D3 compounds strongly induced differentiation and inhibited clonal proliferation of various myeloid leukemia cell lines, suggesting a therapeutic niche for their use in myeloid leukemia.

138. Leuk Res. 1997 Apr;21(4):321-6.

CB1093, a novel vitamin D analog; effects on differentiation and clonal growth on HL-60 and de novo leukemia cells.

Pakkala I, Savli H, Knuutila S, Binderup L, Pakkala S.

Transplantation Laboratory, University of Helsinki, and Helsinki University Central Hospital, Finland.

We studied the effects of a novel vitamin D analog CB1093, EB1089 (one of the most antileukemic analogs yet) and 1 alpha,25(OH)2D3 both on HL-60 cells and cells from 13 AML patients. Differentiation was measured both by induction of superoxide production and non-specific esterase. Cell proliferation was assessed by colony assay and 3H-thymidine incorporation. The effect on serum calcium was measured in rats. The CB1093 proved to be the most efficient of the analogs tested so far, both in inducing differentiation and in inhibiting proliferation. This, combined with its low hypercalcemic effect shown here, makes it a promising candidate for preclinical animal studies.

139. Blood. 1996 Sep 15;88(6):2201-9.

A new series of vitamin D analogs is highly active for clonal inhibition, differentiation, and induction of WAF1 in myeloid leukemia.

Munker R, Kobayashi T, Elstner E, Norman AW, Uskokovic M, Zhang W, Andreeff M, Koeffler HP.

Division of Hematology/Oncology, Cedars-Sinai Medical Center/UCLA School of Medicine 90048, USA.

The active form of vitamin D3 [1 alpha, 25-dihydroxyvitamin-D3 (1 alpha, 25(OH)2D3)] modulates the proliferation and differentiation of hematopoietic cells. Analogs of 1 alpha, 25(OH)2D3 that have greater potency may have the potential as adjuvant therapy for high-risk patients in remission for acute myelogenous leukemia (AML) and myelodysplastic syndromes. A new generation of 11 analogs of 1 alpha, 25(OH)2D3 has been synthesized, and we examined their effects on the human leukemic cell line HL-60. This cell line provides a sensitive monitor of activity of the 1 alpha, 25(OH)2D3 analogs. All the compounds were potent, producing a 50% clonal inhibition (ED50) in the range of 10(-8) to 10(-11) mol/L; nine of the 11 analogs had ED50s at concentrations that were at least 10-fold lower than those for the parental 1,25(OH)2D3. The most active compound [cmpd LA, (22R)-1 alpha, 25-(OH)2-16,22,23-triene-D3] had an ED50 of 2 x 10(-11) mol/L; it was also tested on clonogenic cells from patients with AML, and it achieved an ED50 of approximately 6 x 10(-11) mol/L, while 1 alpha, 25(OH)2D3 produced an ED50 of approximately 10(-8) mol/L on the same population of cells. Five different cell surface markers were examined on HL-60 cells exposed to the 1 alpha, 25(OH)2D3 analogs: HLA-DR and CD11b were induced by all of the compounds; CD13 was induced by six of the 12 compounds, including 1,25(OH)2D3; CD14 was strongly induced by all compounds; and CD38 was induced rather weakly by nine of 12 analogs. WAF1/CIP1/p21, a cyclin-dependent kinase inhibitor (CDKI), which is important in blocking the cell cycle, was examined by Western blot and was found to be induced by all of the compounds, suggesting a possible mechanism by which these analogs inhibit leukemic growth. The induction of WAF1 occurred at concentrations of vitamin D analogs as low as 10(-10) mol/L. This structure-function study showed that a new series of 1 alpha, 25(OH)2D3 analogs was active in clonal inhibition, as well as induction of differentiation and WAF1 expression of HL-60 cells. The key structural motifs included C-16 double bond, double and/or triple bonds in the side chain, lengthening of the side chain, 20-epi-conformation of the side chain, replacement of six hydrogens at the end of the side chain with fluorines, and the removal of C-19. Consideration should be given to further in vivo testing of toxicity and efficacy to move toward a clinical trial, especially in a setting of minimal residual disease.

140. Exp Cell Res. 1996 May 25;225(1):143-50.

Differential regulation of vitamin D receptors in clonal populations of a chronic myelogenous leukemia cell line.

Iwata K, Kouttab N, Ogata H, Morgan JW, Maizel AL, Lasky SR.

Roger Williams Medical Center, Experimental Pathology Section, Department of Pathology and Laboratory, Brown University School of Medicine, Providence, RI 02908, USA. stephen_lasky@brown.edu

RWLeu4 is a chronic myelogenous leukemia cell line that is sensitive to the antiproliferative and differentiation-inducing actions of 1alpha,25(OH)2-vitamin D3 (VD3). The JMRD3 cell line is a VD3-resistant variant of RWLeu4 that was selected by continuous passage of RWLeu4 in the presence of VD3. The isolation of a spontaneous VD3-resistant variant suggests that phenotypically different cells exist within the RWLeu4 cell population. Therefore, single-cell clones of RWLeu4 cells were isolated and characterized. Four clonal cell populations that fall into three groups differing in response to the antiproliferative and differentiation-inducing actions of VD3 were examined. Surprisingly, the extent of response of the clones to VD3 does not show a correlation with the basal level of the vitamin D receptor (VDR). RWLeu4-3 and RWLeu4-4 are the clones most sensitive to the antiproliferative actions of VD3 (ED50 approximately equal to 1 nM); however, RWLeu4-3 expresses basal levels of VDRs similar to those found in the parental cells and the RWLeu4-2 clone, while in RWLeu4-4, VD3 binding and VDR protein are below the limits of detection. Furthermore, RWLeu4-10 expresses the highest basal level of VDR protein but is relatively resistant to the antiproliferative actions of VD3 (ED50 > or = 30 nM). Like JMRD3, RWLeu4-10 is still capable of differentiating in response to VD3, as judged by the induction of biochemical processes and cell-surface antigen expression. Although VD3 treatment increases VDR protein levels and DNA-binding activity in all clones, altered DNA-protein complexes are detected in RWLeu4-4. Our results suggest that sensitivity to the antiproliferative and differentiation-inducing actions of VD3 is not dependent solely upon the level of VDR expressed, but may also require posttranslational modification of the VDR or complex interactions with other nuclear transcription factors.

141. Cancer Lett. 1995 Apr 14;90(2):225-30.

Induction of differentiation in murine erythroleukemia cells by 1 alpha,25-dihydroxy vitamin D3.

Radhika S, Choudhary SK, Garg LC, Dixit A.

Department of Zoology, University of Delhi, India.

The Friend murine erythroleukemia (MEL) cells can be stimulated to differentiate in response to a variety of chemical inducing agents. In the present study, the effect of 1 alpha,25-dihydroxyvitamin D3 on differentiation of MEL cells was investigated. Vitamin D3 induced differentiation of MEL cells in culture as determined by elevated hemoglobin content, a rise in the number of benzidine-positive cells and increase in acetylcholine esterase activity. The optimum concentration of the vitamin required to induce differentiation of MEL cells was found to be 750 nM. The pattern of induction of differentiation was similar to that observed with DMSO and the induction of differentiation by vitamin D3 was inhibited by dexamethasone.

142. Leuk Res. 1994 Jun;18(6):453-63.

1,25(OH)2-16ene-vitamin D3 is a potent antileukemic agent with low potential to cause hypercalcemia.

Jung SJ, Lee YY, Pakkala S, de Vos S, Elstner E, Norman AW, Green J, Uskokovic M, Koeffler HP.

Pusan Women's Junior College, Korea.

Compounds that induce cancer cells to differentiate are clinically effective for several types of malignancies. The 1,25-dihydroxyvitamin D3[1,25(OH)2D3(C)] induces leukemic cells, including HL-60, to differentiate and/or no longer proliferate, but it causes hypercalcemia. Development of vitamin D analogs that are more potent in their abilities to affect leukemic cells without causing greater hypercalcemia, may be useful therapeutically. A novel analog [1,25(OH)2-16ene-D3(HM)] has a double bond between C-16 and C-17; it appears to be an extremely effective antileukemic agent with the same or fewer effects on serum calciums. We define the potency of this compound and compare it with seven, previously reported, potent analogs of 1,25(OH)2D3. HM inhibited clonal growth of HL-60 cells by 50% at 1.5 x 10(-11) M. This was about equipotent to 1,25(OH)2-16ene-23yne-D3(V), about 100-fold more potent than many of the other analogs, and 1000-fold more potent than 1,25(OH)2D3. The rank order of leukemic inhibitory activity was: 1,25(OH)2-16ene-D3(HM) > or = 1,25(OH)2- 16ene-23yne-D3(V) > 1,25(OH)2-23ene-D3(EX) = 1,24(OH)2-22ene-24-cyclopropyl-D3(BT) = 22-oxa- 1,25(OH)2D3(EU) = 1,25(OH)2-24-homo-D3(ER) > 1,25(OH)2D3(C) > 1,25(OH)2-24- dihomo-D3(ES). The rank order of their effects on induction of differentiation of HL-60 cells, as measured by superoxide production and nonspecific esterase activity, was similar to their antiproliferative activities. In contrast, each analog slightly stimulated proliferation of normal human myeloid clonal growth. Serum calcium levels were the same or slightly less when either 1,25(OH)2-16ene-D3(HM) or 1,25(OH)2D3 (0.0625, 0.125, or 0.25 microgram) was given intraperitoneally to mice for 5 weeks. HM bound to 1,25(OH)2D3 receptors about 1.5-fold more avidly than 1,25(OH)2D3. In fact, this vitamin D3 appears to be the most avid binder to 1,25(OH)2D3 receptors that has been identified to date. In contrast, HM had a greater than 50-fold lower affinity for the D-binding proteins as compared with 1,25(OH)2D3, thus increasing the availability of the compound for target tissues. Further differentiation experiments showed that HM was more potent than 1,25(OH)2D3 in the presence of serum, but was equipotent in serum-free conditions. Taken together, our experiments suggest that 1,25(OH)2-16ene-D3(HM) may be more potent than 1,25(OH)2D3(C) because of its higher affinity to the 1,25(OH)2D3 receptors and its low affinity to the D-binding protein present in serum. HM is an ideal compound for clinical studies including patients with preleukemia and other neoplasia, as well as several skin disorders, such as psoriasis.

143. J Biol Chem. 1988 Nov 5;263(31):16039-44.

Ca2+ priming during vitamin D-induced monocytic differentiation of a human leukemia cell line.

Hruska KA, Bar-Shavit Z, Malone JD, Teitelbaum S.

Department of Medicine, Jewish Hospital, Washington University Medical Center, St. Louis, Missouri 63110.

1,25-Dihydroxyvitamin D3 (1,25-(OH)2D3) induces monocytic differentiation of the human promyelocytic leukemia line, HL-60, and enhances Ca2+ transport in target cells of the mineral metabolism system. Hence, we determined whether the steroid's maturational effect on HL-60 involves alterations of intracellular calcium [( Ca2+]i). We found that, as detected by indo-1 fluorescence, [Ca2+]i increases in a slow tonic manner from 99 +/- 11 nM in virgin HL-60 to 182 +/- 19 nM (p less than 0.001) in those treated with 1,25-(OH)2D3 for 24 h. The first apparent rise in [Ca2+]i occurs at between 6 and 12 h and parallels expression of alpha-thrombin and N-formyl-methionyl-leucyl-phenylalanine (fMLP) receptors. This increase in [Ca2+]i is derived from extracellular calcium as its reduction abolishes the effect. The increase in [Ca2+]i is associated with an increase in inositol trisphosphate-stimulated Ca2+ flux from intracellular stores. Interestingly, 1,25-(OH)2D3-mediated HL-60 differentiation as manifest by expression of the macrophage-specific antigen, 63D3, is not blocked by low extracellular calcium. In contrast, the fMLP-induced superoxide ion generation is diminished if the increase in [Ca2+]i is prevented. Furthermore, fMLP-stimulated signal transduction is also reduced by limiting the stimulation of [Ca2+]i during 1,25-(OH)2D3 treatment. Thus, although differentiation of HL-60 to the monocytic phenotype by 1,25-(OH)2D3 is Ca2+-independent, expression of response to regulatory stimuli requires priming of cellular Ca2+ stores. The latter appears to be induced by 1,25-(OH)2D3 via stimulated Ca2+ entry through the plasma membrane.

144. Arch Biochem Biophys. 1987 Nov 1;258(2):421-5.

Biological activity of fluorinated vitamin D analogs at C-26 and C-27 on human promyelocytic leukemia cells, HL-60.

Inaba M, Okuno S, Nishizawa Y, Yukioka K, Otani S, Matsui-Yuasa I, Morisawa S, DeLuca HF, Morii H.

Second Department of Internal Medicine, Osaka City University Medical School, Japan.

Vitamin D compounds added to the culture medium induce HL-60 cells to differentiate into macrophage/monocytes via a receptor mechanism. This system provides a biologically relevant assay for the study of biopotency of vitamin D analogs. Using this system, the biological activity of various fluorinated derivatives of vitamin D3 was compared with that of 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3). As assessed by cell morphology, nitroblue tetrazolium reduction and nonspecific esterase activity, 26,26,26,27,27,27-hexafluoro-1,25-dihydroxyvitamin D3 (26,27-F6-1,25-(OH)2D3) and 26,26,26,27,27,27-hexafluoro-1,24-dihydroxyvitamin D3 (26,27-F6-1,24-(OH)2D3) were about 10 times as potent as 1,25-(OH)2D3 in suppressing HL-60 cell proliferation and inducing cell differentiation. The biological activity of 26,26,26,27,27,27-hexafluoro-1-hydroxyvitamin D3 (26,27-F6-1-OH-D3) was equal to that of 1,25-(OH)2D3 in this system. 1,25-(OH)2D3 and its fluorinated analogs exerted their effects on HL-60 cells in a dose-dependent manner. HL-60 cells have a specific receptor for 1,25-(OH)2D3 with an apparent Kd of 0.25 nM, identical with that of chick intestinal receptor. While the binding affinities of 26,27-F6-1,25-(OH)2D3 and 26,27-F6-1,24-(OH)2D3 for chick intestinal receptor were lower than that of 1,25-(OH)2D3 by factors of 3 and 1.5, respectively, they were as competent as 1,25-(OH)2D3 in binding to HL-60 cell receptor. The ability of 26,27-F6-1-OH-D3 to compete for receptor protein from HL-60 cells and chick intestine was about 1/70 that of 1,25-(OH)2D3. These results indicate that trifluorination of carbons 26 and 27 of vitamin D3 can markedly enhance the effect on HL-60 cells.

145. Endocrinology. 1986 Feb;118(2):679-86.

Reversibility of vitamin D-induced human leukemia cell-line maturation.

Bar-Shavit Z, Kahn AJ, Stone KR, Trial J, Hilliard T, Reitsma PH, Teitelbaum SL.

HL-60 cells are induced to differentiate along a monocytic pathway by the active metabolites of vitamin D3, e.g. 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3]. All such differentiated cells share a number of features in common but are heterogeneous in their ability to adhere to solid substrates and to resorb devitalized bone matrix. Here, we show that, in addition, as compared to the nonadherent, adherent cells are smaller, less likely to be in the S phase, more enriched in the human monocyte-specific cell surface antigen, 63D3, and contain less cmyc messenger RNA (mRNA). In addition, we document that removal of the hormone leads to dedifferentiation. For these susceptible mononuclear cells, removal of 1,25-(OH)2D3 results in a reversion to a more myeloblastic phenotype, renewed cell proliferation, and the rapid appearance of elevated levels of cmyc mRNA. Finally, we report that the cells that do not revert upon 1,25-(OH)2D3 removal are those that became multinucleated during treatment.

146. J Med Chem. 1985 Sep;28(9):1148-53.

Syntheses and differentiating action of vitamin D endoperoxides. Singlet oxygen adducts of vitamin D derivatives in human myeloid leukemia cells (HL-60).

Yamada S, Yamamoto K, Naito H, Suzuki T, Ohmori M, Takayama H, Shiina Y, Miyaura C, Tanaka H, Abe E, et al.

Singlet oxygen adducts of various vitamin D derivatives, 6,19-dihydro-6,19-epidioxyvitamin D (vitamin D endoperoxides, 2 and 2'), were chemically synthesized, and their biological activity in inducing differentiation of a human myeloid leukemia cell line (HL-60 cells) was examined. The potency of the endoperoxides derived from vitamin D derivatives possessing the 1 alpha-hydroxyl group such as 1 alpha, 25-dihydroxyvitamin D3 endoperoxides (2b and 2b') was markedly (10(-2)) diminished relative to the respective parent vitamin D compounds. In contrast, 25-hydroxyvitamin D3 endoperoxides [25-(OH)D3 endoperoxides, 2a and 2a'] and their analogues fluorinated at the 24- or 26- and 27-positions were 2.5-10 times more potent than 25-hydroxyvitamin D3 (1a) in spite of the absence of the conjugated triene structure typical of vitamin D compounds. The potency of these vitamin D endoperoxides (2 and 2'), especially those lacking the 1 alpha-hydroxyl group, in inducing differentiation of HL-60 cells was not correlated with their activity in binding to the cytosol receptor for 1 alpha, 25-dihydroxyvitamin D3 (1b). The binding efficiency to the receptor was relatively lower than the differentiating activity. To examine the action of vitamin D endoperoxides, carbon analogues of 25-(OH)D3 endoperoxides, two C-6 epimers of 25-hydroxy-6,19-dihydro-6,19-ethanovitamin D3 (6 and 6'), were synthesized. The carbon analogues (6 and 6') had no potential to induce differentiation of HL-60 cells. These results suggest that vitamin D endoperoxides (2 and 2') express their biological activity probably after being converted to some other compounds.

Neuroblastoma

147. Biochem Pharmacol. 2003 Jun 15;65(12):1943-55.

Effect of 20-epi-1alpha,25-dihydroxyvitamin D3 on the proliferation of human neuroblastoma: role of cell cycle regulators and the Myc-Id2 pathway.

Gumireddy K, Ikegaki N, Phillips PC, Sutton LN, Reddy CD.

Department of Pediatrics, Brown University School of Medicine, Providence, RI 02905, USA.

The antiproliferative effects of 1alpha,25-dihydroxyvitamin D(3) [1,25(OH)(2)D(3)] and its epimer, 20-epi-1alpha,25-dihydroxyvitamin D(3) [20-epi-1,25(OH)(2)D(3)], in six human neuroblastoma (NB) cell lines (SH-SY5Y, NB69, SK-N-AS, IMR5, CHP134, and NGP) were investigated. We determined the ability of 1,25(OH)(2)D(3) and 20-epi-1,25(OH)(2)D(3) to influence cell viability by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, cell proliferation by bromodeoxyuridine (BrdU) incorporation, and their antineoplastic effect on colony formation in a soft agar assay. A concentration-dependent decrease in cell viability, inhibition of DNA synthesis, and suppression of clonal proliferation was observed with both compounds. 20-epi-1,25(OH)(2)D(3) was more potent in suppressing the proliferation of all six NB cell lines. To understand the mechanisms of action, we examined the effect of 20-epi-1,25(OH)(2)D(3) on the Myc-Id2 cell proliferative network and also on key regulators of the cell cycle. For the first time, we show that 20-epi-1,25(OH)(2)D(3) down-regulated Myc and Id2 expression by western blot analysis. Semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) analysis revealed that 20-epi-1,25(OH)(2)D(3) induced the expression of retinoic acid receptor-beta and p21(Cip1), and down-regulated the expression of cyclin D1 resulting in decreased phosphorylation of retinoblastoma protein (pRB). In sum, we show that 20-epi-1,25(OH)(2)D(3) exerts strong antiproliferative effects by regulating key growth control networks (Myc-Id2-pRB) in NB cells.

148. Brain Res. 2002 Aug 2;945(2):181-90.

Calretinin and calbindin D-28k, but not parvalbumin protect against glutamate-induced delayed excitotoxicity in transfected N18-RE 105 neuroblastoma-retina hybrid cells.

D'Orlando C, Celio MR, Schwaller B.

Institute of Histology and General Embryology, University of Fribourg, CH-1705 Fribourg, Switzerland.

Excitotoxic effects leading to neuronal cell degeneration are often accompanied by a prolonged increase in the intracellular level of Ca(2+) ions and L-glutamate-induced toxicity is assumed to be mediated via a Ca(2+)-dependent mechanism. Due to their buffering properties, EF-hand Ca(2+)-binding proteins (CaBPs) can affect intracellular Ca(2+) homeostasis and a neuroprotective role has been attributed to some of the family members including calretinin, calbindin D-28k and parvalbumin. We have stably transfected N18-RE 105 neuroblastoma-retina hybrid cells with the cDNAs for the three CaBPs and investigated the effect of these proteins on the L-glutamate-induced, Ca(2+)-dependent cytotoxicity. Several clones for each CaBP were selected according to immunocytochemical staining and characterization of the overexpressed proteins by Western blot analysis. In calretinin- and parvalbumin-expressing clones, expression levels were quantitatively determined by ELISA techniques. Cytotoxicity of transfected clones was quantified by measurement of the activity of lactate dehydrogenase (LDH) that was released into the medium after L-glutamate (10 mM) exposure as a result of necrotic cell death. In untransfected and parvalbumin-transfected cells, LDH released into the medium progressively increased (starting from the 20th hour) reaching maximum levels after 28-30 h of glutamate application. In contrast, LDH release in both, calretinin and calbindin D-28k-transfected clones, was not significantly different from unstimulated transfected or untransfected cells over the same period of time. The results indicate that the 'fast' Ca(2+)-buffers calretinin and calbindin D-28k, but not the 'slow' buffer parvalbumin can protect N18-RE 105 cells from this type of Ca(2+)-dependent L-glutamate-induced delayed cytotoxicity.

149. J Steroid Biochem Mol Biol. 2001 Jun;77(4-5):213-22.

Synergistic anti-proliferative effects of vitamin D derivatives and 9-cis retinoic acid in SH-SY5Y human neuroblastoma cells.

Stio M, Celli A, Treves C.

Department of Biochemical Sciences, University of Florence, Viale Morgagni 50, 50134 Florence, Italy.

This study examines the effect of 1,25-dihydroxyvitamin D(3) [1,25(OH)(2)D(3)], 24,25-dihydroxyvitamin D(3) [24,25(OH)(2)D(3)], two vitamin D analogues (KH 1060 and EB 1089, which are 20-epi-22-oxa and 22,24-diene-analogues, respectively), 9-cis retinoic acid and all-trans retinoic acid on proliferation of SH-SY5Y human neuroblastoma cells, after treatment for 7 days. Cell number did not change when the cells were incubated with 1, 10 or 100 nM 1,25(OH)(2)D(3) or its derivatives, but significantly decreased in the presence of the two retinoids (0.001--10 microM final concentration). A synergistic inhibition was observed, when SH-SY5Y cells were treated combining 0.1 microM 9-cis retinoic acid and 10 nM 1,25(OH)(2)D(3) or 10 nM KH 1060, and 1 microM 9-cis retinoic acid and 10 nM 1,25(OH)(2)D(3) or 10 nM EB 1089. Acetylcholinesterase activity showed a significant increase, in comparison with controls, after treatment of the cells for 7 days with 0.1 or 1 microM 9-cis retinoic acid, alone or combined with 10 nM 1,25(OH)(2)D(3) or 10 nM KH 1060 or 10 nM EB 1089. This increase was synergistic, combining 1 microM 9-cis retinoic acid and 10 nM 1,25(OH)(2)D(3) or EB 1089. The levels of the c-myc encoded protein remarkably decreased after treatment of SH-SY5Y cells for 1, 3, 7 days with 0.1 and 1 microM 9-cis retinoic acid, alone or combined with 10 nM 1,25(OH)(2)D(3) or 10 nM KH 1060 or 10 nM EB 1089. In particular, the association of 1 microM 9-cis retinoic acid and 10 nM 1,25(OH)(2)D(3) or 10 nM EB 1089 resulted in a synergistic c-myc inhibition, in comparison with that obtained in the presence of the retinoid alone. These findings may have therapeutic implications in human neuroblastoma.

150. Biochem Biophys Res Commun. 1997 Jun 9;235(1):15-8.

1,25-dihydroxyvitamin D3 regulates the expression of N-myc, c-myc, protein kinase C, and transforming growth factor-beta2 in neuroblastoma cells.

Veenstra TD, Windebank AJ, Kumar R.

Nephrology Research Unit, Mayo Clinic Foundation, Rochester, Minnesota 55905, USA.

1alpha,25-Dihydroxyvitamin D3 (1,25(OH)2D3) alters the proliferation of neuroblastoma cells in culture in part via a nerve growth factor (NGF)-mediated pathway. This suggests that factors other than NGF also play a role in the growth arrest induced by 1,25(OH)2D3. To more fully characterize the effect of 1,25(OH)2D3 on neuroblastoma cells, we treated the cells with 10(-8) M 1,25(OH)2D3 and examined the cells for changes in the expression of N-myc, c-myc, transforming growth factor-beta2 (TGF-beta2), and protein kinase C (PKC) activity. Our results show that 1,25(OH)2D3 causes a decrease in the expression of N-myc and c-myc, as well as a two-fold increase in total PKC activity and a dose-dependent increase in TGF-beta2 expression. These results show that 1,25(OH)2D3 regulates the expression of growth-regulatory factors other than NGF in neuroblastoma cells and that 1,25(OH)2D3 influences the growth of neural cells via multiple growth regulatory pathways.

151. Brain Res Dev Brain Res. 1997 Mar 17;99(1):53-60. (Animal Study)

Effects of 1,25-dihydroxyvitamin D3 on growth of mouse neuroblastoma cells.

Veenstra TD, Londowski JM, Windebank AJ, Brimijoin S, Kumar R.

Nephrology Research Unit, Mayo Clinic Foundation, Rochester, MN 55905, USA.

Epitopes of the 1,25-dihydroxyvitamin D(1,25(OH)2D3) receptor have been shown in developing dorsal root ganglia in fetal mice, as well as in cells maintained in culture [Johnson, J.A., Grande, J.P., Windebank, A.J. and Kumar, R., 1,25-Dihydroxyvitamin D3 receptors in developing dorsal root ganglia of fetal rats, Dev. Brain Res., 92 (1996) 120-124]. To investigate a possible role for 1,25(OH)2D3 in neural cell growth and development, a murine neuroblastoma cell line that expresses 1,25(OH)2D3 receptors, was treated with 1,25(OH)2D3. Treatment with 1,25(OH)2D3 resulted in a decrease in cell proliferation, a change in cell morphology, and the expression of protein markers of mature neuronal cells. The decrease in cell proliferation was accompanied by an increase in the expression of nerve growth factor (NGF). Anti-NGF monoclonal antibody added to the growth medium blocked the decrease in cell proliferation caused by 1,25(OH)2D3 treatment. Our results show that the sterol hormone 1,25(OH)2D3, causes a decrease in the proliferation of mouse neuroblastoma cells through alterations in the expression of NGF.

152. Clin Exp Metastasis. 1996 May;14(3):239-45.

Vitamin D3 analogs inhibit growth and induce differentiation in LA-N-5 human neuroblastoma cells.

Moore TB, Koeffler HP, Yamashiro JM, Wada RK.

Department of Pediatrics, Division of Hematology/Oncology, UCLA School of Medicine, Los Angeles, CA 90024, USA.

The physiologically active metabolite of vitamin D3, 1,25-dihydroxycholecalciferol (D3), plays an important role in embryonic development and cell differentiation. Previously, we have demonstrated that D3 significantly induces differentiation and inhibits growth of LA-N-5 human neuroblastoma cells at concentrations of 24 nm and higher. In this study, we compared two D3 analogs, 20-epi-22oxa-25a,26a,27a-tri-homo-1,25-D3 (KH 1060) and 1,25-dihydroxy-22,24-diene, 24,26,27-trihomo (EB 1089), with D3 with respect to their effects on differentiation and growth inhibition. We report an inhibition of growth by 45-55% in cells treated with 0.24 nm EB 1089 and 0.24 nM KH 1060, similar to that seen in cells treated with 24 nM D3. At these concentrations, both EB 1089 and KH 1060 stimulate the differentiation of LA-N-5 neuroblastoma cells as shown by increased neurite outgrowth, decreased N-myc expression and decreased invasiveness in vitro. An increase in acetylcholinesterase activity, a functional measure of differentiation, was also exhibited. Previous reports have shown that treatment doses needed to achieve 24 nM serum concentrations of D3 in patients would result in hypercalcemia. EB 1089 and KH 1060 can cause the same in vitro effects on LA-N-5 human neuroblastoma cells at 1/100 of the concentration required of D3. These data suggest a potential clinical efficacy of EB 1089 and KH 1060 as biological response modifiers.

153. J Pediatr Hematol Oncol. 1995 Nov;17(4):311-7.

Differentiating effects of 1,25-dihydroxycholecalciferol (D3) on LA-N-5 human neuroblastoma cells and its synergy with retinoic acid.

Moore TB, Sidell N, Chow VJ, Medzoyan RH, Huang JI, Yamashiro JM, Wada RK.

Division of Pediatric Hematology/Oncology, UCLA School of Medicine 90095, USA.

PURPOSE: 1,25-Dihydroxycholecalciferol (D3) plays an important role in embryonic development and cell differentiation. It has previously been reported to decrease c-myc expression by HL-60 cells and downregulate c-myc expression by breast and ovarian cancer cells. We report the results of our investigations into the differentiating effects of D3 on LA-N-5 human neuroblastoma cells. METHODS: LA-N-5 human neuroblastoma cell line was treated with D3, retinoic acid (RA), D3 and RA, or solvent control. Growth inhibitory effects, neurite extension, acetylcholinesterase activity, invasiveness, motility, and N-myc protein expression were examined following treatment. RESULTS: Growth inhibition was observed at concentrations of > 24 nM. D3 stimulated the differentiation of LA-N-5 cells as demonstrated by increased neurite outgrowth, increased acetylcholinesterase activity, and decreased invasiveness. A decrease in N-myc expression was observed in immunostained cells treated with either agent alone, with a more profound effect appreciated with the combination. CONCLUSION: Vitamin D3 decreases N-myc expression in LA-N-5 human neuroblastoma cells, with extended treatment causing growth inhibition and differentiation. When used in combination with RA, these effects are more profound than with either agent alone. The therapeutic use of differentiating agent combinations such as D3 and RA may provide a relatively nontoxic means of treating susceptible tumor types.

154. Pediatr Hematol Oncol. 1994 Mar-Apr;11(2):173-9.

Effects of 1,25-dihydroxyvitamin D3 and retinoic acid on the proliferation and cell cycle phase distribution of neuroblastoma SK-N-SH cells.

Goplen DP, Brackman D, Aksnes L.

Institute of Pediatrics, University of Bergen, Norway.

The hormone 1,25-(OH)2D3 has been shown to modulate cell proliferation and induce differentiation in several normal and malignant cell lines. In this work, we examined the effect of the hormone on the neuroblastoma SK-N-SH cell line. The steroid did not influence cell growth and cell cycle distribution, while retinoic acid inhibited proliferation and induced an accumulation of the cells in the G0/G1 phase of the cell cycle. 1,25-(OH)2D3 did not alter cell morphology. The activities of the 1-alpha- and 24-hydroxylases were low and not regulated by the hormone. The level of the total 1,25-(OH)2D3 receptor was low. We conclude that the lack of effect of 1,25-(OH)2D3 on the SK-N-SH cell line is related to the low level of the 1,25-(OH)2D3 receptor.

Pancreatic Cancer

155. Endocrinology. 2003 May;144(5):1832-41.

Molecular pathways involved in the antineoplastic effects of calcitriol on insulinoma cells.

Galbiati F, Polastri L, Thorens B, Dupraz P, Fiorina P, Cavallaro U, Christofori G, Davalli AM.

Division of General Medicine, Unit of Endocrinology and Metabolic Disease, San Raffaele Scientific Institute, 20132 Milan, Italy.

We have previously reported that in tumorigenic pancreatic beta-cells, calcitriol exerts a potent antitumorigenic effect by inducing apoptosis, cell growth inhibition, and reduction of solid beta-cell tumors. Here we have studied the molecular pathways involved in the antineoplastic activity of calcitriol on mouse insulinoma beta TC(3) cells, mouse insulinoma beta TC expressing or not expressing the oncogene p53, and beta TC-tet cells overexpressing or not the antiapoptotic gene Bcl2. Our results indicate that calcitriol-induced apoptosis was dependent on the function of p53 and was associated with a biphasic increase in protein levels of transcription factor nuclear factor-kappa B. Calcitriol decreased cell viability by about 40% in p53-retaining beta TC and in beta TC(3) cells; in contrast, beta TC p53(-/-) cells were only minimally affected. Calcitriol-induced cell death was regulated by members of the Bcl-2 family of apoptosis regulatory proteins, as shown by calcitriol-induced up-regulation of proapoptotic Bax and Bak and the lack of calcitriol-induced cytotoxicity in Bcl-2-overexpressing insulinoma cells. Moreover, calcitriol-mediated arrest of beta TC(3) cells in the G(1) phase of the cell cycle was associated with the abnormal expression of p21 and G(2)/M-specific cyclin B2 genes and involved the DNA damage-inducible factor GADD45. Finally, in beta TC(3) cells, calcitriol modulated the expression of IGF-I and IGF-II genes. In conclusion, these findings contribute to the understanding of the antitumorigenic effects of calcitriol on tumorigenic pancreatic beta-cells and further support the rationale of its utilization in the treatment of patients with malignant insulinomas.

156. Pancreatology. 2003;3(1):41-6.

Vitamin d receptor is expressed in pancreatic cancer cells and a vitamin d(3) analogue decreases cell number.

Albrechtsson E, Jonsson T, Moller S, Hoglund M, Ohlsson B, Axelson J.

Department of Surgery, Lund University, Lund, Sweden.

BACKGROUND AND AIM: The vitamin D-receptor (VDR) has been detected in both normal and malignant cells of different tissues. Treatment with vitamin D(3) has been suggested as a possible therapy in malignant diseases such as pancreatic cancer. Synthetic analogues of vitamin D(3) have a less hypercalcemic effect than native vitamin D(3). The aim was to study the expression of the VDR in human pancreatic cancers and to study the in vitro effect of an analogue to vitamin D(3) on cell lines established from these cancers. METHODS: The pancreatic cancer cell lines were established from primary cultures with only cancer cells. A probe specific for the human VDR was used. After reverse-transcriptase PCR and Northern blotting, the expression of the VDR in normal pancreas and in pancreatic cancers was compared. The cell lines were incubated with EB 1089, a synthetic analogue vitamin of D(3), in dose-response studies. The cell number was measured by the XTT colorimetric method. RESULTS: The VDR was expressed in all cancers and in six of the cell lines the expression was increased more than 3-fold compared to normal pancreas. All cell lines developed from human pancreatic cancers responded with a decreased cell number to the vitamin D(3) analogue at concentrations of 10(-5) M or higher. CONCLUSION: The VDR was expressed in all pancreatic cancers studied. Cell lines derived from these cancers responded with a decrease in cell number to high concentrations of a vitamin D(3) analogue. These results, and the doses to use, have to be confirmed with in vivo studies. Copyright 2003 S. Karger AG, Basel and IAP

157. Endocrinology. 2002 Oct;143(10):4018-30.

Antitumorigenic and antiinsulinogenic effects of calcitriol on insulinoma cells and solid beta-cell tumors.

Galbiati F, Polastri L, Gregori S, Freschi M, Casorati M, Cavallaro U, Fiorina P, Bertuzzi F, Zerbi A, Pozza G, Adorini L, Folli F, Christofori G, Davalli AM.

Department of Medicine, San Raffaele Scientific Institute, Milan 20132, Italy.

Malignant insulinoma is a rare form of cancer with a poor prognosis because of metastatic dissemination and untreatable hypoglycemia. Effective chemotherapy of patients who are not cured by surgery is needed. Calcitriol has known anticancer properties on different neoplastic cell lines, but no data are available regarding its activity on tumorigenic pancreatic beta-cells. We analyzed the in vitro effects of calcitriol on the murine insulinoma cell line betaTC(3) and primary cultures of human isolated islets and benign insulinoma. The effect of in vivo calcitriol administration on insulinoma of recombinant insulin/Simian virus 40 oncogene-expressing transgenic mice was also investigated. In betaTC(3), calcitriol induced growth inhibition; apoptosis; down-regulation of insulin gene expression; and nongenomic activation of the MAPK pathway. MAPK kinase inhibitor (UO126) and staurosporine reduced calcitriol-mediated betaTC(3) death, and down-regulation of insulin gene transcription was prevented by staurosporine but not UO126. Calcitriol significantly decreased insulin release and mRNA levels of human islets and insulinoma cells. Finally, recombinant insulin/Simian virus 40 oncogene-expressing transgenic mice treated with calcitriol showed reduced insulinoma volumes because of increased apoptosis of adenomatous cells. Together, these findings provide the rationale for testing the efficacy of calcitriol in the treatment of patients with solid beta-cell tumors.

158. Br J Cancer. 2000 Jul;83(2):239-45.

Differential and antagonistic effects of 9-cis-retinoic acid and vitamin D analogues on pancreatic cancer cells in vitro.

Pettersson F, Colston KW, Dalgleish AG.

Department of Oncology, Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School, London, UK.

Retinoids and vitamin D are known to exert important anti-tumour effects in a variety of cell types. In this study the effects of 9-cis-retinoic acid (9cRA) the vitamin D analogues EB1089 and CB1093 on three pancreatic adenocarcinoma cell lines were investigated. All compounds caused inhibition of in vitro growth but the vitamin D analogues were generally the more potent growth inhibitors. They were also more effective on their own than in combination with 9cRA. Growth arrest correlated with an increased proportion of cells in the G0/G1 phase. Apoptosis was induced in the three cell lines by 9cRA, whereas neither EB1089 nor CB1093 had this effect. Furthermore, addition of EB1089 or CB1093 together with 9cRA resulted in significantly reduced apoptosis. Our results show that retinoic acids as well as vitamin D analogues have inhibitory effects on pancreatic tumour cells but different and antagonistic mechanisms seem to be employed.

159. Br J Cancer. 1997;76(8):1017-20. (Animal Study)

Vitamin D receptors and anti-proliferative effects of vitamin D derivatives in human pancreatic carcinoma cells in vivo and in vitro.

Colston KW, James SY, Ofori-Kuragu EA, Binderup L, Grant AG.

Division of Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School, London, UK.

The GER human pancreatic carcinoma cell line possesses receptors for 1,25-dihydroxyvitamin D3. We report that the vitamin D analogue EB 1089 inhibits the growth of these cells in vitro and when grown as tumour xenografts in immunodeficient mice. Tumour-bearing mice were given EB 1089 at a dose of 5 microg kg(-1) body weight i.p. thrice weekly for 4-6 weeks. Tumour growth was significantly inhibited in treated animals compared with controls in the absence of hypercalcaemia. These findings may have therapeutic implications in pancreatic cancer.

160. Br J Cancer. 1997;76(7):884-9.

Vitamin D analogues up-regulate p21 and p27 during growth inhibition of pancreatic cancer cell lines.

Kawa S, Nikaido T, Aoki Y, Zhai Y, Kumagai T, Furihata K, Fujii S, Kiyosawa K.

The Second Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan.

To obtain information regarding the growth-inhibitory effect of 1,25-dihydroxyvitamin D3 and its non-calcaemic analogue 22-oxa-1,25-dihydroxyvitamin D3 on pancreatic cancer cell lines, differences in the effects of G1-phase cell cycle-regulating factors were studied in vitamin D-responsive and non-responsive cell lines. Levels of expression of cyclins (D1, E and A), cyclin-dependent kinases (2 and 4) and cyclin-dependent kinase inhibitors (p21 and p27) were analysed by Western blotting after treatment with these compounds. In the responsive cells (BxPC-3, Hs 700T and SUP-1), our observations were: (1) marked up-regulation of p21 and p27 after 24 h treatment with 10(-7) mol l(-1) 1,25-dihydroxyvitamin D3 and 22-oxa-1,25-dihydroxyvitamin D3; and (2) marked down-regulation of cyclins, cyclin-dependent kinases and cyclin-dependent kinase inhibitors after 7 days' treatment. In non-responsive cells (Hs 766T and Capan-1), no such changes were observed. In conclusion, vitamin D analogues up-regulate p21 and p27 as an early event, which in turn could block the G1/S transition and induce growth inhibition in responsive cells.

161. Gastroenterology. 1996 May;110(5):1605-13.

Inhibitory effect of 220-oxa-1,25-dihydroxyvitamin D3 on the proliferation of pancreatic cancer cell lines.

Kawa S, Yoshizawa K, Tokoo M, Imai H, Oguchi H, Kiyosawa K, Homma T, Nikaido T, Furihata K.

Second Department of Internal Medicine, Shinshu University, School of Medicine, Matsumoto, Japan.

BACKGROUND & AIMS: Effective chemotherapy for pancreatic cancer is urgently needed. The aim of this study was to compare the anti-proliferative activity of a new vitamin D3 analogue, 22-oxa-1,25-dihydroxyvitamin D3 (22-oxa-calcitriol), on pancreatic cancer cells lines with that of 1,25-dihydroxyvitamin D3 (calcitriol) with analysis of vitamin D receptor status. METHODS: Antiproliferative effects of both agents were compared using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide method and by measuring the tumor size of xenograft inoculated into athymic mice. Vitamin D receptor contents by Scatchard analysis and mutational analysis of receptor complementary DNA were performed. RESULTS: In vitro, 22-oxa-calcitriol and calcitriol markedly inhibited the proliferation (3 of 9 cell lines) and caused a G1 phase cell cycle arrest by appearance of numerous domes. In vivo, 22-oxa-calcitriol inhibited the growth of BxPC-3 xenografts more significantly than calcitriol without including hypercalcemia. Hs 766T, showing no response to either agent, had the second highest receptor contents with no abnormalities in its primary structure deduced by receptor complementary DNA. CONCLUSIONS: 22-oxa-calcitriol may provide a more useful tool for the chemotherapy of pancreatic cancer than calcitriol. Also, the susceptibility of the cell lines to both agents is not well determined by evaluating either the contents or the mutation of vitamin D receptor.

162. Br J Cancer. 1996 Jun;73(11):1341-6.

Growth-inhibitory effects of vitamin D analogues and retinoids on human pancreatic cancer cells.

Zugmaier G, Jager R, Grage B, Gottardis MM, Havemann K, Knabbe C.

Department of Medical Oncology, Marburg University Medical Center, Germany.

Retinoids and vitamin D are important factors that regulate cellular growth and differentiation. An additive growth-inhibitory effect of retinoids and vitamin D analogues has been demonstrated for human myeloma, leukaemic and breast cancer cells. We set out to study the effects of the vitamin D analogue EB1089 and the retinoids all-trans- and 9-cis-retinoic acid on the human pancreatic adenocarcinoma cell lines Capan 1 and Capan 2 and the undifferentiated pancreatic carcinoma cell line Hs766T. The cell lines investigated expressed vitamin D receptor, retinoic acid receptor (RAR)-alpha and gamma as determined by polymerase chain reaction after reverse transcription. RAR-beta was expressed only in Hs766T cells. Addition of all-trans-retinoic acid increased the amount of RAR-alpha mRNA in the three cell lines and induced RAR-beta mRNA in Capan 1 and Capan 2 cells. All-trans-retinoic acid at a concentration of 10 nM inhibited the growth of Capan 1 and Capan 2 cells by 40% relative to controls. 9-cis-Retinoic acid was less effective. Neither all-trans-retinoic acid nor 9-cis-retinoic acid affected the growth of Hs766T cells. EB1089, if added alone to the cells, did not significantly inhibit growth. However, the combination of 1 nM EB1089 with 10 nM all-trans-retinoic acid exerted a growth-inhibitory effect of 90% in Capan 1 cells and of 70% in Capan 2 cells. Our data suggest that vitamin D analogues together with retinoids inhibit the growth of human pancreatic cancer cells. However, in vivo studies are necessary to examine the potential use of retinoids and vitamin D analogues on pancreatic cancer.

Multiple Sclerosis

163. Proc Soc Exp Biol Med. 1997 Oct;216(1):21-7.

Vitamin D and multiple sclerosis.

Hayes CE, Cantorna MT, DeLuca HF.

Department of Biochemistry, University of Wisconsin-Madison 53706, USA.

Recently, it has been clearly demonstrated that exogenous 1,25-dihydroxyvitamin D3, the hormonal form of vitamin D3, can completely prevent experimental autoimmune encephalomyelitis (EAE), a widely accepted mouse model of human multiple sclerosis (MS). This finding has focused attention on the possible relationship of this disease to vitamin D. Although genetic traits certainly contribute to MS susceptibility, an environmental factor is also clearly involved. It is our hypothesis that one crucial environmental factor is the degree of sunlight exposure catalyzing the production of vitamin D3 in skin, and, further, that the hormonal form of vitamin D3 is a selective immune system regulator inhibiting this autoimmune disease. Thus, under low-sunlight conditions, insufficient vitamin D3 is produced, limiting production of 1,25-dihydroxyvitamin D3, providing a risk for MS. Although the evidence that vitamin D3 is a protective environmental factor against MS is circumstantial, it is compelling. This theory can explain the striking geographic distribution of MS, which is nearly zero in equatorial regions and increases dramatically with latitude in both hemispheres. It can also explain two peculiar geographic anomalies, one in Switzerland with high MS rates at low altitudes and low MS rates at high altitudes, and one in Norway with a high MS prevalence inland and a lower MS prevalence along the coast. Ultraviolet (UV) light intensity is higher at high altitudes, resulting in a greater vitamin D3 synthetic rate, thereby accounting for low MS rates at higher altitudes. On the Norwegian coast, fish is consumed at high rates and fish oils are rich in vitamin D3. Further, experimental work on EAE provides strong support for the importance of vitamin D3 in reducing the risk and susceptibility for MS. If this hypothesis is correct, then 1,25-dihydroxyvitamin D3 or its analogs may have great therapeutic potential in patients with MS. More importantly, current research together with data from migration studies opens the possibility that MS may be preventable in genetically susceptible individuals with early intervention strategies that provide adequate levels of hormonally active 1,25-dihydroxyvitamin D3 or its analogs.

164. Proc Natl Acad Sci U S A. 1996 Jul 23;93(15):7861-4.

1,25-Dihydroxyvitamin D3 reversibly blocks the progression of relapsing encephalomyelitis, a model of multiple sclerosis.

Cantorna MT, Hayes CE, DeLuca HF.

Department of Biochemistry, University of Wisconsin, Madison 53706, USA.

Experimental autoimmune encephalomyelitis (EAE) is an autoimmune disease believed to be a model for the human disease multiple sclerosis (MS). Induced by immunizing B10.PL mice with myelin basic protein (MBP), EAE was completely prevented by the administration of 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3]. 1,25-(OH)2D3 could also prevent the progression of EAE when administered at the appearance of the first disability symptoms. Withdrawal of 1,25-(OH)2D3 resulted in a resumption of the progression of EAE. Thus, the block by 1,25-(OH)2D3 is reversible. A deficiency of vitamin D resulted in an increased susceptibility to EAE. Thus, 1,25-(OH)2D3 or its analogs are potentially important for treatment of MS.

165. Med Hypotheses. 1986 Oct;21(2):193-200.

Multiple sclerosis: decreased relapse rate through dietary supplementation with calcium, magnesium and vitamin D.

Goldberg P, Fleming MC, Picard EH.

A group of young patients having multiple sclerosis was treated with dietary supplements containing calcium, magnesium and vitamin D for a period of one to two years. The experimental design employed self-pairing: the response of each patient was compared with his/her own case history as control. The number of exacerbations observed during the program was less than one half the number expected from case histories. No side effects were apparent. The dietary regimen may offer a new means of controlling the exacerbation rate in MS, at least for younger patients. The results tend to support a theory of MS which states that calcium and magnesium are important in the development, structure and stability of myelin.

Osteoporosis

166. J Cell Biochem. 2003 Feb 1;88(2):209-15.

Role of the vitamin D-endocrine system in the pathophysiology of postmenopausal osteoporosis.

Riggs BL.

Endocrine Research Unit, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA.

Impaired calcium absorption and impaired adaptation to a low calcium diet are common features of aging in women and these processes are even more severely impaired in patients with osteoporotic fractures. The calcium absorption defects are associated with several abnormalities of the vitamin D-endocrine system including secondary hyperparathyroidism, intestinal resistance to 1,25-dihydroxyvitamin D (1,25(OH)(2)D) action, decreased 1,25(OH)(2)D production due to impaired 25(OH)D 1alpha-hydroxylase activity, and, in some elderly persons, nutritional deficiency of vitamin D. However, in postmenopausal women, most of these abnormalities are normalized by administration of physiologic replacement dosages of estrogen and, thus, appear to be secondary consequences of estrogen deficiency. Nonetheless, a minority of them, especially nutritional vitamin D deficiency and impaired 25(OH)D 1alpha-hydroxylase activity late in life, appear to be primary and are independent of estrogen deficiency. Copyright 2002 Wiley-Liss, Inc.

167. J Cell Biochem. 2003 Feb 1;88(2):381-6. (Animal Study)

Rationale for active vitamin D and analogs in the treatment of osteoporosis.

Nishii Y.

Medical Culture, Inc., Tokyo, Japan. nishiiysh-mc@chugai-phram.co.jp

In 1981, Chugai Pharmaceutical succeeded in marketing alfacalcidol, a prodrug of calcitriol, as a therapeutic agent for renal osteodystrophy. In 1983, Chugai succeeded in extending the application of alfacalcidol to the treatment of osteoporosis as well. Clinicians in Japan have accepted alfacalcidol as a remedy for osteoporosis. However, the use of calcitriol and its analogs for the treatment of osteoporosis is still controversial. Some misunderstandings exist internationally about the efficacy of the active form of vitamin D for the treatment of osteoporosis. It is important to emphasize that patients with osteoporosis have intestinal calcium malabsorption and dysfunction in renal activation of vitamin D. When massive doses of parent vitamin D were administered to OVX rats, bone mass increased, but surprisingly, many porotic area were observed in the cortical bone. On the other hand, administration of alfacalcidol increased physiological bone without porotic observation. It is necessary to give the active form of vitamin D, D-hormone, with an RDA-equivalent supply of calcium. Alfacalcidol forms physiological strong bones that are hardly fractured by regulating calcium and bone metabolism. We proposed a new vitamin D analog, 2beta (3-hydroxypropoxy)calcitriol [ED-71] as a therapeutic drug for osteoporosis, which is more potent than calcitriol. ED-71 is now being investigated in phase 2 clinical studies in Japan. ED-71 will appear as more improved drugs for osteoporosis until 2010. Copyright 2002 Wiley-Liss, Inc.

168. Clin Exp Rheumatol. 2003 Jan-Feb;21(1):19-26.

Calcium, vitamin D and etidronate for the prevention and treatment of corticosteroid-induced osteoporosis in patients with rheumatic diseases.

Loddenkemper K, Grauer A, Burmester GR, Buttgereit F.

Department of Rheumatology and Clinical Immunology, Charite University Hospital, Humboldt University of Berlin, Berlin, Germany. konstanze.loddenkemper@charite.de

INTRODUCTION: Long-term glucocorticoid therapy, a major risk factor for the development of osteoporosis, is often necessary in chronically ill patients. At present there are no generally accepted guidelines for the prevention or treatment of steroid-induced osteoporosis. METHODS: In an open prospective study we investigated 99 patients with chronic rheumatic diseases receiving > or = 5 mg/day of prednisolone or the equivalent for at least one year. The objective was to identify osteoporosis risk factors in addition to glucocorticoid therapy and to evaluate the efficacy of prevention with calcium/vitamin D (group 1--patients with osteopenia) and treatment with cyclical etidronate (group 2--patients with osteoporosis). Biochemical markers of bone turnover, clinical parameters and bone mineral density (BMD) were measured. RESULTS: Increasing age and postmenopausal status were associated with more advanced manifestations of steroid-induced osteoporosis (p < 0.05). One year after the start of therapy parameters of bone metabolism increased significantly in group 1, while BMD did not change. In group 2, lumbar spine BMD increased significantly (p < 0.05) whereas femoral neck BMD and bone metabolism parameters remained constant. The intensity of back pain decreased in both groups (p < 0.05). There were fewer new fractures in group 2 than in group 1. CONCLUSION: Treatment with etidronate is effective in patients with glucocorticoid-induced osteoporosis.

169. Endocr Rev. 2002 Aug;23(4):560-9.

Meta-analyses of therapies for postmenopausal osteoporosis. VIII: Meta-analysis of the efficacy of vitamin D treatment in preventing osteoporosis in postmenopausal women.

Papadimitropoulos E, Wells G, Shea B, Gillespie W, Weaver B, Zytaruk N, Cranney A, Adachi J, Tugwell P, Josse R, Greenwood C, Guyatt G; Osteoporosis Methodology Group and The Osteoporosis Research Advisory Group.

OBJECTIVE: To review the effect of vitamin D on bone density and fractures in postmenopausal women. DATA SOURCE: We searched MEDLINE and EMBASE from 1966 to 1999 and examined citations of relevant articles and proceedings of international meetings. We contacted osteoporosis investigators and primary authors to identify additional studies and to obtain unpublished data. STUDY SELECTION: We included 25 trials that randomized women to standard or hydroxylated vitamin D with or without calcium supplementation or a control and measured bone density or fracture incidence for at least 1 yr. DATA EXTRACTION: For each trial, three independent reviewers assessed the methodological quality and abstracted data. DATA SYNTHESIS: Vitamin D reduced the incidence of vertebral fractures [relative risk (RR) 0.63, 95% confidence interval (CI) 0.45-0.88, P < 0.01) and showed a trend toward reduced incidence of nonvertebral fractures (RR 0.77, 95% CI 0.57-1.04, P = 0.09). Most patients in the trials that evaluated vertebral fractures received hydroxylated vitamin D, and most patients in the trials that evaluated nonvertebral fractures received standard vitamin D. Hydroxylated vitamin D had a consistently larger impact on bone density than did standard vitamin D. For instance, total body differences in percentage change between hydroxylated vitamin D and control were 2.06 (0.72, 3.40) and 0.40 (-0.25, 1.06) for standard vitamin D. At the lumbar spine and forearm sites, hydroxylated vitamin D doses above 50 microg yield larger effects than lower doses. Vitamin D resulted in an increased risk of discontinuing medication in comparison to control as a result of either symptomatic adverse effects or abnormal laboratory results (RR 1.37, 95% CI 1.01-1.88), an effect that was similar in trials of standard and hydroxylated vitamin D. CONCLUSIONS: Vitamin D decreases vertebral fractures and may decrease nonvertebral fractures. The available data are uninformative regarding the relative effects of standard and hydroxylated vitamin D.

170. Bone. 2002 Jul;31(1):114-8.

Amelioration of osteoporosis by menatetrenone in elderly female Parkinson's disease patients with vitamin D deficiency.

Sato Y, Honda Y, Kaji M, Asoh T, Hosokawa K, Kondo I, Satoh K.

Department of Rehabilitation Medicine, Hirosaki University School of Medicine, Hirosaki, Japan. noukenrs@cc.hirosaki-u.ac.jp

Significant reduction in bone mineral density (BMD) occurs in patients with Parkinson's disease (PD), correlating with immobilization and with vitamin D deficiency, and increasing the risk of hip fracture, especially in elderly women. As a biological indicator of compromised vitamin K status, an increased serum concentration of undercarboxylated osteocalcin (Oc) has been associated with reduced BMD in the hip and an increased risk of fracture in otherwise healthy elderly women. We evaluated treatment with vitamin K(2) (menatetrenone; MK-4) in maintaining BMD and reducing the incidence of nonvertebral fractures in elderly female patients with PD. In a random and prospective study of PD patients, 60 received 45 mg of MK-4 daily for 12 months, and the remaining 60 (untreated group) did not. At baseline, patients of both groups showed vitamin D and K(1) deficiencies, high serum levels of ionized calcium, and glutaminic residue (Glu) Oc, and low levels of parathyroid hormone (PTH) and 1,25-dihydroxyvitamin D [1,25-(OH)(2)D], indicating that immobilization-induced hypercalcemia inhibits renal synthesis of 1,25-(OH)(2)D and compensatory PTH secretion. BMD in the second metacarpals increased by 0.9% in the treated group and decreased by 4.3% in the untreated group (p < 0.0001). Vitamin K(2) level increased by 259.8% in the treated group. Correspondingly, significant decreases in Glu Oc and calcium were observed in the treated group, in association with an increase in both PTH and 1,25-(OH)(2)D. Ten patients sustained fractures (eight at the hip and two at other sites) in the untreated group, and one hip fracture occurred among treated patients (p = 0.0082; odds ratio = 11.5). The treatment with MK-4 can increase the BMD of vitamin D- and K-deficient bone by increasing vitamin K concentration, and it can also decrease calcium levels through inhibition of bone resorption, resulting in an increase in 1,25-(OH)(2)D concentration.

171. Med Clin (Barc). 2002 Jun 22;119(3):85-9.

[Prevalence of vitamin D deficiency in populations at risk for osteoporosis: impact on bone integrity]

[Article in Spanish]

Mezquita Raya P, Munoz Torres M, Lopez Rodriguez F, Martinez Martin N, Conde Valero A, Ortego Centeno N, Gonzalez Calvin J, Raya Alvarez E, Luna Jd Jde D, Escobar Jimenez F.

Area de Metabolismo Oseo, Servicio de Endocrinologia. Facultad de Medicina, Hospital Universitario San Cecilio, Granada, Spain.

BACKGROUND: Nowadays, severe deficiency of vitamin D is not a common finding in most developed countries. However, the prevalence of vitamin D insufficiency is relatively high and it can contribute to the descent of bone mass in osteoporosis risk populations. The objective of our study was to evaluate the prevalence of vitamin D insufficiency in postmenopausal women (PMW), patients with inflammatory bowel disease (IBD) and corticosteroid-dependent asthmatic patients (CAP) and to analyze its relationship with bone mineral density (BMD) and calciotropic hormones. PATIENTS AND METHOD: We studied 299 patients (PMW: 161; IBD: 61; CAP: 77). In all cases, serum levels of PTH and 25OHD were determined and the BMD (DXA, Hologic QDR1000) in lumbar spine (LS) and femoral neck (FN) was measured. RESULTS: Vitamin D insufficiency (25OHD < 15 ng/ml) was observed in 39.1% patients with PMW, 70.7% patients with IBD and 44.2% patients with CAP. 25OHD concentrations were lower in EII patients (p = 0.003) and PTH concentrations were higher in MPM (p < 0.001). We found a negative correlation between PTH and 25OHD in the overall group and this correlation persisted after considering each group separately. After adjusting for remaining variables, 25OHD was found to be significantly associated with BMD at lumbar spine and/or femoral neck in the three groups. CONCLUSIONS: In populations at risk of osteoporosis, there is a high prevalence of vitamin D insufficiency. This insufficiency has a significant effect on bone integrity.

172. Biogerontology. 2002;3(1-2):73-7.

Vitamin D deficiency and aging: implications for general health and osteoporosis.

Eriksen EF, Glerup H.

University Department of Endocrinology, Aarhus Amtssygehus, Denmark. eriksen_erik_f@lilly.com

Vitamin D deficiency is extremely prevalent in the elderly. Most often the first symptoms are caused by myopathy with muscle pain, fatigue, muscular weakness and gait disturbances. More severe deficiency causes osteomalacia with deep bone pain, reduced mineralization of bone matrix and low energy fractures. Recent data also suggest that hypovitaminosis D increases the risk of cancer of the prostate, colon and breast. Thus, hypovitaminosis D is associated with many diseases associated with aging. In order to diagnose hypovitaminosis D, the assessment of serum levels of 25-hydroxy vitamin D is mandatory. Screening based on other markers like alkaline phosphatase and parathyroid hormone (PTH) will be incomplete. The treatment of hypovitaminosis D is simple with administration of combined calcium (I g) and vitamin D supplements (calciferol, at least 800 IU). Severe cases may demand initial parenteral administration of vitamin D (repeated injections of 300,000 IU 2-3 times with monthly intervals). More potent analogues are rarely needed. One should aim at achieving S-25(OH)D values in the range 50-100 nmol/l.

173. Aliment Pharmacol Ther. 2002 May;16(5):919-27.

Osteoporosis in inflammatory bowel disease: effect of calcium and vitamin D with or without fluoride.

Abitbol V, Mary JY, Roux C, Soule JC, Belaiche J, Dupas JL, Gendre JP, Lerebours E, Chaussade S; Groupe D'etudes Therapeutiques des Affections Inflammatoires Digestives (GETAID).

Service de Gastroenterologie, Hopital Cochin, Paris, France, INSERM U444, Universite de Paris, Paris, France. vered@club-internet.fr

BACKGROUND: Previous data have indicated low bone formation as a mechanism of osteoporosis in inflammatory bowel disease. Fluoride can stimulate bone formation. AIM: To assess the effect of fluoride supplementation on lumbar spine bone mineral density in osteoporotic patients with inflammatory bowel disease treated in parallel with calcium and vitamin D. METHODS: In this prospective, randomized, double-blind, parallel and placebo-controlled study, 94 patients with inflammatory bowel disease (lumbar spine T score below - 2 standard deviations, normal serum 25OH vitamin D), with a median age of 35 years, were included. Bone mineral density was measured by dual-energy X-ray absorptiometry. Patients were randomized to receive daily either sodium monofluorophosphate (150 mg, n=45) or placebo (n=49) for 1 year, and all received calcium (1 g) and vitamin D (800 IU). The relative change in bone mineral density from 0 to 12 months was tested in each group (fluoride or placebo) and compared between the groups. RESULTS: Lumbar spine bone mineral density increased significantly in both groups after 1 year: 4.8 +/- 5.6% (n=29) and 3.2 +/- 3.8% (n=31) in the calcium-vitamin D-fluoride and calcium-vitamin D-placebo groups, respectively (P < 0.001 for each group). There was no difference between the groups (P=0.403). Similar results were observed according to corticosteroid intake or disease activity. CONCLUSIONS: Calcium and vitamin D seem to increase lumbar spine density in osteoporotic patients with inflammatory bowel disease; fluoride does not provide further benefit.

174. Bone. 2002 Apr;30(4):582-8. (Animal Study)

ED-71, a vitamin D analog, is a more potent inhibitor of bone resorption than alfacalcidol in an estrogen-deficient rat model of osteoporosis.

Uchiyama Y, HiguchI Y, Takeda S, Masaki T, Shira-Ishi A, Sato K, Kubodera N, Ikeda K, Ogata E.

Fuji Gotemba Research Laboratory, Chugai Pharmaceutical Co., Ltd., Shizuoka, Japan.

Although active vitamin D is used in certain countries for the treatment of osteoporosis, the risk of causing hypercalcemia/hypercalciuria means that there is only a narrow therapeutic window, and this has precluded worldwide approval. The results of our previous animal studies have suggested that the therapeutic effect of active vitamin D on bone loss after estrogen deficiency can be dissociated at least partly from its effect of enhancing intestinal calcium absorption and suppressing parathyroid hormone (PTH) secretion. To test this, we compared the effects of ED-71, a hydroxypropoxy derivative of 1alpha,25-dihydroxyvitamin D3, with orally administered alfacalcidol, on bone mineral density (BMD) and the bone remodeling process as a function of their effects on calcium metabolism and PTH, in a rat ovariectomy (ovx) model of osteoporosis. ED-71 increased bone mass at the lumbar vertebra to a greater extent than alfacalcidol, while enhancing calcium absorption (indicated by urinary calcium excretion) and decreasing serum PTH levels to the same degree as alfacalcidol. ED-71 lowered the biochemical and histological parameters of bone resorption more potently than alfacalcidol, while maintaining bone formation markers. These results suggest that active vitamin D exerts an antiosteoporotic effect by inhibiting osteoclastic bone resorption while maintaining osteoblastic function, and that these anticatabolic/anabolic effects of active vitamin D take place independently of its effects on calcium absorption and PTH. The demonstration that ED-71 is more potent in these properties than alfacalcidol makes it an attractive candidate as an antiosteoporotic drug.

175. Urol Nurs. 2002 Dec;22(6):405-9.

Osteoporosis--Part II: Dietary and/or supplemental calcium and vitamin D.

Moyad MA.

University of Michigan Medical Center, Department of Urology, Ann Arbor, MI, USA.

Osteoporosis is a significant problem in women and men. As osteoporosis has garnered more attention there seems to be more attention than ever placed on the potential benefits of calcium and vitamin D. Health professionals need to inform patients that there are numerous healthy dietary sources of calcium and vitamin D. Several forms of calcium supplements are commercially available today and health professionals need to understand the similarities and differences between them. Calcium and vitamin D in moderation also have an excellent safety profile and may actually have benefits far beyond osteoporosis therapy.

176. Pharmacol Ther. 2002 Jan;93(1):37-49.

Role of Ca(2+) and vitamin D in the prevention and treatment of osteoporosis.

Rodriguez-Martinez MA, Garcia-Cohen EC.

Unidad de Ensayos Clinicos y Area de Investigacion Farmacologica, Servicio de Farmacologia Clinica, Hospital Universitario Clinica Puerta de Hierro de Madrid, C/ San Martin de Porres 4, 28035 Madrid, Spain. mariangeles.rodriguez@uam.es

Osteoporosis is defined as a progressive systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. The clinical relevance of osteoporosis derives from the fractures that it produces. More than one-third of the adult women will suffer one or more osteoporotic fractures in their lifetime. The lifetime risk in men is approximately one-half that in women. The decrease of the bone mineral density is the most important cause of risk fracture. Among other factors, Ca(2+) and vitamin D deficiencies are important risk factors for a decrease in bone mineral density, consequently inducing osteoporosis. The high prevalence of vitamin D deficiency in healthy elderly people living mainly in southern European countries increase the risk of osteoporotic fractures in these populations above those anticipated for the general elderly population of the European community. In addition, the ageing of the European population will double the number of osteoporotic fractures over the next 50 years, unless adequate preventative measures are undertaken. The efficacy and safety of Ca(2+) and vitamin D supplements at preventing bone loss and reducing the risk of hip and other fractures have been assessed in different clinical trials, which are extensively discussed in this review.

177. Med J Aust. 2001 Oct 15;175(8):401-5.

Vitamin D status of women in the Geelong Osteoporosis Study: association with diet and casual exposure to sunlight.

Pasco JA, Henry MJ, Nicholson GC, Sanders KM, Kotowicz MA.

The University of Melbourne, Department of Clinical and Biomedical Sciences--Barwon Health, The Geelong Hospital, VIC.

OBJECTIVE: To assess vitamin D intake and casual exposure to sunshine in relation to serum 25-hydroxyvitamin D (25OHD) levels. DESIGN: Cross-sectional study of a population-based, random sample of women aged 20-92 years, assessed between 1994 and 1997. SETTING AND PARTICIPANTS: 861 women from the Barwon Statistical Division (population, 218000), which includes the city of Geelong (latitude 38 degrees south) in Victoria. MAIN OUTCOME MEASURES: Vitamin D intake; serum 25OHD level; season of assessment; exposure to sunshine. RESULTS: Median intake of vitamin D was 1.2 microg/day (range, 0.0-11.4 microg/day). Vitamin D supplements, taken by 7.9% of participants, increased intake by 8.1% to 1.3 microg/day (range, 0.0-101.2 microg/day) (P< 0.001). A dose-response relationship in serum 25OHD levels was observed for sunbathing frequency before and after adjusting for age (P< 0.05). During winter (May-October), serum 25OHD levels were dependent on vitamin D intake (partial r2= 0.01; P<0.05) and were lower than during summer (November-April) (age-adjusted mean, 59nmol/L [95% Cl, 57-62] v 81 nmol/L [95% CI, 78-84]; P<0.05). No association was detected between serum 25OHD and vitamin D intake during summer. The prevalences of low concentrations of serum 25OHD were, for <28nmol/L, 7.2% and 11.3% overall and in winter, respectively; and, for <50 nmol/L, 30.0% and 43.2% overall and in winter, respectively. CONCLUSIONS: At latitude 38 degrees south, the contribution of vitamin D from dietary sources appears to be insignificant during summer. However, during winter vitamin D status is influenced by dietary intake. Australia has no recommended dietary intake (RDI) for vitamin D, in the belief that adequate vitamin D can be obtained from solar irradiation alone. Our results suggest that an RDI may be needed.

178. Leukemia. 2001 Nov;15(11):1701-5.

Loss of bone mass and vitamin D deficiency after hematopoietic stem cell transplantation: standard prophylactic measures fail to prevent osteoporosis.

Massenkeil G, Fiene C, Rosen O, Michael R, Reisinger W, Arnold R.

Department of Internal Medicine, Clinic for Nuclear Medicine and Institute of Radiology, University Hospital Charite, Berlin, Germany.

Bone mineral density (BMD) and biochemical markers of bone metabolism were analyzed in 67 adults with ALL (n = 27), AML (n = 14), MDS (n = 6) and CML (n = 20) before and after allogeneic stem cell transplantation (SCT). Median age was 36 years (17-56). Twenty-six out of 53 patients (49%) had osteopenia and osteoporosis before SCT, 21/26 had acute leukemias and 5/26 had chronic myeloid leukemia (CML). T-score before SCTwas -1.23 in patients with acute leukemias and 0.62 in CML patients (P = 0.001). After SCT, a significant loss of BMD was observed in all patients. After 6 months, 24 of 36 evaluable patients (67%) had pathologic BMD, 11 of them (30%) had developed osteoporosis. After 12 months, 20 of 32 evaluable patients (62%) had BMD values below normal and nine of them (28%) had osteoporosis. Increased pyridinium excretion was observed in 12/20 patients (60%) with acute leukemias, but only in 3/13 (23%) with CML (P = 0.014). A prolonged vitamin D deficiency for more than 6 months developed early after SCT in all patients. Patients with acute leukemias frequently have osteopenia and osteoporosis before SCT. After SCT, a further loss of BMD occurs independent from the underlying disease. Standard prophylactic measures are not sufficient to prevent loss of bone mass. Studies on prophylactic interventions are needed to prevent severe osteoporosis in long-term survivors of SCT.

179. Nurs Clin North Am. 2001 Sep;36(3):417-31, viii.

Role of calcium, vitamin D, and other essential nutrients in the prevention and treatment of osteoporosis.

Dowd R.

Department of Medicine, Creighton University Osteoporosis Research Center, Omaha, Nebraska 68131, USA. racheld@creighton.edu

Calcium is an essential nutrient for the prevention and treatment of osteoporosis. Despite universal recognition of its importance, most people still do not obtain recommended amounts. Recent additions to the treatment of osteoporosis with potent bone active drugs produce an even greater need for calcium and total nutrition for restoration of lost bone. Practitioners and patients need to emphasize and appreciate the role that calcium, vitamin D, and other nutrients play in the promotion of health and in the prevention and treatment of disease.

180. Exp Clin Endocrinol Diabetes. 2001;109(2):87-92.

Vitamin D status, trunk muscle strength, body sway, falls, and fractures among 237 postmenopausal women with osteoporosis.

Pfeifer M, Begerow B, Minne HW, Schlotthauer T, Pospeschill M, Scholz M, Lazarescu AD, Pollahne W.

Institute of Clinical Osteology Gustav Pommer and Clinic Der Furstenhof, Bad Pyrmont, Germany. iko_pyrmont@t.online.de

The aim of this study was to identify factors associated with fractures in patients with postmenopausal osteoporosis. The overall hypothesis was that trunk muscle strength, body sway and hypovitaminosis D would influence daily activities and the likelihood of falls and fractures. - In 237 women (mean age 62.9+/-7.4 years) osteoporosis was defined by a T-score at the femoral neck below -2.5 SD. Trunk muscle strength was determined using isokinetic dynamometry and body sway was measured according to Lord et al. Limitations in everyday life were assessed and the history of falls was documented. A fracture was defined as a vertebral height reduction of more than 20% or at least 4 mm. The assessment was carried out using the Spine Deformity Index (SDI) and was confirmed by an experienced radiologist. Pearson coefficients of correlation were calculated. - After correction for age, significant associations were found for body sway and 25-hydroxyvitamin D (p<0.001), body sway and falls (p<0.001), body sway and rib fractures (p<0.01), trunk muscle strength and limitations in everyday life (p<0.001), trunk muscle strength and SDI (p<0.001), trunk muscle strength and bone density (p<0.001), and bone density and 25-hydroxyvitamin D (p<0.001). No significant correlation was found for trunk muscle strength and 25-hydroxyvitamin D (p=0.712). - Findings suggest that hypovitaminosis D is associated with increased body sway and an elevated risk for falls and falls-related fractures. Musculoskeletal rehabilitation should include strengthening exercises for the trunk muscles and training of neuromuscular co-ordination and balance.

181. Cochrane Database Syst Rev. 2001;(1):CD000227.

Update of: Cochrane Database Syst Rev. 2000;(2):CD000227.

Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis.

Gillespie WJ, Avenell A, Henry DA, O'Connell DL, Robertson J.

Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin, NEW ZEALAND. bill.gillespie@stonebow.otago.ac.nz

BACKGROUND: Due to their known effects on bone metabolism, vitamin D and related compounds have been proposed for the prevention of osteoporosis and fractures. OBJECTIVES: To determine the effects of supplementation with Vitamin D or a Vitamin D analogue in the prevention of fractures of the axial and appendicular skeleton in elderly men or women with involutional or post-menopausal osteoporosis. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CINAHL, LILACS, CABNAR, BIOSIS, HEALTHSTAR, Current Contents, The Cochrane Database of Systematic Reviews, the Cochrane Musculoskeletal Injuries Group trials register, and bibliographies of identified trials and reviews. Date of the most recent search: September 2000. SELECTION CRITERIA: Any randomised or quasi-randomised trial which compared vitamin D or a vitamin D analogue, either alone or in combination with calcium supplementation, with a placebo, no intervention, or the administration of calcium supplements, with eligible fracture outcomes, in elderly men or women with involutional or post-menopausal osteoporosis. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of a nine item scale, and extracted data. Additional information was sought from trialists. Where possible the data were pooled. Pooling of data, where it was admissible, used pooled relative risk and fixed effects model. MAIN RESULTS: Almost all estimates of treatment effects are based on single studies. Administration of vitamin D3 alone without calcium co-supplementation was not associated with any reduction in incidence of hip fracture (relative risk (RR) 1.20, 95% confidence interval (CI) 0.83, 1.75) or other non-vertebral fracture. Administration of vitamin D3 with calcium co-supplementation to frail elderly people in sheltered accommodation was associated with a reduction in incidence of hip fracture (RR 0.74, 95% CI 0.60, 0.91). In healthy younger, ambulant participants the effect on hip fracture is unknown (RR 0.36, 95% CI 0.01, 8.78), although there appears to be a significant overall effect on non-vertebral fracture incidence in this group ( RR 0.46, 95% CI 0.23,0.90). Calcitriol (1,25 dihdyroxy vitamin D) was effective in reducing the incidence of vertebral deformity (RR 0.49, 95% CI 0.25, 0.95). Calcitriol was more effective than calcium in reducing the frequency of new vertebral deformities during the third year of treatment (RR 0.28, 95% CI 0.15, 0.52). 1-alpha-hydroxy vitamin D was effective in reducing the incidence of non-vertebral fractures in a single small study of elderly people whose mobility was impaired by neurological disease (RR 0.12, 95% CI 0.02, 0.95). No statistically significant effects were found for other comparisons of vitamin D or its analogues against each other, with and without calcium supplementation. REVIEWER'S CONCLUSIONS: Uncertainty remains about the efficacy of regimens which include vitamin D or its analogues in fracture prevention. Particularly if co-supplementation of calcium is required, significant cost differences are likely to exist between regimens. Further large randomised trials are currently being conducted to clarify the effectiveness of community fracture prevention programmes employing vitamin D supplementation.

182. Rheum Dis Clin North Am. 2001 Feb;27(1):101-30.

Calcium and vitamin D in osteoporosis.

Morgan SL.

Division of Clinical Nutrition and Dietetics, Departments of Nutrition Sciences and Medicine, Schools of Medicine, Health Related Professions, and Dentistry, University of Alabama at Birmingham, Birmingham, Alabama, USA. slmorgan@uab.edu

Calcium and vitamin D are useful adjunctive therapies in the prevention and treatment of osteoporosis. Peak BMD is optimally achieved with sustained optimal calcium and vitamin D intakes. Calcium and vitamin D intakes continue to be important after the third decade and into senescence. Although calcium and vitamin D are not therapies to be used alone to prevent early postmenopausal bone loss, they assume more prominent roles in late menopause and in the elderly to preserve bone health with advancing age. Calcium and vitamin D supplementation is an important adjunctive therapy to use together with antiresorptive therapies.

183. J Clin Endocrinol Metab. 2001 Mar;86(3):1212-21.

Erratum in: J Clin Endocrinol Metab 2001 Jul;86(7):3008.

A global study of vitamin D status and parathyroid function in postmenopausal women with osteoporosis: baseline data from the multiple outcomes of raloxifene evaluation clinical trial.

Lips P, Duong T, Oleksik A, Black D, Cummings S, Cox D, Nickelsen T.

Department of Endocrinology, Academic Hospital Vrije Universiteit, 1007 M.B. Amsterdam, The Netherlands. p.lips@azvu.nl

Vitamin D deficiency leads to secondary hyperparathyroidism, increased bone turnover, and bone loss and, when severe, to osteomalacia. Vitamin D deficiency is common in elderly people, especially the institutionalized. The definition of vitamin D deficiency is hampered by the fact that large interlaboratory differences exist in assays for serum 25-hydroxyvitamin D (25OHD), the main circulating metabolite. The international Multiple Outcomes of Raloxifene Evaluation study, a large prospective intervention trial in postmenopausal women with osteoporosis, offered the opportunity to compare vitamin D status and parathyroid function throughout many countries over the world. For this study, baseline data were available from 7564 postmenopausal women from 25 countries on 5 continents. All women had osteoporosis, i.e. bone mineral density (BMD) at femoral neck or lumbar spine was lower than t-score -2.5, or they had 2 vertebral fractures. Serum 25OHD was measured by RIA, and serum PTH was measured by immunoradiometric assay. BMD was measured by dual x-ray absorptiometry. The mean (+/-SD) serum 25OHD was 70.8 +/- 30.9 nmol/L. A low serum 25OHD (<25 nmol/L) was observed in 4.1% of all women in the Multiple Outcomes of Raloxifene Evaluation study, ranging from 0% in south east Asia (very few patients) to 8.3% in southern Europe. Serum 25OHD was between 25-50 nmol/L in 24.3% of the women. Serum 25OHD showed a significant seasonal relationship, with lower values in all regions in winter. Serum PTH correlated negatively with serum 25OHD (r = -0.25; P < 0.001). This significant negative correlation was observed in all regions. When serum 25OHD was less than 25, 25-50, or more than 50 nmol/L, respectively, mean serum PTH levels were 4.8, 4.1, and 3.5 pmol/L, respectively (by ANOVA, P < 0.001). Similarly, mean alkaline phosphatase levels were 83.7, 79.1, and 75.7 U/L (P < 0.001), respectively, with increasing serum 25OHD. The effect of serum 25OHD on BMD was only significant for the BMD of the trochanter where a serum 25OHD level less than 25 nmol/L was associated with a 4% lower BMD. After 6 months of treatment with vitamin D(3) (400-600 IU/day) and calcium (500 mg/day), serum 25OHD increased from 70.8 +/- 29.8 to 92.3 +/- 28.6 nmol/L. Serum PTH decreased significantly after 6 months of treatment, and this decrease depended on baseline serum 25OHD. When baseline serum 25OHD was less than 25, 25-50, or more than 50 nmol/L, respectively, serum PTH decreased by 0.8, 0.5, or 0.2 pmol/L, respectively (P < 0.001). In conclusion, serum 25OHD was less than 25 nmol/L in 4% of the women, and this was associated with a 30% higher serum PTH. In 24% of the women serum 25OHD was between 25-50 nmol/L, associated with a 15% higher level of serum PTH compared with women with a serum 25OHD greater than 50 nmol/L. A low serum 25OHD level was also associated with higher serum alkaline phosphatase and lower BMD of the trochanter. Treatment with vitamin D(3) and calcium increased serum 25OHD and decreased serum PTH significantly; the effect was greater for lower baseline serum 25OHD.

184. J Bone Miner Res. 2000 Nov;15(11):2276-83.

A randomized controlled trial of vitamin D supplementation on preventing postmenopausal bone loss and modifying bone metabolism using identical twin pairs.

Hunter D, Major P, Arden N, Swaminathan R, Andrew T, MacGregor AJ, Keen R, Snieder H, Spector TD.

Twin Research and Genetic Epidemiology Unit, St. Thomas' Hospital, London, United Kingdom.

Vitamin D supplementation, when given with calcium, has been shown to increase bone mineral density (BMD) and reduce the incidence of hip fracture in elderly subjects. Despite its widespread use, the benefits of vitamin D supplementation in younger women and as a single agent are less clear. We performed a randomized co-twin, placebo-controlled, double-blind trial over 2 years to measure the effect of vitamin D3 supplementation on bone density and bone metabolism in young postmenopausal women. Seventy-nine monozygotic (MZ) twin pairs (mean age, 58.7 years; range, 47-70 years) were recruited. For each twin pair, one was randomized to 800 IU cholecalciferol/day for 2 years and the other was randomized to placebo. BMD was measured at the spine and hip and heel ultrasound at baseline, 12, 18, and 24 months. Samples were collected at 0, 3, and 6 months to measure serum calcium, 25-hydroxyvitamin D [25(OH)D], parathyroid hormone (PTH), osteocalcin, and urinary deoxypyridinoline (DPD). In total, 64 pairs completed the study. No differences in baseline characteristics were seen between the groups. At 6 months, the treatment group had an increase in serum vitamin D [mean +/- SEM intrapair difference, 14.1+/-2.4 microg/liter (p < 0.001)]. There were no significant differences in other serum measurements or bone markers at 3 months or 6 months. At 24 months, no significant treatment effect was seen on BMD or calcaneal ultrasound change within pairs. Subanalysis of treatment response by vitamin D receptor (VDR) genotype revealed no significant difference in effect on BMD variables with treatment. On the basis of these results, vitamin D supplementation, on its own, cannot be recommended routinely as an osteoporosis prevention for healthy postmenopausal women with normal vitamin D levels under the age of 70 years.

185. Med Clin (Barc). 2000 Jun 10;115(2):46-51.

[Treatment of osteoporosis with calcium and vitamin D. Systematic review]

[Article in Spanish]

Vallecillo G, Diez A, Carbonell J, Gonzalez Macias J.

Servicio de Medicina Interna y Enfermedades Infecciosas, Hospital del Mar, Barcelona.

BACKGROUND: Systematic review of the efficacy of calcium and vitamin D for the treatment of osteoporosis. MATERIAL AND METHOD: Review of the database MEDLINE between 1996 and may 1998, by the key words: osteoporosis, calcium, vitamin D (and related terms) and randomized clinical trial. Review of the electronic versions of Best Evidence, The Cochrane Library, congress abstracts and references from two main textbooks. Ascending review of the literature. All the reviews were performed independently by two of the authors. Design parameters and main results of the primary publications of the identified trials were tabulated. Two independent observers carried out methodological scoring of the studies. Results were tabulated and a judgement made for the results. RESULTS: Eleven studies on calcium, 8 of vitamin D and 12 about calcitriol and other hormone derivatives were included. Studies with calcium were mainly performed on non-clinical populations and in three anti-fracture efficacy was analyzed. Results were positive in population with low baseline intake and substantial supplementation. Trials on vitamin D were done in non-clinical and on institutionalized populations. Trials with calcitriol were developed mainly in osteoporotic fracture populations and reached poorer methodological validity scores. Heterogeneity of the studies precluded a meta-analysis of the different treatments. Studies on calcium showed clinical efficacy in a more consistent way. Inter-observer score was good (kappa = 0.81) and there were no significant correlations between sample size and effect in the different studies. CONCLUSIONS: Calcium treatment is efficacious in populations with low intake receiving substantial supplementation. Vitamin D is efficacious associated with calcium mainly in deficient populations. Efficacy of calcitriol and other derivatives is more controversial.

186. Cochrane Database Syst Rev. 2000;(2):CD000952.

Calcium and vitamin D for corticosteroid-induced osteoporosis.

Homik J, Suarez-Almazor ME, Shea B, Cranney A, Wells G, Tugwell P.

Medicine, 562 Heritage Medical Research Centre, University Of Alberta, Edmonton, Alberta, Canada, T6G 2S2. jhomik@gpu.srv.ualberta.ca

OBJECTIVES: To assess the effects of calcium and vitamin D compared to calcium alone or placebo in the prevention of bone loss in patients taking systemic corticosteroids. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal trials register, Cochrane Controlled Trials Register, EMBASE and Medline up to 1996. We also conducted a hand search of abstracts from various scientific meetings and reference lists of selected trials. SELECTION CRITERIA: All randomized trials comparing calcium and vitamin D to calcium alone or placebo in patients taking systemic corticosteroids. DATA COLLECTION AND ANALYSIS: Data was abstracted from trials by two investigators. Methodological quality was assessed in a similar manner. Analysis was performed using fixed effects models. MAIN RESULTS: Five trials were included, with 274 patients. The analysis was performed at two years after starting calcium and vitamin D. There was a significant weighted mean difference (WMD) between treatment and control groups in lumbar (WMD 2.6 (95% CI 0.7, 4.5), and radial bone mineral density (WMD 2.5 (95% CI 0.6, 4.4). The other outcome measures (femoral neck bone mass, fracture incidence, biochemical markers of bone resorption) were not significantly different. REVIEWER'S CONCLUSIONS: This meta-analysis demonstrated a clinically and statistically significant prevention of bone loss at the lumbar spine and forearm with vitamin D and calcium in corticosteroid treated patients. Because of low toxicity and cost all patients being started on corticosteroids should receive prophylactic therapy with calcium and vitamin D.

187. Arthritis Rheum. 1999 Aug;42(8):1740-51.

Comment in: Arthritis Rheum. 2000 May;43(5):1188-90.

The role of vitamin D in corticosteroid-induced osteoporosis: a meta-analytic approach.

Amin S, LaValley MP, Simms RW, Felson DT.

Boston University Arthritis Center, Massachusetts 02118, USA.

OBJECTIVE: To determine if vitamin D is more effective than no therapy or calcium alone in the management of corticosteroid-induced osteoporosis, and to determine how vitamin D compares with other osteoporosis therapies, e.g., bisphosphonates, calcitonin, or fluoride, for this condition. METHODS: We evaluated all formulations of vitamin D, including its active metabolites and analogs. A systematic search for published and unpublished studies was conducted using MEDLINE (1966-December 1997), bibliographic references, abstracts from proceedings of recent national meetings, and contact with pharmaceutical companies and content experts. We included all randomized controlled trials lasting at least 6 months (and reporting extractable results), of patients receiving oral corticosteroids, that compared vitamin D with either 1) no therapy or calcium alone, or 2) bisphosphonates, calcitonin, or fluoride. The primary outcome measure of interest was change in lumbar spine bone mineral density. RESULTS: We found a moderate beneficial effect of vitamin D plus calcium versus no therapy or calcium alone (9 trials) (effect size 0.60; 95% confidence interval [95% CI] 0.34, 0.85; P < 0.0001). In comparisons of vitamin D with other osteoporosis therapies, bisphosphonates were more effective than vitamin D (6 trials) (effect size 0.57; 95% CI 0.09, 1.05). Calcitonin was similar in efficacy to vitamin D (4 trials) (effect size 0.03; 95% CI -0.39, 0.45). Fluoride was more effective than vitamin D, but there were only 2 trials. CONCLUSION: Vitamin D plus calcium is superior to no therapy or calcium alone in the management of corticosteroid-induced osteoporosis. Vitamin D is less effective than some osteoporosis therapies. Therefore, treatment with vitamin D plus calcium, as a minimum, should be recommended to patients receiving long-term corticosteroids.

188. MMW Fortschr Med. 1999 Aug 12;141(31-32):32-6.

[Therapy of osteoporosis: native vitamin D or as hormone? Advantages of activated vitamin D in secondary osteoporosis]

[Article in German]

Scharla SH.

Abteilung Innere Medizin, Klinikum Berchtesgadener Land, Schonau am Konigssee.

Vitamin D and its active metabolite (D-Hormone) are major weapons in the therapeutic arsenal available for the treatment of osteoporosis. With regard to native vitamin D, controlled studies have confirmed the prophylactic effect of treatment with vitamin D (+ calcium) in the area of nonvertebral fractures, in particular in elderly women with vitamin D deficiency. The widespread prophylactic use of this form of treatment, which is both inexpensive and largely free of side effects, would presumably save costs by greatly reducing the incidence of fractures of the femur. Treatment with D-hormone (calcitriol) or the pro-hormone 1 alpha-hydroxy-vitamin D (alfacalcidol) is a specific form of treatment of osteoporosis that has been shown to prevent fractures, in particular of the vertebrae, in a number of controlled prospective studies. The D-hormone is of particular value in the treatment of secondary forms of osteoporosis (induced by glucocorticoids or chronic inflammatory disease). Although the incidence of severe side effects is low, monitoring of serum calcium ist nevertheless recommended.

189. Calcif Tissue Int. 1999 Oct;65(4):295-306.

Vitamin D therapy of osteoporosis: plain vitamin D therapy versus active vitamin D analog (D-hormone) therapy.

Lau KH, Baylink DJ.

Department of Medicine, Loma Linda University, and Musculoskeletal Disease Center (151), 11201 Benton Street, Loma Linda, California 92357 USA.

Normal intestinal calcium (Ca) absorption is an essential feature of bone homeostasis. As with many other organ systems, intestinal Ca absorption declines with aging, and this is one pathological factor that has been identified as a cause of senile osteoporosis in the elderly. This abnormality leads to secondary hyperparathyroidism, which is characterized by high serum parathyroid hormone (PTH) and an increase in bone resorption. Secondary hyperparathyroidism due to poor intestinal Ca absorption has been implicated not only in senile osteoporosis but also in age-related bone loss. Accordingly, in population-based studies, there is a gradual increase in serum PTH from about 20 years of age onward, which constitutes a maximum increase at 80 years of age of 50% of the basal value seen at 30 years of age. The cause of the increase in PTH is thought to be partly due to impaired intestinal Ca absorption that is associated with aging, a cause that is not entirely clear but at least in some instances is related to some form of vitamin D deficiency. There are three types of vitamin D deficiency: (1) primary vitamin D deficiency, which is due to a deficiency of vitamin D, the parent compound; (2) a deficiency of 1,25(OH)(2)D(3) resulting from decreased renal production of 1,25(OH)(2)D(3); and (3) resistance to 1,25(OH)(2)D(3) action owing to decreased responsiveness to 1, 25(OH)(2)D(3) of target tissues. The cause for the resistance to 1, 25(OH)(2)D(3) could be related to the finding that the vitamin D receptor level in the intestine tends to decrease with age. All three types of deficiencies can occur with aging, and each has been implicated as a potential cause of intestinal Ca malabsorption, secondary hyperparathyroidism, and senile osteoporosis. There are two forms of vitamin D replacement therapies: plain vitamin D therapy and active vitamin D analog (or D-hormone) therapy. Primary vitamin D deficiency can be corrected by vitamin supplements of 1000 U a day of plain vitamin D whereas 1,25(OH)(2)D(3) deficiency/resistance requires active vitamin D analog therapy [1, 25(OH)(2)D(3) or 1alpha(OH)D(3)] to correct the high serum PTH and the Ca malabsorption. In addition, in the elderly, there are patients with decreased intestinal Ca absorption but with apparently normal vitamin D metabolism. Although the cause of poor intestinal Ca absorption in these patients is unclear, these patients, as well as all other patients with secondary hyperparathyroidism (not due to decreased renal function), show a decrease in serum PTH and an increase in Ca absorption in response to therapy with 1, 25(OH)(2)D(3) or 1alpha(OH)D(3). In short, it is clear that some form of vitamin D therapy, either plain vitamin D or 1,25(OH)(2)D(3) or 1alpha(OH)D(3), can be used to correct all types of age-dependent impairments in intestinal Ca absorption and secondary hyperparathyroidism during aging. However, from a clinical standpoint, it is important to recognize the type of vitamin D deficiency in patients with senile osteoporosis so that primary vitamin D deficiency can be appropriately treated with plain vitamin D therapy, whereas 1,25(OH)(2)D(3) deficiency/resistance will be properly treated with 1,25(OH)(2)D(3) or 1alpha(OH)D(3) therapy. With respect to postmenopausal osteoporosis, there is strong evidence that active vitamin D analogs (but not plain vitamin D) may have bone-sparing actions. However, these effects appear to be results of their pharmacologic actions on bone formation and resorption rather than through replenishing a deficiency.

190. Clin Endocrinol (Oxf). 1999 Aug;51(2):217-21.

Vitamin D insufficiency increases bone turnover markers and enhances bone loss at the hip in patients with established vertebral osteoporosis.

Sahota O, Masud T, San P, Hosking DJ.

Ageing and Disability Research Unit, University Hospital, Nottingham, UK.

AIM: The aim of this study was to determine whether the presence of vitamin D insufficiency increases bone turnover and enhances bone loss by examining the relationship between bone turnover markers and Bone mineral density (BMD) in vitamin D insufficient and vitamin D sufficient patients, with established vertebral osteoporosis. SUBJECTS: 119 consecutive, active, community dwelling, elderly women were assessed over a 7-month period between the months of March to October. RESULTS: There was a significant correlation between parathyroid hormone (PTH) and 25 hydroxyvitamin D (25(OH)D), r = - 0. 42 (P < 0.01). The prevalence of vitamin D insufficiency was 26.9% (defined by a 25(OH)D >/= 6.1 microg/l and </= 12 microg/l). This resulted in a statistically significant increase in bone turnover markers compared to the vitamin D sufficient group: bone alkaline phosphatase (P < 0.05), osteocalcin (P < 0.01), hydroxyproline (P < 0.05), free deoxypyridinoline (P < 0.05) and lower bone mineral density at the total hip (P < 0.01). CONCLUSIONS: These results show that there is a high prevalence of vitamin D insufficiency in the active community dwelling elderly with established vertebral osteoporosis presenting to clinical attention, which leads to increased bone turnover, decreased BMD at the hip and thus enhanced risk of further osteoporotic fractures in comparison with vitamin D sufficient subjects.

191. Endocrinol Metab Clin North Am. 1998 Jun;27(2):389-98.

The roles of calcium and vitamin D in the prevention of osteoporosis.

Reid IR.

Department of Medicine, University of Auckland, New Zealand.

Calcium supplementation produces small beneficial effects on bone mass throughout postmenopausal life and may reduce fracture rates by more than this change would predict--possibly by as much as 50%. There is little reason to use vitamin D in young populations that are replete in this compound, but in the elderly at risk of vitamin D deficiency, there is now evidence of significant reductions in nonvertebral fracture rates from physiologic replacement regimens. Some of the most substantial reductions in fracture rates have been found with combined therapy with calcium and vitamin D, and in these protocols it is not clear which is the principal active agent or whether, in fact, the combination is necessary for optimal antifracture efficacy.

192. Nippon Rinsho. 1998 Jun;56(6):1505-10.

[Treatment of osteoporosis by active vitamin D]

[Article in Japanese]

Kawakami H, Morii H.

Osaka City University Medical School.

Supplementation of active vitamin D has been thought to be reasonable for those who convert insufficiently vitamin D to active form, especially for senile persons. Treatment of osteoporosis by vitamin D are accepted as not only supplementation of vitamin D but also direct activation of bone turnover. Several previous clinical trials suggest active vitamin D prevents fractures more effectively rather than the increase of the bone mass. The calcium intake of Japanese people is less than that of Western countries, and many of Japanese have the vitamin D receptor genotype which is more responsive to vitamin D. Therefore, it is probable that active vitamin D is more effective for Japanese than Western people.

193. J Bone Miner Res. 1998 Apr;13(4):544-8.

Seasonal deficiency of vitamin D in children: a potential target for osteoporosis-preventing strategies?

Docio S, Riancho JA, Perez A, Olmos JM, Amado JA, Gonzalez-Macias J.

Service of Pediatrics, Hospital Laredo, Santander, Spain.

Peak bone mass attained after skeletal growth is a major determinant of the risk of developing osteoporosis later in life, hence the importance of nutritional factors that contribute to bone mass gain during infancy and adolescence. An adequate supply of vitamin D is essential for normal bone homeostasis. This study was undertaken to determine what the levels are of 25-hydroxyvitamin D (25(OH)D) that may be considered desirable in children and to assess if normal children maintain these levels throughout the year. Vitamin D metabolites and parathyroid hormone (PTH) serum levels were measured in 21 children in March and October, prior to and after the administration of a daily supplement of 25(OH)D (40 microg for 7 consecutive days). There were inverse correlations between basal 25(OH)D levels and supplementation-induced changes in serum 1,25(OH)2D (r = 0.57, p < 0.05) and PTH (r = 0.41, p < 0.05). When basal levels of 25(OH)D were below 20 ng/ml, the supplement induced an increase in serum 1,25(OH)2D; with basal 25(OH)D under 10-12 ng/ml, the supplement also decreased serum PTH. The lowest serum level of 25(OH)D in 43 normal children studied in summer was 13 ng/ml. Those results suggested that the lowest limit for desirable levels of 25(OH)D in children was somewhere between 12 and 20 ng/ml. However, 31% of 51 normal children studied in winter had levels below 12 ng/ml, and 80% had levels lower than 20 ng/ml. Those children are likely to have suboptimal bioavailability of vitamin D, which might hamper their achievement of an adequate peak bone mass. Since cutaneous synthesis of vitamin D is rather limited in winter, oral vitamin D supplementation should be considered.

194. Am J Med Sci. 1996 Dec;312(6):278-86.

Therapy of osteoporosis: calcium, vitamin D, and exercise.

Reid IR.

Department of Medicine, University of Auckland, New Zealand.

Calcium supplementation has long been regarded as a fundamental part of the prevention and treatment of postmenopausal osteoporosis, but it is only in recent years that clear evidence has emerged demonstrating its impact on bone mass. Calcium supplementation does not completely arrest postmenopausal bone loss but slows the rate of decline by 30 to 50%. The effect of calcium supplementation on fracture incidence in postmenopausal women has not been established. Vitamin D deficiency is common in the frail elderly, particularly in countries where fortification or food with this vitamin is not practiced. Treatment of vitamin D deficiency has been associated with significant reductions in the number of hip fractures. The role of the potent vitamin D metabolites, calcitriol and alphacalcidol, in the management of postmenopausal osteoporosis is not clear. Although some studies show substantial benefits in bone density or fracture rate from the use of these compounds, the published data are inconsistent. In general, hormone replacement therapy and the potent bisphosphonates produce greater effects on bone density and there is a greater consistency among the results of the published studies of these other interventions. Controlled trials of exercise interventions in postmenopausal women show that exercise can positively influence bone density by a few percent. Exercise interventions in the elderly have been reported to decrease fall frequency by 10%. This latter effect may have a greater impact on fracture frequency than the modest benefits of exercise on bone-density.

195. CMAJ. 1996 Oct 1;155(7):955-61.

Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 8. Vitamin D metabolites and analogs in the treatment of osteoporosis.

Jones G, Hogan DB, Yendt E, Hanley DA.

Department of Biochemistry, Queen's University, Kingston, Ont.

OBJECTIVE: To review recent findings on the skeletal actions of vitamin D and to examine results of the latest clinical trials of vitamin D in the treatment of osteoporosis. OPTIONS: The vitamin D analog 1-alpha hydroxycholecalciferol (1 alpha-OH-D3); the vitamin D metabolite calcitriol. OUTCOMES: Fracture and loss of bone mineral density in osteoporosis; increased bone mass, prevention of fractures and improved quality of life associated with vitamin D therapies. EVIDENCE: Relevant laboratory and clinical studies and reports were examined. Greatest reliance was placed on recent large-scale, randomized, controlled trials; others were noted and their methods critiqued. Clinical practice in Japan was also considered. VALUES: Reducing fractures, increasing bone mineral density and minimizing side effects of treatment were given a high value. BENEFITS, HARMS AND COSTS: Vitamin D maintains the dynamic nature of bone and so presumably helps to keep it healthy. Calcitriol and 1 alpha-OH-D3 may be effective in increasing bone mass and preventing fractures in osteoporosis. Calcitriol may be an alternative treatment in the prevention and management of corticosteroid-induced osteoporosis. Possible side effects of vitamin D analogs and metabolites are hypercalcemia, hypercalciuria, renal calcification and renal stones. RECOMMENDATIONS: The use of 1 alpha-OH-D3 for the treatment of osteoporosis in Canada cannot be supported without larger and longer randomized, controlled clinical trials. Calcitriol appears to prevent vertebral fractures in patients with osteoporosis. More information is needed on its mechanism of action and efficacy in preventing hip fractures. Future studies should focus on comparisons with other effective therapies and on determining whether its effect on fractures is greater than that achieved through improved vitamin D nutrition. Patients taking calcitriol at dose levels required for antifracture effects should be monitored for serum and urine calcium response to the drug. Calcitriol should not be given to patients whose calcium intake is at current generally recommended levels. At present, prescription of calcitriol for the treatment of osteoporosis should be reserved for physicians with a special interest in the treatment of metabolic bone disease.

196. J Rheumatol. 1996 Jun;23(6):995-1000.

Comment in: J Rheumatol. 1997 Feb;24(2):407.

Vitamin D and calcium in the prevention of corticosteroid induced osteoporosis: a 3 year followup.

Adachi JD, Bensen WG, Bianchi F, Cividino A, Pillersdorf S, Sebaldt RJ, Tugwell P, Gordon M, Steele M, Webber C, Goldsmith CH.

Rheumatic Disease Unit, St. Joseph's Hospital, McMaster University, Hamilton, Canada.

OBJECTIVE: To determine the efficacy and safety of vitamin D 50,000 units/week and calcium 1,000 mg/day in the prevention of corticosteroid induced osteoporosis. METHODS: A minimized double blind, placebo controlled trial in corticosteroid treated subjects in a tertiary care university affiliated hospital. The sample was 62 subjects with polymyalgia rheumatica, temporal arteritis, asthma, vasculitis, or systemic lupus erythematosus. The primary outcome measure was the percentage change in bone mineral density (BMD) of the lumbar spine in the 2 treatment groups from baseline to 36 mo followup. RESULTS: BMD of the lumbar spine in the vitamin D and calcium treated group decreased by a mean (SD) of 2.6% (4.1%) at 12 mo, 3.7% (4.5%) at 24 mo, and 2.2% (5.8%) at 36 mo. In the placebo group there was a decrease of 4.1% (4.1%) at 12 mo, 3.8% (5.6%) at 24 mo, and 1.5% (8.8%) at 36 mo. The observed differences between groups were not statistically significant. The difference at 36 mo was-0.693% (95% CI -5.34, 3.95). CONCLUSION: Vitamin D and calcium may help prevent the early loss of bone seen in the lumbar spine as measured by densitometry of the lumbar spine. Longterm vitamin D and calcium in those undergoing extended therapy with corticosteroids does not appear to be beneficial.

197. Proc Soc Exp Biol Med. 1996 Jun;212(2):110-5.

Vitamin D in the treatment of osteoporosis revisited.

Fujita T.

Calcium Research Institute, Osaka, Japan.

Interest in vitamin D treatment for osteoporosis has recently been revived because of the focus in various parts of the world on the elderly population, which is predominantly vitamin D deficient, in addition to postmenopausal osteoporosis due to estrogen withdrawal, which has been the central theme of osteoporosis research for many years. Combined use of other agents along with vitamin D has fortified the therapeutic armory against osteoporosis. The recent suggestion of a role of vitamin D receptor polymorphism in the development and progress of osteoporosis, possibly by interfering with its expected action, provoked intense discussions on the role of vitamin D in the pathogenesis and treatment of osteoporosis. Vitamin D receptor polymorphism may explain some of the racial differences in the incidence of osteoporosis and its complications. Responses to vitamin D treatment may also be predicted by vitamin D receptor allelic analysis, though the currently proposed allelic patterns are yet far from being widely accepted. The outlook for vitamin D treatment for osteoporosis may require insight into vitamin D receptor, not only for vitamin D's given form, but also for a possible future form designed to intervene at the genomic level.

198. Clin Rheumatol. 1995 Sep;14 Suppl 3:9-13.

Role of calcium and vitamin D in the prevention and the treatment of postmenopausal osteoporosis: an overview.

Kaufman JM.

Department of Endocrinology and Rheumatology, University Hospital, Ghent, Belgium.

When discussing the use of calcium and vitamin D in the prevention and the treatment of osteoporosis one can make a distinction between the use as dietary supplementation to correct or prevent deficiencies, and the pharmacologic use of higher doses, whether or not in association with other drugs. However, in practical terms it is not always possible to clearly make this distinction. Available evidence suggests that increasing the calcium intake can favourably affect the build-up of bone mass in adolescence. In this population, the daily consumption of calcium in the diet should, optimally, be at least 1200 mg/day. In view of the lack of data pertaining to the effect on the final peak bone mass, there is at present time no basis for the systematic administration of calcium supplements to healthy children and adolescents. Calcium supplementation, aiming at a total calcium intake of at least 1500 mg/day, has a partial protective effect on postmenopausal bone loss, this effect being documented mainly in women more than 5 years after menopause. In the present state of our knowledge, there is no established role for vitamin D supplementation in the prevention of postmenopausal osteoporosis, except in elderly patients presenting with a higher risk for relative vitamin D deficiency and with low calcium intake. The results of a controlled trial suggest that in institutionalised elderly patients, systematic administration of calcium and vitamin D supplements can substantially reduce the risk of hip fracture. In the treatment of established postmenopausal osteoporosis, calcium supplementation has only a role as a general adjuvant therapeutic measure and as a specific complement to the treatment with other active compounds. There are indications that treatment alpha-calcidol or calcitriol has a positive effect on the evolution of bone mass, but awaiting further confirmation of a favourable effect on the incidence of osteoporotic fractures, treatment with these drugs remains experimental.

199. Nord Med. 1995;110(10):253-7.

[Vitamin D and osteoporosis]

[Article in Swedish]

Ljunghall S, Charles P, Falch J, Haug E, Melhus H, Mellstrom D, Mosekilde L, Pedersen JI, Sorensen OH, Toss G.

Medicinkliniken, Akademiska Sjukhuset, Uppsala.

Vitamin D constitutes a complex endocrine-regulated system, and is both a prohormone for the endogenous synthesis of the active hormone, calcitriol, and a vitamin which may be administered to supply the organism's requirements. No single test or investigation is available for the demonstration of vitamin D deficiency. Both vitamin D intake and ability to synthesise vitamin D decrease with increasing age, and particularly the elderly in institutionalised care are at risk of developing vitamin D deficiency. Iceland excepted, mean daily vitamin D consumption in the Nordic countries is less then 5 micrograms; and in approximately 10-25 per cent of the population, daily intake is less than 2.5 micrograms which is insufficient to maintain an adequate serum calcidiol concentration in individuals unexposed to sunlight. The recommended daily intake of 5 micrograms, currently adopted in the Nordic countries, may be too low-an intake of 10 micrograms is probably necessary to satisfy requirements in the elderly.

200. Rheum Dis Clin North Am. 1994 Aug;20(3):759-75.

Role of vitamin D, its metabolites, and analogs in the management of osteoporosis.

Bikle DD.

University of California, San Francisco.

Vitamin D and its metabolites are well-established regulators of bone mineral homeostasis. Their clearest role is in the prevention and treatment of rickets and osteomalacia, bone diseases characterized by inadequate bone formation, and mineralization. Much of the effectiveness of vitamin D and its active metabolite 1,25(OH)2D in treating such disorders rests with their ability to increase serum levels of calcium and phosphate principally by stimulating intestinal calcium and phosphate absorption. Osteoporosis is not a disease resulting from obvious deficiencies in vitamin D, calcium, and phosphate. More subtle deficiencies, however, may be found, especially among the elderly with decreased intake of dairy products, reduced sunlight exposure, and less efficient intestinal absorption of bone minerals. Such subtle deficiencies may account for the ability of vitamin D and calcium supplementation to have a beneficial effect on bone mineral density in this population. Estrogen administration to postmenopausal females raises 1,25(OH)2D levels, presumably through increased renal production, and this increase is associated with increased intestinal calcium transport. Serum measurements of the vitamin D metabolites in general, however, and 1,25(OH)2D in particular do not consistently show evidence of a decrease at the time of menopause. Although most studies show a fall in intestinal calcium transport with age, which can be reversed with 1,25(OH)2D or estrogen, even these observations have not been found consistently. Thus, some investigators have addressed the issue of tissue resistance to 1,25(OH)2D and have noted decreased VDR in the intestine and reduced 1,25(OH)2D accumulation by bone with age. Despite no obvious deficiency of vitamin D in most patients with osteoporosis, clinical trials with vitamin D or 1,25(OH)2D show promise. Vitamin D treatment will probably prove most efficacious in populations with marginal vitamin D intake and/or limited sunlight exposure; high doses would not be required, and the treatment would be safe. This would be a physiologic and not a pharmacologic use of vitamin D. The use of 1,25(OH)2D for treatment of osteoporosis in individuals with adequate nutrition and sunlight exposure may require somewhat higher than physiologic doses to be effective. Perhaps such doses are necessary to stimulate osteoblast activity and/or differentiation; by raising the serum calcium level, such doses of 1,25(OH)2D might block its otherwise stimulatory effect on osteoclast number and activity. Such doses run the risk of hypercalcemia and hypercalciuria, leading to nephrolithiasis and/or nephrocalcinosis. These undesirable side effects appear to be less common with the use of 1 alpha OHD compared with 1,25(OH)2D, but this may be because of the lower levels of calcium consumption in Japan where 1 alpha OHD is widely prescribed.(ABSTRACT TRUNCATED AT 400 WORDS)

201. Eur J Gastroenterol Hepatol. 1995 Jul;7(7):609-14.

Prevention of bone mineral loss in patients with Crohn's disease by long-term oral vitamin D supplementation.

Vogelsang H, Ferenci P, Resch H, Kiss A, Gangl A.

Clinic of Internal Medicine IV (Department of Gastroenterology and Hepatology), University of Vienna, Austria.

OBJECTIVE: To determine whether long-term dietary supplementation with low doses of vitamin D helps to prevent bone loss and the development of osteoporosis or osteomalacia in out-patients with Crohn's disease. DESIGN: A randomized controlled study. SETTING: The out-patient clinic of a tertiary centre (university hospital). PATIENTS: Seventy-five out-patients (31 men and 44 women, aged 16-77 years) with Crohn's disease. INTERVENTIONS: All patients were randomly assigned to receive either an oral supplement of 1000 IU/day vitamin D for 1 year or no supplement. Bone mineral density, assessed in the distal part of the nondominant forearm using single photon absorptiometry, and serum levels of 25-hydroxyvitamin D, assessed using a competitive protein binding assay, were measured before and after the period of dietary supplementation. MAIN OUTCOME MEASURE: Relative change of bone mineral density. RESULTS: Serum levels of 25-hydroxyvitamin D increased in 57% of patients who received a supplement (compared with 37% of control patients). Bone mineral density decreased significantly in control patients [median -7%, interquartile range -12.6-(+0.4%)] but not in patients who received a supplement [median -0.2%, interquartile range -3.8-(+14%); P < 0.005]. Increases in bone mineral density were especially prevalent among patients who received the supplement and had normal serum levels of 25-hydroxyvitamin D (68%), whereas increases occurred in only 18% of patients with low serum levels of 25-hydroxyvitamin D (P = 0.008). Patients without an intestinal resection and receiving the vitamin D supplement had a marginally greater increase in bone mineral content than patients who had undergone a resection (P = 0.05). CONCLUSION: Long-term oral vitamin D supplementation seems to be an efficient means of preventing bone loss in patients with Crohn's disease and could be recommended, especially for patients at high risk of osteoporosis.

202. Osteoporos Int. 1993 Jul;3(4):209-14.

Metabolic effects of thiazide and 1,25-(OH)2 vitamin D in postmenopausal osteoporosis.

Sakhaee K, Zisman A, Poindexter JR, Zerwekh JE, Pak CY.

Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75235-8885.

It was previously shown that the stimulation of intestinal calcium absorption by exogenous 25-hydroxyvitamin D (25-OHD) in postmenopausal women with osteoporosis was attenuated when thiazide was added, probably due to the suppression of endogenous synthesis of 1,25-(OH)2 vitamin D (1,25-(OH)2D). To test whether the above attenuation could be averted if exogenous 1,25-(OH)2D replaced 25-OHD, 10 women with postmenopausal osteoporosis participated in a three-phase study comprising control (pretreatment), treatment with 1,25-(OH)2D 0.5 microgram/day for 4 weeks, and combined 1,25-(OH)2D and trichlormethiazide (TZ) 2 mg/day for 4 weeks. The 1,25-(OH)2D treatment significantly increased serum 1,25-(OH)2D from 60 +/- 7.2 (SD) to 154 +/- 48 pmol/l, fractional intestinal calcium absorption (alpha) from 0.386 +/- 0.055 to 0.613 +/- 0.081, and urinary calcium from 3.7 +/- 0.8 to 6.6 +/- 1.9 mmol/day. Addition of TZ significantly reduced urinary calcium from 6.6 +/- 1.9 to 4.8 +/- 1.3 mmol/day, without changing alpha (0.613 +/- 0.081 to 0.584 +/- 0.070), serum calcium or 1,25-(OH)2D (154 +/- 48 to 154 +/- 38 pmol/l). Thus, estimated calcium balance (absorbed minus urinary calcium, increased marginally to +5.6 mmol/day on 1,25-(OH)2D alone (p = 0.028) and significantly to +6.8 mmol/day on 1,25-(OH)2D+TZ, from the control value of +4.0 mmol/day. Seven patients who were treated long-term with combined 1,25-(OH)2D and TZ for 11-29 months maintained their alpha (0.593 +/- 0.099) and a marginally more positive estimated calcium balance (+6.4 mmol/day, p = 0.025 from the control phase). Moreover, there was a stability of bone density of radial shaft, femoral neck, and lumbar spine.(ABSTRACT TRUNCATED AT 250 WORDS)

203. J Cell Biochem. 1992 May;49(1):19-25.

Osteoporosis and vitamin D.

Nordin BE, Morris HA.

Division of Clinical Chemistry, Institute of Medical and Veterinary Science, Adelaide, South Australia.

Bone "density" (bone mass/bone volume) declines with age from the menopause in women and from about age 55 in men. This fall in bone density (osteoporosis) weakens the bones and leads to a progressive rise in fracture rates, particularly in women. Many risk factors contribute to the bone-losing process, but one which attracts increasing attention is calcium absorption. The main physiological regulator of calcium absorption is vitamin D. This is manufactured in the skin under the influence of UV-light and then converted to more potent metabolites in the liver and kidney. Although the serum levels of the most potent metabolite 1,25(OH)2D3 (calcitriol) are generally normal in osteoporotic women, treatment with small doses of calcitriol (about 0.25 micrograms daily) has a remarkable effect on absorptive performance and slows down the rate of bone loss. Improved synthetic metabolites are under development. There is likely also to be greatly increased scope for the use of vitamin D itself in osteoporosis. With advancing age, there is a tendency for men and women to be exposed to less and less sunlight, which is the main natural source of vitamin D. Vitamin D levels, therefore, decline with age, particularly in those who are housebound, and are found to be low in most reported series of hip fractures. It is likely that this form of vitamin D "insufficiency" has an adverse effect on calcium absorption in the elderly which accelerates bone loss and increases the risk of hip fracture and can be treated with small doses of vitamin D or its 25-hydroxy derivative.(ABSTRACT TRUNCATED AT 250 WORDS)

204. Calcif Tissue Int. 1991 Feb;48(2):78-81.

The relationship between serum vitamin D concentrations and in vivo tetracycline labeling of osteoid in crush fracture osteoporosis.

Mawer EB, Arlot ME, Reeve J, Green JR, Dattani J, Edouard C, Meunier PJ.

Department of Medicine, University of Manchester, UK.

Twenty of 22 consecutive British patients with crush fracture osteoporosis had transiliac bone biopsies following double in vivo tetracycline labeling synchronized with the collection of serum for the measurement of vitamin D metabolites. A significant but direct (rather than inverse) relationship was found between 25-hydroxyvitamin D (calcidiol) levels and the fraction of cancellous surfaces covered with osteoid not taking either tetracycline label (r = 0.53, P less than 0.02). There was no correlation with 1,25-dihydroxyvitamin D levels. No patient had frankly thickened osteoid seams although 3 had reduced but measurable calcidiol levels. These results make it unlikely that the majority of patients with osteoporosis who have osteoid of normal thickness but reduced uptake of tetracycline have a mineralization defect secondary to vitamin D deficiency. The pathophysiological significance of unlabeled osteoid in osteoporosis requires further investigation.

205. Calcif Tissue Int. 1991;49 Suppl:S46-9.

Is there a role for vitamin D in osteoporosis?

Lamberg-Allardt C.

Endocrine Research Laboratory, University of Helsinki, Minerva Foundation Institute for Medical Research, Finland.

Vitamin D has certain clearly defined effects on bone: vitamin D deficiency results in defective bone mineralization, whereas 1,25-dihydroxy-vitamin D3 (1,25-(OH)2D3) stimulates bone resorption. Studies of the use of 1,25-(OH)2D3 to prevent or treat osteoporosis have given conflicting results concerning bone remodeling. However, 1,25-(OH)2D3 or other vitamin D metabolites seem to play a role in the correction of calcium malabsorption, which is a common feature in osteoporosis.

206. Calcif Tissue Int. 1989 Sep;45(3):137-41.

Effect of calcitonin and vitamin D in osteoporosis.

Palmieri GM, Pitcock JA, Brown P, Karas JG, Roen LJ.

Department of Medicine, University of Tennessee, Memphis.

Vitamin D has complex effects in bone: it stimulates matrix formation and bone maturation but also enhances osteoclastic activity and may influence differentiation of bone cell precursors. Calcitonin inhibits the function of osteoclasts, reducing bone resorption, thus, the combination of vitamin D and calcitonin could result in a positive bone balance. We tested the hypothesis that chronic treatment with high doses of vitamin D (150,000 U/week), moderate doses of salmon calcitonin (120 MRC U/week), and adequate Ca supplementation (1 g/day) could be beneficial in osteoporosis. Thirteen women with postmenopausal osteoporosis received this treatment for 2-6 years (mean 3.5 years). No side effects, hypercalcemia, or hypercalciuria occurred. There was marked reduction in bone pain. The fracture rate in 11 patients with vertebral compression fracture was 240/1,000 patient years, threefold lower than the reported 834 fractures for untreated patients of similar age. Single photon bone densitometry of the radius did not change. Iliac crest bone biopsies obtained at the initiation and conclusion of the study showed a 43% increment in trabecular bone volume (P = 0.0003), without changes of the normal osteoid thickness, surface, and volume. Because single photon densitometry reflects mostly cortical bone, the data suggest that the combination of vitamin D and calcitonin increases trabecular bone mass and prevents the fall of cortical bone mass in osteoporosis. Previous reports suggest that calcitonin alone or with small doses of vitamin D increased bone mass for about 2 years. The present study suggests a prolonged beneficial effect of the combination of high doses of vitamin D with rather moderate (less than 150 MRC U/week) doses of calcitonin in postmenopausal osteoporosis.

207. Am J Med. 1987 Sep;83(3):593-5.

Premenopausal osteoporosis associated with vitamin D-responsive calcium malabsorption. A case report.

Glauber HS, Catherwood BD.

Department of Medicine, Veterans Administration Medical Center, San Diego, California 92161.

A premenopausal woman with severe osteoporosis was found to have impaired calcium absorption, without other evidence of intestinal malabsorption. Although circulating levels of 25-OH-vitamin D and 1,25-(OH)2-vitamin D were normal, calcium absorption improved markedly following two weeks of treatment with synthetic 1,25-(OH)2-vitamin D. This suggests that a partial intestinal resistance to the actions of 1,25-(OH)2-vitamin D contributed to the development of her osteoporosis. This case report demonstrates the feasibility of using the calciuric response to a standard oral calcium load to screen for impaired calcium absorption in osteoporotic patients.

208. Am J Med. 1987 Feb;82(2):224-30.

Vitamin D toxicity complicating the treatment of senile, postmenopausal, and glucocorticoid-induced osteoporosis. Four case reports and a critical commentary on the use of vitamin D in these disorders.

Schwartzman MS, Franck WA.

Hypervitaminosis D developed in four patients with osteoporosis or osteomalacia. All patients were given pharmacologic doses of vitamin D, had reduced baseline levels of renal function, and became hypercalcemic with acute renal failure. Measured 25-hydroxyvitamin D (25-OH D) levels were elevated in three patients; levels were not determined in a fourth patient who became normocalcemic when vitamin D therapy was discontinued. Published data on the use of vitamin D for prophylaxis or treatment of any form of osteoporosis fail to document benefits superior to those of calcium alone or calcium with estrogens and fluoride. Data on the use of 25-OH D show no greater benefit than for vitamin D. The use of 1,25-dihydroxyvitamin D (1,25-OH2 D) plus calcium may be superior to the use of calcium alone in some forms of osteoporosis. Vitamin D toxicity is associated with enhanced resorption of bone in some patients. Morbidity included extended hospitalization, dialysis, and chronic renal failure. Pharmacologic doses of vitamin D cannot be recommended for any form of osteoporosis.

209. Miner Electrolyte Metab. 1987;13(2):96-103.

Safety of osteoporosis treatment with sodium fluoride, calcium phosphate and vitamin D.

Hasling C, Nielsen HE, Melsen F, Mosekilde L.

Department of Medical Endocrinology, Aarhus Amtssygehus, Denmark.

During an 8-year period, 163 consecutive patients with spinal crush fracture osteoporosis started a 5-year treatment with a combination of sodium fluoride (60 mg/day), calcium phosphate (45 mmol/day) and vitamin D2 (18,000 IU/day), and were followed in the outpatient clinic every 3 months. Fourty-three patients completed the 5-year treatment. Mean observation time was 2.8 years, totalling 460 patient-years. Fifty-one percent of the patients experienced joint-related (37%) or gastrointestinal (25%) side effects at one time or another. All side effects subsided after a median 6-week withdrawal of fluoride. Six percent of the patients withdrew from treatment due to side effects. Mean serum calcium values slightly decreased during treatment and no hypercalcemic episodes were seen. Urinary excretion of calcium did not change during treatment. No changes in renal, bone marrow or thyroid functions could be detected. The liver function might be slightly affected as indicated by minute increases in serum bilirubin and decreases in serum coagulation factors and albumin, but no other changes in liver function were observed.

210. Eur J Nucl Med. 1987;13(9):462-6.

99mTc-MDP retention in osteoporosis: relationship to other indices of bone cell activity and response to calcium and vitamin D therapy.

Davie MW, Britton JM, Haddaway M, McCall IW.

Department of Metabolic Medicine, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK.

Serum calcium, albumin, phosphorus, and alkaline phosphatase, urinary creatinine and retention of 99mTc-methylene bisphosphonate (99mTc-MDP) were measured in 61 subjects with osteoporosis and the values compared with those obtained in normal subjects. 99mTc-MDP retention was inversely related with urinary creatinine output in normal subjects. In osteoporotic subjects urinary creatinine output was lower and 99mTc-MDP retention higher even when urinary creatinine output was taken into account. Other measurements were similar. In 21 subjects these measurements together with urinary hydroxyproline were performed before and after treatment with calcium and vitamin D. 99mTc-MDP and alkaline phosphatase fell; urinary hydroxyproline was unchanged. A single 24 h urine measurement after 99mTc-MDP injection is a valuable method of predicting whether calcium and vitamin D therapy will be useful in a particular case of osteoporosis.

211. J Nutr Sci Vitaminol (Tokyo). 1985 Dec;31 Suppl:S61-5. (Animal Study)

Effect of vitamin D metabolites on bone metabolism in a rat model of postmenopausal osteoporosis.

Matsumoto T, Ezawa I, Morita K, Kawanobe Y, Ogata E.

A rat model of postmenopausal osteoporosis was introduced, using ovariectomized rats on a low Ca diet. CT treatment of these animals for one month prevented the decrease in both mineral contents and physical properties of the femoral bone. Treatment of the animals with 1,25(OH)2D3 was effective in increasing bone mineral contents and maintaining positive mineral balance, but did not increase the physical tolerance of bones. In contrast, 24,25(OH)2D3 increased the breaking force of the femoral bone, with minimal effect on bone mineral contents and mineral balance. These results suggest that 1,25(OH)2D3 and 24,25(OH)2D3 act differently on the matrix phase and mineral phase of bones, but that they act together to maintain mineral balance and structural integrity of bones. The mechanism of how these vitamin D metabolites affect bone metabolism remain to be clarified.

212. Schweiz Med Wochenschr. 1985 Jul 9;115(27-28):922-31.

[Multidisciplinary study of the prolonged treatment of involution osteoporosis using sodium fluoride with calcium, phosphate and vitamin D]

[Article in French]

Courvoisier B, Baud CA, Very JM, Assimacopoulos A, Tochon-Danguy HJ, Boivin G, Donath A, Garcia J, Gasser A, Fischer J, et al.

A multidisciplinary study on the prolonged treatment of involution osteoporosis with fluoride was performed on a homogeneous population of 31 women aged 51 to 75 years (mean 64 years). The selection criteria were the following: significant backache, vertebral compression fractures on X-rays, bone biopsy evidence of osteoporosis, and absence of other risk factors after a complete workup. The patients were treated for a period of 3 to 6 years (mean 4 years) with daily doses of 30 mg (10 mg 3 times) fluorides ion associated during the last 3 years with 500 mg calcium twice daily, 750 mg phosphate and 1000 units vitamin D daily. The study demonstrated a favourable effect of the treatment on the backache and that it was well tolerated in the majority of cases, the side effects being intermittent osteo-articular pains of the lower extremities due to the fluoride in 9 patients, and gastric intolerance to the phosphate in 7. X-ray follow-up showed slowing of the vertebral compressions after the first year of treatment, but no effect on fractures of the extremities. There was no evidence of alterations in parameters of mineral and bone metabolism, and in endocrine, hepatic, renal or hematological assays. Histomorphometric and biophysical examination of biopsies indicated that, although there was no significant increase in the quantity of mineralized bone under the treatment, there was a very significant improvement in the crystallinity of the mineral substance, thus enhancing the quality of the bone tissue and its resistance to pressure. This study is the first in which a catamnesis of the patients was undertaken, 28 of them having received a clinical and radiological examination 2 years after the end of therapy: a favourable evolution was observed in most of the cases, both in those patients treated for a period of 3 years and in those whose treatment had lasted for a longer period.

213. J Endocrinol Invest. 1984 Aug;7(4):373-8.

The hormonal form of vitamin D in the pathophysiology and therapy of postmenopausal osteoporosis.

Caniggia A, Nuti R, Lore F, Vattimo A.

Sixty-two women with symptomatic postmenopausal osteoporosis underwent long-term treatment with 1,25-dihydroxyvitamin D3. The following results were obtained: i) a dramatic improvement of the intestinal transport of radioactive calcium, which was impaired prior to the treatment; ii) non significant increases in fasting serum calcium; iii) significant increases in the 24 h urinary excretion of calcium and phosphate, resulting from the improvement of intestinal calcium absorption, and a decrease in the urinary cAMP/Cr ratio; iv) non significant changes in serum phosphate, serum alkaline phosphatase, urinary hydroxyproline; v) non significant increases in bone mineral content; vi) relief from pain and improvement of motility in all the patients; vii) no side effect was noticed. In conclusion the treatment with 1,25-dihydroxyvitamin D3 was shown to be useful in postmenopausal osteoporosis.

214. J Clin Invest. 1984 Jun;73(6):1668-72.

Impaired vitamin D metabolism with aging in women. Possible role in pathogenesis of senile osteoporosis.

Tsai KS, Heath H 3rd, Kumar R, Riggs BL.

Calcium absorption decreases with aging, particularly after age 70 yr. We investigated the possibility that this was due to abnormal vitamin D metabolism by studying 10 normal premenopausal women (group A), 8 normal postmenopausal women within 20 yr of menopause (group B), 10 normal elderly women (group C), and 8 elderly women with hip fracture (group D) whose ages (mean +/- SD) were 37 +/- 4, 61 +/- 6, 78 +/- 4, and 78 +/- 4 yr, respectively. For all subjects, serum 25-hydroxyvitamin D [25(OH)D] did not decrease with age, but serum 1,25-dihydroxyvitamin D [1,25(OH)2D], the physiologically active vitamin D metabolite, was lower (P = 0.01) in the elderly (groups C and D; 20 +/- 3 pg/ml) than in the nonelderly (groups A and B; 35 +/- 4 pg/ml). The increase of serum 1,25(OH)D after a 24-h infusion of bovine parathyroid hormone fragment 1-34, a tropic agent for the enzyme 25(OH)D 1 alpha-hydroxylase, correlated inversely with age (r = -0.58; P less than 0.001) and directly with glomerular filtration rate (r = 0.64; P less than 0.001). The response was more blunted (P = 0.01) in elderly patients with hip fracture (13 +/- 3 pg/ml) than in elderly controls (25 +/- 3 pg/ml). We conclude that an impaired ability of the aging kidney to synthesize 1,25(OH)2D could contribute to the pathogenesis of senile osteoporosis.

215. Spec Top Endocrinol Metab. 1983;5:83-148.

The vitamin D endocrine system, calcium metabolism, and osteoporosis.

Slovik DM.

Although the nutritional aspects related to bone development and subsequent bone loss have been appreciated for many years, they are now being reemphasized in view of current information concerning the vitamin D endocrine system, the development of new assay procedures and more sensitive radiologic techniques to assess changes in bone mass, and the realization that clinical problems related to bone loss will increase as individuals live longer. The vitamin D endocrine system is complex, involving the skin, liver, and kidney for synthesis of the vitamin D metabolites and, primarily, the intestine and bone for biologic expression. Numerous factors and disorders affecting the skin, gastrointestinal tract, and kidney will adversely affect vitamin D metabolism. Vitamin D deficiency is common in elderly individuals, especially those who are chronically ill, house-bound, and poorly nourished. Subclinical vitamin D deficiency and osteomalacia may also be complicating problems in elderly patients with osteoporosis and hip fractures. At present the role of the vitamin D endocrine system in the pathogenesis and treatment of osteoporosis is unclear. There is little evidence that vitamin D or its metabolites are helpful in osteoporosis, except perhaps to heal osteomalacia which may be present. It is hoped that encouraging results will follow the use of more potent vitamin D metabolites, either alone or in combination with other agents. Calcium homeostasis is affected by numerous dietary factors (including protein, phosphorus, fiber, and lactose) and drugs (including alcohol, diuretics, and antacids), and calcium absorption in the intestine and the ability to adapt to low-calcium diets will decrease with advancing age. There are conflicting reports concerning the relation between low-calcium intake and osteoporosis, and about the role of calcium intake in the development and then maintenance of bone mass. There is little doubt that many older individuals ingest less calcium than is recommended, especially at a time when even more may be required to maintain bone mass. Several studies show that calcium supplementation producing a total calcium intake of 1,200-1,500 mg/day can slow the rate of bone loss. When the high doses of calcium are given along with vitamin D, periodic monitoring of blood and urine calcium is necessary to avoid hypercalcemia and hypercalciuria.

216. Arch Fr Pediatr. 1981 Mar;38(3):165-70.

[Serum concentrations of vitamin D metabolites in idiopathic juvenile osteoporosis (author's transl)]

[Article in French]

Leroy D, Garabedian M, Guillozo H, Bourdeau A, Sauvegrain J, Balsan S.

This report concerns a 13 year old girl with the clinical and radiological features of mild idiopathic juvenile osteoporosis. In this patient, no alteration was detected in serum calcium (total + ionized) and phosphorus concentration, serum alkaline phosphatase activity, nor in urinary calcium and phosphorus excretions. Plasma concentrations of cortisol were normal during daytime and sleep. Circulating immunoreactive parathyroid hormone was normal or low. The serum 25-(OH)D and 24,25-(OH)2D concentrations were below the normal range, and the 1,25-(OH)2D concentrations were above the normal range (720 pmol/l) at the beginning of the investigation. All vitamin D metabolites concentrations returned to normal values at the time of radiological recovery and after calcium and 25-(OH)D3 supplementation. A possible relationship between alterations of bone and of circulating vitamin D metabolites is discussed.

217. Curr Med Res Opin. 1981;7(5):337-48.

The vitamin D metabolites in the pathogenesis and management of osteoporosis.

Crilly RG, Horseman A, Peacock M, Nordin BE.

Studies on post-menopausal osteoporotic patients indicate that 1,25-(OH)2 D3 concentrations are no different from those in age-matched normal subjects and the data suggest that the malabsorption of calcium found in many osteoporotic patients cannot generally be attributed to low plasma 1,25-(OH)2 D3 levels. The effects are discussed of three different therapies - sex hormones alone, vitamin D metabolites alone and a combination of both - on calcium balance and peripheral bone loss in treated compared with untreated osteoporotic patients. The results indicate that combined therapy with a vitamin D metabolite and an oestrogen is more effective in inhibiting the rate of bone resorption in post-menopausal osteoporosis than treatment with either agent used alone, and should be regarded as the treatment of choice at the present time. It is suggested that, using this regimen which is suitable for patients up to about 65 years of age, calcium supplementation is not required, provided daily calcium intake is reasonably adequate, and may even be undesirable by increasing the risk of hypercalcaemia.

218. Rev Rhum Mal Osteoartic. 1980 Dec;47(12):693-8.

[Histological effects of the treatment of osteoporosis with the combination of sodium fluoride, vitamin D and calcium]

[Article in French]

Briancon D, Charhon S, Edouard C, Meunier PJ.

A histomorphometric and dynamic study of non-decalcified transiliac biopsies was carried out in 51 cases of osteoporosis who had received double marking with tetracycline before and after two years treatment with association of sodium fluoride (50 mg/day) vitamin, D2 (8,000 IU/day) and calcium (1 g/day). The main effect of fluoride is an increase in the osteoblastic population, which is shown by an increase in the osteoid parameters. The osteoid volume is multiplied by 3,6, the osteoid surfaces by 2,4, and the index of osteoid thickness by 1,2. There exists a lesser increase in the reabsorption surfaces (X 1,2). There results a very significant increase in bony trabecular volume, the average value of which increase from 9,8 +/- 3,1% to 16,6 +/- 9.3% (X 1,8; p < 0.001). These results were found again both in apparently primary osteoporosis and in secondary osteoporosis. No significant depression was noted in the rate of calcification, but six patients developed a state of histological osteomalacia associated in 5 cases with an increased calcified volume. All these results are in good agreement with those of the world literature and indicate that fluoride is able in most cases (60%) to restore normal bones in osteoporosis with reduced risk of fracture.

219. J Clin Endocrinol Metab. 1980 Dec;51(6):1359-64.

Effect of estrogen on calcium absorption and serum vitamin D metabolites in postmenopausal osteoporosis.

Gallagher JC, Riggs BL, DeLuca HF.

Osteoporotic women have decreased calcium absorption and decreased serum 1,25-dihydroxyvitamin D [1,25-(OH)2D] and are usually in negative calcium balance. Estrogen therapy improves calcium balance in patients with postmenopausal osteoporosis. In birds, estrogen administration increases the conversion of 25-hydroxyvitamin D (25OHD) to 1,25-(OH)2D. To determine if estrogen therapy affects vitamin D metabolism in human subjects, we studied 21 osteoporotic women before and after 6 months of treatment. We compared groups treated with either placebo (9 patients) or conjugated equine estrogen (1.2-2.5 mg/day; 12 patients). Fractional calcium absorption (mean +/- SE) was unchanged after treatment with placebo (0.51 +/- 0.03 to 0.52 +/- 0.01) but increased after treatment with estrogen (0.53 +/- 0.02 to 0.65 +/- 0.04; P < 0.005). The increase after estrogen was similar to the increase observed in 10 additional osteoporotic women treated for 6 months with a small dose of 0.5 microgram/day 1,25-(OH)2D (0.54 +/- 0.03 to 0.68 +/- 0.04; P < 0.005). Serum 1,25-(OH)2D was unchanged after treatment with placebo (27.5 +/- 1.3 to 27.6 +/- 1.7 pg/ml) but increased after treatment with estrogen (23.6 +/- 2.7 to 33.2 +/- 3.7 pg/ml; P < 0.005). Serum immunoreactive parathyroid hormone (PTH) increased (23.0 +/- 4.2 to 32.7 +/- 4.6 microliter eq/ml; P < 0.05) after estrogen but not after placebo treatment. After treatment with estrogen, the increases in serum immunoreactive PTH and serum 1,25-(OH)2D were correlated (r = 0.68; P < 0.05), and the increases in serum 1,25-(OH)2D and calcium absorption were highly correlated (r = 0.89; P < 0.001). We conclude that estrogen treatment increases calcium absorption in postmenopausal osteoporosis by increasing serum 1,25(OH)2D. This effect appears to be mediated indirectly through stimulation of renal 1 alpha-hydroxylase by increased serum PTH.

220. Endocrinol Jpn. 1979 Jun;26(Suppl):7-13.

Vitamin D and osteoporosis.

Ohato M, Fujita T.

In elderly people with marginal exposure to the sunlight, males showed higher serum 25-hydroxycalciferol than females, whereas in those with ample or poor sunlight exposure, serum 25-hydroxycalciferol was higher or very low, respectively, exhibiting no sex difference in the vitamin D metabolite levels. The male predominance in serum 25-hydroxycalciferol levels seen among some aged population would be explained, at least in part, by the result of animal experiment suggesting the stimulatory effect of testosterone on vitamin D biosynthesis induced by ultaviolet irradiation. Testosterone was, furthermore, shown to have hypocalcemic action, probably through suppression of bone resortopton in vitamin D depleted but not in replete rats. Clinical implication of these two-fold effects of testosterone observed in rats was discussed in relevance to male predominance in serum 25-hydroxycalciferol level and bone mineral content in the aged population.

221. J Clin Endocrinol Metab. 1977 Aug;45(2):199-208.

Vitamin D metabolism and the response to 1,25-dihydroxycholecalciferol in Osteoporosis.

Davies M, Mawer EB, Adams PH.

The metabolism of isotopically-labelled cholecalciferol and the response to small doses of 1,25-dihydroxycholecalciferol (1,25-(OH)2D3) was studied in a group of women with osteoporosis presenting with crush vertebral fracture. No abnormality of vitamin D metabolism was detected. The administration of 1 microgram 1,25-(OH)2D3 for between 8 and 20 days was associated with an increased intestinal absorption and urinary excretion of calcium but caused no improvement in calcium balance. There was a small but significant rise in serum calcium and phosphorus and significant reduction in immunoassayable parathyroid hormone levels during treatment. It is concluded that 1,25-(OH)2D3 is unlikely to be of value in the management of osteoporosis.

222. J Clin Endocrinol Metab. 1976 Jun;42(6):1139-44.

Effects of oral therapy with calcium and vitamin D in primary osteoporosis.

Riggs BL, Jowsey J, Kelly PJ, Hoffman DL, Arnaud CD.

Eighteen patients (17 women and 1 man) with primary osteoporosis were divided into two groups of 9 patients each. Group A received 2.0 to 2.5 g of calcium and 400 units of vitamin D per day orally and was studied before and after short-term (3 to 4 months) treatment; group B received 1.5 to 2.0 g of calcium per day and 50,000 units of vitamin D twice weekly and was studied before, after short-term, and after long-term (1 year) treatment. In group A there was a decrease (P is less than 0.01) in bone-resorbing surfaces (microradiography of bone biopsy samples) after short-term treatment. In group B there was a decrease (P is less than 0.01) in bone-forming and bone-resorbing surfaces after both short-tern and long-term treatment. Fasting-state (morning) serum immunoreactive parathyroid hormone (iPTH) concentrations decreased after short-term treatment (combined data of groups A and B) and after long-term treatment (group B). We conclude that the principal effect of the oral calcium and vitamin D therapy in primary osteoporosis is to decrease bone turnover. The most probable mechanism for this effect on bone is a partial inhibition of PTH secretion.

Older persons

223. J Am Geriatr Soc. 2003 Sep;51(9):1219-26.

Effects of vitamin d supplementation on strength, physical performance, and falls in older persons: a systematic review.

Latham NK, Anderson CS, Reid IR.

Clinical Trials Research Unit Department of Medicine, University of Auckland, Auckland, New Zealand Center for Rehabilitation Effectiveness, Sargent College, Boston University, Boston, Massachusetts.

OBJECTIVES: : To identify, appraise, and synthesize data from randomized, controlled trials of vitamin D supplementation in older people. DESIGN: : A systematic review of trials identified from searches of databases, reference lists, review articles, and recent conference proceedings. SETTING: : Most studies performed in ambulatory setting. PARTICIPANTS: : Older people (mean age=60). INTERVENTIONS: : Vitamin D or vitamin D metabolites. MEASUREMENTS: : Strength, physical performance, or falls. RESULTS: : Thirteen trials involving 2,496 patients met this study's inclusion criteria. Most of the trials were small and had methodological problems. In 10 trials, there was no evidence that vitamin D or vitamin D metabolites had an effect on falls or physical function, but three trials showed a positive effect of vitamin D in combination with calcium. When available data from the four highest quality trials were pooled (n=1,317), there continued to be no evidence that vitamin D reduced the risk of falling (relative risk= 0.99, 95% confidence interval=0.89-1.11), although a single trial of vitamin D and calcium showed a positive effect. CONCLUSION: : Although there is insufficient evidence that vitamin D supplementation alone improves physical performance in older people, some data suggest a benefit from vitamin D combined with calcium supplementation, but this requires confirmation in large, well-designed trials.

224. Joint Bone Spine. 2003 Jun;70(3):203-8.

Effects on bone mineral density of calcium and vitamin D supplementation in elderly women with vitamin D deficiency.

Grados F, Brazier M, Kamel S, Duver S, Heurtebize N, Maamer M, Mathieu M, Garabedian M, Sebert JL, Fardellone P.

Rheumatology Department, North Hospital Group, 80054 cedex 1, Amiens, France.

OBJECTIVE: Calcium and vitamin D deficiency is common in older individuals, particularly those who live in nursing homes, and increases the risk of osteoporosis and fractures. METHODS: We conducted a randomized double-blind placebo-controlled study of combined supplementation with 500 mg of elemental calcium, as carbonate, and 400 IU of vitamin D bid for 12 months in women older than 65 years of age with vitamin D deficiency, defined as serum 25(OH)D concentrations </=12 ng/ml. RESULTS: Mean patient age was 75 +/- 7 years, and median daily dietary intakes of calcium and vitamin D were 697 mg and 66.8 IU in the supplemented group (n = 95) and 671 mg and 61.8 IU in the placebo group (n = 97). The median serum 25(OH)D level was 7.0 ng/ml in both groups, and the medial intact parathyroid hormone (PTHi) levels were 49 and 48 pg/ml in the supplemented and placebo groups, respectively. The median increase in serum 25(OH)D was 22.0 ng/ml in the supplemented group and 4 ng/ml in the placebo group (P < 0.0001), and the median PTHi decrease was 17 and 5 pg/ml, respectively (P < 0.0001). The median bone mineral density increase was significantly greater in the supplemented group than in the placebo group: +2.98% vs. -0.21% at L2-L4 (P = 0.0009), +1.19% and -0.83% at the femoral neck (P = 0.015), +0.86% and -0.56% at the trochanter (P = 0.015), and +0.99% and +0.11% for the whole body (P = 0.01). Similarly, the median decrease in the main bone markers was significantly greater in the treated group than in the placebo group: -1.35 microg/l vs. +0.50 microg/l for bone alkaline phosphatase (P = 0.008), -16.6 nmol/mmol creatinine vs. -2.3 nmol/mmol creatinine for urinary type I amino-terminal telopeptide (P = 0.001), and -896 pmol/l vs. -201 pmol/l for serum type I carboxy-terminal telopeptide (P = 0.003). We found no significant differences between the two groups for serum calcium, although urinary calcium excretion changed more in the supplemented group than in the placebo group. In conclusion, bone mass in older women with vitamin D deficiency increases significantly at the lumbar spine, femur, trochanter, and whole body after calcium and vitamin D supplementation for 1 year, and concomitantly bone markers improved as vitamin D levels returned to normal.

225. Am J Clin Nutr. 2003 May;77(5):1324-9.

Vitamin D supplementation and bone mineral density in early postmenopausal women.

Cooper L, Clifton-Bligh PB, Nery ML, Figtree G, Twigg S, Hibbert E, Robinson BG.

Department of Diabetes, Endocrinology and Metabolic Medicine, Northern Metabolic Bone Centre, Royal North Shore Hospital, St Leonards, Australia.

BACKGROUND: Increased vitamin D intake may preserve or increase bone mineral density (BMD) in older persons. OBJECTIVE: A 2-y double-blind study was undertaken to determine whether weekly administration of 10 000 units of vitamin D(2) maintained or increased BMD in younger postmenopausal women more efficiently than did calcium supplements alone. DESIGN: One hundred eighty-seven women who were >or= 1 y postmenopausal were randomly assigned to take either 1000 mg Ca/d after the evening meal or 1000 mg Ca/d plus 10 000 U vitamin D(2)/wk in a double-blind, placebo-controlled format. The BMD of the proximal forearm, lumbar spine, femoral neck, Ward's triangle, and femoral trochanter was measured at 6-mo intervals by osteodensitometry. RESULTS: During the 2-y period, there was no significant difference in the change in BMD at any site between the subjects taking calcium supplements and those taking calcium plus vitamin D(2). Both groups significantly (P < 0.005) gained BMD in Ward's triangle and the femoral trochanter but significantly (P < 0.005) lost bone in the proximal radius. There was no significant change in the lumbar spine or femoral neck BMD. CONCLUSION: In younger postmenopausal women ( age: 56 y) whose average baseline serum 25-hydroxyvitamin D concentration was well within the normal range, the addition of 10 000 U vitamin D(2)/wk to calcium supplementation at 1000 mg/d did not confer benefits on BMD beyond those achieved with calcium supplementation alone.

226. Maturitas. 2003 Apr 25;44(4):299-305.

Calcium-vitamin D3 supplementation is cost-effective in hip fractures prevention.

Lilliu H, Pamphile R, Chapuy MC, Schulten J, Arlot M, Meunier PJ.

CLP-Sante, 9-11 rue du Mont Aigoual, F-75015 Paris, France. herve.lilliu@clp-sante.fr

OBJECTIVE: To assess the cost implications for a preventive treatment strategy for institutionalised elderly women with a combined 1200 mg/day calcium and 800 IU/day vitamin D(3) supplementation in seven European countries. DESIGN: Retrospective cost effectiveness analysis based on a prospective placebo-controlled randomised clinical trial. DATA SOURCES: Recently published cost studies in seven European countries. Clinical results from Decalyos, a 3-year placebo-controlled study in elderly institutionalised women. TRIALS: Decalyos study, with 36 months follow-up of 3270 mobile elderly women living in 180 nursing homes, allocated to two groups. One group received 1200 mg/day elemental calcium in the form of tricalcium phosphate together with 800 IU/day (20 microg) of cholecalciferol (vitamin D(3)), the other placebo. RESULTS: In the 36 months analysis of the Decalyos study, 138 hip fractures occurred in the group of 1176 women, receiving supplementation and 184 hip fractures in the placebo group of 1127 women. The mean duration of treatment was 625.4 days. Adjusted to 1000 women, 46 hip fractures were avoided by the calcium and vitamin D(3) supplementation. For all countries, the total costs in the placebo group were higher than in the group receiving supplementation, resulting in a net benefit of 79000-711000 per 1000 women. CONCLUSION: This analysis suggests that the supplementation strategy is cost saving. The results may underestimate the net benefits, as this treatment has also shown to be effective in decreasing the incidence of other non-vertebral fractures in elderly institutionalised women.

227. J Bone Miner Res. 2003 Feb;18(2):343-51.

Comment in: J Bone Miner Res. 2003 Jul;18(7):1342; author reply 1343.

Effects of vitamin D and calcium supplementation on falls: a randomized controlled trial.

Bischoff HA, Stahelin HB, Dick W, Akos R, Knecht M, Salis C, Nebiker M, Theiler R, Pfeifer M, Begerow B, Lew RA, Conzelmann M.

Department of Orthopaedics, University of Basel, Basel, Switzerland. hbischof@hsph.harvard.edu

Specific receptors for vitamin D have been identified in human muscle tissue. Cross-sectional studies show that elderly persons with higher vitamin D serum levels have increased muscle strength and a lower number of falls. We hypothesized that vitamin D and calcium supplementation would improve musculoskeletal function and decrease falls. In a double-blind randomized controlled trial, we studied 122 elderly women (mean age, 85.3 years; range, 63-99 years) in long-stay geriatric care. Participants received 1200 mg calcium plus 800 IU cholecalciferol (Cal+D-group; n = 62) or 1200 mg calcium (Cal-group; n = 60) per day over a 12-week treatment period. The number of falls per person (0, 1, 2-5, 6-7, >7 falls) was compared between the treatment groups. In an intention to treat analysis, a Poisson regression model was used to compare falls after controlling for age, number of falls in a 6-week pretreatment period, and baseline 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D serum concentrations. Among fallers in the treatment period, crude excessive fall rate (treatment - pretreatment falls) was compared between treatment groups. Change in musculoskeletal function (summed score of knee flexor and extensor strength, grip strength, and the timed up&go test) was measured as a secondary outcome. Among subjects in the Cal+D-group, there were significant increases in median serum 25-hydroxyvitamin D (+71%) and 1,25-dihydroxyvitamin D (+8%). Before treatment, mean observed number of falls per person per week was 0.059 in the Cal+D-group and 0.056 in the Cal-group. In the 12-week treatment period, mean number of falls per person per week was 0.034 in the Cal+D-group and 0.076 in the Cal-group. After adjustment, Cal+D-treatment accounted for a 49% reduction of falls (95% CI, 14-71%; p < 0.01) based on the fall categories stated above. Among fallers of the treatment period, the crude average number of excessive falls was significantly higher in the Cal-group (p = 0.045). Musculoskeletal function improved significantly in the Cal+D-group (p = 0.0094). A single intervention with vitamin D plus calcium over a 3-month period reduced the risk of falling by 49% compared with calcium alone. Over this short-term intervention, recurrent fallers seem to benefit most by the treatment. The impact of vitamin D on falls might be explained by the observed improvement in musculoskeletal function.

228. J Rheumatol. 2003 Jan;30(1):132-8.

Comment in: J Rheumatol. 2003 Jan;30(1):1-3.

A cost effectiveness analysis of calcium and vitamin D supplementation, etidronate, and alendronate in the prevention of vertebral fractures in women treated with glucocorticoids.

Buckley LM, Hillner BE.

Virginia Commonwealth University, Richmond 23298, USA. lbuckley@hsc.vcu.edu

OBJECTIVE: To assess the relative costs and benefits of calcium and vitamin D supplements, cyclic etidronate, or alendronate in the prevention of vertebral fractures for women and with normal bone density and osteopenia who are about to initiate moderate dose glucocorticoid treatment. METHODS: Using a decision analysis model, we evaluated the following patients: 4 hypothetical cohorts: 30-yr-old women with normal lumbar spine (LS) bone mineral density (BMD) (t score = 0), 50-yr-old women with borderline osteopenia (t score = -1), 60-yr-old women with moderate osteopenia (t score = -1.5), and 70-yr-old women with severe osteopenia (t score = -2) treated with a mean prednisone dose of 10 mg/day for one year. The main outcomes included the development of vertebral fractures 10 years after glucocorticoid treatment and at age 80 (life-time risk) and direct and indirect costs. RESULTS: At 10 years, calcium and vitamin D supplements decreased fracture rates by 30-50% at a minimal cost (US$800 or less per vertebral fracture avoided) or at a cost saving compared to no treatment for women with osteopenia (t score -1 to -2). Etidronate and alendronate are most cost effective in women with borderline osteoporosis (t scores of -1.5 and -2) in the 10 year analysis. In the life-time analysis, calcium and vitamin D treatment yielded a cost savings compared to no treatment for all groups with osteopenia. Etidronate decreased fracture rates further in all groups at a cost of less than $2,000 per fracture prevented. Alendronate reduced the fracture risk further at cost of $3,000-7,000 per fracture avoided. CONCLUSION: Calcium and vitamin D supplements and low cost bisphosphonate regimens such as cyclic etidronate decrease the life-time vertebral fracture risk at acceptable costs and should be considered when initiating glucocorticoid treatment for women who do not have osteoporosis.

229. Stroke. 2001 Jul;32(7):1673-7.

Vitamin D deficiency and risk of hip fractures among disabled elderly stroke patients.

Sato Y, Asoh T, Kondo I, Satoh K.

Department of Neurology, Kurume University Medical Center, Japan. noukenrs@cc.hirosaki-u.ac.jp

BACKGROUND AND PURPOSE: Risk of hip fracture after stroke is 2 to 4 times that in a reference population. Osteomalacia is present in some patients with hip fractures in the absence of stroke, while disabled elderly stroke patients occasionally have severe deficiency in serum concentrations of 25-hydroxyvitamin D (25-OHD) (</=5 ng/mL). To determine the effects of vitamin D status on hip fracture risk, we prospectively studied a cohort of patients with hemiplegia after stroke who were aged at least 65 years. METHODS: We compared baseline serum indices of bone metabolism, bone mineral density, and hip fracture occurrence in stroke patients with serum 25-OHD </=25 nmol/L (</=10 ng/mL; deficient group, n=88) with findings in patients from the same cohort who had 25-OHD levels 26 to 50 nmol/L (10 to 20 ng/mL; insufficient group, n=76) or >/=51 nmol/L (>/=21 ng/mL; sufficient group, n=72). RESULTS: Over a 2-year follow-up interval, hip fractures on the paretic side occurred in 7 patients in the deficient group and 1 patient in the insufficient group (P<0.05; hazard ratio=6.5), while no hip fractures occurred in the sufficient group. The 7 hip fracture patients in the deficient group had an osteomalacic 25-OHD level of <5 ng/mL. Higher age and severe immobilization were noted in the deficient group. Serum 25-OHD levels correlated positively with age, Barthel Index, and serum parathyroid hormone. CONCLUSIONS: Elderly disabled stroke patients with serum 25-OHD concentrations </=12 nmol/L (</=5 ng/mL) have an increased risk of hip fracture. Immobilization and advanced age cause severe 25-OHD deficiency and consequent reduction of BMD.

230. Eur J Clin Nutr. 2000 Aug;54(8):626-31.

Comment in: Eur J Clin Nutr. 2001 Apr;55(4):221-2; discussion 306-7. Eur J Clin Nutr. 2001 Apr;55(4):305-7.

Vitamin D(3) and vitamin K(1) supplementation of Dutch postmenopausal women with normal and low bone mineral densities: effects on serum 25-hydroxyvitamin D and carboxylated osteocalcin.

Schaafsma A, Muskiet FA, Storm H, Hofstede GJ, Pakan I, Van der Veer E.

Department of Research & Development Leeuwarden, Friesland Coberco Dairy Foods, Leeuwarden, The Netherlands. SchaafsA@FDF.NL

OBJECTIVE: Improvement of vitamin D and K status of about 60 -y-old postmenopausal Dutch women. DESIGN: In a randomized study postmenopausal women with normal (T-score >-1; n=96) and low (T-score< or =-1; n=45) bone mineral density (BMD) of the lumbar spine, were supplemented with 350-400 IU vitamin D(3), 80 microg vitamins K(1) vitamins K(1)+D(3), or placebo for 1 y. Serum 25-hydroxyvitamin D [25(OH)D] and percentage carboxylated osteocalcin (%carbOC) were measured at baseline and after 3, 6 and 12 months. RESULTS: Baseline %carbOC of the entire study population was positively correlated with BMD of the lumbar spine and femoral neck. Correspondingly, women with low BMD had lower %carbOC at baseline than women with normal BMD but this difference disappeared after 1 y of supplementation with vitamin K(1) ((mean+/-s.d.) 68+/-11% (95% CI, 64. 5-71.2%) vs 72+/-6% (95% CI, 70.1-72.9%), respectively). One year of supplementation with vitamin D(3) showed maximum increases in 25(OH)D of 33+/-29% (95% CI, 24.8-41.8%) and 68+/-58% (95% CI, 50.1-84.6%) in women with normal and low BMD, respectively. During winter, however, a 29% decline in maximum 25(OH)D levels was not prevented in women with low BMD. CONCLUSION: Daily supplementation of Dutch postmenopausal women with >400 IU vitamin D(3) is indicated to prevent a winter decline in 25(OH)D and to control serum parathyroid hormone levels. Daily supplementation with 80 microg vitamin K(1) seems to be necessary to reach premenopausal %carbOC levels. A stimulatory effect of calcium and/or vitamin D on %carbOC cannot be excluded. European Journal of Clinical Nutrition (2000) 54, 626-631.

231. J Clin Endocrinol Metab. 1999 Nov;84(11):3988-90.

Vitamin D supplementation in postmenopausal black women.

Kyriakidou-Himonas M, Aloia JF, Yeh JK.

Department of Medicine, Winthrop-University Hospital, Mineola, New York 11530, USA.

Black women have lower levels of serum 25-hydroxyvitamin D (25OHD) with higher serum PTH levels than white women. Correction of these alterations in the vitamin D-endocrine system could lead to less bone loss in postmenopausal women and, consequently, preservation of bone mass. Ten healthy postmenopausal black women were given 20 microg vitamin D3 daily for 3 months. At the end of the study, mean serum 25OHD levels had increased from 24 to 63 nmol/L. Serum intact PTH and nephrogenous cAMP declined significantly, and there was a 21% drop in the fasting urinary N-telopeptide of type I collagen. Vitamin D3 supplementation raises serum 25OHD levels in postmenopausal black women, decreases secondary hyperparathyroidism, and reduces bone turnover. These findings should spur further investigation of the use of vitamin D supplementation in the prevention of osteoporosis in this population.

232. Bone. 1998 Dec;23(6):555-7.

High prevalence of vitamin D deficiency and reduced bone mass in elderly women with Alzheimer's disease.

Sato Y, Asoh T, Oizumi K.

Department of Neurology, Futase Social Insurance Hospital, Iizuka, Japan. y-sato@ktarn.or.jp

Patients with Alzheimer's disease (AD) are at increased risk for falls and hip fractures. To better understand causes and prevention, we measured bone mineral density (BMD) in the second metacarpals of 46 ambulatory elderly women with AD and analyzed its relation to serum biochemical indices, sunlight exposure, and vitamin D intake. BMD was significantly less than in age-matched controls. In 26% of AD patients, the serum 25-hydroxyvitamin D (25-OHD) concentration was at a deficient level (5-10 ng/mL), and in 54% it was at an osteomalacic level (<5 ng/mL). Concentrations of ionized calcium were significantly lower in patients. Conversely, concentrations of serum bone Gla-protein and urinary hydroxyproline in patients were significantly higher than in controls. BMD correlated positively with 25-OHD concentration (p = 0.0041) and negatively with parathyroid hormone (PTH) concentration (p = 0.0022). PTH was higher in patients than in controls, and correlated negatively with 25-OHD (p < 0.0001). Many AD patients were sunlight-deprived and consumed less than 100 IU of vitamin D per day. We concluded that vitamin D deficiency due to sunlight deprivation and malnutrition, together with compensatory hyperparathyroidism, contributes significantly to reduced BMD in AD patients. Low BMD increases risk of hip fractures in patients with AD, but may be improved by vitamin D supplementation.

233. Med J Aust. 1998 Aug 3;169(3):138-41.

Hip fracture in elderly men: the importance of subclinical vitamin D deficiency and hypogonadism.

Diamond T, Smerdely P, Kormas N, Sekel R, Vu T, Day P.

St George Hospital, Sydney, NSW.

OBJECTIVE: To determine the major risk factors for hip fracture in elderly men. DESIGN: Prospective recruitment, followed by analysis of clinical and biochemical variables. PATIENTS AND SETTING: Men aged 60 years and older who presented to St George Hospital (a 650-bed tertiary-care centre) in 1995, comprising all 41 men with hip fractures, as well as 41 hospital inpatient and 41 outpatient control subjects without hip fractures. MAIN OUTCOME MEASURES: Osteoporotic risk factors (including age, body weight, comorbid illnesses, alcohol intake, cigarettes smoked, and corticosteroid use) and serum concentrations of creatinine, urea, calcium, albumin, alkaline phosphatase, parathyroid hormone, 25-hydroxyvitamin D and free testosterone. RESULTS: There were no significant differences between the hip fracture and two control groups on any of the osteoporotic risk factors. Men with hip fracture had significantly lower mean serum 25-hydroxyvitamin D concentration (45.6 nmol/L; 95% confidence interval [CI], 36.9-52.3 nmol/L) than both inpatient (61.1 nmol/L; 95% CI, 50.0-72.2 nmol/L) and outpatient (65.9 nmol/L; 95% CI, 59.0-72.8 nmol/L) controls (P=0.007). Subclinical vitamin D deficiency (defined as <50 nmol/L serum 25-hydroxyvitamin D) was 63% in the fracture group, compared with 25% in the control groups combined (odds ratio, 3.9; 95% CI, 1.74-8.78; P=0.0007). Inpatients with and without hip fractures had significantly lower mean serum albumin, calcium and free testosterone concentrations than outpatients (P< 0.05). In a multiple regression analysis, subclinical vitamin D deficiency was the strongest predictor of hip fracture (beta [regression coefficient], 0.34+/-0.19; P=0.013). CONCLUSIONS: Subclinical vitamin D deficiency in Australian men may contribute significantly to the development of hip fracture through the effects of secondary hyperparathyroidism, resulting in increased bone loss.

234. Nutr Rev. 1998 May;56(5 Pt 1):148-50.

Combined calcium and vitamin D supplementation reduces bone loss and fracture incidence in older men and women.

O'Brien KO.

Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD 21205-2179, USA.

A recent supplementation study of 389 men and women, over the age of 65 years was conducted to address the impact of combined calcium and vitamin D supplementation on nonvertebral fracture incidence and maintenance of bone mass. Daily supplementation with 500 mg calcium and 700 IU vitamin D for 3 years moderately reduced bone loss at several sites and significantly decreased the rate of nonvertebral fractures, compared with a placebo group. Optimal intake of both calcium and vitamin D may be an easily implemented strategy to maintain existing bone mass and reduce the risk of fracture in older men and women.

235. Osteoporos Int. 1998;8(3):255-60.

Calcium and vitamin D supplementation increases spinal BMD in healthy, postmenopausal women.

Baeksgaard L, Andersen KP, Hyldstrup L.

Department of Endocrinology (157), Hvidovre Hospital, Denmark.

We undertook a double-masked, randomized, placebo-controlled trial to evaluate the effect of a calcium and vitamin D supplement and a calcium supplement plus multivitamins on bone loss at the hip, spine and forearm. The study was performed in 240 healthy women, 58-67 years of age. Duration of treatment was 2 years. Bone mineral density (BMD) was measured at the lumbar spine, hip and forearm. A dietary questionnaire was administered twice during the study and revealed a fairly good calcium and vitamin D intake (919 mg calcium/day; 3.8 micrograms vitamin D/day). An increase in lumbar spine BMD of 1.6% was observed in the treatment group after 2 years (p < 0.002). In the placebo group no significant changes were observed during the 2 years. Lumbar spine BMD was significantly higher in the treatment group at both 1 (p < 0.01) and 2 years (p < 0.05) compared with the placebo group. Though not significant, the same trend was seen at the hip. No significant changes from baseline values were observed at the distal forearm in either the treatment or the placebo group. In conclusion, we found a significant increase in urinary calcium excretion in the treatment group compared with the placebo group. Together with significant changes in serum calcium and serum parathyroid hormone, this indicates that a long-term calcium and vitamin supplement of 1 g elementary calcium (calcium carbonate) and 14 micrograms vitamin D3 increases intestinal calcium absorption. A positive effect on BMD was demonstrated, even in a group of early postmenopausal age, with a fairly good initial calcium and vitamin D status.

236. N Engl J Med. 1997 Sep 4;337(10):670-6.

Comment in: ACP J Club. 1998 Mar-Apr;128(2):47. N Engl J Med. 1997 Sep 4;337(10):701-2.

Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older.

Dawson-Hughes B, Harris SS, Krall EA, Dallal GE.

Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging at Tufts University, Boston, MA 02111, USA.

BACKGROUND: Inadequate dietary intake of calcium and vitamin D may contribute to the high prevalence of osteoporosis among older persons. METHODS: We studied the effects of three years of dietary supplementation with calcium and vitamin D on bone mineral density, biochemical measures of bone metabolism, and the incidence of nonvertebral fractures in 176 men and 213 women 65 years of age or older who were living at home. They received either 500 mg of calcium plus 700 IU of vitamin D3 (cholecalciferol) per day or placebo. Bone mineral density was measured by dual-energy x-ray absorptiometry, blood and urine were analyzed every six months, and cases of nonvertebral fracture were ascertained by means of interviews and verified with use of hospital records. RESULTS: The mean (+/-SD) changes in bone mineral density in the calcium-vitamin D and placebo groups were as follows: femoral neck, +0.50+/-4.80 and -0.70+/-5.03 percent, respectively (P=0.02); spine,+2.12+/-4.06 and +1.22+/-4.25 percent (P=0.04); and total body, +0.06+/-1.83 and -1.09+/-1.71 percent (P<0.001). The difference between the calcium-vitamin D and placebo groups was significant at all skeletal sites after one year, but it was significant only for total-body bone mineral density in the second and third years. Of 37 subjects who had nonvertebral fractures, 26 were in the placebo group and 11 were in the calcium-vitamin D group (P=0.02). CONCLUSIONS: In men and women 65 years of age or older who are living in the community, dietary supplementation with calcium and vitamin D moderately reduced bone loss measured in the femoral neck, spine, and total body over the three-year study period and reduced the incidence of nonvertebral fractures.

237. Osteoporos Int. 1997;7(5):439-43.

Prevalence of vitamin D insufficiency in an adult normal population.

Chapuy MC, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg S, Meunier PJ.

INSERM U. 403, Hopital Edouard Herriot, Lyon, France.

The vitamin D status of a general adult urban population was estimated between November and April in 1569 subjects selected from 20 French cities grouped in nine geographical regions (between latitude 43 degrees and 51 degrees N). Major differences in 25-hydroxyvitamin D (25(OH)D) concentration were found between regions, the lowest values being seen in the North and the greatest in the South, with a significant 'sun' effect (r = 0.72; p = 0.03) and latitude effect (r = -0.79; p = 0.01). In this healthy adult population, 14% of subjects exhibited 25(OH)D values < or = 30 nmol/l (12 ng/ml), which represents the lower limit (< 2 SD) for a normal adult population measured in winter with the same method (RIA Incstar). A significant negative correlation was found between serum intact parathyroid hormone (iPTH) and serum 25(OH)D values (p < 0.01). Serum iPTH held a stable plateau level at 36 pg/ml as long as serum 25(OH)D values were higher than 78 nmol/l (31 ng/ml), but increased when the serum 25(OH)D value fell below this. When the 25(OH)D concentration became equal to or lower than 11.3 nmol/l (4.6 ng/ml), the PTH values reached the upper limit of normal values (55 pg/ml) found in vitamin D replete subjects. These results showed that in French normal adults living in an urban environment with a lack of direct exposure to sunshine, diet failed to provide an adequate amount of vitamin D. It is important to pay attention to this rather high prevalence of vitamin D insufficiency in the general adult population and to discuss the clinical utility of winter supplementation with low doses of vitamin D.

238. Rev Rhum Engl Ed. 1996 Feb;63(2):135-40.

Biochemical effects of calcium and vitamin D supplementation in elderly, institutionalized, vitamin D-deficient patients.

Chapuy MC, Chapuy P, Thomas JL, Hazard MC, Meunier PJ.

National Institute for Health and Medical Research (INSERM) unit 403, Edouard Herriot Hospital, Lyon, France.

Forty-five subjects (41 women and 4 men) in long-stay and medium-stay facilities, aged 74 to 95 years (mean 86.4 years), with 25-hydroxy-vitamin D levels less than 12 ng/ml, were treated for six consecutive months with two tablets per day of a preparation containing vitamin D3 (800 IU/day) and calcium carbonate (1 g elemental calcium/day). Serum levels of 25-hydroxy-vitamin D were very low at baseline (5.6 +/- 0.4 ng/ml) and rose significantly under treatment, to normal values, 33.2 +/- 1.2 and 40.9 +/- 2.1 ng/ml after three and six months, respectively (p < 0.001 for both comparisons). Serum calcium increased significantly, by 4.5% (p < 0.001) during the first three months, and remained at a plateau thereafter. Corrected serum calcium rose by 8.9% (p < 0.001) during the trial. No patient developed hypercalcemia. Serum parathyroid hormone levels, which were elevated at baseline (71.6 +/- 5.8 pg/ml; normal, 12 to 54 pg/ml), decreased gradually and significantly throughout the treatment period, by 43.0% and 67.1% after three and six months, respectively (p < 0.001 for both comparisons). Serum alkaline phosphatase activity fell concomitantly, by 9.9% after three months (p < 0.01) and 36.5% after six months (p < 0.001). In conclusion, the preparation used in our study is effective in correcting both the vitamin D deficiency that is prevalent in elderly institutionalized patients and the resultant increase in bone turnover.

239. JAMA. 1995 Dec 6;274(21):1683-6.

Comment in: JAMA. 1996 Mar 20;275(11):838-9.

Vitamin D deficiency in homebound elderly persons.

Gloth FM 3rd, Gundberg CM, Hollis BW, Haddad JG Jr, Tobin JD.

Department of Medicine, Union Memorial Hospital, Baltimore, MD 21218, USA.

OBJECTIVE--To assess the vitamin D status in homebound, community-dwelling elderly persons; sunlight-deprived elderly nursing home residents; and healthy, ambulatory elderly persons. DESIGN--A cohort analytic study. PARTICIPANTS--Of 244 subjects at least 65 years old, 116 subjects (85 women and 31 men) had been confined indoors for at least 6 months, either in private dwellings in the community (the Hopkins Elder Housecall Program) or in a teaching nursing home (The Johns Hopkins Geriatrics Center). The 128 control subjects, a healthy ambulatory group, came from the Baltimore Longitudinal Study on Aging. All subjects were free of diseases or medications that might interfere with their vitamin D status. MAIN OUTCOME MEASURES--Serum levels of 25-hydroxyvitamin D (25-OHD) and 1,25-dihydroxyvitamin D (1,25-[OH]2D) were measured in all subjects. In a subgroup of 80 subjects, serum levels of intact parathyroid hormone (PTH), ionized calcium, and osteocalcin and intake of vitamin D (through 3-day food records) were assessed. A randomly selected cohort of sunlight-deprived subjects also had serum levels of vitamin D binding protein measured. RESULTS--In sunlight-deprived subjects overall, the mean 25-OHD level was 30 nmol/L (12 ng/mL) (range, < 10 to 77 nmol/L [< 4 to 31 ng/mL]) and the mean 1,25-(OH)2D level was 52 pmol/L (20 pg/mL) (range, 18 to 122 pmol/L [7 to 47 pg/mL]). In the sunlight-deprived subjects, 54% of community dwellers and 38% of nursing home residents had serum levels of 25-OHD below 25 nmol/L (10 ng/mL) (normal range, 25 to 137 nmol/L [10 to 55 ng/mL]). A significant inverse relationship existed between 25-OHD (ie, Log [25-OHD]) and PTH when they were analyzed together (r = -0.42; R2 = 0.18; P < .001) and for each cohort separately. All other parameters measured, except ionized calcium, differed significantly from the Baltimore Longitudinal Study Group means. The mean (SD) daily intakes of vitamin D (121 [132] IU) and calcium (583 [322] mg) were below the recommended dietary allowance only in the community-dwelling homebound population. The mean vitamin D binding protein level in the sunlight-deprived subgroup was in the normal range. CONCLUSIONS--Despite a relatively high degree of vitamin supplementation in the United States, homebound elderly persons are likely to suffer from vitamin D deficiency.

240. Rev Rhum Engl Ed. 1995 Oct;62(9):576-81.

Prevalence and biological consequences of vitamin D deficiency in elderly institutionalized subjects.

Fardellone P, Sebert JL, Garabedian M, Bellony R, Maamer M, Agbomson F, Brazier M.

Department of Rheumatology, North Hospital, Amiens, France.

The prevalence of vitamin D deficiency was evaluated in a population of elderly institutionalized subjects in seven long-term geriatric care facilities in France (Amiens, Francheville, Ivry, Lille, Montpellier, Oissel and Villejuif). Residents whose functional capability was relatively good were entered into the study. There were 126 patients (99 females and 27 males) with a mean age +/- SD of 84 +/- 6.6 years. All subjects had been institutionalized for over six months and were capable of walking at least as far as the dining room. None had received vitamin D or other compounds known to affect the metabolism of phosphorus and calcium within six months before the study. Vitamin D status was evaluated by determining serum 25 hydroxyvitamin D (25 OH D) levels using a radiocompetition assay after extraction and chromatographic separation. Mean serum 25 OH D was 3.17 +/- 2.52 ng/ml (median 2.5). Eighty-five per cent of subjects had serum 25 OH D values of less than 5 ng/ml and 98% had values under 10 ng/ml, which is the cutoff usually taken to define vitamin D deficiency. Mean serum levels of intact parathyroid hormone were increased approximately two-fold as compared with values in healthy adults (70 +/- 39 pg/ml versus 33 +/- 12 pg/ml). Biochemical markers for bone formation (alkaline phosphatase, osteocalcin) and bone resorption (TRAP, hydroxyproline, pyridinoline) were all increased, with mean values 1.4-fold to 3.4-fold those seen in healthy adults. Serum 25 OH D levels were negatively correlated with serum intact parathyroid hormone levels (r = 0.41; p < 0.0001). Serum intact parathyroid hormone levels were positively correlated with alkaline phosphatase activity (r = 0.30; p < 0.001) and serum osteocalcin levels (r = 0.36; p < 0.0001) and negatively correlated with corrected serum calcium levels (r = -0.20; p < 0.02). Conclusion. Our data demonstrate that severe vitamin D deficiency is present in virtually all elderly institutionalized subjects and is accompanied with secondary hyperparathyroidism responsible for increases in markers of bone remodeling. Routine vitamin D supplementation is warranted in elderly institutionalized subjects.

241. J Clin Endocrinol Metab. 1995 Apr;80(4):1052-8.

Prevention of bone loss by vitamin D supplementation in elderly women: a randomized double-blind trial.

Ooms ME, Roos JC, Bezemer PD, van der Vijgh WJ, Bouter LM, Lips P.

Institute for Research in Extramural Medicine (EMGO-Institute), Vrije Universiteit, Amsterdam, The Netherlands.

The purpose of the study was to determine the effect of vitamin D supplementation on bone turnover and bone loss in elderly women. Three hundred forty-eight women, ages 70 yr and older, were randomized to receive 400 IU vitamin D3 per day (n = 177) or placebo (n = 171), double-blind, for a period of 2 yr. Main outcome measures were bone mineral density of both hips (femoral neck and trochanter) and the distal radius, as well as biochemical markers of bone turnover. The effect of vitamin D supplementation was expressed as the difference in mean (percentage) change between the placebo group and the vitamin D group. The measurements were repeated in 283 women after 1 yr and in 248 women after 2 yr. Vitamin D supplementation significantly increased serum 25-hydroxyvitamin D (250HD) (+35 nmol/L) and 1,25-dehydroxyvitamin D [1,25-(OH)2D] (+7.0 pmol/L) levels and urinary calcium/creatinine ratios (+0.5%) and significantly decreased PTH(1-84) secretion (-0.74 pmol/L) after 1 yr. No effect was found for the parameters of bone turnover. The effect on the bone mineral density of the left femoral neck was +1.8% in the first yr, +0.2% in the second yr, and +1.9% during the whole period (95% confidence interval 0.4, 3.4%). At the right femoral neck the effects were +1.5%, +1.1%, and +2.6% (confidence interval 1.1, 4.0%), respectively. No effect was found at the femoral trochanter and the distal radius. Supplementation with 400 IU vitamin D3 daily in elderly women slightly decreases PTH secretion and increases bone mineral density at the femoral neck.

242. Am J Clin Nutr. 1993 Aug;58(2):187-91.

Secondary hyperparathyroidism in elderly people: combined effect of renal insufficiency and vitamin D deficiency.

Freaney R, McBrinn Y, McKenna MJ.

Metabolic Unit, St. Vincent's Hospital, Dublin, Ireland.

The relative effects of renal insufficiency and vitamin D deficiency on parathyroid gland function were assessed in 29 free-living elderly subjects by using a sensitive assay for intact parathyroid hormone (PTH). Serum calcium, phosphate, alkaline phosphatase, creatinine, 25-hydroxyvitamin D [25(OH)D], and PTH were measured after an overnight fast during wintertime, after oral vitamin D therapy (20 micrograms cholecalciferol/d for 4 wk), and at the end of the subsequent summer. Hypovitaminosis D [serum 25(OH)D < 25 nmol/L] was evident in 86% of the subjects during wintertime and 52% had elevated PTH concentrations. Multiple-regression analysis identified serum creatinine as the strongest predictor variable for serum PTH (multiple r = 0.73, P < 0.001). Mean (+/- SD) serum PTH declined from 6.3 +/- 2.8 to 5.0 +/- 2.0 pmol/L (P < 0.001) by the end of the summer season, coincident with an increase in serum 25(OH)D). Secondary hyperparathyroidism is common in elderly people, and in Ireland is the result of both renal insufficiency and hypovitaminosis D.

243. J S C Med Assoc. 1993 Jun;89(6):273-8.

Vitamin D deficiency found in the diet of the elderly in South Carolina.

Ryan C, Lui JH.

Department of Family and Preventive Medicine, University of South Carolina School of Medicine.

Dietary intake of vitamin D was assessed from a 24-hour food recall collected from 293 independent living adults 55 years of age or older who participated in the South Carolina Nutrition Survey. Mean vitamin D intake was only 46 percent of the RDA. The data in this study indicated that insufficient dietary intake of vitamin D is prevalent among older South Carolinians. Possible methods to correct this include: increased exposure to the sun, increased intake of food sources containing this nutrient or prescribing a vitamin D supplement.

244. N Engl J Med. 1992 Dec 3;327(23):1637-42.

Vitamin D3 and calcium to prevent hip fractures in the elderly women.

Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, Delmas PD, Meunier PJ.

Institut National de la Sante et de la Recherche Medicale (INSERM), Unite 234, Hopital Edouard Herriot, Lyon, France.

BACKGROUND. Hypovitaminosis D and a low calcium intake contribute to increased parathyroid function in elderly persons. Calcium and vitamin D supplements reduce this secondary hyperparathyroidism, but whether such supplements reduce the risk of hip fractures among elderly people is not known. METHODS. We studied the effects of supplementation with vitamin D3 (cholecalciferol) and calcium on the frequency of hip fractures and other nonvertebral fractures, identified radiologically, in 3270 healthy ambulatory women (mean [+/- SD] age, 84 +/- 6 years). Each day for 18 months, 1634 women received tricalcium phosphate (containing 1.2 g of elemental calcium) and 20 micrograms (800 IU) of vitamin D3, and 1636 women received a double placebo. We measured serial serum parathyroid hormone and 25-hydroxyvitamin D (25(OH)D) concentrations in 142 women and determined the femoral bone mineral density at base line and after 18 months in 56 women. RESULTS. Among the women who completed the 18-month study, the number of hip fractures was 43 percent lower (P = 0.043) and the total number of nonvertebral fractures was 32 percent lower (P = 0.015) among the women treated with vitamin D3 and calcium than among those who received placebo. The results of analyses according to active treatment and according to intention to treat were similar. In the vitamin D3-calcium group, the mean serum parathyroid hormone concentration had decreased by 44 percent from the base-line value at 18 months (P < 0.001) and the serum 25(OH)D concentration had increased by 162 percent over the base-line value (P < 0.001). The bone density of the proximal femur increased 2.7 percent in the vitamin D3-calcium group and decreased 4.6 percent in the placebo group (P < 0.001). CONCLUSIONS. Supplementation with vitamin D3 and calcium reduces the risk of hip fractures and other nonvertebral fractures among elderly women.

245. Rev Rhum Mal Osteoartic. 1990 Nov;57(11):809-13.

[Vitamin D supplementation in institutionalized elderly. Effects of vitamin D3 (100,000 IU) orally administered every 3 months on serum levels of 25-hydroxyvitamin D]

[Article in French]

Zeghoud F, Jardel A, Garabedian M, Salvatore R, Moulias R.

C.N.R.S. URA 583, Universite Paris V, Hopital Necker, Paris.

A clinical trial carried out during the autumn/winter season in 46 institutionalized elderly subjects (35 women, 11 men) (group mean age = 83 +/- 2 years) revealed a severe deficiency in vitamin D in these subjects (25-hydroxyvitamin D level less than or equal to 3 ng/ml). After oral administration of 100,000 IU of vitamin D3, an increase in 25-hydroxyvitamin D levels above the 10 ng/ml threshold was observed and maintained for three months. A second dose, administered after 3 months, made it possible to sustain this level. No sign of toxicity was detected, notably no trace of hypercalcemia. In contrast, no change in the deficit (25-hydroxyvitamin D level less than or equal to 3 ng/ml) was seen in the placebo population. Three-monthly administration of the moderate dosage of 100,000 IU of vitamin D3 all year round would offer a simple, effective and risk-free system to counteract vitamin D deficiency in the elderly and of preventing the risk of osteomalacia, thus reducing the incidence of fractures.

246. Exp Clin Endocrinol. 1990 Apr;95(2):275-8.

Increased serum osteocalcin levels in elderly females with vitamin D deficiency.

Pietschmann P, Woloszczuk W, Pietschmann H.

Department of Medicine II, University of Vienna, Austria.

Serum levels of osteocalcin (OC), a 49 amino acid bone matrix protein, have been found to be a biochemical parameter of bone formation. In order to study bone metabolism in aging subjects we measured serum levels of OC, parathyroid hormone (PTH) and 25 hydroxy-vitamin D (25 OH Vit D) in 36 institutionalized elderly females (age range: 80-93 years) and in 21 premenopausal control subjects. Serum levels of 25 OH Vit D were significantly decreased in the elderly subjects (p less than 0.0001), whereas serum levels of OC and PTH were significantly higher in the elderly subjects than in the controls (p less than 0.0025 and p less than 0.0001, respectively). Serum OC levels correlated significantly with the serum PTH levels (p less than 0.009). Our data demonstrate that in elderly females with vitamin-D deficiency secondary hyperparathyroidism is associated with increased serum OC levels indicating an increased bone formation; these conditions might contribute to the bone disease of geriatric patients.

247. J Am Geriatr Soc. 1989 Jul;37(7):589-92.

Vitamin D deficiency in elderly patients in a general hospital.

Goldray D, Mizrahi-Sasson E, Merdler C, Edelstein-Singer M, Algoetti A, Eisenberg Z, Jaccard N, Weisman Y.

Department of Geriatric Medicine, Ichilov Hospital, Tel-Aviv Medical Center, Israel.

Serum 25-hydroxyvitamin D (25-OHD) levels were measured in 338 elderly patients admitted to the Geriatric Medicine Departments of a general hospital in Israel in the course of one year. The mean (+/- SD) serum 25-OHD levels were significantly lower (P less than .01) in the elderly patients (13.5 +/- 8.9 ng/mL) than in healthy young controls (24.7 +/- 6.1 ng/mL). One hundred ten patients (35.5%) were either vitamin D deficient (25-OHD less than 5 ng/mL) or had borderline serum levels of 25-OHD (5-9 ng/mL). The mean (+/- SD) serum 25-OHD concentration of patients who were completely mobile before hospitalization was 15.5 +/- 8.8 ng/mL (n = 239). In patients mainly immobilized but able to leave the house occasionally, it was 10.2 +/- 6.3 ng/mL (n = 84) and of bed-ridden patients, it was 5.2 +/- 3.2 ng/mL (n = 15). No correlation was found between serum 25-OHD levels and the patients' age or serum calcium, phosphorus, alkaline phosphatase, and albumin values. Thus, in order to detect vitamin D deficiency in the elderly, it is necessary to measure serum 25-OHD concentration. The results demonstrate that vitamin D deficiency is common among elderly patients even in sunny climates and indicate the need for development of effective programs of prevention and treatment.

248. Isr J Med Sci. 1988 Mar;24(3):160-3.

Vitamin D-deficiency in the elderly: treatment with ergocalciferol and hydroxylated analogues of vitamin D3.

Shany S, Chaimovitz C, Yagev R, Bercovich M, Lowenthal MN.

Department of Clinical Biochemistry, Soroka Medical Center, Beer Sheva, Israel.

The purpose of the present work was to study the effect of vitamin D and its metabolites in correcting hypovitaminosis D in the elderly. Thirty elderly people (mean age 78.4 years) participated in this study. They all had low serum levels of 25-hydroxyvitamin D (25-OH-D), of 24,25-dihydroxyvitamin D [24,25(OH)2D] and of 1,25-dihydroxyvitamin D [1,25(OH)2D]. These low levels did not increase in nine subjects after oral administration of vitamin D2 (3,000 IU/day for 12 weeks). However, administration of 1 alpha-hydroxyvitamin D3 (1 alpha-OH-D3) to 12 other subjects (0.5 micrograms/day for 8 weeks) led to a significant increase in the serum levels of 1,25(OH)2D. The other vitamin D metabolite levels remained unchanged. A significant increase in the levels of all three main vitamin D metabolites was obtained following administration of 25-hydroxyvitamin D3 (25-OH-D3) to a third group of nine subjects (25 micrograms/day for 1 week). These results suggest that vitamin D nutrition in elderly people insufficently exposed to the sun could be maintained by regular administration of 25-OH-D, whereas the administration of native vitamin D (ergocalciferol) in the doses used was inadequate for vitamin D nutrition.

249. Scott Med J. 1986 Jul;31(3):144-9.

The prevention of vitamin D deficiency in the elderly.

Dunnigan MG, Fraser SA, McIntosh WB, Moseley H, Sumner DJ.

Vitamin D deficiency is common in the house-bound and institutionalised elderly population of Britain. A study of patients over 65 years discharged with a diagnosis of osteomalacia from Greater Glasgow Health Board hospitals between 1970 and 1981 inclusive showed a low incidence in the 65 to 74 years age group but a steeply rising incidence in older age groups. The majority (83%) of patients were female. The fortification of margarine, butter and milk with concentrations of vitamin D acceptable to the general population does not produce significant elevations in serum 25-hydroxyvitamin D (25-OHD) levels in vitamin D-deficient elderly patients. Low intensity background ultraviolet radiation (UVR) and intermittent high intensity UVR produce significant elevations in serum 25-OHD levels in elderly patients but both methods have disadvantages which limit their widespread use. Vitamin D supplements equivalent to 10 micrograms daily produce significant elevations in serum 25-OHD levels in vitamin D-deficient elderly patients. A vitamin D supplement policy for the housebound and institutionalised elderly population of Britain is required.

250. Age Ageing. 1986 Mar;15(2):77-83.

Seasonal changes in the biochemical indices of vitamin D deficiency in the elderly: a comparison of people in residential homes, long-stay wards and attending a day hospital.

Davies M, Mawer EB, Hann JT, Taylor JL.

The seasonal changes in the biochemical indices of vitamin D nutrition have been measured in elderly people with differing requirements for institutionalized care. Residents of local authority homes (LAH) showed an increase in serum 25-hydroxyvitamin D3 [25(OH)D3] between spring and autumn (means 14-17 nmol/l, P less than 0.002). No significant seasonal changes were seen in patients on long-stay wards [(GW) serum 25(OH)D3 9.5 and 9.5 nmol/l] and in day-hospital attenders [(GDH) 25 and 26.8 nmol/l]. Significant differences (P less than 0.02 to P less than 0.0001) were found between the mean serum 25(OH)D3 amongst the three groups. A significant linear relationship (r = 0.84, P = 0.036) was found between mean serum 25-hydroxyvitamin D2[25(OH)D2] and dietary vitamin D2. The intake of vitamin D was suboptimal in all groups. The incidence of 25-hydroxyvitamin D deficiency [25(OH)D less than 12.5 nmol/l] varied from 11.7% of residents in LAH in autumn to 47% of GW patients in spring; but hypocalcaemia occurred less often (LAH 1.3% in autumn, GW 4.7% in spring). The diet assumes a greater role in protecting against vitamin D deficiency when the total 25(OH)D is low. Because most diets contain insufficient amounts of vitamin D, elderly institutionalized people will remain at high risk of developing vitamin D deficiency unless specific preventative measures are adopted.

251. Am J Clin Nutr. 1985 Sep;42(3):470-4.

A prospective trial of the effect of vitamin D supplementation on metacarpal bone loss in elderly women.

Nordin BE, Baker MR, Horsman A, Peacock M.

The effect on cortical bone loss of treating elderly women with 15,000 IU vitamin D2 weekly was evaluated by sequential radiographic morphometry of the metacarpals. One hundred nine randomly selected women aged 65-74 yr were studied for 2 yr. The women were randomly allocated to control or treated groups taking placebo or vitamin D2 capsules. Hand radiographs and blood samples were obtained at the beginning and end of the trial. Plasma 25-hydroxyvitamin D was measured by radio-competitive protein binding assay. Comparing the treated and control groups, vitamin D treatment significantly raised the plasma 25-hydroxyvitamin D levels (p less than 0.001) and reduced the rate of cortical bone loss (p less than 0.01). The placebo had no measurable effect on the plasma levels.

252. Acta Med Scand. 1982;212(3):157-61.

Oral vitamin D and ultraviolet radiation for the prevention of vitamin D deficiency in the elderly.

Toss G, Andersson R, Diffey BL, Fall PA, Larko O, Larsson L.

Different methods for the prevention and treatment of vitamin D deficiency were studied in 42 institutionalized elderly people. One group received ultraviolet radiation (UVR) on a large area of the body surface once a week for three months. The results were compared with those in groups receiving either 450 IU vitamin D2 together with 420 mg calcium daily, 420 mg calcium alone, or no treatment. A significant increase in serum 25-hydroxyvitamin D was obtained with UVR. A similar increase was obtained with oral vitamin D2. A small but significant decrease in serum alkaline phosphatase was observed in subjects receiving vitamin D and calcium or calcium alone. No effects on serum phosphate, urinary cyclic adenosine monophosphate and urinary calcium were seen. Though brief UVR at one-week intervals is an efficient and safe method for prevention of vitamin D deficiency in the elderly, it is in our experience time-consuming for the ward staff and thus less convenient than oral vitamin D supplementation.

Hyperparathyroidism

253. Calcif Tissue Int. 2003 Sep 10 [Epub ahead of print].

Role of Vitamin D and Parathyroid Hormone in the Regulation of Bone Turnover and Bone Mass in Men: The MINOS Study.

Szulc P, Munoz F, Marchand F, Chapuy MC, Delmas PD.

INSERM 403 Research Unit, 69437 Lyon, France.

We investigated the role of vitamin D and of parathyroid hormone (PTH) in the regulation of bone mineral density (BMD), tone dimensions and seasonal variation of bone turnover in 881 men aged 19-85 years. Bone mineral content (BMC) and BMD of the lumbar spine, hip and whole body were measured with HOLOGIC 1000W and those of distal forearm with an OSTEOMETER DTX 100 device. Bone formation was evaluated using osteocalcin, bone alkaline phosphatase and N-terminal extension propeptide of type I collagen (PINP). Bone resorption was evaluated by 24-hour excretion of deoxypyridinoline and of C-terminal telopeptide of collagen type I. In young men (<55 yrs) PTH level decreased with age (r = -0.18, P < 0.005) whereas 25-hydroxyvitamin D (25OHD) concentration was stable. In older men (>55 years) 25OHD decreased whereas PTH increased with age (r = -0.27 and r = 0.21, P = 0.0001). In young men, 25OHD level varied with season but not PTH, biochemical markers of bone turnover nor BMD. In young men, 25OHD, but not PTH, was a significant determinant of BMC, cortical thickness and of biomechanical properties of the femoral neck. Biochemical bone markers and BMD were not correlated with PTH nor with 25OHD. In elderly men, winter levels of 25OHD were lowest whereas those of PTH, bone resorption markers and PINP were highest. After adjustment for age, body weight and season, biochemical markers of bone turnover were correlated with PTH. In elderly men, 25OHD and PTH were significant determinants of BMC, cortical thickness and of biomechanical parameters of the femoral neck. Men with vertebral deformities had lower concentrations of 25OHD, higher PTH levels and slightly elevated urinary excretion of biochemical markers of bone resorption compared with men without vertebral deformities. In conclusion, in young men, 25OHD discloses a seasonal variability in contrast to PTH and biochemical bone markers. In this group, 25OHD is a significant determinant of BMC and BMD but not of bone size. In elderly men, seasonal variation of 25OHD and PTH concentrations result in seasonal variation of bone resorption. In this group, both 25OHD and PTH are determinants of BMC and cortical thickness of the femoral neck and, consequently, of its mechanical parameters.

254. J Clin Endocrinol Metab. 2003 Jan;88(1):185-91.

Age-related changes in the 25-hydroxyvitamin D versus parathyroid hormone relationship suggest a different reason why older adults require more vitamin D.

Vieth R, Ladak Y, Walfish PG.

Department of Laboratory Medicine and Pathology, University of Toronto and Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada. rvieth@mtsinai.on.ca

Vitamin D requirements are thought to vary with age, but there is little comparative evidence for this. One goal in establishing a vitamin D requirement is to avoid secondary hyperparathyroidism. We studied 1741 euthyroid, thyroid clinic outpatients without evidence of calcium abnormalities, ranging in age from 19 to 97 yr, whose serum and urine had been analyzed for calcium, vitamin D, and parathyroid status. We found no effect of age on the 25-hydroxyvitamin D [25(OH)D] concentration associated with specific vitamin D intakes, and there was no relationship between 25(OH)D and 1,25hydroxyvitamin D [1,25(OH)2D]. In every age group, serum 1,25(OH)2D declined with increasing creatinine (P < 0.001). What changed with age included creatinine, which correlated with 25(OH)D (r = 0.146, P < 0.001) only in the youngest age group (19-50 yr) but not in the older age groups (P > 0.1). Creatinine did not correlate with PTH in the youngest age group, but the relationship became significant as age increased (e.g. for the elderly, r = 0.365, P < 0.001). Linear regression of log PTH vs. log 25(OH)D agreed with the natural shape of the relationship observed with scatterplot smoothing, and this showed no plateau in PTH as 25(OH)D increased. We compared PTH concentrations among age groups, based on 20 nmol/liter increments in 25(OH)D. Mean PTH in adults older than 70 yr was consistently higher than in adults younger than 50 yr (P < 0.05 by ANOVA and Dunnett's t test). PTH levels of the elderly who had 25(OH)D concentrations greater than 100 nmol/liter matched PTH of younger adults having 25(OH)D concentrations near 70 nmol/liter. This study shows that all age groups exhibit a high prevalence of 25(OH)D insufficiency and secondary hyperparathyroidism. Older adults are just as efficient in maintaining 25(OH)D, but they need more vitamin D to produce the higher 25(OH)D concentrations required to overcome the hyperparathyroidism associated with their diminishing renal function.

255. Osteoporos Int. 2002 Mar;13(3):257-64.

Combined calcium and vitamin D3 supplementation in elderly women: confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: the Decalyos II study.

Chapuy MC, Pamphile R, Paris E, Kempf C, Schlichting M, Arnaud S, Garnero P, Meunier PJ.

Hopital Edouard Herriot, Lyon, France. chapuy@lyon151.inserm.fr

Vitamin D insufficiency and low calcium intake contribute to increase parathyroid function and bone fragility in elderly people. Calcium and vitamin D supplements can reverse secondary hyperparathyroidism thus preventing hip fractures, as proved by Decalyos I. Decalyos II is a 2-year, multicenter, randomized, double-masked, placebo-controlled confirmatory study. The intention-to-treat population consisted of 583 ambulatory institutionalized women (mean age 85.2 years, SD = 7.1) randomized to the calcium-vitamin D3 fixed combination group (n = 199); the calcium plus vitamin D3 separate combination group (n = 190) and the placebo group (n = 194). Fixed and separate combination groups received the same daily amount of calcium (1200 mg) and vitamin D3 (800 IU), which had similar pharmacodynamic effects. Both types of calcium-vitamin D3 regimens increased serum 25-hydroxyvitamin D and decreased serum intact parathyroid hormone to a similar extent, with levels returning within the normal range after 6 months. In a subgroup of 114 patients, femoral neck bone mineral density (BMD) decreased in the placebo group (mean = -2.36% per year, SD = 4.92), while remaining unchanged in women treated with calcium-vitamin D3 (mean = 0.29% per year, SD = 8.63). The difference between the two groups was 2.65% (95% CI = -0.44, 5.75%) with a trend in favor of the active treatment group. No significant difference between groups was found for changes in distal radius BMD and quantitative ultrasonic parameters at the os calcis. The relative risk (RR) of HF in the placebo group compared with the active treatment group was 1.69 (95% CI = 0.96, 3.0), which is similar to that found in Decalyos I (RR = 1.7; 95% CI = 1.0, 2.8). Thus, these data are in agreement with those of Decalyos I and indicate that calcium and vitamin D3 in combination reverse senile secondary hyperparathyroidism and reduce both hip bone loss and the risk of hip fracture in elderly institutionalized women.

256. Calcif Tissue Int. 2002 Feb;70(2):78-82. Epub 2002 Jan 28.

Influence of daily regimen calcium and vitamin D supplementation on parathyroid hormone secretion.

Reginster JY, Zegels B, Lejeune E, Micheletti MC, Kvsaz A, Seidel L, Sarlet N.

Bone and Cartilage Research Unit, University of Liege, Liege, Belgium. jyreginster@ulg.ac.be

Calcium and vitamin D supplementation has been shown to reduce secondary hyperparathyroidism and play a role in the management of senile osteoporosis. In order to define the optimal regimen of calcium and vitamin D supplementation to produce the maximal inhibition of parathyroid hormone secretion, we have compared the administration of a similar amount of Ca and vitamin D, either as a single morning dose or split in two doses, taken 6 hours apart. Twelve healthy volunteers were assigned to three investigational procedures, at weekly intervals. After a blank control procedure, when they were not exposed to any drug intake, they received two calcium-vitamin D supplement regimens including either two doses of Orocal D3 (500 mg Ca and 400 IU vitamin D) 6 hours apart or one water-soluble effervescent powder pack of Cacit D3 in a single morning dose (1000 mg Ca and 880 IU vitamin D). During the three procedures (control and the two calcium-vitamin D supplementations), venous blood was drawn every 60 minutes for up to 9 hours, for serum Ca and serum PTH measurements. The order of administration of the two Ca and vitamin D supplementation sequences was allocated by randomization. No significant changes in serum Ca were observed during the study. During the 6 hours following Ca and vitamin D supplementation, a statistically significant decrease in serum PTH was observed with both regimens, compared with baseline and with the control procedure. Over this period of time, no differences were observed between the two treatment regimens. However, between the sixth and the ninth hour, serum PTH levels were still significantly decreased compared with baseline with split dose Orocal D3 administration, while they returned to baseline value with the Cacit D3 preparation. During this period, the percentage decrease in serum PTH compared with baseline was significantly more pronounced with Orocal D3 than with Cacit D3 (P = 0.0021). We therefore conclude that the administration of two doses of 500 mg of calcium and 400 IU of vitamin D3 6 hours apart provides a more prolonged decrease in serum PTH levels than the administration of the same total amount of Ca and vitamin D as a single morning dose in young healthy volunteers. This might have implications in terms of protection of the skeleton against secondary hyperparathyroidism and increased bone resorption and turnover in elderly subjects.

257. J Clin Endocrinol Metab. 2001 Apr;86(4):1633-7.

Effects of a short-term vitamin D(3) and calcium supplementation on blood pressure and parathyroid hormone levels in elderly women.

Pfeifer M, Begerow B, Minne HW, Nachtigall D, Hansen C.

Institute of Clinical Osteology Gustav Pommer, Clinic der Furstenhof, 31812 Bad Pyrmont, Germany. iko-pyrmont@t-online.de

Calcium supplementation is effective in reducing blood pressure in various states of hypertension, including pregnancy-induced hypertension and preeclampsia. In addition, calcitropic hormones are associated with blood pressure. The hypothesis is that short-term therapy with calcium and vitamin D(3) may improve blood pressure as well as secondary hyperparathyroidism more effectively than calcium monotherapy. The effects of 8 weeks of supplementation with vitamin D(3) (cholecalciferol) and calcium on blood pressure and biochemical measures of bone metabolism were studied. The sample consisted of 148 women (mean +/- SD age, 74 +/- 1 yr) with a 25-hydroxycholecalciferol (25OHD(3)) level below 50 nmol/L. They received either 1200 mg calcium plus 800 IU vitamin D(3) or 1200 mg calcium/day. We measured intact PTH, 25OHD(3), 1,25-dihydroxyvitamin D(3), blood pressure, and heart rate before and after treatment. Compared with calcium, supplementation with vitamin D(3) and calcium resulted in an increase in serum 25OHD(3) of 72% (P < 0.01), a decrease in serum PTH of 17% (P = 0.04), a decrease in systolic blood pressure (SBP) of 9.3% (P = 0.02), and a decrease in heart rate of 5.4% (P = 0.02). Sixty subjects (81%) in the vitamin D(3) and calcium group compared with 35 (47%) subjects in the calcium group showed a decrease in SBP of 5 mm Hg or more (P = 0.04). No statistically significant difference was observed in the diastolic blood pressures of the calcium-treated and calcium- plus vitamin D(3)-treated groups (P = 0.10). Pearson coefficients of correlation between the change in PTH and the change in SBP were 0.49 (P < 0.01) for the vitamin D(3) plus calcium group and 0.23 (P < 0.01) for the calcium group. A short-term supplementation with vitamin D(3) and calcium is more effective in reducing SBP than calcium alone. Inadequate vitamin D(3) and calcium intake could play a contributory role in the pathogenesis and progression of hypertension and cardiovascular disease in elderly women.

258. J Bone Miner Res. 2000 Jun;15(6):1113-8.

Erratum in: J Bone Miner Res 2001 Oct;16(10):1935. J Bone Miner Res 2001 Sep;16(9):1735.

Effects of a short-term vitamin D and calcium supplementation on body sway and secondary hyperparathyroidism in elderly women.

Pfeifer M, Begerow B, Minne HW, Abrams C, Nachtigall D, Hansen C.

Institute of Clinical Osteology Gustav Pommer and Clinic DER FURSTENHOF, Bad Pyrmont, Germany.

Long-term vitamin D and calcium supplementation is effective in reducing nonvertebral fractures in elderly people. Increased bone fragility caused by secondary hyperparathyroidism (sHPT) and impaired balance are known risk factors for hip fractures. The hypothesis is that short-term therapy with calcium and vitamin D may improve body sway as well as sHPT more effectively than calcium monotherapy. The effects of 8 weeks of supplementation with vitamin D (cholecalciferol) and calcium on body sway and biochemical measures of bone metabolism were measured. The sample consisted of 148 women (mean [+/-SD] age, 74 +/- 1 years) with a 25-hydroxycholecalciferol level below 50 nmol/liter. They received either 1200 mg of calcium plus 800 IU of vitamin D or 1200 mg of calcium per day. We measured intact parathyroid hormone (PTH), markers of bone turnover, and body sway before and after treatment. Falls and fractures among the participants were followed over a 1-year period. Compared with calcium mono, supplementation with vitamin D and calcium resulted in an increase in serum 25-hydroxyvitamin D of 72% (p < 0.0001), a decrease in the serum PTH of 18% ( p = 0.0432), and a decrease in body sway of 9% (p = 0.0435). The mean number of falls per subject during a 1-year follow-up period was 0.45 for the calcium mono group and 0.24 for the calcium and vitamin D group (p = 0.0346). Short-term supplementation with vitamin D and calcium improves sHPT and body sway and therefore may prevent falls and subsequent nonvertebral fractures in elderly women.

259. Rev Rhum Engl Ed. 1996 Feb;63(2):135-40.

Biochemical effects of calcium and vitamin D supplementation in elderly, institutionalized, vitamin D-deficient patients.

Chapuy MC, Chapuy P, Thomas JL, Hazard MC, Meunier PJ.

National Institute for Health and Medical Research (INSERM) unit 403, Edouard Herriot Hospital, Lyon, France.

Forty-five subjects (41 women and 4 men) in long-stay and medium-stay facilities, aged 74 to 95 years (mean 86.4 years), with 25-hydroxy-vitamin D levels less than 12 ng/ml, were treated for six consecutive months with two tablets per day of a preparation containing vitamin D3 (800 IU/day) and calcium carbonate (1 g elemental calcium/day). Serum levels of 25-hydroxy-vitamin D were very low at baseline (5.6 +/- 0.4 ng/ml) and rose significantly under treatment, to normal values, 33.2 +/- 1.2 and 40.9 +/- 2.1 ng/ml after three and six months, respectively (p < 0.001 for both comparisons). Serum calcium increased significantly, by 4.5% (p < 0.001) during the first three months, and remained at a plateau thereafter. Corrected serum calcium rose by 8.9% (p < 0.001) during the trial. No patient developed hypercalcemia. Serum parathyroid hormone levels, which were elevated at baseline (71.6 +/- 5.8 pg/ml; normal, 12 to 54 pg/ml), decreased gradually and significantly throughout the treatment period, by 43.0% and 67.1% after three and six months, respectively (p < 0.001 for both comparisons). Serum alkaline phosphatase activity fell concomitantly, by 9.9% after three months (p < 0.01) and 36.5% after six months (p < 0.001). In conclusion, the preparation used in our study is effective in correcting both the vitamin D deficiency that is prevalent in elderly institutionalized patients and the resultant increase in bone turnover.

260. J Clin Endocrinol Metab. 1988 Oct;67(4):644-50.

The effect of vitamin D supplementation on vitamin D status and parathyroid function in elderly subjects.

Lips P, Wiersinga A, van Ginkel FC, Jongen MJ, Netelenbos JC, Hackeng WH, Delmas PD, van der Vijgh WJ.

Department of Endocrinology, Academisch Ziekenhuis Vrije Universiteit, Amsterdam, The Netherlands.

Vitamin D deficiency is common in the elderly and may lead to secondary hyperparathyroidism, cortical bone loss, and hip fractures. The effect of vitamin D supplementation for 1 yr was studied in 72 people living in a nursing home and 70 people living in an aged people's home. The subjects were randomized into 3 groups: control, and 400 or 800 IU vitamin D3/day. The initial vitamin D status of each subject was classified as deficient or borderline [serum 25-hydroxyvitamin D (25OHD) less than 30 nmol/L] in 79% and adequate (serum 25OHD greater than or equal to 30 nmol/L) in 21%. Serum 25OHD concentrations increased about 3-fold in both groups receiving vitamin D supplementation. Serum 1,25-dihydroxyvitamin D [1,25-(OH)2D] concentrations increased slightly but significantly, and the increase was inversely related to the initial serum 25OHD concentration. Serum intact PTH-(1-84) concentrations decreased about 15% during supplementation in both nursing home and aged people's home residents, whereas serum osteocalcin significantly decreased in the nursing home residents only. We conclude that a vitamin D3 supplement of 400 IU/day adequately improves vitamin D status in elderly people and increases 1,25-(OH)2D concentrations in those with vitamin D deficiency. Supplementation decreases parathyroid function and may depress bone turnover to some degree.

Serum Levels

261. Osteoporos Int. 1998;8(3):222-30.

Vitamin D and its major metabolites: serum levels after graded oral dosing in healthy men.

Barger-Lux MJ, Heaney RP, Dowell S, Chen TC, Holick MF.

Osteoporosis Research Center, Creighton University, Omaha, Nebraska 68131, USA.

We determined the quantitative relationships between graded oral dosing with vitamin D3, 25(OH)D3, and 1,25(OH)2D3 for short treatment periods and changes in circulating levels of these substances. The subjects were 116 healthy men (mean age, 28 +/- 4 years, with usual milk consumption of < or = 0.47 l/day and mean serum 25(OH)D of 67 +/- 25 nmol/l). They were distributed among nine open-label treatment groups: vitamin D3 (25, 250 or 1250 micrograms/day for 8 weeks), 25(OH)D3 (10, 20 or 50 micrograms/day for 4 weeks) and 1,25(OH)2D3 (0.5, 1.0 or 1.0 microgram/day for 2 weeks). All treatment occurred between January 3 and April 3. We measured fasting serum, calcium, parathyroid hormone, vitamin D3, 25(OH)D and 1,25(OH)2D immediately before and after treatment. In the three groups treated with vitamin D3, mean values for circulating vitamin D3 increased by 13, 137 and 883 nmol/l and serum 25(OH)D increased by 29, 146 and 643 nmol/l for the three dosage groups, respectively. Treatment with 25(OH)D3 increased circulating 25(OH)D by 40, 76 and 206 nmol/l, respectively. Neither compound changed serum 1,25(OH)2D levels. However, treatment with 1,25(OH)2D3 increased circulating 1,25(OH)2D by 10, 46 and 60 pmol/l, respectively. Slopes calculated from these data allow the following estimates of mean treatment effects for typical dosage units in healthy 70-kg adults: an 8-week course of vitamin D3 at 10 micrograms/day (400 IU/day) would raise serum vitamin D by 9 nmol/l and serum 25(OH)D by 11 nmol/l; a 4-week course of 25(OH)D3 at 20 micrograms/day would raise serum 25(OH)D by 94 nmol/l; and a 2-week course of 1,25(OH)2D3 at 0.5 microgram/day would raise serum 1,25(OH)2D by 17 pmol/l.

Osteomalacia

262. Am J Med. 2000 Mar;108(4):296-300.

Osteomalacia due to vitamin D depletion: a neglected consequence of intestinal malabsorption.

Basha B, Rao DS, Han ZH, Parfitt AM.

Bone and Mineral Metabolism Research Laboratory, Bone and Joint Center, Henry Ford Health System, Detroit, Michigan, USA.

PURPOSE: Osteomalacia due to vitamin D depletion is believed to be rare in the United States because of the routine fortification of milk and other dairy products with vitamin D. We present a series of patients with histologically verified osteomalacia due to vitamin D depletion to emphasize the need for more careful and systematic surveillance of patients at risk of this metabolic bone disease. METHODS: Between 1989 and 1994, 17 patients with osteomalacia due to vitamin D depletion were seen in the Bone and Mineral Division of Henry Ford Health System, Detroit. All patients had a transiliac bone biopsy after in vivo double tetracycline labeling. Biochemical indexes of vitamin D nutritional status, parathyroid function, markers of bone turnover, and bone mineral density were assessed at the time of bone biopsy. The duration of symptoms, the lag between the cause of vitamin D depletion and the development of symptoms, and the radiologic findings were recorded. RESULTS: Osteomalacia was suspected by the referring physician in only 4 of the 17 patients, although a gastrointestinal disorder that can lead to vitamin D depletion was present in every patient. Thirteen of the patients had sustained at least one osteoporotic fracture (wrist, spine, or hip), and most had low appendicular and axial bone mineral density. All patients had one or more biochemical abnormalities consistent with vitamin D depletion. In 4 patients, a progressive rise in the serum alkaline phosphatase level was recorded but was not investigated until the patient presented with bone pain, muscle weakness, or fracture. CONCLUSIONS: Osteomalacia due to vitamin D depletion appears not to be suspected or diagnosed promptly in susceptible patients, perhaps because their physicians were not sufficiently aware of this condition.

Immune

263. J Clin Endocrinol Metab. 1989 Jul;69(1):127-33.

Inhibition of interleukin-1 production by 1,25-dihydroxyvitamin D3.

Tsoukas CD, Watry D, Escobar SS, Provvedini DM, Dinarello CA, Hustmyer FG, Manolagas SC.

Department of Biology, San Diego State University, California 92182.

The hormonal form of vitamin D, 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3], inhibits the proliferation of T lymphocytes and production of growth-promoting factors (including interleukin-2) (IL2) in CTLL2 murine cells. In this study, we investigated the role of monocytes in this hormone-mediated inhibitory effect, by testing the effects of 1,25-(OH)2D3 on the ability of the mitogenic lectin phytohemagglutinin (PHA) to induce T cell activation in either a monocyte-dependent or phorbol myristate acetate (PMA)-driven (monocyte-independent) system. The results indicate that proliferation of T cells and production of growth-promoting factors are inhibited by 1,25-(OH)2D3 only in the monocyte-dependent system. Preincubation of monocytes with 1,25-(OH)2D3 for various periods of time and subsequent removal of the hormone resulted in inhibition of the PHA-driven proliferation of T cells. Preincubation for 2 h resulted in 20% inhibition, while preincubation for 36 h reduced proliferation to 50% of the control value [no 1,25-(OH)2D3 exposure]. These data suggested that monocytes are important participants in 1,25-(OH)2D3-mediated events. Therefore, we tested the effects of the hormone on the production of IL1, a monocyte-derived product thought to be involved in the induction of IL2 release and the subsequent development of the T cell proliferative response. 1,25-(OH)2D3 inhibited the production of both extracellular and cell-associated immunoreactive IL1 alpha and IL1 beta. Indomethacin, a prostaglandin synthetase inhibitor, did not alter the inhibitory properties of 1,25-(OH)2D3, suggesting that prostaglandins are not responsible for the inhibitory phenomenon. We conclude that part of the ability of 1,25-(OH)2D3 to inhibit T cell proliferation may be due to direct effects on monocytes by down-regulating IL-1 production. However, it is unlikely that the immunoregulatory properties of 1,25-(OH)2D3 on T cells are mediated solely through monocytes, and it is possible that the hormone also exerts its influence directly on T cells.

264. Mol Cell Endocrinol. 1985 Dec;43(2-3):113-22.

Interactions of 1,25-dihydroxyvitamin D3 and the immune system.

Manolagas SC, Provvedini DM, Tsoukas CD.

A series of recent discoveries indicate that the hormonal form of vitamin D3, namely, 1,25(OH)2D3 plays a role in the regulation of the immune system. Cells of the monocyte/macrophage lineage possess receptors for 1,25(OH)2D3 regardless of their activation stage; cells of the lymphoid lineage also express these receptors but only at certain stages of their differentiation pathway and upon activation. Further, 1,25(OH)2D3 promotes the differentiation of monocyte precursors towards monocyte/macrophages and enhances monocyte function in antigen presentation. In addition 1,25(OH)2D3 is a potent inhibitor of interleukin-2 (IL-2) and suppresses effector functions of both T and B lymphocytes via IL-2-dependent as well as via IL-2-independent mechanisms. The theoretical and clinical implications of these discoveries are discussed.

Osteoarthritis

265. Arthritis Rheum. 1999 May;42(5):854-60.

Serum vitamin D levels and incident changes of radiographic hip osteoarthritis: a longitudinal study. Study of Osteoporotic Fractures Research Group.

Lane NE, Gore LR, Cummings SR, Hochberg MC, Scott JC, Williams EN, Nevitt MC.

Division of Rheumatology, University of California, San Francisco 94143, USA.

OBJECTIVE: The purpose of this study was to determine the relationship of serum levels of 25-vitamin D and 1,25-vitamin D to incident changes of radiographic hip osteoarthritis (OA) among elderly white women. METHODS: Baseline and followup hip radiographs of 237 subjects were obtained an average of 8 years apart. Hips were scored for individual radiographic features (IRF) and assigned a summary grade based on the number and type of IRF present. Serum 25- and 1,25-vitamin D levels from baseline samples were analyzed by radioimmunoassay. Logistic and linear regression were used to examine the association of 25- and 1,25-vitamin D levels with radiographic changes, adjusting for age, health status, physical activity, weight, vitamin D supplement use, and calcaneal bone mineral density. RESULTS: The risk of incident hip OA defined as the development of definite joint space narrowing was increased for subjects who were in the middle (odds ratio [OR] 3.21, 95% confidence interval [95% CI] 1.06, 9.68) and lowest (OR 3.34, 95% CI 1.13, 9.86) tertiles for 25-vitamin D compared with subjects in the highest tertile. Vitamin D levels were not associated with incident hip OA defined as the development of definite osteophytes or new disease according to the summary grade. No association between serum 1,25-vitamin D and changes in radiographic hip OA was found. CONCLUSION: Low serum levels of 25-vitamin D may be associated with incident changes of radiographic hip OA characterized by joint space narrowing.

266. Ann Intern Med. 1996 Sep 1;125(5):353-9.

Relation of dietary intake and serum levels of vitamin D to progression of osteoarthritis of the knee among participants in the Framingham Study.

McAlindon TE, Felson DT, Zhang Y, Hannan MT, Aliabadi P, Weissman B, Rush D, Wilson PW, Jacques P.

Boston University Medical Center, Tufts University, Massachusetts, USA.

BACKGROUND: Evidence suggests that pathophysiologic processes in bone are important determinants of outcome in osteoarthritis of the knee. Low intake and low serum levels of vitamin D may compromise favorable responses of bone to osteoarthritis, predisposing patients to progression. OBJECTIVE: To determine whether dietary intake and serum levels of vitamin D would predict the incidence and progression of osteoarthritis of the knee in participants of the Framingham Study. DESIGN: Prospective observational study. SETTING: The Framingham Study. PARTICIPANTS: Participants in the Framingham Heart Study who had knee radiography at examinations 18 (done between 1983 and 1985) and 22 (done between 1992 and 1993) and received interim assessments of vitamin D intake and serum levels. MEASUREMENTS: Intake of vitamin D and serum levels of 25-hydroxyvitamin D, calculated on the basis of dietary habits and supplement use as reported on a questionnaire, were evaluated at examination 20 (1988 to 1989). Knee radiographs were given scores for global severity of osteoarthritis, using a modification of the scale of Kellgren and Lawrence (range, 0 to 4), and for the presence of osteophytes and joint-space narrowing (range, 0 to 3). Covariates measured at examinations 18 and 20 were age, sex, body mass index, weight change, injury, physical activity, health status, bone mineral density, and energy intake. RESULTS: 556 participants (mean age at baseline +/- SD, 70.3 +/- 4.5 years) had complete assessments. Incident osteoarthritis occurred in 75 knees; progressive osteoarthritis occurred in 62 knees. Serum levels of vitamin D were modestly correlated with vitamin D intake (r = 0.24). Risk for progression increased threefold in participants in the middle and lower tertiles for both vitamin D intake (odds ratio for the lower compared with the upper tertile, 4.0 [95% Cl, 1.4 to 11.6]) and serum levels of vitamin D (odds ratio for the lower compared with the upper tertile, 2.9[Cl, 1.0 to 8.2]). Low serum levels of vitamin D also predicted loss of cartilage, as assessed by loss of joint space (odds ratio, 2.3 [Cl, 0.9 to 5.5]) and osteophyte growth (odds ratio, 3.1 [Cl, 1.3 to 7.5]). Incident osteoarthritis of the knee occurring after baseline was not consistently related to either intake or serum levels of vitamin D. CONCLUSIONS: Low intake and low serum levels of vitamin D each appear to be associated with an increased risk for progression of osteoarthritis of the knee.

1: Teng M, Wolf M, Lowrie E, Ofsthun N, Lazarus JM, Thadhani R.
Survival of patients undergoing hemodialysis with paricalcitol or calcitriol
therapy.
N Engl J Med. 2003 Jul 31;349(5):446-56.
PMID: 12890843 [PubMed - indexed for MEDLINE]

2: Guyton KZ, Kensler TW, Posner GH.
Vitamin D and vitamin D analogs as cancer chemopreventive agents.
Nutr Rev. 2003 Jul;61(7):227-38. Review.
PMID: 12918875 [PubMed - indexed for MEDLINE]

3: Briffa NK, Keogh AM, Sambrook PN, Eisman JA.
Reduction of immunosuppressant therapy requirement in heart transplantation by
calcitriol.
Transplantation. 2003 Jun 27;75(12):2133-4.
PMID: 12829925 [PubMed - indexed for MEDLINE]

4: Tsuruoka S, Wakaumi M, Sugimoto K, Saito T, Fujimura A.
Chronotherapy of high-dose active vitamin D3 in haemodialysis patients with
secondary hyperparathyroidsm: a repeated dosing study.
Br J Clin Pharmacol. 2003 Jun;55(6):531-7.
PMID: 12814446 [PubMed - indexed for MEDLINE]

5: Peehl DM, Feldman D.
The role of vitamin D and retinoids in controlling prostate cancer progression.
Endocr Relat Cancer. 2003 Jun;10(2):131-40. Review.
PMID: 12790775 [PubMed - indexed for MEDLINE]

6: Garcion E, Sindji L, Nataf S, Brachet P, Darcy F, Montero-Menei CN.
Treatment of experimental autoimmune encephalomyelitis in rat by
1,25-dihydroxyvitamin D3 leads to early effects within the central nervous
system.
Acta Neuropathol (Berl). 2003 May;105(5):438-48. Epub 2003 Jan 31.
PMID: 12677443 [PubMed - indexed for MEDLINE]

7: Zittermann A.
Vitamin D in preventive medicine: are we ignoring the evidence?
Br J Nutr. 2003 May;89(5):552-72. Review.
PMID: 12720576 [PubMed - indexed for MEDLINE]

8: Borissova AM, Tankova T, Kirilov G, Dakovska L, Kovacheva R.
The effect of vitamin D3 on insulin secretion and peripheral insulin
sensitivity in type 2 diabetic patients.
Int J Clin Pract. 2003 May;57(4):258-61.
PMID: 12800453 [PubMed - indexed for MEDLINE]

9: Mirzaei S, Zajicek HK, Knoll P, Hahn M, Levi M, Kohn H, Pohl W.
Effect of rocaltrol on bone mass in patients with pulmonary disease treated
with corticosteroids.
J Asthma. 2003 May;40(3):251-5.
PMID: 12807168 [PubMed - indexed for MEDLINE]

10: Maasalu K, Haviko T, Martson A.
Treatment of children with Osteogenesis imperfecta in Estonia.
Acta Paediatr. 2003 Apr;92(4):452-5.
PMID: 12801112 [PubMed - indexed for MEDLINE]

11: [No authors listed]
What you need to know about calcium. Calcium is billed as the bone-building
nutrient. But some experts argue that we should pay more attention to exercise
and vitamin D.
Harv Health Lett. 2003 Apr;28(6):1-3. No abstract available.
PMID: 12777228 [PubMed - indexed for MEDLINE]

12: Khajehdehi P, Taheri S.
Effect of oral calcitriol pulse therapy on the lipid, calcium, and glucose
homeostasis of hemodialysis-patients: its safety in a combination with oral
calcium carbonate.
J Ren Nutr. 2003 Apr;13(2):78-83.
PMID: 12671829 [PubMed - indexed for MEDLINE]

13: Gartner LM, Greer FR; Section on Breastfeeding and Committee on Nutrition.
American Academy of Pediatrics.
Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D
intake.
Pediatrics. 2003 Apr;111(4 Pt 1):908-10.
PMID: 12671133 [PubMed - indexed for MEDLINE]

14: Trivedi DP, Doll R, Khaw KT.
Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on
fractures and mortality in men and women living in the community: randomised
double blind controlled trial.
BMJ. 2003 Mar 1;326(7387):469.
PMID: 12609940 [PubMed - indexed for MEDLINE]

15: Boffa MJ.
Erosive pustular dermatosis of the scalp successfully treated with calcipotriol
cream.
Br J Dermatol. 2003 Mar;148(3):593-5. No abstract available.
PMID: 12653759 [PubMed - indexed for MEDLINE]

16: Campbell BG, Ketchell D, Gunning K.
Do calcium supplements prevent postmenopausal osteoporotic fractures?
J Fam Pract. 2003 Mar;52(3):234, 237.
PMID: 12620181 [PubMed - indexed for MEDLINE]

17: Calvo MS, Whiting SJ.
Prevalence of vitamin D insufficiency in Canada and the United States:
importance to health status and efficacy of current food fortification and
dietary supplement use.
Nutr Rev. 2003 Mar;61(3):107-13. Review.
PMID: 12723644 [PubMed - indexed for MEDLINE]

18: Feskanich D, Willett WC, Colditz GA.
Calcium, vitamin D, milk consumption, and hip fractures: a prospective study
among postmenopausal women.
Am J Clin Nutr. 2003 Feb;77(2):504-11.
PMID: 12540414 [PubMed - indexed for MEDLINE]

19: McCullough ML, Robertson AS, Rodriguez C, Jacobs EJ, Chao A, Carolyn J,
Calle EE, Willett WC, Thun MJ.
Calcium, vitamin D, dairy products, and risk of colorectal cancer in the Cancer
Prevention Study II Nutrition Cohort (United States).
Cancer Causes Control. 2003 Feb;14(1):1-12.
PMID: 12708719 [PubMed - indexed for MEDLINE]

20: Kubodera N, Tsuji N, Uchiyama Y, Endo K.
A new active vitamin D analog, ED-71, causes increase in bone mass with
preferential effects on bone in osteoporotic patients.
J Cell Biochem. 2003 Feb 1;88(2):286-9.
PMID: 12520528 [PubMed - indexed for MEDLINE]

21: Pedersen P, Michaelsen KF, Molgaard C.
Children with nutritional rickets referred to hospitals in Copenhagen during a
10-year period.
Acta Paediatr. 2003;92(1):87-90.
PMID: 12650306 [PubMed - indexed for MEDLINE]

22: Loddenkemper K, Grauer A, Burmester GR, Buttgereit F.
Calcium, vitamin D and etidronate for the prevention and treatment of
corticosteroid-induced osteoporosis in patients with rheumatic diseases.
Clin Exp Rheumatol. 2003 Jan-Feb;21(1):19-26.
PMID: 12673885 [PubMed - indexed for MEDLINE]

23: Vieth R, Ladak Y, Walfish PG.
Age-related changes in the 25-hydroxyvitamin D versus parathyroid hormone
relationship suggest a different reason why older adults require more vitamin D.
J Clin Endocrinol Metab. 2003 Jan;88(1):185-91.
PMID: 12519850 [PubMed - indexed for MEDLINE]

24: Amil B, Fernandez-Fuente M, Santos F, Rodriguez J, Diaz-Tejon L, Garcia E,
Carbajo E.
[Effect of growth hormone and calcitriol on the growth plate in uremic rats]
Nefrologia. 2003;23 Suppl 2:23-6. Spanish.
PMID: 12778849 [PubMed - indexed for MEDLINE]

25: Kutluk G, Cetinkaya F, Basak M.
Comparisons of oral calcium, high dose vitamin D and a combination of these in
the treatment of nutritional rickets in children.
J Trop Pediatr. 2002 Dec;48(6):351-3.
PMID: 12521277 [PubMed - indexed for MEDLINE]

26: Bellantone R, Lombardi CP, Raffaelli M, Boscherini M, Alesina PF, De Crea
C, Traini E, Princi P.
Is routine supplementation therapy (calcium and vitamin D) useful after total
thyroidectomy?
Surgery. 2002 Dec;132(6):1109-12; discussion 1112-3.
PMID: 12490862 [PubMed - indexed for MEDLINE]

27: Gewirtz DA, Gupta MS, Sundaram S.
Vitamin D3 and vitamin D3 analogues as an adjunct to cancer chemo-therapy and
radiotherapy.
Curr Med Chem Anti-Canc Agents. 2002 Nov;2(6):683-90. Review.
PMID: 12678720 [PubMed - indexed for MEDLINE]

28: Kragballe K.
Vitamin D and UVB radiation therapy.
Cutis. 2002 Nov;70(5 Suppl):9-12. Review.
PMID: 12467333 [PubMed - indexed for MEDLINE]

29: Katayama I, Ohkawara A, Ohkido M, Harada S, Tamaki K, Nakagawa H, Hori Y,
Nishiyama S.
High-concentration (20 mug/g) tacalcitol ointment therapy on refractory
psoriasis vulgaris with low response to topical corticosteroids.
Eur J Dermatol. 2002 Nov-Dec;12(6):553-7.
PMID: 12459526 [PubMed - indexed for MEDLINE]

30: Wray CJ, Mayes T, Khoury J, Warden GD, Gottschlich M.
The 2002 Moyer Award. Metabolic effects of vitamin D on serum calcium,
magnesium, and phosphorus in pediatric burn patients.
J Burn Care Rehabil. 2002 Nov-Dec;23(6):416-23.
PMID: 12432318 [PubMed - indexed for MEDLINE]

31: Oades GM, Dredge K, Kirby RS, Colston KW.
Vitamin D receptor-dependent antitumour effects of 1,25-dihydroxyvitamin D3 and
two synthetic analogues in three in vivo models of prostate cancer.
BJU Int. 2002 Oct;90(6):607-16.
PMID: 12230626 [PubMed - indexed for MEDLINE]

32: Rummens K, van Bree R, Van Herck E, Zaman Z, Bouillon R, Van Assche FA,
Verhaeghe J.
Vitamin D deficiency in guinea pigs: exacerbation of bone phenotype during
pregnancy and disturbed fetal mineralization, with recovery by 1,25(OH)2D3
infusion or dietary calcium-phosphate supplementation.
Calcif Tissue Int. 2002 Oct;71(4):364-75. Epub 2002 Aug 29.
PMID: 12196905 [PubMed - indexed for MEDLINE]

33: Shin MH, Holmes MD, Hankinson SE, Wu K, Colditz GA, Willett WC.
Intake of dairy products, calcium, and vitamin d and risk of breast cancer.
J Natl Cancer Inst. 2002 Sep 4;94(17):1301-11.
PMID: 12208895 [PubMed - indexed for MEDLINE]

34: Gupta AK, Browne M, Bluhm R.
Nonpsoriatic uses of calcipotriol.
J Cutan Med Surg. 2002 Sep-Oct;6(5):442-8. Epub 2002 Aug 29. Review.
PMID: 12196891 [PubMed - indexed for MEDLINE]

35: Albert DM, Nickells RW, Gamm DM, Zimbric ML, Schlamp CL, Lindstrom MJ, Audo
I.
Vitamin D analogs, a new treatment for retinoblastoma: The first Ellsworth
Lecture.
Ophthalmic Genet. 2002 Sep;23(3):137-56.
PMID: 12324873 [PubMed - indexed for MEDLINE]

36: Nowson CA, Margerison C.
Vitamin D intake and vitamin D status of Australians.
Med J Aust. 2002 Aug 5;177(3):149-52. Review.
PMID: 12149085 [PubMed - indexed for MEDLINE]

37: Ichikawa C, Takiguchi N, Koda K, Oda K, Suzuki H, Miyazaki M.
Early phase metabolic bone disorders after gastrectomy: influence of active
vitamin D treatment.
Dig Dis Sci. 2002 Aug;47(8):1886-90.
PMID: 12184546 [PubMed - indexed for MEDLINE]

38: Papadimitropoulos E, Wells G, Shea B, Gillespie W, Weaver B, Zytaruk N,
Cranney A, Adachi J, Tugwell P, Josse R, Greenwood C, Guyatt G; Osteoporosis
Methodology Group and The Osteoporosis Research Advisory Group.
Meta-analyses of therapies for postmenopausal osteoporosis. VIII: Meta-analysis
of the efficacy of vitamin D treatment in preventing osteoporosis in
postmenopausal women.
Endocr Rev. 2002 Aug;23(4):560-9. Review.
PMID: 12202471 [PubMed - indexed for MEDLINE]

39: Kim G, Sprague SM.
Use of vitamin D analogs in chronic renal failure.
Adv Ren Replace Ther. 2002 Jul;9(3):175-83. Review.
PMID: 12203199 [PubMed - indexed for MEDLINE]

40: Dhesi JK, Moniz C, Close JC, Jackson SH, Allain TJ.
A rationale for vitamin D prescribing in a falls clinic population.
Age Ageing. 2002 Jul;31(4):267-71.
PMID: 12147564 [PubMed - indexed for MEDLINE]

41: Holick MF.
Too little vitamin D in premenopausal women: why should we care?
Am J Clin Nutr. 2002 Jul;76(1):3-4. No abstract available.
PMID: 12081814 [PubMed - indexed for MEDLINE]

42: De Sevaux RG, Hoitsma AJ, Corstens FH, Wetzels JF.
Treatment with vitamin D and calcium reduces bone loss after renal
transplantation: a randomized study.
J Am Soc Nephrol. 2002 Jun;13(6):1608-14.
PMID: 12039990 [PubMed - indexed for MEDLINE]

43: Abitbol V, Mary JY, Roux C, Soule JC, Belaiche J, Dupas JL, Gendre JP,
Lerebours E, Chaussade S; Groupe D'etudes Therapeutiques des Affections
Inflammatoires Digestives (GETAID).
Osteoporosis in inflammatory bowel disease: effect of calcium and vitamin D
with or without fluoride.
Aliment Pharmacol Ther. 2002 May;16(5):919-27.
PMID: 11966500 [PubMed - indexed for MEDLINE]

44: Gysemans C, Van Etten E, Overbergh L, Verstuyf A, Waer M, Bouillon R,
Mathieu C.
Treatment of autoimmune diabetes recurrence in non-obese diabetic mice by mouse
interferon-beta in combination with an analogue of
1alpha,25-dihydroxyvitamin-D3.
Clin Exp Immunol. 2002 May;128(2):213-20.
PMID: 11985511 [PubMed - indexed for MEDLINE]

45: Peleg S, Uskokovic M, Ahene A, Vickery B, Avnur Z.
Cellular and molecular events associated with the bone-protecting activity of
the noncalcemic vitamin D analog Ro-26-9228 in osteopenic rats.
Endocrinology. 2002 May;143(5):1625-36.
PMID: 11956143 [PubMed - indexed for MEDLINE]

46: Lehtonen-Veromaa M, Mottonen T, Nuotio I, Irjala K, Viikari J.
The effect of conventional vitamin D(2) supplementation on serum 25(OH)D
concentration is weak among peripubertal Finnish girls: a 3-y prospective study.
Eur J Clin Nutr. 2002 May;56(5):431-7.
PMID: 12001014 [PubMed - indexed for MEDLINE]

47: Hedstrom M, Sjoberg K, Brosjo E, Astrom K, Sjoberg H, Dalen N.
Positive effects of anabolic steroids, vitamin D and calcium on muscle mass,
bone mineral density and clinical function after a hip fracture. A randomised
study of 63 women.
J Bone Joint Surg Br. 2002 May;84(4):497-503.
PMID: 12043767 [PubMed - indexed for MEDLINE]

48: Nakamura K, Nashimoto M, Okuda Y, Ota T, Yamamoto M.
Fish as a major source of vitamin D in the Japanese diet.
Nutrition. 2002 May;18(5):415-6.
PMID: 11985947 [PubMed - indexed for MEDLINE]

49: Cope MB, Steele VE, Eto I, Juliana MM, Hill DL, Grubbs CJ.
Prevention of methylnitrosourea-induced mammary cancers by 9-cis-retinoic acid
and/or vitamin D3.
Oncol Rep. 2002 May-Jun;9(3):533-7.
PMID: 11956623 [PubMed - indexed for MEDLINE]

50: Martinez ME, Marshall JR, Sampliner R, Wilkinson J, Alberts DS.
Calcium, vitamin D, and risk of adenoma recurrence (United States).
Cancer Causes Control. 2002 Apr;13(3):213-20.
PMID: 12020102 [PubMed - indexed for MEDLINE]

51: Koshikawa S, Akizawa T, Kurokawa K, Marumo F, Sakai O, Arakawa M, Morii H,
Seino Y, Ogata E, Ohashi Y, Akiba T, Tsukamoto Y, Suzuki M.
Clinical effect of intravenous calcitriol administration on secondary
hyperparathyroidism. A double-blind study among 4 doses.
Nephron. 2002 Apr;90(4):413-23.
PMID: 11961400 [PubMed - indexed for MEDLINE]

52: Harris S.
Can vitamin D supplementation in infancy prevent type 1 diabetes?
Nutr Rev. 2002 Apr;60(4):118-21. Review.
PMID: 12002683 [PubMed - indexed for MEDLINE]

53: van de Kerkhof PC, Berth-Jones J, Griffiths CE, Harrison PV, Honigsmann H,
Marks R, Roelandts R, Schopf E, Trompke C.
Long-term efficacy and safety of tacalcitol ointment in patients with chronic
plaque psoriasis.
Br J Dermatol. 2002 Mar;146(3):414-22.
PMID: 11952541 [PubMed - indexed for MEDLINE]

54: Ginarte M, Fabeiro JM, Toribio J.
Confluent and reticulated papillomatosis (Gougerot-Carteaud) successfully
treated with tacalcitol.
J Dermatolog Treat. 2002 Mar;13(1):27-30.
PMID: 12006135 [PubMed - indexed for MEDLINE]

55: Chapuy MC, Pamphile R, Paris E, Kempf C, Schlichting M, Arnaud S, Garnero P,
Meunier PJ.
Combined calcium and vitamin D3 supplementation in elderly women: confirmation
of reversal of secondary hyperparathyroidism and hip fracture risk: the Decalyos
II study.
Osteoporos Int. 2002 Mar;13(3):257-64.
PMID: 11991447 [PubMed - indexed for MEDLINE]

56: Deroisy R, Collette J, Albert A, Jupsin I, Reginster JY.
Administration of a supplement containing both calcium and vitamin D is more
effective than calcium alone to reduce secondary hyperparathyroidism in
postmenopausal women with low 25(OH)vitamin D circulating levels.
Aging Clin Exp Res. 2002 Feb;14(1):13-7.
PMID: 12027147 [PubMed - indexed for MEDLINE]

57: Liu W, Asa SL, Fantus IG, Walfish PG, Ezzat S.
Vitamin D arrests thyroid carcinoma cell growth and induces p27
dephosphorylation and accumulation through PTEN/akt-dependent and -independent
pathways.
Am J Pathol. 2002 Feb;160(2):511-9.
PMID: 11839571 [PubMed - indexed for MEDLINE]

58: Kreuter A, Gambichler T, Sauermann K, Jansen T, Altmeyer P, Hoffmann K.
Extragenital lichen sclerosus successfully treated with topical calcipotriol:
evaluation by in vivo confocal laser scanning microscopy.
Br J Dermatol. 2002 Feb;146(2):332-3. No abstract available.
PMID: 11903254 [PubMed - indexed for MEDLINE]

59: Gniadecki R.
Calcipotriol for erythema annulare centrifugum.
Br J Dermatol. 2002 Feb;146(2):317-9.
PMID: 11903248 [PubMed - indexed for MEDLINE]

60: Turk U, Akbulut M, Yildiz A, Gurbilek M, Gonen S, Tombul Z, Yeksan M.
Comparative effect of oral pulse and intravenous calcitriol treatment in
hemodialysis patients: the effect on serum IL-1 and IL-6 levels and bone mineral
density.
Nephron. 2002 Feb;90(2):188-94.
PMID: 11818704 [PubMed - indexed for MEDLINE]

61: Harbuzova VIu.
[Effect of nifedipine, vitamin E, and bisphosphonates on intensity of lipid
peroxidation in arterial and venous walls in hypervitaminosis D]
Fiziol Zh. 2002;48(6):70-3. Ukrainian.
PMID: 12577473 [PubMed - indexed for MEDLINE]

62: Harbuzova VIu.
[Intensity of lipid peroxidation and antioxidant enzyme activity in arterial
and venous walls during hypervitaminosis D]
Fiziol Zh. 2002;48(1):87-90. Ukrainian.
PMID: 11928638 [PubMed - indexed for MEDLINE]

63: Willis MS.
The health economics of calcium and vitamin D3 for the prevention of
osteoporotic hip fractures in Sweden.
Int J Technol Assess Health Care. 2002 Fall;18(4):791-807.
PMID: 12602080 [PubMed - indexed for MEDLINE]

64: Polek TC, Weigel NL.
Vitamin D and prostate cancer.
J Androl. 2002 Jan-Feb;23(1):9-17. Review.
PMID: 11780928 [PubMed - indexed for MEDLINE]

65: Arekat MR, And G, Lemke S, Moses AM.
Dramatic improvement of BMD following vitamin D therapy in a bone marrow
transplant recipient.
J Clin Densitom. 2002 Fall;5(3):267-71.
PMID: 12357064 [PubMed - indexed for MEDLINE]

66: Iwamoto J, Takeda T, Ichimura S, Uzawa M.
Effects of 5-year treatment with elcatonin and alfacalcidol on lumbar bone
mineral density and the incidence of vertebral fractures in postmenopausal women
with osteoporosis: a retrospective study.
J Orthop Sci. 2002;7(6):637-43.
PMID: 12486466 [PubMed - indexed for MEDLINE]

67: Takahashi F, Furuichi T, Yorozu K, Kawata S, Kitamura H, Kubodera N,
Slatopolsky E.
Effects of i.v. and oral 1,25-dihydroxy-22-oxavitamin D(3) on secondary
hyperparathyroidism in dogs with chronic renal failure.
Nephrol Dial Transplant. 2002;17 Suppl 10:46-52.
PMID: 12386269 [PubMed - indexed for MEDLINE]

68: Kasai K, Abe R, Wakabayashi M, Nakamura K, Sawatani S, Wakabayashi T.
[The clinical evaluation of maxacalcitol on therapy for secondary
hyperparathyroidism of chronic hemodialysis patients]
Nippon Jinzo Gakkai Shi. 2002;44(5):464-70. Japanese.
PMID: 12216479 [PubMed - indexed for MEDLINE]

69: Terry P, Baron JA, Bergkvist L, Holmberg L, Wolk A.
Dietary calcium and vitamin D intake and risk of colorectal cancer: a
prospective cohort study in women.
Nutr Cancer. 2002;43(1):39-46.
PMID: 12467133 [PubMed - indexed for MEDLINE]

70: Kochetkova EA, Gel'tser BI.
[Alphacalcidol in the treatment of osteopenic syndrome in patients with
bronchial asthma]
Ter Arkh. 2002;74(3):32-5. Russian.
PMID: 11980117 [PubMed - indexed for MEDLINE]

71: Vieth R, Cole DE, Hawker GA, Trang HM, Rubin LA.
Wintertime vitamin D insufficiency is common in young Canadian women, and their
vitamin D intake does not prevent it.
Eur J Clin Nutr. 2001 Dec;55(12):1091-7.
PMID: 11781676 [PubMed - indexed for MEDLINE]

72: Ritzerfeld M, Klasser M, Mann H.
Alfacalcidol in the therapy of renal bone disease.
Int J Clin Pharmacol Ther. 2001 Dec;39(12):546-50.
PMID: 11770836 [PubMed - indexed for MEDLINE]

73: Madelenat P, Bastian H, Menn S.
[Winter supplementation in the 3rd trimester of pregnancy by a dose of 80,000
IU of vitamin D]
J Gynecol Obstet Biol Reprod (Paris). 2001 Dec;30(8):761-7. French.
PMID: 11917727 [PubMed - indexed for MEDLINE]

74: Kurtoglu V, Kurtoglu F, Coskun B.
Effects of boron supplementation of adequate and inadequate vitamin
D3-containing diet on performance and serum biochemical characters of broiler
chickens.
Res Vet Sci. 2001 Dec;71(3):183-7.
PMID: 11798292 [PubMed - indexed for MEDLINE]

75: Larrosa M, Gratacos J, Vaqueiro M, Prat M, Campos F, Roque M.
[Prevalence of hypovitaminosis D in elderly institutionalized residents:
influence of a substitutive treatment]
Med Clin (Barc). 2001 Nov 17;117(16):611-4. Spanish.
PMID: 11714466 [PubMed - indexed for MEDLINE]

76: Hypponen E, Laara E, Reunanen A, Jarvelin MR, Virtanen SM.
Intake of vitamin D and risk of type 1 diabetes: a birth-cohort study.
Lancet. 2001 Nov 3;358(9292):1500-3.
PMID: 11705562 [PubMed - indexed for MEDLINE]

77: Akpede GO, Solomon EA, Jalo I, Addy EO, Banwo AI, Omotara BA.
Nutritional rickets in young Nigerian children in the Sahel savanna.
East Afr Med J. 2001 Nov;78(11):568-75.
PMID: 12219961 [PubMed - indexed for MEDLINE]

78: Krall EA, Wehler C, Garcia RI, Harris SS, Dawson-Hughes B.
Calcium and vitamin D supplements reduce tooth loss in the elderly.
Am J Med. 2001 Oct 15;111(6):452-6.
PMID: 11690570 [PubMed - indexed for MEDLINE]

79: Tsuruoka S, Nishiki K, Sugimoto K, Fujimura A.
Chronotherapy with active vitamin D3 in aged stroke-prone spontaneously
hypertensive rats, a model of osteoporosis.
Eur J Pharmacol. 2001 Oct 5;428(2):287-93.
PMID: 11675047 [PubMed - indexed for MEDLINE]

80: Akizawa T, Suzuki M, Akiba T, Nishizawa Y, Kurokawa K.
Clinical effects of maxacalcitol on secondary hyperparathyroidism of uremic
patients.
Am J Kidney Dis. 2001 Oct;38(4 Suppl 1):S147-51.
PMID: 11576942 [PubMed - indexed for MEDLINE]

81: Lindberg J, Martin KJ, Gonzalez EA, Acchiardo SR, Valdin JR, Soltanek C.
A long-term, multicenter study of the efficacy and safety of paricalcitol in
end-stage renal disease.
Clin Nephrol. 2001 Oct;56(4):315-23.
PMID: 11680662 [PubMed - indexed for MEDLINE]

82: Bunyaratavej N, Kitimanon N, Tunjariyanond K.
Efficacy of calcitriol to bone resorption and PTH level: clinical study.
J Med Assoc Thai. 2001 Oct;84 Suppl 2:S582-5.
PMID: 11853285 [PubMed - indexed for MEDLINE]

83: Sih TR, Morris JG, Hickman MA.
Chronic ingestion of high concentrations of cholecalciferol in cats.
Am J Vet Res. 2001 Sep;62(9):1500-6.
PMID: 11560284 [PubMed - indexed for MEDLINE]

84: Ermis O, Alpsoy E, Cetin L, Yilmaz E.
Is the efficacy of psoralen plus ultraviolet A therapy for vitiligo enhanced by
concurrent topical calcipotriol? A placebo-controlled double-blind study.
Br J Dermatol. 2001 Sep;145(3):472-5.
PMID: 11531839 [PubMed - indexed for MEDLINE]

85: Ameen M, Exarchou V, Chu AC.
Topical calcipotriol as monotherapy and in combination with psoralen plus
ultraviolet A in the treatment of vitiligo.
Br J Dermatol. 2001 Sep;145(3):476-9.
PMID: 11531840 [PubMed - indexed for MEDLINE]

86: Hara K, Kobayashi M, Akiyama Y.
[Effect of combined treatment with vitamin K2 and 1 alpha-(OH)-vitamin D3 on
bone loss in ovariectomized rats]
Nippon Yakurigaku Zasshi. 2001 Sep;118(3):231-40. Japanese.
PMID: 11577464 [PubMed - indexed for MEDLINE]

87: Dowd R.
Role of calcium, vitamin D, and other essential nutrients in the prevention and
treatment of osteoporosis.
Nurs Clin North Am. 2001 Sep;36(3):417-31, viii. Review.
PMID: 11532657 [PubMed - indexed for MEDLINE]

88: Korbel JN, Sebok B, Kerenyi M, Mahrle G.
Enhancement of the antiparakeratotic potency of calcitriol and tacalcitol in
liposomal preparations in the mouse tail test.
Skin Pharmacol Appl Skin Physiol. 2001 Sep-Oct;14(5):291-5.
PMID: 11586070 [PubMed - indexed for MEDLINE]

89: Brot C, Vestergaard P, Kolthoff N, Gram J, Hermann AP, Sorensen OH.
Vitamin D status and its adequacy in healthy Danish perimenopausal women:
relationships to dietary intake, sun exposure and serum parathyroid hormone.
Br J Nutr. 2001 Aug;86 Suppl 1:S97-103.
PMID: 11520426 [PubMed - indexed for MEDLINE]

90: Peehl DM, Seto E, Feldman D.
Rationale for combination ketoconazole/ vitamin D treatment of prostate cancer.
Urology. 2001 Aug;58(2 Suppl 1):123-6. Review.
PMID: 11502466 [PubMed - indexed for MEDLINE]

91: Harsch IA, Hubner RH, Hahn EG, Hensen J.
[Osteoporosis and multiple pregnancy--a case report with positive outcome]
Med Klin. 2001 Jul 15;96(7):402-7. German.
PMID: 11494915 [PubMed - indexed for MEDLINE]

92: Hattori M, Morita N, Tsujino Y, Yamamoto M, Tanizawa T.
Vitamins D and K in the treatment of osteoporosis secondary to
graft-versus-host disease following bone-marrow transplantation.
J Int Med Res. 2001 Jul-Aug;29(4):381-4.
PMID: 11675913 [PubMed - indexed for MEDLINE]

93: Dhingra RK, Sprague SM, Ojo AO, Leavey SF.
Posttransplant bone disease: a case illustrating dramatic improvements in bone
density with vitamin D replacement therapy.
Transplantation. 2001 Jun 27;71(12):1856-9.
PMID: 11455270 [PubMed - indexed for MEDLINE]

94: Beer TM, Munar M, Henner WD.
A Phase I trial of pulse calcitriol in patients with refractory malignancies:
pulse dosing permits substantial dose escalation.
Cancer. 2001 Jun 15;91(12):2431-9.
PMID: 11413535 [PubMed - indexed for MEDLINE]

95: Prudencio J, Akutsu N, Benlimame N, Wang T, Bastien Y, Lin R, Black MJ,
Alaoui-Jamali MA, White JH.
Action of low calcemic 1alpha,25-dihydroxyvitamin D3 analogue EB1089 in head
and neck squamous cell carcinoma.
J Natl Cancer Inst. 2001 May 16;93(10):745-53.
PMID: 11353784 [PubMed - indexed for MEDLINE]

96: Queille-Roussel C, Duteil L, Parneix-Spake A, Arsonnaud S, Rizova E.
The safety of calcitriol 3 microg/g ointment. Evaluation of cutaneous contact
sensitization, cumulative irritancy, photoallergic contact sensitization and
phototoxicity.
Eur J Dermatol. 2001 May-Jun;11(3):219-24.
PMID: 11358728 [PubMed - indexed for MEDLINE]

97: Jara A, Chacon C, Valdivieso A, Aris L, Jalil R, Felsenfeld AJ.
Effect of calcitriol treatment and withdrawal on hyperparathyroidism in
haemodialysis patients with hypocalcaemia.
Nephrol Dial Transplant. 2001 May;16(5):1009-16.
PMID: 11328908 [PubMed - indexed for MEDLINE]

98: Kreuter A, Gambichler T, Avermaete A, Jansen T, Hoffmann M, Hoffmann K,
Altmeyer P, von Kobyletzki G, Bacharach-Buhles M.
Combined treatment with calcipotriol ointment and low-dose ultraviolet A1
phototherapy in childhood morphea.
Pediatr Dermatol. 2001 May-Jun;18(3):241-5.
PMID: 11438008 [PubMed - indexed for MEDLINE]

99: Gysemans C, Waer M, Laureys J, Bouillon R, Mathieu C.
A combination of KH1060, a vitamin D(3) analogue, and cyclosporin prevents
early graft failure and prolongs graft survival of xenogeneic islets in nonobese
diabetic mice.
Transplant Proc. 2001 May;33(3):2365. No abstract available.
PMID: 11377560 [PubMed - indexed for MEDLINE]

100: Gannage-Yared MH, Tohme A, Halaby G.
[Hypovitaminosis D: a major worldwide public health problem]
Presse Med. 2001 Apr 7;30(13):653-8. French.
PMID: 11346909 [PubMed - indexed for MEDLINE]

101: Langner A, Stapor W, Ambroziak M.
Efficacy and tolerance of topical calcitriol 3 microg g(-1) in psoriasis
treatment: a review of our experience in Poland.
Br J Dermatol. 2001 Apr;144 Suppl 58:11-6.
PMID: 11501507 [PubMed - indexed for MEDLINE]

102: Gerritsen MJ, Van De Kerkhof PC, Langner A.
Long-term safety of topical calcitriol 3 microg g(-1) ointment.
Br J Dermatol. 2001 Apr;144 Suppl 58:17-9.
PMID: 11501508 [PubMed - indexed for MEDLINE]

103: Kowalzick L.
Clinical experience with topical calcitriol (1,25-dihydroxyvitamin D3) in
psoriasis.
Br J Dermatol. 2001 Apr;144 Suppl 58:21-5. Review.
PMID: 11501509 [PubMed - indexed for MEDLINE]

104: Rizova E, Corroller M.
Topical calcitriol--studies on local tolerance and systemic safety.
Br J Dermatol. 2001 Apr;144 Suppl 58:3-10. Review.
PMID: 11501511 [PubMed - indexed for MEDLINE]

105: Pfeifer M, Begerow B, Minne HW, Nachtigall D, Hansen C.
Effects of a short-term vitamin D(3) and calcium supplementation on blood
pressure and parathyroid hormone levels in elderly women.
J Clin Endocrinol Metab. 2001 Apr;86(4):1633-7.
PMID: 11297596 [PubMed - indexed for MEDLINE]

106: Gennari C.
Calcium and vitamin D nutrition and bone disease of the elderly.
Public Health Nutr. 2001 Apr;4(2B):547-59. Review.
PMID: 11683549 [PubMed - indexed for MEDLINE]

107: Zhao XY, Feldman D.
The role of vitamin D in prostate cancer.
Steroids. 2001 Mar-May;66(3-5):293-300. Review.
PMID: 11179737 [PubMed - indexed for MEDLINE]

108: Van der Stede Y, Cox E, Van den broeck W, Goddeeris BM.
Enhanced induction of the IgA response in pigs by calcitriol after
intramuscular immunization.
Vaccine. 2001 Feb 28;19(15-16):1870-8.
PMID: 11228356 [PubMed - indexed for MEDLINE]

109: Daragon A, Vittecoq O.
[Osteoporosis in the elderly. Practical prevention and treatment]
Presse Med. 2001 Feb 24;30(7):317-20. French.
PMID: 11262805 [PubMed - indexed for MEDLINE]

110: Vieth R, Chan PC, MacFarlane GD.
Efficacy and safety of vitamin D3 intake exceeding the lowest observed adverse
effect level.
Am J Clin Nutr. 2001 Feb;73(2):288-94.
PMID: 11157326 [PubMed - indexed for MEDLINE]

111: Takahashi M, Naitou K, Ohishi T, Kushida K, Miura M.
Effect of vitamin K and/or D